Find published Prevention of Future Deaths reports, the concerns they raise, who received them and any published responses.
6,433 reports
Information drawn from published reports and official responses.
John Keith William Shelley, who was wholly dependent on others following a brain injury at birth, consumed fairy liquid at a residential care home and quickly became ill. There was a significant delay in seeking and communicating advice, no timely contact with emergency services despite deterioration, and evidence that some care staff lacked current basic life-support training.
Hywel Dda University LHB
Toni Elizabeth Skillington took an excess of methadone and alcohol and contacted family members, who alerted the London Ambulance Service. Emergency paramedics arrived almost three hours later, after failures to follow procedures following unanswered welfare checks and other concerns about call handling and dispatch.
London Ambulance Service NHS Trust
Antonio Jerome Allen was admitted to Trafford General Hospital in cardiac arrest on 26 June 2013 after being found unresponsive at home, and could not be revived. Concerns were raised that midwives could not be contacted for the planned home birth and arrived only after the delivery had occurred.
Manchester University NHS Foundation Trust
Christopher John Royal suffered a cardiac event on 25 January 2013 and was found collapsed in the en-suite bathroom of Baron’s Park Nursing Home; CPR was unsuccessful. Concerns included unreliable 15-minute observation records, inadequate emergency response and first-aid training, and the potential impact of lengthy staff shifts on care.
Barons Park Care
At approximately 12:20 on 23 December 2013, Lynn Margaret Graham Gormley jumped from level 11 of Queensgate Car Park and died of multiple injuries. The report raises concerns that the car park design did not provide effective barriers to jumping, that falls also posed a risk to pedestrians, and that there had been a number of suicides from the car parks since 2006.
Hammerson PLCPelican Partners (Peterborough) LLPPeterborough City Council
Monique Susanna Whitbread died from pulmonary aspergillosis and sepsis following intra-abdominal complications related to bariatric procedures, including a gastric bypass performed for obesity. The report raised concern that freeing omental fat during the bypass may have allowed her hernia to strangulate, and noted that sleeve gastrectomy may be safer for patients with a hernia.
University College HospitalUniversity College London Hospitals NHS Foundation Trust
Edna Smither choked on sausage while being fed lunch at Peel Moat Care Home on 25 April 2013 and died later that day in hospital. Concerns included limited up-to-date first-aid certification, a delay caused by a locked door, panic and a lack of calm leadership or training, and failures to report incidents under RIDDOR without delay.
Harbour Healthcare Ltd.United Care (North) Limited
Anne Whitworth developed worsening abdominal symptoms and became acutely unwell on 8 September 2013. She suffered respiratory and cardiac arrest while being taken to hospital and died later that evening; a post-mortem examination identified aspiration of gastric contents due to intestinal obstruction caused by volvulus of the sigmoid colon. Concerns included the failure to access her prior GP records out of hours and a missed opportunity to escalate her treatment.
Local Care Direct Limited
Gary William Million telephoned 111 on 23 November 2013 but could not provide clear information about his location and then became silent. There was a prolonged delay in locating his address, including an incorrect address being given to the ambulance, and the crew attended the correct address at 01:10. The concerns included inadequate procedures and training for locating potentially seriously ill callers, communication issues with BT, weaknesses in the investigation and insufficiently robust follow-up procedures.
Department of Health and Social CareNorth East Ambulance Service NHS Foundation Trust
Andrew John Hooper died after taking methadone prescribed to his girlfriend, with the stated cause of death being respiratory failure, hypoxic brain injury and methadone toxicity. The concerns were that the medication was not secured, was available in a quantity sufficient for a fatal dose, and that the person prescribed it appeared unaware of the risks to others and unable to keep it safe.
Clinical Commissioning Group (Devon)Local Drug and Alcohol Team (Devon)NHS Devon Integrated Care Board
Suzanne Cammell died on 3 October 2013 after lying beneath the wheels of a lorry in a layby near Burford Golf Club; she sustained severe blunt head injuries when the lorry drove away. The principal concern was that high-risk information about the incident and a previous similar incident may not have been communicated by Thames Valley Police to Gloucestershire Constabulary or made available to the officer conducting a welfare check.
Gloucestershire Constabulary
Frances Claire Andrade died after taking an overdose of fluoxetine and insulin, following a period involving repeated overdoses and increasing distress around criminal proceedings. The report raised concerns about advice and support for vulnerable witnesses, explanations of trial directions, and securing medication prescribed to another family member after repeated overdoses.
Crown Prosecution ServiceSurrey and Borders Partnership NHS Foundation Trust
Hope Erin Evans, a premature baby born at 26 weeks, died from sepsis contributed to by ESBL E. coli contracted in hospital. The report states that the source was likely another baby, although the means of transfer was unknown. Concerns included important patient history not being captured and passed between hospitals, and the failure to complete All Wales Inter Hospital Transfer documentation.
Welsh Government
Faye Elizabeth RIPPON was delivered prematurely at 21 weeks’ gestation on 8 February 2014 at North Devon District Hospital following medical termination of pregnancy to save her mother’s life. The report raised concerns that a late termination resulted in a live birth, including the distress caused to the midwives and parents, and noted that a similar case had recently occurred.
North Devon District Hospital
Charles Cecil Lawrence fell twice at the residential home where he lived on 2 April 2013, later deteriorated, and was diagnosed with an untreatable spinal injury before dying in hospital on 23 May 2013. The concern identified was that Alexandra Rose Care Home did not have a protocol requiring a doctor to examine a resident who suffered more than one fall within 24 hours.
Alexandra Rose Residential Care Home
Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.
NHS Surrey and Sussex Integrated Care BoardRoyal College of PathologistsRoyal College of PhysiciansRoyal College of PsychiatristsSurrey and Borders Partnership NHS Foundation TrustWoodlands Surgery
The supplied material identifies Stephen Mark AMER as the deceased person. It does not provide details of the circumstances of death or substantive concerns.
Hertfordshire County Council
Nathan James Healer was born on 03/02/2014 and died on 05/02/2014 after developing signs including low temperature, poor feeding and jittering arms. His first blood glucose measurement, taken almost five hours after birth, was 0.2 mmol/L. The principal concern was that the severity of his condition was not appreciated and he was not given a more timely blood glucose test, in the context of existing clinical guidance.
Department of Health and Social Care
Edna Bulmer, who had a history of falls, suffered an unwitnessed fall on 10 September 2013 and was later found unconscious in bed. She died in hospital on 15 September 2013 after sustaining a serious intracranial haemorrhage. The concerns identified were inconsistent recording of her falls risk, delays in providing the identified pressure mat and pendant, and the apparent absence of a clear process for reviewing her risk assessment after further falls.
Dovecote Lodge
Donna Kirkland was found deceased in her bed on 22 August 2013 after ingesting alcohol-based hand sanitising gel while detained on a mental health ward. The principal concerns were patients’ unrestricted access to the gel, permission to decant and keep it in rooms, and insufficient staff awareness of its alcohol content and potential ingestion.
Coventry and Warwickshire Partnership NHS TrustDepartment of Health and Social CareAccount
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