Reports

Mrs Ann Caldicott · Prevention of Future Deaths report View report

7 Jun 2025 North East Kent S. Clarke

Mrs Ann Caldicott had a long-standing history of weight loss, anaemia, declining renal function and frailty, and died in hospital on 21 February 2024 after a urinary catheter insertion caused a bladder perforation. The report identifies concerns that her malnutrition and declining frailty were not adequately investigated or treated, leaving her too physiologically frail for potentially lifesaving treatment. It also raises concerns that relevant internal investigations and reviews did not take place.

Frederick Ireland-Rose · Prevention of Future Deaths report View report

6 Jun 2025 Inner North London S. Bourke

Frederick Ireland-Rose, who had a history of opiate misuse and had been using cannabinoid vapes, was found unresponsive at home and later died in hospital after sustaining hypoxic-ischaemic brain injury. Toxicology identified the synthetic opioid N-pyrrolidino isotonitazene, and the inquest concluded that his death was drug related. The concerns were that nitazenes in vaping fluids are less well known, vaping exposure can vary substantially with a significant overdose risk, and cannabinoid vape users may be less likely to receive information about these risks or access to Naloxone.

Esme Vera Louise Atkinson · Prevention of Future Deaths report View report

6 Jun 2025 Manchester South A. Mutch

Esme Vera Louise Atkinson was born on 7 February 2024 and died at Stepping Hill Hospital on 17 March 2024 after suddenly stopping breathing. A post-mortem examination found a ventricular septal defect, and the report states that earlier identification would probably have prevented her death at that time. Concerns included missed opportunities to identify the defect, inadequate recognition of feeding and weight concerns, gaps in professional training and information sharing, and the absence of routine echocardiography and auditing of cardiac images in relevant circumstances.

Thomas William OLDCORN · Prevention of Future Deaths report View report

5 Jun 2025 Blackpool and the Fylde M. Taylor

Thomas William Oldcorn was admitted with cardiac symptoms, diagnosed with a non-ST elevation myocardial infarction, and later found to have severe left main stem coronary artery disease. He died of a cardiac arrest while awaiting cardiac MRI and coronary artery bypass surgery. The report raised concern that surgery waiting times exceeded the national seven-day target and that inadequate resources prevented the target from being met; it stated that the inability to perform surgery within the target contributed to his death.

Nicholas Alan Gray · Prevention of Future Deaths report View report

5 Jun 2025 Essex S. Hayes

Nicholas Alan Gray died at home on 24 July 2023 following an overdose of ████████ with the intention to end his life. Before his death, he had made attempts to harm himself and expressed suicidal intent, but was discharged without a psychiatric review or recommended mental health risk assessment. The Trust’s post-death monitoring record also contained inaccurate information and significant omissions about contacts with mental health services and known self-harm concerns.

Richard Mohamed Fekry Osman · Prevention of Future Deaths report View report

5 Jun 2025 Carmarthenshire and Pembrokeshire M. Layton

Richard Mohamed Fekry Osman was a passenger on flight MS804, which crashed into the Mediterranean Sea on 19 May 2016 after a fire broke out on the flight deck; there were no survivors. The inquest stated that the fire was caused by an ignition source of unknown origin, most likely associated with the first officer’s oxygen supply system. The substantive concerns included cockpit fire and smoke procedures, oxygen-system risks, fire-protection equipment and extinguishers, smoking regulations, and arrangements for participation in or transfer of aircraft accident investigations.

Edward Thomas WILSON · Prevention of Future Deaths report View report

5 Jun 2025 Cheshire J. Devonish

Edward Thomas Wilson was attended by paramedics at home and later transported to hospital after worsening breathing difficulties; he suffered cardiac arrests during transit. The principal concern was that paramedics did not take his significant heart failure into account when administering salbutamol nebulisers, which lowered his blood pressure.

Cain Alex River Donald · Prevention of Future Deaths report View report

5 Jun 2025 Oxfordshire N. Graham

Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.

Colin Charles BROOKS · Prevention of Future Deaths report View report

5 Jun 2025 Birmingham and Solihull S. Brenchley

Colin Charles Brooks underwent complex cardiac surgery on 7 May 2024 and developed a hypoxic ischaemic brain injury after blood flow to his brain was compromised during emergency surgery. He remained unresponsive and died in a neurology ward on 11 September 2024. The concern was that out-of-hours staffing and the lack of an additional on-site perfusionist contributed to delayed identification of the missing bridge clamp, creating a risk of similar future deaths.

David Thomas BENDELL · Prevention of Future Deaths report View report

5 Jun 2025 Suffolk N. Parsley

David Bendell fell while trying to use a commode at home after being discharged from hospital following a stroke, and later died in hospital from a large brain bleed. The report raises concern that rehabilitation options limited to specialist inpatient care or treatment at home may place people who cannot safely manage alone at risk when discharged home.

