6,433 reports
Information drawn from published reports and official responses.
Mark Anthony Nicols was struck by two cars on Ringinglow Road, Sheffield, on 28 October 2017. During the inquest, concerns were raised that a pedestrian path near a site cabin remained open but was likely unsafe, with no signage or lighting installed, and that similar circumstances might not have led to different action.
Amey Hallam Highways Limited
Marian Grant, aged 74, tripped and fell on 14 April 2018 and died from a pulmonary embolism during surgery for a fractured neck of femur on 16 April 2018. The principal concerns were the omission of VTE prophylaxis, particularly for patients placed on non-trauma wards, and the failure of EPR alerts and other checks to ensure that prophylaxis was prescribed and acted upon.
Oxford University Hospitals NHS Foundation Trust
Paul David Ryley died at Birmingham Heartlands Hospital on 14 April 2018 from the effects of a paracetamol overdose and paracetamol-induced liver injury. After initially attending hospital, he re-presented with symptoms but routine blood tests were not undertaken and his symptoms were attributed to alcohol withdrawal. The principal concern was that guidance did not clearly address patients re-presenting after a paracetamol overdose, creating a risk that potentially life-saving treatment would not be given.
TOXBASE
Daniel Hubert Collins attempted to take his own life by overdose on 07/04/18 and was discharged from hospital and then from the FTB crisis team, with responsibility placed on him to contact counselling services. He went missing on 26/04/18 and was found deceased in woodland on 28/04/18; the medical cause of death was venlafaxine overdose. The report identified concern that the transfer between mental health services was not communicated or followed up, creating a risk that patients in or recently out of crisis could be lost to mental health services.
Birmingham Women'S and Children'S NHS Foundation TrustNHS Birmingham and Solihull Integrated Care Board
Terence Andrew Bennett, who had schizo-affective disorder and was severely mentally ill, suicidal and threatening harm to his mother, died by suicide after self-inflicting deep wounds to his neck and wrists on 26 October 2016. The inquest found that his death was contributed to by neglect. Concerns included inadequate care and risk-management plans, failures in record use and handover, insufficient family and multidisciplinary involvement, reliance on unqualified staff, and deficiencies in supervision, training and consultant working arrangements.
Avon and Wiltshire Mental Health Partnership NHS Trust
Laila Habibi and her two-year-old son, Danial Ghafuri, were passengers in a car diverted from the M1 motorway when it entered the wrong carriageway on the A426 Lutterworth Road and collided with an oncoming HGV; both died at the scene on 17 February 2018. The concerns included previous road traffic incidents and fatalities on the road, its use as a regular M1 diversion route carrying large volumes of traffic, and the absence of an illuminated single-carriageway warning sign.
Warwickshire County Council
Greg HUTCHINS committed suicide on 28 August 2017 in a hotel room after suffocating himself with a plastic bag and helium. Concerns included the lack of recollection and contemporaneous or subsequent records of a telephone triage, no update in the RIO system, uncertainty about the triage’s purpose, and limited rapid information sharing for people from outside the Birmingham area.
Birmingham and Solihull Mental Health NHS Foundation Trust
On 20 February 2018, Kevin Phillip Sherwood was struck and killed by a passenger train while standing on the railway line near Hitchin Station. The report raised concern that the railway boundary in the area had only post and wire fencing, and that nearby areas were used by dog walkers and others.
Network Rail
On 13 November 2017, Darren Urquhart was struck by a train after jumping from platform 1 at Hitchin Railway Station and was confirmed dead at the scene. The substantive concerns related to the position of a trespass mat, the lack of gates at the south ends of platforms 1 and 2, and inadequacies in fencing and the placement of a trespass deterrence mat.
Network Rail
On 31 August 2018, Elijah Oluwagbenga Shotade died after his vehicle crossed into the eastbound carriageway on Britannia Bridge and collided with a heavy goods vehicle. The concerns identified were the road layout, which may leave westbound motorists unable to return to their nearside lane, and sat-nav directions telling motorists to bear right and encouraging entry into the eastbound lane.
