6,433 reports
Information drawn from published reports and official responses.
Stephen Martin Verrall fell from the window of his first-floor room at St John’s Nursing Home and died from his injuries two days later. Concerns included an inadequate window restrictor, lack of a window-maintenance risk assessment, unrestricted windows remaining years later, and risks of residents leaving the home unaccompanied.
Care Quality CommissionSt Johns Nursing Home Limited
Stephen Thomas BARTON, a serving prisoner, was found dead in his cell at HMP Dovegate on 27 July 2019; the circumstances state that death resulted from an ear condition. He missed numerous outpatient appointments, and concerns were raised about the lack of systems to track such appointments and about insufficient access to secondary healthcare, alongside a conclusion of natural causes following a lack of proper primary healthcare intervention.
Department of Health and Social Care
Robert Walaszkowski, a detained mental health patient, sustained head and cervical spine injuries after likely colliding with a locked door and later died from catastrophic cervical spine, vertebral artery and hypoxic brain injuries on 15 November 2019. Concerns included excessive lorazepam dosing, failure to perform a cervical spine CT scan and full medical assessment before discharge, and his transfer in an unsuitable vehicle without support or restraints while in very poor physical condition. The inquest heard that placing detained mental health patients on the floor of secure vans appeared to be an accepted practice, and the jury concluded that his death was contributed to by neglect.
Patient Transport (UK) Limited
Stephen David Cope died by suspension in his own cell block at Belmarsh prison on 18 November 2019. The principal concern was the transfer and review of prisoners on an ACCT, particularly the closure of an ACCT shortly after a prisoner’s transfer before support services had sufficient time to assess and communicate about them.
Belmarsh PrisonDepartment of Health and Social CareMinistry of JusticeOxleas NHS Foundation Trust
Mohammad Abu Farhan drowned while swimming in the water below Goit Stock Waterfall, Hallas Lane, Cullingworth, Bradford, on 30 March 2021. At the inquest, concern was raised that signs prohibiting swimming were obscured by vegetation and appeared old, making the dangers less explicit and noticeable.
Harden & Bingley Park LimitedRecipient name withheld
Mary Land, aged 76, was being treated for COVID pneumonia when she was found unresponsive with the tubing connecting her facemask to a BIPAP ventilator detached. The Inquest could not determine whether the detachment contributed to her death, but identified concern that the push-on connection could come undone and may require a more robust docking mechanism.
Department of Health and Social CareMid Yorkshire Teaching NHS TrustPhilips Respironics
On 9 November 2016, a tram travelling between Lloyd Park Station and Sandilands station derailed and overturned after the driver became disorientated and failed to brake before a tight curve; seven passengers were killed. The substantive concerns included inadequate risk assessment and mitigation, a lack of a just culture discouraging reporting of health and safety concerns, and the risk of under-reporting incidents.
Alstom Engineering And Services LimitedDepartment for TransportLight Rail Safety and Standards BoardTransport FocusTransport for LondonUKTram Limited
Richard Boateng became very unwell after contacting his GP surgery and was later found on a street bench. Police and ambulance services attended, but he died from Covid 19 shortly after arriving at hospital; concerns included the handling of urgent GP calls, communication between ambulance and police services, and practical guidance for police when ambulances were unavailable.
College of PolicingLondon Ambulance Service NHS TrustNHS England
Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent investigation.
Greater Manchester Mental Health NHS Foundation Trust
Clay Daniel Wanckiewicz was born in very poor condition following failed forceps delivery and caesarean section complicated by a deeply impacted head, and died at 22 minutes of age from skull fractures. The principal concerns were confirmation bias, insufficiently open-minded assessment of the overall clinical picture, inadequate staff training and a continuing risk that similar situations could place mothers and babies at risk.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustHealth Services Safety Investigations BodyRecipient name withheldSwitalskis Solicitors Limited
Hamish John Cameron HOWITT, a 20-year-old university student, died unexpectedly overnight in Frome on 1 July 2016 after an evening involving alcohol, a traumatic brain injury and self-administered ketamine. The concerns were that police did not recommend hospital assessment after he reported being injured, and that police training and national policy should address the risk of serious underlying conditions being masked by apparent intoxication.
Avon and Somerset ConstabularyCollege of PolicingHome OfficeNational Police Chiefs’ Council
Anthony James Preston died at home on 16 November 2020 after being found suspended by a ligature. The report describes his attendance at A&E after an apparent attempted hanging, his disappearance before a mental health assessment, and his later discovery deceased at home. The substantive concern was whether the Police Missing Person Policy was fit for purpose.
Essex PoliceNational Police Chiefs’ Council
On 2 September 2019, Charlie Brian Todd, a prisoner at HMP Durham, was found hanging by a ligature in his cell in the Segregation & Care Unit and died despite resuscitation attempts. The report identifies concerns about staffing and supervision arrangements, including an incomplete record of hourly checks and no check of Mr Todd’s cell at 3pm, alongside the absence of a real-time system to alert staff to missed checks.
Durham Prison
Uyapo Theodore Hayunga-Macha went missing from Arrowe Park Hospital on 4 December 2020 before he could be assessed for his mental health. He was found drowned on 9 March 2021, and it remained unclear how he ended up in the water. Concerns were raised about why he was not looked after and why he was left alone while waiting for assessment.
Cheshire and Wirral Partnership NHS Foundation TrustNorth West Ambulance Service NHS TrustWirral University Teaching Hospital NHS Foundation Trust
Heike Mojay-Sinclare drowned after her car became stuck in high and rising flood water at a ford on Doles Lane, Derbyshire, in late December 2018. The report raised concerns about the lack of mandatory standards, inspection and maintenance requirements for ford depth gauges, and insufficient sharing of information about previous serious incidents.
Department for Transport
Colin Blackburn died at HMP Hewell on 6 July 2019 after spending 15 days on remand and having been found with a ligature around his neck on three prior occasions. Concerns included multiple accepted failings in the management of his ACCT suicide and self-harm risk, and uncertainty about the correct process for urgent mental-health referrals, particularly at weekends.
Hewell PrisonPractice Plus Group
Frankie Gray Macritchie, aged 9, died on 13 April 2019 from injuries inflicted in a dog attack after being left unsupervised with the dog at a caravan park. The concerns included whether previous reports of dog attacks had been fully investigated and whether appropriate action, including euthanasia where appropriate, could reduce the risk of further incidents.
Devon & Cornwall Police
Maya Zab died from multi-organ failure associated with chronic severe microcytic hypochromic anaemia and severe iron deficiency on 6 August 2020. The report raised concerns about increased severe nutritional anaemia and deaths among children in the Yorkshire & Humber region during 2020, with possible indirect effects of the pandemic including fewer consultations, reduced social contact, and widening socioeconomic inequalities.
Department of Health and Social CareNHS England
Irene Ann Esaw, who had dementia and was dependent on her grandson for all nutritional, mobility, hygiene and personal care, was discharged from hospital without a formal care package or community referrals. She was later found deceased at home in an emaciated state, with severe untreated pressure sores, tissue damage and widespread sepsis. The principal concerns were failures to assess mental capacity, recognise clinical signs of neglect, and ensure effective multi-agency assessment and working.
Tameside and Glossop Integrated Care NHS Foundation TrustTameside Borough Council
Eldine Loretta Lashley suffered an unwitnessed fall at a care home on 6 April 2021, sustaining a subdural haemorrhage, and died at home on 14 April 2021 despite medical intervention. Concerns were raised that her mobility care plan was not updated to reflect increased monitoring needs and that progress notes did not accurately record the frequency of checks carried out.
Cherry Orchard Nursing Home, Dagenham
