6,433 reports
Information drawn from published reports and official responses.
Joshua Adey Rennard died by hanging at his parents’ home on 29 September 2021. The principal concern was an eight-day delay in actioning a professional view that he should be assessed for detention under section 2 of the Mental Health Act, with concern that similar delays could place people at risk of harm or death.
Sheffield Health Partnership University NHS Foundation Trust
Joyce May Dennis, a resident of Roseacre Care Home, became unwell on 9 September 2019 and deteriorated over the following days before being admitted to hospital with sepsis and the onset of a heart attack. She died at 15.30 on 13 September 2019. The principal concerns were inadequate monitoring and record-keeping, failure to investigate or escalate worsening symptoms, insufficient staff training about illness and sepsis in older people, poor liaison, and failure to record family concerns.
Roseland
Sarah-Louise Jennifer Doyle, aged 19, was found hanging in her room while detained under the Mental Health Act and subject to five-minute observations. She was taken to hospital but died at 01:40 on 27 February 2022; concerns were raised that observations were recorded at predictable times and may not have been precise.
Mersey Care NHS Foundation TrustMerseyside Police
Andrew David Kitson was walking on the pavement of the A61 Leeds Road on 9 June 2020 when a Peugeot being pursued by police lost control, mounted the pavement and struck him. He sustained multiple injuries and was pronounced dead at the scene. The concerns related to insufficient statistical evidence for evaluating spontaneous police pursuits and the burden placed on police personnel when assessing the safety of continuing high-speed pursuits in residential areas.
West Yorkshire Combined AuthorityWest Yorkshire Police
Mr Alan Hodgson died at Sunderland Royal Hospital on 14 January 2021. The report describes failures to recognise the severity of his condition, delays in acting on and reporting imaging, failures to follow the vascular pathway, inadequate communication and continuity of care, and an insufficient review of the circumstances leading to his death.
County Durham and Darlington NHS Foundation Trust
Marvin Rue was admitted to hospital on 8 January 2021 after a fall and fell five times during his admission. On 2 February 2021, he suffered a fatal head injury after another fall and died on 3 February 2021. The principal concerns were failures to complete falls-risk assessments after admission, hospital transfers and previous falls, resulting in inadequate supervision; the report also identified failures to investigate staff non-compliance and to carry out audits.
Aneurin Bevan University LHB
Martha sustained a handlebar injury while cycling on a family holiday in Wales, was transferred to King’s College Hospital London, and died approximately one month later from refractory shock, sepsis, pancreatic transection and abdominal trauma. At King’s, she was not referred promptly to paediatric intensivists; concerns also included the paper-based paediatric early warning score system and stalled plans to improve coordination between paediatric hepatology and intensive care.
King'S College Hospital NHS Foundation Trust
Neil Hickman was treated for myelodysplastic syndrome and referred for a stem cell transplant, but died before the transplant could take place from disseminated angio-invasive mycotic infection in the context of immunosuppression and myelodysplasia. The concern was that frequent platelet transfusions at Kent and Canterbury Hospital were not accompanied by ferritin measurements, meaning iron overload might go undetected, although this did not affect the outcome in his case.
East Kent Hospitals University NHS Foundation TrustKent and Canterbury Hospital
Vijaykumar Girishbhai Gadhavi died from a drug overdose while an in-patient at Whipps Cross Hospital under enhanced one-to-one care. The report raised concerns about breaches of the Enhanced Care Policy, the absence of an alert or risk-management plan, inadequate recording of property and medication, insufficient family involvement, and a lack of evidence that learning from earlier self-harming incidents had been implemented.
Royal London Hospital
Stephanie Moyce, who had a history of mental health issues and repeated suicide attempts, took her own life on 30 July 2021 and was discovered by her partner. The report identified concerns about unclear responsibility for care and oversight after psychotherapy discharge, inadequate discharge planning and safety-netting, the lack of routine multidisciplinary discussion, and insufficient involvement of her carer in Section 117 after-care reviews.
