Reports

Andrea Denise MANN · Prevention of Future Deaths report View report

6 Mar 2025 West Yorkshire (Western) A. Brocklehurst

Andrea Denise MANN was discovered hanging at her home on 10 February 2024 and died in hospital the following day after invasive medical care was withdrawn and palliative care was provided. The inquest identified concerns about limited Community Mental Health Trust involvement, the absence of a requested psychiatric appointment, delays in psychological therapy, and the lack of an overarching tool to scrutinise and measure the care provided.

Mohammed Azad KHAN · Prevention of Future Deaths report View report

6 Mar 2025 West Yorkshire (Western) A. Brocklehurst

Mohammed Azad Khan died at the scene after his vehicle collided with a brick wall on Dryden Street, Bradford, in the early hours of 31 July 2022. The report identified concerns that the bend and wall were obscured by darkness, street lighting was insufficient, and there were no warning signs for the dead end or turn, which may have contributed to the collision.

Raymond JENNINGS · Prevention of Future Deaths report View report

6 Mar 2025 West Yorkshire (Western) S. Eccleston

Raymond JENNINGS, aged 84, was admitted to hospital with sepsis due to community-acquired pneumonia and died on 7 March 2023. His care home failed to promptly administer prescribed antibiotics or seek further medical advice when initial attempts to obtain them were unsuccessful. The report raised a concern that other vulnerable residents may be at future risk if prescribed medications are not administered promptly.

Annette Lewis · Prevention of Future Deaths report View report

6 Mar 2025 South Wales Central K. Burge

Annette Lewis re-presented to hospital with worsening abdominal pain and was discharged without full consideration of her symptoms and test results. She was declared deceased at home on 18 April 2023; the medical cause of death was recorded as peritonitis and upper gastrointestinal haemorrhage due to a perforated pyloric ulcer. The principal concern was that she should have been referred for surgical review rather than discharged, and that a proposed “Failed Discharge” policy had no definitive implementation timescale.

Mark Anthony Fernandez · Prevention of Future Deaths report View report

4 Mar 2025 Manchester North J. Kearsley

Mark Anthony Fernandez, who had cerebral palsy, complex medical needs and lived in supported accommodation with full-time carers, was admitted to hospital with suspected meningitis and recurring infections and remained there until his death; he was later placed on end-of-life care. The substantive concerns included inadequate information in a referral, failure to use his hospital passport, and a best-interests decision that did not take account of the knowledge and views of his long-term carers and social services.

Jack Matthew Shields · Prevention of Future Deaths report View report

4 Mar 2025 Sunderland D. Place

Jack Matthew Shields, a 29-year-old man with extensive heart conditions, experienced shortness of breath at home and died on 28 April 2024 after deteriorating into cardiac arrest despite resuscitation attempts. The report raises concerns about the delayed ambulance response and the failure to recognise his deteriorating condition and request the highest-priority backup.

Matthew John LYNCH · Prevention of Future Deaths report View report

4 Mar 2025 Birmingham and Solihull L. Hunt

Matthew John Lynch was attacked in the garden of his supported living accommodation in Birmingham on 11 July 2023 and was killed by decapitation. The concerns included whether medication non-compliance and a change of address had been adequately followed up, the quality of mental health assessments, and information sharing and training between mental health services, the council, housing providers and support workers.

Chloe Elizabeth Burgess · Prevention of Future Deaths report View report

4 Mar 2025 Hampshire, Portsmouth and Southampton N. Walker

Chloe Elizabeth Burgess was found deceased at home on 8 September 2023. The report states that interactions between amitriptyline, paroxetine and ivabradine, together with an episode of sleep apnoea, contributed to severe cardiac arrhythmia and sudden cardiac death. The principal concerns were that the potential dangers of this medication combination were not widely appreciated and did not trigger alerts in prescribing software, and that prescribers of ivabradine should have a full understanding of the potential interaction.

Alfie Lawless · Prevention of Future Deaths report View report

4 Mar 2025 Manchester South C. Morris

Alfie Lawless died by hanging after suspending himself by the neck with a ligature. His mental health had deteriorated following an incident on 18 May 2024, and he had used cocaine before his death. The principal concern was the length of time Greater Manchester Police took to recognise his death as a Death or Serious Injury under section 12 of the Police Reform Act 2002.

Robert John EVANS · Prevention of Future Deaths report View report

4 Mar 2025 Liverpool and the Wirral D. Lewis

Robert John EVANS was found dead at his home in Liverpool on 3 July 2022. His death resulted from drug use and underlying pneumonia, with fractures sustained during police detention contributing more than minimally to his death. The principal concerns were the lack of guidance, training, medical escalation and information-sharing when a person detained for a drug search is suspected of swallowing drugs, particularly after release from detention.

JAVED IQBAL · Prevention of Future Deaths report View report

3 Mar 2025 Birmingham and Solihull J. Bennett

Javed died on 1 June 2024 after deliberately igniting his room with flammable liquid and sustaining major burn injuries and smoke inhalation, followed by multi-organ failure. The report identified concerns that staff did not recognise and appropriately act on serious acute mental health issues, including not escalating worsening mood and irrational behaviour to the GP in writing. It also identified the absence of a formal internal post-death investigation and outstanding internal training that had not addressed these concerns.

