6,433 reports
Information drawn from published reports and official responses.
JAKUB DAWID MOCZYK was taking part in a boxing match when he received a blow to the head, became unresponsive and died from his injuries on 21 November 2016. Concerns included incomplete pre-fight medical checks, medics not notifying the referee or promoter, and medics not assessing the opponent after he gagged or vomited before continuing the fight.
Lifeshield Medical Service Limited
Wycliffe Ashton Matthews sustained traumatic spinal cord injuries after letting go of a standing hoist during a third hoisting at Alexander Grange Care Home on 11 December 2016, and this led to his death and pneumonia. Concerns included apparently untrained or inadequately trained staff in the use of the hoist and failures to keep proper notes of the events leading to the death.
Alexandra Grange Care Home
Jeremy Michael Holt Marshall developed a small bowel obstruction and other complications after elective surgery for colonic adenocarcinoma, deteriorated in hospital, and died on 17 November 2016 after life support was withdrawn. Concerns included delays in escalating his deteriorating condition, insufficiently specified review and fallback arrangements, and inadequate recording of observations for a critically ill patient with a high NEWS score.
Great Western Hospitals NHS Foundation Trust
Ms Christina Ann Fletcher was found dead at home after Zomorph, an opiate and controlled drug, was mistakenly delivered to her on 4 August 2016 and the error went undetected. Post-mortem examination found markedly elevated free morphine, which was attributed directly to the cause of death. Concerns were raised about the absence of specific regulatory guidance on pharmacy red-flag systems for similar names and addresses, and on the chain of custody for controlled drugs.
General Pharmaceutical Council
Ruth Thompson became unwell in Italy on 14 April 2017 after suffering a dissecting aortic aneurysm and underwent surgery, but subsequently sustained a pontine brain infarction and developed pressure sores during prolonged immobility. She was repatriated to the United Kingdom, entered end-of-life care on 30 May 2017, and died on 31 May 2017. The substantive concerns included inadequate communication and transfer documentation, lack of proper or informed consent, and insufficient clinical information being provided to UK clinicians, causing delay and uncertainty in treatment and care.
InsureandGo
Douglas Hodges died in hospital on 3 April 2017 after developing multiple organ failure and systemic sepsis; antibiotics prescribed by his GP had not been dispensed by the pharmacy. The principal concerns were that community pharmacy systems did not communicate prescription urgency at the point of downloading, and that a prescription could be mislaid or accidentally disposed of without detection, creating a risk of future deaths.
Cegedim Healthcare SolutionsNHS EnglandWell Pharmacy
Carol Buchanan was admitted to hospital after a fall and later deteriorated following the combined prescription of Itraconazole and Simvastatin, which led to rhabdomyolysis and muscle necrosis. She died on 26 May 2017 despite treatment. Concerns included inadequate prescription record checking and documentation, failure to recognise the serious drug interaction, missed opportunities to act on relevant history, and delays in monitoring and diagnosis.
Royal Bolton Hospital
Jeremiah Obaka, who was 77 and had several medical conditions including chronic lymphoid leukaemia, was found dead at home on 2 July 2016 after carers received no reply on subsequent visits following their last visit on 27 June 2016. The principal concern was that there was no agreed, consistent policy or guideline for responding when a service user did not reply or could not be found, and the local authority and care agency had different guidelines that had not been communicated to each other.
London Borough of Sutton
Patrick Clifford fell in a hospital toilet after fainting on 19 March 2016 and suffered a fractured acetabulum. His condition deteriorated, and he developed pneumonia due to immobility and heart failure before dying on 18 September 2016. The principal concerns were inadequate understanding of toilet supervision, difficulties transferring radiology images between hospitals, and refusal to undertake requested Judet X-rays, causing delays to treatment.
East Lancashire Hospitals NHS Trust
Mark Daniel Vagnoni, who had paranoid schizophrenia and was on remand at HM Prison Bedford, was found hanging in his cell on 11 July 2016 and died two days later. Concerns included the arrangements for risk assessment and observation after an ACCT was opened, the accessibility of information about previous ACCTs in NOMIS, and the lack of Wing Transfer documentation containing relevant risk information.
