Reports

Jonathan Mark George Hamer · Prevention of Future Deaths report View report

10 Apr 2025 West London L. Brown

Jonathan Mark George Hamer, who had bipolar affective disorder and was receiving community mental health care, died by suicide on 24 April 2024 after going onto railway tracks in front of a train. Concerns included communication failures during care-coordinator absences, the lack of systems to redirect or action unanswered communications, and the failure to prioritise and regularly review his case.

Mr Joel Kenneth Ineson · Prevention of Future Deaths report View report

10 Apr 2025 Sunderland D. Place

Joel Kenneth Ineson died by drowning at Hetton Lyons County Park on 1 June 2023 after participating in an open water swimming event and suffering an unexpected cardiac event. The principal concerns were uncertainty about responsibility for safety measures, inadequate or absent safety briefings, lack of knowledge about participants and numbers in the water, and the absence of specific regulation, oversight and safety requirements for such events.

Robert Leighton SMITH · Prevention of Future Deaths report View report

10 Apr 2025 Manchester South A. Mutch

Robert Leighton Smith was found unresponsive at home on 25 October 2024 while prescribed high levels of painkillers; toxicology found above-therapeutic levels of his prescribed medication, and the inquest concluded accidental death. He had been assessed as likely to benefit from Interpersonal Psychotherapy but had not started it because of a significant waiting list, with average waits of 12 months attributed to demand exceeding commissioned capacity.

Ivy May DIXON · Prevention of Future Deaths report View report

9 Apr 2025 Inner North London I. Potter

Ivy Dixon choked on food while being fed by staff at Acorn Lodge Care Home on 6 October 2024, causing cardiac arrest. Staff did not perform CPR, and concerns were raised about inaccurate communication to paramedics, staff integrity, and possible training or clinical skills gaps in emergency care.

Bernard Lyon · Prevention of Future Deaths report View report

9 Apr 2025 Manchester South A. Mutch

Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.

Emma Jane Hill · Prevention of Future Deaths report View report

9 Apr 2025 North Wales (East and Central) J. Gittins

Emma Jane Hill was a pillion passenger on a motorcycle that collided with a motor vehicle at a junction on the A534, and she sustained fatal injuries. Concerns were raised that obstructed visibility, vehicles travelling at speed, the road layout and previous collisions in the area created an ongoing risk of further collisions and loss of life.

Ruth Ann PINGREE · Prevention of Future Deaths report View report

8 Apr 2025 Suffolk D. Stewart

Ruth Ann Pingree died after an accidental fire engulfed the caravan in which she was holidaying with her family. The caravan door became jammed, the smoke detector did not activate, and she was unable to escape before being overcome by fire fumes. The report raised concerns about a lack of clear standards for fire safety measures, risk assessments, and assurance and enforcement for businesses providing paid accommodation.

Christopher McDonald · Prevention of Future Deaths report View report

7 Apr 2025 South London S. Reeves

Christopher McDonald, who had been detained under section 3 of the Mental Health Act and was receiving care at Bethlem Royal Hospital, died by strangulation by a ligature he had applied around his neck. Concerns included shortcomings in the individualised assessment and management of his leave after he went AWOL, failure to follow the AWOL policy, inadequate review of observation levels, and avoidable delay in identifying the ligature and communicating his relevant medical history to ambulance staff.

Sandra Ann MILLARD · Prevention of Future Deaths report View report

7 Apr 2025 Berkshire R. Simpson

Sandra Ann Millard called 111 on 19 May 2024 because she was unable to move from her chair. A clinician could not reach her by telephone, no ambulance was dispatched, and she was found deceased by a neighbour the following day; the cause of death was recorded as sepsis from infected leg ulcers, with ischaemic heart disease, coronary artery atheroma and chronic kidney disease also noted. The concern was that additional enquiries and support arrangements used for people lying on the floor were not applied to people unable to move from other positions, such as a chair.

Christian James Gabriel Hobbs · Prevention of Future Deaths report View report

7 Apr 2025 Cambridgeshire and Peterborough D. Heming

Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.

June Thompson · Prevention of Future Deaths report View report

6 Apr 2025 Cornwall and Isles of Scilly G. Davies

June Thompson died on 1 November 2023 from radiation-induced metastatic sarcoma following radiotherapy for cervical cancer. She underwent a hindquarter amputation after a CT scan showed that the cancer had spread to her lungs, but the surgical team and multidisciplinary team were not informed of the change from a potentially curative to a palliative condition. Concerns included proceeding with major operations without full knowledge of disease progression, failure to report and investigate the error, and the absence of policy or guidance for processing medical reports received from other hospitals.

