Find published Prevention of Future Deaths reports, the concerns they raise, who received them and any published responses.
6,433 reports
Information drawn from published reports and official responses.
Marjory Rosina Ellery was taken to Frimley Park Hospital with chest pains and was administered medication to which she was known to be allergic. She developed anaphylactic shock and died on 16 January 2014; concerns related to administering medication despite a known allergy and obtaining informed consent in those circumstances.
Frimley Park Hospital
Amanda Hawkins, aged 44, had schizophrenia and experienced multiple moves to accommodation with reduced levels of care and changes in care co-ordination. She was last seen on 30 May 2014 and reported missing that evening; her naked, decomposed body was found on 22 July 2014, and the cause of death was unascertained. Concerns included increased vulnerability following the moves and inadequate follow-up of essential hospital appointments because care co-ordination workers were not informed of missed appointments.
Dudley Integrated Health and Care NHS TrustWest Midlands Police
Stephen Anthony Mayoll fell from a ladder at work and sustained a right Achilles tendon injury, for which he received outpatient treatment at Queen Alexandra Hospital between 11 and 20 June 2013. He became very unwell at home on 21 June and died in hospital at 03.20 hours on 22 June 2013 from a pulmonary thromboembolism arising from a deep vein thrombosis. Concerns included the lack of reassessment under the hospital’s DVT assessment policy for similar fracture-clinic outpatients and delays in making fracture-clinic doctors’ notes available.
Portsmouth Hospitals University NHS Trust
Richard Anthony Turner was working as a slinger when a crane jib section fell onto him during a lifting manoeuvre on 10 January 2014. He was taken to hospital and underwent several procedures before dying on 4 February 2014. Concerns included possible complacency among employees, a lack of a standard procedure to remind employees about lifting plans and risks, and limited evidence of toolbox talks.
TGF Management Services Limited
Four children died in 2013 following treatment at the National Hospital for Sick Children at Great Ormond Street in London. They had been treated with stem cell transplants, and a possible problem with cryopreservation of the stem cells later emerged. Concerns included the lack of national governance and disease-specific benchmarking for autologous stem cell engraftment, which made it difficult to identify abnormal recovery and could compromise the optimal care of some children with cancer.
NHS England
Michael Terence Harman lived in sheltered housing and was found unresponsive at home on 28 July 2014 after being contacted daily by intercom but not seen. He was diagnosed with severe dehydration, acute kidney injury and a large pressure sore, and died despite treatment. Concerns included the lack of a follow-up check after he was found soiled, indicators that he may no longer have been suitable for independent living, and inadequate review and handover arrangements.
Circle Care and Support Limited
William Philip Hafele, who had a history of mental ill health and alcohol dependence, was admitted to hospital after being found intoxicated and wanting to take his own life. After leaving the ward and being redesignated by police from missing to absent, no immediate enquiries were made; he was later found dead in a hotel room after suffocating using helium gas. The principal concerns related to inadequate training, risk assessment, communication, and understanding of responsibilities between the police and hospital staff.
Surrey and Borders Partnership NHS Foundation TrustSurrey Police
William Walter Jackson was diagnosed with severe aortic disease and underwent aortic valve and ascending-aorta replacement surgery in June 2013. After becoming unwell in August, a CT scan showed haemorrhage in the descending aorta, but the report did not identify features of a contained rupture; he died on 4 September 2013. The concerns included the lack of a formal record of advice from the Freeman Hospital, uncertainty about whether the CT images were reviewed, and the potential risk to patients from how such advice was given.
the Newcastle Upon Tyne Hospitals NHS Foundation Trust
Lara Mamula had a history of aortic dissection and Loeys-Dietz syndrome. After developing chest pain similar to that experienced during her earlier dissection, she was assessed by ambulance staff and later attended A&E, where she was diagnosed with gastritis and discharged. Five days later, she was found deceased at home; concerns included that the ambulance service did not appreciate the seriousness of her condition or the significance of her recurrent pain, and that a CT scan was not undertaken.
