6,433 reports
Information drawn from published reports and official responses.
Patricia Lilian Parker suffered a cardiac arrest after sedation for an endoscopy on 5 January 2017 and died on 8 January 2017 despite resuscitation. The report identified a failure to follow the Trust’s intravenous sedation policy and BNF recommendations on titrating sedation, and raised concerns about clinicians’ awareness and training regarding sedation, particularly for older people.
NHS England
Ben Alan Jukes was an army captain serving in the Royal Corps of Signals; the supplied text does not state the circumstances or date of his death. The report identified concerns that army drug testing failed to detect his regular heroin and cocaine use, that he was forewarned of at least one test and evaded it, and that he supplied heroin to homeless drug users in Manchester city centre.
Ministry of Defence
Richard Thomas Davies was killed by a police firearms officer during an incident on 21 October 2015 after he threatened his children and fired a homemade firearm at armed police officers. The report raised concerns about the use of unbonded ammunition by the joint Bedfordshire, Cambridgeshire and Hertfordshire Armed Policing Unit, including the absence of safeguards against excessive injury from bullet fragmentation and inadequate records of ammunition decisions.
Bedfordshire PoliceNational Police Chiefs’ Council
Khuong Lam, a 42-year-old man with schizophrenia, died after absconding while on Section 17 leave, following a struggle involving pressure to the neck. The concerns included the lack of review or revocation of Section 17 leave when he was transferred to the Psychiatric Intensive Care Ward, the arrangements for escorts during leave, and the need to share related learning across Wales.
Welsh Government
James David Allbones, aged five, died from sepsis caused by Influenza B virus infection at Bassetlaw Hospital on 2 March 2016, after being admitted within 12 hours and having been unwell with cough and breathlessness. The report identified concerns that the seriousness of his condition and red-flag signs of sepsis were not recognised, sepsis fluid management was not given, Consultant management and review were limited, and he was not considered early for transfer to a hospital providing Paediatric Intensive Care. Further concerns included paediatric staffing, handover arrangements, and communication about deteriorating children.
Care Quality CommissionDoncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustNHS Nottingham and Nottinghamshire Integrated Care Board
Pauline Taylor, who was bedbound and living alone, died in her home after a fire developed around her bed on 30 May 2015. The report identified concerns about the fire risks of low-paraffin emollient creams, limited warnings and awareness of those risks, the contribution of the airflow mattress, and the absence of a further risk assessment after her circumstances changed.
Arjo UK LimitedCare Quality CommissionDepartment of Health and Social CareHomecare Association LimitedLocala Community Partnerships C.I.C.Medicines and Healthcare products Regulatory AgencyNHS EnglandProprietary Association of Great BritainThornton & Ross Limited
James Albert Harris died in hospital on 3 April 2017 after a fall at his care home, sustaining a fractured neck of femur and subsequently deteriorating with pneumonia, Clostridium difficile infection and underlying health conditions. Concerns included inadequate falls-policy awareness and application, failure to seek medical attention after he reported pain, lack of analgesia, inadequate records of routine checks, and the care home being without a registered manager.
Care First Class (UK) LimitedCare Quality Commission
Nina MAGGS died at the scene from multiple traumatic injuries after being struck by an Iveco road sweeper while attempting to cross Hyde Road at a junction in Swindon on 23 February 2017. The report raises concerns about the safety of pedestrians at the junction, including inadequate pedestrian signals and insufficient time to cross safely, particularly for people with physical, visual or hearing impairments.
Department for TransportSwindon Borough Council
Ms Edith Robinson was admitted to Accident and Emergency after a fall, with problems identified with her prosthetic hip. Surgery was delayed and, as she deteriorated, action was not taken to rescue her; she died at Royal Oldham Hospital on 20 June 2016. The report identified concerns about weekend consultant review, early warning score calculation and use, record keeping, escalation, communication and other aspects of care.
Department of Health and Social Care
Ivy Mitchell, a care home resident with a history of falls, fell on 29 December 2016 and later developed a subcapital fracture and pneumonia. She deteriorated and died on 26 January 2017; concerns included inaccurate falls-risk documentation, inadequate understanding of post-fall processes and observations, failure to escalate appropriately, and lack of understanding about referral to the community nutrition team.
