Reports

Joshua Lee Allcock · Prevention of Future Deaths report View report

7 Jan 2026 Black Country Z. Siddique

Joshua Lee Allcock, a five-year-old boy with complex medical needs and a limited diet, developed severe dehydration after entering foster care and died on 3 January 2023 despite hospital treatment. Concerns included the lack of a formal autism diagnosis and related dietary support, variation in autism assessment practice, and the potential for the capillary refill time test to provide misleading reassurance when assessing dehydration in children with similar circumstances.

Robert Shaun GRACEY · Prevention of Future Deaths report View report

6 Jan 2026 Greater Lincolnshire P. Smith

Robert Shaun Gracey died in hospital on 29 September 2021 after police restraint and transportation following behaviour associated with cocaine use. The jury found that the effects of cocaine, restraint and struggle against restraint contributed to his death. Concerns included the absence of a Lincolnshire protocol for treating suspected excited delirium as a medical emergency, inadequate police training and monitoring, and delays or shortcomings in medical response and de-escalation.

Theo Gordon Tuikubulau · Prevention of Future Deaths report View report

6 Jan 2026 Devon, Plymouth and Torbay L. Wiltshire

Theo Gordon Tuikubulau, a three-year-old boy, died on 8 July 2022 from sepsis arising from an invasive Group A streptococcal infection. The report identified variation between the MPDS and NHS Pathways triage systems in assessing respiratory distress and cyanosis in children under five, resulting in different ambulance response categories for similar symptoms. The report stated that this two-tiered system continued to exist while work to review and align the systems had not yet occurred.

Adam Ali Hussain · Prevention of Future Deaths report View report

6 Jan 2026 Nottinghamshire E. Didcock

Adam Ali Hussain died on 16 May 2025 at Queens Medical Centre, Nottingham, from complicated appendicitis with perforation, peritonitis, severe intra-abdominal sepsis and multiple organ failure. The report identifies missed opportunities to recognise worsening illness and sepsis and to arrange face-to-face assessment, particularly on 14 May 2025. Concerns include unreliable handling and transfer of clinical information, unclear Category 3 ambulance-call criteria, and inadequate communication with families.

Mohammed Ashraful Islam CHOUDHURY · Prevention of Future Deaths report View report

6 Jan 2026 Bedfordshire and Luton E. Whitting

Mohammed Ashraful Islam CHOUDHURY, aged 26, died at hospital on 11 January 2023 after being attacked and stabbed by another resident at his supported accommodation. The concerns included inadequate management of the other resident’s known risks, lack of a multidisciplinary plan after he stopped taking medication, and withdrawal of medication support without checking with his GP that prescriptions were being obtained.

Suzanne Pemberton · Prevention of Future Deaths report View report

5 Jan 2026 Essex S. Horstead

Suzanne Pemberton died at Colchester General Hospital on 16 September 2024 from pneumonia and sepsis arising from an exacerbation of long-standing bronchiectasis, against a background of severe depressive disorder, malnutrition and chronic frailty. The report identified that she had not received a full in-person dietetic assessment before her death despite repeated referrals, and raised concern that the hospital had no specialist dietetic service or cover outside weekday working hours, creating a risk of avoidable future deaths.

Jake Kieran Hartwright · Prevention of Future Deaths report View report

5 Jan 2026 Nottinghamshire E. Didcock

Jake Kieran Hartwright developed severe illness associated with bowel ischaemia and had a cardiac arrest at home on 16 January 2025. He died at Queens Medical Centre in the early hours of 17 January 2025 from multiple organ failure secondary to extensive bowel ischaemia. The report identified serious issues in the urgent care pathway, including missed opportunities to arrange a Category 2 ambulance and problems with clinical information transfer and management of Category 3 calls.

Brian Mitchell · Prevention of Future Deaths report View report

29 Dec 2025 East London G. Irvine

Brian Mitchell, aged 72, was struck by multiple trains after falling onto the tracks at platform 13 at Stratford Underground Station on 26 December 2023. The report identifies concerns that train operators failed to notice him or override automatic train operation, and that technological measures and training intended to mitigate similar risks had not been clearly implemented or shown to improve performance.

Fallon Leanne ADAMS · Prevention of Future Deaths report View report

29 Dec 2025 Cambridgeshire and Peterborough S. Milburn

Fallon Leanne Adams was found unresponsive and cold in her cell at HMP Peterborough on 9 February 2023 and was declared deceased after CPR and a negative heart trace. The inquest concluded that she died from intoxication by mixed drugs, with illicitly obtained medication having a high probability of causing her death. Concerns included the combined sedative effects of prescribed and non-prescribed medication, a lack of specific warnings about over-sedation and death, and inadequate welfare checks and observations.

Mohamed Abdisamad · Prevention of Future Deaths report View report

28 Dec 2025 West London A. van Dellen

Mohamed Abdisamad underwent a non-therapeutic male circumcision on 12 February 2023 and developed symptoms of illness three to four days later. He suffered a cardiorespiratory arrest while being taken to hospital and was declared dead on 19 February 2023; the inquest recorded invasive Streptococcus pyogenes infection following male circumcision as the medical cause of death. The report raised concerns about the lack of training, accreditation, record keeping, consent, infection-control requirements and aftercare requirements for individuals conducting such procedures.

