Reports

Shaun Michael Bass · Prevention of Future Deaths report View report

23 May 2025 Manchester West T. Brennand

Shaun Michael Bass, aged 23, was found collapsed and unresponsive at his residence on 23 February 2020 after ingesting a fatal quantity of sodium nitrate/nitrite. The report identified concerns about gaps in continuity of mental healthcare, a missed mental health assessment review, inadequate responses to family concerns, and the availability and online promotion of reportable poisons for self-harm.

Andrew Alexander Roger BROWN · Prevention of Future Deaths report View report

23 May 2025 Manchester West T. Brennand

Andrew Alexander Roger BROWN was found collapsed and unresponsive at his residence on 9 August 2023 and was pronounced dead after paramedics attended. The cause of death was toxicity from a self-administered poison, although his intentions remained unclear. Concerns included gaps in guidance for online sellers and the public regarding suspicious purchases and the potential use of the poison for suicide or self-harm, as well as access to websites providing information about obtaining and administering poisons.

Chantelle Williams · Prevention of Future Deaths report View report

23 May 2025 Manchester West T. Brennand

Chantelle Williams was found collapsed and unresponsive in her room on Keats Ward on 29 May 2020 and could not be resuscitated. Post-mortem analysis identified fatally toxic levels of two substances, likely from a batch she had previously sourced, retained and hidden. The report raises concerns about the online sale and regulation of reportable poisons, the failure to identify suspicious purchases for self-harm or suicide, and websites providing information about obtaining and using poisons to cause death.

Samuel David Dickenson · Prevention of Future Deaths report View report

23 May 2025 Manchester West T. Brennand

Samuel David Dickenson died after ingesting a substance acquired over the internet and was confirmed dead in hospital on 11 March 2020. The concerns relate to gaps in guidance and oversight of online sales of reportable poisons, including the failure to identify or address purchases intended for suicide or self-harm, and the availability of online information promoting access to poisons and methods of administration.

Lewis Dean JOHNSON · Prevention of Future Deaths report View report

23 May 2025 Inner North London M. Hassell

Lewis Johnson died aged 18 as a consequence of a road traffic collision while riding a motorcycle during a police pursuit in London on 9 February 2016. The inquest identified that the forensic collision investigation had not been instructed to measure the distance between the pursuing police vehicle and the motorcycle, leaving the jury without clear objective evidence on that issue.

Mathew Anthony Price · Prevention of Future Deaths report View report

23 May 2025 Manchester West T. Brennand

On 28 June 2021, Mathew Anthony Price was found collapsed and unresponsive at his residence after consuming a significant and fatally toxic quantity of a substance. The report identifies concerns about the sale and purchase of the substance, including inadequate guidance for sellers and the failure to recognise small-quantity purchases as potential self-harm risks. It also describes online access to information about poisons and methods of suicide.

Lewis Dean JOHNSON · Prevention of Future Deaths report View report

23 May 2025 Inner North London M. Hassell

Lewis Johnson, aged 18, died following a motorcycle road traffic collision at Clapton Common A107 in London on 9 February 2016, after a police pursuit. The jury concluded that the Metropolitan Police Service failed to effectively implement, disseminate and train relevant staff on relevant policies. The report also identified inconsistent expectations among police officers about how long police control authorisation decisions generally take during pursuits.

Kelly Michelle Walsh · Prevention of Future Deaths report View report

23 May 2025 Manchester West T. Brennand

Kelly Michelle Walsh was discovered dead at her residence on 27 February 2021 after ingesting a fatally toxic substance obtained from an internet-based supplier. The report raised concerns about insufficient guidance for online sellers and the failure to identify suspicious small-quantity purchases that may be intended for self-harm. It also identified online access to information about obtaining and using poisons to end life.

Robert Maxwell SMITH · Prevention of Future Deaths report View report

21 May 2025 South Wales Central A. Morse

Robert Maxwell Smith died by hanging on 26 October 2023, and the inquest concluded that his death was suicide. Concerns were raised that mental health services’ guidance and patient information about sharing and gathering information from family members lacked clarity and sufficient detail.

Etta-Lili Stockwell-Parry · Prevention of Future Deaths report View report

21 May 2025 North West Wales K. Robertson

Etta-Lili Stockwell-Parry was born in poor condition on 3 July 2023 and died four days later after transfer for specialist neonatal care. The report identified missed opportunities to recognise static growth and fetal distress, inadequate monitoring and incomplete records during labour, and concerns that the neonatal investigation and sharing of learning were insufficiently thorough and contextualised.

