Reports

Joseph William Cooper · Prevention of Future Deaths report View report

30 Apr 2026 Manchester South C. Morris

Joseph William Cooper died outside his home on 19 June 2025 after sustaining multiple traumatic injuries in a fall while profoundly intoxicated. His death was contributed to by depression and alcohol dependence syndrome. Concerns included unmet mental health needs for people with co-occurring mental health and substance misuse conditions, the ready online availability of large quantities of alcohol, and professionals’ lack of access to his mental health records.

Poppy Hope LOMAS · Prevention of Future Deaths report View report

30 Apr 2026 North London A. Walker

Poppy Hope LOMAS died in hospital on 26 October 2022, aged 7 days, after being born in poor condition following a home delivery. The report describes multiple unrecognised risk factors during the delivery and identifies concerns about consent and risk communication, multidisciplinary review, terminology used for unsafe deliveries, and the absence of a maternal pulse oximeter from the home delivery kit.

Dr Kenneth Wilson CULLY · Prevention of Future Deaths report View report

30 Apr 2026 East Riding and Hull L. Harris

Dr Kenneth Wilson CULLY died after a catastrophic, uncontrollable bleed from the foot while taking blood-thinning medication. The report identified a concern that the ambulance service’s newer NHS Pathway system may lack sufficient questions to recognise the seriousness of an uncontrolled bleed, potentially leading to incorrect categorisation and delayed treatment.

Alice, Sarah, Dearden (Alice) · Prevention of Future Deaths report View report

29 Apr 2026 Wiltshire and Swindon N. Rheinberg

Alice had mental health difficulties, including anorexia nervosa and emotionally unstable personality disorder, and a history of self-harm and overdoses. She bought prescription medication online on 11 February 2020, consumed some of the substance at home in Wiltshire, and died on 28 February 2020. Concern was expressed that website content referring to a method of self-destruction, suicide websites and a link encouraging suicide might assist people inclined towards deliberate self-harm.

Name not published · Prevention of Future Deaths report View report

29 Apr 2026 Birmingham and Solihull J. Bennett

An experienced Operational Department Practitioner was found deceased in on-call accommodation after deliberately injecting himself with anaesthetic medication accessed from a secure hospital drug store. Concerns were raised that NHS England guidance did not adequately address risk assessment, prompt police notification, suspension decisions, or removal of access to potentially fatal drugs following serious allegations.

Alice, Sarah, Dearden (Alice) · Prevention of Future Deaths report View report

29 Apr 2026 Wiltshire and Swindon N. Rheinberg

Alice had mental health difficulties associated with anorexia nervosa and emotionally unstable personality disorder, including acts of self-harm and overdoses. She died by suicide at age 19. Evidence suggested that a strict commissioning cut-off at age 18 could adversely affect mental health by making transitions from child to adult mental health services insufficiently gradual.

Alice Dearden · Prevention of Future Deaths report View report

29 Apr 2026 Wiltshire and Swindon N. Rheinberg

Alice Dearden suffered from mental health difficulties and died at home in Wiltshire on 28 February 2020 after consuming a quantity of a substance bought online. The report raised concerns that mail-order businesses may not be able to identify suspicious transactions involving reportable substances, and that eBay’s prohibited-items policy did not include concentrated reportable poisons.

Christine Joan Clegg · Prevention of Future Deaths report View report

27 Apr 2026 East Riding and Hull S. Robinson

Christine Joan Clegg died at Hull Royal Infirmary after an unwitnessed fall at her care home, in which she sustained a traumatic brain injury and later deteriorated. The report raises concern that inaccurate information given to NHS 111 led to a minor-wounds pathway being followed instead of the head-injury pathway, resulting in basic first-aid advice without clinical input. It also concerns the availability of the minor-wounds script for injuries above the neck, which may lead to a non-clinical outcome for head injuries.

Amy Clare CHAPMAN · Prevention of Future Deaths report View report

27 Apr 2026 West Sussex, Brighton and Hove N. Armstrong

Amy Clare Chapman, who was experiencing a mental health crisis and assessed as at high risk of suicide, was admitted to the Haven Unit at Millview Hospital on 23 March 2025. On 27 March, she was permitted to leave the unit twice without adequate checking of her records, family contact, or documentation, and later jumped from a bridge, dying from her injuries. The principal concerns included insufficient risk assessment and planning for trips out, failures to read and record notes, inadequate family involvement, uncertainty over care and safety plans, and gaps in training, alerts, checklists, and auditing.

Michael Chadwick · Prevention of Future Deaths report View report

27 Apr 2026 Nottinghamshire N. Hartley

Michael Chadwick died from injuries sustained when the motorcycle he was driving left the road. The principal concern was that, despite repeated reports of cough syncope, he was not advised to stop driving or notify the DVLA, raising concern that similar guidance may not be provided to other patients.

