Find published Prevention of Future Deaths reports, the concerns they raise, who received them and any published responses.
6,433 reports
Information drawn from published reports and official responses.
Marie Bell underwent surgery for a bowel obstruction on 25 July 2025. An unrecognised small-bowel perforation developed into faecal peritonitis, and she died in hospital on 29 July 2025. The report also raises concern that being unable to undergo colonoscopy was treated as declining all investigations, rather than prompting consideration of alternative methods.
NHS England
Eleisha Skinner died in hospital from crush injuries sustained when her car slipped down an icy, inclined driveway and trapped her against a house while she was unloading it. Concerns included the absence of effective barriers against vehicle over-run, uncertainty about arrangements for gritting or salting the driveway, and a lack of guidance on safely unloading vehicles on the incline.
Howarth Properties LTD
Scott Alan Taylor, who had treatment-resistant obsessive compulsive disorder and was receiving community treatment, died by suicide on 12 May 2023. The report raises concerns about the limited number, geographical concentration, access criteria and capacity of tertiary services for patients with treatment-resistant OCD, including a reported waiting list of over 12–15 months.
Department of Health and Social Care
Graham Keith Hollis, who had dementia and increasing frailty, developed swallowing difficulties and experienced coughing and choking episodes while being fed under an agreed modified-diet plan. He was admitted to hospital with aspiration pneumonia and died on 14 August 2025. The principal concern was that staffing shortages prevented a further face-to-face Speech and Language Therapy assessment, resulting in a best-interests decision to feed him at risk without specialist assessment; safeguards relating to his diet and medical review were also not consistently followed.
Staffordshire and Stoke-on-Trent Integrated Care BoardUniversity Hospitals of Derby and Burton NHS Foundation Trust
Johnpaul Digweed died by suicide by hanging in his cell at HMP Garth between 17:06 on 12 April 2024 and 11:31 on 13 April 2024. The concerns included failures to open an ACCT process after incidents of self-harm, inadequate assurance about staff training and information-sharing, and welfare observations not being carried out in accordance with prison procedures, including when observation panels were obscured.
HM Prison and Probation ServiceHM Prison & Probation Service
Susan Dale, a resident of Westfields Residential Home, fell while being assisted with her morning routine on 8 April 2026 and later deteriorated, was taken to hospital, and died on 18 April 2026. The principal concerns were inaccurate and inconsistent records about the fall, moving her despite a recorded possible head injury without prompt clinical assessment, and the absence of an effective handover to staff taking over her care.
Care Quality CommissionWestfield Residential HomeWestfield Residential Home Willerby East Riding of Yorkshire
David Joyce, who had a history of mental health difficulties, died by suicide at his home on 31 August 2023 after being found having suspended himself. The concerns included a lack of follow-up and consideration of mental health referral after he first sought help, prescribing Quetiapine without specialist input despite his reported symptoms and overdose, and a delay of 15 weeks before a medication review led to a change in treatment.
Foxhayes Surgery GP PracticeThe Foxhayes Surgery GP Practice
Kerry Teresa Singh died on 14 July 2025 after urgent extraction of a failing pacemaker lead caused a tear to the superior vena cava, severe bleeding and unsuccessful resuscitation. The report identified delays in involving a tertiary centre, failures to review a critical test result and complete a referral, inadequate systems for patient involvement and task monitoring, and a lack of internal investigation or review.
East Kent Hospitals University NHS Foundation Trust
Jacqueline Frances O'Brien was treated for injuries from an accidental fall and later developed an intra-abdominal infection. She died in hospital on 4 November 2025 after deteriorating following transfer to a community hospital. The principal concerns were that staff failed to carry out checks or observations for about eight hours and failed to respond to family concerns about her worsening condition, resulting in a missed opportunity for earlier treatment.
Worcestershire Acute Hospitals NHS Trust
Naeem Ahmed, a Consultant Anaesthetist, was found dead in a hospital rest room on 21 June 2025 after using alcohol and a substance that is redacted in the report. The concerns included access to potentially fatal medicines from sharps bins and fragmented systems for managing doctors’ working patterns, secondary employment and cumulative workload across providers.
Department of Health and Social CareNHS England
Nola-Reign Morgan was born prematurely on 5 February 2024 after her mother developed suspected chorioamnionitis, and died three days later despite resuscitation and neonatal care. The report identified delays in transferring her mother to the labour ward and high dependency unit, a period without fetal monitoring, and gaps in national and local guidance and staff training on monitoring and managing suspected chorioamnionitis in pre-term pregnancies.
