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Harry Joseph Purcell and Matilda (Tilly) Grace Seccombe · Prevention of Future Deaths report View report

8 Dec 2025 Coventry and Warwickshire L. Lee

Harry Joseph Purcell and Matilda (Tilly) Grace Seccombe sustained fatal injuries in a single-vehicle collision on 21 April 2023, when a recently qualified 17-year-old driver travelled at excessive speed on a rural road and lost control. The report raised concerns about the combined risks of driver inexperience, peer passengers, vehicle loading and rural-road conditions, as well as issues concerning driver licensing, insurance oversight, unsafe-driving content shared on Snapchat and the lack of coordinated responses to unsafe behaviour.

Syeda Meerab FATIMA · Prevention of Future Deaths report View report

8 Dec 2025 Birmingham and Solihull A. Hodson

Baby Syeda was born prematurely by a difficult footling breech vaginal delivery after delays in preparing for and carrying out an emergency Caesarean section. She was born in a poor condition, required resuscitation, and died a few hours later. The principal concern was a wider, systemic bullying and hierarchical workplace culture in the maternity department at Good Hope Hospital, which was identified as contributing to delays in the emergency response.

John Graham ALSTON · Prevention of Future Deaths report View report

5 Dec 2025 Lancashire and Blackburn with Darwen K. Bisset

Mr Alston, a 70-year-old man with dementia living in a specialist care home, was punched by another resident on 2 November 2022, suffered an unsurvivable brain bleed, and died in a hospice on 8 November 2022. The concerns relate to confusion over which commissioning body was responsible for the other resident, delays in finding a safer placement, and difficulties sharing discharge information; the report warns that similar delays could contribute to future deaths.

Alan Paul Peet · Prevention of Future Deaths report View report

5 Dec 2025 Manchester South A. Mutch

Alan Paul Peet, who was quadriplegic following an accidental fall, was admitted to hospital after his condition deteriorated at Acer Mews Care Home on 26 July 2025. He was found to be septic, possibly due to bronchopneumonia, and died at Tameside General Hospital on 28 July 2025. Concerns included inadequate observation and record-keeping, lack of clear management oversight of tracheostomy-trained nursing cover, and agency staff lacking access to electronic systems.

Leonardo Cardoso Machado · Prevention of Future Deaths report View report

5 Dec 2025 Dorset B. Allen

Leonardo Cardoso Machado, aged 17, died on 16 April 2023 after losing control of a motorcycle while travelling at speed and colliding with metal railings. The report raised concerns about limited oversight of rented food delivery licences being provided to children under 18, and the resulting risks of lone night work and road traffic collisions.

Man Yin ‘Anita’ Ng · Prevention of Future Deaths report View report

5 Dec 2025 Coventry R. Brittain

Man Yin ‘Anita’ Ng attended hospital with a subarachnoid haemorrhage caused by an aneurysm. Her coiling procedure was delayed while staff sought an available neurointerventional catheter lab and anaesthetist; she suffered a re-rupture shortly before the procedure and died on 22 January 2025. The principal concern was that complex arrangements and unclear overall clinical responsibility for managing ruptured aneurysms may place patients at risk, particularly because of variation in access to neurointerventional procedures.

Andrew John Hughes · Prevention of Future Deaths report View report

5 Dec 2025 Manchester South A. Mutch

Andrew John Hughes was found deceased at his home after concerns about his wellbeing and unsuccessful attempts to contact him. The inquest concluded that he died by suicide, with the medical cause recorded as hanging. The principal concern was a lack of clarity about how people raising urgent mental-health concerns could be directed to mental-health services and what emergency response those services could provide.

Lina Piroli · Prevention of Future Deaths report View report

4 Dec 2025 Inner North London M. Lee

Lina Piroli, aged 93, was admitted with an E. coli infection and later suffered an unstable C2 fracture and a stable L1 fracture after a fall down stairs. She remained in A&E for a prolonged period because no elderly care ward bed was available, while experiencing pain, confusion and delirium. The report raises concerns about delayed transfer to a ward and the resulting lack of access to specialist, coordinated care and appropriate symptom management for an elderly, complex patient.

Samuel Martin BROWN · Prevention of Future Deaths report View report

4 Dec 2025 South Yorkshire (Eastern) A. Combes

Samuel Martin BROWN, a 29-year-old male, was found deceased at Elliott Court, Rotherham, on 30 March 2025; the inquest conclusion was drug-related death due to drug intoxication. The principal concern was that primary care prescribing did not identify potential addiction and drug-seeking behaviour or adequately review whether medications were still required.

Brigitte Dominique FAVRE · Prevention of Future Deaths report View report

2 Dec 2025 Suffolk D. Stewart

Brigitte Dominique FAVRE, who had small cell leukaemia and was receiving chemotherapy, was discharged on 25 January 2025, readmitted the following day after her condition deteriorated, and died on 30 January 2025 from neutropenic sepsis following chemotherapy. Concerns were raised about the lack of oncology input for weekend and out-of-hours discharge planning and about emergency department record management, which meant recent chemotherapy and the need for support medication were not identified promptly.

