Reports

Gary Lee JAMES · Prevention of Future Deaths report View report

12 Feb 2025 Teesside and Hartlepool C. Bailey

Gary Lee James died at James Cook University Hospital on 11 January 2019 from injuries sustained when metal frames fell on him while he was trying to move them at Ward Bros. The report identified concerns including inadequate risk assessment, training, equipment, supervision and first-aid provision, as well as failures to address employees’ safety concerns and unsafe working conditions.

John Tompkins · Prevention of Future Deaths report View report

11 Feb 2025 Inner North London R. Brittain

John Tompkins died on 25 July 2024 after hepatic artery embolisation and right-sided portal vein embolisation were undertaken simultaneously rather than sequentially. He subsequently developed acute-on-chronic liver failure and died from consequential multiorgan failure. Concerns included limited internal review of the circumstances and the Trust’s apparent failure to consider NatSSIPS2 standards when undertaking or reviewing the procedures.

Amelia Alexandra Anuszka RIDOUT · Prevention of Future Deaths report View report

11 Feb 2025 Cambridgeshire and Peterborough E. Gray

Amelia Ridout, a six-year-old girl with suspected aplastic anaemia, died after a bone marrow aspirate and trephine procedure under general anaesthetic caused internal bleeding from an iliac artery injury. Despite prolonged resuscitation and emergency surgery, the bleeding could not be stopped. The concerns identified were the development and publication of national guidelines and a standard operating procedure for these procedures, including recommended methodology, and the development of a database to record procedures and outcomes.

Nicholas J D’Ourou · Prevention of Future Deaths report View report

11 Feb 2025 Inner North London R. Brittain

Nicholas J D’Ourou, who had been admitted to Highgate Acute Mental Health Centre as a voluntary patient, was found on 15 April 2024 with a ligature around his neck and died from asphyxiation. The report raises concerns about inconsistent practice and limited guidance for cross-titrating psychiatric medication, and about the lack of patient observation, including electronic monitoring, in psychiatric wards.

Anne TOWLSON · Prevention of Future Deaths report View report

10 Feb 2025 Rutland and North Leicestershire I. Thistlethwaite

Anne Towlson was found dead at home on 17 May 2024 after travelling to Turkey for planned tummy tuck and liposuction surgery, and additionally undergoing arm tuck surgery. Her arm wounds had not healed, with open, swollen and weeping wounds noted after her return to the UK; the cause of death was recorded as unascertained. Concerns included the lack of information about the Turkish hospital’s assessment, surgery and postoperative care, uncertainty about whether surgical risks were explained, the consenting process for the additional arm surgery, and limited follow-up after returning to the UK.

Yahya Muhammad Hayat · Prevention of Future Deaths report View report

10 Feb 2025 Manchester South P. Merchant

Yahya Muhammad Hayat was born at Tameside Hospital on 12 April 2024 following a maternal uterine rupture and severe hypoxic-ischaemic encephalopathy, and died at Royal Oldham Hospital on 25 April 2024 after compassionate care was commenced and he was extubated. The inquest identified concerns about the lack of continuous monitoring and delays in medical review and decision-making before delivery, as well as changes to paediatric specialist training for neonatal intubation.

Ella Louise Murray · Prevention of Future Deaths report View report

7 Feb 2025 Mid Kent and Medway C. Wood

Ella Louise Murray was 13 years old when she died at Kings College hospital on 15 November 2023 following an episode of hanging, after a period of self-harm, suicidal ideation and deteriorating mental health. The report raised concerns about the adequacy of her risk assessment and the failure to take urgent protective action, including removing her from home or convening an urgent multi-agency response. It also identified the lack of shared information and records across health, social care and education services.

Anthony Binfield and 2 others · Prevention of Future Deaths report View report

7 Feb 2025 Nottinghamshire L. Bower

Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous deaths.

Dafydd Hûw CRAVEN-JONES and 2 others · Prevention of Future Deaths report View report

7 Feb 2025 Staffordshire and Stoke-on-Trent K. Dixon

On 25 May 2024, a Ford Ka travelling at speed over a hump back bridge on the B5012 Cannock Road lost control and collided head-on with a tree, resulting in the deaths of Dafydd Hûw Craven-Jones and Dafydd Morgan Jones at the scene, and Sophie Chloe Bates in hospital on 28 May 2024. The concerns identified were two fatal collisions on this road between January and May 2024, the prominence of signage, and the absence of road markings approaching the hump back bridge.

Carla James · Prevention of Future Deaths report View report

7 Feb 2025 Manchester North J. Kearsley

Carla James died unexpectedly at her home address in Tottington, Bury, on 18 August 2024, aged 50. Evidence at the scene indicated she may have ingested material from a plant. The report raises concern that highly poisonous and toxic products were being imported and sold nationally without warnings that they could endanger life.

