Reports

Mrs Rashida Sultana · Prevention of Future Deaths report View report

23 Oct 2025 Black Country Z. Siddique

Mrs Rashida Sultana died on 20 November 2024 after choking on chips and water while admitted to hospital. Concerns included confusion among nursing staff about when to call the Emergency Medical Response Team when a DNAR was in place, and insufficient risk assessment regarding Speech and Language Therapy assessments for patients at risk of dysphagia.

Lynn SILCOCK · Prevention of Future Deaths report View report

23 Oct 2025 Shropshire, Telford and Wrekin H. Westerman

Lynn Silcock was admitted to hospital in September 2022 with symptoms including breathlessness and fatigue, and was diagnosed with aortic stenosis among other conditions. She was discharged without a cardiology referral, appointment or plan, and a gastroscopy report was not followed by a cardiology referral. She died at home on 10 July 2025; the postmortem identified aortic stenosis on a background of bicuspid aortic valve, with myocardial fibrosis. The report raised concerns about communication and document exchange between teams, the absence of an appropriate referral, and the lack of an investigation into what went wrong.

Ann Campbell · Prevention of Future Deaths report View report

23 Oct 2025 Cornwall and Isles of Scilly A. Cox

Ann Campbell was found deceased at the foot of steep concrete steps leading to her basement flat on 15 November 2024, having sustained a skull fracture likely caused by falling down the steps; alcohol intoxication was also recorded. The principal concern was that the steps were difficult to access because the handrail was too low to allow someone descending to steady themselves.

Ricky James MONAHAN · Prevention of Future Deaths report View report

22 Oct 2025 Birmingham and Solihull L. Hunt

Ricky James MONAHAN, a resident of a rehabilitation unit detained under section 37 of the Mental Health Act, died after falling from a height on 18 March 2025. The report identified an unprotected fire escape accessible from the garden and roof, no environmental risk assessment of this access, reliance on individual risk assessments, and a lack of guidelines for protecting fire escapes in rehabilitation settings.

Amber Grace Walker · Prevention of Future Deaths report View report

21 Oct 2025 Dorset B. Allen

Amber Grace Walker, who had epilepsy and uncontrolled nocturnal tonic-clonic seizures, was found deceased at home on 19 April 2023. A post-mortem examination identified Sudden Unexpected Death in Epilepsy (SUDEP) as the medical cause of death. The concerns were that SUDEP and Amber’s individual risk, including the implications of declining increased medication, were not discussed with her, and that SUDEP discussions and related training for doctors were not consistent or universal.

Paul John APPLEBY · Prevention of Future Deaths report View report

21 Oct 2025 Northamptonshire A. Pember

Paul Appleby was arrested for drink driving, remanded in custody, and advised to be seen by Court Liaison and Diversion before release. He was not seen by the team and was found deceased after jumping from the Grosvenor Centre on 22 February 2025; the concern was that the lack of a Saturday Court Service could give rise to future deaths.

Steven Roy Davidson · Prevention of Future Deaths report View report

21 Oct 2025 Essex S. Simblet

Steven Roy Davidson died while in prison after a history of self-harm during a previous prison stay. The report identifies concerns that healthcare staff at HMP Chelmsford could not sufficiently navigate or search System One records, or did not sufficiently understand the importance of previous self-harm information when assessing his mental health and risk.

Scott Stephen Berry · Prevention of Future Deaths report View report

20 Oct 2025 East Riding and Hull S. Middleton

Scott Stephen Berry was a prisoner serving an Imprisonment for Public Protection sentence when, after expressing suicidal thoughts, he was found hanging on 12 October 2023. He was resuscitated and taken to hospital but died on 21 October 2023 after sustaining a hypoxic brain injury. The principal concern was that unreleased IPP prisoners may face prolonged detention, limited access to progression or therapeutic support, poor mental health and little hope of release, creating a risk of future deaths.

STUART MARTIN FOWKES · Prevention of Future Deaths report View report

20 Oct 2025 Black Country J. Lees

STUART MARTIN FOWKES died at his home on 26 May 2025 after travelling from the West Midlands to Cornwall and back while reportedly suicidal and likely under the influence of alcohol. The principal concern was that Devon and Cornwall Police recorded information about a known risk to his life, but this risk was not shared with West Midlands Police; by the time concerns for his safety were raised locally, he was likely already deceased.

Declan Carr · Prevention of Future Deaths report View report

20 Oct 2025 East Riding and Hull S. Middleton

On 28 August 2023, Declan Carr was found deceased in his cell at HMP Humber and was declared deceased by paramedics. The report identified failures involving communication about his psychosocial substance-misuse support during transfer between prisons, healthcare reception screening, induction documentation and allocation of a keyworker. It raised concern that inadequate continuity of psychosocial support for drug misuse could pose a risk of future deaths.

