Reports

Mary Margaret Pomeroy · Prevention of Future Deaths report View report

1 Apr 2025 Devon, Plymouth and Torbay N. Lane

Mary Margaret Pomeroy, an 89-year-old hospital inpatient, died after being pushed to the floor by a fellow patient on 3 March 2022, suffering bilateral humeral fractures and deteriorating before her death on 15 March 2022. The inquest found that inadequate assessment and management of the fellow patient’s psychiatric, behavioural and cognitive needs materially contributed to the incident and death. It also identified inadequate analysis of the incident in the hospital’s internal investigation, including failure to identify relevant prior incidents and consider appropriate learning and recommendations.

Abu RAHMAN · Prevention of Future Deaths report View report

31 Mar 2025 Inner North London H. Lambert

Abu Rahman, aged 88, suffered a traumatic fall causing a fractured hip and underwent hemi-arthroplasty before deteriorating with pneumonia on a background of end stage renal failure. Concerns included delays in obtaining Naloxone when supplies ran out and limited awareness of opioid toxicity or accumulation in patients with kidney impairment or failure.

Andrew James Tizard-Varcoe · Prevention of Future Deaths report View report

31 Mar 2025 Devon, Plymouth and Torbay P. Spinney

Andrew James Tizard-Varcoe died at home on 11 May 2022 due to the progression of an ear infection, later described at inquest as complications of necrotising otitis externa. Concerns included fragmented care across three hospital trusts, difficulties accessing medical records and establishing responsibility, delayed outpatient follow-up, and discharge without oral antibiotics despite microbiology advice.

Derrick Frederick Tully · Prevention of Future Deaths report View report

28 Mar 2025 Inner North London M. Lee

Derrick Frederick Tully was found deceased at home on 20 March 2024 after suffering a massive traumatic subdural haemorrhage, following months of falls and declining health. Concerns included unsuitable temporary accommodation, the absence of a key safe despite repeated concerns, an inappropriate reablement care package, failures to record or escalate injuries after a fall, and the discharge of Derrick from a community team without adequately factoring in his cognitive, mental health and safety difficulties.

William David Patrick HEWES · Prevention of Future Deaths report View report

27 Mar 2025 Inner North London M. Hassell

William David Patrick HEWES was a fit and healthy young man who died from meningococcal septicaemia. Although his life-threatening condition was recognised immediately at hospital, he did not receive the necessary treatment as promptly as he should have, and the report identified a need to share the learning nationally.

Derek William COLE · Prevention of Future Deaths report View report

26 Mar 2025 Norfolk S. Goward

Derek Cole, who had metastatic prostate cancer, was found unresponsive at Dereham Hospital in the early hours of 16 June 2024 and was not resuscitated in accordance with his previously expressed wishes. The principal concerns were that an abnormally high PSA result was not promptly flagged to the Urology team and that the GP practice had not held a review or implemented learning nine months after his death, creating a risk of similar future events.

Oladeji Adeyemi Omishore · Prevention of Future Deaths report View report

25 Mar 2025 Inner West London F. Wilcox

Oladeji Adeyemi Omishore died on 4 June 2022 after being tasered during an incident involving police officers on Chelsea Bridge and then entering the River Thames; his medical cause of death was complications arising from drowning. The report identified concerns about the recording and transmission of mental health information by call handlers and dispatchers, and about training for responding officers in tactical options before taser deployment.

Peter David Konitzer · Prevention of Future Deaths report View report

25 Mar 2025 Wiltshire and Swindon N. Rheinberg

Peter David Konitzer, a volunteer working on the rehabilitation of a canal lock, died when a recently excavated retaining wall collapsed onto him while he was removing props. The inquest concluded that he died from compression of the chest and that he was unlawfully killed. The principal concerns related to inadequate management of construction work involving volunteers, including failures concerning temporary works designs, risk assessments, method statements and other required safety documentation, and to the adequacy of HSE guidance for voluntary organisations.

Imogen Alice NUNN · Prevention of Future Deaths report View report

24 Mar 2025 West Sussex, Brighton and Hove P. Schofield

Imogen Alice NUNN was found deceased at her home on 1 January 2023 after leaving a party and being reported as a high-risk missing person; the circumstances text states that she had consumed a substance bought online. The principal concern was the lack of available British Sign Language interpreters for Deaf patients receiving mental health support, particularly for urgent assessments when patients were in crisis.

Thomas Alexander GLOVER · Prevention of Future Deaths report View report

24 Mar 2025 Suffolk N. Parsley

Thomas Glover died at Broomfield Hospital on 22 May 2024 after a delayed presentation of a strangulated hiatus hernia with an ischaemic stomach, followed by emergency surgery, multi-organ failure and end-of-life care. The report identified a missed opportunity for earlier diagnosis after his discharge from Ipswich Hospital, and raised concerns about limited awareness among NHS clinicians of the differing risks associated with para-oesophageal hiatus hernias and the lack of distinction in NHS England guidance.