Edward Muwanga · Prevention of Future Deaths report View report

24 Apr 2026 Inner West London P. Rogers

Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.

Michelle DAWES · Prevention of Future Deaths report View report

24 Apr 2026 Black Country I. Thislethwait

Michelle Dawes was admitted to hospital with worsening symptoms and a large right-sided pleural effusion, but her transfer to the respiratory ward was delayed and a chest drain was never inserted. She deteriorated, suffered a cardiac arrest and died. The principal concerns were missed opportunities and delays in her care, including delayed implementation of changes identified by the Trust, leaving a continuing risk to patient safety.

Kenneth John Morris · Prevention of Future Deaths report View report

24 Apr 2026 East Riding and Hull P. Marks

Kenneth John Morris, aged 78, died at Hull Royal Infirmary on 10 December 2025 after a second unwitnessed ward fall caused intracranial haemorrhage, brain damage and early post-traumatic epilepsy. The principal concern was that he did not receive required one-to-one nursing care because of understaffing and more pressing cases, and evidence indicated that similar deaths may occur while resources remain critically stretched.

Ellie Mae Herron · Prevention of Future Deaths report View report

24 Apr 2026 East Riding and Hull P. Marks

Ellie Mae Herron, who had a significant history of mental health issues, alcohol dependence and a chaotic lifestyle, was found suspended from a steel gate on 8 December 2025 and was later declared deceased in hospital. The inquest concluded suicide. The report raised concerns about the risks to vulnerable people associated with drug use, alcohol abuse, rough sleeping and criminal activity in Pearson Park.

Stephanie Anne Barkley Link · Prevention of Future Deaths report View report

23 Apr 2026 Birmingham and Solihull S. Brenchley

Stephanie Anne Barkley Link attended hospital with acute pancreatitis, later developing malnutrition, sepsis, acute liver injury, aspiration and multi-organ failure. She died in intensive care after a cardiac arrest on 30 June 2024. The principal concern was the absence of an effective multidisciplinary approach and an agreed, documented care pathway for complex acute pancreatitis across hospital sites, alongside missed opportunities for specialist transfer and continued paracetamol despite deteriorating liver biochemistry.

Thomas Alexander Ferdinand MAYHEW (known as Ned) · Prevention of Future Deaths report View report

23 Apr 2026 East Sussex L. Bradford

On 6 May 2024, 16-year-old Ned Mayhew was found hanging in a wooded area after leaving school and was taken to hospital, where his death was confirmed on 9 May 2024 following brain stem testing. The principal concern was that routing an emergency call reporting an apparently deceased person to the police before the ambulance service may result in valuable minutes being lost during the limited period in which treatment might prevent death.

Theresa Lydon · Prevention of Future Deaths report View report

21 Apr 2026 Gateshead and South Tyneside J. Thompson

Theresa Lydon had severe ulcerative colitis and was admitted to hospital on four occasions before her death following complications of surgery, including an intra-abdominal haemorrhage. The report identifies concerns about delayed prescribing, unclear communication of treatment plans, inadequate access to medical records between NHS Trusts, and the absence of repeated blood tests that contributed to her death.

Paul Guy Robert Harries · Prevention of Future Deaths report View report

20 Apr 2026 West Sussex, Brighton and Hove J. Turner

Paul Guy Robert Harries was diagnosed with an abdominal aortic aneurysm and was subsequently lost to follow-up after missing a surveillance scan. He later died at home in Brighton on 9 October 2024 from a ruptured AAA while awaiting an outpatient appointment. Concerns included the handling of missed appointments, the downgrading and delayed booking of an urgent referral, reliance on separate referral systems, and failure to consistently report significant incidental emergency-department findings to the GP.

Paul HUTCHINSON · Prevention of Future Deaths report View report

19 Apr 2026 West London R. Furniss

Paul HUTCHINSON died of burns after setting himself alight while smoking in his Extra Care Sheltered Accommodation on 21 January 2025. The report raised concerns about the lack of specific requirements for individual fire risk and evacuation assessments, non-standardised staff training, and whether fire risk assessments adequately considered vulnerable residents who may be unable to self-evacuate.

Julie Ley · Prevention of Future Deaths report View report

17 Apr 2026 Cumbria R. Cohen

Julie Ley, aged 71, died on 15 May 2025 at Westmorland General Hospital after her physical condition deteriorated while she was detained under the Mental Health Act. The inquest identified inadequate care, including failures in nutrition monitoring, physical health monitoring, transfer to a hospital able to provide appropriate treatment, and use of available legal powers to administer medication. A further concern was that CPR was performed on her bed, a soft surface, and a senior clinician was unaware that this could reduce its effectiveness.