Reports

Mr Barry Peter Joseph Davies · Prevention of Future Deaths report View report

12 Jun 2026 Manchester North J. Kearsley

Mr Barry Peter Joseph Davies fell while walking to his GP surgery on 20 October 2025 and was admitted to hospital with a brain bleed. The concerns were that neurological observations were not carried out as frequently as required before his deterioration, and that they were discontinued while he was awaiting a second CT scan.

Suzanne FREDERICKS · Prevention of Future Deaths report View report

12 Jun 2026 Essex S. Simblett

Suzanne FREDERICKS, who had previously undergone a liver transplant, was admitted to Colchester General Hospital with liver and kidney problems and died there on 4 November 2024 after treatment was unsuccessful. The principal concern was whether clinicians caring for transplant patients in non-specialist hospitals could obtain sufficiently up-to-date blood test results, as delays in processing laboratory results might affect treatment and survival.

Ismaeel ISLAM · Prevention of Future Deaths report View report

11 Jun 2026 Inner North London M. Hassell

Ismaeel Islam died at the Royal London Hospital after a cardiorespiratory arrest, with the stated medical causes including pulmonary and chronic lung complications, hypoxic-ischaemic encephalopathy, and trisomy 21 with congenital heart defects and lung growth disorder. Before the collapse, his desaturation and respiratory arrest were not recognised for approximately half an hour because the monitor alarm was not usefully audible and his cot was not within the caring nurse’s line of sight. The principal concern was whether monitor alarm volumes should be locked or set to maximum by default to improve patient safety.

Lesley Katherine HIGGINSON · Prevention of Future Deaths report View report

10 Jun 2026 Cheshire Jacqueline Devonish

Lesley Katherine HIGGINSON, a medically vulnerable adult aged 72, was found deceased at home on 18 January 2026 after failed remote welfare and medication contacts. A principal concern was uncertainty about the ambulance service policy for declining welfare-check requests, including whether the request in these circumstances was properly rejected and whether responsibility was affected by the police RCRP policy.

Judith Marsland · Prevention of Future Deaths report View report

10 Jun 2026 Manchester South A. Morris

Mrs. Marsland died in hospital on 14 November 2025 after a urinary infection progressed to sepsis, septic shock and multiorgan failure. The principal concerns were that abnormal blood results were not reviewed or escalated, she was discharged without antibiotics, and key action-plan measures for structured handover and named clinical responsibility had not been implemented.

Edie Grace Smart · Prevention of Future Deaths report View report

9 Jun 2026 Newcastle and North Tyneside Georgina Nolan

Edie Grace Smart, aged 13, died in hospital on 28 July 2025 after being rescued from the sea at Whitley Bay four days earlier. Emergency crews struggled to secure her airway, and the first ambulance personnel on scene were Ambulance Support Practitioners who were not permitted to use an i-gel without paramedic supervision. The substantive concern was that Ambulance Support Practitioners may often be first on scene at an out-of-hospital cardiac arrest but are trained to use i-gels only under paramedic supervision.

Charlotte Marie SAUNDERS · Prevention of Future Deaths report View report

8 Jun 2026 Staffordshire and Stoke-on-Trent L. Tonks

Charlotte Marie Saunders was struck by a tipper lorry while crossing Christchurch Way in Stone, Staffordshire, on 27 August 2024, sustaining multiple injuries and a severe traumatic brain injury that resulted in prolonged disorder of consciousness and 24-hour care. She died on 13 January 2026; the principal concern was that the road layout, including gaps in pedestrian guardrails between a supermarket and the town centre, encouraged pedestrians to cross at an unsafe location near a busy bypass despite nearby controlled crossings.

Barbara Joan COPE · Prevention of Future Deaths report View report

8 Jun 2026 South Yorkshire (West) Louise Slater

Barbara Joan COPE, a 75-year-old woman, presented to Rotherham Hospital with decreased conscious levels, slurred speech and reduced oral intake, and was later found to have a high paracetamol level. The result was not reviewed or acted upon for approximately 19 hours, delaying time-critical treatment. The principal concerns were failures in communicating and following up abnormal results, reviewing investigations during clinical deterioration, and clearly assigning responsibility for ongoing care.

Prabhabi Cangi · Prevention of Future Deaths report View report

5 Jun 2026 North London Andrew Walker

Prabhabi Cangi died in Harefield Hospital on 12 August 2025 after an ST elevation myocardial infarction, following an ambulance attendance at her home where she had chest pain, breathlessness and an abnormal ECG. The principal concerns were the lack of a clear pathway for specialist interpretation of abnormal ECGs when paramedics did not convey patients to hospital, and the failure to ensure that intermittent chest pain, breathlessness and abnormal ECG findings resulted in hospital assessment.

Keith Richard Gandy · Prevention of Future Deaths report View report

5 Jun 2026 North London Andrew Walker

Keith Richard Gandy died in hospital on 29 October 2025 after deterioration following a fall and was found to have a rare radiation-induced osteosarcoma of the pelvis. The concerns were that guidance did not clearly identify previous cancer as a red flag requiring specialist referral without waiting for further tests, and that specialist evaluation waiting times could be between six and twelve months.