Kenton Clete BEASLEY · Prevention of Future Deaths report View report

7 Feb 2025 West Sussex, Brighton and Hove J. Turner

Kenton Clete Beasley was found hanging at an address in Ashurst, Steyning on 19 May 2024 and was confirmed deceased at the scene; third-party involvement was ruled out. The report described delays and communication failures in the renewal of his HGV licence, which prevented him from securing professional employment and contributed to distress and deterioration in his mental health.

Ian Augustus Jones · Prevention of Future Deaths report View report

7 Feb 2025 South Wales Central G. Knox

Ian Augustus Jones died at University Hospital Wales, Cardiff, on 29 October 2022 from a traumatic brain injury sustained after the electrically motorised bicycle he was riding without a helmet collided with a pavement bollard. The report raised concern about the accessibility of electric motors and parts that can convert a pedal bicycle into a high-powered, throttle-controlled scooter capable of high speeds and rapid acceleration, posing a danger to riders and other members of the public.

Jane BENNETT · Prevention of Future Deaths report View report

6 Feb 2025 Northamptonshire A. Pember

Mrs Bennett was involved in a road traffic collision at the junction of St Johns Road, Tiffield and the A43 on 13 March 2024 and was later confirmed deceased on 15 March 2024. The report raises concern that the junction is very difficult to manoeuvre and that, without changes, further accidents or fatalities are likely.

Katrina Veronica Francesca Insley · Prevention of Future Deaths report View report

6 Feb 2025 Worcestershire J. Puzey

Katrina Insley died on 1 January 2024 at Alexandra Hospital, Redditch, from sepsis due to an infected pressure sore and pneumonia. The report identified concerns about the absence of a formal, documented handover system between hospital and the Neighbourhood Team, limited access to hospital records, and the resulting risk of delayed recognition and treatment of pressure sores, infection and sepsis.

Sapphire Kathleen BERNARD · Prevention of Future Deaths report View report

5 Feb 2025 West Sussex, Brighton and Hove P. Scofield

Sapphire Kathleen BERNARD was detained under the Mental Health Act and waited 19 days in an A&E department for a psychiatric bed while continuing to self-ligature. After admission to Langley Green Hospital, she self-tied a ligature while on intermittent observations and died at East Surrey Hospital on 30 October 2023. The principal concerns were the lack of psychiatric beds, the unsuitability of A&E as a holding environment for people needing mental health care, and vulnerabilities in the risk assessment and observation requirements at Langley Green Hospital.

Simon Timothy Harding · Prevention of Future Deaths report View report

5 Feb 2025 Somerset S. Marsh

Simon Timothy Harding died after becoming separated from his motocross bike during a jump at Granfield Moto-Cross Track on 10 September 2022; the bike landed on his head, causing catastrophic and unsurvivable head injuries. Concerns included limited rider registration, no safety briefing, inadequate track regulation and stewarding, lack of rider segregation, and no first-aid training for venue staff. The report also identified a lack of mandatory minimum safety and risk-management standards for motocross venues as a risk of future deaths.

Mr Leslie Hurwood · Prevention of Future Deaths report View report

5 Feb 2025 Northamptonshire J. Dixey

Mr Leslie Hurwood died on 13 January 2023 at Kettering General Hospital, having had a history of Type I diabetes and other health conditions, and a recent diagnosis of dementia. During a December 2022 admission after a fall, he experienced multiple episodes of hypoglycaemia. The report raises concerns that nurses at Northampton General Hospital administered insulin after meals rather than before them, and that this practice continued to occur occasionally despite advice and training.

Terence Grainger · Prevention of Future Deaths report View report

5 Feb 2025 Manchester South C. Morris

Terence Grainger died at The Alexandra Hospital, Cheadle, from an acute left thoracic cavity haemorrhage following removal of a left-sided intercostal drain placed after coronary artery bypass graft surgery. The principal concern was that Circle Healthgroup Ltd had no plans to introduce electronic systems for recording patient observations, creating potential risks in recording timings, analysing trends and calculating NEWS 2 scores.

Dorothy Lilian REID · Prevention of Future Deaths report View report

4 Feb 2025 North East Kent C. Wood

Dorothy Reid, a 91-year-old woman, suffered spinal fractures after a fall and later died from a pulmonary embolism on 3 April 2024. Concerns included delays and poor conditions in the emergency department, the impact of hospital bed shortages on emergency care, and patients’ reluctance to attend hospital because of long waiting times.

Peter Keith JONES · Prevention of Future Deaths report View report

4 Feb 2025 Inner North London M. Hassell

On 5 November 2022, Peter Keith Jones spent approximately 18 hours in the public waiting area of Stoke Newington Police Station before jumping from the flat hood of a telephone booth onto the concrete floor. He suffered devastating injuries and died shortly afterwards. The jury identified concerns about the presence of a flat-topped telephone hood and insufficient oversight of the public reception area by police station staff.