Aneurin Bevan University LHBChief Executive of National Institution for Health and Care ExcellenceChief Executive of Royal College of MidwivesChief Executive of Royal College of Obstetricians and GynaecologistsDepartment of Health and Social CareHealthcare Inspectorate WalesNational Institute for Health and Care ExcellenceRoyal College of MidwivesRoyal College of Obstetricians and Gynaecologists
John Edward Brynmor Phillips, aged 37, died by suicide in his cell at HMP Dartmoor on 29 October 2022 after using a ligature. A referral to the prison mental health team was cancelled when his electronic health records were deactivated during a records-uploading process, causing a delay of approximately 2.5 months in his mental health assessment and treatment. The principal concern was that SystmOne could deactivate an active record and cancel current clinical tasks and referrals without this being apparent, creating a risk of unsafe care.
NHS England
Geoffrey Gordon Fuller, aged 91, called an ambulance for a dislocated hip and experienced a 13-hour delay, including prolonged periods waiting for an ambulance response and hospital handover, during which he suffered pain and was unable to move. He later died at Royal Cornwall Hospital from a ruptured abdominal aortic aneurysm, which the report states was unrelated to the dislocated hip and to which the delay contributed no more than minimally. The principal concerns were persistent ambulance handover delays, emergency department overcrowding, and insufficient social care provision, with associated risks to patient care and ambulance availability.
Department of Health and Social CareRoyal Cornwall Hospitals NHS TrustSouth West Ambulance Service Trust (SWAST)
Muluembet Yohanes underwent surgery to remove a pituitary tumour and was discharged with advice that repeated vomiting required immediate medical attention. After developing vomiting, NHS 111 and Clinical Assessment Service calls resulted in home management advice, and she later suffered a seizure and cardiac arrest due to severe hyponatraemia before dying from hypoxic brain injury. The principal concerns were the absence of a dedicated neurosurgery pathway and the failure to ask about post-surgical discharge or red-flag advice during the calls.
NHS England
Jake Harvey READ was declared deceased at home on 5 May 2025 after sustaining self-inflicted knife injuries. He had attended an emergency department two days earlier seeking mental health support but left before planned Diazepam was prescribed. The principal concerns were the absence of national guidance or timelines for administering medication during mental health agitation or crisis, and the lack of direct access to the medication for a qualified non-medical prescriber, which contributed to a delay in prescribing.
Department of Health and Social Care
Derek Thomas Burt died at home on 15 May 2025 after a spontaneous rupture of an arterio-venous malformation at the back of his right ankle caused severe bleeding. The report raises concerns about communication between the careline service and ambulance services, including failure to pass on key information, delays in escalating the emergency, inadequate recording of information, and the loss of opportunities to provide basic first-aid advice.
Appello Careline LimitedAssociation of Ambulance Chief ExecutivesNHS EnglandSouth East Coast Ambulance Service NHS Foundation TrustTSA – The Voice of Technology Enabled Care
On 04 January 2026, Trevor John Ridd’s bedding caught fire while he was unable to leave his bed because of mobility issues. The sprinkler system activated, but its fault and fire signals were treated as one incident and no 999 call was raised by the Alarm Receiving Centre operator; Mr Ridd was later found with burns and died after suffering cardiac arrest. Concerns included the handling and wording of the two signals, operator training and briefing, and the testing and maintenance of the sprinkler system.
Birmingham City Council
Daniel Charles Forrest, aged 85, suffered a witnessed fall outside his home on 30 September 2025 and later an unwitnessed fall at home on 1 October 2025. Ambulance attendance was delayed and subsequently cancelled before the second fall, after which he was taken to hospital and died from an unsurvivable head injury. The concerns were that callers were told an ambulance was being arranged and were not given reliable information about expected waiting times, potentially limiting informed decisions about waiting or escalating worsening symptoms.
NHS EnglandSouth East Coast Ambulance Service NHS Foundation Trust
Alex Ganski, aged 19, died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The principal concerns were the absence of a designated lead with oversight and authority across services, fragmented information sharing, and no clear national mechanism to identify and communicate his wider mental health and drug-misuse risks.
Department of Health and Social CareNHS England
Mr Arron Hamer, who had been in custody since 2009 and was held at HMP Buckley Hall, was found hanging in his cell on 18 June 2026. The principal concern was that prison officers did not cut the ligature or commence CPR for nearly three minutes, and that most prison officers do not receive mandatory refresher training in basic life support after their initial training.
Ministry of JusticePrison, Probation and Reducing Reoffending
