6,433 reports
Information drawn from published reports and official responses.
George Stone suffered from long-term depressive illness and ended his own life on 19 November 2012 after a grand mal seizure following treatment with Venlafaxine. The concern was that severe seizures are a rare side effect of Venlafaxine and similar antidepressants, but the national warning guidelines did not then include the risk of severe seizures.
National Patient Safety Agency
Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.
Tees, Esk and Wear Valleys NHS Foundation Trust
Nicola Valerie MARSDEN developed neurological symptoms before and after giving birth by Caesarean Section at Bedford Hospital on 14 November 2012. An MRI scan was mis-interpreted, and her condition was not recognised as a haemorrhagic infarct; she died on 17 November 2012 from raised intracranial pressure due to a cerebral haemorrhage. The concern was that neurological and brain scans were interpreted by a Radiologist rather than a Neuro-Radiologist, despite a guideline for specialist review.
NHS England
Thomas Warren, a child with cerebral palsy, died after receiving a 25 microgram fentanyl patch for pain and subsequently developing symptoms before suffering a cardiac arrest. The report identified concerns about prescribing an opiate to an opiate-naïve child without hospital admission, missed opportunities to stop dispensing the drug and provide parents with adequate monitoring information, and gaps in checks on the fitness to practise of a locum doctor.
Department of Health and Social CareGeneral Medical CouncilNHS EnglandUniversity Hospital Lewisham
Oлеgs Sulaimovs, a Latvian national and migrant worker, was struck by a vehicle while walking along an unlit, single-carriageway road towards Stafford in the early hours of 9 March 2014. The reported concerns included limited information for migrant workers about the road’s dangers, insufficient encouragement to wear reflective clothing, the absence of a footpath and suitable lighting, and a lack of speed restrictions in a populated area.
Staffordshire County CouncilStaffordshire PoliceT.W. Busby & Son
Dorothy Joan Robinson developed pneumonitis after Busulphan was prescribed despite a previous recorded intolerance and died after being admitted to hospital severely unwell. The principal concern was the continuing risk of prescribing errors because previous drug intolerances, reactions or allergies may not be adequately identified across the Trust.
Royal United Hospital
Dylan Arwel Rattray, a fit and healthy young man, fell approximately 200 metres after following a path descending Snowdon that appeared to be established but petered out on loose scree. The concern was that misleading paths on Snowdon had caused multiple casualties and rescues, and that the Snowdonia National Park Authority had not followed Llanberis Mountain Rescue Team advice to break up such paths and implement more robust safeguards.
Eryri National Park Authority
Aaron Michael VRANAS died after falling from a tenth-floor window at Bury Court, Church Lane, Bedford, on 13 April 2014, sustaining fatal multiple injuries. A concern was raised that treatment for psychiatric illness and ADHD was provided at two different hospitals many miles apart, making the patient difficult to manage.
NHS Central East Integrated Care Board
Sean Brock died by hanging in his prison cell at Woodhill Prison on 10 November 2013, during his fourth day in prison and his first time in an adult high-security prison. The report raised concern that a one-third reduction in prison officer numbers could compromise prison safety and put prisoner lives at risk.
HM Prison and Probation ServiceMinistry of Justice
On 24 December 2013, Charles Albert William Pierson was involved in a vehicle collision in a Tesco car park. His seat belt had a clip that inhibited its proper operation, and he sustained a fractured sternum that led to his death; the report noted that such clips remained available for sale and their use was not presently unlawful.
Department for TransportGeneral Optical Council
Noleen Mary McPHARLANE had longstanding contact with mental health services and a history of overdoses and self-inflicted wounds. She died after ingesting an excess of a drug purchased on the internet, although her intentions were unclear. Concerns included that her suicide thoughts and continued illicit amitriptyline use were not directly explored, and that there was no consideration of input from an alternative healthcare professional despite limited therapeutic engagement.
