6,433 reports
Information drawn from published reports and official responses.
Joseph O’Neill developed bronchopneumonia, suffered heat stroke, became dehydrated and died. Concerns included the failure to resolve faulty heating during a heatwave, inadequate rehydration and prompting to drink, and failure to recognise his deterioration.
Care Outlook Ltd
Jerome Alexander Peat was found dead from an overdose of morphine at his student accommodation on 12 December 2019. The report identifies inadvertent duplication of morphine prescriptions, after the medical record failed to alert a practice that he had already registered with another GP, resulting in significantly more morphine being prescribed than intended.
Medical Centre
Daniel Brian Mervis died aged 23 after a mixed drug overdose on 25 October 2019. He had a history of drug misuse and addiction, relapsed in the final two months of his life, and was found deceased in the flat of a known drug dealer. Concerns included the lack of an overarching drug policy across Oxford University colleges, a potential conflict between disciplinary measures and support for students with drug addiction, and the need for drug misuse policies to be more widely advertised.
St John's College, Oxford
Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.
Kent County CouncilMedway NHS Foundation Trust
Mrs. Monica McCormick developed a colonic perforation in October 2019 and underwent emergency surgery, after which pathology identified adenocarcinoma. The diagnosis was not communicated to her or her general practitioner until April 2020, following cancelled outpatient appointments, and the cancer had then spread to the liver and abdominal cavity. She died at home on 24 May 2020; the concerns included failures to follow up the pathology result, review medical records, communicate the diagnosis, and make an earlier referral for adjuvant chemotherapy.
Northern Care Alliance NHS Foundation Trust
Michael Yemm had dementia and complex medical needs and was placed in a residential care home despite concerns that it was unsuitable and unsafe. He experienced several falls, including an in-patient fall that fractured his hip and required surgery, and later died in hospital. The principal concerns were the care-home placement, his discharge back to a home that had said it could not meet his needs, and the management of falls and dementia patients in hospital.
Norfolk and Norwich University HospitalNorfolk County Council
Cyril Cheetham, aged 91 and resident in a care home, became unwell on 20.02.19, was admitted to hospital later that day, placed on an end-of-life pathway, and died on 25.02.19. The principal concern was that unclear responsibility between Mastercall and his own GP resulted in no same-day GP attendance, alongside concerns that the ATT service lacked adequate auditing and that its triage arrangements could delay hospital admission and contribute to future deaths.
Department of Health and Social CareNHS Greater Manchester Integrated Care Board
Betty Annie Tadman died after an unwitnessed fall at home caused a pelvic fracture with extensive local haemorrhage. She was treated for suspected urosepsis and deep vein thrombosis, but no imaging was conducted despite signs of possible injury, and the pelvic fracture and internal bleeding were not diagnosed. Concerns were also raised that the Trust did not investigate the death or review it through its morbidity and mortality processes.
Medway NHS Foundation Trust
Allan David Gunnell died on 24 August 2020 from progression of severe pulmonary fibrosis due to silicosis, following workplace exposure to silica dust. Concerns were raised about the absence of evidence regarding occupational health checks, compliance with HSE guidance and COSHH Regulations, employee risk information, and required health surveillance.
Marble Ideas Limited
Aaron Antony Lauder died in a road traffic collision while riding his Kawasaki motorbike on the A30 near Penzance. The principal concern was the lack of view available to both the tractor driver and Mr Lauder at the collision location.
Cornwall Council
Michael Chahwanda was born on 19 September 2018 and died at Royal Manchester Children’s Hospital on 16 December 2018 after suffering a seizure at home. The report states that his death was associated with severe Vitamin D deficiency, with circulatory failure following an out-of-hospital cardiac arrest and cardiomyopathy associated with Vitamin D deficiency recorded at inquest. Concerns included the lack of specific postnatal Vitamin D supplementation advice in the Red Book and the absence of a directive for, or provision of supplements to, women and breast-fed babies at increased risk of deficiency.
