Reports

Nathan Thomas CYSTER · Prevention of Future Deaths report View report

2 Feb 2026 Staffordshire and Stoke-on-Trent D. Howe

Nathan Thomas Cyster died at the scene on 29 March 2025 after his motorcycle collided with a BMW X5 on the A5 Watling Street. The report identifies concerns about the hazardous right-turn layout at the Moss Farm Shop exit, the absence of left-turn-only signage, ineffective road markings against prohibited overtaking, and ambiguity in legal guidance about right turns across double white lines.

Simon Moss · Prevention of Future Deaths report View report

1 Feb 2026 Inner South London X. Mooyaart

Simon Moss was discovered on the roof of his family home on 14 February 2024 after recently developing paranoid thinking, becoming extremely anxious and appearing to be considering suicide. After ambulance attendance and a mental health assessment that did not use detailed information in the ambulance record or contact his wife for collateral information, he was discharged and deliberately fell from a nearby building to his death later that day. The concern was that gaps in training, practice, policy or procedures could result in important risk information and family contact details not being used, undermining the assessment and mitigation of risk to patients presenting with potential risk to self.

Pamela George · Prevention of Future Deaths report View report

30 Jan 2026 Devon, Plymouth and Torbay D. Archer

Pamela George, aged 70, died at Derriford Hospital on 30 June 2023 after being urgently admitted with suspected sepsis. The report identified missed opportunities to carry out required blood tests, manage a breast infection, document and escalate a fall and medical concerns, assess and record capacity, and maintain relevant care-home policies and records.

Antonio Galisi-Swallow · Prevention of Future Deaths report View report

29 Jan 2026 West Yorkshire Eastern O. Longstaff

Antonio Galisi-Swallow died in hospital on 7 October 2021 after developing Propofol-Related Infusion Syndrome following continuous propofol sedation after cardiac surgery. The inquest heard that there was no national guidance for short-term propofol sedation in children and young people on PICUs, and an expert witness supported a guideline subsequently developed by Leeds Teaching Hospitals Trust.

Akhona MOYO · Prevention of Future Deaths report View report

28 Jan 2026 Northamptonshire H. Shah

Akhona Moyo, aged 4, died on 26 November 2022 at Queens Medical Centre, Nottingham, from a brain tumour. The principal concern was that hospital doctors lacked electronic access to detailed primary care records, which the evidence indicated would assist in delivering better treatment and care, particularly for patients who are autistic and non-verbal.

Nigel Anthony FECKEY · Prevention of Future Deaths report View report

28 Jan 2026 Leicester City and South Leicestershire D. Hocking

Nigel Anthony Feckey was found suspended by a ligature in his prison cell at HMP Fosse Way on 23 September 2024 and was declared deceased at the scene. The inquest concluded suicide, with concerns including bullying and abuse of prisoners convicted of sexual offences, offence-neutral prison arrangements, staffing pressures, weaknesses in information-sharing and ACCT processes, and failures to respond adequately to reported concerns and risks.

Mrs Patricia Irene Walker · Prevention of Future Deaths report View report

28 Jan 2026 East Riding and Hull S. Robinson

Patricia Irene Walker suffered a fractured neck of femur after a fall, followed by further falls in hospital, including a fall that resulted in an acute bilateral subdural haematoma. She was later discharged to a care home on a fast-track basis and died after poor nutritional intake, medication refusal and worsening confusion; the report raised concerns about suboptimal staffing on Ward 90 and increased falls risk.

Haaris Amin BHATTI · Prevention of Future Deaths report View report

27 Jan 2026 Inner North London M. Hassell

Haaris Amin BHATTI took drugs before entering Fold Nightclub and took more drugs while inside. He became seriously unwell, but nightclub staff delayed calling an ambulance; the report states that this delay decreased his chance of survival and reflected the club’s training and culture.

Pippa Isobel Waller GILLIBRAND · Prevention of Future Deaths report View report

27 Jan 2026 Cheshire V. Davies

Pippa Isobel Waller Gillibrand was delivered by forceps in poor condition after a home birth was continued despite staffing, equipment and fetal heart-rate monitoring issues, and she later died in hospital from a severe irreversible brain injury. The report identified concerns about the lack of guidance on home-birth staffing, midwife competence, transfer thresholds, equipment, supervision, electronic-recording failures and information for parents, as well as the absence of national or local home-birth outcome data.

Lucy Ann THORNTON · Prevention of Future Deaths report View report

27 Jan 2026 Hampshire, Portsmouth and Southampton J. Pegg

Lucy Ann THORNTON died on 18 February 2025 after suspending herself; the time of death and whether there was a missed opportunity to prevent this could not be ascertained. The report raises concerns about call handlers’ training and understanding of procedures for incidents involving hanging, including response categorisation and failure to telephone THORNTON for further information.