North and Mid Wales Trunk Road Agent
Gladys May Williams fell at her care home on 6 March 2018, was discharged from hospital, deteriorated, and experienced delays in ambulance response and handover on 7 March. The report raises continuing concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that patients’ lives may be at risk.
Betsi Cadwaladr University LHBWelsh Ambulance Services NHS Trust
Scott Patrick Carton was released from prison on 5 January 2017 to the Westgate Project Hostel in Wakefield and was found dead there on 10 January 2017. His death involved the synergistic combination of prescribed methadone, pregabalin and tramadol. Concerns included the suitability of his hostel placement, the lack of anticipated psychological support and a clear management plan, and wider gaps in support for prisoners with mental health and drug dependence issues before and after release.
Ministry of JusticeProbation Service
Collin Gary Griffiths received a yellow fever vaccination on 23 March 2018 despite having previously undergone a thymectomy for a thymoma, and subsequently died from yellow fever vaccine-associated viscerotropic disease and multi-organ failure. The concerns identified were reliance on verbal communication to record medical conditions and the lack of auditing of the accuracy of nurses’ records at the travel clinic.
Masta Limited
Andrew Arthur Dickson died on 15 February 2018, aged 30, after sustaining fatal injuries by jumping from a viaduct; the inquest recorded a conclusion of suicide. The report raised concerns that information about his suicidal thoughts, provided to the GP practice by telephone, was not incorporated into the screen seen by the doctor conducting the subsequent face-to-face consultation. It identified potential risks where information depends on clinician memory or on a patient or representative repeating it, particularly in group practices and for vulnerable or reluctant patients.
Stockport Medical Group
Mrs Doris Douthwaite, who had vascular dementia and other complex medical conditions, suffered three falls at Greatwood House Residential Care Home over 11–13 February 2018. She sustained a hip fracture, developed bronchopneumonia and died at Willow Wood Hospice on 26 February 2018. Concerns included vulnerable residents being left unsupervised, an unclear falls assessment tool, and the absence of an investigation into Mrs Douthwaite’s falls.
Hc-One Limited
On 18 December 2017, Daniel James O’Mahony was struck and killed by a train at Hemel Hempstead Railway Station after jumping from the platform onto the track. The concerns identified included inadequate signage, anti-trespass measures, platform markings, gaps between platforms, and the absence of gates to prevent unauthorised access.
West Midlands Trains Limited
Michael John Drewell fell from his bike while travelling to work on 16 November 2017, sustained a hip fracture, and underwent surgery. He later suffered a cardiac arrest at home and died on 22 December 2017 from a pulmonary thromboembolism, likely a complication of the hip surgery. The concerns were that a Senior Clinician’s advice for six weeks of Tinzaparin was not followed and was not recorded in the electronic notes, resulting in a four-week prescription that ended two days before his death.
Leeds Teaching Hospitals NHS Trust
Henry Miller died on 23 April 2014 in Colombia after consuming a psychoactive substance during a tribal ceremony and becoming intoxicated. The concern was whether travellers planning to participate in such ceremonies should receive warnings or advice before travelling and deciding whether participation was safe.
Foreign, Commonwealth & Development Office
Mr David Worthington suffered fatal injuries while taking part in a cycling event on 30 April 2017, after colliding with a coach turning across the cyclists’ path at a bend with limited visibility. Concerns included inadequate identification of the location’s risks, the high potential severity of harm, and the need to review risk-assessment methods for future events.
A.S.O. U.K. Limited
On 9 March 2018, Peter John Lett was volunteering at Heckington Windmill when his clothing became entangled in the crankshaft of a Ruston Rornssby engine, causing fatal injuries. The inquest identified a lack of HSE guidance for historic and heritage equipment, much of which was unguarded and potentially dangerous.
Health and Safety Executive
