Reports

Roger Knight SMITH · Prevention of Future Deaths report View report

6 Feb 2026 Suffolk D. Stewart

Roger Knight SMITH, who had cerebral amyloid angiopathy and a history of strokes, was readmitted to West Suffolk Hospital in August 2023 and received tinzaparin for venous thromboembolism prophylaxis. He later suffered a cerebral haemorrhage and died on 12 September 2023; the inquest narrative attributed his death to the effects of a stroke brought about by tinzaparin administration. The principal concerns were failures in the electronic records system to flag relevant anticoagulation advice, inadequate communication with the patient and his family, and insufficient timely specialist stroke-team input.

Emmett Peter MORRISON · Prevention of Future Deaths report View report

6 Feb 2026 Worcestershire D. Reid

Emmett Peter Morrison, a serving prisoner at HMP Long Lartin, was found suspended by a ligature in his cell on 13 October 2024 and died from his injuries at hospital on 16 October 2024. The report raised concerns about the continued influx of illicit drugs into the prison and failures to record support actions in ACCT care plans and arrange a further ACCT review sooner.

Sam Alexander Dudley · Prevention of Future Deaths report View report

5 Feb 2026 Sefton, St Helens and Knowsley A. Bhardwaj

Sam Alexander Dudley, aged 29, died after being struck by a train at Hoggs Hill Level Crossing on 24 August 2025 while wearing headphones and entering the crossing when a red light was displayed and a klaxon was sounding. The principal concern was limited signage on the gate before the decision point, particularly as increasing numbers of people wear earphones; clearer pictorial signage warning against earphone use was suggested as potentially helpful.

Mia Maisie Lucas · Prevention of Future Deaths report View report

5 Feb 2026 South Yorkshire (Western) T. Rawden

Mia Maisie Lucas, aged 12, was admitted to hospital after experiencing hallucinations, extreme changes in behaviour and suicidal thoughts. She was later found unresponsive with a bedsheet around her neck and died on 30 January 2024. The inquest identified autoimmune encephalitis and acute psychosis, and raised concerns about the absence of national guidance for recognising and diagnosing autoimmune encephalitis and the failure to undertake a lumbar puncture, which possibly contributed to her death.

Della Bridget CALVEY · Prevention of Future Deaths report View report

5 Feb 2026 Gwent C. Saunders

Della Bridget Calvey developed a urinary tract infection, deteriorated with confusion, dehydration and a raised NEWS score, and died at home from overwhelming sepsis caused by the infection. The inquest found that she should have been admitted to hospital but could not determine that admission would have prevented her death. The principal concern was the downgrading of NEWS scores for patients with COPD when baseline oxygen saturations were unknown, and the need for more robust clinical assessments.

Angela Frances Darlow · Prevention of Future Deaths report View report

5 Feb 2026 North Wales (East and Central) K. Robertson

Angela Frances Darlow suffered a stroke at home on 6 January 2025, but an ambulance arrived 23 hours and 20 minutes later. She was diagnosed with an extensive left middle cerebral artery infarct, was not suitable for thrombectomy because of the delay, and died in hospital on 7 June 2025. The principal concern was the prolonged ambulance delay, in the context of high demand, hospital handover delays, patient flow and limited social care provision, resulting in lost opportunities for investigation and potential treatment.

Kallum Josh REED · Prevention of Future Deaths report View report

5 Feb 2026 West London L. Brown

Kallum Josh REED died after being found fully suspended during a police search following his disappearance on 11 February 2025. The report raises concerns about delays in autism spectrum disorder and ADHD referrals, assessments and diagnoses, and about crisis-care referral pathways and coordination between mental health services.

His Honour Bruce Caulfield · Prevention of Future Deaths report View report

5 Feb 2026 Manchester South C. Morris

His Honour Bruce Caulfield died at Trafford General Hospital on 19 August 2025 from complications arising from coronary artery disease, against a background including an acute on chronic subdural haematoma requiring surgery, hypertension and frailty. Concerns included the delay between a family member requesting medical review and the review taking place, whether nursing practices ensured vulnerable patients received adequate hydration and nutrition, and whether measures relating to communication about sitting-out recommendations were in place across the Trust.

Lauren Rae MORET-DELL · Prevention of Future Deaths report View report

4 Feb 2026 Suffolk D. Stewart

Lauren Rae Moret-Dell developed neurological symptoms, later suffered bilateral embolic strokes, and died on 10 January 2024. Concerns were raised about failures to make timely referrals to the TIA Clinic and about the lack of commissioned stroke consultant input at West Suffolk Hospital out of hours, both of which were considered to give rise to a risk of death.

Ryan Harding · Prevention of Future Deaths report View report

4 Feb 2026 South Wales Central D. Regan

Ryan Harding died overnight between 7 and 8 January 2023 in his prison cell after consuming drugs. Concerns included prison infrastructure and gatehouse security measures that required upgrading to reduce illicit materials entering the prison, and a delayed morning welfare check due to insufficient staffing.

