6,433 reports
Information drawn from published reports and official responses.
Sonia Elvira Stante was struck by a double-decker bus after stepping into the road in London on 10 July 2017, and died from her injuries on 21 July 2017. A review identified concerns about unclear pedestrian crossing arrangements, independently phased signals, missing louvre signage, and possible confusion for foreign visitors.
Transport for London
Mr Harold Chapman, who had hypertrophic cardiomyopathy, died on 14 June 2016 after developing a significant cardiac arrhythmia. The inquest found that non-sustained ventricular tachycardia identified in 2015 was not reviewed promptly, delaying consideration of an implantable cardioverter defibrillator. A further concern was that patient emails sent to consultants were often not viewed or acted upon, with no response provided.
Barts Health NHS TrustDepartment of Health and Social CareGuy'S and St Thomas' NHS Foundation Trust
Jason Basalat was arrested after grabbing the steering wheel of a bus, causing it to crash into road barriers, and was remanded to HMP Woodhill. He was found hanging in his cell the following day and later pronounced dead at hospital. Concerns included inadequate sharing of information about his behaviour and mental state with the prison, and the lack of a mental health assessment or appropriate placement consideration before his transfer.
HM Courts & Tribunals ServiceNorthamptonshire Police
Barbara Joan Howard fell at home on 19 July 2017, experienced delays in ambulance response and backup, and was taken to hospital, where she died from injuries sustained in the fall on 20 July 2017. The concerns included ambulance and clinician staffing shortages, failure to make a priority-assessment call when the response exceeded the target time, and ambulance-call auditing below the stated target.
South East Coast Ambulance Service NHS Foundation Trust
Rafe Robbie Angelo was born at 17:30 on 23 September 2014 after his mother was transferred from the Blake Birthing Centre to hospital during labour. He was born pale and floppy, without breathing or a heart rate, and died after 37 minutes of resuscitation. The principal concerns included delays in recognising the need for urgent delivery and communication failures between the birthing centre, ambulance service and hospital, including failure to request a time-critical transfer and a non-urgent ambulance stop.
Department of Health and Social CarePortsmouth Hospitals University NHS TrustSouth Central Ambulance Service NHS Foundation Trust
Shaun Mark Berryman was found dead at his home address. The medical cause of death was recorded as morphine toxicity and acute bronchopneumonia, with the inquest conclusion recorded as drug-related. Concerns included a clinical assessment for a chest infection being conducted in a waiting area rather than a consultation room, no chest examination being performed, and no clinical record being made.
Recipient name withheldWells Road Surgery
Bernard Aziengbe Ovu entered a non-public area of Canning Town Station and was later seen falling down emergency exit stairs to the DLR platforms. He was found several hours later and died from a head injury. Concerns included an incorrect assumption that he had left the non-public area, the lack of clear written procedures for lone-working staff, difficulties accessing recorded CCTV, and inconsistent dissemination of policies and procedures.
London Underground Limited
Ayse Yalcinkaya, aged 35, was the sole occupant of a stationary car at Junction 14 of the M1 when a lorry collided with it, and she died from multiple injuries. Concerns included unclear signage and uncertainty about lane use on the slip road, as well as whether a run-off lane should be provided before the junction.
National Highways
Owen Widlake was born full term and healthy but aspirated meconium and developed worsening respiratory failure. He died at Southampton General Hospital on 31 May 2016 after late diagnosis of persistent pulmonary hypertension of the newborn and an acute intraventricular haemorrhage. Concerns included staffing and medical cover, recognition and escalation of respiratory distress, observation records, staff training, transfer arrangements, and handovers.
Isle of Wight NHS Trust
Ronald Frank JONES fell in the bathroom of his sheltered housing on 25 January 2017, was moved to his bed, admitted to hospital the following day, and died on 4 February 2017. The principal concern was that staff who moved him after the fall had not received first aid training, creating a risk of injury or worsening existing injuries.
