Reports

Abbigail Louise SMITH · Prevention of Future Deaths report View report

27 May 2026 Essex Sonia Hayes

Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

Abigail Louise SMITH · Prevention of Future Deaths report View report

27 May 2026 Essex Sonia Hayes

Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after attempting to suspend herself; resuscitation was unsuccessful and she was pronounced deceased at 00:08 on 16 February 2022. The report identifies concerns about inadequate trained staffing and observation, unsuitable care arrangements, access to ligature materials, insufficient risk assessments and care plans, communication adjustments for autism and learning disability, and an unsafe discharge from hospital.

Abigail Louise SMITH · Prevention of Future Deaths report View report

27 May 2026 Essex Sonia Hayes

Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after unsuccessfully trying to suspend herself, and was pronounced dead at 00:08 on 16 February 2022 from compression of the neck. The report describes concerns about failures in mental-health care, including inaccurate records and diagnosis information, inadequate adjustments for autism and learning difficulties, medication-management problems, and discharge from detention without an effective plan to mitigate a known and immediate risk of suicide.

Kristian Edward Allen · Prevention of Future Deaths report View report

26 May 2026 West Sussex, Brighton and Hove G. Jones

Kristian Edward Allen, who had complex mental health issues and a history of drug and alcohol abuse, died at Millview Hospital on 16 February 2025 after taking heroin, cocaine and alcohol. The report identifies concerns about inappropriate authorisation of leave, inadequate searches and observations, poor communication, and a delayed and ineffective response to his cardiac arrest. The concerns also include staff being insufficiently trained to manage cardiac arrests and drug overdoses in acute mental health wards.

John Thomas Cleave · Prevention of Future Deaths report View report

26 May 2026 Devon, Plymouth and Torbay Stephen Covell

John Thomas Cleave sustained a cervical spine fracture and probable haemothorax in an unwitnessed fall at his allotment on 28 December 2023. He died at Torbay Hospital on 29 December 2023 after vomiting, aspirating and suffering cardiac arrest. Concerns included the CT scan report failing to identify a high suspicion of haemothorax, the lack of out-of-hours consultant radiologist cover, and his care not being transferred promptly to a major trauma centre.

David John Smart · Prevention of Future Deaths report View report

22 May 2026 West Sussex, Brighton and Hove J. Andrews

David John Smart developed a life-threatening rectal bleed after a polypectomy and required surgery after conservative management continued to be unsuccessful. He died from known complications of Andexanet Alfa, used to reverse Rivaroxaban so that surgery could be performed. The inquest raised concerns about patients being cared for in corridors when the Emergency Department reached capacity, including the continued use of corridors despite actions intended to improve patient flow.

Jacqueline Marie Antoinette Frehe · Prevention of Future Deaths report View report

22 May 2026 Somerset V. McKinlay

Jacqueline Marie Antoinette Frehe, aged 97, was admitted to hospital with swallowing difficulties, vomiting and suspected aspiration pneumonia. Her nil by mouth status was not communicated to ward staff, and she was given food and drink, after which she vomited, deteriorated significantly and died within about two hours. The concerns related to communication and documentation of nil by mouth status and checking this status when patients with dysphagia and suspected aspiration pneumonia arrive on the ward.

George Edward James Haldenby · Prevention of Future Deaths report View report

21 May 2026 Dorset Rachael Griffin

George Edward James Haldenby was a serving prisoner with severe heart failure who collapsed at HMP The Verne on 29 January 2022 and died that day at Dorset County Hospital. The report identifies delays in receiving an increased dose of Furosemide, and a delay in recognising the collapse and starting CPR, as substantive concerns. It also raises concerns about the absence of regular refresher training in first aid and CPR and the lack of a clear process for handling hospital prescriptions issued outside prison healthcare hours.

Leslie Keith Williams · Prevention of Future Deaths report View report

21 May 2026 Swansea and Neath Port Talbot A. Gruffydd

Leslie Keith Williams lost consciousness while in the sea at a resort in Hurghada, Egypt, and died from drowning after being taken to hospital. The report raises concerns that a defibrillator took 15 minutes and a doctor took 40 minutes to arrive, delaying lifesaving measures beyond basic CPR. It also records an unverified concern that this may have been the third drowning at the resort.

Patricia Mary BARNETT · Prevention of Future Deaths report View report

21 May 2026 County Durham and Darlington R. Sutton

Patricia Mary BARNETT died on 13 March 2026 from a head injury sustained in an unwitnessed fall at a care home on 26 February 2026. The principal concern was that she, a resident with reduced mobility, cognitive impairment and a high risk of falls, had been left unsupervised in the lounge area, creating a risk of future deaths.

