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.
Nigel John Keenan died by hanging at HMP Haverigg between 8 pm on 12 March 2025 and 4:20 am on 13 March 2025; the inquest concluded suicide. Concerns included the lack of seven-day mental health support at the prison, limited staffing for constant observation, and a possible incentive for prisoners in crisis to minimise their suicidal intent.
NHS England
Oliver Charles Major Shelley became seriously unwell on 22 July 2024 with symptoms including a non-blanching rash, vomiting and reduced consciousness. After no ambulance was dispatched, his parents took him to hospital, where he was treated for meningococcal septicaemia but died approximately 7.5 hours after arrival. The report identified concerns about the lack of a sepsis algorithm for emergency medical advisors and the training and description of those advisors’ role.
NHS EnglandNHS Pathways
Trevor Anthony Evans was struggling with his mental health and had contact with police, ambulance, mental health professionals and healthcare staff before taking his own life by hanging at home on 27 February 2020. The principal concerns were over-reliance on what he told a mental health nurse, failure to review medical records and insufficient investigation of available background information, resulting in concerns that mental health risk assessments could be incomplete or inadequate.
Hywel Dda University LHB
Tung Thanh Tran, who had a renal transplant and chronic hepatitis B, died after Entecavir was inadvertently discontinued following a change to home medication delivery. He developed acute liver disease from hepatitis B reactivation, was too unwell for a liver transplant, and died on 12 September 2025. Concerns included a lack of national guidance on responsibility for monitoring and prescribing hepatitis B reactivation prevention, and insufficient specialised commissioning to maintain engagement with some patients diagnosed through Emergency Department screening.
The British Association for the Study of the LiverUK Health Security Agency
Glen Edward Robert Jay was admitted to Broomfield Hospital for planned preoperative preparation and subsequently underwent emergency abdominal surgery for small bowel obstruction with suspected ischaemia. He did not regain consciousness after further surgery and died following severe sepsis; the principal concern was that Preoperative Progressive Pneumoperitoneum may induce adhesional small bowel obstruction in patients with a history of recurrent adhesional small bowel obstruction, and the Trust updated its protocol to list this as a contraindication.
NHS England
Garth Pretorius became unwell after a medical procedure and was diagnosed with sepsis at Goole Urgent Treatment Centre. He was directed to Hull Royal Infirmary, where confusion over an impending emergency led to him and other patients being told to leave, delaying appropriate sepsis treatment by approximately 24 hours; this delay contributed to his death. The report also raises concern about two different triage systems being used simultaneously in the Emergency Department, with insufficient resources for universal adoption of the validated Manchester system.
Hull University Teaching Hospitals NHS Trust
Ollie Lee, who had a history of suicidal thoughts and self-harm, died by suicide on 6 October 2024. The principal concerns were poor communication and engagement between the agencies involved, including failures to share information about self-harm and CAMHS discharge, which resulted in missed opportunities for continued mental health support. Important discussions about Ollie’s preferred name and pronouns were also not recorded or acted upon.
Barnsley AcademyBarnsley Borough CouncilSouth West Yorkshire Partnership Teaching NHS Foundation Trust
Jake Daniel Taylor, aged 19, suffered a cardiac arrest at his care home on 16 January 2025 and died in Kingston hospital on 20 January 2025. The report identified delays in first aid and concerns about the lack of individual emergency planning, staff training, immediately available equipment, and airway training and equipment.
Choice SupportNHS EnglandNHS South West London Integrated Care Board
Shay Middleton-Pierce, aged 15, died on 29 March 2025 from multiple traumatic injuries following suicide near the Nutfield train line crossing in Redhill, Surrey. British Transport Police failed to establish whether officers could meet him at Redhill Station and did not inform Surrey Police that they were not attending after the incident log was moved from the dispatch queue to a sub queue in error. The report raises concerns about human error, insufficient supervisory oversight, and the lack of computer checks to prevent priority logs being removed from dispatch attention.
British Transport Police
Elsie Margaret Jones, who had advanced dementia and was at high risk of falling, spent several months in hospital while awaiting discharge to a specialist service. She experienced several falls, including a fall on 1 November 2025 that caused a hip fracture, and died on 16 November 2025 after receiving palliative care. The concern was that lengthy delays in securing funding and suitable specialist placements for patients with severe dementia can leave them inadequately supervised on acute hospital wards, creating a risk of future deaths.
