Reports

Martin Douglas Bryant · Prevention of Future Deaths report View report

19 Jan 2026 Essex R. Mundy

Martin Douglas Bryant died by suicide on 19 January 2025 after presenting to the Mental Health Urgent Care Department following a suicide attempt. While awaiting informal admission and a bed, he was asked to wait in an open reception area from which he was free to come and go, and he subsequently left and did not return. The substantive concerns related to reliance on this waiting arrangement, the suitability of the waiting area, and shortages of mental health admission beds resulting in prolonged waits.

Wayne Pierce Walton · Prevention of Future Deaths report View report

16 Jan 2026 Coventry D. Lakin

Wayne Pierce Walton was discharged from the Caludon Centre on 21 June 2024 after taking an overdose with the intention of ending his life. He failed to engage consistently with the Home Treatment Team and died by asphyxiation on 29 June 2024. Concerns included inadequate completion and transfer of risk assessment and safety plan information, and a lack of guidance on potential conflicts of interest involving staff who recognised a patient outside the circumstances covered by an existing policy.

Matilda Pomfret Thomas · Prevention of Future Deaths report View report

15 Jan 2026 Hampshire, Portsmouth and Southampton H. Charles

Matilda Pomfret Thomas died aged 15 days from hypoxic ischaemic encephalopathy after a difficult home labour in which fetal distress and meconium were observed, but transfer to hospital did not occur until later. The principal concern was the lack of regulation, registration, training and guidance for doulas, including how their role should interact with midwifery services.

Ronald Colin Nelson · Prevention of Future Deaths report View report

15 Jan 2026 Nottinghamshire S. Wood

Ronald Colin Nelson died from aspiration pneumonia on a background of advanced dementia after developing pressure sores that deteriorated to category 4, with sacral osteomyelitis, following a period of being bed bound. The principal concerns were potential poor record keeping and inadequate compliance with care plans at the care home.

Margaret Elizabeth GRIMSLEY · Prevention of Future Deaths report View report

15 Jan 2026 Shropshire, Telford and Wrekin J. Ellery

Margaret Elizabeth Grimsley was admitted to hospital after a fall at home and died there on 22 January 2025 following an infection during the last 24 to 48 hours of her life. Concerns included the apparent absence or use of an upper alarm setting on a bedside oxygen meter, inconsistencies in evidence about a response to her daughter, and uncertainty about whether an upper alarm could be set or was routinely used.

Dorothy Margaret Hoyberg · Prevention of Future Deaths report View report

14 Jan 2026 Inner North London M. Lee

Dorothy Margaret Hoyberg called emergency services with worsening severe leg, abdominal and back pain and was assessed as requiring a Category 3 ambulance response. The ambulance arrived five and a half hours later, and she was found deceased; post-mortem toxicology showed elevated morphine and methadone levels, and the inquest determined that her death was drug related. The principal concern was the prolonged ambulance delay during extreme pressure on ambulance services, with insufficient capacity for regular welfare call-backs.

Mr Turner · Prevention of Future Deaths report View report

14 Jan 2026 Staffordshire and Stoke-on-Trent E. Serrano

Mr Turner was a 63-year-old man who was found deceased at his home on 18 April 2025; a postmortem identified citalopram toxicity as the cause of death. The concern raised was that there was no local or national guidance on what steps to take when a high serum level is returned in patients monitored while taking clozapine.

Stephen Taylor · Prevention of Future Deaths report View report

14 Jan 2026 Kent and Medway S. Clarke

Stephen Taylor experienced worsening mental distress linked to work and financial concerns, with escalating risk indicators and repeated contact with health services. He died on 26 May 2025 after deliberately jumping from Louisa Bay Cliffs. The principal concerns were the lack of coordinated escalation and ownership of risk across services, reliance on his denial of immediate intent despite other risk indicators, routine rather than urgent referrals, and the absence of a same-day urgent face-to-face assessment despite family concerns.

Oliver Anderson Long · Prevention of Future Deaths report View report

14 Jan 2026 East Sussex L. Bradford

Oliver Anderson Long, known as Ollie, was found dead on 23 February 2024 after travelling to East Sussex and leaving notes indicating an intention to take his own life from cliffs. He had a history including gambling disorder and, despite self-exclusion from licensed online gambling, was able to access unlicensed gambling sites. The principal concern was that unlicensed sites are outside the protections of regulated gambling and that there is inadequate public health information and warning about their risks.

Heidi Audrey Diana WILLIAMS · Prevention of Future Deaths report View report

13 Jan 2026 Northamptonshire A. Pember

Heidi Williams died at her home on 14 December 2024, and the stated cause of death was opioid and bromazolam toxicity. A review of her mobile phone indicated that she had been ordering tablets from a number linked to banking details and a suspect in Essex. Northamptonshire Police asked Essex Police to investigate, but the report states that Essex Police had refused to do so at that time; the investigation and inquest had not concluded.

