Reports

Andrew Nathan Paul Kenward · Prevention of Future Deaths report View report

9 Jul 2025 Surrey A. Loxton

Andrew Nathan Paul Kenward was found deceased in his car on 24 October 2022 after an overdose of a poisonous substance. He had previously expressed an intention to end his life, and the inquest recorded a conclusion of suicide. The concerns included the availability, purity and quantity of certain reportable substances, limited monitoring and restrictions, and the absence of apparent consideration of measures to reduce the risk to life.

Mr Marriott · Prevention of Future Deaths report View report

9 Jul 2025 West Sussex, Brighton and Hove J. Andrews

Mr Marriott underwent haemorrhoidal artery ligation with mucopexy surgery as a day patient and died at home on 15 April 2024; a post-mortem found pulmonary embolism, which the evidence indicated resulted from the surgery. The pre-assessment system did not directly require questions about a patient's haematological family history or record negative answers about the patient's own haematological history.

John Michael Kirkman · Prevention of Future Deaths report View report

8 Jul 2025 East Riding and Hull P. Marks

John Michael Kirkman, who had a long history of paranoid schizophrenia and previous detentions and admissions under the Mental Health Act, died after ingesting ████████ between 26 and 27 December 2023. The principal concern was that mental health screening information from one part of the country might not be promptly available in another because of different IT systems, potentially affecting subsequent assessments and referral prioritisation.

Peter Ramsden · Prevention of Future Deaths report View report

8 Jul 2025 East Riding and Hull P. Marks

Peter Ramsden, who had not been seen for approximately two months, was found deceased in an advanced state of decomposition at his premises on 2 January 2025. The inquest concluded that his death was from natural causes, although no specific disease process was identified. The principal concern was a perceived gap in the law concerning powers of entry for ambulance and fire services when an incapacitated person may require urgent treatment.

Miles Robinson · Prevention of Future Deaths report View report

8 Jul 2025 South London S. Reeves

Miles Robinson developed chest pains and vomiting on 19 December 2022 and experienced delays and incorrect triage after his granddaughter called 999. He travelled by Uber to an urgent treatment centre, where he suffered a cardiac arrest, and died at 06:36 after further cardiac arrests. The principal concerns were the incorrect categorisation of the 999 call and the rigidity of the triage system, alongside ambulance allocation and dispatch delays that may place patients reporting a heart attack at risk of death before an ambulance arrives.

SEAN FITZGERALD · Prevention of Future Deaths report View report

8 Jul 2025 Coventry and Warwickshire J. Saunders

On 4 January 2019 in Coventry, Sean Fitzgerald emerged from the rear door of a house during a West Midlands Police firearms operation and was shot in the chest by a police firearms officer. He died at 6.55pm despite first aid and medical treatment. The report identifies concerns about inconsistent guidance and training on when to announce “armed police” and how firearms officers should position themselves near property entrances, including the risks associated with close proximity.

Liliwen Iris THOMAS · Prevention of Future Deaths report View report

8 Jul 2025 South Wales Central R. Knight

Liliwen Iris THOMAS was delivered unattended in hospital after her mother, who had received analgesia, was not attended to or physically checked frequently enough for progression to active labour to be recognised. Liliwen was in a very poor condition and died later that day; the inquest identified concerns including the effects of analgesia, insufficient supervision, absence of resuscitation at birth, congenital infection and placental malperfusion. The report also identified that current NICE guidelines did not explicitly address analgesia levels and supervision.

Elaine TARBUCK · Prevention of Future Deaths report View report

7 Jul 2025 Manchester West T. Brennand

Elaine TARBUCK died after an accidental fall at home, sustaining a head injury and exsanguinating before she was found unresponsive on 29 March 2025. The report identified concerns about the assessment and information gathering by emergency services, delays in arranging forced entry, and the application of the ‘Right Care, Right Person’ policy.

David Gifford · Prevention of Future Deaths report View report

7 Jul 2025 Avon D. Rookes

David Gifford died at Southmead Hospital on 26 November 2024 after an acute ruptured abdominal aortic aneurysm associated with a fractured stent and endoleak. In the weeks before his death, he had multiple GP visits and made two 999 calls about pain before being conveyed to hospital. The report raised concerns that ambulance training and guidance may not sufficiently address subtle or non-classic signs of vascular emergencies, particularly in people with an extensive aortic history.

Sarah Jayne Lewis · Prevention of Future Deaths report View report

7 Jul 2025 Avon D. Rookes

Sarah Jayne Lewis, who had severe ME/CFS and was largely bedbound, was found deceased at home on 9 August 2024 after taking an overdose with the intention of ending her life. The inquest concluded suicide, with acute toxicity recorded as the cause of death. Concerns included inconsistent national provision of ME services, limited research and treatment options, insufficient professional understanding and training, and unclear implementation of updated NICE guidance.