Alan Richard BAKER · Prevention of Future Deaths report View report

24 Dec 2025 Norfolk J. Thompson

Alan Richard BAKER died on 25 August 2024 after a reversing LGV ran over his motorcycle on Muck Lane, causing catastrophic injuries. The concerns were that LGVs are not required to have reversing cameras and that there is no mandatory requirement for owners to ensure fitted cameras are fully functioning.

Colin Richard BROWN · Prevention of Future Deaths report View report

23 Dec 2025 North Yorkshire and York G. Kane

Colin Richard Brown attended York Hospital Emergency Department on 28 March 2025 and choked on food provided by the hospital, leading to a cardiac arrest and transfer to intensive care. He died on 31 March 2025. The concerns were that his care plan was not transported to hospital and that information about his choking risk might not be reliably communicated or checked during the handover period.

Winifred Mary Wardle · Prevention of Future Deaths report View report

22 Dec 2025 Manchester South A. Farrow

Winifred Mary Wardle was admitted to hospital with vomiting and an undiagnosed intestinal problem; an incarcerated hernia was identified by CT scan after delays in obtaining the scan. She underwent surgery, aspirated stomach contents immediately beforehand, developed pneumonia, and died after active treatment was withdrawn. The substantive concerns related to the lack of a clear multidisciplinary protocol for CT scan requests, radiology decision-making and escalation processes, and incomplete records of those decisions.

Wendy Siobhan EYLES · Prevention of Future Deaths report View report

22 Dec 2025 Northamptonshire H. Shah

Wendy Siobhan Eyles died aged 55 on 31 October 2024 after being struck by a train at Kettering Station; the inquest concluded that appropriate mental health support and intervention had not been provided. Concerns included the absence of a protocol for patients receiving both private and NHS psychiatric care, risks from poor communication about medication changes, and possible lack of NHS awareness of private psychiatric treatment.

Elaine Jean GRIFFITHS · Prevention of Future Deaths report View report

22 Dec 2025 Northamptonshire H. Shah

Elaine Jean Griffiths died at Northampton General Hospital on 7 October 2022 from COVID pneumonitis, with congestive cardiac failure and a fall resulting in a fractured neck of femur also recorded. Concerns included incomplete fluid and diet charts, uncertainty about her gluten and dairy intolerance, limited suitable food options, and family-provided food not being recorded; the report states these matters were not causative of death in this case.

Wendy Siobhan EYLES · Prevention of Future Deaths report View report

22 Dec 2025 Northamptonshire H. Shah

Wendy Siobhan Eyles died on 31 October 2024 after being struck by a train at Kettering Station having climbed down from the platform. The report identified concerns about the lack of a protocol for patients receiving both private and NHS psychiatric care, including risks that medication changes and treatment arrangements may not be communicated between services.

Ramona Doreen Harbott · Prevention of Future Deaths report View report

19 Dec 2025 Surrey S. Ridge

Ramona Doreen Harbott was admitted to Windmill Manor Care Home with very limited mobility and a high risk of pressure sores. She developed serious sacral and heel pressure sores, and later died in hospital from sepsis having contracted pneumonia. Concerns included inadequate repositioning, skin monitoring, pressure sore treatment and record keeping, with improvements still ongoing and not yet completed and audited.

Jason Ricardo White · Prevention of Future Deaths report View report

19 Dec 2025 South Yorkshire (Eastern) N. Mundy

Jason Ricardo White died on 10 December 2024; the cause of death is redacted in the supplied text, and the inquest conclusion was suicide. The principal concerns were the abrupt cessation of olanzapine, failure to follow the planned daily monitoring, and the resulting risk of relapse and serious deterioration in mental health.

Shre Kumar CHATTERJEE · Prevention of Future Deaths report View report

18 Dec 2025 Hampshire, Portsmouth Southampton Rosamund Rhodes-Kemp

Shre Chatterjee developed a sudden severe headache in August 2023 and died at University Hospital Southampton on 12 October 2023 from an acute on chronic subdural haematoma. The report identifies repeated unsuccessful attempts to obtain timely face-to-face medical assessment, including missed opportunities to refer him for hospital assessment and a CT scan. It also raises concern that out-of-hours and 111 doctors could not directly book urgent appointments with some GP surgeries.

Edward Richard Jones · Prevention of Future Deaths report View report

18 Dec 2025 West Yorkshire Eastern O. Longstaff

Edward Richard Jones died in the Leeds General Infirmary from bacterial sepsis caused by invasive Group A Streptococcus. The inquest identified concerns including failure to respond adequately to a continuously high PAWS score, failure to repeat a venous blood gas showing raised lactate, and delay in administering antibiotics. The hospital trust’s Sepsis Screening Tool was not used, and staffing and bed shortages prolonged shared care in the Paediatric Emergency Department.