6,433 reports
Information drawn from published reports and official responses.
Henry James Holcombe’s death was investigated, and the inquest concluded that he died from natural causes. The report raised concerns about the ongoing failure to comply with therapeutic engagement and observation policies, including observations of patients described as asleep who were later found to have been dead for several hours.
Sussex Partnership NHS Foundation Trust
Catherine Jane Best was pronounced dead on 23 June 2012 at Morriston Hospital after an anoxic brain injury caused by a cardiac arrest associated with malnourishment and sepsis. The report raised concerns that nasogastric feeding was removed despite poor oral intake and was not consistently reinstated, resulting in inadequate nutritional supplementation. The inquest concluded that there had been a failure to invoke nasogastric feeding sooner when oral intake was insufficient, although it could not be determined whether this would have prevented the cardiac arrest.
Swansea Bay University Local Health Board
Ted died in hospital on 30 October 2019 from an acute on chronic subdural haematoma following a head injury. He had experienced falls, increasing frailty, low sodium and anaemia, and the inquest concluded that the combination of these factors contributed to his death. Neurological observations advised after the head injury were started but not continued, and the reason was not documented in the medical records.
Kent and Medway Mental Health NHS Trust
Rhian Margaret Roberts was admitted to hospital after being found unresponsive at home following a presumed overdose, with extremely high paracetamol levels identified on admission. ICU clinicians did not become aware of the results until the early hours of the following morning, and she died on 25 November 2020. Concerns included uncertainty about whether a requested toxicology screen was undertaken, delays in approving an updated procedure for communicating life-threatening blood results, and delays in investigating incidents, sharing learning and implementing actions.
Betsi Cadwaladr University LHB
Mr Abiodun Adisa Oritogun was admitted with severe acute pancreatitis, deteriorated on the ward, and died after collapsing while self-discharging; the inquest concluded that he died from complications of pancreatitis and ileus. Concerns included inadequate monitoring and escalation after his condition worsened, and uncertainty about whether patients with severe pancreatitis received an appropriate level of care and ITU referral.
Lewisham and Greenwich NHS TrustUniversity Hospital Lewisham
Jonathan Mark Kingsman died from a pulmonary thromboembolism caused by deep vein thrombosis after admission to Fulbourn Hospital. The VTE risk assessment considered mobility first and did not consider other risk factors unless that step was passed, while the form provided no guidance or definitions for certain terms. The report raised concern that this process could fail to identify risk in other patients with significant risk factors but no obviously reduced mobility.
Department of Health and Social Care
Valmai West suffered falls on 11 and 16 January 2020, was admitted to hospital after fracturing her pubic ramus, and was later found unresponsive with an extensive subdural haemorrhage. She died at the Royal Gwent Hospital on 22 January 2020. The concern identified was that Emergency Department staffing levels may have contributed to observations not being performed in accordance with hospital protocol and NICE guidance, potentially putting future patients at risk.
Aneurin Bevan University LHB
Stephen Francis Walker was admitted for an ileostomy reversal and developed vomiting and severe illness several days later. A nasogastric tube was not placed until that evening, and he died the following day after admission to intensive care. Concerns included delayed assessment and treatment, inadequate or missing records of clinical reviews and consent, and confusing medical records; the inquest found that earlier tube placement would have improved his chance of survival.
Royal Free Hospital
Johanna Marie Moreland died on 8 March 2021 at Medway Maritime Hospital following intra-abdominal haemorrhage after a liver biopsy, in the context of advanced hepatocellular carcinoma. Concerns included delays in receiving lumbar puncture results and starting antiviral treatment, and failure to follow or record required observations after the biopsy due to miscommunication between Trust staff.
Medway NHS Foundation Trust
Ellis died on 30 September 2020 after jumping from a footbridge onto a railway track in front of an oncoming train, intending to end his life. Concerns included gaps in the safety plan, a deviation from it without an updated risk assessment, incomplete sharing of information about a recent failed hanging attempt, and advice that did not account for the risk of Ellis leaving the centre.
