Reports

Isaiah Adekunle OLUGOSI · Prevention of Future Deaths report View report

24 Feb 2025 West London R. Furniss

Isaiah Adekunle OLUGOSI died by suicide after hanging himself in his prison cell overnight on 27/28 March 2022. His wife and police were unable to contact the prison because calls were diverted to an unmanned or obsolete number, while the prison’s buzzer/intercom system was out of action. The jury found that the failure to provide a working buzzer/intercom system was a failure, and the report raised concern that the prison or Ministry of Justice still considered it unnecessary.

Ann Margaret Cotgrave · Prevention of Future Deaths report View report

21 Feb 2025 North Wales (East and Central) J. Gittins

Ann Margaret Cotgrave was admitted to Glan Clwyd Hospital on 31 March 2022 for investigation of jaundice, underwent ERCP on 19 April, sustained a perforation, and died on 3 May 2022. The principal concern was that discussions and advice between Glan Clwyd and a tertiary centre were not documented, and there was no formal documented process for such referrals and advice.

Mr Luke Alexander Worrell · Prevention of Future Deaths report View report

21 Feb 2025 London South A. Harris

Mr Luke Alexander Worrell, who had treatment-resistant schizophrenia and was taking Clozapine, developed persistent vomiting, dehydration and an ileus before suffering a ruptured oesophagus and dying in hospital on 2 January 2021. The report identified concerns about clinical staff failing to recognise the potentially fatal gastrointestinal side effects of Clozapine and about the inappropriate use of a community treatment order instead of continued detention under a mental health section. The inquest narrative also described failures to recognise the need for face-to-face psychiatric assessment after his deterioration following discharge.

Lady Lola Kay Crouch · Prevention of Future Deaths report View report

21 Feb 2025 Essex S. Hayes

Lady Lola Kay Crouch died at Broomfield Hospital on 26 February 2023 from multi-organ failure due to small bowel obstruction associated with leiomyosarcoma of the small intestine and abdominal adhesions. A December 2022 CT finding suggestive of malignancy was not followed up or communicated to her, and it was not included in her later hospital history. The report also identifies delayed medical review overnight because of doctor staffing levels.

Duncan HOLLOWAY · Prevention of Future Deaths report View report

20 Feb 2025 Inner North London M. Hassell

Duncan Holloway died after jumping from a bridge at approximately 5am on 18 July 2024, being killed by the impact with the railway tracks below. The concerns included psychotherapy note-keeping, training and response to suicidality, whether psychotherapists unable to manage suicidality should practise with at-risk clients, and a lack of joined-up care between agencies.

Hayley Joanne BEAVINGTON · Prevention of Future Deaths report View report

20 Feb 2025 Inner North London E. Buckett

Slightly before 1am on 21 September 2024, Hayley Joanne Beavington jumped from the fifth-floor balcony of her home and died by suicide after being discharged from hospital the previous day. The substantive concerns relate to the failure to secure a place for her at a local crisis house despite concerns about cuckooing and a view that she was definitely at risk of suicide, and the lack of instructions to challenge that decision.

Janet Scott · Prevention of Future Deaths report View report

20 Feb 2025 Cumbria R. Cohen

Janet Scott, who had schizophrenia and diabetes and was at serious risk of self-neglect, was found unresponsive at home on 28 March 2023 after concerns about her living conditions and welfare had been raised. She died in hospital on 30 March 2023 after developing sepsis. The report identified missed opportunities to provide assistance and a failure to activate multi-agency safeguarding procedures, raising concern that safeguarding referrals may not be made when agencies assume others are already aware.

Paul Stephen Collingridge · Prevention of Future Deaths report View report

20 Feb 2025 Essex S. Hayes

Paul Stephen Collingridge, aged 28, died on 6 December 2022 from multiple traumatic injuries after his motorcycle high-sided near overnight roadworks and he was struck by oncoming traffic. The report raised concerns about the setting out and measurement of roadworks in darkness and on curved roads, the placement of a warning sign that obscured visibility, and the absence of a requirement to report a fatality on a retrospective permit application.

Margaret Kathleen Rodgers · Prevention of Future Deaths report View report

19 Feb 2025 Surrey S. Ridge

Margaret Kathleen Rodgers fell at home on 3 December 2023, sustained rib and spinal fractures, and was admitted to hospital. During her admission she developed hospital-acquired pneumonia, a sacral pressure ulcer requiring two surgical procedures, and a urinary tract infection; she died from congestive cardiac failure on 12 January 2024. The coroner was concerned that unresolved recommendations about pressure-ulcer risk assessments and ward staffing were placing patients at risk of early death.

Kenneth James CLAYTON · Prevention of Future Deaths report View report

19 Feb 2025 Manchester South A. Mutch

Kenneth James Clayton was admitted to Tameside General Hospital after falls at home and later had an unobserved fall in the Emergency Department while waiting about eight hours for an inpatient bed. He fractured his neck of femur, underwent surgery, deteriorated with complications, and died at the hospital. The concerns included prolonged Emergency Department waits, an environment and equipment that were not suited to prolonged observation of high-risk patients, limited bed availability linked to delayed discharges, and uncertainty about consistent national falls-risk management.

