Reports

Richard Charles HUNT · Prevention of Future Deaths report View report

8 Oct 2025 Rutland and North Leicestershire F. Butler

Richard Charles HUNT was a serving prisoner at HMP Stocken who set fire to his cell on 11 July 2025, was taken to hospital, and died later that day from smoke inhalation. The report raises concerns that the aspirating fire detection system’s buzzer failed to sound because it had been deliberately disabled or tampered with, and that similar issues were found across the prison estate without central oversight of faults.

Angela Christine Thompson · Prevention of Future Deaths report View report

7 Oct 2025 East Riding and Hull P. Marks

Angela Christine Thompson died after being struck by a taxi on 11 April 2022, following repeated attempts to place herself in the path of traffic. The report raised concern about inadequate liaison between prison medical services and community psychiatric services when people with ongoing psychiatric issues are released from custody, particularly when the prison is geographically distant from their home.

Amanda Wood · Prevention of Future Deaths report View report

7 Oct 2025 Manchester South C. Morris

Amanda Wood died on 3 January 2025 at Tameside General Hospital as a consequence of sepsis related to a long-term gastrostomy and Crohn’s disease. The principal concern was that there was no evidence of a sepsis screen being undertaken before her discharge from the Emergency Department on 28 December 2024, after which she was readmitted within 24 hours.

Ann Sabrina LASKOWSKY · Prevention of Future Deaths report View report

7 Oct 2025 West Yorkshire (Western) C. Keighley

Ann Sabrina Laskowsky was found unresponsive at home on 5 October 2024 after police attended when an inactivity alarm was triggered. She was taken to hospital later that day and died on 6 October 2024 from naturally occurring disease contributed to by self-neglect and exacerbated by longstanding alcohol dependence. The principal concerns were the adequacy and clarity of police first-aid training, including recognising abnormal breathing and unresponsiveness, and officers’ knowledge, use and training regarding the Partner Triage Line.

Imogen Alice NUNN · Prevention of Future Deaths report View report

7 Oct 2025 West Sussex, Brighton and Hove P. Schofield

Imogen Alice Nunn died at home on 1 January 2023 after consuming a substance she had obtained approximately six weeks earlier, during a period of deteriorating mental health. The report raises concerns about failures in mental-health risk management and the shortage of British Sign Language interpreters and BSL-proficient clinicians supporting deaf patients.

Steven Paul TURZYNSKI · Prevention of Future Deaths report View report

6 Oct 2025 Gwent C. Saunders

Steven Paul Turzynski, who had lung cancer and a history of treated oropharyngeal cancer, died from the effects of lung cancer on 29 July 2024. The report identified very limited communication between the two dietetic teams, lack of shared records, and inadequate nutritional assessment, with significant undernutrition by the time of his death.

Georgia Jay Barter · Prevention of Future Deaths report View report

2 Oct 2025 East London S. Radcliffe

Georgia Jay Barter died on 26 April 2020 after an act of self-harm following an assault by her partner during a long-term abusive relationship. The principal concern was that frontline police officers may have limited access to the Police National Database, making it difficult to identify reported domestic abuse linked to individuals across different police-force areas.

Beatrice Smith · Prevention of Future Deaths report View report

2 Oct 2025 Cumbria R. Cohen

Beatrice Smith, who was living at Riverside Court Care Home, developed seriously deteriorating leg and heel ulcers after 15 April 2025. Specialist attention was not sought and the ulcer was not always properly dressed; she developed sepsis, was admitted to hospital on 23 April 2025, and died that day. Concerns included the apparent absence of an effective internal investigation and of additional staff training or guidance, creating risks of missed learning and repeated inadequate care.

Milos JANKOVIC · Prevention of Future Deaths report View report

1 Oct 2025 South Wales Central R. Knight

Milos JANKOVIC had been diagnosed with Barrett’s Oesophagus in 2014 but was lost to follow-up surveillance after bowel cancer took priority. In 2020, he developed symptoms and was found to have brain metastases from primary oesophageal cancer. Concerns included inadequate processes for Barrett’s surveillance, particularly in primary care, and the absence of recall or prescribing prompts to identify patients needing surveillance or endoscopy.

Jake Hickey Girton · Prevention of Future Deaths report View report

29 Sep 2025 East London G. Irvine

Jake Hickey Girton was admitted to psychiatric hospital following suicidal ideation and serious, sustained alcohol misuse, and was later arrested after an incident on the ward. He was released from police custody without the psychiatric Trust being informed and was subsequently found deceased at home on 26 January 2024; the inquest identified concerns about the failure to notify the Trust and the lack of evidence of reflection or remediation by the Metropolitan Police Service.

