Reports

Joanna HILLARD · Prevention of Future Deaths report View report

5 Mar 2026 Somerset S. Marsh

Joanna Hillard was discovered at her home on 25 February 2021 and could not be revived despite CPR. The inquest concluded that her death was suicide contributed to by coercive and controlling behaviour. The principal concern was that the effects of coercive and controlling behaviour on a person's decision-making ability may not be adequately recognised under the Mental Capacity Act 2005 and current capacity law.

Caroline Adeyelu · Prevention of Future Deaths report View report

5 Mar 2026 East London N. Persaud

Caroline Adeyelu died after suffering a fatal stab wound to her chest at home on 30 October 2022, inflicted by her son, who was under the care of community mental health services. The inquest identified inadequate risk assessment and management, insufficient safeguarding and family engagement, poor care coordination and information sharing, and ineffective communication between mental health services and the police.

Viviana-Ray Winnie Elsie Wendy Butnaru · Prevention of Future Deaths report View report

4 Mar 2026 Essex J. Gill

Viviana-Ray Winnie Elsie Wendy Butnaru attended the Children’s Emergency Department on 24 October 2024 and died at Basildon Hospital on 25 October 2024 after cardiac arrest. The stated cause of death was myocarditis caused by Parvovirus, contributed to by bronchiolitis and bronchopneumonia. Concerns included delayed reporting of chest X-rays showing cardiomegaly, incomplete exploration of metabolic acidosis, failures in escalation and review processes, and incomplete documentation and handovers.

Mrs Oriel Vasey · Prevention of Future Deaths report View report

4 Mar 2026 Sunderland A. Combes

Mrs Oriel Vasey died at Sunderland Royal Hospital on 5 March 2025 after a pressure sore deteriorated and resulted in sepsis. An erroneous penicillin allergy from a funding and placement form was added to her clinical record, leading penicillin to be ruled out on several occasions. The report’s concerns include that the unchanged process could allow the same error to recur and that it is unclear why the funding form required an allergies section.

Roman Louie BARR · Prevention of Future Deaths report View report

4 Mar 2026 Coventry L. Lee

Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after no ambulance was available for several hours, leading his family to transport him to hospital. The principal concerns were limited awareness and follow-up of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks to families transporting critically unwell patients, and unclear NHS Pathways triage wording.

Mark Alan Hughes · Prevention of Future Deaths report View report

4 Mar 2026 Manchester South B. Myers

Mark Alan Hughes, who had a history of anxiety and was assessed as at high risk of self-harm and suicide, died after taking codeine and morphine and stabbing himself during the night of 22–23 June 2025. The report raised concerns that urgent referrals from general practice could not be made directly to the Home Based Treatment Team in South Trafford, resulting in a delay over the weekend before assessment or onward referral could occur.

Roman Louie BARR · Prevention of Future Deaths report View report

4 Mar 2026 Coventry L. Lee

Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.

Wendy BODDINGTON · Prevention of Future Deaths report View report

3 Mar 2026 Derby and Derbyshire P. Nieto

Wendy BODDINGTON was found deceased at home on 24 March 2025 after friends had been unable to contact her for several days. She had two fentanyl patches on her body instead of the single prescribed patch; toxicology found fentanyl at a fatal level, with prescribed codeine adding to the toxicity. The principal concern was that people receiving long-term, often high-dose opiate and opioid prescriptions for chronic pain may not receive adequate support to reduce, stop, or substitute these medications.

Mujahid Adam · Prevention of Future Deaths report View report

3 Mar 2026 Inner North London E. Buckett

Mujahid Adam died by suicide after being found hanging in his prison cell on 15 March 2025; he was declared dead on 21 March 2025 at University College Hospital. The concerns included inadequate and non-contemporaneous recording of 15-minute observations, no clear definition of what constituted an observation, delays in calling Code Blue and cutting him down, and disrepair in the cell that allowed access to ligature material.

Susan Elizabeth SAMSON · Prevention of Future Deaths report View report

2 Mar 2026 County Durham and Darlington R. Sutton

Susan Elizabeth SAMSON died on 7 May 2025 after falling down the stairs at her home, following discharge from a six-week rehabilitation placement. Concerns were raised about the delay in arranging installation of a second banister rail and the potential risk to tenants awaiting such installations.

Maisie Kate Almond · Prevention of Future Deaths report View report

27 Feb 2026 Manchester South A. Farrow

Maisie Kate Almond, aged 14, developed acute liver failure in September 2024 and died on 2 October 2024 after cerebral oedema and multi-organ failure developed while she was awaiting an urgent liver transplant. The report identifies a national shortage of donor livers, particularly for children in the “super urgent” category, with waiting times extending from historically around 48 hours to up to a week. It states that this delay creates a clear risk that lives will be lost because suitable donor organs are unavailable.