Essex Partnership University NHS Foundation Trust
Adrian Vincent Balog died at age 13 on 2 April 2015 at Royal Manchester Children’s Hospital after longstanding morbid obesity, dilated cardiomyopathy and heparin-induced thrombocytopenia. His obesity made him ineligible for heart transplantation and interim mechanical support, and the inquest concluded that it significantly contributed to his death. A principal concern was that national safeguarding guidance did not identify obesity as a sign or symptom of neglect, unlike malnourishment or being underweight.
Department for Education
Amanda Gibbens died on 13 July 2020 at Stoke Mandeville Hospital after suffering a cardiac arrest while detained under Section 2 of the Mental Health Act at Ruby Ward. The concerns included the use of a monitor rather than continuous direct observation during Level 3 observations and ineffective bedroom searches for prohibited items that could be used for self-harm.
Oxford Health NHS Foundation Trust
Mr Osland was admitted to hospital after an ischaemic stroke and later suffered hypoxia, cardiorespiratory arrest and catastrophic ischaemic brain injury. He did not regain consciousness and died after the withdrawal of clinical support. The principal concerns were reduced room-monitor alarm volume, disconnection between the room and central monitors, inadequate responses to the persistent “OFF COMS” notification, and unclear procedures for nursing staff.
East Kent Hospitals University NHS Foundation Trust
Jane Louise Shilton, who had severe and enduring mental health difficulties and lived in a residential care home, was found unresponsive in her bedroom and was pronounced dead at the scene. The report raises concerns about the failure to check on her after missed medication, dinner and cigarettes, the absence of overnight proactive checks, and the staff’s response to the medical emergency, including not checking breathing or pulse and not attempting CPR. It also raises concerns about the quality and frequency of first-aid training.
Hamilton Community Homes Limited
Dorothy Ann Spiby, a nursing home resident with dementia, frailty and type 1 diabetes, suffered an unwitnessed fall in her bedroom on 22 October 2021. She sustained an eye-socket fracture and two rib fractures, developed pneumonia in hospital, and died on 28 October 2021. Concerns included unclear and undocumented accounts of the incident, no incident form, no investigation, and no evidence of learning to safeguard residents in future.
Prime Life Limited
Van Thai Tuyen was admitted to hospital for stroke treatment and, after a nasogastric tube was misplaced into his right lung, approximately 300ml of liquid feed was administered through it. He died from cavitating necrotising pneumonia. The principal concerns were the use of misplaced nasogastric tubes, the recurrence of such incidents, and the absence of a unified approach to preventing avoidable deaths from this problem.
Barts Health NHS TrustDepartment of Health and Social CareNHS England
Sean Ennis was found in his flat after a fire and died in hospital from the consequences of smoke inhalation. The principal concerns included incomplete fire-risk assessment and inadequate smoke detection and telecare arrangements for a vulnerable resident, including the alarm centre not knowing he was a smoker and not responding when he did not answer calls.
Barnet AssistLondon Borough of BrentSovereign Network Homes
Irene Muriel Fitches was admitted to hospital on 17 July 2021 with dizziness, nausea and general illness, and was diagnosed with Benign Positional Paroxysmal Vertigo. On 21 July 2021 she had an unwitnessed fall, suffered a head injury, deteriorated and became unresponsive; she died on 22 July 2021. The substantive concerns included a Falls Policy that did not comply with NICE Guidelines, no appointed Falls Lead, undeveloped staff training, and limited progress on assisted technology.
Norfolk and Norwich University Hospital
Sasha Raven Marie Brown was the unaccompanied driver of a car that lost control on a very wet section of the A6068 and collided with an oncoming vehicle on 19 January 2021. The principal concerns were inadequate drainage and road design, the absence of flood-risk signage, and the reported ongoing high risk to motorists from surface water at that location.
North Yorkshire Council
Chloe May Lumb, who was known to have a genetic risk of aortic dissection, died in Redcar on 8 January 2021. She presented to hospital on 4 January with clinical symptoms and imaging findings, but the dissection was not diagnosed, and when she contacted the hospital on 5 January because of ongoing symptoms, she was advised to contact her GP rather than return to hospital. The principal concerns were the absence of an Emergency Department pathway requiring an ECG-gated CT scan for suspected aortic dissection and the lack of a mechanism alerting staff to her genetic risk.
Department of Health and Social Care
