6,433 reports
Information drawn from published reports and official responses.
On 25 November 2016, Luke Alf Edward Moulding entered a railway line near his home after consuming alcohol and drugs, collided with a train, and died from severe traumatic injuries. The report raised concerns that an “opt in” letter following a mental-health consultation was not sent, and that the process for sending such letters could be made more effective.
East London NHS Foundation Trust
Chadrack Mbala Mulo, aged four, died of dehydration and acute protein-energy malnutrition after his mother died unexpectedly at home and he was left alone for approximately a fortnight. He was found about 48 hours after his death. The substantive concerns were that the school had contact details only for his mother, did not immediately visit the home when he failed to attend, and did not immediately contact the police when staff could not gain access.
Department for Education
Mr Jamie Fairclough, who had complex difficulties and was receiving mental health services, was discharged from the Community Mental Health Team in November 2016 after unsuccessful attempts to engage with him. He was found dead at home on 9 December 2016 from chemical asphyxiation, and the inquest recorded a conclusion of suicide. Concerns included the discharge decision being contrary to the agreed care plan and made without meaningful consultation, and high caseloads for care co-ordinators.
Kent and Medway Mental Health NHS Trust
Christiana Pelle developed a grade 4 sacral pressure ulcer while living at home under the care of community nursing and a planned care package. The ulcer became infected, and she later died in hospital after contracting pneumonia while receiving inpatient treatment. The principal concerns were unclear guidance about when nurses should involve a GP and inadequate systems for sharing information and escalating concerns between community nursing, other agencies, and the care provider.
East London NHS Foundation TrustHomerton Healthcare NHS Foundation Trust
Mr John Higgs died at Barnsley General Hospital on 18 November 2015 from a ruptured abdominal aortic aneurysm. A CT scan in March 2011 had identified the aneurysm, but the finding was not communicated to Mr Higgs, other clinicians, or his general practitioner. The report raised concern that the Trust’s current system for communicating unexpected, significant non-cancerous radiological findings remained reliant on one doctor noticing and recording the information, with no red-flag facility or equivalent protocol.
Department of Health and Social Care
Annette KRASINSKY-LLOYD died at Royal Surrey County Hospital on 20 April 2016 after an unwitnessed fall caused a pelvic fracture and retro-peritoneal haemorrhage, resulting in hypovolemic shock. The report identified inadequate A&E governance and delays in consultant involvement, investigations, reversal of anticoagulation and blood transfusions, as well as inadequate monitoring that contributed to poor intravenous access.
Royal Surrey NHS Foundation Trust
Christina Bernadette Withey was an inpatient at Great Western Hospital when she suffered a stercoral perforation, leading to faecal peritonitis, sepsis and multi-organ failure, and died on 15 September 2015. The concerns included patient record-keeping and urine-output measurement, delays in reviewing patients whose condition had not improved, sepsis guidance, and the training of locum and other temporary staff.
Great Western Hospitals NHS Foundation TrustNHS England
Raymond Dathan Berry died at the scene on 26 December 2015 after the Honda Jazz in which he was travelling crashed into a tree; he was not wearing a seatbelt and sustained serious head and chest injuries. The concern was that the parameters for activating the vehicle’s Supplementary Restraint System might need adjustment so that airbags could deploy in collisions occurring away from the sensors, such as at the front centre of the vehicle.
Department for TransportDriver and Vehicle Standards AgencyHonda of the U.K. Manufacturing Limited
Theresa Mary Thompson died on 9 October 2016 after admission with sepsis caused by a Streptococcus pneumonia infection, following a history of splenectomy and recent ventriculo-peritoneal shunt insertion. Concerns were raised that she was not receiving lifelong antibiotic prophylaxis and had no antibiotic cover for the shunt procedure, and that there was no evidence she had been advised or prescribed antibiotics before or after the procedure.
Public Health England
John Haughey, who had increasing confusion, consumed a large amount of alcohol-based hand sanitiser while admitted to Hull Royal Infirmary in September 2015. He developed acute alcohol toxicity, later suffered aspiration and progressive respiratory deterioration, and died on 12 September 2015. The principal concern was the risk that confused patients or others could consume alcohol-based hand-washing gels, and that information about this hazard had not been disseminated widely enough.
