Reports

Emma Irene TURNER · Prevention of Future Deaths report View report

25 Feb 2026 Derby and Derbyshire S. Kaushal

Emma Irene Turner died at home on 29 January 2023 after her airway became obstructed by vomit following her eating some cake. The report identified concerns about inadequate and untimely multi-agency processes, safeguarding referrals, face-to-face assessments and welfare checks, as well as poor information sharing between services. It also identified a risk that the safeguarding referral form used by GPs could omit key information and delay responses.

Patrick Griffin · Prevention of Future Deaths report View report

24 Feb 2026 Manchester South C. Morris

Patrick Griffin died on 17 August 2025 at the Stamford Unit, Tameside General Hospital, from bronchopneumonia against a background of Alzheimer’s disease. He had been admitted from residential care, where it was recognised that he needed support with dietary and fluid intake and full assistance with hygiene and personal care. On admission, he was dehydrated and had not opened his bowels for seven days; the inquest found that a number of his basic care needs had not been met.

Susan Elizabeth SAMSON · Prevention of Future Deaths report View report

23 Feb 2026 County Durham and Darlington R. Sutton

Susan Elizabeth SAMSON died on 7 May 2025 after falling down the stairs at her home, following discharge from a rehabilitation placement. The principal concern was that patients may be discharged before they can consistently use stairs without assistance, potentially resulting in a death.

Alan CRABTREE · Prevention of Future Deaths report View report

20 Feb 2026 Cheshire E. Wheeler

Alan Crabtree was prescribed methotrexate on 3 February 2025, developed rapid-onset pancytopenia, was admitted to hospital on 18 February, and died of pneumonia on 1 March 2025. The report identified concerns that the methotrexate dosing guidance was outdated and that its advice about which healthcare professional patients should contact for signs of toxicity was ambiguous, potentially delaying appropriate treatment.

Sean Perry WILLIAMS · Prevention of Future Deaths report View report

20 Feb 2026 Inner North London I. Potter

Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.

Rajwinder Singh · Prevention of Future Deaths report View report

19 Feb 2026 Inner West London B. Richmond

Rajwinder Singh was imprisoned after being sentenced at Southwark Crown Court and was identified as at risk of self-harm and suicide. He was transferred to St George’s Hospital after failures including unanswered cell bells and inadequate observations, and died there on 25th June 2026. The principal concerns included inadequate risk assessment and record keeping, failures in observations and handovers, and insufficient mandatory ACCT training for prison and agency healthcare staff.

Jacqueline JOSEPH · Prevention of Future Deaths report View report

19 Feb 2026 Bedfordshire and Luton B. Patel

Jacqueline JOSEPH, who had limited mobility and care and support needs, was found deceased on 15 June 2025 after sustaining flame and heat while seated in an armchair at home. The inquest evidence identified two incorrectly installed battery-operated smoke alarms at the housing association property.

Jane Ann FENWICK · Prevention of Future Deaths report View report

19 Feb 2026 Northamptonshire H. Shah

Jane Ann Fenwick died on 21 August 2025 at Kettering General Hospital after choking on a piece of beef at her care home. She had no teeth, did not wear dentures, tended to rush and overfill her mouth, preferred softer food, and had a care plan identifying a choking risk. The principal concerns were the threshold for Speech and Language Therapy intervention and support, and the waiting time for that support, despite her identified risks and lack of supervision while eating.

Martin Ormond · Prevention of Future Deaths report View report

18 Feb 2026 Blackpool and the Fylde A. Wilson

Martin Ormond died in hospital on 25 January 2025 after suffering an acute myocardial infarction. An ECG performed two days earlier led to reports indicating possible serious cardiac disease, but he was not advised to attend hospital and a cardiology referral was made instead. The concerns identified were that relevant ECG reports and amended information were not effectively communicated to the GP, and that the urgency of a later ECG was under-appreciated by ambulance personnel.

Edward James HANDS · Prevention of Future Deaths report View report

17 Feb 2026 Bedfordshire and Luton B. Patel

Edward James Hands, known as Eddie, died in his cell at HMP Bedford on 16 February 2024 after consuming methadone and developing aspiration pneumonitis. The inquest identified failures in follow-up care, monitoring, escalation, and the implementation of the Under the Influence protocol, with confusion between prison and healthcare staff about their responsibilities.

Benjamin WEBSDALE · Prevention of Future Deaths report View report

17 Feb 2026 West Sussex, Brighton and Hove P. Schofield

Benjamin Websdale, a serving police officer, died by suicide on 16 January 2025 while under investigation for alleged police misconduct. The report raised concerns about the lack of local or national recording of police suicides or suicide attempts during police misconduct investigations, and about inconsistent implementation of the STEP suicide trauma education and prevention campaign across police forces.

