Reports

David John Thompson · Prevention of Future Deaths report View report

10 Feb 2026 Devon, Plymouth and Torbay A. Longhorn

David John Thompson went missing from his home on 6 March 2023 after experiencing low mood, previous thoughts of suicide and challenging life events, and was located the following morning. The report raises concerns that police use and understanding of the term “suicidal ideation” led to relevant risk information not being recorded and may have prevented the risk posed by a missing person from being fully appreciated.

Josh Yemi TARRANT · Prevention of Future Deaths report View report

9 Feb 2026 Kent and Medway S. Matthewson

Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine intoxication and exertion during a lengthy and challenging restraint. The principal concern was that acute behavioural disturbance was not recognised by healthcare staff, who lacked relevant training, and that an ambulance was not called at the earliest appropriate opportunity.

Ellen Victoria Floyd Taylor · Prevention of Future Deaths report View report

9 Feb 2026 Northumberland S. Middleton

Ellen Victoria Floyd Taylor, aged 69, died on 1 July 2025 after a nasogastric tube perforated her small intestine, resulting in acute peritonitis. Her previous gastric bypass surgery and altered anatomy were not known to treating professionals, and the report raises concerns about the lack of guidance and wider NHS risk regarding nasogastric tube insertion in patients with previous gastric surgery.

Helen Patching and 2 others · Prevention of Future Deaths report View report

9 Feb 2026 South Wales Central R. Knight

Helen Patching, Rachael Patching and Corey Longdon died accidental deaths in Waterfall Country within Bannau Brycheiniog National Park. The principal concerns were inadequate signage about the risk of accidental falling, walkers’ lack of understanding of routes and risks, and poor mobile telephone signal delaying alerts to emergency services.

Josh Yemi TARRANT · Prevention of Future Deaths report View report

9 Feb 2026 Kent and Medway S. Matthewson

Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine toxicity following a lengthy and challenging restraint while experiencing an acute behavioural disturbance. The principal concerns were that the disturbance was not recognised by healthcare staff, that an ambulance was not called at the earliest appropriate opportunity, and that prison and healthcare staff lacked training in acute behavioural disturbance. The inquest jury found that the failure to provide sufficient medical treatment probably significantly contributed to his death and that his death was contributed to by neglect.

Josh Yemi TARRANT · Prevention of Future Deaths report View report

9 Feb 2026 Kent and Medway S. Matthewson

Josh Yemi Tarrant died at HMP Elmley on 1 November 2023 after cocaine intoxication and a lengthy, challenging restraint while he was experiencing acute behavioural disturbance. The report raises concerns that acute behavioural disturbance was not recognised, that sufficient medical treatment was not provided at the earliest appropriate opportunity, and that prison staff lacked training to identify and respond to it.

Brody O'Brien · Prevention of Future Deaths report View report

9 Feb 2026 Lancashire and Blackburn with Darwen E. Mather

On 7 October 2025, Brody O'Brien, aged 12, died after being found hanging at a redacted location in Rochdale. Concerns included that the area remained unsecured and could be accessed to secure a ligature, and that emergency services faced difficult and treacherous access while carrying equipment.

JANET MARY TRIPP · Prevention of Future Deaths report View report

9 Feb 2026 Cornwall and Isles of Scilly G. Davies

Janet Mary Tripp died from frailty of old age and an ischaemic right foot caused by peripheral vascular disease. An avoidable pressure sore developed during a seven-hour stay in the Royal Cornwall Hospital discharge lounge and more than minimally contributed to her death. The report identified failures including a lack of care rounds, inadequate repositioning, absent risk assessment, and insufficient handover information; there was insufficient evidence that these failings had been addressed by the hospital.

Ellen Victoria Floyd Taylor · Prevention of Future Deaths report View report

9 Feb 2026 Northumberland S. Middleton

Ellen Victoria Floyd Taylor, aged 69, died on 1 July 2025 after a nasogastric tube perforated her small intestine, leading to acute peritonitis. Her previous gastric bypass surgery and altered anatomy were not known to treating professionals, and the perforation was not initially recognised. The report identifies concerns about the absence of guidance for inserting nasogastric tubes in patients with previous gastric surgery and a wider risk to patients nationally.

Gareth Chumber-Kelly · Prevention of Future Deaths report View report

9 Feb 2026 Inner North London J. Stevens

Gareth Chumber-Kelly died after hanging himself while in custody at HMP Pentonville on 17 July 2023. The report identified concerns about lost or incomplete transfer documentation, inadequate recognition and management of suicide and self-harm risks, insufficient staff training, failures to provide basic life support, and inadequate staffing and support during crucial periods.