Isle of Wight Ambulance ServiceIsle of Wight NHS Trust
Sandra Bodrožič’ died after running to the attic, saying goodbye and jumping from a window, landing three storeys below. She had previously been detained under the Mental Health Act and treated in hospital and the community. The substantive concerns included delays in finding a hospital bed, arranging a Mental Health Act assessment, and the absence of clear urgency or timeframe protocols for such assessments.
North London NHS Foundation Trust
HAROLD PENNY was admitted to hospital on 12 June 2014 and died on 20 June after investigations found a grossly distended bladder and a misplaced urinary catheter. The principal concern was that there was no system requiring radiology staff to rectify such problems where possible or urgently report them to treating clinicians.
Tameside and Glossop Integrated Care NHS Foundation Trust
Gaenor Moore, who had chronic obstructive pulmonary disease and required an oxygen concentrator with humidifier, became breathless, deteriorated and died at her residential care home after the humidifier cap was not properly engaged, preventing oxygen flow to her nasal cannula. Concerns included the absence of a visual or audible alarm to indicate loss of oxygen flow and training and literature that did not explain the implications of failing to properly engage the humidifier cap.
Dolby VivisolInvacare LimitedSalter Labs
Noreen Porter, who had dementia and was at high risk of aspiration, died after aspirating food material while being fed tea at a nursing home on 18 September 2014. The concerns were that staff did not undertake CPR when she collapsed and that there appeared to be no process or procedure to ensure resuscitation during an emergency.
Ardenlea Grove Care Home
Tracey Bannister, aged 29, became unwell after an elective ERCP procedure on 24 June 2014, was admitted to hospital on 26 June with cyanosis, low blood pressure and acidosis, and died after cardiac arrest. The concern raised was that discharge advice should tell patients to contact both their GP and the department where surgery was performed if pain or a raised temperature continued for more than 24 hours.
Walsall Healthcare NHS Trust
Martin Dilwyn McCabe was admitted to hospital with gastrointestinal bleeding and later fell while being assisted out of bed, suffering an extensive bilateral subdural haemorrhage. The principal concern was that no new falls risk assessment was completed on admission, despite reported previous falls and night-time sedation, and staff relied on an assessment from three months earlier.
Cwm Taf Morgannwg University Local Health Board
George Christian Werb was receiving inpatient treatment for serious mental health issues and died after walking onto a railway track near his home while on home leave. The report raises concerns about the distant placement, inadequate risk assessment, poor communication and engagement with the family, and insufficient local child psychiatric beds.
NHS Devon Integrated Care BoardNHS England
Leanne Carmen Gower was a passenger in a car that lost control and collided with an oncoming vehicle; she died at the scene. The report raised concerns that damage-only road collision data was not routinely checked or recorded and may not have been considered when assessing whether highway works were needed.
Northamptonshire Police
Mrs Elsie Mallaliu fell at home on 12 August 2013, broke her hip, was admitted to hospital, and died four days later. The report raised concerns that she was moved to an inappropriate ward, where staff were not trained to use her high-flow oxygen, records and observations were inadequate, staffing pressures affected care, and antibiotics were not administered because the drip was not turned on. It also stated that she was considered “written off”, that a DNAR should not have been placed, and that escalation to ITU/HDU might have allowed treatment of the infection that led to her death.
Tameside and Glossop Integrated Care NHS Foundation Trust
Mrs Gladys Smith died while resident at a care home; the supplied text does not provide further circumstances of her death. The concerns included failures in repositioning, bruise and wound monitoring, falls assessment, weight and nutrition monitoring, dementia care, and delays or gaps in district nursing wound documentation and referral. The report also identified a lack of comprehensive national guidance on wounds and ulcers caused by impact injuries.
Leeds City CouncilLeeds Community Healthcare NHS TrustMoorfield House SurgeryNational Institute for Health and Care ExcellenceRecipient name withheldSt Armands Court
Peter Dorney was admitted to Frenchay Hospital and deteriorated overnight on 3–4 April 2014 before suffering a cardiac arrest and dying on 4 April from bronchopneumonia. The report identified that required increased observations and notification of a senior staff member were not carried out after his EWS score rose, and noted that EWS training for nurses was not mandatory.
Southmead Hospital
