Reports

Christopher John O’Donnell · Prevention of Future Deaths report View report

21 Jul 2025 Wiltshire and Swindon I. Singleton

Christopher John O’Donnell died on 12 December 2023 in supported living accommodation after taking a substantial amount of methadone, vomiting and suffering airway obstruction by vomit. The principal concern was that excess medication remained within his control despite recognised risks, with no apparent basis or consideration for the accommodation provider to remove it as a safeguarding measure during a mental health crisis.

Melissa Louise Mathieson · Prevention of Future Deaths report View report

21 Jul 2025 Avon M. Voisin

Melissa Louise Mathieson, an 18-year-old autistic woman with ADHD and a diagnosis of Asperger’s, was attacked by another resident at Alexandra Homes on 12 October 2014 and died a few days later from her injuries. Concerns included misleading descriptions of supervision, the absence of a formal induction and weekly review process, and inadequate review of support plans and risk assessments.

Jean DYE · Prevention of Future Deaths report View report

21 Jul 2025 Greater Lincolnshire P. Smith

Jean Dye died at Scunthorpe General Hospital after an artery dissection during a cardiac procedure, followed by an unexpected electrical power failure that delayed emergency stenting for approximately 10 minutes. The principal concerns were that activation of the Emergency Power Off circuit overrode backup power, there was no indicator or local reset control in the treatment room, and guidance on the location of such controls and related training may require review.

Jacqueline Mary LANGWORTHY · Prevention of Future Deaths report View report

18 Jul 2025 Coventry and Warwickshire L. Lee

Jacqueline Mary Langworthy, an experienced care assistant, died after becoming trapped and pinned by a stand aid in a descending platform lift; resuscitation was unsuccessful. The principal concerns were that many platform lifts lack hold-to-run controls, these controls may be relatively inexpensive to retrofit, and awareness of the risks and retrofit feasibility is limited.

Dorothy Elizabeth Wagstaff · Prevention of Future Deaths report View report

18 Jul 2025 West Yorkshire Eastern J. Hobson

Dorothy Elizabeth Wagstaff died at the scene after the car she was driving collided with a post, temporary plastic barriers, railings and a lamp post on the A660 Leeds Road at Otley. It was found more likely than not that she had suffered a medical episode before the collisions. The principal concern was that temporary plastic barriers provided little resistance, allowing the car to leave the road, and that similar barriers remained elsewhere along the road.

Patryk Gladysz · Prevention of Future Deaths report View report

18 Jul 2025 Inner West London P. Malhotra

Patryk Gladysz, who had schizophrenia and was detained at HMP Wandsworth, was found in his cell with a ligature around his neck on 5 January 2024 and died at St George’s Hospital. The inquest concluded that he had hung himself with a ligature, with his intentions unknown. Concerns included delays and staffing pressures affecting mental health assessments, inadequate communication between prison and healthcare staff, gaps in knowledge of his history and risks, and shortcomings in prison monitoring and training.

David Joseph HAYES · Prevention of Future Deaths report View report

18 Jul 2025 Manchester West M. Pemberton

David Joseph HAYES, who had dementia, accidentally ingested washing detergent after confusing its packaging with a milk carton. He subsequently suffered vomiting, aspiration and pneumonitis, and died on 21 April 2025. The principal concerns were the detergent’s packaging and colouring, its accessible screw-top lid, and whether labelling and public awareness adequately addressed risks to vulnerable adults.

Darren Christopher Reilly and Tyler Cox · Prevention of Future Deaths report View report

18 Jul 2025 Hertfordshire J. Howell

On 1 April 2024, Darren Christopher Reilly and Tyler Cox sustained fatal injuries when the Range Rover in which they were travelling left the M1 carriageway and collided with trees. The principal concern was the unexplained gap in the safety barrier at the collision location, creating a risk that future vehicles could leave the carriageway and occupants could suffer serious or fatal injuries.

Marie Louise Theobald · Prevention of Future Deaths report View report

18 Jul 2025 East London G. Irvine

Marie Louise Theobald, aged 48, died after being struck by a car travelling at high speed while walking her dogs near her home on 22 December 2023. The report raises concerns about delays in the criminal investigation, with no charging decision made and no conditional bail, driving disqualification or remand measures in place for the identified suspect, creating a risk of further fatal harm.

Kaine Regan FLETCHER · Prevention of Future Deaths report View report

17 Jul 2025 South Yorkshire (Western) A. Pountney

Kaine Regan FLETCHER died on 3 July 2022 after deteriorating during a period of restraint following detention under section 136 of the Mental Health Act, with cocaine and other substances also identified in the stated cause of death. The report raises concern that the police and ambulance service did not share an understanding of the applicable local policy and working standards for managing section 136 incidents, creating a potential risk of preventable future deaths.

