Reports

Alonzo Christopher Andrew Wood · Prevention of Future Deaths report View report

18 Mar 2025 West Sussex, Brighton and Hove J. Andrews

Alonzo Christopher Andrew Wood was born on 23 September 2023 and died on 26 September 2023 from multi-organ failure associated with a significant hepatic congenital haemangioma. A spontaneous bleed occurred between 21 September and his birth, leaving him critically unwell at delivery. The report also identified insufficient guidance on management actions following an abnormal antenatal CTG, including whether and when delivery should occur.

DARREN NEIL TURNER · Prevention of Future Deaths report View report

17 Mar 2025 Essex S. Horstead

Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.

Dominic Martin PHILIP · Prevention of Future Deaths report View report

14 Mar 2025 Northamptonshire H. Shah

Dominic Martin Philip died at Kettering General Hospital on 3 February 2023 from an anaphylactic reaction to contrast medium injected for an abdominal CT scan. Concerns included whether potential allergies to contrast medium could be identified before injection, the unexplained presence of Lidocaine in his blood despite his disclosed Lidocaine allergy, and controls over the storage and removal of Lidocaine.

Alexander Robert EASTWOOD · Prevention of Future Deaths report View report

14 Mar 2025 Manchester West M. Pemberton

On 29 June 2024, 15-year-old Alexander Eastwood became unresponsive after taking part in a kickboxing competition in Wigan. He was found to have a significant brain bleed, underwent surgery, and was declared deceased on 2 July 2024. The investigation identified concerns about the lack of guidance or regulation for children participating in contact sports, including minimum standards for medical support, rest periods, welfare checks, risk assessments and critical incident planning.

William Owen RADFORD · Prevention of Future Deaths report View report

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

William Owen RADFORD died on 13 June 2024 from fatal injuries sustained after losing control of his vehicle and being struck by an oncoming vehicle while driving on the A281 Brighton Road. He had only recently passed his driving test and was carrying a young passenger. The inquest heard that distraction from another young person could increase the risk of an accident for an inexperienced driver, amid public concern about young-passenger restrictions for newly qualified drivers.

Billie Diane WICKS · Prevention of Future Deaths report View report

13 Mar 2025 Inner North London M. Hassell

Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.

Mr Paul Timothy Dunne · Prevention of Future Deaths report View report

13 Mar 2025 South London A. Harris

Mr Paul Dunne was brought to A&E after a paracetamol overdose and was considered at high risk of suicide, but did not receive continuous 1:1 observation. He absconded several times and was found dead after suspending himself in a nearby children's playground. Concerns included failures in risk assessment, observation, communication, documentation and escalation, as well as separate clinical-record systems used by mental health and A&E staff.

Colin Colley · Prevention of Future Deaths report View report

13 Mar 2025 South Wales Central R. Knight

Colin Colley, who had dementia, frailty and a high assessed risk of falls, suffered an unwitnessed fall from a hospital bed after being left unsupervised with bed rails in place. He sustained a fatal brain bleed and died after transfer to the University Hospital of Wales. The principal concern was insufficient staff confidence and training in falls risk assessments, enhanced supervision and use of the Enhanced Supervision Document.

Barry Myers · Prevention of Future Deaths report View report

12 Mar 2025 West Sussex, Brighton and Hove L. Milner

Barry Myers died at Royal Sussex County Hospital on 28 January 2024 after suffering an ischaemic cerebral artery stroke. The report describes that a mechanical thrombectomy was not available outside departmental operational hours, and notes insufficient funding for urgent thrombectomy provision between 4 pm and 8 am, as well as missed opportunities for transfer to another centre.

Rhiannon Auriol Mary Williams · Prevention of Future Deaths report View report

12 Mar 2025 Swansea and Neath Port Talbot K. Heaven

Rhiannon Auriol Mary Williams, aged 24, died by suicide following prolonged suicidal thoughts and worsening mental health. The inquest recorded the medical cause of death as asphyxia due to combined drug toxicity, neck ligature and submersion. The principal concern was that an online suicide forum and a social media platform provided information and advice about methods of suicide, concealing suicidal intentions and misleading professionals and family members.

Mr Allan Taylor · Prevention of Future Deaths report View report

11 Mar 2025 Sunderland D. Place

Mr Allan Taylor was admitted to Sunderland Royal Hospital after an unwitnessed fall at home and later suffered a further unwitnessed fall in hospital, fracturing his right neck of femur. He died in theatre on 1 June 2024 after becoming hypotensive and suffering cardiac arrest during surgery. The report identified that required Level 2 observations were not provided because the side room was not within sight or sound of the nursing station, and the issue was not escalated; it noted that closer observation might have enabled assistance and possibly prevented the fall.