DAVID ARTHUR SHARP BATEMAN · Prevention of Future Deaths report View report

21 May 2025 Cornwall and Isles of Scilly G. Davies

David Arthur Sharp Bateman underwent elective surgery for high-risk cancerous colon polyps on 3 September 2023 and subsequently experienced complications, repeated admissions, deconditioning and cognitive impairment. He died from frailty syndrome on 22 July 2024. The principal concerns were poor nursing care, including inadequate nutritional support, weight monitoring and physiotherapy, and failures in personal and stoma care; the report states that these issues may have contributed to his death and that there was no evidence they had been addressed.

Malcolm Morris · Prevention of Future Deaths report View report

21 May 2025 Northumberland J. Thompson

Malcolm Morris developed lymphoedema after surgery for penile cancer and died on 5 January 2024 after collapsing with right-thigh pain. The report raises concerns about hospitals being unable to electronically refer patients living outside their usual catchment area to community nursing services, resulting in inadequate discharge information and delayed or absent support for wound and catheter care.

Marina Lorraine Waldron · Prevention of Future Deaths report View report

20 May 2025 Gwent C. Saunders

Marina Lorraine Waldron was admitted to hospital on 17 December 2023 with gastrointestinal bleeding caused by angiodysplasia and died on 15 February 2024 despite appropriate treatment. During her admission, her nutritional needs were poorly considered or managed, including failures to respond to family concerns, monitor dietary intake, act on a low albumin level, and consider dietary advice and parenteral feeding promptly. The medical staff who gave evidence agreed that malnutrition contributed to her death.

Mr Brown · Prevention of Future Deaths report View report

20 May 2025 Birmingham and Solihull L. Hunt

Mr Brown was found hanging at his home on 24 January 2024 and was confirmed deceased by police. The report identified concerns about the lack of post-death investigation and the absence of adequate welfare support and welfare-recording mechanisms for senior staff experiencing significant stress or disciplinary investigations.

Emily Rose STOKES · Prevention of Future Deaths report View report

19 May 2025 North East Kent C. Wood

Emily Stokes, a 17-year-old looked after child, became critically unwell after apparently taking MDMA at a music festival and died after suffering a cardiac arrest in hospital. Concerns included limited training of private ambulance staff in managing illicit substance use, unclear responsibility for pre-alerting the hospital, and ambulance equipment that was less comprehensive than that of an NHS ambulance.

Emmy Russo · Prevention of Future Deaths report View report

19 May 2025 Essex T. Wilson

Emmy Russo was born in very poor condition after a hypoxic injury shortly before birth and died following severe hypoxic-ischaemic brain injury. The report raised concerns about information given to patients considering induction beyond 41 weeks and about inconsistent escalation of concerns regarding labouring mothers and CTG traces for medical review. The inquest identified missed opportunities to deliver Emmy sooner.

John Charles Spencer · Prevention of Future Deaths report View report

19 May 2025 East Riding and Hull E. Steele

John Charles Spencer became unwell on 17 May 2024 and died on 21 May 2024 after a bowel perforation caused by obstruction within a recurrent right inguinal hernia, resulting in purulent peritonitis. The principal concern was that the GP out-of-hours surgery could not access his relevant GP medical history because different computer systems prevented the exchange of information, potentially affecting the examinations undertaken when patients do not report relevant history.

Joseph David POWELL · Prevention of Future Deaths report View report

17 May 2025 Cheshire S. Murphy

Joseph David POWELL, aged 28, was found suspended at his home on 6 September 2024 and did not respond to resuscitation. The principal concern was that requiring patients with mental health difficulties to book their own GP follow-up may result in missed reviews and no further medication.

Tina Louise DOIG · Prevention of Future Deaths report View report

16 May 2025 Birmingham and Solihull L. Hunt

Tina Louise Doig had myelodysplasia that progressed to acute myeloid leukaemia and underwent two stem cell transplants after the first failed. She developed sepsis, multiple organ failure and cardiac arrests, and died after becoming critically unwell. The report identified concern that an understaffed haematology department was working beyond capacity, and described failures in donor-recipient testing before the first transplant.

Patricia Heidi BUSHELL · Prevention of Future Deaths report View report

16 May 2025 Rutland and North Leicestershire L. Pinder

Patricia Heidi BUSHELL was a pillion passenger on a motorcycle that was struck by a car at a junction on 9 September 2023. She sustained fatal injuries and died in hospital the same day. The principal concern was that temporary signage regarded as compliant with national guidance was nevertheless inadequate to alert drivers to the junction, raising a potentially wider national issue about temporary signage regulations.