Jean GROVES · Prevention of Future Deaths report View report

23 Jan 2026 Norfolk J. Thompson

Jean Groves, who had a complex health background, became unwell with diarrhoea and vomiting and was later found deceased at home on 24 March 2025 from excessive bleeding related to her underlying health condition. The concern was that emergency responders may not receive access details for vulnerable patients when supporting the ambulance service under the NHS “Access to the Stack” initiative, potentially leading to future deaths.

Roger Gary Leadbeater · Prevention of Future Deaths report View report

23 Jan 2026 South Yorkshire (Western) T. Rawden

Roger Gary Leadbeater died on 9 August 2023 from multiple stab wounds inflicted by a patient detained under the Mental Health Act who had absconded from escorted leave. The report identified concerns about inadequate and poorly recorded handovers between police forces and the mental health trust, which meant significant risk information was not clearly communicated and may have affected decisions to grant leave. It also noted that, as of January 2026, relevant policies and auditing arrangements had not been updated to support the use of new handover forms.

Tamara Jade Logan · Prevention of Future Deaths report View report

22 Jan 2026 Manchester South A. Mutch

Tamara Jade Logan had a history of self-harm and suicidal ideation. After her enhanced daily living allowance was incorrectly withdrawn and she received a standard letter about the decision, her mental health deteriorated; she was found suspended on 18 May 2025 and died in hospital on 20 May 2025. The substantive concerns were the incorrect benefits assessment and the failure to adapt communication to her known vulnerabilities.

Clive Mark Hyman · Prevention of Future Deaths report View report

22 Jan 2026 Inner North London S. Bourke

Clive Mark Hyman, who was taking apixaban, fell and hit his head on 1 August 2025 but did not seek medical advice because he felt well. He later developed a sudden severe headache, became unresponsive, and was found to have a subdural haemorrhage and extensive brain injury; he died in hospital on 10 August 2025. The concerns relate to guidance for people taking apixaban after head trauma, including the absence of clear advice in reviewed patient leaflets to seek medical attention after such an injury.

Sidra Aliabase · Prevention of Future Deaths report View report

21 Jan 2026 Inner West London F. Wilcox

Sidra Aliabase was born prematurely at Chelsea and Westminster Hospital and later died there aged 3 weeks after being wrongly prescribed sodium acid phosphate instead of sodium chloride at approximately five times the recommended neonatal dose. The report describes concerns about communication between paediatric cardiology and hospital teams, delayed planning and diagnosis for long QT syndrome, reliance on appropriate cardiology advice, and prescribing systems that may contribute to errors involving similarly named drugs.

George Lawrence RITCHIE · Prevention of Future Deaths report View report

21 Jan 2026 Worcestershire D. Reid

George Ritchie suffered an unwitnessed fall at The Meadows Nursing Home, sustaining a fractured hip that was surgically fixed; he later died on 29 April 2025 after further treatment for infections and continued decline. Concerns included inadequate falls-risk assessments and care plans, insufficient oversight, and concerningly low night-time staffing levels at The Meadows Nursing Home, with potential risks to residents at other homes operated by Cardinal Healthcare.

George Lawrence RITCHIE · Prevention of Future Deaths report View report

21 Jan 2026 Worcestershire D. Reid

George Ritchie suffered an unwitnessed fall at The Meadows Nursing Home, sustaining a fractured hip that was surgically fixed; he later died on 29 April 2025 after further treatment for infections and continued decline. Concerns included inadequate falls-risk assessments and care plans, insufficient oversight, and concerningly low night-time staffing levels at The Meadows Nursing Home, with potential risks to residents at other homes operated by Cardinal Healthcare.

Mrs Dhananji Denawawake Dona · Prevention of Future Deaths report View report

21 Jan 2026 Staffordshire and Stoke-on-Trent E. Serrano

Mrs Dhananji Denawawake Dona attended hospital while pregnant, experiencing bleeding, abdominal pain, sepsis and a miscarriage. There was a delay in her assessment, and the sepsis screening tool and specialist National Early Warning Score matrix for prenatal women were not used in the A&E department. She deteriorated and died on 2 October 2024; the principal concern was that the specialist warning-score matrix was not used throughout the hospital and there were no plans to introduce it within a reasonable timescale.

Dennis Keith Price · Prevention of Future Deaths report View report

20 Jan 2026 South Yorkshire (Eastern) N. Mundy

Dennis Keith Price, a 71-year-old man, died on 28 October 2024 after falling while making his way unescorted to the toilet during a hospital admission. He suffered a subdural haemorrhage after the fall, and concerns included incomplete post-fall review, unclear neurological-observation instructions, and delays or failures in responding to Nerve Centre alerts.

Linda Fury · Prevention of Future Deaths report View report

20 Jan 2026 Manchester South C. Morris

Linda Fury, who had a long history of severe and enduring mental illness, died at home on 3 May 2025 after being discharged from hospital following the rescinding of her detention. The report identifies concerns about the discharge decision, including insufficient consideration of family information and the failure to trial home leave or provide step-down care. It also raises concerns about the insufficient rigour of the Trust’s investigation and ward-round processes not routinely allowing families to share risk concerns privately.