Department of Health and Social CareNHS Birmingham and Solihull Integrated Care Board
Alan Whelan, a serving prisoner at HMP Leeds, was moved to the Segregation Unit after starting a fire in his cell while on an open ACCT document. A required mental health assessment was not carried out within 24 hours, and he was later found hanging in his cell and died in hospital on 30 December 2024. Concerns included non-compliance with the mandatory assessment requirement and failures relating to the frequency of ACCT observations.
Ministry of JusticePractice Plus Group
Sunny Elise EYMOND died at Winchester Hospice on 27 May 2024 after a long history of anorexia nervosa, personality disorder and complex post-traumatic stress disorder, including hospital admissions and periods of forced feeding. The report identified communication and oversight failings during her transfer of care between Hampshire and Bristol services, including the absence of a robust care package, planned 1:1 professional support and a suitable risk management plan. Concerns were raised about the lack of national guidance and treatment pathways for cross-Trust transfers involving people with eating disorders and complex emotional needs.
NHS EnglandOffice of the Chief Coroner
Lisa Jayne Townsend had abdominal pain and was diagnosed with cholecystitis and pancreatitis in late September 2024. Her gallbladder surgery was delayed and, during the operation on 1 October 2024, an injury was sustained to the bile duct; subsequent attempts to rectify it were unsuccessful. She later developed chronic sepsis and died on 20 March 2025. The report identified multiple delays and issues in her care, including the bile duct injury, as contributing to her death.
Cardiff & Vale University LHBCwm Taf Morgannwg University Local Health BoardWelsh Government
Peter Edwin Spencer Gurney had an unwitnessed fall at home on 19 September 2025 and was pronounced deceased at the scene; the inquest concluded that he died of heart failure contributed to by co-morbidities including terminal bladder cancer. A substantive concern was that current and former employees exposed to Nitrobenzene and other explosives had not been warned to get tested, despite possible links to bladder cancer.
Ministry of Defence
Suseel RANA, who had mental health conditions and was experiencing anxiety and fear linked to domestic abuse, died by suicide after ingesting an excess of a substance. Concerns included the failure to progress her Clare’s Law application, a misunderstanding about its use for a previous partner, and the failure to recognise her anxiety as requiring further safety planning and multi-agency support.
Bedfordshire PoliceHome Office
Somtera Bibi, aged 80, died from fatal stab wounds to the chest at her home on 2 April 2022. The report identified concerns about the absence of robust community mental-health risk management, including relapse prevention, family safety planning, DASH risk assessments, safeguarding referrals and multi-agency involvement, despite known risks posed by the family member who inflicted the injuries.
East London NHS Foundation Trust
John McKinlay died at Beech Hill Grange nursing home on 19 November 2025 after receiving end-of-life care. His death involved natural causes alongside a subdural haematoma and fractured neck of femur associated with a series of falls, including inpatient falls at Good Hope Hospital, Birmingham Heartlands Hospital and Queen Elizabeth Hospital. The principal concern was that some falls may have occurred without the observation required by his falls risk assessment and care plan, and that evidence was not provided of investigations into falls at Birmingham Heartlands Hospital and Queen Elizabeth Hospital.
University Hospitals Birmingham NHS Foundation Trust
Natasha Hill, who had been in care and was experiencing grooming, exploitation, self-harm, substance misuse and domestic violence, was pronounced dead at her abuser’s home in the early hours of 15 April 2018. The jury concluded that she was unlawfully killed by her abuser. The report raised concerns about safeguarding during the transition to adulthood, protection from exploitation and domestic abuse, and coordination of relevant policing and safeguarding policies.
Department for EducationHome OfficeNational Police Chiefs’ Council
Kevin Lapwood, aged 63, was acting as a volunteer safety diver at Wraysbury Dive Centre on 12 February 2022 after failing an HSE medical in October 2021. He got into difficulty in very cold water and died at Wexham Park Hospital the next day; the recorded cause of death was immersion pulmonary oedema, hypertension and coronary artery disease. Concerns included medical requirements and awareness for volunteer divers, awareness of immersion pulmonary oedema risks, the guidance on shore support, and potential ambiguity in HSE legislation and guidance concerning volunteers.
British Diving Safety GroupHealth and Safety Executive
Moira Diane Parker, a microbiologist, had experienced declining memory and cognitive function, increasing work pressure, and worsening mental health before she was found with self-inflicted stab wounds on 11 April 2025; her death was confirmed by paramedics. The report raised concerns that occupational health referral was delayed despite her raising concerns over a prolonged period, and that staff may lack sufficient knowledge and training about when such referrals can be made and what support is available.
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