Reports

Ronald William MEIKLE · Prevention of Future Deaths report View report

24 Mar 2026 Milton Keynes S. Cummings

Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

James Scott COATES · Prevention of Future Deaths report View report

24 Mar 2026 Cumbria R. Cohen

James Scott Coates died after a head-on collision while driving around a bend at approximately 90 mph on an unlit rural road, where 75% of the Cats Eye reflectors were not functioning. He sustained unsurvivable injuries and was declared dead at the roadside. The principal concern was that drivers with potentially significant conditions, including epilepsy and cannabis use, may not notify the DVLA, while legislation places the reporting responsibility on licence holders rather than doctors, which was considered insufficiently robust to ensure proper licence review.

Thomas Daniel RUGGIERO · Prevention of Future Deaths report View report

23 Mar 2026 Kent and Medway I. Potter

Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report identifies concerns about the emergency cell bell system, incomplete ACCT documentation, confusion over calling a “code blue”, and staffing, experience and communication at the prison, with risks to future prisoners remaining.

Richard Gary Hopkins · Prevention of Future Deaths report View report

23 Mar 2026 Coventry and Warwickshire L. Lee

Richard Gary Hopkins sustained fatal injuries when a defective trailing arm suddenly failed while he was beneath the rear axle of a newly assembled vehicle during a visual pre-delivery inspection. The principal concerns were an unrecognised risk from proximity beneath raised and pressurised air suspension during undisturbed inspection, a lack of guidance addressing that risk, the limitations of batch sample testing, and limited awareness of the risk across the sector.

Peter COATES · Prevention of Future Deaths report View report

23 Mar 2026 Teesside and Hartlepool P. Appleton

Peter Coates, who had very severe COPD and relied on mains-powered respiratory equipment, died at home after an unplanned electrical power failure stopped that equipment. The report identifies delays in ambulance attendance and a concern that the ambulance response categories have a gap for patients who are not in cardiac or respiratory arrest but require an immediate response, particularly when alone and unable to update the ambulance service.

Luke Owen ASHCROFT · Prevention of Future Deaths report View report

20 Mar 2026 Greater Lincolnshire P. Smith

Luke Ashcroft was admitted to Lincoln County Hospital from HMP Lincoln after being found unconscious in his cell in the Care and Separation Unit. His death was confirmed on 1 July 2020, with the post-mortem finding hypoxic brain injury consistent with ligature application. The inquest identified concerns about missed healthcare opportunities, inadequate information sharing and risk mitigations, shortcomings in the ACCT plan, and failures to carry out required observations; it also raised concerns about the safety and availability of corded telephone access in the unit.

Graham Ian OXLEY · Prevention of Future Deaths report View report

19 Mar 2026 South Yorkshire (Western) C. Fitch

Graham Ian Oxley developed serious toxicity after receiving pembrolizumab immunotherapy following kidney cancer surgery, including inflammation affecting his heart, muscles and nerves. He deteriorated despite hospital treatment and life-sustaining treatment was withdrawn. The investigation identified concerns about delays in urgent oncology advice and the lack of a distinct priority pathway for patients presenting immunotherapy alert cards.

John Malcolm FISHER · Prevention of Future Deaths report View report

19 Mar 2026 West Sussex, Brighton and Hove K. Taylor

John Malcolm Fisher was admitted to hospital on 22 April 2025 with persistent focal seizures that developed into status epilepticus, and he died on 4 May 2025 after the seizures could not be controlled. The report raises concerns about inaccurate or incomplete medication information during transfers between community services and the omission of sodium valproate from the care agency’s medication record, resulting in six days without that medication.

Paul Robert Joseph NASH · Prevention of Future Deaths report View report

19 Mar 2026 Bedfordshire and Luton E. Whitting

Paul Robert Joseph NASH, who had epilepsy secondary to HSV encephalitis, was found deceased at home on 23 October 2025 after apparently suffering a seizure during the night. He had run out of Carbamazepine and missed three doses. The concerns included that the GP surgery did not appear to be told that he had completely run out of medication and did not prioritise the prescription for same-day collection, as well as wider difficulties for epilepsy patients in obtaining sufficient medication supplies.

JOHN DAVID BEAGLEY · Prevention of Future Deaths report View report

19 Mar 2026 Gloucestershire R. Wooderson

JOHN DAVID BEAGLEY died of squamous cell carcinoma after treatment for carcinoma of the scalp. Following surgery in November and December 2023, his wound did not heal, a radiotherapy referral was not submitted, and opportunities for referral were missed; the cancer later progressed and radiotherapy was administered between September and October 2024. The inquest heard concerns about a national shortage of maxillofacial surgeons and the potential impact on patient care, including the effects of lengthy and insufficiently funded training.