Luke Harry Brockwell Barnes · Prevention of Future Deaths report View report

11 Mar 2025 Surrey S. Ridge

Luke Harry Brockwell Barnes was found dead at his home in Cobham on 9 February 2024 after taking sufficient substance to cause toxicity, and his death was recorded as drug related. The principal concerns included probation staff not having access to relevant specialist reports, whether frontline probation staff had sufficient training about neurodiversity, and a potential loophole where a court-imposed requirement not actioned by probation might not be referred back to the court.

NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report View report

11 Mar 2025 West Yorkshire Eastern O. Longstaff

Nicholas Oliver James Gedge was found unresponsive in a police station cell on 14 November 2022 and was pronounced deceased at hospital later that day. The principal concerns were the delay in commencing CPR, the lack of a shared understanding and coordinated roles among detention and medical staff, and uncertainty about protocols for responding to medical emergencies in cells.

Marta Elena Vento · Prevention of Future Deaths report View report

11 Mar 2025 Dorset R. Griffin

Marta Elena Vento was working alone as a hotel receptionist in Bournemouth when she was fatally beaten in an unprovoked attack on 9 December 2020. The report raises concerns about the sharing of remand prisoners’ risk information with sentencing courts, continuity of mental healthcare after release from prison, risk assessment of violent offenders managed by MOSOVO units, and access to patient information through the National Record Locator.

Mr Christopher Granville Bradbury · Prevention of Future Deaths report View report

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

Christopher Granville Bradbury fell at home, sustained a cut to his right foot, and was admitted to hospital several days later with diarrhoea, vomiting, collapse, and swelling of the right leg. He was diagnosed with a severe invasive soft tissue infection and underwent a below-the-knee amputation, but died the following day. Concerns included a lack of national knowledge and guidelines for these infections, ineffective training and learning measures, and the absence of an audit trail when medication was omitted because it was unavailable or for another reason.

Sean Higgins · Prevention of Future Deaths report View report

11 Mar 2025 Mid Kent and Medway P. Harding

Sean Higgins, who was imprisoned at HMP Rochester, had a history of mental health issues and substance abuse and died after a period of deteriorating mental health, medication non-adherence and repeated self-harm concerns. The inquest concluded that his death was suicide. Concerns included failures to follow prison and mental health policies, inadequate review of relevant records and risk, and ACCT support plans being incomplete when the ACCT was closed.

Jean Pike · Prevention of Future Deaths report View report

7 Mar 2025 Swansea and Neath Port Talbot K. Heaven

Jean Pike, who had suicidal thoughts and intended to hang herself, was left unattended for between 20 and 45 minutes in her supported living accommodation and was then found suspended and declared deceased on 18 May 2022. The concerns included hospital discharge decisions made without multidisciplinary consultation with community professionals, inadequate consideration of risks, and an inadequate safety plan before Jean was left unattended.

Arsalan Khalid BAIG · Prevention of Future Deaths report View report

6 Mar 2025 West Yorkshire (Western) A. Brocklehurst

Arsalan Khalid Baig was a front-seat passenger in a car that collided with a brick wall on Dryden Street, Bradford, after the driver was intoxicated following drug use and travelling at more than twice the speed limit. Mr Baig sustained severe head injuries and died in hospital on 31 July 2022. The substantive concern was that poor street lighting and the absence of appropriate traffic warning signs may have contributed to the death.

John Peter MCLOUGHLIN · Prevention of Future Deaths report View report

6 Mar 2025 West Sussex, Brighton and Hove G. Jones

John Peter McLoughlin, a pilot employed by West Atlantic UK, died by suicide in a Brighton hotel bathroom on 19 July 2023 while attending a stressful and highly pressured training course. The report raised concerns that peer support from trained mental health first aiders was inadequate for pilots experiencing severe mental health difficulties and suicidal thoughts, and that wider industry support was insufficient when problems escalated.

Henok Zaid GEBRSSLASIE · Prevention of Future Deaths report View report

6 Mar 2025 Coventry D. Henry

Henok Zaid GEBRSSLASIE, who was detained under the Mental Health Act at the Caludon Centre, was found partially suspended by a ligature in his bedroom on Sherbourne Ward on 12 August 2021, nearly three hours after his last observation. The report identifies continuing concern about the known high risk posed by bedroom door tops as ligature anchor points and notes that door-top alarms had not been installed on the ward by March 2025.