Patrick Anthony COFFEY · Prevention of Future Deaths report View report

7 Jul 2025 Berkshire R. Simpson

Patrick Anthony Coffey fell at home, fractured multiple ribs, remained on the floor for about 17 hours, developed a chest infection and subsequently deteriorated in hospital. The report identified concerns that his pain was not always effectively controlled and that he was probably not repositioned every 2–4 hours as required, with gaps of up to 27 hours in the records; it stated that this posed a risk of future deaths in people with chest infections or at risk of pressure damage.

Daniel Norman Hatchett · Prevention of Future Deaths report View report

4 Jul 2025 East London N. Persaud

Daniel Norman Hatchett had declining physical and mental health, including stress alongside chronic health conditions. In the early hours of 9 November 2024, he was found hanging at home and pronounced dead at the scene; the circumstances were deemed non-suspicious. The report identified missed opportunities for mental health follow-up and therapy, and concerns about chronic disease reviews not adequately addressing patients’ mental health, particularly where men may not disclose concerns without being asked directly.

George EMMETT · Prevention of Future Deaths report View report

4 Jul 2025 Buckinghamshire C. Butler

George Emmett died after taking synthetic cannabinoid in G-Wing at HMP Aylesbury on 25 May 2023. The report raises a continuing concern that emergency responses involving prisoners may be compromised if staff do not follow the HMPPS Medical Emergency Response Codes policy, including promptly summoning an ambulance and calling a Code Blue.

Neil John Clarke · Prevention of Future Deaths report View report

2 Jul 2025 Manchester South C. Murray

Neil John Clarke, aged 81, died at Stepping Hill Hospital on 26 February 2024 after vomiting, aspiration and a cardiac arrest following a right hemicolectomy. The report raises concerns about the safety and wellbeing considerations for surgical procedures involving elderly patients, documentation and guidance about treatment choices, and the accuracy of handover communications when patients return to the main ward from HDU.

JASON JAMES CLEMENS · Prevention of Future Deaths report View report

2 Jul 2025 Cornwall and Isles of Scilly G. Davies

Jason James Clemens died on 23 March 2024 after a seven-hour delay in administering antibiotics prescribed for immediate use following a medical episode at the renal unit. The report identified four missed opportunities to administer the antibiotics and stated that the delay likely hastened his death and more than minimally contributed to his cause of death. It also raised concerns about the absence of implemented procedures for managing worsening renal-unit patients and uncertainty about the appropriate admission pathway.

Jody Lee ROBB · Prevention of Future Deaths report View report

1 Jul 2025 County Durham and Darlington C. Oliver

Jody Lee ROBB died at 23:03 on 8 April 2025 on the carriageway of Station Approach after taking deliberate steps to end her own life. Concerns included insufficiently restricted access from the station platform and the possibility that her presence was not detected or reported by train crews or station staff, despite 11 trains passing during the preceding hour.

Barry Christopher Spooner · Prevention of Future Deaths report View report

1 Jul 2025 Nottinghamshire N. Hartley

Barry Christopher Spooner engaged with police after concerns that a woman was financially exploiting him to buy drugs. He was financially exploited until his death and was found at home having been murdered by the woman. The principal concern was insufficient information sharing from Nottinghamshire Police to the Local Authority, including that one Public Protection Notice was not referred to Adult Social Care.

Ella Colette La-India DAVID-FONG · Prevention of Future Deaths report View report

30 Jun 2025 West London L. Brown

Ella Colette La-India DAVID-FONG was found collapsed outside her home and died in hospital later the same day after taking illicit drugs that resulted in an unintentional overdose. The principal concern was that, when Ella withdrew consent for information to be shared with her family, agencies could not use information held by her family to assist her care. The report also identified inadequate information for families and carers about consent, confidentiality, and how to communicate concerns when consent is withdrawn.

Thomas Raymond Mallinson · Prevention of Future Deaths report View report

30 Jun 2025 Cumbria N. Shaw

Thomas Raymond Mallinson became unwell with vomiting and diarrhoea and, after repeated contacts with health services over four days, was admitted to hospital gravely ill. He developed cardiogenic shock and acute kidney failure and died on 23 November 2024. The report raised concerns about delays and gaps in responsibility and communication across general practice, out-of-hours care, and ambulance services, and described the delay as amounting to neglect.

Aaron ATKINSON · Prevention of Future Deaths report View report

30 Jun 2025 Derby and Derbyshire P. Nieto

Aaron Atkinson was found deceased at his home on 20 April 2023, and the death was unexpected. The inquest conclusion was unascertained, with medical evidence considering seizure and positional asphyxia, or cardiac arrhythmia associated with prescribed medication. The principal concern was that annual reviews for people taking long-term antipsychotic medication may not consistently include ECGs despite recognised risks of QT interval prolongation and lethal cardiac arrhythmias.