Neeshat Dalal · Prevention of Future Deaths report View report

5 Jun 2026 East Sussex R. REDMAN

Neeshat Dalal was admitted for severe depression after experiencing difficulty eating and drinking and undergoing three attempts to end her life with an insulin overdose. She collapsed during her third ECT treatment on 13 December 2022, was transferred to the emergency department, and died in the Acute Medicine Unit in the early hours of 14 December 2022. The concerns included inadequate consideration of her nutritional needs and vomiting, insufficient medical information before ECT, and delays or omissions in aspects of her acute hospital care.

Mrs Mary (also known as Moira) Forlin · Prevention of Future Deaths report View report

5 Jun 2026 West Sussex, Brighton and Hove Joseph Turner

Mrs Mary Forlin was admitted to hospital after a fall at home with a long lie and was suffering from respiratory failure, likely driven by an infection of unknown source. She later collapsed and died from multiorgan failure arising from the infection and respiratory failure. The principal concerns were that clinicians did not actively follow guidance to review antibiotic treatment, microbiological testing was not undertaken early, and policies, systems and electronic records did not provide proactive checks or alerts to support infection testing, treatment and review when treatment was ineffective.

David MARRIOTT · Prevention of Future Deaths report View report

3 Jun 2026 Nottingham and Nottinghamshire Laurinda Bower

David Marriott died at City Hospital, Nottingham, on 18 July 2025 from metastatic lung cancer diagnosed in May 2025. The report identified missed opportunities to arrange a follow-up chest x-ray after his February 2024 Emergency Department visit, including failures to follow guidance and to review radiology reports received after discharge. It also raised concerns about inadequate discharge summaries, lack of quality assurance, and failure to provide summaries to patients.

JOHN SOUTHAM KEEN · Prevention of Future Deaths report View report

3 Jun 2026 Devon, Plymouth and Torbay Nicholas Lane

John Southam Keen, who had a known ascending aortic aneurysm, developed sudden chest pain radiating to his back and neck at home on 19 August 2023. Paramedics recorded the aneurysm incorrectly as abdominal and took him to a local acute hospital rather than directly to a specialist arterial centre; after a delay, he suffered cardiac arrest before surgery, sustained a fatal hypoxic brain injury and died on 24 August 2023. The report raises concerns about the paramedics’ assessment, SWAST NHS’s inadequate incident review, and confusing and unclear ambulance guidance on suspected aortic dissection.

Jack Horace BURTON · Prevention of Future Deaths report View report

3 Jun 2026 Worcestershire D. Lakin

Jack Horace BURTON, who had schizophrenia and was prescribed Clozapine, died of Clozapine toxicity after stopping smoking while on holiday in North Yorkshire. Concerns included inconsistent medical accounts about the relevance of reducing smoking and a lack of standardised guidance for asking and recording information about possible medication side effects.

Francis Leech · Prevention of Future Deaths report View report

2 Jun 2026 Worcestershire D. Reid

Francis Leech, who had advanced dementia and other significant medical conditions, died on 26 August 2024 after a decline following severe facial injuries inflicted by another care home resident. The principal concerns were that the resident’s aggressive behaviour and associated risks were not properly reflected in updated care and behavioural support plans, and that management and the subsequent internal investigation failed to identify or address these deficiencies.

Phillip Tetley · Prevention of Future Deaths report View report

1 Jun 2026 Nottingham and Nottinghamshire Nathanael Hartley

Phillip Tetley died on 1 December 2025 after being struck by vehicles while crossing the A620 Straight Mile in Ranby. The report raised concerns about the lack of provision to assist people crossing the road, the increased use of the overflow carpark, and incomplete warning signage that might leave drivers unaware of the risks.

Katharine Emma Corrigan · Prevention of Future Deaths report View report

1 Jun 2026 Essex Sonia Hayes

Katharine Emma Corrigan, a patient detained under the Mental Health Act, died by suicide after failing to return from unescorted leave on 22 July 2023. The report identifies concerns about failures in the management and recording of Section 17 leave, inadequate risk assessments and care planning, staffing and oversight, and failures concerning access to recognised treatment for a pre-existing hormonal imbalance.

Alex Alfred ROBINSON · Prevention of Future Deaths report View report

28 May 2026 Shropshire, Telford and Wrekin J. Ellery

Alex Alfred Robinson was admitted to Royal Shrewsbury Hospital on 8 September 2025 and was later found unresponsive at Church Lane, Little Wenlock, Telford, on 10 September 2025 after ligaturing himself; he was declared deceased at the scene. The principal concern was conflicting information about whether the Mental Health Liaison Team was available and whether a formal referral had been made, representing a possible lost opportunity for him to receive appropriate care, although this could not be known to have prevented his death.

Lacey Carole Anne HEATH · Prevention of Future Deaths report View report

28 May 2026 Essex S. Hayes

Lacey Carole Anne HEATH died on 16 February 2025 after collapsing at home and suffering cardiac arrest en route to hospital. The death followed thrombosis and complete stenosis of her mechanical aortic valve in the context of sub-therapeutic anticoagulation. Concerns included difficulty maintaining therapeutic anticoagulation, lack of access to affordable at-home monitoring, absence of a funding application, insufficient medical review or haematology referral, and inadequate clinical records.