Luke John ABRAHAMS · Prevention of Future Deaths report View report

8 Feb 2026 Northamptonshire S. Lomas

Luke Abrahams developed a sore throat followed by severe leg pain, necrotising fasciitis and septic shock, and died after cardiac arrest on 23 January 2023 despite emergency surgery and resuscitation. The principal concern was that NHS website information about necrotising fasciitis focused on wounds and did not clearly explain that it can present with intense or disproportionate pain without noticeable skin changes or a wound.

Hilary Jane CHAPMAN · Prevention of Future Deaths report View report

8 Feb 2026 County Durham and Darlington S. Connolly

Hilary Jane Chapman, who was detained under section 3 at Lanchester Road Hospital, left on unescorted leave and was later found unconscious in her car after a suspected overdose. She suffered cardiac arrest and hypoxic brain injury, received palliative care, and died at St Cuthbert’s Hospice on 11 March 2025. The principal concern was that the Trust’s updated section 17 leave processes were not reflected in its overarching policy, including issues concerning communication of leave arrangements to relevant people.

Elise Kay Louise Sebastian · Prevention of Future Deaths report View report

8 Feb 2026 Essex S. Hayes

Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

Janet Springall · Prevention of Future Deaths report View report

7 Feb 2026 Blackpool and the Fylde A. Anthony

Janet Springall, who had a learning disability and was immunosuppressed, was taken to hospital with pneumonia and sepsis after being found unresponsive. She remained in an ambulance outside the emergency department for almost six hours amid exceptional pressures, and the report raises concern that delays in clinical assessment, blood testing and treatment may place similarly unwell patients at increased risk.

Bonita Cleary · Prevention of Future Deaths report View report

7 Feb 2026 Blackpool and the Fylde A. Wilson

Bonita Cleary, who was severely frail and largely bedbound, died after choking on food during a vacant episode while eating crumpet at a nursing care home. Although a DNACPR authorisation was in place, CPR was not initially commenced, and the report raises concern about a lack of awareness among care and nursing staff about when CPR should be attempted for potentially reversible causes such as choking.

Paul Christopher THOMPSON · Prevention of Future Deaths report View report

6 Feb 2026 Suffolk D. Stewart

Paul Christopher THOMPSON died on 15 July 2024 after moving onto the railway tracks at Elmswell Railway Station and lying in the path of an oncoming freight train. He had a history of suicidal ideation and had been receiving mental health care in custody. The report identified shortcomings in the internal passage of information at HMP Norwich about the release of prisoners receiving mental health care, and in the timely provision of release information to Probation Services.

Mr Stephen Martin Rhodes · Prevention of Future Deaths report View report

6 Feb 2026 Black Country Z. Siddique

Mr Stephen Martin Rhodes, who had progressive shortness of breath, had a markedly raised NT-proBNP result that was filed in the mistaken belief that there was no abnormal finding. He collapsed and died after developing a cardiac arrest while working as a delivery driver on 11 March 2025. The principal concern was that the blood test result was not adequately scrutinised and the recommended specialist referral and echocardiography within two weeks did not occur; the inquest conclusion was narrative, with natural causes contributed to by neglect.

Linda Brooks · Prevention of Future Deaths report View report

6 Feb 2026 Devon, Plymouth and Torbay D. Archer

Linda Brooks, a 78-year-old care-home resident with respiratory and other comorbidities, was admitted after a fall and later died at Torbay Hospital on 17 May 2022. The inquest identified concerns about oxygen being switched off for an unknown period before her death, and about failures to report, investigate, escalate, and record the incident and related Datix referrals.

Michaela FINCH · Prevention of Future Deaths report View report

6 Feb 2026 Manchester West T. Brennand

Michaela FINCH died on 2 August 2025 following combined drug toxicity after a period of acute mental health deterioration, alcohol misuse and an earlier non-fatal overdose. The report raises concerns that possible co-occurring mental health and addiction needs were not fully recognised, that family concerns were not effectively communicated to the assessing clinician, and that risk assessment, diagnosis, discharge and follow-up may have been inadequate. It also identifies possible funding limitations affecting access to escalated community-based care.

Mansoor Zaman · Prevention of Future Deaths report View report

6 Feb 2026 East London G. Irvine

Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.