Reports

Connor Nelson · Prevention of Future Deaths report View report

25 Nov 2025 Nottinghamshire E. Didcock

Connor Nelson died at Kings Mill Hospital on 30 November 2024 from hypoxic ischaemic encephalopathy following a prolonged cardiac arrest on 10 November 2024. The report describes an undiagnosed congenital prolonged QT syndrome, a nine-minute delay in administering a necessary shock, and concerns about cardiac-arrest response and processes for identifying and investigating prolonged QTc syndrome.

Benedict BLYTHE · Prevention of Future Deaths report View report

25 Nov 2025 Cambridgeshire and Peterborough E. Gray

Benedict died at Peterborough City Hospital on 1 December 2021, aged 5, from fatal anaphylaxis following accidental exposure to cow’s milk protein. The report identifies concerns about the retention and testing of samples, including blood and stomach contents, and the police seizure and retention of relevant evidence such as vomitus during investigations of unexplained deaths.

Diana Ocean Grant · Prevention of Future Deaths report View report

24 Nov 2025 Surrey R. Travers

Diana Ocean Grant, who was experiencing a relapse of paranoid schizophrenia and symptoms of psychosis, died in her prison cell after a foreign object became lodged in her upper airway. The report identified concerns about failures and delays in mental health assessment, treatment, information-sharing, observation and prison placement, as well as the limited availability of secure mental health beds for people requiring admission.

Timothy Thomas Reading · Prevention of Future Deaths report View report

21 Nov 2025 Worcestershire J. Puzey

Timothy Thomas Reading died on 9 January 2025. He had a history of mental illness and had been discharged from inpatient care into the community under a community treatment order. The report identified the absence of a formal documented section 117 support plan, slow and disjointed transition arrangements, and no handover between responsible clinicians; the inquest concluded that he died by suicide, with hanging recorded as the medical cause of death.

Lisa Marie Bowen · Prevention of Future Deaths report View report

20 Nov 2025 Surrey R. Travers

Lisa Marie Bowen died instantaneously from fatal injuries after her Toyota Corolla’s tyre detached while she was driving on the M25, and the vehicle failed to stop before colliding with a stationary lorry. The principal concerns were that the anti-locking braking system substantially reduced braking after tyre detachment, and that the lorry’s under-run protection device was insufficiently strong to prevent or reduce the under-run. The report also raised concerns about the adequacy of relevant testing, regulations and protection requirements.

Anna Maria Burns · Prevention of Future Deaths report View report

19 Nov 2025 Wiltshire and Swindon G. Davies

Anna Maria Burns was found unresponsive on 12 January 2024 after taking more than her prescribed amounts of medication, including methadone, and was declared deceased that day. The inquest concluded that she died from multidrug toxicity involving methadone, zopiclone and pregabalin, while her intent remained unclear. The principal concern was that the methadone prescribing authority was not informed of her November 2023 opioid overdose and hospital admission, limiting its ability to review overdose risks and prescribing arrangements.

Lynsey Ellen Dearden · Prevention of Future Deaths report View report

18 Nov 2025 Staffordshire and Stoke-on-Trent E. Serrano

Mrs Lynsey Ellen Dearden was found deceased at her home on 11 March 2025. The inquest concluded with a short-form conclusion of suicide; the stated cause of death was asphyxiation, with anxiety and depression recorded in Part II. Concerns included failures to provide allocated Community Psychiatric Nurse appointments and to complete a standard assessment framework, alongside the absence of policies or guidance governing these processes.

Steven Lee RUDDICK · Prevention of Future Deaths report View report

18 Nov 2025 County Durham and Darlington C. Oliver

Steven Lee Ruddick was transported to University Hospital North Durham while en route to HMP Durham for an ankle check and died shortly after using the toilet in a police waiting room. The report identifies differences between police and GeoAmey/HM Prison Service procedures for observing detained people during toilet visits, which could allow prohibited items to be removed from the rectum without direct observation.

Jack Richard BROWN · Prevention of Future Deaths report View report

18 Nov 2025 Northamptonshire S. Lomas

Jack Richard BROWN, aged 86, was found unresponsive and died at a care home on 26 January 2023 after remaining asleep on a toilet overnight; the post-mortem examination concluded that he died due to ischemic heart disease. The report raised concerns that care agencies supplying staff to care and nursing homes are not required to register with or be regulated by the CQC or another body, creating risks around recruitment, suitability and training of agency carers.

Dominic Edward Arthur HURLEY · Prevention of Future Deaths report View report

18 Nov 2025 West Sussex, Brighton and Hove P. Schofield

On 8 July 2024, Dominic Hurley became unwell during an offshore dive, made a rapid uncontrolled ascent, became unconscious, and later died in hospital. The principal concern was that he had not disclosed a previous serious diving incident and cardiac history when renewing his diving licence, with reliance on self-declaration questionnaires without further enquiry or access to previous medical history identified as a potential risk.

