Reports

Afolabi Oluwafemi OJERINDE · Prevention of Future Deaths report View report

3 Feb 2025 Manchester City Z. Golombeck

Afolabi Oluwafemi OJERINDE attended a petrol station, dispensed petrol into a plastic water bottle, ignited it and placed himself in the fire. He died at hospital from injuries sustained during the incident. The concern was that the petrol station’s controls did not ensure compliance with regulations governing the dispensing of petrol into suitable containers and to eligible persons.

Kim Jeannette ROBINSON · Prevention of Future Deaths report View report

31 Jan 2025 Suffolk N. Parsley

Kim Robinson died at home in Suffolk on 12 May 2024 after toxicological analysis identified a significantly toxic level of a medication obtained from an online pharmacy. The report identified concerns that the online prescriber could not access her GP records, the ordering process used incorrect details, and the medication was delivered in a quantity that gave her direct access to a fatal amount. The report stated that the online prescription system needed review.

Aeran Luke Sebastian Taylor · Prevention of Future Deaths report View report

31 Jan 2025 West Sussex, Brighton and Hove J. Turner

Aeran Luke Sebastian Taylor, a former Army serviceman diagnosed with PTSD, died at his home in Crawley on 27 October 2023. The inquest found that multiple substances combined to a fatal toxic effect, likely resulting from an accidental overdose. Concerns included the lack of mental-health assessment at discharge, limited awareness of veteran welfare support, and insufficient long-term rehabilitation and substance-abuse recovery services for veterans with PTSD.

Alexander Channing · Prevention of Future Deaths report View report

31 Jan 2025 Dorset R. Middleton

Alexander Channing, known as Alec, was found suspended by a ligature in his university halls of residence on 27 January 2022 and was pronounced dead at the scene. The report records concerns about delays in transferring his mental health care, discharge planning without Home Treatment Team involvement, postponed assessment, limited proactive attempts to obtain consent to share information, and a lack of relevant training and policies.

Nicola Emma OWENS · Prevention of Future Deaths report View report

31 Jan 2025 Liverpool and the Wirral A. Bhardwaj

Nicola Emma Owens collapsed at work on 4 October 2024 and, after a delay of 7 hours and 28 minutes before an ambulance arrived, suffered a cardiac arrest and died in hospital at 00:25 on 5 October 2024. The report identified concerns about ambulance unavailability, hospital handover delays, and backlogs of patients awaiting social care packages, which reduced ambulance availability for seriously ill patients.

James Collier SIDDONS · Prevention of Future Deaths report View report

30 Jan 2025 Inner South London L. Field

James Collier Siddons, who had very severe frailty and multiple co-morbidities, was admitted to hospital after sustaining a fractured left humerus at a nursing home. He subsequently developed aspiration pneumonia and pyelonephritis and died suddenly from sepsis on 31 January 2022. Concerns were raised that the investigation into his fracture was flawed, that the organisation lacked detailed investigation guidance and routine training, and that relevant issues were not communicated promptly by the local authority.

Graham Whiteley · Prevention of Future Deaths report View report

30 Jan 2025 Somerset V. McKinlay

Graham Whiteley, who had Alzheimer’s disease, a history of seizures and falls, and lived in a care home, walked out when doors were left unlocked and was found having fallen by the roadside with head injuries. He was conveyed to hospital by police after a substantial ambulance delay, developed pneumonia, and died in hospital on 18 June 2024. The principal concerns were delays in ambulance allocation linked to handover delays at acute hospitals, with the report stating that these delays were continuing.

Shaun Kenny HALL · Prevention of Future Deaths report View report

30 Jan 2025 Northamptonshire A. Pember

Shaun Hall had mixed anxiety, depressive disorder and emotionally unstable personality disorder, and was found deceased on 14 December 2023 after hanging himself. A referral to the Urgent Care and Assessment Team was declined despite information about escalating factors and his statement that he would take his own life if not allowed to see his children. The identity of the person who declined the referral was unknown and no notes were made of it.

Alex Edward CROOK · Prevention of Future Deaths report View report

30 Jan 2025 Manchester West J. Pollard

Alex Edward Crook, aged 15, drowned after going out of his depth while playing at the edge of Scotsmans Flash on 7 September 2024. The concerns included failures to provide statutory swimming lessons, inadequate wording and siting of warning signs, and proposed siting of throw lines away from obvious water entry points.

Liam Stephen Allan · Prevention of Future Deaths report View report

30 Jan 2025 West London A. Van Dellen

Liam Stephen Allan was arrested alongside the River Thames on the evening of 26 August 2022, entered the river, and drowned. The report identified concerns about inadequate lighting and visibility of riverside buoyancy aids, and about delays in alerting the London Fire Brigade because notification was made by telephone rather than through the faster CAD-mediated system.