Bedford PrisonHM Prison and Probation Service
Bernard Cosgrove was admitted to hospital on 28 February 2017 after being observed unresponsive and was discharged to his nursing home on 10 March 2017 with a dislocated right hip joint that had started to become infected. He died at the nursing home on 21 March 2017 from bronchopneumonia, with significant heart disease and hip joint infection contributing to his death. The principal concerns were that the dislocation was not recognised for seven days, that relevant medical-record information was not incorporated into his care, and that patient monitoring and consideration of medical records were insufficient.
Blackpool Teaching Hospitals NHS Foundation Trust
Tahnie Lee Martin, aged 29, died after being struck by a large wooden panel that became detached from the roof of the disused Blackrock building during strong winds on 23 February 2017. The principal concerns were that inspections did not identify two hazardous roof structures, and that surveyors were not required to report inaccessible areas or advise clients about the risks of not obtaining access and subsequent inspection.
Royal Institution of Chartered Surveyors
Christopher Cyril Kiernan, who had a history of depression, alcohol use and cannabis use, made threats to harm himself and had contact with emergency services during the night of 3–4 June 2017. He was later found hanging from a tree in nearby woodland. The principal concern was the ineffectiveness of the pathway for communicating information directly to the RDaSH Crisis Team, with the crisis team not being notified.
Yorkshire Ambulance Service NHS Trust
Marcin Miroslaw Mazarek became mentally unwell, a condition exacerbated by a very long period in segregation, began to self-harm and ultimately hanged himself. Concerns included very poor medical record keeping, missed or unrecorded medical checks in segregation, an inappropriately long period in segregation, failure to properly implement ACCT procedures, lack of multidisciplinary working and mental health involvement, and inadequate reporting by discipline and medical teams.
NHS England
Geoffrey Spencer, a resident at The Lakes Care Centre, was found on the floor after an unwitnessed fall and later died in hospital from respiratory arrest secondary to aspiration pneumonia. The principal concern was that The Lakes had not formally investigated the incident, reducing the potential for learning to improve the safety of other residents.
The Lakes Care Centre
Levi Cronin, a serving prisoner at HMP Highpoint, was found hanging in a shower and later confirmed deceased at West Suffolk Hospital. The inquest recorded a conclusion of suicide and identified concerns about insufficient recording and information-sharing, inadequate staffing, and inadequate support and supervision within the mental health department and prison staff.
Highpoint Prison
Jennifer Ann Midgley had chronic obstructive pulmonary disease, malnutrition, non-alcoholic fatty liver disease and cirrhosis. After fracturing her left femur and undergoing surgery, she received intravenous paracetamol that was not adjusted for her weight, and this was described as contributing to organ failure and her death. The concerns included unclear drug administration charting distinguishing oral from intravenous paracetamol and the lack of a recorded patient weight for intravenous dosing.
Mid Yorkshire Teaching NHS Trust
Simon Willans was admitted to Ysbyty Gwynedd with breathlessness, recent loss of consciousness and a swollen right calf, and was discharged with diagnoses of orthostatic hypotension and anxiety. He died from a pulmonary embolism the following day. Concerns included inadequate assessment and follow-up, failure to elicit a family history of pulmonary embolism, lack of safety-netting, and failure to commence heparin despite DVT/PE being a differential diagnosis.
Betsi Cadwaladr University LHB
Christopher John Llewellyn Roberts was pronounced dead at his home on 19 October 2015 after an overdose involving prescribed opiate medication. He was receiving treatment for mental illness, and his medication use was described as chaotic. The report raised concerns that a care plan review was not recorded, including whether a recent overdose attempt had been considered, and that nomad trays may be unsuitable for some patients.
Swansea Bay University Local Health Board
Sofia Ann Legg had a history of low mood and self-harm, received care from CAMHS, and was placed on a six-month waiting list for CBT. On 26 September 2016, her mother discovered her hanging at home, and the inquest concluded that her death was suicide. Concerns included access to CAMHS, delays in CBT, the lack of urgent psychiatric input, shortcomings in the recording and follow-up of a critical CAMHS meeting, and inappropriate language in the SIRI Report.
NHS Somerset Integrated Care BoardSomerset CouncilSomerset NHS Foundation Trust
