Reports

Hollie Elizabeth Loraine · Prevention of Future Deaths report View report

1 Apr 2026 Sunderland D. Place

Hollie Elizabeth Loraine, who had a history of mental health concerns, suicidal ideation and previous attempts, died at home in Washington on 30 August 2025 by hanging after consuming a large quantity of alcohol. The report raises concern that the NHS pathways telephone triage system provided no guidance on whether, or how, to maintain telephone contact with a patient clearly expressing suicidal intent while awaiting an ambulance.

Lucy Jane PHELAN · Prevention of Future Deaths report View report

1 Apr 2026 Worcestershire D. Reid

Lucy Jane Phelan was found unresponsive at home after taking prescribed medications with a significant amount of alcohol and was later treated in hospital for likely aspiration pneumonia. She subsequently vomited, suffered cardiopulmonary arrest, and died shortly after midnight on 14 May 2025; the inquest concluded that her death was contributed to by neglect. The principal concern was that latching on Emergency Department monitoring equipment may contribute to alarm fatigue and hinder recognition of new alarms, with its use in other hospitals in England and Wales unknown.

Colin Foley · Prevention of Future Deaths report View report

1 Apr 2026 East Riding and Hull P. Marks

Colin Foley, aged 84, was admitted with decompensated cardiac failure and treated with intravenous frusemide. After an intravenous cannula became painful, failed and was removed, it became infected, leading to cellulitis, sepsis, multiorgan failure and his death. The concerns relate to meticulous insertion, maintenance and documentation of intravenous access devices, and awareness of potentially life-threatening complications.

Raisa Cristina Iordan · Prevention of Future Deaths report View report

31 Mar 2026 West Yorkshire Western C. Keighley

Raisa Cristina Iordan became less responsive and developed seizures and severe neurological symptoms after returning to Dewsbury District Hospital with a suspected viral illness. She was later transferred to Sheffield Children’s Hospital, where imaging showed catastrophic and irreversible brain herniation, and her death was confirmed on 30 November 2023. Concerns included missed escalation of care, inaccurate interpretation of imaging by an external general radiologist without paediatric radiology experience, and delays in scanning and intubation.

Jack Saunders · Prevention of Future Deaths report View report

31 Mar 2026 Lancashire and Blackburn with Darwen J. Newman

Jack Saunders was found deceased in his tent at Waddecar Scout Camp on 3 April 2017, after arriving alone on 29 March 2017. The cause of death was carbon monoxide poisoning from a Landman outdoor heater that generated high levels of carbon monoxide inside the tent. The principal concerns were the absence of available equipment instructions, inadequate delivery of carbon monoxide safety training to local trainers, and Jack’s exposure to adult leaders using fuel-burning equipment in tents.

Mr John Hay · Prevention of Future Deaths report View report

31 Mar 2026 Northamptonshire H. Shah

Mr John Hay, who lived alone and received domiciliary care, suffered an unwitnessed fall at home on 26 September 2024 and later died from a subdural haemorrhage on 2 October 2024. The report raised concerns about incomplete risk assessment, unclear escalation for medical input after a fall, and unclear processes for addressing missing or spent medication.

Ethan Michael Hanson · Prevention of Future Deaths report View report

30 Mar 2026 Warwickshire L. Lee

Ethan was assessed by his GP and then at hospital for abdominal pain, vomiting and concern about appendicitis, but was discharged without senior review after abnormal observations and the GP’s concerns were not transferred to the hospital assessment. He later collapsed, suffered cardiac arrest, and died after imaging confirmed perforated appendicitis, peritonitis and sepsis. The principal concerns include inaccurate or incomplete observations and pain assessment, pathway and escalation arrangements that did not align with guidance, inadequate support for assessing neurodivergent children and parents, and loss of critical information during transfer from primary to hospital care.

Oliver John Roberts · Prevention of Future Deaths report View report

30 Mar 2026 Dorset R. Griffins

Oliver John Roberts was found suspended by a ligature in a wooded area on 28 January 2024, after being reported missing and after communications data had been requested by police. The principal concern was a lack of practical national guidance for police officers on when and how to make communications data requests, including urgent Grade 2 applications; in this case, the Grade 2 request was submitted almost 24 hours after he was reported missing.

Rickie Wai Kee POON · Prevention of Future Deaths report View report

30 Mar 2026 Inner North London M. Hassell

Rickie Poon, a dismissed police officer detained under the Mental Health Act and later remanded in custody at HMP Pentonville, was found hanging in his cell one month after arriving at the prison. The jury found failures in the prison’s ACCT process contributed to his death, including inadequate management, accountability, training, implementation of actions and the early closure of the ACCT; concerns were also raised about inappropriate CPR after he had died.

