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.
The report identifies Neil Richard Clark as the deceased person, but the supplied transcription does not include details of the circumstances of his death or any substantive concerns.
Leonardo Royal Hotel Birmingham
Luke James Lyons died at the scene of a road accident on 25 January 2013 after his vehicle hit overnight black ice on the A396. The area was affected by water flowing across the road, which washed away salt, and information indicated that a subsequently installed drain may have been inadequate.
Devon County Council
Reggie Johns, a prisoner on constant watch after two attempts to hang himself, was transferred to HMP Hewell on 19 October 2010. His constant watch status was discontinued after a review by two prison officers, and he was found hanging from a bed-sheet ligature about six hours later; he died in hospital the next day. Concerns included inadequate communication between prisons and healthcare staff, insufficiently robust review of his ACCT status, and failure to involve appropriate qualified personnel.
Bristol PrisonHerefordshire and Worcestershire Health and Care NHS TrustHewell Prison
Felix Stefan CEMBROWICZ was found hanging after deterioration in his mental health while awaiting a planned mental health assessment, was admitted to Bristol Royal Infirmary, and subsequently died. The report raised concerns that the electronic Rio record system did not transfer important records, including relapse management plans, for some discharged patients, potentially leaving staff unaware of relevant histories or delaying assessments.
Avon and Wiltshire Mental Health Partnership NHS Trust
Matthew Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.
Norfolk and Suffolk NHS Foundation Trust
Caroline LEE died in circumstances recorded in a narrative verdict, which is not provided here. The concerns identified were that medical staff failed to recognise the significance of abnormal potassium results and that laboratory staff failed to inform ward staff about them.
Recipient name withheldUniversity Hospitals Coventry and Warwickshire NHS Trust
David Hackman took up to 32 paracetamol tablets at home and was taken to hospital. After a mental health assessment, he left the Ambulatory Care Unit unnoticed, travelled to a multi-storey car park and jumped from it, dying from multiple traumatic injuries. The concern was how the lessons from this incident had been disseminated to the wider healthcare community, including other Trusts, and whether further action was needed to prevent future deaths.
NHS England
Martin Daffydd Barker became unwell after taking MDMA at a large event on 9 December 2012 and was transported to Salford Royal Hospital, where he was pronounced deceased; his cause of death was confirmed as MDMA toxicity. Concerns included the absence of clear guidance for independent medical providers to pre-alert hospitals about critically ill incoming patients, resulting in the hospital not being prepared for his arrival, and difficulties accessing the resuscitation unit overnight.
Ambulnz Community Partners Ltd.Department of Health and Social CareNorthern Care Alliance NHS Foundation TrustNorth West Ambulance Service NHS Trust
Ricky Anderson was admitted to hospital with command hallucinations and suicidal thoughts, was discharged, and was later found suspended from a tree at Chatham Cemetery on 21 May 2012. Concerns included failures to inform his GP of his hospital admissions, reliance on family information when assessing his wellbeing after discharge, and the lack of contact with the Access team and a care plan before his death.
Kent and Medway Mental Health NHS Trust
Peter Pattinson, who had complex medical needs, was readmitted to hospital after falling from his bed at Cedar Court Care Centre and died on 19 March 2013. Concerns included family requests for raised bed rails not being acted on or documented or subject to risk assessment, delayed repair of the bed rails, and missing or non-sequentially paginated daily statements.
European Care & Lifestyles (UK) Limited
Mrs Vaghadia developed bleeding after receiving an anticoagulant injection for suspected deep vein thrombosis and died in hospital on 27 August 2012 from haemorrhage and haematoma of the abdominal wall. Concerns included the community nurse administering a further anticoagulant injection without seeking medical advice despite knowing about the bleeding, failing to share that information with other healthcare professionals, and lacking training, experience, and insight into the potential risks of her actions.
Leicestershire Partnership NHS Trust
John Michael Bailey died from a cardiac arrest on 6 September 2013. The report raised concerns about the absence of a robust system for providing patients with arteriovenous fistulas with clear information about risks and complications, and about inconsistencies in information provided by different sources.
Department of Health and Social Care
Karen Lesley Sutton, who had primary antibody deficiency disorder and had undergone a splenectomy, was readmitted on 11 October 2012 with severe sepsis and died that evening after cardiac arrest. Concerns included the Immunology team not being notified of her hospital admissions, discontinuation of her prophylactic antibiotics on discharge, and inadequate arrangements for follow-up and communication between departments.
University Hospitals of Leicester NHS Trust
Michael Stuart Irlam was suffering from severe depression and anxiety and had been discharged from the CHRTT while awaiting further contact from IAPT. On 13 November 2012, he hung himself from the banister at his home. The principal concern was that vulnerable patients could experience a feeling of abandonment and deterioration while waiting without a confirmed appointment or clear information about the next stage of treatment.
Trafford Crisis Resolution and Home Treatment TeamTrafford Improving Access to Psychological Therapies Service
Jessica Florence Ashton-Pyatt became acutely unwell on 28 October 2012 and died after unsuccessful resuscitation following admission to hospital. Concerns included unco-ordinated care, initially absent consultant leadership, an uncharged defibrillator, and no defibrillation pads initially being available.
United Lincolnshire Teaching Hospitals NHS Trust
Mrs May Gibson sustained fatal injuries in a significant fall in her room at Herries Lodge Care Home on 21 March 2013. The report identified failures in assessment, care planning, falls risk management, preventative measures, and staff training and supervision; the inquest found that her death was contributed to by neglect.
Herries LodgeLNT Software
Martin Leslie Brown died of multiple injuries after skidding on a relayed road surface that was excessively slippery due to excess bitumen. The principal concern was that the BBA certificate for Milepave did not clearly specify its correct use, creating a risk that the product could be used inappropriately; the resurfacing work was also not carried out correctly and the fault was not recognised before the road reopened.
British Board of Agrément
Terrance O’Connell was admitted to a care home for respite and later developed abdominal and penile pain with reduced catheter drainage. After a communication breakdown, he was not seen by clinical staff and was found extremely unwell two days later; he was diagnosed with sepsis from a urinary tract infection and died that evening. Concerns included failures in communication, monitoring of oral and urinary output, and clinical assessment, with the inquest conclusion stating that the infection went undiagnosed and untreated before hospital admission and that his condition was contributed to by neglect.
Monkstone HouseSwansea Bay University Local Health BoardThe Grove Medical Centre
On 13 June 2013, Muniza Mehrban jumped from a multi-storey car park at Accrington Arndale Centre and sustained fatal injuries. The report raised concern that this was the fourth such death within three years involving people attending the car park with the specific purpose of jumping from a height.
Jesta Capital Corp.
Jill Felicity Sinson had schizophrenia, an anxiety-related disorder, non-epileptic seizures, and a history of self-harm and suicidal tendencies. She was last seen alive on 3 September 2012 and was found lifeless at her home on 10 September 2012; life was pronounced extinct by paramedics. The concerns included inadequate GP monitoring, failure to review or refer her after a GP surgery consultation, insufficient consideration of her medical history when prescribing medication unsupervised, and failure to act appropriately on correspondence from her Consultant Psychiatrist.
Beeston Health Centre