North East London NHS Foundation Trust
Alan Howard Foster Griffin died by suicide at home on 8 November 2020 while under investigation by his former and current dioceses. The principal concerns were systemic and individual failings in the handling of unverified allegations, including inadequate verification, inaccurate and incomplete information-sharing, unclear responsibility, and failure to seek recommended legal advice.
Catholic Safeguarding Standards AgencyChurch of EnglandChurch of England
Anita Mandalia took an overdose of prescribed medications at home on 7 February 2021 and died in hospital on 11 February 2021 from complications of the overdose. Concerns included prescribing beyond recommended guidance, failure to re-refer her to mental health services when concerns arose, and prescribing pain medication that gave her access to an excess of medication despite overdose-risk mitigation measures.
Newbury Group PracticeNewbury Park Health Centre
Benjamin Clark died in hospital on 17 January 2021 after a series of falls, including an unwitnessed fall on the ward, resulting in Acute on Chronic Subdural Haematomas. The concerns included an undocumented downgrading of his falls-risk assessment, unclear observation requirements, suboptimal record keeping, lack of observational charts, and insufficient written evidence of daily reassessment or reassessment after significant changes.
Northumbria Healthcare NHS Foundation Trust
Maria STANCLIFFE-COOK was found dead on 1 August 2019 after intentionally taking her own life using helium, causing asphyxiation. The principal concern was that her suicide risk was downgraded from high to medium by members of the mental health team who had not previously dealt with her, followed by a brief telephone contact that did not include an assessment or plan to manage her risk.
Avon and Wiltshire Mental Health Partnership NHS TrustDepartment of Health and Social Care
Nadeem Ahmed lacerated his brachial artery after putting his hand through a glass pane at his home on 8 February 2020. He suffered hypovolaemic shock, later cardiac arrest and multiple organ ischaemia, and died at the Royal London Hospital on 13 February 2020. The principal concerns were incorrect triage of emergency calls and failures to communicate accurate and relevant clinical information to the HEMS team, which denied him the opportunity to receive life-saving treatment before cardiac arrest.
London Ambulance Service NHS TrustLondon's Air Ambulance
Mr Kishorkumar Patel and Mr Kofi Aning were treated at the Nightingale Hospital in London in April 2021, where the wrong filter was found to have been used in the breathing systems of their intensive care ventilators. The principal concern was widespread confusion among intensive care staff about filter types, names, colour coding, positioning and use in wet or dry breathing systems, with the expert recommending review, simplification and standardisation; causation of the deaths had not been determined.
Faculty of Intensive Care MedicineRoyal College of Anaesthetists
Brian Rochell was admitted to hospital on 10 April 2019 for surgery related to tongue cancer. He died on 26 April 2019 after an unsuccessful extubation caused a hypoxic brain injury. The principal concerns were that the extubation decision was made without adequate risk assessment, concerns from clinicians were given insufficient weight, and there was no clear plan for reintubation. The report also raised concerns about timely referral of professional practice concerns to the relevant professional body.
Sheffield Teaching Hospitals NHS Foundation Trust
Dorothy Seekings, a resident of Clifton Court Nursing Home, was found dead in her room on 8 August 2019 after another resident entered the room; a post-mortem examination showed blunt force injuries, which were probably caused by that resident. Concerns included care plans not recording the other resident’s aggressive incidents towards staff, failure to raise a safeguarding alert, and staff appearing unaware of the care plan contents.
Care Quality CommissionClifton Court Nursing HomeCrosscrown LimitedFamily of Dorothy SeekingsOffice of the Chief Coroner
Levi Craig Don Pettit was reported to police as having suicidal ideations on 8 December 2019. Four days later, he died by suicide; concerns included the handling of the police response, including the failure to complete or make required referrals and uncertainty about relevant policy and training.
Lincolnshire PoliceRecipient name withheld
Brooke Martin was detained under the Mental Health Act at Isla House, where she was found hanging in her room on 11 June 2019 after earlier ligature-related incidents and concerns about observation and risk assessment. She died at Milton Keynes University Hospital. A principal concern was that incompatible NHS record systems prevented healthcare providers from accessing complete patient records, including information from an out-of-area hospital.
Department of Health and Social Care