Philip John UNWIN · Prevention of Future Deaths report View report

19 Feb 2025 Staffordshire and Stoke-on-Trent D. Howe

Philip John Unwin, aged 68, was admitted to hospital with fever, shortness of breath and chest pain, and was later confirmed to have sepsis secondary to pneumonia. His condition deteriorated while he remained in the Emergency Department resuscitation area, and he died in hospital on 3 April 2024 from multi-organ failure secondary to pneumonia. Concerns included delayed medical review and escalation to intensive care, staffing in the resuscitation area not complying with national guidance, and recommendations from an internal investigation not having been acted upon in this respect.

Ronald Bainborough · Prevention of Future Deaths report View report

18 Feb 2025 Inner North London S. Bourke

Ronald Bainborough lived in supported living accommodation and had schizophrenia, substance misuse, malnutrition and a history of disengagement from mental health and primary care services. A warrant under section 135(1) of the Mental Health Act was sought after he refused assessment, but there were delays before it was granted and arrangements were made for execution; he was admitted to hospital with severe malnutrition before the warrant was executed and died from community acquired pneumonia and malnutrition. The concerns identified included the time taken to apply for and execute warrants, the absence of an official fast-track procedure, and the resulting risk of fatal harm to individuals awaiting assessment.

Zahra Sharif Mohamed · Prevention of Future Deaths report View report

18 Feb 2025 Inner North London S. Bourke

Zahra Sharif Mohamed, who had been detained under the Mental Health Act and sent on home leave, expressed suicidal thoughts and threatened to jump from the balcony of her fifth-floor flat. She jumped from the balcony on 12 October 2022 and died at the scene. The principal concerns were that a warrant to return her to hospital was not applied for, and that delays in obtaining and executing such warrants create a risk of patients harming themselves or others, including fatal harm.

Mrs Marina May Raisbeck · Prevention of Future Deaths report View report

18 Feb 2025 Nottinghamshire E. Didcock

Mrs Marina May Raisbeck died on 7 November 2023 at Doncaster Royal Infirmary from sepsis secondary to a perianal abscess. The report identifies concerns about the lack of systems to prioritise urgent surgical patients awaiting transfer and to monitor their clinical parameters at Bassetlaw District General Hospital.

Jeffrey Martin Tyler · Prevention of Future Deaths report View report

18 Feb 2025 Gwent C. Saunders

Jeffrey Martin Tyler called emergency services with chest pains and difficulty breathing, but his condition deteriorated while he was alone at home. An ambulance arrived several hours later, and his death was confirmed by paramedics on 20 February 2024. The substantive concern was that, despite his deterioration and being alone and in extremis, the emergency call remained categorised as Amber 1, with a reported waiting time of between 5 and 7 hours.

Diana FAIRWEATHER-PURKIS · Prevention of Future Deaths report View report

17 Feb 2025 Teesside and Hartlepool P. Appleton

Diana Fairweather-Purkis waited 9 hours and 56 minutes for an ambulance after calling the 111 Service, was admitted to hospital, and died on 3 October 2022 due to multi-organ failure secondary to urosepsis. The report identifies insufficient ambulance availability, delays in releasing ambulance crews after hospital attendance because of patient handover delays, and delays in prescribing and administering antibiotics as substantive concerns or contributing factors.

Carl Edmond EASTMAN · Prevention of Future Deaths report View report

17 Feb 2025 Inner North London I. Potter

Carl Eastman was admitted to hospital after a fall at home and later suffered an unwitnessed fall on 28 July 2024 while in hospital. He sustained an irreversible brain bleed and died in hospital that evening as a direct result of the injury. Concerns included delays in CT scans after falls, widespread communication and record-keeping issues, failure to follow post-fall procedures, and possible wider skills or knowledge deficits among staff.

Joshua Jay Weavers · Prevention of Future Deaths report View report

17 Feb 2025 Hertfordshire J. Howell

Joshua Jay Weavers died on 4 March 2021 after jumping from a railway bridge and being struck by a high-speed train. The report raises concerns about lengthy waits for autism spectrum disorder assessments, delays in implementing assessment-service reforms, and bridge safety measures that did not meet current guidance.

DAVID WAYNE BENNETT · Prevention of Future Deaths report View report

17 Feb 2025 Essex S. Hayes

David Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.

Jason Myles · Prevention of Future Deaths report View report

14 Feb 2025 East Riding and Hull P. Marks

Jason Myles died at the scene after his van entered a sharp bend at excessive speed, collided with a wall and then a disused cattle shed, and he sustained fatal head and chest injuries. Concerns included a history of fatal and non-fatal collisions at the site and evidence that improved signage warning of the hill and sharp turn might be valuable, particularly when visibility is poor.