SUMMER RAE MANT · Prevention of Future Deaths report View report

27 Feb 2026 South Wales Central R. Knight

Summer Rae Mant, a four-year-old child with MIRAGE syndrome, developed severe infection and virus while an inpatient and suffered hypoxia and cardiac arrest during events on 17 and 18 March 2024. She later developed sudden multi-organ failure of uncertain cause and died at Ty Hafan on 21 September 2024. A substantive concern was a delay in obtaining adrenaline during resuscitation, associated with non-standardised crash trolleys and staff unfamiliarity with different hospital configurations.

Brema Elizabeth VIRGO · Prevention of Future Deaths report View report

27 Feb 2026 Gwent F. Stuart

Brema Elizabeth Virgo died after tripping over a raised manhole cover while walking on a pavement, sustaining a significant head injury. The report identified concerns that pavement-defect assessment methods may fail to reflect the full height of defects, meaning hazards may not be identified and remedial action may not be taken.

Louis Robert SAUNDERS · Prevention of Future Deaths report View report

27 Feb 2026 East Sussex L. Bradford

Louis Robert Saunders, who had been diagnosed with ADHD and experienced suicidal ideation as a side effect of medication, travelled to the East Sussex coast on 9 October 2024 and was found dead at the base of a cliff the following morning. The principal concern was insufficient communication and continuity of care between the private ADHD clinic and NHS GP, resulting in concurrent prescribing of different ADHD medications and a risk of duplicate prescriptions or confusion about treatment.

David James FENN · Prevention of Future Deaths report View report

27 Feb 2026 Essex L. Brookes

David James FENN was admitted to hospital with suspected sepsis and septic left knee arthritis, after attending several days earlier with similar symptoms and being discharged home. He subsequently developed severe sepsis and multiorgan failure and died on 12 February 2025. The principal concerns were that sepsis was not appropriately recognised on 28 January, the Sepsis 6 pathway was not followed, timely consultant review was not obtained, and relevant clinical discussions and escalation did not occur adequately.

William Anthony Elvis WEBB · Prevention of Future Deaths report View report

26 Feb 2026 Cheshire V. Davies

William Webb was reported missing after failing to return home and was later found deceased in the Shropshire Union canal on 24 November 2025. CCTV indicated that he likely accidentally fell into the canal on 23 November and died by drowning after being unable to self-rescue. The report raised concerns about the absence of safety equipment and nearby warning signage, and the difficulty of getting out because of the distance between the water and the ground edge.

Urmila Patel · Prevention of Future Deaths report View report

26 Feb 2026 East London G. Irvine

Urmila Patel, aged 78, was admitted to hospital with suspected sepsis and later fell in a ward toilet on 29 June 2025. She subsequently deteriorated and died in hospital on 7 July 2025 after a CT scan identified a significant subdural haematoma. The concerns included inadequate falls-risk assessment, mobility care planning, supervision, assessment for intracranial bleeding, timely CT referral, and review of her warfarin after the fall.

Yunus Hoque · Prevention of Future Deaths report View report

26 Feb 2026 Manchester South B. Myers

Yunus Hoque, aged 13, became increasingly unwell with a viral infection and Group A streptococcal infection before suffering respiratory and cardiac arrest after a delayed ambulance response. The principal concern was that, when an ambulance response is significantly delayed beyond the time indicated to the caller, there was no follow-up communication to reassess the patient, inform the caller of the delay, or identify deterioration requiring a more urgent response.

Raymond John MORAN · Prevention of Future Deaths report View report

25 Feb 2026 East Riding and Hull P. Marks

Raymond John Moran, who had metastatic prostate cancer and other significant comorbidities, died on 24 December 2025 after an unwitnessed fall in hospital caused a right femur fracture. The report identifies concerns that his falls risk assessment was inaccurate, was not updated as required, and was incompletely documented.

Lesley Marie Krommendijk · Prevention of Future Deaths report View report

25 Feb 2026 Manchester South J. Gill

Lesley Marie Krommendijk fell at home, fractured her right hip, and was discharged home on 5 June 2025. She was later found on the floor, admitted to hospital with confusion and abnormal clinical findings, and died on 20 June 2025. The principal concern was that discharge-assessment processes may have created an unrealistic impression of her mobility, leading to an unsafe discharge.