6,433 reports
Information drawn from published reports and official responses.
On 4 April 2014, John Ioannou fatally injured himself after jumping from a window at his home. The report identified a concern that there was no guidance for GPs when a patient was not collecting medication required to treat a mental health condition, and that this information was not available to the Mental Health Team.
Department of Health and Social Care
Carla London was born extremely premature and died in hospital on 26 April 2011 after rapidly deteriorating following treatment for suspected sepsis. The report raised concerns about the need for NICE guidance on late-onset sepsis in babies weighing under 1500 g and research into HeRO or other infection-monitoring systems.
Department of Health and Social Care
James Wilson Fyfe died on 21 April 2011 from pneumonia significantly contributed to by a cervical spine fracture sustained when he fell from a hospital trolley after its cot side gave way. Concerns related to the trolley remaining raised but unlocked due to design, maintenance and use issues, and to uncertainty about whether the known hazard had been communicated to other users of the trolley.
Anetic Aid LimitedMedicines and Healthcare products Regulatory AgencyRoyal Berkshire Hospital
Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.
Cookham Wood PrisonLondon Borough of Tower HamletsMedway Youth Offending TeamMinistry of JusticeOxleas NHS Foundation Trust
Anthony Maurice Huggan, who had a longstanding drug problem, was admitted to hospital after an accidental opiate overdose but self-discharged against medical advice on 3 June 2014. He was found deceased at home the following day after taking excessive amounts of prescribed and illicit substances; post-mortem examination and toxicology identified combined drugs toxicity involving Pregabalin, Morphine and Methadone. Concerns included the lack of an out-of-hours community drugs service and the timeliness of follow-up or welfare checks after a life-threatening overdose and self-discharge.
Bury Borough Council
David John Mountain was found to have a slow heart rate, underwent permanent pacemaker insertion on 20 June 2014, and developed chest pain on the way home after discharge. He deteriorated and died on 23 June 2014; the report raised concern that bleeding and vascular damage were not fully investigated promptly and that echocardiogram results showing a mild to moderate bleed around the heart were unavailable until after his death.
The Queen Elizabeth Hospital, King's Lynn
Alois Piska fell in the lounge of his nursing home on 29 May 2014, where no staff member was present, and sustained a non-survivable head injury. He died in hospital on 31 May 2014; the substantive concern was inadequate staffing to supervise residents in communal areas whenever they were in use.
Care UKHarry Sotnick HousePortsmouth City Council
Percy William Gurton was an elderly passenger on a bus who was propelled from his seat when the bus made an emergency stop and collided with the front interior. He died from the injuries sustained; the report raised concern that there was no barrier in front of the front right-hand seat where he was sitting.
First Essex Buses Limited
Edwin Thompson, a 77-year-old residential care home resident with dementia, was found dead in a bathroom on 8 October 2011. The post-mortem identified a previously undiagnosed cardiovascular disease as the natural cause of death. The report identified concerns about protective measures for a vulnerable resident, delayed medical assistance, loss of contact with a resident prone to wandering, response to a final medical crisis, staff training, and record keeping.
Care Quality CommissionSouth Tyneside Borough Council
Ms Pauline Verona Edwards, a healthy 49-year-old woman, died at St Georges Hospital on 15 December 2010 after developing laryngospasm, hypoxia, cardiac arrest and irreversible brain damage following surgery for an ovarian cyst. The report identified concerns that EU-trained doctors’ qualifications could be accepted without equivalent training and experience, and that hospitals might consequently allow such doctors to practise unsupervised, increasing risks to patients.
Department of Health and Social Care
Ms Samia Yasmin Shara, aged 15, died from acute heart failure caused by an aneurysm of the aortic sinus and a ruptured cusp of the aortic valve, following an undiagnosed congenital heart problem. Her brother made calls to 999 and 111, but the seriousness of her condition was not recognised until the final 999 call, delaying emergency ambulance services. Concerns included the audit of complex 999 and 111 calls and preventing call takers from downgrading calls to a lower-acuity pathway.