Naomi Aylott · Prevention of Future Deaths report View report

29 Sep 2025 Hampshire, Portsmouth and Southampton R. Simpson

Naomi Aylott died on 12 September 2024 after jumping from a railway bridge with the intent to end her own life, following a period of poor mental health and previous suicide attempts. Concerns included that she was not seen face to face by her care co-ordinator, formal risk assessments and care planning were not completed, risk-assessment training and auditing were inadequate, and family involvement during telephone-based care had not been properly considered.

Mohammad Ali Asghar · Prevention of Future Deaths report View report

29 Sep 2025 East London G. Irvine

Mohammad Ali Asghar was admitted to hospital with worsening shortness of breath and fluid overload, and later suffered a cardiac arrest after catheter removal following haematuria and clots. The principal concerns were failures in Trust governance and incident-reporting processes, including the failure to identify and investigate the case through the Patient Safety Framework despite concerns about an iatrogenic injury and a court direction for review.

Honoria Culshaw · Prevention of Future Deaths report View report

26 Sep 2025 Manchester South A. Morris

Honoria Culshaw developed an infected pacemaker site and later underwent surgery to extract the pacemaker. She subsequently developed fatal pneumonia and died on 25 October 2024. The principal concern was that information about a positive wound swab may not have been shared or properly considered, potentially delaying extraction of the pacemaker.

Richard Ellis · Prevention of Future Deaths report View report

26 Sep 2025 West Sussex, Brighton and Hove J. Andrews

Richard Ellis died at the scene after a tractor’s handbrake failed while the tractor was on an incline, causing it to roll onto him as he detached a towing strap. The principal concern was that agricultural tractors may have no legal servicing or maintenance requirements, leaving maintenance dependent on vehicle owners’ discretion.

Catherine Moore · Prevention of Future Deaths report View report

26 Sep 2025 Suffolk D. Sharpstone

Catherine Moore died from traumatic injuries after a road traffic collision between an MOD Land Rover and an HGV, in which the HGV crossed the central reservation and crushed her car. The report found that defective steering, associated with inadequate maintenance and repair of the MOD Land Rover, contributed to the collision and her death. Concerns included unclear and limited information in the JAMES maintenance system, and the absence of formal processes for inspecting, auditing, providing feedback on, and testing MOD vehicle repairs and maintenance.

Zara Alice Cheesman · Prevention of Future Deaths report View report

25 Sep 2025 Nottinghamshire E. Didcock

Zara Alice Cheesman died in hospital on 23 December 2024 from meningococcal meningoencephalitis after becoming progressively unwell. The report identified concerns about inadequate assessment and non-conveyance by ambulance staff on 21 December, alongside insufficient organisational oversight, audit, monitoring and continuing professional development for assessing seriously ill children.

Pamela Ann HONEYBONE · Prevention of Future Deaths report View report

25 Sep 2025 North Yorkshire and York C. Cundy

Pamela Ann Honeybone was admitted to Scarborough General Hospital after a fall and died there on 19 October 2024 after being moved to end-of-life care. Another patient with the same first name underwent her required CT scan in error, delaying diagnosis of an abdominal mass suggestive of lymphoma; the inquest concluded that it was not possible to determine whether this contributed to her death. The report identified continuing patient-safety risks from patient misidentification, delayed responses to recognised errors, incomplete investigation, and gaps in patient-identification processes.

Susan Margaret Barrett · Prevention of Future Deaths report View report

25 Sep 2025 Essex S. Horstead

Susan Margaret Barrett died on 30 July 2024 from sepsis arising from osteomyelitis caused by a Grade 4 sacral pressure ulcer, against a background of dementia. The ulcer deteriorated during and after hospital care, with communication failures contributing to at least a two-month delay in daily nursing care. Concerns were also raised about the absence of embedded Tissue Viability Nurses or a Tissue Viability Service across community hospital wards and the resulting risk to vulnerable patients.

Mark Alan Smith · Prevention of Future Deaths report View report

24 Sep 2025 Essex S. Horstead

Mark Alan Smith was found deceased at home on 5 March 2024 after ingesting large quantities of prescription medication, including Mirtazapine and Pregabalin, together with a significant quantity of alcohol. The report identified a lack of GP policies or procedures for reviewing medication quantities prescribed to vulnerable patients with histories of addiction, self-harm, suicidal ideation or prescription medication overdose, and stated that this failure probably contributed more than minimally to the death.

Honoria Culshaw · Prevention of Future Deaths report View report

24 Sep 2025 Manchester South A. Morris

Honoria Culshaw died at home on 25 October 2024 after developing fatal pneumonia following treatment for sepsis from an infected pacemaker site. Her underlying cardiac and immunological conditions contributed to her deterioration after pacemaker extraction surgery. The report identified concern that inadequate communication about the need for pacemaker extraction delayed referral between treating hospitals and specialist services.