Reports

Ruslans Burkevics · Prevention of Future Deaths report View report

15 Mar 2026 Manchester West M. Pemberton

Ruslans Burkevics died after sustaining multiple injuries in a likely unwitnessed fall from an open 12th-floor bedroom window at his home, after police had escorted him home the previous evening. The report raised concern that frontline officers receive no regular refresher training in mental health first aid, despite evidence of the deceased’s mental health difficulties and substance use contributing to episodes of crisis.

Albert Thomas Bellingham · Prevention of Future Deaths report View report

12 Mar 2026 North London A. Walker

Albert Thomas Bellingham died in hospital on 10 November 2024 from bacteraemia associated with an infected sacral pressure sore that developed after his admission following a fall. The principal concern was inadequate preventative nursing care, with the inquest concluding that neglect in treating the sacral sore contributed to his death; the report also raises consideration of guidance and training for doctors working in care homes.

Paul Walker GREEN · Prevention of Future Deaths report View report

12 Mar 2026 West Sussex, Brighton and Hove G. Jones

Paul Walker Green, aged 16, died on 27 November 2024 after a car carrying him as a rear passenger collided with a tree and rolled onto its roof; he suffered fatal head injuries. Concerns included the driver’s recent qualification and inexperience, the passengers’ lack of adult supervision, and the ability of newly qualified 17-year-olds to drive without adult supervision, including on motorways.

Tania Louise JARMAN · Prevention of Future Deaths report View report

12 Mar 2026 Cheshire E. Wheeler

Tania Louise JARMAN died aged 54 on 27 February 2024 at Park House, a non-clinical crisis placement, after tying a ligature with the probable intention of ending her life. Her mental health had worsened before her death, and her admission removed her from protective factors including her mother and home. The principal concerns were the longstanding shortage of mental health beds and the risk that this could lead to an artificially elevated threshold for referrals, potentially denying beds to patients with a clinical need.

CHARLOTTE LOUISE JONES · Prevention of Future Deaths report View report

11 Mar 2026 Cumbria K. Gomersal

Charlotte Louise Jones was found deceased at her home on 10 February 2025, with her death attributed to fatal levels of alcohol and bromazolam. She had a history of self-harm and substance use, and had multiple attendances at A&E following overdose and self-harm before her death. The principal concern was that CNTW and Recovery Steps did not have an adequate procedure for exchanging information about service users, including those not accepted onto a particular treatment pathway.

Janette Margaret PALMER · Prevention of Future Deaths report View report

11 Mar 2026 Suffolk N. Parsley

Janette Palmer died at St Nicholas Hospice on 24 February 2025 after an unwitnessed fall causing a left hip fracture, a heart attack, and subsequent bronchopneumonia. A power cut had occurred at her supported living accommodation, but it could not be established whether the lights were out when she fell or whether this contributed to the fall. The report raises concern that providers of care homes and sheltered housing may lack knowledge of the UK Power Networks Priority Services Register and therefore may not access enhanced support during power outages.

Peter Asher CAMPBELL · Prevention of Future Deaths report View report

11 Mar 2026 Inner North London M. Hassell

Peter Asher Campbell collapsed in his prison cell at Pentonville after smoking a drug and died five days later. The principal concerns were the failure to prevent drugs entering the prison and shortcomings in the prison drug service’s response, including inadequate engagement, harm-minimisation advice, staff training, supervision and auditing.

Malcolm WELCH · Prevention of Future Deaths report View report

11 Mar 2026 North Yorkshire and York M. Armitage

Malcolm WELCH, who had a history including prostate cancer, pulmonary fibrosis and falls, suffered an unwitnessed fall in hospital on 22 January 2025, sustaining right-sided rib fractures. He developed pneumonia and deteriorated after discharge, dying at home on 22 February 2025. The principal concern was inconsistent provision of mobility aids when patients were transferred between hospital wards, creating a risk of future deaths.

Mark Simpson · Prevention of Future Deaths report View report

11 Mar 2026 Blackpool and the Fylde A. Wilson

Mark Simpson died on 22 October 2025 after being found unresponsive and not breathing at home; the medical cause of death was acute heart failure due to ischaemic heart disease and coronary artery atheroma, with renal cell carcinoma also recorded. The report raises concerns that information about his NHS 111 consultation for prolonged chest pain was assessed by non-medically qualified staff, was not relayed to a clinician, and was not added to his medical record.

John Ioannou · Prevention of Future Deaths report View report

10 Mar 2026 East London G. Irvine

John Ioannou, a 61-year-old non-verbal man receiving 24-hour residential care, died after a cardiac arrest on 24 June 2025 following treatment for a problem with his PEG apparatus. An autopsy identified an infection at the PEG site that spread to his small intestine and caused peritonitis. The principal concerns were that the death was not investigated under NHS England’s Patient Safety Framework, and that the cause and timing of the infection and possible communication failures were not fully explored.

Ruariri Thomas STEWART · Prevention of Future Deaths report View report

10 Mar 2026 Cheshire E. Wheeler

Ruariri Thomas Stewart, aged 29, died from fatal cocaine toxicity at Weaver Lodge Independent Hospital on 31 July 2025 after a period of unescorted leave during which he probably obtained cocaine. The report identifies concerns about failures in documentation, communication, information sharing, leave decision-making, substance-misuse management, record keeping, and the quality of post-incident investigation.

