Reports

Malik BUNTON · Prevention of Future Deaths report View report

15 Oct 2025 North Yorkshire and York C. Cundy

Malik Bunton was found suspended from a ligature on 17 July 2023, and his death was confirmed at the scene. The inquest concluded that he died as a result of suicide, following earlier incidents involving suicidal intent and self-harm concerns. The principal concerns related to insufficient inquiry into an earlier incident, weaknesses in the Defence Medical Service Clinical Care Review process, and delays or obstructions in gathering important evidence.

Tony Montana Duncan · Prevention of Future Deaths report View report

15 Oct 2025 City of London A. Hewitt

Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.

Paula Doreen Hughes · Prevention of Future Deaths report View report

14 Oct 2025 Inner South London L. Field

Paula Doreen Hughes was admitted to hospital after a fall and received paracetamol in excess of the recommended dose because paracetamol was prescribed alongside co-codamol. The overdose was not recognised until she had developed fulminant acute liver failure, and timely treatment was not provided. The principal concerns included preventing duplicate paracetamol prescriptions and administration, recognising and managing therapeutic excess, accurately assessing confusion, recording over-the-counter medicines, mitigating confirmation bias, and providing guidance for virtual patient reviews.

Mohan Singh Hothi · Prevention of Future Deaths report View report

14 Oct 2025 East London G. Irvine

Mohan Singh Hothi was admitted to hospital after a fall at home and was found to have a catastrophic subdural haematoma; he died later that day. Concerns included the Trust not investigating two serious injuries from previous unwitnessed falls through its Patient Safety Framework, and vague and incomplete evidence about reflection and remediation.

David Charles Noel Jones · Prevention of Future Deaths report View report

14 Oct 2025 Nottinghamshire N. Hartley

David Charles Noel Jones attended hospital after dizziness and was found to have low blood pressure and a low pulse rate. After developing chest pain and sweatiness while mobilising, he was discharged the following day and died later that day from the effects of an aortic dissection. Concerns included the failure to escalate his changing clinical condition to a senior doctor and possible gaps in learning, training and review processes relating to atypical aortic dissections.

William Roath · Prevention of Future Deaths report View report

14 Oct 2025 Worcestershire D. Reid

William Roath was admitted to hospital after falling down concrete steps and sustaining skull fractures and a traumatic brain injury. He subsequently developed aspiration pneumonia and died at Worcestershire Royal Hospital on 12 December 2024. The principal concern was that, after staff identified difficulty swallowing, there was a five-day delay in referral for specialist assessment and oral feeding continued, contributing to the development or worsening of aspiration pneumonia; the report also identified a lack of action to prevent similar errors by doctors at the Trust.

Mark Townsend · Prevention of Future Deaths report View report

13 Oct 2025 South Yorkshire (Western) T. Rawden

Mark Townsend attended a football match at Hillsborough Stadium on 28 September 2024, suffered a cardiac arrest, and later died at Northern General Hospital; the medical cause of death was acute myocardial infarction due to coronary artery disease. The Court found that stewards took additional time to summon medical assistance because they did not know where to find the nearest staff member with a radio. It found that this delay did not cause or contribute to Mark’s death, but raised concerns that similar delays could contribute to future deaths.

Jack Mathew Peatling · Prevention of Future Deaths report View report

13 Oct 2025 Essex S. Horstead

Jack Mathew Peatling, who had a very high risk of suicide, made further serious suicide attempts and was assessed as requiring urgent inpatient mental health care. No suitable inpatient bed was available for six days, during which he was managed in the community despite clinical recognition that his risk could not be safely managed there; he died by suicide on 5 June 2023. The report identified the chronic lack of available high-risk mental health inpatient beds as a principal concern.

Jamie Stuart Funnell · Prevention of Future Deaths report View report

13 Oct 2025 East Sussex R. Redman

Jamie Stuart Funnell died at HMP Lewes on 16 December 2023 while withdrawing from alcohol and drugs. The inquest concluded that his death was due to the effects of drug and alcohol withdrawal, exacerbated by omissions by healthcare and prison staff. Concerns included failures in withdrawal assessment and monitoring, communication, CPR response, staff training, equipment maintenance, and updating relevant procedures.

Abigail Eleanor Ann Jelly · Prevention of Future Deaths report View report

13 Oct 2025 Hampshire, Portsmouth and Southampton N. Walker

Abigail Eleanor Ann Jelly, a 34-year-old mother of two experiencing post-natal depression, died on 12 November 2024 after intentionally harming herself, causing fatal blood loss. The report identified concerns about inadequate perinatal mental-health training, limits on urgent specialist visits, insufficient engagement with her parents, and wider failings in professional curiosity, escalation, decision-making and risk assessment.

