Reports

Tracey Oldfield · Prevention of Future Deaths report View report

11 Nov 2025 Cornwall and Isles of Scilly A. Cox

Tracey Oldfield underwent an elective fistula revision procedure on 17 October 2024 and was admitted after developing low oxygen saturations and low blood sugars. She became drowsy and unresponsive after receiving opiate pain relief that was contraindicated in end-stage renal failure, while her CPAP device was unavailable and there was no senior medical review. She suffered a cardiac arrest, developed a hypoxic brain injury, and died on 24 October 2024. A continuing concern was the timely prescription of patients’ usual medication after unexpected admission, including appropriate pain relief.

Liliane Andree BOWDEN · Prevention of Future Deaths report View report

11 Nov 2025 Hampshire, Portsmouth and Southampton H. Charles

Liliane Andree Bowden died at Oak View Care Home on 23 September 2024 from bronchopneumonia, with vascular dementia and recent falls making substantial contributions. The inquest raised concerns about a prolonged ambulance delay following her fall, in the context of ambulance demand and hospital handover delays, particularly for elderly or vulnerable Category 3 patients.

Joan Elizabeth Talbot · Prevention of Future Deaths report View report

11 Nov 2025 Inner South London L. Field

Joan Talbot had progressive complications from previous radiotherapy, including recurrent urinary tract infections, hydronephrosis and bloody diarrhoea. She was admitted to hospital on 14 August 2022, developed sepsis associated with a dislodged ureteric stent, and died on 24 August 2022 despite treatment. The principal concern was a lack of continuity of care across three earlier admissions, which meant the significance of her diarrhoea was not fully appreciated and delayed investigation.

Alan MITCHELL · Prevention of Future Deaths report View report

10 Nov 2025 Cheshire A. Frodsham

Alan Mitchell was admitted to hospital on 8 March 2025 with evidence of an upper gastro-intestinal bleed. On 12 March 2025, he suffered a heart attack, became unresponsive and died shortly afterwards. The report raised concern that software could remove a lifelong repeat prescription without notifying or obtaining a choice from the GP, creating a risk that patients may not receive needed medication.

Costas CHRYSOSTOMOU · Prevention of Future Deaths report View report

10 Nov 2025 Inner North London I. Potter

Costas Chrysostomou died in hospital on 14 December 2024 after developing cardiac failure and acute renal failure linked to pacemaker-mediated cardiomyopathy, described as a rare but known complication. The report raised concerns about ambiguity in the use of “urgent” referrals, differing understandings of cardiology pathways between GPs and hospital consultants, and the need for clearer guidance for complex cases.

Jacqueline Aarons · Prevention of Future Deaths report View report

10 Nov 2025 North London A. Walker

Jacqueline Aarons died at her care home on 19 November 2024 from the consequences of a strangulated umbilical hernia, following vomiting and deterioration over approximately two days. The substantive concerns were the need for a lower threshold for hospital admission for patients with learning disability, face-to-face medical consultation, and clear written safety-netting instructions for care-home staff.

Unnamed deceased persons · Prevention of Future Deaths report View report

10 Nov 2025 Inner West London F. Wilcox

Following an aircraft crash on 12 June 2025, the remains of deceased persons were repatriated to Westminster Public Mortuary wrapped and saturated with high concentrations of formalin. Dangerously high levels of formalin, carbon monoxide and cyanide were detected when coffins were opened and bodies were unwrapped. The report raises concerns about under-appreciation of formalin’s risks in mortuaries, the lack of routine monitoring, and the possible unavailability or non-use of appropriate protective equipment.

Joanna Chamberlain · Prevention of Future Deaths report View report

10 Nov 2025 West Sussex, Brighton and Hove J. Turner

Joanna Chamberlain took her own life at home on 23 January 2025 after a recent overdose, other self-harm incidents and an assessment that she was at moderate risk. The report raises concerns about the lack of safe, supportive spaces for people needing more support than home treatment teams can provide, and about clinicians seeking and including family or other relevant input when care plans depend on protective factors.

Ernest Roy Gray · Prevention of Future Deaths report View report

7 Nov 2025 Kent and Medway P. Harding

Ernest Roy Gray was admitted to hospital after a myocardial infarction and developed hyperactive delirium and heart failure, with episodes of agitation and aggression. He was discharged home while still confused and later became unwell, was admitted to hospital, developed pneumonia, and died on 24 November 2023. Concerns included failure to involve his partner in discharge planning, inadequate holistic discharge planning and communication, and insufficient information about the possible fluctuating and aggressive manifestations of his delirium and what to do if symptoms occurred.