Derrion Jack ADAMS · Prevention of Future Deaths report View report

18 Nov 2025 Birmingham and Solihull E. Brown

Derrion Adams died at HMP Birmingham on 31 October 2024 after being found unresponsive in his cell and subsequently being pronounced deceased following a cardiac arrest. The report states that his death was due to toxicity from a substance. The principal concerns were the availability of drugs and contraband in the prison, surges in drug-related incidents, and staffing levels that were insufficient to ensure his cell call bell was answered within the target time, delaying identification and response.

Andrew Herrin Dodds · Prevention of Future Deaths report View report

17 Nov 2025 South Yorkshire (Western) M. Whittle

Andrew Herrin Dodds was assessed and detained under section 136 after expressing suicidal thoughts and threatening to harm himself, but was later released and allowed to board a train. He took his own life on the train and was pronounced deceased at Tamworth train station. The principal concerns were failures to pass on next-of-kin and recent section 136 information, and missing information that might have prompted further contact with mental health services.

Ethel Mitchell ROBERTSON · Prevention of Future Deaths report View report

17 Nov 2025 Hampshire, Portsmouth and Southampton N. Walker

Ethel Mitchell ROBERTSON, who had a long history of depression and anxiety, chronic alcohol consumption and previous intentional drug overdoses, was found deceased at home on 18 February 2024. The inquest concluded that she died from the consequences of an intentional overdose taken to end her life. The report raised concerns that the Older Persons Mental Health Service was not routinely informed when its patients attended or were discharged from an emergency department for physical-health issues, potentially delaying follow-up, risk management and decision-making.

Paolino AMICO · Prevention of Future Deaths report View report

17 Nov 2025 Essex S. Hayes

Paolino Amico, who had metastatic bladder cancer and advanced clinical frailty, was admitted with severe bilateral pneumonia and died in hospital on 12 June 2024. He received multiple overdoses of slow-release morphine following a prescription error, with concerns also raised about medication administration, delayed emergency escalation, oxygen provision after discharge, and the management of morphine reversal and pain relief.

Thomas Colin Morrell · Prevention of Future Deaths report View report

17 Nov 2025 Newcastle and North Tyneside T. Crookes

Thomas Colin Morrell had hypertrophic obstructive cardiomyopathy and was admitted to hospital in October 2024 after initially being treated for abdominal issues before being found to be in heart failure. He underwent heart transplantation, which was complicated by massive bleeding and irreversible failure of the transplanted heart; support was withdrawn and he died on 3 December 2024. Concerns included delayed recognition of heart failure and the absence of a standard operating process for referring HOCM patients, as well as a lack of cardiac imaging between 2021 and 2024 to monitor deterioration.

Ronald PERRY · Prevention of Future Deaths report View report

14 Nov 2025 Manchester South A. Mutch

Ronald Perry became increasingly frail after discharge to The Lakes Care Home and experienced several falls, including a fall on 25 April 2025 that resulted in a brain bleed and fractures. He deteriorated after surgery and died at Salford Royal Hospital on 30 May 2025. Concerns included poor care and risk documentation, incomplete falls risk assessments, and inconsistent adherence to the policy on seeking medical advice for unwitnessed falls involving residents on anticoagulants.

Suzanne Julia ELLERBY · Prevention of Future Deaths report View report

14 Nov 2025 Surrey A. Loxton

Suzanne Ellerby was found deceased at her father’s home in Addlestone, Surrey, on 4 January 2025, after a period of mental health deterioration and no contact with mental health or medical practitioners since 13 December 2024. The principal concern was the transfer of vulnerable patients from secondary mental health services to primary care without universal guidance, safety-netting, or arrangements to ensure timely follow-up, leaving patients responsible for arranging care themselves.

Margaret Crooks · Prevention of Future Deaths report View report

14 Nov 2025 Manchester South A. Mutch

Margaret Crooks attended Stepping Hill Hospital after being diagnosed with a stroke and received intravenous thrombolysis. She developed a large bleed attributed to the thrombolysis, and died at Salford Royal Hospital on 20 February 2025. The report identified confusion about the level of overnight specialist stroke support and concern that time-critical treatment advice was not provided promptly or with stroke consultant input.

Christopher Graham Ayerst SAMPSON · Prevention of Future Deaths report View report

12 Nov 2025 Birmingham and Solihull A. Hodson

Christopher Graham Ayerst Sampson was a front-seat passenger in a Mazda that was struck by a Mercedes travelling at speeds exceeding 100 mph after its driver suffered an unexpected medical event. Christopher sustained unsurvivable injuries and was declared deceased at the scene. The principal concern was the risk of future deaths arising from drivers failing to self-report medical conditions to the DVLA, and uncertainty about the effectiveness and awareness of medical professionals’ reporting guidance.

Mr Barry Clive Loxston · Prevention of Future Deaths report View report

12 Nov 2025 Inner West London F. Wilcox

Mr Barry Clive Loxston died at St George’s Hospital on 30 July 2023 after complications following renal transplant surgery, including electrolyte imbalance and delayed graft function. The report identifies concerns about failures to recognise his unfitness for surgery, inadequate patient handling, unsupervised medication administration, insufficient investigation, incomplete review of blood tests, and gaps in systems for assessing transplant-list suitability and communication between nephrology teams.