Reports

Keith REYNOLDS · Prevention of Future Deaths report View report

10 Sep 2025 Newcastle and North Tyneside T. Crookes

Keith Reynolds underwent carotid artery stenting followed by coronary artery bypass and mitral valve repair. He subsequently suffered an ischaemic stroke after the stent became blocked by a blood clot and died on 14 November 2024. The report raises concern that mechanical thrombectomy was unavailable outside 9.00am to 5.00pm because of insufficient neuroradiologists, potentially preventing treatment for some patients.

Walter Colin HORTON · Prevention of Future Deaths report View report

10 Sep 2025 South Yorkshire (Eastern) N. Mundy

Walter Colin HORTON, an 88-year-old male, died in a nursing home on 10 January 2025. The recorded causes included sepsis and an advanced sacral pressure sore, with ischaemic heart disease also noted. Concerns included poor record keeping and failures to understand or follow aseptic techniques and cleanliness when managing wounds, increasing the risk of infection.

Stuart GILCHRIST · Prevention of Future Deaths report View report

10 Sep 2025 East Riding and Hull L. Harris

Stuart GILCHRIST, aged 77, died after choking on food at a restaurant during an outing with care home staff and other service users. Despite prompt first aid, emergency treatment and CPR, he was declared deceased. The principal concern was that restaurants and food establishments may not be aware of, or have access to, LifeVac-type suction devices that may assist during choking incidents.

Mabel Olivia Williams · Prevention of Future Deaths report View report

10 Sep 2025 Avon R. Sowersby

Mabel Olivia Williams was born alive after a trial of vaginal birth after caesarean section and died six days later in a neonatal intensive care unit following severe hypoxic-ischaemic encephalopathy associated with an undiagnosed uterine rupture. The concerns included inadequate information and informed consent about the risks of uterine rupture, failures to recognise or communicate signs of distress in time, and delays in making appropriate changes after serious clinical incidents.

Brian Burrows (also known as Brian Smith) · Prevention of Future Deaths report View report

9 Sep 2025 West Yorkshire Eastern N. McLoughlin

Brian Burrows died on 15 May 2024 after using a ligature while detained at HMP Leeds. He was subject to ACCT monitoring requiring three observations per hour, but was not checked for 53 minutes during a period when the landing was extremely busy and numerous emergency cell bells were activated. The concerns identified were a lack of training and briefing guidance for prison officers on prioritising competing tasks, including emergency cell bells and ACCT checks.

Mabel Olivia Williams · Prevention of Future Deaths report View report

8 Sep 2025 Avon R. Sowersby

Mabel Olivia Williams suffered a fatal hypoxic injury during a trial of vaginal birth after caesarean section and died six days later in a neonatal intensive care unit in Bristol. The report identified concerns that information about VBAC did not explain that uterine rupture could be fatal, and that indicators of Mabel’s distress and her mother’s worsening condition were not recognised or conveyed in time to expedite her birth safely.

Maureen Gilbert · Prevention of Future Deaths report View report

8 Sep 2025 Derby and Derbyshire M. Kewley

Maureen Gilbert, who was 83 years old, drowned in her home on 21 October 2023 after flood waters entered her property during Storm Babet. The report raises concern that the absence of flood defences at Tapton Terrace leaves residents, particularly those who may be elderly, vulnerable or immobile, at risk of life.

Victoria Anne TAYLOR · Prevention of Future Deaths report View report

5 Sep 2025 North Yorkshire and York C. Cundy

Victoria Anne Taylor’s mental health deteriorated between May and October 2024, involving suicidal ideation, self-harm and binge drinking. She was reported missing on 1 October 2024, and her body was recovered from the River Derwent on 22 October 2024. The principal concerns were that mental health services did not offer a treatment pathway addressing reported childhood trauma, provided limited safety planning, and did not suggest or convene a multi-agency approach despite knowing that several agencies were involved.

James Ralph COCHRANE · Prevention of Future Deaths report View report

5 Sep 2025 Rutland and North Leicestershire R. Connell

James Ralph Cochrane, who had schizoaffective disorder with fluctuating mood and psychosis, died on 17 November 2023 after jumping from an overbridge into the carriageway and being struck by a vehicle. The report raises concerns about how carers’ views and video evidence are considered and used in safety planning, and about the support provided to carers assisting mental health patients at home.

Nicola MULLISS · Prevention of Future Deaths report View report

4 Sep 2025 Newcastle and North Tyneside T. Crookes

Nicola Mulliss died on 18 February 2025 after a wound infection following meningioma surgery spread and caused staphylococcal meningitis, disrupting the blood supply to her brain. The principal concern was that no wound swab was taken when it was re-sutured, so the infection might not have been detected and treated before it spread; such testing was not policy or guidance at the time.