DAVID HEFFER · Prevention of Future Deaths report View report

4 Jun 2025 Essex S. Hayes

David Heffer died on 13 April 2024 from septicaemia due to acute peritonitis following duodenal and omental perforation after an ERCP performed for obstructive jaundice. He was discharged on the day of the procedure and readmitted the next day in severe pain with biliary sepsis and perforation. Concerns included failure to inform the treating doctor of the readmission and incomplete or illegible medical records.

DAVID CHIAKA EJIMOFOR · Prevention of Future Deaths report View report

4 Jun 2025 Swansea and Neath Port Talbot E. Ramsay

DAVID CHIAKA EJIMOFOR, aged 15, drowned after jumping into the sea from a breakwater at Aberavon on 19 June 2023. The principal concerns were the absence of lifeguards during higher-risk periods, despite their historical use to deter jumping, and the lack of evidence that alternative deterrence measures were effective.

Esther Jane Lancaster Byrne · Prevention of Future Deaths report View report

3 Jun 2025 County Durham and Darlington J. Richards

Esther Jane Lancaster Byrne, who had vascular dementia and was extremely frail, died at her care home on 18 December 2024 after deterioration following a fall, a neck of femur fracture, surgery and discharge back to the care home. Concerns included poor communication with the family and power-of-attorney holder, misunderstandings about her baseline and mobility affecting discharge planning, failure to arrange follow-up, and doubts about the quality and accuracy of outsourced radiological reporting.

Mark Anthony VILLERS · Prevention of Future Deaths report View report

3 Jun 2025 Birmingham and Solihull L. Hunt

Mark Anthony Villers attended hospital with severe chest pain and was later found collapsed and unable to be resuscitated after returning to hospital. A post-mortem examination confirmed death from dissection of the ascending aorta. The report identified missed signs of aortic dissection and insufficient radiologist staffing to report CT scans as substantive concerns.

Benjamin Finch Arnold · Prevention of Future Deaths report View report

3 Jun 2025 West Yorkshire Eastern O. Longstaff

Benjamin Finch Arnold was born prematurely at Saint James’ University Hospital after his mother was redirected there because the intended delivery unit was closed due to lack of capacity. He developed breathing difficulties during a LISA procedure, suffered bilateral pneumothoraces and a subsequent right-sided tension pneumothorax, and died after a devastating brain injury caused by prolonged low oxygen levels. The concerns included the organisation and classification of maternity services, the lack of standardised guidance for LISA procedures and newborn cardiac arrest, and updates to the hospital risk register.

Brian GARRICK · Prevention of Future Deaths report View report

3 Jun 2025 Devon, Plymouth and Torbay S. Covell

Brian Garrick experienced severe chest pain on 10 August 2022 and was taken to hospital after a substantial ambulance response delay. He suffered a cardiac arrest during a procedure and was pronounced deceased at 1145. The principal concern was that severe delays in patient handovers at acute hospitals were affecting ambulance response times and timely treatment for acute illnesses.

Pellumb Olaj · Prevention of Future Deaths report View report

3 Jun 2025 Inner North London M. Hassell

Pellumb Olaj, who had paranoid schizophrenia and a history of suicide attempts including attempts to jump from a high window, jumped from the sixth-floor balcony outside his flat on 30 October 2024 and was killed instantly. The principal concern was that Islington Council failed to take this history into account when housing him in a sixth-floor property in 2020, and it was unclear whether the council had mapped how to address this for new and existing tenants.

Anthony Haydn WOOD · Prevention of Future Deaths report View report

3 Jun 2025 South London J. Taylor

Anthony Haydn WOOD was admitted to St. Helier Hospital and fell from his bed while being prepared to be washed and changed on 22 September 2024. He sustained intracranial injuries and died in hospital on 26 September 2024; concerns included the absence of crash mats, the bed-rail being lowered, and the patient being attended by one staff member despite identified fall risk and a need for two staff members.

Patrick Anthony MONGAN · Prevention of Future Deaths report View report

2 Jun 2025 South Yorkshire (Eastern) N. Mundy

Patrick Anthony MONGAN, an 18-year-old male, died after a road traffic collision on the M18 on 7 September 2024. The vehicle struck a mound of earth on the central reservation, became airborne, and Patrick was ejected; he was pronounced dead at 03:10 hours. The concern identified was that the mound remained a hazard capable of causing vehicles to lose control and putting road users at risk of death.

Charlotte Louise WERNER · Prevention of Future Deaths report View report

2 Jun 2025 Inner North London M. Hassell

Charlotte Louise Werner, aged 13, hanged herself at home and the inquest determined that she died by suicide. Her mother believed Charlotte was suffering from an eating disorder and that the referral to a UCLH dietitian was partly to explore this, but Charlotte had not been diagnosed with an eating disorder and the referral was solely to consider whether her nutritional status affected her height.