Richard Charles Worswick · Prevention of Future Deaths report View report

7 Nov 2025 Manchester South A. Mutch

Richard Charles Worswick, who had Parkinson’s disease, frailty and complex health needs, developed an infected spinal wound and died from sepsis at Stepping Hill Hospital on 19 May 2025. The principal concerns were unclear communication and documentation of the wound-care plan between the hospital and care home, together with unclear escalation arrangements and limited documentation of concerns and escalation attempts.

Anthony Robert CARD · Prevention of Future Deaths report View report

7 Nov 2025 Suffolk P. Taheri

Anthony Robert CARD, known as Tony, died by suicide by suspension by ligature at 15 Duke Street, Ipswich, between about noon on 21 and 22 November 2023. The report identifies a concern that, outside Care Act safeguarding criteria, there was no mechanism for police to communicate medium-risk mental-health information to relevant medical or mental-health providers, potentially resulting in missed support or affecting later decision-making.

SAMUEL GEORGE VASS · Prevention of Future Deaths report View report

6 Nov 2025 Cornwall and Isles of Scilly G. Davies

Samuel George Vass, a Royal Navy serviceman, died after the car he was driving crossed the carriageway and collided with an oncoming vehicle. The principal concern was the absence of speed enforcement on the A3083 between RNAS Culdrose and Helston, where there had been a number of collisions and previous deaths.

Aaron Lee Taylor · Prevention of Future Deaths report View report

6 Nov 2025 Lancashire and Blackburn with Darwen C. Long

Aaron Lee Taylor was discovered suspended from a ligature in his cell at HMP Garth on 28 August 2023. The inquest concluded that he had taken steps intending to take his own life and identified multiple failures in suicide-prevention measures, mental-health interventions, assessments, documentation, and adherence to policies and procedures.

Aaron Lee Taylor · Prevention of Future Deaths report View report

6 Nov 2025 Lancashire and Blackburn with Darwen C. Long

Aaron Lee Taylor was discovered in his prison cell on 28 August 2023, having died between the evening of 27 August and the morning of 28 August 2023. The inquest heard that he had taken steps intending to take his own life and identified multiple failures in measures to prevent self-harm and suicide, including inadequate assessments, documentation, policy compliance and mental health interventions.

Judith Hughes · Prevention of Future Deaths report View report

6 Nov 2025 Cambridgeshire and Peterborough S. Milburn

Judith Hughes had significant heart disease, was admitted to hospital following a seizure and later worsening heart failure, and died at home at 0030 hours on 07 October 2020. The inquest heard concerns that ambiguity in the Trust’s Close Observation Risk Assessment could lead to incorrect scoring, insufficient observation, and an increased risk of falls and death.

Vivian Joan Tuddenham NOLAN · Prevention of Future Deaths report View report

5 Nov 2025 Teesside and Hartlepool P. Appleton

Vivian Joan Tuddenham NOLAN underwent a diagnostic colonoscopy on 31 March 2025 after referral for iron deficiency anaemia and a positive FIT test. She developed a colonic perforation, deteriorated despite medical and surgical treatment, and died on 10 May 2025. The concern was that clinicians may lack knowledge and guidance about the increased risks of diagnostic colonoscopy in people aged over 80.

Matthew Lucas Sundeep Singh · Prevention of Future Deaths report View report

5 Nov 2025 North Wales (East and Central) K. Robertson

Matthew Lucas Sundeep Singh, a prisoner at HMP Berwyn, was found unresponsive in his cell on 23 November 2019 after consuming a novel psychoactive substance and died shortly afterwards from cardiac arrest due to substance abuse. The report identified the continuing availability and use of psychoactive substances at HMP Berwyn, and the significant risks they pose to prisoners, as a concern for future deaths.

Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report View report

5 Nov 2025 Manchester North J. Kearsley

Jennifer Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.

Oliver Luke Gorman · Prevention of Future Deaths report View report

4 Nov 2025 Manchester South A. Bridgman

Oliver Luke Gorman, aged 12, died at home on 5 May 2025 after inhaling butane gas from an aerosol spray. The report raised concerns about the lack of age restrictions on some products containing butane or propane, the adequacy of warnings about inhalation risks, and social media content promoting dangerous challenges.

Mrs Maureen Christy · Prevention of Future Deaths report View report

4 Nov 2025 Blackpool and the Fylde T. Holloway

Mrs Maureen Christy fell at home in November 2020, sustained a hip fracture, and was admitted to hospital. She contracted hospital-acquired Covid-19 after exposure on a hospital ward and later died at home; the narrative records conflicting dates for her death and verification of death. The principal concern was shortcomings in the dissemination and understanding of policy and practice changes, including guidance concerning the testing of people identified as Covid contacts.