Joan Marilyn READ · Prevention of Future Deaths report View report

4 Feb 2026 South Wales Central R. Knight

Joan Marilyn Read, aged 91, died at the University Hospital of Wales on 18 March 2025 after a period of deterioration and decline. A severely deranged B12 result was not communicated or treated following her 2023 admission, and the report states that failure to address the deficiency more than minimally contributed to her death. The principal concern was the absence of year-round cross-cover for the single consultant responsible for geriatric perioperative care, creating a risk that urgent results could be missed during absences.

Oliver Marc Robinson · Prevention of Future Deaths report View report

4 Feb 2026 Manchester North C. McKenna

Oliver Robinson was 34 when his body was discovered at home on 24 November 2023. The Court found that he died by self-ligature tied during acute emotional dysregulation, in the context of multiple psychosocial stressors and cannabis dependence. The principal concerns were that Cureleaf prescribed medicinal cannabis despite incomplete information, insufficient relevant psychiatric expertise and treatment options not being exhausted, failed to liaise with treating psychiatrists, and that continued prescriptions obstructed appropriate psychiatric and addictions care.

Georgia Charlotte SCARFF · Prevention of Future Deaths report View report

4 Feb 2026 Suffolk D. Stewart

Georgia Charlotte SCARFF, aged 16, died immediately on 15 April 2024 after stepping into the path of a lorry on the A14 near Bury St Edmunds; the inquest concluded that she had been experiencing anxiety and acted impulsively in taking her own life. Concerns were raised that staff were not always proficient in using CPOMS, resulting in important safeguarding information not being recorded, and that the absence of a single standard safeguarding information management tool could create risks to life.

Ellame FORD-DUNN · Prevention of Future Deaths report View report

3 Feb 2026 West Sussex, Brighton and Hove J. Andrews

Ellame FORD-DUNN, aged 16, was detained on an acute paediatric ward because no Tier 4 Paediatric Mental Health bed was available. She absconded from the ward during a toilet visit and died following her absconding. The principal concerns included insufficient Tier 4 beds, inadequate security and risk management, inconsistent handovers and unclear procedures for responding to absconsion, and poor coordination between agencies.

Lyn Maher · Prevention of Future Deaths report View report

3 Feb 2026 South Wales Central R. Knight

Lyn Maher, aged 79, was prescribed clarithromycin while taking simvastatin and was not advised to stop the statin. She was admitted to hospital, where the contraindicated co-ingestion was not identified, the statin continued, and rhabdomyolysis was missed; she died following cardiac arrest due to hyperkalaemia on 23 January 2024. The concerns included confusion among community pharmacists about clinical checks and confidentiality, and their limited access in Wales to relevant drug history and test results.

Scott Darren TAYLOR · Prevention of Future Deaths report View report

2 Feb 2026 Essex S. Hayes

Scott Darren Taylor died at Basildon Hospital on 13 August 2022 following multiorgan failure and rhabdomyolysis associated with cocaine use, physical exertion, prone restraint and Neuroleptic Malignant Syndrome. The report raised concerns about inconsistent ambulance response categorisation for acute behavioural disturbance with active restraint, terminology and training, police training, and the removal of restraints during conveyance.

Avery Jake Hall · Prevention of Future Deaths report View report

2 Feb 2026 Sunderland D. Place

Avery Jake Hall died at Sunderland Royal Hospital on 13 November 2024, aged four days, after developing global hypoxia and diffuse alveolar damage following his birth. The report was concerned that his mother continued taking Candesartan during pregnancy because she was not given clear and definitive advice to stop it, and that the medication remained available on repeat prescription without warnings identifying her pregnancy.

David ROOMES · Prevention of Future Deaths report View report

2 Feb 2026 Kent and Medway I. Potter

David ROOMES, who had bipolar affective disorder and a relapse in depressive symptoms, was found deceased in the garage of his address on 14 April 2025, having suspended himself by ligature. The concerns included delays and shortcomings in referral triage, the absence of assessment by a qualified clinician, delays and missed opportunities for clinical review, and potential wider training issues for non-clinical decision makers.

Janet Sylvia Daniels · Prevention of Future Deaths report View report

2 Feb 2026 Essex S. Horstead

Janet Sylvia Daniels died at Colchester General Hospital on 6 October 2024 from pulmonary thromboembolism caused by sepsis arising from a Hickman Line infection, against a background of chronic kidney disease and congestive cardiac failure. The report identified failures to communicate the clinical basis for transitioning her to end-of-life care with her and her family, affecting decisions about withdrawing active treatment. It raised a risk that end-of-life care and withdrawal of treatment may be undertaken prematurely when patients and families are not appropriately consulted.

Heather Louise Parkhill · Prevention of Future Deaths report View report

2 Feb 2026 North Wales (East and Central) J. Gittens

Heather Louise Parkhill died at home on 8 April 2025 after more than fifteen hours had elapsed since the first 999 call for assistance. Multiple calls did not result in an ambulance response because of resource issues, and an earlier response was considered likely to have prevented the death. The principal concerns were persistent ambulance resource shortages and delays in emergency response, with the report stating that lives continued to be put at risk.