North London NHS Foundation Trust
Vijay Sonagara, who had alcoholic liver disease, underwent routine surgery for repair of an inguinal hernia on 8 February 2013. His condition deteriorated rapidly, and he died at St Thomas’ Hospital on 22 February 2013 after developing decompensated alcoholic liver disease requiring intensive care. The concerns were that medical records were held under different hospital numbers and in a temporary file, were not amalgamated or cross-referenced, and contained potentially relevant information that was unavailable to his treating doctors.
Barts Health NHS Trust
Lee Michael Friend died on 21 February 2013 after his motorcycle collided with stationary traffic near temporary road works on a blind bend. The report raised concerns about the positioning and visibility of temporary traffic lights, the adequacy of risk assessments and training for road works, the response to public safety concerns, and Surrey Police’s procedures for identifying and reporting risks created by road works.
Department for TransportReigate & Banstead Borough CouncilSurrey PoliceSutton And East Surrey Water PLC
Jack Dulson became seriously ill after initially being diagnosed with a viral illness and was later diagnosed with pericarditis causing a pericardial effusion. He suffered a cardiac arrest on 03/04/14 and could not be resuscitated. The concerns identified were that the GP practice had no system for reviewing abnormal blood test results and that the results were reviewed only after the family arranged and insisted on an appointment.
Heathcote Street Surgery
Vivian Herbert HUNT, an 84-year-old patient on the Mental Health ward, fell in his hospital room on 3 April 2014 after a similar fall the previous day, sustained a facial injury, deteriorated, and later died from a brain bleed. The report raised concern that no neurological observations were made during specified periods after the falls and facial injury.
Cwm Taf Morgannwg University Local Health Board
Martin Rowland HILL died on 24 April 2014 after an abdominal x-ray taken during an A&E attendance showed small bowel obstruction, but the report was not seen by subsequent doctors and he was treated for constipation. The concerns included the failure to act on the radiology report, which might have led to surgical review and readmission, as well as medication not being provided on discharge and no discharge summary being sent to his GP.
the Shrewsbury and Telford Hospital NHS Trust
Mr Wilsher, a resident of Springdale Care Home, deteriorated after falls and was found to have extradural and subdural haemorrhages. He died on 21 December 2013 after discharge from hospital to the care home, which quickly became unable to cope with his mobility. Concerns included inaccurate discharge information, inadequate communication about his care needs and prior referral, and delays or gaps in care assessments.
East of England Community Health and Care NHS TrustNorfolk and Norwich University Hospitals NHS Foundation TrustNorfolk County Council
Clare Louise BAIN, who was prescribed Methadone and Valium, was found collapsed after ingesting a fatal quantity of prescribed and non-prescribed Methadone and Valium. She initially responded to Naloxone but later suffered cardiac arrest and died. The concerns were that paramedics may have treated the incident as a heroin overdose and that insufficient repeat Naloxone could fail to counteract the longer respiratory-depressant effects of Methadone.
South Western Ambulance Service NHS Foundation Trust
Carol Lynne Walker died at home on 19 November 2013 after developing a pulmonary thromboembolism due to deep vein thrombosis following a left ankle fracture treated with a plastercast. The report raised concerns that chemical thromboprophylaxis and formal venous thromboembolism risk assessments were not routinely provided for conservatively treated lower-limb injuries immobilised in casts that were considered low risk.
Harrogate District Hospital
Gerald Trevor Werrett was admitted to hospital with an infective exacerbation of chronic obstructive airways disease and other co-morbidities. During treatment, a chest drain was mistakenly inserted on the left instead of the right after chest X-rays were inverted, mislabelled and misinterpreted. The inquest concluded that he died from bilateral bronchopneumonia, chronic obstructive airways disease and ischaemic heart disease, with his death contributed to by the misplaced chest drain; concerns included failures in X-ray marking, labelling, interpretation, review and examination before insertion.
Department of Health and Social CareRoyal College of AnaesthetistsRoyal College of Emergency MedicineThe British Thoracic Society
