Reports

Adam Ankers · Prevention of Future Deaths report View report

16 Apr 2026 West London V. Charbit

Adam Ankers suffered a cardiac arrest while playing grassroots football on 31 January 2024 due to a previously unidentified inherited cardiac condition, and died in hospital on 4 February 2024 following brain stem death. Agonal breathing and cardiac arrest were not recognised at the pitch or by the 999 call handler, and an AED was brought to the pitch but not used. The report identified concerns about recognition of agonal breathing and cardiac arrest, access to and use of defibrillators, dissemination of sudden cardiac arrest training, cardiac screening, and cascade communication of inherited disease information.

Lisa Marie Elizabeth Beatrice TAYLOR-PENNY · Prevention of Future Deaths report View report

15 Apr 2026 Cheshire E. Wheeler

Lisa Marie Elizabeth Beatrice Taylor-Penny was found deceased at home on 11 July 2025 after carers and social workers spent nearly seven hours trying to obtain emergency assistance to enter the property. The principal concern was that the rigid implementation of “Right care right person” did not provide sufficient scope for call handlers to escalate requests for senior professional judgment, including where other professionals expressed concern for life and limb and requested police attendance.

Kiefer Kiam Bolangi Fraser-Phillips · Prevention of Future Deaths report View report

15 Apr 2026 Birmingham and Solihull L. Hunt

Kiefer Kiam Bolangi Fraser-Phillips, who had treatment-resistant paranoid schizophrenia and several physical health conditions including sleep apnoea, was found deceased in bed at a mental health unit on 18 September 2025. The post-mortem medical cause of death was recorded as sudden unexplained death in schizophrenia. Concerns included incomplete recording of therapeutic observations because of Wi-Fi problems and the absence of a care plan addressing physical health risks associated with his medication and sleep apnoea.

Catherine Oliver · Prevention of Future Deaths report View report

14 Apr 2026 Oxfordshire N. Graham

Catherine Oliver, aged 88, fell at home in a confined space between her armchair and boxes that had remained in her living room for nearly four weeks during housing works. She later died following complications arising from a fractured neck of femur sustained in the fall. The substantive concerns were the prolonged storage hazard, the absence of clear controls or time limits, and the potential risk to other elderly, disabled or mobility-restricted tenants.

Susan Toft · Prevention of Future Deaths report View report

14 Apr 2026 Manchester South A. Bridgman

Susan Toft, a wheelchair user, was injured when her adapted vehicle braked suddenly and she slipped from her wheelchair into the passenger footwell. She later died in hospital from myocardial infarction and pneumonia, with sepsis and fractures also recorded in the medical cause of death. Concerns included failure of the wheelchair cushion attachment and inadequate fitting of the vehicle seat belt to her wheelchair and position.

James Patrick · Prevention of Future Deaths report View report

14 Apr 2026 Cumbria R. Cohen

James Stewart, aged 52, died on 27 December 2024 after leaving hospital during alcohol withdrawal and placing a ligature around his neck at a nearby hotel, sustaining catastrophic injuries. The report describes concerns that he was discharged prematurely, without reassessment by the Psychiatric Liaison Team or intervention when safety concerns were raised, and that Flow Coordinators might not receive information about patient vulnerabilities when arranging discharge.

Wayne AUSTIN · Prevention of Future Deaths report View report

10 Apr 2026 Shropshire, Telford and Wrekin H. Westerman

Wayne Austin became unwell and collapsed at Shrewsbury Probation office on 10 October 2024 after reporting that he had consumed cider; paramedics were subsequently informed that he had consumed crack cocaine. He was treated with CPR, advanced life support and Naloxone, transferred to hospital, and died as a result of combined buprenorphine and alcohol toxicity. Concerns included difficulty locating and applying the appropriate Naloxone guidance, the practical difficulty of complying with dosing guidelines during cardiac arrest, and the number of Naloxone vials carried by ambulances.

Garry MILLS · Prevention of Future Deaths report View report

10 Apr 2026 Surrey D. Stewart

Garry MILLS, aged 46, died on 6 September 2021 after experiencing considerable anxiety and stress while subject to a financial restraint order limiting his and his family’s weekly living expenses to £250. The inquest concluded that he took his own life while suffering from the effects of stress and anxiety. The principal concern was that the £250 weekly figure had not been reviewed since 2009 despite increases in living costs, with the report stating that this significantly affected the mental health and wellbeing of people subject to restraint orders and their dependants.

Richard Mark WHELAN · Prevention of Future Deaths report View report

9 Apr 2026 West Yorkshire (Western) P. Merchant

Richard Mark Whelan died on 15 December 2024 from exsanguination caused by incised wounds to both wrists after a deliberate act intended to end his life. In the preceding weeks, his mental health had deteriorated, and a referral to the Mental Health Trust Single Point of Access made on 11 December had not been acted on by the time of his death. The principal concern was that non-urgent referrals could take up to 14 days to be triaged, with a further plan only devised after triage.

