6,433 reports
Information drawn from published reports and official responses.
On 14 March 2014, Aaron Jacob Plowman was found to have fallen through a damaged plastic roof over garage premises onto a concrete floor. The principal concerns were that access to the roofs of commercial units under the railway arches had not been blocked and that a specific access point from nearby shops remained viable.
Network RailRecipient name withheld
Linda Anne Rignall's condition changed on 5 May 2014, but the change was not reported to a doctor and she was not assessed; her condition worsened approximately four hours later without a medical review. The report states that this failure to refer her for assessment resulted in the only available window of opportunity to treat her being lost, raising concern about the Acute Medical Unit's fitness for purpose.
Recipient name withheldRoyal Sussex County Hospital
Satheeskumar Mahathevan hanged himself in his cell at HM Prison Pentonville on 14 April 2013. The report identified concerns about failures in information sharing, multi-agency communication procedures, and inadequate training for prison staff.
Pentonville PrisonThameside Prison
Marjorie Phillips, aged 82, fell from a hoist while being transferred from her bed to a wheelchair and landed on its metal supporting legs. She died several days later from resultant pneumonia. Concerns included possible sling design issues, lifting her with only one staff member present, inadequate adherence to hoist training, and unclear arrangements for calling emergency services, which delayed her transfer to hospital.
Faversham House Nursing HomeSunrise Medical Limited
Brian Christopher Dalrymple died at Colnbrook Immigration Removal Centre on 31 July 2011 after a fatal rupture associated with extreme hypertension, which he declined to have treated and monitored for most of his detention. The report raised concerns that indicators of his deteriorating mental health were not recognised or communicated to healthcare staff, that medical practitioners lacked necessary knowledge, that medical visits to segregated detainees were inadequate, and that clinical records were not comprehensive or accessible.
Home OfficeNestor Primecare Services LimitedOperose Health (Group) LimitedSerco Group plcThe GEO Group UK Ltd
William Dennis France died on 21 March 2013 when his car was struck by a high-speed train while he attempted to cross Athelney Railway Crossing with the automatic half barriers down. The barriers had remained down for an unusually prolonged period due to an earlier engineering train movement and signalling issues. Concerns included obstructed visibility for motor vehicle drivers approaching the crossing and the position of the crossing telephone beyond the pedestrian stop line.
Network Rail
Beatrice Wright Herriot Gatt was found unresponsive at home on 18 July 2012 and later died at Kettering General Hospital. The report describes an error in which her clozapine medication was not administered on 6, 7 and 8 May 2012, following which her mental state deteriorated; she later suffered falls, fractured her hip and was found on the floor. The principal concern was the medication-transfer error and the apparent lack of formal training for nursing staff on the medication recording system.
Shirelodge Nursing Home
Janet Doreen Goodacre, aged 88, was admitted to Leicester Royal Infirmary on 1 May 2013 and died there on 21 May 2013 after developing a gastrointestinal bleed while receiving warfarin, deltaparin and aspirin. The report raised concerns that the Trust’s investigation report was factually incorrect and flawed, that its identified root causes were wrong, and that the Trust did not communicate these shortcomings or revisit the report before the inquest.
University Hospitals of Leicester NHS Trust
Mr Page was admitted to hospital after a fall, underwent surgery, and later fell from his bed, fracturing his cervical spine; his condition deteriorated and he died on 2 May 2014. Concerns included the absence of a falls risk assessment and low bed, communication needs after handover, and the provision of sufficient nursing staff when greater staffing levels were required.
Withybush General Hospital
Sybil Roberts fell at her care home on 30 December 2013 and again on 1 February 2014, sustaining a fractured hip on each occasion before dying at Maelor Hospital Wrexham on 15 March 2014. The investigation identified that a further falls risk assessment had not been undertaken, and that her care plan and falls risk had not been reassessed and updated before her return from hospital, after which she sustained her second fracture two days later.
Maesglas Care Home
Barbara Monica May Cooke, an 84-year-old resident of Waxham House Residential Care Home, developed severe pressure ulcers, sepsis and multiple organ failure, and died in hospital on 11 April 2014. The report raised concerns about inadequate staffing, delays in toileting and cleaning, failure to recognise and manage infection risks associated with pressure sores, and gaps in communication and safeguarding procedures after her admission and death.
