6,433 reports
Information drawn from published reports and official responses.
Alasdair Neal Penny, a 23-year-old man, jumped from a road bridge onto the road below on 4 May 2014 and died from multiple injuries. The bridge had previously been the site of a suicide, and the concern was whether additional protection could make it more difficult to use the bridge as a suicide site and minimise recurrence.
Sussex PoliceWest Sussex County Council
Captain Tom Sawyer and Corporal Danny Winters died in Afghanistan on 14 January 2009 after a Javelin missile fired by friendly forces struck the compound roof where they were located. The report identified ineffective communications, mistaken identification of their position, poor visibility, loss of situational awareness and inadequate assessment of the weapon’s use in the anti-personnel role as contributing factors. A substantive concern was the absence of FIRESNET logs and the lack of secure recording of radio communications, which hindered investigation of what went wrong.
Ministry of Defence
Joshua David Booth sustained fatal injuries after his vehicle lost control on a heavily subsided section of road, collided with a wooden post and entered Fodder Drain. The report identified the road subsidence, inadequate warning signage and the posts at the foot of the bank as serious dangers to motorists and contributory concerns relating to the death.
Lincolnshire County Council
Mr James Mc Manus was admitted with acute lower limb ischaemia requiring thrombolysis and subsequently developed bleeding and hypovolaemic shock. He died on 3 November 2013 following recognised but rare complications of medical intervention; concerns included failures to follow protocols for managing thrombolytic-associated bleeding and massive blood loss.
Pennine Acute Hospitals NHS Trust
Barbara Joan Harrison was admitted on 5 February 2015 for surgery after worsening swallowing and regurgitation symptoms, and subsequently developed significant surgical emphysema and undetected mediastinitis. Concerns included potentially harmful postoperative physiotherapy, failed attempts to site an endotracheal tube due in part to unavailable fibre-optic equipment, inadequate lighting during critical surgery, distress caused to her family, and delayed recognition of swelling around her neck and face.
Circle Health Group LimitedThe Alexandra Hospital
Philip Robinson developed vomiting, breathlessness, coughing up blood and pain before being assessed at Bassetlaw Hospital, discharged, and later readmitted in cardiac arrest. The inquest concluded that he died from an acute myocardial infarction with severe coronary artery disease, after the significance of his clinical condition was not appreciated by the treating team. Concerns included inadequate escalation and recording of Early Warning Scores, unclear guidance on ECG use, an extreme risk arising from the absence of senior medical review, and incomplete implementation of systems intended to improve monitoring.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Maurice Cowling and Robert Cannon died directly as a result of a procedure, while Leonard Ireland died later from complications arising from the procedure. The report raises concerns that resources within the Trust area may have been inadequate to manage recognised complications during or after such procedures.
Northern Lincolnshire and Goole NHS Foundation Trust
Ronald Gittens was taken to hospital, assessed for an informal psychiatric admission and transferred while waiting for a bed, but left before admission. He was later found at home having hanged himself. The principal concerns were the transfer of acute psychiatric patients when no bed is available and the use of CRHTT as a filter for patients needing a bed.
Department of Health and Social CareNorth London NHS Foundation Trust
On 22 April 2014, 11-year-old Robbie Mark Williamson fell from an exposed, wet and slippery gas pipe into a canal while attempting to cross it, and died after drowning and suffering a head injury. The principal concern was that exposed raised pipework accessible to the public might exist without warning signs or barriers to prevent access.
Northern Gas Networks LimitedScotland Gas Networks plcThe Independent Networks AssociationWales & West Utilities Limited
Mrs Tweedy underwent elective varicose vein surgery as a day-case patient on 27 March 2014 and was found collapsed and died at home on 29 March 2014. The inquest recorded pulmonary embolism following recent varicose vein surgery. Concerns included incomplete thromboprophylaxis risk assessment, missing procedure and aftercare leaflets, and incomplete discharge checks and documentation.
Norfolk and Norwich University Hospitals NHS Foundation Trust
Mrs Elizabeth Ann Cox, who was 84 and had a high risk of falls, fell from her hospital bed on 18 July 2014 after the equipment accepted as necessary—a Hi-Lo bed and crash mats—had not been provided. Her condition deteriorated and she died at Kingsmill Hospital on 10 August 2014; the report found a clear link between the fall and her death. The report also raised concerns about insufficient night staffing and the lack of equivalent additional staffing support during night hours.
Sherwood Forest Hospitals NHS Foundation Trust
Neil Thomas Westerman attended Stepping Hill Hospital for an elective cholecystectomy on 2 July 2014, after which a bile leak caused septicaemia. Concerns included the pre-operative assessment being conducted by a junior doctor, incomplete operation notes about equipment and materials, and insufficient junior doctors available in practice, particularly at night.
Stockport NHS Foundation Trust
Leah Levine died on 5 October 2014 after getting through a window onto the roof of a house and either jumping or falling. Concerns were raised that the conditions of her temporary leave from hospital, including responsibility for supervision and any observation regime, had not been clearly agreed, documented, or consistently understood by staff.
Greater Manchester Mental Health NHS Foundation Trust
Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.
Greater Manchester Mental Health NHS Foundation TrustManchester PrisonMinistry of JusticeNHS England
Leonardus Adrianus Vries apparently obtained medical-grade drugs from his workplace and injected himself at his family home, where he died; the inquest concluded that his death was accidental, involving respiratory depression and combined toxicity of bupivacaine, morphine and diamorphine. The principal concern was inadequate documentation and auditing of medication, particularly non-controlled medication, at the Royal Orthopaedic Hospital, creating an opportunity for abuse or theft.
the Royal Orthopaedic Hospital NHS Foundation Trust
Andrew James Peacock suffered fatal injuries after swerving his motorcycle when a large tractor with a long trailer entered the main road from a minor road. A substantive concern was that the tractor did not have or display an amber warning beacon, which might have made it more visible and provided greater opportunity to avoid the collision; the report raises whether such beacons should be required on these vehicles on all roads.
Department for Transport
Darren Linfoot was found unresponsive in his room at Broadmoor Hospital on 18 December 2011 and was declared deceased at Frimley Park Hospital. A post-mortem examination found lobar pneumonia as the cause of death, with dihydrocodeine toxicity contributing. Concerns included inadequate auditing of some potent medications, inconsistent four-hourly patient observations, and inconsistent understanding of the radio nurse’s duties.
West London NHS Trust
Connor Adrian Turner, who had cystic fibrosis, congenital heart disease and required oxygen, stopped breathing while shopping with his parents after the oxygen cylinder valve was found to be off. His death was unascertained, with the inquest stating that lack of oxygen was a contributory factor. The concerns identified included the absence of a system to train and supervise parents or carers in transferring and checking portable oxygen equipment before leaving hospital.
Leeds Teaching Hospitals NHS Trust
Thor Dalhaug was delivered by caesarean section on 23 September 2013 in poor condition after difficulties delivering his deeply engaged head, and died approximately one hour after birth. The report identified concerns including lack of supervision of the operating surgeon, use of an inappropriate forceps technique, inadequate contemporaneous records and shortcomings in the internal investigation and disclosure of the circumstances of his death.
United Lincolnshire Teaching Hospitals NHS Trust
Emmeline Hampson died in hospital on 6 November 2014 after a fall at her nursing home caused a subdural haematoma and intracerebral bleeding. The concerns included repeated falls without review of her falls risk assessment or referral back to the Falls Service, inadequate procedures and record keeping, shortcomings in alarm audibility and differentiation, and insufficient training of agency staff.
Pindy Enterprises Limited