Department of Health and Social CareNational Institute for Health and Care ExcellenceRoyal College of Paediatrics and Child Health
Norma Bradbury underwent aortic valve replacement on 15 February 2019, was discharged home on 22 February, and was found deceased beside her bed on 3 March 2019. The report identified concern that the discharge letter, which required GP involvement within one week to check bloods and blood pressure and restart and titrate Losartan, was not received until 25 February. The medical cause of death was recorded as intracerebral haemorrhage, with systemic hypertension and oral anticoagulation for atrial fibrillation contributing.
Manchester University NHS Foundation Trust
Philip Noel Sheridan suffered smoke inhalation and subsequently died after a fire on 26 June 2019 in the cellar flat where he lived. The flat had no smoke detector, had a single exit door without a handle positioned next to the fire, and had not received relevant planning, building-regulation, or housing inspection approval. Concerns included potential fire hazards in other properties, the processing of Local Housing Allowance without establishing safety, and the absence of an ongoing requirement to check that smoke alarms remained effective.
Ministry of Housing, Communities and Local GovernmentRecipient name withheld
On 7 June 2019, Jason Lee Mercer and Alexandru Murgeanu were involved in a minor collision on the M1 Northbound and stopped in an active lane. About six minutes later, both were struck by a Mercedes goods vehicle and died at the scene. The report identifies concerns about the absence of a hard shoulder on smart motorways, driver awareness, detection of stationary vehicles, and the need for a wider review of smart motorways.
Department for TransportNational Highways
Anya Lily Buckley, aged 17, attended the Leeds Festival, took various illicit drugs, collapsed and died at the festival site on 24 August 2019 despite CPR. The concerns included the admission of unsupervised 16- and 17-year-olds to the festival, their exposure to illicit drugs and alcohol, and whether Leeds City Council’s licensing arrangements adequately addressed risks to potentially vulnerable teenagers.
Festival Republic LimitedLeeds City CouncilLive Nation Entertainment plc
Vhari Ingall died from an oxycodone drug overdose, with the inquest returning a conclusion of suicide. The principal concerns were the failure to review an outdated Treatment Escalation Plan/Do Not Resuscitate form after her diagnosis changed, and whether healthcare professionals and emergency services could access accurate and current information about such forms.
Association of Ambulance Chief ExecutivesCare Quality CommissionDepartment of Health and Social CareSouth Western Ambulance Service NHS Foundation Trust
On 13 April 2020, paramedics attended Mrs Lynn Hadley at home for COVID-19-type symptoms and began administering oxygen. The oxygen cylinder sparked and caught fire, and despite efforts by family members and paramedics, Mrs Hadley could not be removed from the house and died from fatal burn injuries. The concerns included possible ignition caused by adiabatic compression or particle impact when the oxygen regulator was opened, limited awareness of these risks among equipment users, and other reported cases of ignition involving oxygen-cylinder valve components.
Care Quality CommissionHealth and Safety ExecutiveMedicines and Healthcare products Regulatory AgencyWest Midlands Ambulance Service University NHS Foundation Trust
Michael Jonathan Woods died at Southampton Hospital on 9 October 2019 after using a rifle to shoot himself while taking part in a supervised shooting experience at a rifle range in Charmouth. The substantive concerns were the need for training to help range staff identify abnormal behaviour and for periodic emergency response exercises; these had been adopted but not yet delivered because of COVID restrictions.
National Rifle AssociationNational Small-bore Rifle Association
Norma Lockton was a resident in a nursing home whose reduced mobility and vulnerable skin required care measures that were not followed. She developed a wound behind her left knee, which became infected and led to cellulitis and systemic sepsis; medical assistance was not sought until her condition was life threatening, and she died in hospital on 4 March 2020. The principal concerns included failures in skin care planning and implementation, repositioning, recognition of changing care needs and deteriorating health, and management review following the death.
Care Quality CommissionCourt Nursing Home
Kevin John LOVATT was a serving prisoner at HMP Dovegate who died at the prison on 22 December 2017 after swallowing a package of illicit drugs and choking. The report identified concerns about communication, the response to choking, confusion at the scene, access to Advanced Life Support-trained staff and training on managing prisoners with items in their mouths that could compromise breathing.
HM Prison and Probation ServiceNHS England