Peter William THOMPSON · Prevention of Future Deaths report View report

13 Jan 2026 Derby and Derbyshire S. Huntbach

Peter William Thompson, who had Type 2 Diabetes and had moved into residential care after worsening mobility, became ill with a urinary tract infection, reduced food and fluid intake, swallowing difficulties and refusal of medication. His blood sugar levels were not tested until paramedics attended on 5 March 2025, by which time he had developed Hyperglycaemic Hyperosmolar State and severe kidney damage; he died in hospital on 9 March 2025. The principal concerns were the absence of blood sugar testing by care home staff and the lack of formal handovers between shifts, which could delay escalation of a resident’s deteriorating condition.

Rory Colin Williams · Prevention of Future Deaths report View report

13 Jan 2026 North Wales (East and Central) K. Robertson

Rory Colin Williams was referred for urgent suspected cancer investigations in May 2023 after experiencing dysphagia and weight loss, but did not attend a scheduled outpatient appointment and later missed a recommended repeat endoscopy. Adenocarcinoma was identified in July 2024, and he died in hospital on 10 August 2024 after being admitted with severe abdominal pain. The report raised concerns about delays, staffing shortages, inadequate infrastructure, lengthy waiting times, and inadequate corporate risk recognition within the gastroenterology and endoscopy service.

Amy Grace Pugh · Prevention of Future Deaths report View report

12 Jan 2026 East Riding and Hull P. Marks

Amy Grace Pugh took an overdose of drugs around midnight on 10 April 2024 and died on the morning of 11 April 2024; the inquest could not determine her intent. Concerns included clinical staff being unable to access important mental-health records from partner NHS institutions and overnight observations that did not involve entering her room or physically examining her.

STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report View report

12 Jan 2026 Essex S. Horstead

STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.

Mark Stuart VIDLER · Prevention of Future Deaths report View report

11 Jan 2026 Kent and Medway I. Potter

Mark Vidler had severe depression and was receiving mental health care from Kent and Medway Mental Health NHS Trust. After serious suicide attempts on 30 April and 7 May 2025, he was discharged from the Home Treatment Team and was not reviewed by an out-of-hours clinician on the night of 7 May after a Rapid Response Team referral was declined. He was found dead at home on 8 May 2025, and the inquest concluded that his suicide was contributed to by a failure in care. Concerns included shortcomings in patient-centred care, clinical oversight and referral processes, risk recognition, discharge decision-making, continuity of care, care coordination, and the implementation and recording of suicidality management.

Ayan SEDIQI · Prevention of Future Deaths report View report

9 Jan 2026 Greater Lincolnshire J. Wilkes

Ayan Sediqi, aged 7 months, died on 3 January 2025 from injuries sustained when the vehicle in which he was travelling slid on ice and collided with a tree on the A1. The ice formed where water was flowing across the carriageway from a blocked drainage pipe. The principal concern was a lack of public awareness about who, where and how motorists should report conditions presenting an immediate danger to road users.

Sarah Heaver · Prevention of Future Deaths report View report

9 Jan 2026 Kent and Medway S. Clarke

Sarah Heaver, aged 59, was found unconscious at home on 21 May 2024 and later entered the sea at Whitstable in a deliberate attempt to end her life; she was pronounced deceased in hospital on 27 May 2024. Concerns included the absence of a CT head scan and structured neurological observations after presentation with a very low GCS, inconsistent and incomplete medical records, and gaps in access to psychiatric input after discharge from acute hospital care.

Drew John GREAVES-PIMBLETT · Prevention of Future Deaths report View report

8 Jan 2026 Sefton, St Helens and Knowsley A. Bhardwaj

Drew John Graves-Pimblett, aged 26 and with a history of epilepsy, was found unresponsive and not breathing at home on 22 March 2025. An ambulance was initially stood down after telephone triage, but police later commenced CPR and Drew was pronounced deceased. The inquest concluded that he died from Sudden Unexpected Death in Epilepsy (SUDEP), related to epilepsy and natural causes. The principal concern was that call handlers lacked sufficient guidance and did not ask probing questions about breathing, body temperature, turning Drew over, or stiffness before deciding that resuscitation would not be effective.

Jean Alice WALDRON · Prevention of Future Deaths report View report

8 Jan 2026 Worcestershire D. Reid

Jean Waldron had a long-standing cervical spinal cord injury, vascular dementia and a sacral pressure ulcer, later developed a chest infection, and died at home in Worcester on 12 March 2025. Concerns were raised that a Team Leader carer removed wound dressings and attempted to clean the pressure sore despite instructions that carers were not licensed to provide wound care; the Tissue Viability Nurse said that using gauze was inappropriate and could have caused further complications. The report also questioned whether agency carers had received adequate training about the limits of their care and following specialist clinical advice.

David Joseph DUGDALE · Prevention of Future Deaths report View report

8 Jan 2026 East Sussex R. Redman

David Joseph Dugdale was admitted to hospital in January 2024, sustained bilateral hip fractures and developed a pressure sore, before undergoing surgery and dying on 19 May 2024. Concerns included inadequate pain management, insufficient nutritional support, deterioration of the pressure sore to grade 4, and poor nursing care, including soiled dressings and the sore being left exposed.