Grant Nicholas LOWRY · Prevention of Future Deaths report View report

30 Mar 2026 Teesside and Hartlepool C. Bailey

Grant Nicholas LOWRY left home on 1 June 2022 after sending a text indicating suicidal intent and was found deceased in the early hours of 3 June 2022 following an uncoordinated search. Concerns included inaccurate and incomplete recording of search information, communication failures, delayed requests for additional search resources, and inadequate operational equipment for one officer. The inquest found that missed opportunities in mental health care and the search deficiencies contributed to the circumstances surrounding his death.

John Albert TARRANT · Prevention of Future Deaths report View report

30 Mar 2026 Berkshire R. Simpson

John Albert Tarrant, aged 84, died at Wexham Park Hospital after an unwitnessed fall while an inpatient on 29 April 2025, sustaining a brain bleed that later became unsurvivable. The principal concerns were inaccurate falls risk assessments and insufficient awareness or prompting regarding the urgency of anticoagulation reversal after a fall.

Edith Millington · Prevention of Future Deaths report View report

27 Mar 2026 Manchester South A. Bridgman

Edith Millington, aged 90, fell while attempting to enter a convenience store using a mobility scooter and walking stick, striking her head. She died at Salford Royal Hospital on 09.09.25, with the medical cause of death recorded as traumatic intracranial haemorrhage. The concern was that the store’s ramp was unsafe because it was unsecured, its rubber mat was not fixed, accessible handrails were absent, and the ramp was too short and steep, creating a risk of a similar fatal fall.

Elizabeth Anne LANG and Katie Alice LANG · Prevention of Future Deaths report View report

26 Mar 2026 Northumberland A. Hetherington

Elizabeth Lang was driving a vehicle with her daughter Katie Lang as the front-seat passenger when it lost control on a bend on the A1068 Sheepwash Road and collided with another vehicle. Both sustained fatal injuries and died at the scene. The report raised concerns about low road friction and the absence of advance warning signage for the bend, which may present an ongoing risk to road users unfamiliar with the road layout.

Melanie Ruth Pinnell · Prevention of Future Deaths report View report

26 Mar 2026 Suffolk D. Sharpstone

Melanie Ruth Pinnell had a history of depression and recently described suicidal thoughts and ideation. No follow-up was arranged by the GP practice after February 2025, and a psychiatrist’s recommendation to start Sertraline was not actioned. Melanie was found hanging at home on 4 May 2025. The report identified these matters as significant risks to patient safety.

Alex Ganski · Prevention of Future Deaths report View report

26 Mar 2026 West Sussex, Brighton and Hove J. Turner

Alex Ganski died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The report identified concerns about fragmented information sharing between services and the absence of a clear lead with overall oversight and authority for his care, creating missed opportunities to address the combined risks of poor mental health, drug misuse and self-harm.

Madison James Bruce SMITH · Prevention of Future Deaths report View report

26 Mar 2026 Manchester South A. Mutch

Madison James Bruce Smith was found unresponsive in his cot on 18 October 2024 after being placed prone to sleep by a person describing themselves as a maternity nurse. He died in hospital, and the cause of death was unascertained, although prone sleeping was identified as increasing the risk of sudden unexpected death. The report raised concerns about the lack of statutory regulation, training and qualification requirements for maternity nurses and agencies, and the misleading use of the term “nurse”.

Name not published · Prevention of Future Deaths report View report

25 Mar 2026 Inner West London F. Wilcox

A baby died unexpectedly at home on 15 January 2024, after being found unresponsive in a bassinet; chlorpheniramine was present in his blood and had probably been administered by the night nanny. The coroner reached an open conclusion, with expert evidence that the drug could possibly have caused or contributed to the death. Concerns included an inadequate scene examination, failure to seize feeding equipment or search relevant property, insufficient consideration of poisoning, and the lack of specific nanny regulation and guidance about chlorpheniramine.

Thomas Daniel RUGGIERO · Prevention of Future Deaths report View report

24 Mar 2026 Kent and Medway I. Potter

Thomas Daniel Ruggiero, a 39-year-old man serving a prison sentence at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report raised concerns about insufficient communication between prison staff and the wider prison estate’s high levels of inexperienced officers, linked to recruitment and retention issues.

Thomas Daniel RUGGIERO · Prevention of Future Deaths report View report

24 Mar 2026 Kent and Medway I. Potter

Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing and died later that day following attempts at treatment and resuscitation. The principal concern was that healthcare or mental health team attendance at ACCT reviews was not consistently secured, creating an ongoing risk for vulnerable prisoners relying on those processes as a safety-net and protective factor.

Robert Joseph DAY · Prevention of Future Deaths report View report

24 Mar 2026 Kent and Medway I. Potter

Robert Day died on 15 January 2025 after taking a significant overdose of prescription medication and refusing treatment after an ambulance and police response. The principal concern was the absence of national guidance for frontline emergency services dealing with complex, time-critical situations involving mental health concerns, which the report said risks the lives of others.