Portsmouth City Council
Jonathan Philip Armstrong Shaw died at the scene from injuries after his Mini crossed into the opposite carriageway and collided with another vehicle on a bend. The report raised concerns about previous incidents at the same location and noted that proposed speed-reduction signs and road markings had not been implemented by the day before the inquest.
Bath and North East Somerset Council
Michaela Marie Haines died on 23 December 2016 after police were dispatched to a report of a female hanging in the stairwell of flats at Tenby Mount, Tenby. The principal concern was that the STORM report was not updated with actions taken, creating uncertainty about whether enquiries had been completed and whether evidence had been preserved.
Dyfed-Powys Police
Ann Maguire was stabbed by a 15-year-old pupil while teaching Spanish at Corpus Christi Catholic School in Leeds. She sustained seven stab wounds and died within two hours at Leeds General Infirmary. The report raised concerns about variation in how schools perceive and manage the risks associated with weapons, and asked OFSTED to give greater prominence to school safety and the prevention of violent attacks.
Ofsted
Susan Ann Smalley, aged 67, suffered a witnessed fall at home on 8 August 2016, sustaining a significant head injury. Delays occurred in the initial ambulance response, the diagnosis and transfer between hospitals, and the urgent transfer for neurosurgical care; she died on 12 August 2016 after active care was withdrawn. The principal concerns related to ambulance resources, clarity about which hospital should treat patients, and how urgent inter-hospital transfers are expedited.
Gloucestershire Hospitals NHS Foundation TrustSouth Western Ambulance Service NHS Foundation Trust
Kathleen Joan Devine, a 94-year-old resident of a nursing home with advanced dementia and a history of falls, suffered an unwitnessed fall on 8 June 2017 while attempting to mobilise unsupervised. She sustained a right femur fracture, underwent surgery, and died on 10 June 2017 after her condition deteriorated post-operatively. Concerns included gaps in recorded observations, the removal and unplugging of a falls mat and sensor, and inadequate handover information for agency staff.
Arden CourtSalford City CouncilSon of the deceased
Tomas Kelly, aged 3, was admitted to hospital after choking and being diagnosed with aspiration pneumonia and a chest infection. After later developing chicken pox, he deteriorated rapidly at home and died in hospital on 22 November 2016; the cause of death was confluent bronchopneumonia. The principal concerns were that his parents may not have been informed about the increased infection risks associated with Down’s Syndrome, and whether children with Down’s Syndrome should routinely be offered chicken pox vaccination.
Department of Health and Social CareJoint Committee on Vaccination and ImmunisationNHS EnglandPublic Health England
Robert John Richards died by suicide after being found hanging by a sheet in his cell at HMP Wandsworth on 29 July 2014. The report identified concerns about bullying, extortion, inadequate risk management and communication, unsuitable cell allocation, staffing and training, and failings in resuscitation equipment and procedures.
St George's HospitalWandsworth Prison
Peter Blakeney King was admitted to hospital with confusion, headache, fever and limb weakness, and later fell from his bed on 18 March 2017, sustaining fatal head injuries. The concerns included inadequate documentation and implementation of falls precautions, use of bed rails despite an assessment that they were not recommended, failure to provide an observable bed and crash mat, and failure to address falls risk at handover.
East Kent Hospitals University NHS Foundation Trust
Terence DAVIES fell from his mobility scooter while travelling along a canal path, suffered a head injury and later died in hospital. The report identified an extant dangerous informal pathway used by pedestrians and cyclists to access or leave the tow path, potentially placing users in danger.
Bath and North East Somerset CouncilB&NES HighwaysCanal & River Trust
Harold Graham Wonfor was admitted to hospital with confusion, reduced mobility and a history of falls, but no falls assessment or prevention measures were put in place before he suffered an unwitnessed fall and head injury. He sustained a subdural haematoma, declined and died on 30 January 2017. The principal concerns were inadequate falls-risk assessment for vulnerable patients and inadequate monitoring and enforcement of falls-prevention policies and procedures.
East Kent Hospitals University NHS Foundation Trust