NHS England
Isabel Lily Gentry became ill with meningitis on 17 May 2016, was discharged from hospital on 18 May with a diagnosis of viral gastroenteritis, and was readmitted later that day when her condition worsened. Meningitis was confirmed, but despite care and treatment she deteriorated and died on 20 May 2016. The principal concern was that extending meningitis B vaccination to the teenage group might prevent future deaths.
Department of Health and Social CareJoint Committee on Vaccination and Immunisation
Steven John Amos died after a leak from a gastrojejunal anastomosis led to peritonitis and multiple organ failure following emergency abdominal surgery. The principal concern was whether care was escalated appropriately when a patient acutely deteriorated during night shifts over the weekend; senior medical review, antibiotics and urgent CT scanning did not occur until 8am, and surgery took place at 2pm.
Gloucestershire Hospitals NHS Foundation Trust
Ronald William Bennett was the subject of an inquest whose circumstances are referred to in the Record of Inquest, which is not provided here. The substantive concerns included delays in ambulance crews reaching incidents because of hospital handover delays, inadequate urgent and emergency services, and bed availability; the report states that the delay in Mr Bennett’s admission did not contribute to his death.
Department of Health and Social CareNHS EnglandSouth East Coast Ambulance Service NHS Foundation TrustUniversity Hospitals Sussex NHS Foundation Trust
Christina Ingrid Smith was referred to Yeovil District Hospital on 30 March 2016 and returned later that day for investigation of a suspected abdominal aneurysm. She deteriorated overnight and died at home; the inquest concluded that she died from a naturally occurring haemorrhage associated with a ruptured dissecting aortic aneurysm. Concerns included that her thoracic aneurysm was not communicated to her or her GP and was not placed under surveillance.
Bute House SurgeryYeovil District Hospital NHS Foundation Trust
Kimberley Holden, who had a chronic neurological condition and chronic pain, died from Oxycodone toxicity on 26 November 2014 after a dose significantly higher than intended was prescribed. The concerns included unsafe prescribing of controlled drugs and poorly coordinated management and prescribing between healthcare providers.
Derbyshire Community Health Services NHS Foundation TrustIvy Grove Surgery
Arthur Albert Morley was a prisoner serving an indeterminate sentence at HMP Grendon when he was found hanging from a pipe in a sanitation area shortly after being told he would be returned to his previous prison. The report raised concerns about accessible ligature points, inadequate sanitation-room security and inspection arrangements, delays in reviewing procedures and incident learning, and insufficient communication and healthcare involvement in return-to-unit decisions.
Grendon Prison
Robert John Owens was admitted to hospital with back pain, developed acute kidney injury and respiratory failure, and was transferred to intensive care. After a naso-gastric tube was replaced and incorrectly positioned, feeding commenced; he became unwell and died on 16 December 2016. The report identified concerns about outdated guidance, failure to follow national pH-testing and x-ray guidance, and inconsistent use of insertion checklists and procedures.
Cwm Taf Morgannwg University Local Health Board
Sean Craig Salvin died on 30 December 2015 from severe injuries sustained when his car left a heavily flooded road at Woolley Wood Bottom, Sheffield. The report identified concerns about failures by authorities to collect, share and collate information about incidents and flooding, as well as concerns about risk assessment and the identification of the location's increasing risk.
Amey plcSheffield City CouncilSouth Yorkshire PoliceYorkshire Water Services Limited
Ms Abigail Baynham had a history of suicidal ideation and was found deceased at her flat after taking her own life. The inquest heard that no further referral to the Mental Health Liaison Service was made when she left hospital, which may have led to a further assessment of her mental state and risk of self-harm.
Black Country Healthcare NHS Foundation TrustNew Cross Hospital
Malcolm Langford was walking with his wife when a vehicle, forced off course after a collision at the Highmoor Road junction, mounted the pavement and struck him. He sustained a non-survivable head injury and died the same day. Evidence at the inquest raised concerns about restricted visibility at the junction and the difficulty of safely emerging from Highmoor Road even when Albert Road appeared clear.
Reading Borough Council