Julie Anne Pytches · Prevention of Future Deaths report View report

18 Mar 2026 Essex S. Hayes

Julie Anne Pytches died on 14 October 2023 during elective spinal surgery after suffering a covert probable arterial bleed, major haemorrhage and cardiac arrest while prone in the operating theatre. The report identifies concerns about emergency protocols, staff understanding and training, communication of clinicians’ practice limitations, and uncertainty about ambulance attendance and possible transfer to a tertiary centre.

Clare Louise Dupree · Prevention of Future Deaths report View report

18 Mar 2026 Avon M. Vision

Clare Louise Dupree, aged 48, was taken into custody at HMP Eastwood Park and suffered smoke inhalation after a fire in her cell. The jury concluded that the lack of automatic in-cell fire detection delayed detection of the fire and resulted in her death; the use of external domestic smoke detectors possibly contributed to her death.

Edna May Wiggett · Prevention of Future Deaths report View report

18 Mar 2026 Norfolk R. Weyell

Edna May Wiggett fell at home and sustained a fractured hip, underwent surgery, and later died from heart failure following surgery. The report identified a failure to re-triage a second ambulance call reporting increased pain, leading to delays in dispatch and a prolonged wait on the floor, which more than minimally contributed to her death.

Delwyn PREECE · Prevention of Future Deaths report View report

17 Mar 2026 South Yorkshire (Eastern) L. Slater

Delwyn Preece, a 64-year-old man, died at Rotherham Hospital on 19 August 2025 from a hypoxic brain injury following deliberate self-suspension by ligature while he was an informal patient at an acute mental health hospital. The principal concerns were repeated granting of leave without documented mental state examinations or risk assessments, poor and retrospective record-keeping, and shortcomings in the patient safety investigation arising from unfamiliarity with the medical records system.

Scott Maxwell Henry CATTON · Prevention of Future Deaths report View report

17 Mar 2026 Nottinghamshire K. Boyle

Scott Maxwell Henry Catton died on 7 June 2025 after a serious head injury sustained when he collided with the open door of a parked vehicle while travelling on an electric scooter. The report raised concern that electric scooter riders are not required to wear helmets, creating a risk of death for riders involved in collisions while not wearing protective headwear.

Natalie Louise AINSWORTH · Prevention of Future Deaths report View report

17 Mar 2026 County Durham and Darlington J. Richards

Natalie Louise Ainsworth, aged 29, was found deceased on 13 February 2025 at an address in Stanley, County Durham. Police were informed that she had earlier threatened to take her own life, but this information was not known to key officers and was not included in the subsequent risk assessment or response. The report also identified that the risk assessment failed to properly consider known or expected information about her vulnerability and history of mental health issues, self-harm and substance abuse.

DARREN ROBERT DICKSON · Prevention of Future Deaths report View report

16 Mar 2026 Cumbria A. Cousins

Darren Robert Dickson was found unresponsive at home after last being seen on 5 February 2025 and died in hospital on 6 February 2025. Toxicology found benzodiazepine and alcohol, and concerns were raised about incomplete records of information and signposting provided by Recovery Steps, and possible confusion or insufficient communication between Recovery Steps and GP services about benzodiazepine use and doses.

JARDINE WILLIAMS · Prevention of Future Deaths report View report

16 Mar 2026 Cumbria A. Cousins

Jardine Williams, a mental health nurse experiencing worsening mental ill health, made a 999 call on 24 March 2025 stating that she had suicidal thoughts, a plan and an intention to carry it out. An ambulance arrived later that evening and found that she had died as a result of a deliberate act; the cause of death was recorded as hanging. The principal concern was that the emergency call pathway did not ask about the immediacy of the stated plan, which may have limited the clarity of the information available to the call handler.

DARREN ROBERT DICKSON · Prevention of Future Deaths report View report

16 Mar 2026 Cumbria A. Cousins

Darren Robert Dickson was found unresponsive at home on 5 February 2025 and died in hospital on 6 February 2025. Toxicology showed benzodiazepine and alcohol, which the report states led to his death on the balance of probabilities. The principal concern was that records had been overwritten and later destroyed, with insufficient reassurance that the trust’s policy addressed the retention and non-destruction of records.

Jardine Williams · Prevention of Future Deaths report View report

16 Mar 2026 Cumbria A. Cousins

Jardine Williams, a 29-year-old mental health nurse, died on 24 March 2025 after making a 999 call reporting worsening mental health, suicidal thoughts, a plan and an intention to carry it out. The report raised concerns about unclear and confused communication between the North West Ambulance Service and Cumbria Health on Call, including a delay in returning the call after repeated unsuccessful attempts to contact her. The report did not find a causative link between that delay and the outcome, and stated that her intent could not be determined on the balance of probabilities.