Geoffrey Gudgeon · Prevention of Future Deaths report View report

16 Feb 2026 Cornwall and Isles of Scilly A. Cox

Geoffrey Gudgeon suffered a spontaneous ischaemic stroke on 11 June 2024 and was admitted to West Cornwall Hospital the following morning. After difficulties securing appropriate stroke and rehabilitation beds, he was transferred between care settings before moving to Poldhu Nursing Home, where he died on 1 December 2024. The principal concern was a capacity issue in Cornwall affecting the timely admission and treatment of stroke patients.

Edward Richard Jones · Prevention of Future Deaths report View report

13 Feb 2026 West Yorkshire Eastern O. Longstaff

Edward Richard Jones died from invasive Group A Streptococcus sepsis after presenting to the Paediatric Emergency Department with abdominal and leg pain, diarrhoea, previous vomiting and dehydration. The substantive concerns included failure to repeat a venous blood gas showing raised lactate, non-use of the trust’s Sepsis Screening Tool, delayed recognition and treatment of sepsis, and delays associated with communication, staffing and bed pressures.

James Fitzpatrick · Prevention of Future Deaths report View report

12 Feb 2026 Dorset R. Griffin

James Fitzpatrick, an 89-year-old man with decompensated heart failure and respiratory illness, became unresponsive after coughing and was found with food material in his mouth; his death was confirmed on 14 February 2024. The principal concerns were the lack of written national and local guidance for care handovers, and the risk that incomplete or incorrect handover information could affect patient care and contribute to a future death.

Barry HARMER · Prevention of Future Deaths report View report

12 Feb 2026 Buckinghamshire C. Butler

Barry Harmer was found deceased at home on 11 April 2024 after sustaining a neck injury he had likely inflicted upon himself. He had been known to community mental health services, had agreed to voluntary psychiatric admission, and was awaiting a bed while remaining at home. Concerns included inadequate pursuit and communication regarding bed availability and home safety responsibilities, the absence of an earlier face-to-face psychiatric review, and shortcomings in the robustness and timely review of the investigation and learning process.

Rita Margaret Thomas and Christine Dale · Prevention of Future Deaths report View report

12 Feb 2026 Cumbria R. Cohen

On 19 September 2024, Rita Thomas was driving and Christine Dale was a passenger when their vehicle collided with a bus on the M6 Junction 37 exit ramp, causing both to sustain life-ending injuries. The principal concern was that the national speed limit on the A684, together with the junction design, may give drivers insufficient time to react when a vehicle crosses their path.

Chloe Angela Ulett · Prevention of Future Deaths report View report

11 Feb 2026 Birmingham and Solihull E. Brown

Chloe Angela Ulett died at Birmingham Heartlands Hospital on 28 September 2024 from a previously undiagnosed urea cycle disorder that had been unmasked by giving birth. She developed confusion and excessive drowsiness after childbirth, was initially diagnosed with iron deficiency and discharged, and ammonia testing was delayed until several days later. The principal concerns were that early ammonia testing was not routine, relevant guidance was unclear and not embedded in adult medicine, and there remained a national risk of delayed diagnosis.

Barbara Wingate · Prevention of Future Deaths report View report

10 Feb 2026 Kent and Medway C. Wood

Barbara Wingate, a 71-year-old woman, fell at home on 18 May 2025, sustained multiple pelvic fractures, suffered a cardiac arrest and died on 21 May 2025 following multiple organ failure. The inquest identified avoidable delays in diagnosing and treating her pelvic fractures. The report also raised concerns about emergency department capacity, delayed discharge of medically fit patients, and insufficient timely community care or alternative placements, creating risks for other critically ill patients.

Samuel John DICKINSON · Prevention of Future Deaths report View report

10 Feb 2026 Manchester West M. Pemberton

Samuel John DICKINSON, a 39-year-old farmer who held firearms and shotgun licences, was found on 15 September 2025 with a shotgun wound to the head in an outbuilding at the farm where he lived. The inquest concluded that his death was suicide, with the medical cause recorded as severe head injury. Concerns were raised about gaps in firearms legislation and General Practitioner recording and reporting obligations relating to licence holders’ illnesses or mental health conditions.

Liam Andrew SUTTON · Prevention of Future Deaths report View report

10 Feb 2026 Kent and Medway C. Wood

Liam Sutton became unconscious at home after discharge following a total knee replacement with increased opioid medication, and was subsequently treated for suspected opioid toxicity, pneumonia or sepsis, respiratory complications and acute kidney injury. After intensive care treatment involving ventilation and repeated extubation attempts, he suffered an unresuscitable cardiac arrest during reintubation and died. The principal concerns were prolonged occupancy of the emergency department resuscitation area and hospital bed-blocking linked to delays in discharge and access to appropriate community or care placements.