William Stephen GREEN · Prevention of Future Deaths report View report

28 Feb 2025 Shropshire, Telford and Wrekin H. Westerman

William Stephen Green was admitted to hospital after a seizure and was prescribed Lamotrigine. He was later readmitted with a collapse and rash, developed Stevens-Johnson Syndrome, and died on 9 July 2023 from toxic epidermal necrolysis secondary to Lamotrigine, with alcohol dependent disease contributing to his death. The concerns were that patients were not given or recorded as receiving counselling about drug side effects and complications, and that there was no provision to record what should happen when a patient lacked capacity to understand such an explanation.

Lachlan Charles Campbell · Prevention of Future Deaths report View report

28 Feb 2025 Cornwall and Isles of Scilly A. Cox

Lachlan Charles Campbell was found unconscious outside a railway station after taking drugs and died in hospital on 1 November 2022 following hypothermia, bronchopneumonia and combined drug intoxication. The report identifies concerns about delayed ambulance attendance, delays in hospital handovers, inadequate care by responding police officers, and information sharing between police and ambulance services.

June PHILLIPS · Prevention of Future Deaths report View report

28 Feb 2025 Birmingham and Solihull L. Hunt

June Phillips lived in a care home and, while taking clopidogrel, fell on 7 April 2023 and subsequently deteriorated. She was admitted to hospital on 24 April, where a CT scan confirmed a large traumatic subdural haemorrhage; she died on 30 April 2023. The substantive concerns were inaccurate care home records, failure to update fall-risk assessments, and an inadequate post-falls investigation.

Lachlan Charles Campbell · Prevention of Future Deaths report View report

28 Feb 2025 Cornwall and Isles of Scilly A. Cox

Lachlan Charles Campbell died on 1 November 2022 after being found outside a railway station in a distressed and possibly drug-affected state, where he remained for several hours in heavy rain and cold conditions. The report identifies concerns about delays in ambulance attendance, incomplete information sharing between ambulance and police services, and police officers not providing shelter, warmth, or timely medical attention. The inquest concluded that these failures contributed to his death.

Philip Lesnes · Prevention of Future Deaths report View report

27 Feb 2025 Dorset R. Middleton

Philip Lesnes, who was living in a care home and had dementia, was found with denture adhesive gel in his mouth, ears and nose on 23 June 2024. His breathing became laboured, he was taken to hospital, and he died that day; the inquest recorded choking and inhalation of adhesive gel among the medical causes of death. Concerns included the product’s choking risk, its potential use by older people or people with cognitive decline, the need to consider it in care-home risk assessments, and the absence of choking warnings on its packaging or leaflet.

Joshua William Leatham-Prosser · Prevention of Future Deaths report View report

27 Feb 2025 Dorset R. Middleton

Joshua William Leatham-Prosser was found unresponsive at his home on 5/6/24 and pronounced dead at the scene. The inquest recorded a drug-related death, with urinary sepsis, severe acute on chronic cystitis and pyelonephritis, and chronic ketamine use identified in the medical cause of death; concerns were raised about ketamine’s addictive and harmful nature and the increasing number of young people presenting with potentially fatal health problems linked to its use.

Khadija Kerri · Prevention of Future Deaths report View report

25 Feb 2025 South Yorkshire (Eastern) L. Slater

Khadija Kerri was admitted to hospital after an unwitnessed fall downstairs that caused a head laceration and multiple traumatic injuries. Two cervical fractures and a rib fracture were missed in the initial radiology report, and although the discrepancy was identified and communicated within 24 hours, the information was not acted on until 23 June 2024 because there was no clear internal process for disseminating addendum reports. The inquest concluded that she died primarily from heart disease, against a background of traumatic injuries and other co-morbidities.

Amy Marie Padley · Prevention of Future Deaths report View report

24 Feb 2025 Swansea and Neath Port Talbot K. Heaven

Amy Marie Padley suffered from alcohol addiction, depression and emotionally unstable personality disorder, and was found deceased at home on 8 July 2022 after taking her own life by suspension. The concerns included missed opportunities to refer her for community mental health assessment, insufficient guidance on managing co-occurring addiction and mental health conditions, and a reluctance to provide mental health support alongside addiction services.

Pamela Anne Marking · Prevention of Future Deaths report View report

24 Feb 2025 Surrey K. Henderson

Pamela Anne Marking was admitted with abdominal symptoms, was diagnosed with a nosebleed by a Physician Associate and discharged without medical review or direct medical supervision. She later returned with small bowel obstruction caused by an incarcerated femoral hernia and aspirated feculent fluid during induction of anaesthesia for emergency surgery, subsequently dying from respiratory failure and sepsis. The concerns included the Physician Associate’s role, supervision and scope of practice, and the absence of updated guidance for rapid sequence induction, TIVA and airway protection.