Khalif Mohammed · Prevention of Future Deaths report View report

4 Sep 2025 Birmingham and Solihull L. Hunt

Khalif Mohammed, who was detained in hospital under section 3 of the Mental Health Act, failed to return from unescorted leave on 6 January 2025 and was found deceased at his flat the following day. The medical cause of death was recorded as haemopericardium and haemothorax due to a stab wound, and the inquest conclusion was suicide. The report raised concerns about insufficient police resources and a significant delay in allocating officers to his priority missing-person case.

Cheryl Dawn Lorna Edwards · Prevention of Future Deaths report View report

4 Sep 2025 Hertfordshire G. Sullivan

Cheryl Dawn Lorna Edwards was struck and killed by a car while crossing Sarratt Road, Croxley Green, on 28 September 2023. The principal concern was that the 60mph speed limit was too high for the stretch of Sarratt Road between the M25 over-bridge and the speed restriction sign for Sarratt Village.

Peter Malcolm THOMAS · Prevention of Future Deaths report View report

3 Sep 2025 South Wales Central R. Knight

Peter Malcolm Thomas, aged 78, was admitted with a serious infection and delirium after collapsing, but was treated under the CIWA protocol after giving an erroneous account of alcohol use. He received 80 mg of diazepam over six hours, did not regain consciousness after antidote treatment, and died from bronchopneumonia associated with osteomyelitis and peripheral vascular disease. The principal concerns were that CIWA may not account adequately for age, delirium, confusion, metabolic differences, or lack of collateral information, and that its use could result in unnecessary high-dose sedation and future deaths.

Lucy-Anne DYSON · Prevention of Future Deaths report View report

3 Sep 2025 Hampshire, Portsmouth and Southampton D. Stewart

Lucy Rushton died on 23 June 2019 in the early hours of the morning following a prolonged, severe and brutal attack, with multiple blunt force injuries; the narrative conclusion recorded that she was unlawfully killed. The principal concerns were the lack of a national interface for sharing safeguarding information between schools and relevant agencies, and the lack of national guidance or standards governing safeguarding referrals.

Marcia Grant · Prevention of Future Deaths report View report

3 Sep 2025 South Yorkshire (Western) M. Whittle

Marcia Grant, a foster carer, died on 5 April 2023 after suffering significant chest injuries when a vehicle driven by her foster child collided with her. The report identified concerns about a shortage of placements, incomplete documentation and communication of risks, and inadequate risk assessment when placing the child with the Grant family.

Margaret Bailey · Prevention of Future Deaths report View report

3 Sep 2025 Manchester South A. Bridgman

Margaret Bailey, who was bed-bound and wholly dependent on personal care, became unwell at home on 17 December 2023, later vomited while resting in bed, and was found unresponsive. The medical cause of death was aspiration of gastric contents following an episode of vomiting. Concerns included the absence of a triage algorithm for calls reporting that a client was unwell and the lack of equipment or ability to take basic observations, including a temperature reading.

Edward John FUNNELL · Prevention of Future Deaths report View report

2 Sep 2025 South Wales Central A. Morse

Edward John Funnell died on 29 April 2023 at Ystradgynlais Community Hospital after developing a worsening pressure ulcer and an ischaemic left leg during hospital care, for which he received palliative care. The principal concerns were that a podiatry referral was not followed up, nursing staff lacked knowledge about podiatric interventions for pressure wounds and circulatory problems, and recommended wound dressings were not followed.

Name not published · Prevention of Future Deaths report View report

1 Sep 2025 Inner North London I. Potter

████████ was detained under the Mental Health Act and admitted to psychiatric wards at the Tower Hamlets Centre for Mental Health before being found unresponsive in a patient room on 7 June 2022; her death was verified later that day. The jury identified several contributing factors, including a non-functioning door-locking system and shortcomings in patient observations. Further concerns included risk assessment, staff understanding and attitudes towards risk, auditing, and clinical oversight.

Audrey Newman · Prevention of Future Deaths report View report

29 Aug 2025 Manchester South A. Bridgman

Audrey Newman was admitted after a seizure and suspected encephalitis, but a planned lumbar puncture was delayed until 18 November 2024 because of difficulties involving staff competence, patient agitation and lack of consultant ownership. She subsequently developed severe renal failure while receiving acyclovir and antibiotics, and died from recognised risks of antiviral therapy for a suspected life-threatening condition. The principal concern was the absence of a formal pathway for escalating or referring difficult or delayed lumbar punctures to the anaesthetic team, creating a risk of future delays to crucial diagnostic tests and a risk of death.

Edwin Everett Milne Price · Prevention of Future Deaths report View report

28 Aug 2025 Somerset V. McKinlay

Edwin Everett Milne Price, who lived in a nursing home and required hoisting for transfers, was admitted to hospital with diabetic ketoacidosis and fell out of bed the following day. He sustained a fractured humerus and a retroperitoneal bleed, which was recorded as the cause of his death. The principal concerns were that his falls risk assessment was not completed within 24 hours, relevant information was not obtained from the nursing home, and mitigation measures were not put in place.