Lewis Bates · Prevention of Future Deaths report View report

1 Dec 2025 Manchester South C. Morris

Lewis Bates was reported missing after leaving his mother and stepfather’s house, having previously expressed an intention to end his life if he could not see his children. His body was found approximately two hours and 21 minutes after the missing-persons report. Concerns included the absence of guidance for call handlers about reasonable enquiries, advice to contact healthcare providers, and apparent confusion about the applicable police response process.

ABDULLAH MOHAMED ALI · Prevention of Future Deaths report View report

1 Dec 2025 Inner North London M. Lee

Abdullah Mohamed Ali, aged six months, died after being found unresponsive at home on 20 July 2025; the stated cause of death was encephalitis due to Varicella Zoster Virus (chicken pox). The report raised concern about extensive mould and other disrepair in the family’s property, and the potential risk posed by mould in other properties renovated and managed by Grandwell Estates.

John Charles HICKMOTT · Prevention of Future Deaths report View report

1 Dec 2025 Milton Keynes A. Smith

John Charles Hickmott died at the scene after stepping from a pedestrian island into the path of a moving car on V11 Tongwell Street, Milton Keynes, on 19 February 2025. The incident occurred in darkness, with several nearby streetlights not working, making pedestrians difficult to see. The principal concerns were the timeliness and monitoring of streetlight repairs and the extent of proactive inspections for faulty lights.

Gurkirat Singh · Prevention of Future Deaths report View report

28 Nov 2025 Black Country Z. Siddique

Gurkirat Singh, a child, died after being struck by a single-decker bus on High Street, Tipton, on 6 December 2024. The report raises concerns about repeated incidents on the road, the absence of pedestrian crossings and central road markings, poor street lighting, and visibility being obscured by parked vehicles and building-line shadows.

June Violet FINDLAY · Prevention of Future Deaths report View report

27 Nov 2025 Berkshire R. Simpson

June Violet Findlay fell at home on 23 October 2024, fracturing her hip and wrist, and later died at Thames Hospice on 11 December 2024 after her health deteriorated. Concerns included substantial weight loss and sub-optimal management, monitoring, recording, and auditing of the risk of malnutrition during her hospital admission.

Evie Gladys Muir · Prevention of Future Deaths report View report

26 Nov 2025 Essex S. Simblet

Evie Gladys Muir, aged 17, died after suffering a cardiac arrest on 19 February, less than two weeks after a hospital admission for cardiac problems and treatment for axial spondylarthritis. The concerns were that reviews of unusual cardiac deaths may not be widely shared with clinicians involved in a patient’s care, and that patients with cardiac problems who are HLA B27 positive or have rheumatological conditions may not be adequately assessed for related risks, including vasculitis.

Aminata Coulibaly · Prevention of Future Deaths report View report

26 Nov 2025 Essex S. Hayes

Aminata Coulibaly died at home between the evening of 24 June and the morning of 25 June 2022 from acute alcohol toxicity, with respiratory depression as the mechanism; the manner in which the alcohol entered her system could not be determined. The report identifies concerns about safeguarding, information-sharing and recording by Essex Police and the mental health trust, including failures relating to her expressed suicidal thoughts and the handling of the hate crime investigation.

Evie Rae Le Masurier-O'Sullivan · Prevention of Future Deaths report View report

26 Nov 2025 South London S. Reeves

Evie became unwell with respiratory distress on the post-natal ward less than a day after birth and died after deteriorating with sepsis-related complications. The report identified concerns that staff did not elicit or provide an opportunity for her parents to share concerns about her crying and breathing, contributing to a lack of neonatal assessment and escalation, and that antibiotics were delayed. It also identified a training gap for temporary staff in eliciting parental concerns, creating a risk of future deaths unless action is taken.

Celia Marion PHILLIPS · Prevention of Future Deaths report View report

26 Nov 2025 Birmingham and Solihull A. Samuel

Celia Marion PHILLIPS had a complex medical history and was bed bound, receiving care at home four times a day. She was admitted to hospital on 27 April 2025 with a probable chest infection, acute kidney injury and dehydration; a fractured ventriculo-peritoneal shunt had eroded through the skin and was protruding. She died on 1 May 2025 from multiple organ failure and sepsis of unknown origin, with the malfunctioning shunt contributing to her neurological decline and predisposing her to infection and dehydration. Concerns included a lack of evidence that she was repositioned or that carers had received training on pressure sores, skin assessment and repositioning, and she was found to have a deep tissue injury and a grade 1 pressure sore on admission.

Andrew Thomas MCCLEARY · Prevention of Future Deaths report View report

25 Nov 2025 Bedfordshire and Luton E. Whitting

Andrew Thomas MCCLEARY died after cocaine use and the physiological and psychological effects of restraint, with his death confirmed at Bedford Hospital on 30 May 2021. The report identified concerns about failures to establish his capacity under the Mental Capacity Act, collaborative planning before restraint, monitoring of his physical and psychological wellbeing, and responding when he said he could not breathe.