Fairfield ViewTameside Borough Council
Matthew Robert Edwards was found dead at home on 25 September 2016 after attending hospital twice with chest pain and being referred for further tests. The report identified concerns about delayed dispatch of his discharge summary, failure to arrange follow-up investigations and appointments, and a delay in obtaining a CT angiogram due to a shortage of slots.
Tameside and Glossop Integrated Care NHS Foundation Trust
Steffan Bonnot, a 17-year-old in the care of Brighton and Hove Local Authority, left a group during an outing on 1 January 2016 and was later found at a footcrossing after being struck by a train. The report states that he had anxiety about moving to a new foster placement and whether the prospective foster carers had been fully informed about his background. A principal concern was the lack of formal documentation showing exactly what information had been disclosed to the prospective foster carers.
Ofsted
Sabrina Michelle Walsh was detained under the Mental Health Act at Woodlands Acute Care and was found hanging with a ligature around her neck. The inquest concluded that she deliberately attached the ligature, but the evidence did not fully explain whether she intended a fatal outcome; this was contributed to by neglect. Concerns included the lack of formal risk assessment, inadequate observations and the absence of CCTV in corridors and communal areas.
Department of Health and Social CareSussex Partnership NHS Foundation Trust
Edwin Lewis O'Donnell died on 23 October 2016 after being found unresponsive and hanging by a ligature from his cell tap; resuscitation was unsuccessful. The inquest found that his accidental death was contributed to by neglect, including failures to conduct an ACCT review, act on a referral for a mental health assessment, and escalate information that he had said he would be dead by 8.00 p.m.
HM Prison and Probation Service
Elaine Edith Davison was fatally injured when part of a tree fell onto the car in which she was travelling as a passenger during a storm on 11 November 2010. The principal concern was that the tree had visible defects and longstanding decay that should have led to closer inspection and urgent felling, but its condition was not identified before it fell.
Forestry CommissionNational Tree Safety Group
John Wilson died in hospital on 9 August 2016 after suffering burns and multiple fractures while escaping a house fire caused by a faulty Beko fridge freezer. The principal concerns were that the product recall may not have reached the Wilsons and that further direct attempts to contact customers with recalled products were not made, despite a further death in 2014 and the increasing fire risk as the products aged.
Beko PLC
Margery Annie Astill was admitted to the Evington Centre under Section 2 of the Mental Health Act. On 2 September 2016, she collided with another agitated patient, fell, and was diagnosed with unsurvivable head injuries; she died three days later. Concerns included ineffective referral and incident-reporting systems, inadequate communication with family members, and delays in providing first aid after falls. The inquest also found that there was no care plan, the ward was understaffed, and not all patient observations were completed.
Leicestershire Partnership NHS Trust
Ms Hannah Barney was acutely ill with an infected groin wound and required multidisciplinary care. Surgical debridement was performed on 16 and 18 September, after which she died in intensive care from multi-organ failure associated with extensive soft tissue infection. The report raised concerns about delays in urgent debridement and the absence of 24-hour consultant plastics cover at King’s College Hospital.
King's College Hospital
Doreen Willis, who had a history of strokes due to clotting, was admitted to hospital after a stroke and later discharged to Belle Vue Care Home for end-of-life care, where she died on 9 June 2015. The inquest found that her risk of stroke was mitigated by Rivaroxiban, which she did not receive for a period of time, and that its absence may have contributed to her death. The report also refers to key learning from a Root Cause Analysis Report and concerns about future inspections of care homes.
Care Quality Commission
Mark William Berry suffered a cardiac arrest after apparently taking morphine or heroin and pregabalin, and was declared dead in hospital. The medical cause of death was recorded as morphine toxicity. Concerns included delays in notifying police, incomplete handover information about the address where he was found, and communication of information from a private ambulance service to the control room.
Hampshire Hospitals NHS Foundation TrustSouth Central Ambulance Service NHS Foundation Trust