Claire Louise Driver · Prevention of Future Deaths report View report

24 Mar 2025 South Yorkshire (Western) T. Rawden

Claire Louise Driver had a history of schizoaffective disorder and polysubstance misuse and was found in significant decomposition in a shallow stream on 14 September 2024 after being reported missing on 24 June 2024. The cause of death was unascertained. The inquest heard concerns about limited attempts to engage her while her mental health was deteriorating, liaison between police and mental health services, and staff training on substance misuse and mental health.

Ida Jean Lock · Prevention of Future Deaths report View report

21 Mar 2025 Lancashire and Blackburn with Darwen J. Adeley

Ida Jean Lock died on 16 November 2019 after suffering a lack of oxygen during delivery on 9 November 2019, resulting in severe hypoxic-ischaemic brain damage. The report describes missed opportunities for enhanced care and obstetric input, delays in responding to fetal distress, and initially ineffective neonatal resuscitation. The principal concerns include the Trust’s alleged lack of candour and transparency, deficient clinical and maternity governance, inadequate investigations, gaps in mandatory and remedial training, and inappropriate grading of the harm suffered.

Lee Derek Jamie ADAMS · Prevention of Future Deaths report View report

20 Mar 2025 Inner South London J. Morris

Lee Derek Jamie ADAMS was at home alone after taking an excessive number of propranolol tablets, intending to take his own life, and was pronounced dead at 03.39 on 24 July 2020. The report highlights concerns about propranolol’s toxicity at relatively small doses, the absence of a specific antidote, and the need for doctors, particularly GPs, to be aware of the consequences of excess ingestion.

Lee Derek Jamie ADAMS · Prevention of Future Deaths report View report

20 Mar 2025 Inner South London J. Morris

Lee Derek Jamie Adams died after taking an excessive number of propranolol tablets on 24 July 2020, following extensive online gambling and in the context of depressive illness. The substantive concerns included the rapid absorption and high toxicity of propranolol, the lack of a specific antidote, and the need for GPs to consider patients’ gambling habits and the risks of excess propranolol ingestion.

Sheridan Tate Pickett · Prevention of Future Deaths report View report

19 Mar 2025 Manchester South J. Gill

On 9 August 2024, Sheridan Tate Pickett sustained fatal injuries after falling from a height out of a window; the inquest concluded that the death was suicide. The concern was that information about an overdose and advice not to recommence ADHD medication was not shared with the private ADHD provider, and that there were no current guidelines governing information sharing between private psychiatry providers and NHS services involved in parallel care.

Leanne Marie Carroll · Prevention of Future Deaths report View report

19 Mar 2025 North Wales (East and Central) K. Robertson

Leanne Marie Carroll, aged 27, died on 29 June 2024 after excessive consumption of prescribed and non-prescribed medications. She had experienced anxiety and deteriorating OCD following the birth of her first child and had been referred to mental health support, but not to the Perinatal Mental Health Service. The report raises concerns about inadequate awareness and staffing of that service and the lack of written records of Single Point of Access discussions and decisions.

Winnie Harrop · Prevention of Future Deaths report View report

19 Mar 2025 Manchester South J. Gill

Winnie Harrop collapsed at a care centre on 12 August 2024, was treated in hospital after sustaining facial fractures, and was discharged back to the care centre with a new oxygen requirement but without oxygen. She became drowsy and unresponsive, was readmitted on 13 August, and died in hospital on 16 August 2024. The principal concerns were unclear health and social care guidance about discharge to a care home, discharge while overly sedated, and a discharge letter that did not record the sedation level or new oxygen requirement.

Benjamin Robert Compton · Prevention of Future Deaths report View report

19 Mar 2025 Devon, Plymouth and Torbay P. Spinney

Benjamin Robert Compton, who had autism, experienced a deterioration in his physical and mental wellbeing and escalating distress. In the early hours of 1 February 2022, he left his supported accommodation and was hit by a lorry on the M5. The substantive concerns included gaps in support for autistic people in crisis and the inability of the Special Allocation Scheme to meet Benjamin’s needs.

Mr William Anthony Grieve · Prevention of Future Deaths report View report

19 Mar 2025 Staffordshire and Stoke-on-Trent E. Serrano

Mr William Anthony Grieve was found deceased at his home on 20 August 2024. The inquest recorded hanging as the cause of death and concluded with suicide. Concerns included separate electronic systems preventing Stoke Talking Therapies and the Stoke crisis Evolution Team from accessing each other’s notes, resulting in incorrect suicide risk assessments, and staff training needs not being addressed.

Renate MARK · Prevention of Future Deaths report View report

18 Mar 2025 Northumberland A. Hetherington

Renate MARK suffered an unwitnessed inpatient fall in hospital on 24 April 2024, sustaining a cervical spinal fracture and subdural haematoma, and died there on 25 April 2024 after receiving palliative care. Concerns included that she was assessed as a level 3 falls risk but was not under direct observation, that investigations relied on the incorrect belief that the fall was witnessed, and that too many patients at risk of falls were being monitored through peripheral vision. Further concern was raised about insufficient scrutiny of witness accounts during the Trust’s investigation.