Surendrakumar Patel · Prevention of Future Deaths report View report

10 Mar 2026 Worcestershire J. Puzey

Surendrakumar Patel died at Alexandra Hospital, Redditch, on 31 October 2024 after collapsing with a lower respiratory tract infection, with self-neglect through malnutrition contributing to his death. While on remand at HMP Hewell, he stopped eating, expressed that he no longer wished to live, lost weight, and developed acute kidney injury. The report identified concerns about healthcare staff’s failure to recognise the need for a timely mental capacity assessment, consider hospital transfer and expedited senior medical and psychiatric assessment, and consider family contact; prison staff also lacked awareness of procedures for informing or consulting next of kin about food refusal.

Jennine Sasha Romeo · Prevention of Future Deaths report View report

10 Mar 2026 City of London A. Hewitt

Jennine Sasha Romeo died on 29 May 2025 after developing multiorgan failure following complications of mitral valve surgery and subsequent re-do surgery. The January 2025 echocardiogram showing serious cardiac abnormalities was not clinically reviewed until May, after hospital outpatient appointments had been cancelled. The report identified concerns about the absence of systems to ensure timely review of results and a pathway for the echocardiography team to flag significant findings.

Sheila Creagan · Prevention of Future Deaths report View report

10 Mar 2026 East London G. Irvine

Sheila Creagan, an 81-year-old woman with heart failure, underwent emergency abdominal surgery in February 2025 and was later admitted with breathing difficulties, anaemia and a suspected gastrointestinal bleed. She died in hospital on 17 March 2025; the inquest determined that untreated and undiagnosed infective endocarditis caused her death. Concerns included the failure to investigate the source of her worsening infection, the missed diagnosis of infective endocarditis, inadequate monitoring of her heart failure, and the decision not to conduct a Patient Safety Framework investigation.

Darryl JOHNSON · Prevention of Future Deaths report View report

10 Mar 2026 Bedfordshire and Luton E. Whitting

Darryl JOHNSON was found deceased at home on 24 February 2025 after failing to attend work. Earlier that day, he had called ambulance services with breathing problems and feeling faint, but the crew was directed to a different address because of an address and map database error. The principal concern was why the database lacked full details of his property despite his having purchased it and paid Council Tax there for over 11 years; it remained unclear whether attending the correct address would have avoided his death.

Taylor Malcolm Maddox · Prevention of Future Deaths report View report

9 Mar 2026 Devon, Plymouth and Torbay S. Covell

Taylor Malcolm Maddox, who had a history of mental health illness and previous suicide attempts, was found unresponsive in his car on 9 April 2024 after leaving short-term accommodation and indicating he intended to sleep in the car. The inquest concluded that he had taken his own life by overdosing on painkilling medication. The principal concerns were delays and difficulties in securing suitable accommodation for psychiatric patients leaving hospital, and an assessment process that did not adequately account for psychiatric vulnerability and the effects of unstable housing.

Terrence FROST · Prevention of Future Deaths report View report

9 Mar 2026 Suffolk N. Parsley

Terrence Frost died at Ipswich Hospital on 17 July 2024 after a sudden collapse and cardiac arrest during a final admission following repeated presentations with abdominal pain, rectal bleeding and concerning blood test results. Postmortem examination identified significant cardiac and vascular disease, and sepsis was considered to have played a factor despite no infection being identified. The principal concerns were difficulties contacting the hospital’s Medical Assessment Unit and Accident and Emergency department, and Terrence’s five-hour wait in Accident and Emergency before being seen.

Alan Bevis TOMLINSON · Prevention of Future Deaths report View report

6 Mar 2026 Gwent M. Lanchester

Alan Bevis TOMLINSON attended hospital on 16 April 2024 with illness, significant weight loss, anaemia and swelling around his pacemaker site, but was advised to return home because no cardiac bed was available. He died at home on 18 April 2024 from the effects of untreated infective endocarditis, likely associated with a longstanding infection at the pacemaker implant site. Concerns included missed referral to cardiology despite increasing pacemaker thresholds and visible illness, and failures to identify infective endocarditis, gather and document clinical information, and communicate findings effectively.

Kay Wilson · Prevention of Future Deaths report View report

6 Mar 2026 County Durham and Darlington J. Chipperfield

Kay Wilson drowned shortly after 23:30 on 6 December 2025 after accidentally passing through a gap in a protective stone wall near County Bridge in Barnard Castle, falling approximately 9 metres onto rocks and then into the River Tees. The principal concern was that the breach provided unrestricted and unguarded access from a public area to the vertical drop and river below.

Asher Blackman · Prevention of Future Deaths report View report

6 Mar 2026 North London A. Walker

Asher Blackman died in hospital on 21 September 2025 after collapsing at home, where he was found to be profoundly hypoglycaemic. Concerns included the District Nurses’ failure to record next-of-kin details or procedures for inability to gain access, and a no-access policy that did not address police involvement where the patient’s life might be at risk.