Isaac Charles ARROWSMITH · Prevention of Future Deaths report View report

20 May 2026 Cheshire V. Davies

Isaac Arrowsmith, aged 19, died on 2 January 2026 after repeated hospital attendances for chest pain, breathing difficulty and coughing blood, followed by deterioration at home and an unsuccessful resuscitation. The report identified concerns about failure to recognise the clot risk associated with haemoglobin Rainier disease, failure to make a virtual ward referral that would have led to hospital admission, and shortcomings in the Trust’s internal investigation and learning processes.

Ricky Crosher and Matthew Osborne · Prevention of Future Deaths report View report

20 May 2026 Nottinghamshire L. Bower

Ricky Crosher and Matthew Osborne were prisoners at HMP Lowdham Grange who died by suicide in October and November 2023, respectively. Both had been identified as at increased risk of suicide and self-harm and placed on ACCT plans, but the plans and welfare checks were not managed in accordance with policy. The report identified concerns about Safer Custody staffing and systems, the safety and management of the Care and Separation Unit, learning from deaths, retention of evidence, and cooperation between prison and healthcare staff.

Jennifer Susan BIRCH · Prevention of Future Deaths report View report

20 May 2026 Nottingham City & Nottinghamshire Laurinda Bower

Jennifer Susan Birch died on 11 April 2025 after suffering anaphylaxis to teicoplanin during the peri-operative period of an elective procedure, resulting in hypoxic brain injury. Concerns included failure to make a 2222 call during the anaesthetic emergency, failures to promptly record and retain evidence after the event, and the absence of a penicillin allergy de-labelling pathway at the Trust.

[PM] · Prevention of Future Deaths report View report

20 May 2026 Kent & Medway Ian Potter

The deceased was arrested on 18 June 2025, released on bail, and found deceased at his home on 19 June 2025. The inquest concluded that he died by suicide. Concerns included the absence of a Kent Police policy or standard operating procedure for risk assessing and safety-netting people arrested for this type of offence, and the lack of required face-to-face refresher training for officers conducting welfare checks.

Catherine Mary MORGAN · Prevention of Future Deaths report View report

19 May 2026 Kent and Medway P. Harding

Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ leave.

Najib Ahmed NAAGI · Prevention of Future Deaths report View report

19 May 2026 Inner North London M. Hassell

Najib Naagi was found unresponsive in his mental health hospital bed on 3 January 2025, was resuscitated, and died in intensive care the following day from natural causes. The report raises concerns that observations were not conducted at the required times and that the clinical support worker’s records did not accurately reflect the observations made, misleading the court and undermining confidence in patient records.

Patricia Hazell · Prevention of Future Deaths report View report

19 May 2026 Oxfordshire N. Graham

Patricia Hazell fell from a coach at Broadway Rail Station when a wheelchair access door was opened from outside without warning or checks. She sustained serious injuries, reduced mobility and subsequently developed a fatal chest infection. The principal concerns were the design and operation of wheelchair access doors, reliance on warnings and checks that may be ineffective, and the potential for similar incidents involving serious injury or death.

Rebecca Jessie Mclellan (known as Becca) · Prevention of Future Deaths report View report

18 May 2026 Suffolk D. Sharpstone

Becca was found hanging in her flat on 20 November 2023 after police forced entry following concerns raised by a colleague; the postmortem concluded that her death was due to hanging, and the inquest concluded suicide. The report identified an ongoing risk arising from the lack of a dedicated, named care co-ordinator during prolonged planned leave, including a period of approximately nine weeks before Becca’s death.

Edith May Jones · Prevention of Future Deaths report View report

15 May 2026 Manchester South Alison Mutch

Edith May Jones had limited mobility and underlying health conditions, including heart failure, and developed a deteriorating sacral pressure ulcer. She was admitted to hospital with an infected stage 4 pressure ulcer, did not improve despite intravenous antibiotics, and died on 17 October 2025; the stated cause was heart failure exacerbated by the infected ulcer. Concerns included poor District Nursing documentation, limited managerial oversight, delayed escalation, shortcomings in the gateway referral triage process, and ineffective GP triage of referrals and family information.

Natalia Violet Cestaro (known as “Tali”) · Prevention of Future Deaths report View report

14 May 2026 Coventry and Warwickshire L. Lee

Natalia Violet Cestaro, known as “Tali”, was an 18-year-old inpatient who died on 15 November 2023 after ingesting a foreign object, undergoing endoscopic removal, and subsequently developing gastric perforation, sepsis and multi-organ failure. The principal concerns included the proactive assessment of risks from impulsive ingestion, liaison between mental health and acute services, and assurance and auditing of communication processes.