NHS EnglandNHS West and North London Integrated Care Board
Mr. Thomas Jenkins developed pressure sores while receiving care after a cerebrovascular accident, including an infected chronic pressure sore on his right heel. He was readmitted to hospital and died of sepsis on 8 August 2014. The principal concern was inadequate and delayed tissue viability nursing and wound care input, attributed to specialist nurses not being based in the hospital and insufficient staffing across the region.
Cwm Taf Morgannwg University Local Health BoardNHS Wales Shared Services PartnershipOffice of the Chief CoronerSon of the deceased
Mr Kevin Lawrenson died after his works van collided with the rear of a slow-moving lorry on the M40 southbound near Junction 6 in Oxfordshire. The concerns related to slow-moving vehicles, signage and possible measures to reduce the likelihood of similar collisions, noting that there had been several similar accidents and three fatalities at or near the location since 2008.
National Highways
Brendan Owain Ryan, aged 21, was the front-seat passenger in a Peugeot 205 that left the A488 between Pen-Y-Bont and Knighton on 31 July 2013 and collided with a fence before entering a field. He was declared deceased at the scene; the inquest concluded the death was due to a road traffic collision, with neck injuries recorded as the medical cause. The principal concern was an unusually high number of collisions at or near the location, with evidence indicating that excessive speed was likely, and consideration of a restricted speed area was raised.
Office of the Chief CoronerPowys County CouncilRecipient name withheld
John Derek Stabler was found hanging in a cell at HMP Lincoln on 4 March 2013 and died in Lincoln County Hospital on 6 March 2013. The substantive concerns were the need to review and redesign the Prisoner Escort Record and to ensure medical records were available at HMP North Sea Camp and HMP Lincoln.
HM Prison and Probation ServiceLincoln PrisonNHS EnglandNorth Sea Camp PrisonNottinghamshire Healthcare NHS Foundation Trust
Robert James Stuart and Darren Llewellyn Hughes developed meningoencephalitis after receiving kidney transplants from the same donor and died on 17 and 19 December 2013 respectively. The infection was caused by a Halicephalobus nematode in the transplanted kidneys. Concerns included incomplete transmission of donor information, inadequate use of the EOS system and the need for a more multidisciplinary organ-acceptance process.
NHS Blood and TransplantUniversity Hospital of Wales
Corporal William Savage, Fusilier Samuel Flint and Private Robert Hetherington died on 30 April 2013 when their Mastiff armoured patrol vehicle was hit by a large improvised explosive device placed in a tunnel under Route 611 in Helmand, Afghanistan. The principal concerns were that frequent and continuous surveillance hits indicating possible digging were not accurately and widely shared, and that the route may have been marked as cleared without sufficiently detailed consideration of the threat warnings.
Ministry of Defence
Darren Hayes had significant physical health problems, opiate dependence and alcohol abuse, and was losing weight, struggling with nutrition and personal care, living alone without a cooker. He died on 11 March 2014 before a planned community care assessment could take place; the inquest recorded poisoning by morphine and benzodiazepines, with empyema of the gallbladder. Concerns included delayed and inadequately documented attempts to contact him, insufficient consideration of the risks he presented, and failure to contact other relevant services when he did not respond.
Norfolk County Council
Rebecca Louise Overy died from hypoxic brain injury caused by asphyxia while in adult secure mental health detention. Her fatal injury was self-inflicted after she was transferred from child and adolescent secure mental health detention to an adult admission ward the day after her 18th birthday, without a gradual transition plan; concerns included the immediate transfer and the lack of secure mental health care for young adults aged 18–24 with a similar clinical picture.
Department of Health and Social Care
Connor Steven Paul Smith, aged 20, died in custody at HMP Altcourse in the early hours of 2 January 2013 after being found hanging from a bed sheet; resuscitation was unsuccessful. The report identifies a concern about the quality of the PPO investigation, because a prison custody officer was recorded as attending a review hearing despite not being present, potentially hindering learning in another case.
HM Prison and Probation ServiceMinistry of JusticeNational Offender Management ServicePrisons and Probation Ombudsman