Care Quality CommissionIsle of Wight Adult Safeguarding TeamIsle of Wight NHS TrustSt Mary's Hospital, Isle of WightWaxham House
Evelyn Mary Smith was 7 years old when she died after an acute deterioration in her breathing at home on 13 September 2013, following several healthcare consultations for croup-like symptoms. A post-mortem examination identified Parainfluenza Virus Type 2 and Staphylococcus Aureus, resulting in Acute Ulcerative Laryngotracheobronchitis. The principal concern was that a relatively inexperienced paediatric doctor was the only clinical contact for a child attending A&E, and that discussion with the paediatric team might have led to longer observation and consideration of non-viral causes.
NHS EnglandRoyal College of Emergency MedicineRoyal College of Paediatrics and Child Health
Clive Harold Turner was taken to hospital after delays in the response to a call for medical assistance and was discharged after being incorrectly diagnosed as constipated. He was later found deceased at home from a gastrointestinal haemorrhage due to ischaemic bowel resulting from atherosclerosis. Concerns included uncertainty about pain relief provided by the ambulance service, lack of awareness of overnight discharge policies, and the absence of senior clinicians available for a second opinion.
Betsi Cadwaladr University LHBWelsh Ambulance Services NHS TrustYsbyty Gwynedd
Nicholas James Megginson was found unresponsive at home on 22 May 2014 after fracturing his left ankle and undergoing surgery earlier that month. A post-mortem examination found that he died from a pulmonary embolism. The report raised concern that patients discharged after surgery were not consistently advised, orally or in writing, about venous thromboembolism risks and warning signs requiring urgent treatment.
Cwm Taf Morgannwg University Local Health BoardParents of the deceasedWife of the deceased
Ann Mary Wells, a resident of Julian Hospital, fell in her room on 21 November 2013 while attempting to access the wall beside her bed, sustaining a fractured pelvis and later dying on 28 December 2013. The concerns identified were the positioning of the light switch beside her bed and the absence of a risk assessment for placing her in that room.
Hellesdon HospitalNorfolk and Suffolk NHS Foundation TrustNorfolk County CouncilThe Queen Elizabeth Hospital, King's Lynn
Mrs Gloria Foster was left without care for nine days after her care provider was closed, despite the council knowing that she required care four times a day. She was admitted to hospital seriously ill, including with dehydration, and died on 4 February 2013; the inquest concluded that she died from natural causes contributed to by neglect. The concerns included support and training for staff handling care-provider closures, supervision of delegated tasks, and managing communication channels so affected service users could obtain help.
Care Quality CommissionSurrey County Council
James Dwayne Clarke was involved in a motorcycle collision, became paraplegic and had a tracheotomy tube. After he was discharged home, carers failed to check him during parts of the night and did not notice that his tracheotomy tube had become blocked, resulting in his death. The principal concerns were that the standard of care was seriously lacking and that the carers had received theoretical but no practical training, potentially placing others receiving services at risk.
Care Quality Commission
Rosalind Ann Adshead had previously undergone a total gastrectomy and was later found to have severe adhesions causing strictures. During treatment for an anastomotic leak, she was transferred between hospitals in the early hours of 21 March 2014 while severely ill. Concern was raised that the timing of the transfer was unsafe and added anxiety and distress, and that ambulance shortages during normal working hours were not a valid justification.
North West Ambulance Service NHS TrustStockport NHS Foundation Trust
Joyce Nelson fell at home on 7 March 2014 and fractured her pelvis in several places. The report raises concerns about delays in medical assessment, documentation and imaging results at the Emergency Department, and that she was to be discharged despite having a multi-fractured pelvis; it states that the delays were linked to reported shortages of emergency medicine doctors and radiologists.
Department of Health and Social Care
Anne Elizabeth Sandever, a diabetic woman with acute on chronic renal failure, was admitted to hospital on 3 February 2014, deteriorated after transfer to Walnut ward, and died on 6 February 2014. The concerns included gaps in nursing and medical observation, poor communication and handover about her diabetes, lack of intravenous fluids despite renal failure, and insufficient investigation of the incident.
Hinchingbrooke Hospital