Mr YZ · Prevention of Future Deaths report View report

4 Apr 2025 Berkshire H. Godfrey

Mr YZ died at home on 2 March 2024 from extensive blood loss following a traumatic open fracture of the right ankle. He activated his emergency careline but did not receive medical assistance after the operator treated the brief call as accidental. The principal concern was that careline procedures and questioning may fail to identify serious injury in users with impairments similar to those associated with Huntington’s Disease.

Hailey Anne Thompson · Prevention of Future Deaths report View report

4 Apr 2025 Manchester West M. Pemberton

Hailey Anne Thompson was found unresponsive at home on 19 December 2022 and died after unsuccessful resuscitation. Her death was attributed to sepsis and pneumonia arising from a Streptococcus A infection. The principal concerns were unclear pathways and guidance for care navigators handling reports of allergic reactions to medication, including referral to an appropriately competent clinician and recording an auditable trail.

Mr Alexi Susiluoto · Prevention of Future Deaths report View report

4 Apr 2025 Inner North London R. Brittain

Mr Alexi Susiluoto, who had a history of mental health disorders, substance misuse and epilepsy, was found deceased in a hotel room on 22 May 2024. His death was attributed to alcohol misuse disorder resulting in acute ethanol toxicity, with epilepsy and prescribed medication as contributing factors. The report raised concerns about fragmented care for people with dual diagnoses who are homeless, including confusion over which services and local authority were responsible for care and funding.

Jacqueline GREEN · Prevention of Future Deaths report View report

4 Apr 2025 Bedfordshire and Luton E. Whitting

Jacqueline GREEN was admitted to Bedford Hospital after a fall and was found to be very weak, frail, cachectic and dehydrated. She received paracetamol at a dose intended for patients weighing over 50 kg despite weighing 33.6 kg, subsequently developed paracetamol-induced liver injury and died from liver failure. The concerns included inadequate safeguards for prescribing paracetamol to low-weight adults, unexplained variation in the administration of doses, and incomplete implementation of relevant safety measures.

Linda Christine FARMER · Prevention of Future Deaths report View report

4 Apr 2025 Northamptonshire E. Wheeler

Linda Farmer died at Northampton General Hospital on 22 August 2023 from bronchopneumonia, with underlying medical conditions and poor nutritional status contributing. Concerns were raised about the low albumin levels during her previous admission, but these care concerns were not investigated despite a recommendation for a detailed investigation, leaving potential underlying system issues unresolved.

Andrew Waters · Prevention of Future Deaths report View report

3 Apr 2025 Cornwall and Isles of Scilly G. Davies

Andrew Waters died at Royal Cornwall Hospital on 24 May 2024 after experiencing symptoms of a heart attack and a delay in receiving an ambulance. He went into cardiac arrest shortly after arriving at hospital, and the inquest found that the ambulance delay, attributed to systemic failure across health and social care, possibly denied him potentially lifesaving treatment. The principal concerns were significant ambulance handover delays, emergency department crowding, and insufficient social care provision affecting patient flow.

Alexander Adnan Cardoza · Prevention of Future Deaths report View report

3 Apr 2025 City of London A. Hewitt

Alexander Adnan Cardoza, a 16-year-old child, died on 27 March 2025 after falling from a location in the City of London. The principal concerns were that barriers remained surmountable, could potentially be assisted by horizontal wiring and a movable object, and that operational security was insufficient to prevent the fall; there was also no CCTV security camera monitoring of the location. The report identifies an ongoing risk of further deaths, noting that two deaths had occurred in similar circumstances.

Loraine Michelle CHEESMAN · Prevention of Future Deaths report View report

3 Apr 2025 County Durham and Darlington C. Oliver

Loraine Michelle CHEESMAN died in Darlington on 13 May 2023 as a consequence of a fire at the property. Her Hoarding Disorder and Executive Dysfunction made a more than minimal contribution to the fire, and concerns were raised about the lack of specific guidance on incorporating Executive Dysfunction into mental-capacity assessments and determining when external intervention should be triggered.

James Paul Michael Masheter · Prevention of Future Deaths report View report

3 Apr 2025 Lancashire and Blackburn with Darwen K. Bisset

James Paul Michael Masheter died by hanging at his home on 1 April 2024, after experiencing a significant mental health crisis and making calls for ambulance assistance. The report raises concerns that existing NHS Pathways mental health triage may not properly risk-assess serious crises involving a risk to life, and that categorisation as category 3 contributed to significant delays in ambulance attendance. Incorrect information about the expected waiting time was also provided to his friend, who believed the ambulance was arriving imminently and left him.