Jonathan Mark Thornton · Prevention of Future Deaths report View report

8 Apr 2026 Nottinghamshire A. Pountney

Jonathan Mark Thornton died at Queens Medical Centre in Nottingham on 12 July 2024 after sustaining a severe head injury in an attack by a fellow inmate at HMP Nottingham on 28 June 2024. The report raises concerns about inadequate information sharing between community forensic, prison healthcare and operational prison staff, and about the categorisation and visibility of risk alerts on NOMIS/DPS, creating a risk of future deaths.

Gary STARBUCK · Prevention of Future Deaths report View report

8 Apr 2026 Surrey D. Stewart

Gary STARBUCK developed metastatic cutaneous squamous cell carcinoma after recurrent skin cancer affecting his right pinna and died at home on 16 August 2021 following palliative care. The concern was that mandated care standards, including referral to specialist skin multidisciplinary teams, applied to NHS patients but not necessarily to privately treated patients, creating a risk that privately treated patients could receive inferior care and a risk of death.

Mark Robert Smith · Prevention of Future Deaths report View report

7 Apr 2026 Inner South London J. Goldring

Mark Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.

Matilda Rose Davis · Prevention of Future Deaths report View report

7 Apr 2026 Warwickshire D. Sewell

Matilda was found deceased at her home shortly after an urgent safeguarding visit concerning her mental health and the welfare of her children. The inquest identified concerns that suicide prevention training was not mandatory for frontline practitioners, that she was not asked directly about suicidal ideation, and that she was not signposted to crisis support services.

Joshua Christopher Edward PERRY · Prevention of Future Deaths report View report

7 Apr 2026 Liverpool and the Wirral H. Rimmer

Joshua Perry died on 14 March 2025 after falling from the nineteenth floor of a multi-storey car park and suffering multiple injuries. Ketamine had been consumed before his death, and the inquest could not establish whether he intended to take his own life. The principal concerns were an unresolved conflict between building regulations and BSI standards about measuring barrier heights, and guidance that addresses horizontal railings in relation to young children but not adults or older children.

Allan STEVENSON · Prevention of Future Deaths report View report

6 Apr 2026 Suffolk N. Parsley

Allan Stevenson, a 73-year-old cyclist, died from injuries sustained in a road traffic collision involving an HGV at a roundabout with a temporary traffic management system. The inquest concluded that his death was contributed to by the temporary road layout. Concerns included the flipping of a complex traffic management plan without an enhanced safety review, inadequate or missing signage, limited escalation and inspection processes, delayed responses to reported defects, and the absence of spare signage for immediate changes.

David ABBOTT · Prevention of Future Deaths report View report

2 Apr 2026 Suffolk D. Stewart

David ABBOTT underwent surgery at West Suffolk Hospital on 25 October 2023 and was discharged the following day with advice that he interpreted as meaning he should not mobilise. He remained immobile for four days, subsequently developed deep vein thrombosis and pulmonary embolism, and died in cardiac arrest at home on 29 November 2023. Concerns included potentially incorrect discharge advice, inadequate recording of important advice, and ineffective communication between hospital staff, patients and families.

Peter PETTITT · Prevention of Future Deaths report View report

2 Apr 2026 Suffolk D. Stewart

Peter PETTITT, aged 86, died on 11 September 2023 after developing sepsis due to bronchopneumonia and acute pyelonephritis. The report raised concerns about inadequate care records, gaps in medication and catheter support, and insufficiently assured training and management arrangements for the commissioned care provided to him.

Lajos MANDRIK · Prevention of Future Deaths report View report

1 Apr 2026 West London R. Furniss

Lajos MANDRIK died on 13 September 2023 after hanging himself during a period when no staff member was allocated to carry out intermittent observations on Ellis Ward at Tolworth Hospital. The report’s principal concern is that general and intermittent observations appeared not to be carried out in accordance with the Trust’s policy, including the required attempt at engagement.

Susan Jane WHITTLES · Prevention of Future Deaths report View report

1 Apr 2026 East Riding and Hull L. Harris

Susan Jane WHITTLES died at the scene of a road traffic collision on 24 November 2023 after another vehicle failed to give way and collided with her vehicle. The substantive concerns relate to non-designated-country nationals being able to continue driving in Great Britain on a foreign or international licence after failing GB driving tests, without appropriate supervision, potentially creating a risk of serious injury or harm to other road users.

Benjamin Daniel Rowley · Prevention of Future Deaths report View report

1 Apr 2026 Greater Lincolnshire P. Smith

On 7 November 2025, Benjamin Daniel Rowley attended dialysis when a connector on his central venous catheter disconnected, causing blood loss. He was taken to hospital, where his death was later confirmed; the stated clinical cause included haemorrhage from the catheter port. The investigation raised concerns about mechanical failure of the catheter and a possible wider vulnerability affecting this brand or dialysis lines.