John Christopher RUST · Prevention of Future Deaths report View report

20 Oct 2025 Birmingham and Solihull A. Hodson

John Christopher RUST underwent elective thoracic aortic replacement surgery and subsequently suffered uncontrolled cerebrospinal fluid loss after his drain became disconnected, causing a catastrophic and unsurvivable brain injury. He died on 29 March 2025. The principal concern was that staff training on automated CSF drainage systems was not mandatory or embedded sustainably, creating a risk of future deaths.

Ms. Amy Jo Cross · Prevention of Future Deaths report View report

20 Oct 2025 Avon P. Harrowing

Ms. Amy Jo Cross was arrested on 9 June 2023, experienced reported drug and alcohol withdrawal symptoms, and died in a prison cell on 10 June 2023 after being found unresponsive before prescribed medication was administered. The report identified concerns about the transfer of healthcare information, including recent medication administration and physical observations, between police, court and prison healthcare providers, and the absence of a shared medical records system.

Marc Daniel DAVIES · Prevention of Future Deaths report View report

20 Oct 2025 Gwent C. Saunders

Marc Daniel Davies was found unconscious at the Huntsman Hotel on 16 October 2024 after staff were alerted that he was unwell. He was not revived and died at the hotel; the inquest recorded the medical cause of death as the combined toxic effects of methadone, clonazepam and nitrazepam. The report raises concerns about inadequate welfare checks, insufficient documentation, and a lack of evidence that staff had been trained to conduct or document welfare checks.

Alexander Philip MCCORMACK · Prevention of Future Deaths report View report

19 Oct 2025 Northamptonshire S. Lomas

Alexander Philip McCormack was found deceased in a tent at Fermyn Woods Country Park on 27 February 2023 after expressing suicidal thoughts and plans and contacting mental health services with an intention to end his life. The inquest concluded that his death was suicide. Concerns were raised that delays in transferring missing-persons information between police forces could affect risk assessment and the formulation of lines of inquiry, particularly where officers lacked training in importing cases onto the COMPACT system.

OWEN AUSTIN DONNELLY · Prevention of Future Deaths report View report

17 Oct 2025 Manchester West T. Brennand

OWEN AUSTIN DONNELLY was discovered collapsed and unresponsive in the garden of his residence on 16 February 2025, with a self-inflicted head wound, and was verified dead by attending paramedics. The inquest concluded suicide. Concerns included the ability to research, access, download and use material widely available on the internet, the fact that possession of material enabling construction of such a weapon was not then a criminal offence, and the risk posed while proposed legislation remained under consideration.

MELANIE JAYNE WALKER · Prevention of Future Deaths report View report

17 Oct 2025 Manchester West T. Brennand

Melanie Jayne Walker, who had a complex medical history and drug and alcohol dependency, was found collapsed and partially responsive on 17 December 2024 and later suffered an unobserved cardiac arrest in hospital. She sustained an irreversible hypoxic brain injury and died on 26 December 2024 after life support was withdrawn. The principal concern was that her heart monitor did not alert staff to the cardiac event, partly because monitoring equipment had become disconnected and the monitor’s alert system did not re-alarm after acknowledgement, creating an ongoing patient-safety risk.

Martin Gareth EVANS and 2 others · Prevention of Future Deaths report View report

16 Oct 2025 Cumbria R. Cohen

Martin Gareth Evans and Patricia Mary Evans died after another driver experienced syncope and collided with their vehicle on 13 February 2023. Neil Errington died after another driver had a seizure and collided with his vehicle; he died in hospital on 12 May 2022. The substantive concern was that relying on drivers with medical impairments to self-report to the DVLA may allow some to continue driving despite advice not to do so, risking future deaths.

Theo Treharne-Jones · Prevention of Future Deaths report View report

16 Oct 2025 South Wales Central G. Knox

Theo Treharne-Jones, aged 5, died by drowning in a swimming pool at a holiday village in Kos, Greece, after leaving his hotel room unnoticed while his parents were asleep. The hotel room locks did not prevent him from leaving, there was no secondary security measure, and the pool had no physical barrier to prevent uncontrolled or unsupervised access by children. Theo was unable to swim and had developmental delay and no sense of danger.

Mr Thompson Elliott · Prevention of Future Deaths report View report

15 Oct 2025 Sunderland D. Place

Thompson Elliott, a care home resident, was admitted to hospital with chest pains and discharged with changed opioid medication. Because the discharge letter could not be located, both old and new opioids were administered, resulting in an overdose; he later contracted influenza A in hospital and died after respiratory failure. The principal concerns were unclear procedures, inadequate medication recording and administration, and inconsistent staff decisions when discharge information was unavailable.

Katie Overd · Prevention of Future Deaths report View report

15 Oct 2025 Manchester North J. Kearsley

Katie Overd, aged 46, died at home on 20 March 2025. The inquest concluded that she died from an unintended overdose of prescribed medication against a background of longstanding inappropriate prescribing and delayed medication reduction. The report raised concern that the lack of proactive public communication about the Right Care Right Person process could delay families seeking assistance in emergencies.