Carla Marie SMITH · Prevention of Future Deaths report View report

29 Jan 2025 Norfolk S. Goward

Carla Marie SMITH died on 7 June 2023 after rapidly progressing metastatic endometrial cancer. The report identified missed opportunities in referral and use of the correct pathway, delays in laboratory results, and lengthy waiting lists. Concerns included the risk that patients may deteriorate while waiting and the lack of systems to monitor patients on routine or urgent waiting lists.

Naomi SULEYMAN · Prevention of Future Deaths report View report

29 Jan 2025 Inner South London L. Field

Naomi Suleyman developed and later died from pneumonia and complications of an unstageable sacral pressure sore after discharge from hospital, during a period when she was deconditioned and bedbound while her long-term needs were assessed. Concerns included inaccurate discharge information, missed welfare and therapy visits, an incorrect district nursing referral, poor communication between services, and missed opportunities to recognise and address that her discharge was unsafe.

William Antony Northcott · Prevention of Future Deaths report View report

27 Jan 2025 Devon, Plymouth and Torbay L. Wiltshire

William Antony Northcott, who had treatment-resistant schizophrenia, was found deceased on 13 July 2021 after suffering a sudden fatal cardiac arrhythmia. The report raised concerns about the adequacy and consistency of information on clozapine side effects and cardiac warning signs, the detection of cardiomyopathies in patients taking clozapine, and communication between agencies and care teams.

WILLIAM CAMPBELL BISSETT · Prevention of Future Deaths report View report

27 Jan 2025 Liverpool and the Wirral N. Rheinberg

William Campbell Bissett, aged 88, died by suicide by hanging in his cell at HMP Wymott on 13 October 2023, shortly before his planned release on licence. The report raised concerns about inadequate advance planning for his accommodation, insufficient engagement by prison offender management and probation services, and the failure to notify local authorities that he would be homeless on release.

Charlie Marriage · Prevention of Future Deaths report View report

24 Jan 2025 Inner South London X. Mooyaart

Charlie Marriage, who had epilepsy controlled with Fycompa, was unable to obtain his repeat medication after being told to self-isolate for Covid and encountering difficulties with his GP practice, pharmacy and 111. He suffered a fatal seizure at home after going without medication. The report identified concerns about whether patients with medication-dependent, “cliff-edge conditions” are recognised, prioritised and given appropriate safety-netting and access to emergency supplies.

Andrew Dominic HEYS · Prevention of Future Deaths report View report

24 Jan 2025 Manchester West J. Pollard

Andrew Dominic HEYS received a Covid-19 booster vaccination in December 2021 and subsequently suffered from Auto-Immune Encephalopathy. On 12 March 2024, he fell into the Manchester Ship Canal from a bridge, and his body was discovered four days later. Concerns included inadequate training for an out-of-hours GP in following referral pathways and accessing patient records, as well as incompatible health-record IT systems that prevented health professionals from accessing records held elsewhere in the NHS.

Neville Daniel Elisha MCKENZIE · Prevention of Future Deaths report View report

24 Jan 2025 Birmingham and Solihull E. Brown

Neville Daniel Elisha MCKENZIE died in hospital on 25 August 2024 after choking at his care home on 13 August 2024, which led to cardiac arrest and an unsurvivable brain injury. The report raised concerns about limited awareness and availability of anti-choking devices in care settings, including homes with residents at high risk of choking.

Cynthia Mary Gilbert · Prevention of Future Deaths report View report

24 Jan 2025 Somerset V. McKinlay

Cynthia Mary Gilbert, who had cardiac and respiratory illness and reduced mobility, was admitted to hospital after being found unable to stand from the toilet. During her admission, pressure ulcers deteriorated and became infected, and she died from septicaemia on 20 December 2023. Concerns included repeated failures to follow her repositioning care plan despite her very high risk of pressure ulcers, and an unsatisfactory explanation for those failures in the Trust’s post-death investigation.

Harry Benjamin SOUTHERN · Prevention of Future Deaths report View report

23 Jan 2025 West Sussex, Brighton and Hove G. Jones

Harry Southern had a history of mental illness, previous suicide attempt and traumatic events in the final year of his life. He died after tying a ligature around his neck with the intention of ending his life. The report raised concerns that young people and their families may not receive accessible, reliable information or timely contact with mental health and suicide-prevention services, and that funding reductions could further reduce available support.

Brian Kneale · Prevention of Future Deaths report View report

23 Jan 2025 Blackpool and the Fylde A. Wilson

Brian Kneale, aged 70, attended hospital after more than a week of illness, including vomiting and worsening shortness of breath, and died on 29 June 2024. The report records concerns that he received fluids contributing to worsening heart failure and that fluid balance monitoring and recording were not sufficiently accurate, leaving clinicians without important information and affecting the reliability of internal hospital reviews.