Izzah Fatima Ali · Prevention of Future Deaths report View report

12 Oct 2025 Cornwall and Isles of Scilly A. Cox

Izzah Fatima Ali was a nine-month-old infant who consumed cow’s milk after her parents were not informed of the risks, and the milk was not identified during multiple healthcare interactions. She was later found to be profoundly anaemic, suffered cardiac arrests during treatment, and was verified deceased on 7 September 2024. The principal concerns were the lack of appropriate interpreting support and the failure of feeding guidance to explain the risks of cow’s milk for infants under one year.

Sarah Louise Healey · Prevention of Future Deaths report View report

11 Oct 2025 West Sussex, Brighton and Hove J. Turner

Sarah Louise Healey was admitted to hospital on 4 May 2024 with severe malnutrition and complex infections after longstanding mental health difficulties and a highly restricted diet. She deteriorated and died on 1 August 2024 from respiratory failure secondary to pleural effusions, hypoalbuminaemia and malnutrition. The principal concerns were inadequate, inconsistent and insufficiently joined-up mental health care, information sharing and collaboration, particularly for patients with physical health issues, neurodiversity or difficulty attending in-person appointments.

Adrienne Caroline STUDHOLME · Prevention of Future Deaths report View report

10 Oct 2025 Lancashire and Blackburn with Darwen C. Long

Adrienne Caroline STUDHOLME died on 23 September 2023 at Royal Blackburn Hospital after readmission following a left nephrectomy, with a spontaneous splenic haemorrhage and rupture identified later that day and subsequent myocardial infarction. The report states that her death was contributed to by a delay in diagnosing and treating the splenic rupture. Concerns included inaccurate fluid-balance charts, seizure activity not being considered unless witnessed by staff, and the absence of procedures, standard operating practice, and training to ensure recent surgery was considered and communicated during emergency-department triage.

William John Puplett · Prevention of Future Deaths report View report

10 Oct 2025 North London A. Walker

William John Puplett died on 9 November 2024 after his tracheostomy tube became blocked at home, where there was no working suction unit. He suffered a significant hypoxic injury and died despite treatment; the report states that an earlier ambulance arrival might have prevented his death at that time. The substantive concern was whether emergency dispatch protocols should ask about available suction equipment and the ability to use it, with a Category 1 response if either was absent.

Jillian Anne Steedman · Prevention of Future Deaths report View report

10 Oct 2025 Essex S. Hayes

Jillian Anne Steedman died at Pitsea Station on 12 May 2023 after intentionally going into the path of an oncoming train, following a deterioration in her mental health. The report identifies concerns including failures in information sharing, risk assessment, care planning, escalation, crisis response, and review of her placement and support arrangements.

Matthew Goldsmith · Prevention of Future Deaths report View report

9 Oct 2025 East London N. Persaud

Matthew Goldsmith died on 29 October 2024 after an occluded superior mesenteric artery caused bowel ischaemia and perforation. Relevant vascular abnormalities were missed on multiple CT scans, including severe stenosis or occlusion of the superior mesenteric artery. The report also identified concern that the Trust did not have the required radiology peer review process in place.

Pauline Stirling · Prevention of Future Deaths report View report

9 Oct 2025 Gateshead and South Tyneside L. Benyounes

Pauline Stirling, who had Alzheimer’s disease and Lewy Body Dementia, deteriorated with immobility, reduced nutritional intake and increased frailty before developing worsening pressure damage. She died on 7 March 2024 at Covent House Care Home in Gateshead; the inquest recorded chronic infection due to pressure damage on a background of natural disease. Concerns included inadequate wound monitoring and documentation, inconsistent positional changes and wound care, gaps in staff training, and ongoing record-keeping problems.

Derek Crowther · Prevention of Future Deaths report View report

9 Oct 2025 Manchester South C. Morris

Derek Crowther died on 16 December 2024 on the Saffron Unit, The Meadows, Stockport, as a consequence of complications arising from cerebral amyloid angiopathy. The concerns identified were that a registered nurse was not up to date with mandatory Intermediate Life Support training and that observations were not being recorded contemporaneously through a digital system, creating potential risks in monitoring and recording deteriorating patients.

Leo Alexander Barber · Prevention of Future Deaths report View report

9 Oct 2025 South London E. Gritt

Leo Alexander Barber, aged 16, died by suicide on 28 November 2023 after stepping in front of a train. The report states that exposure to an online forum discussing methods of suicide probably reinforced his decision to end his life. Concerns include vulnerable people, including children, accessing potentially harmful online material and difficulties obtaining online activity data from service providers outside the jurisdiction of England and Wales.

William King · Prevention of Future Deaths report View report

8 Oct 2025 Milton Keynes S. Cummings

William King died at Milton Keynes University Hospital on 26 January 2025 following an aspiration episode during preparation for emergency laparotomy for bowel obstruction. The principal concerns were inadequate explanation and documentation of the risks and necessity of a nasogastric tube, failure to implement the relevant consent policy, and unclear responsibility for ensuring this aspect of care was addressed.