Alfie Lydon · Prevention of Future Deaths report View report

15 Jul 2025 Inner North London R. Brittain

Alfie Lydon was admitted to hospital after being found profoundly unwell at home, transferred for intensive care, and died from the consequences of a viral infection. Before admission, his parents had raised concerns about his feeding and increasing lethargy, and discussions between midwives and the neonatal team were not consistently documented. The report raised concern that inadequate, contemporaneous documentation of discussions between community and hospital teams could affect continuity and escalation of care and result in future deaths in similar circumstances.

Myles Edward SCRIVEN · Prevention of Future Deaths report View report

14 Jul 2025 West Yorkshire (Western) C. Oliver

Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that he had several contacts with Dalton Surgery while suffering from an ongoing pulmonary embolism, none of which resulted in referral to secondary care, and that the handling of his care contributed to his death. Concerns also included insufficient adjustments and understanding of his autism and learning disabilities, failure to record numeric observations properly, and failure to undertake a rigorous internal review.

Myles Edward Scriven · Prevention of Future Deaths report View report

14 Jul 2025 West Yorkshire (Western) C. Oliver

Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that lack of adjustments for his Autism and Learning Disabilities contributed to incorrect decisions about his care and medication. The principal concern was that existing training, policies and support arrangements were not effectively applied or audited to ensure safe care and medication decisions.

Norah McGLYNN aka Noreen Philomena McGLYNN · Prevention of Future Deaths report View report

11 Jul 2025 Inner North London M. Hassell

Noreen McGlynn developed throat and urinary tract infections, was prescribed amoxicillin, suffered an anaphylactic reaction and died three days later from her underlying conditions. The concern was whether rehydration could have been provided at home when she became severely dehydrated, potentially avoiding hospital admission for her and others in the future.

Patricia Heaviside · Prevention of Future Deaths report View report

10 Jul 2025 County Durham and Darlington R. Sutton

Patricia Heaviside, a resident of Howlish Hall Care Home, suffered an unwitnessed fall on 4 October 2024, fractured her left hip, and died on 26 December 2024 as a consequence of the fracture. Concerns included the failure to implement recommended falls-prevention equipment, failures to share relevant information with family and social services, and apparent reluctance to provide adequate resources for falls prevention. The report also raised concerns that no DoLS assessment application appeared to have been made despite her lack of mental capacity and inability to keep herself safe.

Paul David RANSOM · Prevention of Future Deaths report View report

10 Jul 2025 Hampshire, Portsmouth and Southampton H. Charles

Paul David Ransom died on 24 May 2023 after losing control of his motorcycle on the A272 and colliding with a lorry. The road had received a thin surface treatment less than six hours earlier, and the slippery surface caused or substantially contributed to the collision; concerns were raised about reduced and unpredictable friction during the treatment’s early life, particularly for motorcycles, without guidance requiring warning signage.

Jairus Joshua Timothy Earl · Prevention of Future Deaths report View report

10 Jul 2025 Dorset R. Griffin

Jairus Joshua Timothy Earl, aged 15, died by suicide on 14 April 2024 after using one of his father’s shotguns at the family’s Dorset property. The concerns relate to gaps in the regulation of shotgun licences, including the lack of requirements to notify police about additional properties, inadequate information-sharing and address flagging between police forces, and limited access to medical information about other people living at a licence holder’s property.

Gavin James WHEALE · Prevention of Future Deaths report View report

10 Jul 2025 Birmingham and Solihull I. Dreelan

Gavin James Wheale was found unresponsive in a care and separation unit cell at HMP Birmingham on 8 August 2024 and was pronounced dead shortly afterwards. The medical cause of death was mixed drug interactions involving morphine, cocaine and diazepam. Concerns included unclear guidance for staff where a previously concealed item was allegedly ingested, and reduced monitoring after handover from transport and police custody to the prison.

Doreen Swann · Prevention of Future Deaths report View report

10 Jul 2025 Manchester South A. Mutch

Doreen Swann was a patient at Tameside General Hospital whose discharge had been delayed while she awaited a suitable social care placement. She was a high falls risk, fell while unobserved with the bed rails up, suffered a traumatic brain injury and died. The concerns included delayed discharges due to shortages of suitable social care placements, the challenges of managing high falls risk patients in an acute setting, and impacts on hospital bed availability and the Emergency Department.

Mrs Gemma Louise Poterajko · Prevention of Future Deaths report View report

10 Jul 2025 Nottinghamshire E. Didcock

Mrs Gemma Louise Poterajko died on 22 August 2024 at City Hospital in Nottingham following a pacemaker lead extraction procedure. She suffered catastrophic bleeding from tears in the left subclavian and left innominate veins and subsequently developed multi-organ failure. The concerns identified were the lack of formal risk stratification, a written Trust standard operating procedure, and clarity about timely cardiac surgical support for lead extraction procedures.