6,433 reports
Information drawn from published reports and official responses.
Leigh Nardelli died in a road traffic collision on the A5 Southbound in Milton Keynes after his vehicle aquaplaned in torrential rain, struck barriers and hit a concrete support. The principal concern was that a known hazardous P1 terminal had not been replaced with a safer system for financial reasons and continues to present a significant risk.
National Highways
Susan Elizabeth CLISSOLD had multiple sclerosis, was registered blind, and received care for a pressure sore and a burn. She was admitted to hospital with symptoms of infection, her condition later deteriorated, and she died on 9 June 2024. The report raised concerns that district nurses sometimes could not attend required appointments because of insufficient staffing, in the context of increasingly complex cases and growing demand for community nursing support.
Department of Health and Social Care
Brenda Fisher died at Stepping Hill Hospital on 16 January 2025 following complications from wounds sustained in a minor accident at home, with her death contributed to by rhabdomyolysis. The court heard that during her final hospital attendance she remained in the Emergency Department’s Rapid Assessment and Triage Corridor for at least 23 hours before a bed was found. The concern was the residual and inherent risk of death when patients remain for lengthy periods in areas not designed for observations and care.
Department of Health and Social Care
Jordanne Rose ROBERTS was assessed in hospital after falling down stairs, but was discharged before the full CT scan report was read. The final report identified a pulmonary embolism, and Jordanne collapsed and died at home two days later. The principal concern was that locum doctors might not have received or completed training on reading both parts of CT scan reports, creating a risk that life-threatening conditions could go undiagnosed.
Worcestershire Acute Hospitals NHS Trust
Callan was found hanging at his home on 18 May 2023 and was confirmed dead at the scene. The report identified a missed opportunity for a face-to-face mental health assessment the previous day, although it found no possible or probable contribution to his death from this. Concerns were raised that crisis-team staff capacity could determine whether patients were assessed when clinically needed, and that additional resources might not be explored when the team lacked capacity.
Gloucestershire Health and Care NHS Foundation Trust
Michael Ernest Kerslake sustained fatal injuries while using a petrol-driven brush cutter with a metal blade near an electricity pylon at Colley Lane Industrial Estate on 7 September 2023. The principal concern was that no risk assessment warned workers about the risks of using machinery near electrical equipment, and no such assessment remained in place.
Kenny And Murphy Limited
Muhammad QASIM died on 2 October 2023 after a high-speed BMW collision in which the vehicle left the road and struck two trees; he suffered unsurvivable traumatic head injuries. The report raises concerns about differing interpretations and training regarding spontaneous police pursuits, and about investigative responsibilities and the absence of a full forensic collision investigation report in fatal incidents involving a conduct investigation.
College of PolicingIndependent Office for Police Conduct
Karl Dunstan died at Milton Keynes University Hospital on 14 January 2025 from a pulmonary embolism arising from a deep vein thrombosis. The investigation identified missed opportunities to investigate and treat the pulmonary embolism, including the declined CT pulmonary angiogram request, failure to complete D-dimer testing, and lack of emergency treatment when his condition deteriorated.
Milton Keynes University Hospital
Susan Nora Elizabeth Young was admitted to hospital after taking overdoses of prescription medication on 22 and 23 August 2024. She was transferred to a ward with directions for cardiac monitoring, but no clinical handover or monitoring instructions were provided. She was later found unresponsive and not attached to monitoring, and resuscitation failed; unused medication was subsequently found among her belongings.
James Paget University Hospitals NHS Foundation Trust
The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient care.
49 Marine Avenue SurgeryDepartment of Health and Social CareMoorbridgeNHS North East and North Cumbria Integrated Care BoardNorthumbria Healthcare NHS Foundation Trust
David Lee Walsh died at the scene after the Mercedes GLC300 he was travelling in left the road at Whitegates Farm, Tetney Lock Road, Tetney, and entered the Louth Canal on 6 January 2024. The concern was that highway-related collisions are not reported directly to the Highways Department immediately, meaning incidents may occur before the annual review and potentially before preventative action is taken.
Lincolnshire County CouncilLincolnshire Police
Louise Elizabeth Amy Crane, who had a history of mental health diagnoses and was detained in hospital under the Mental Health Act, was found suspended by a ligature at Highgate Mental Health Centre on 19 September 2024. The jury found that factors contributing to her death included chronic suicide risk, unsatisfactory information sharing and recording, inadequate risk management, staffing, and insufficient care and treatment on Topaz Ward. The report also raised concerns about record keeping, therapeutic engagement and professional curiosity, ward observations, communication, transitions between wards, and outstanding actions in the Trust’s action plan.
North London NHS Foundation Trust
Louise Crane died at Highgate Mental Health Centre on 19 September 2024 from ligature compression to the neck while detained under section 3 of the Mental Health Act. The report identifies concerns about information sharing and recording, risk management, staffing and care and treatment on Topaz Ward, and notes a lack of a nationwide policy or approach to anti-ligature measures in mental health settings.
Department of Health and Social CareNHS England
Finlay’s parents took him to Whittington Hospital the night before he died, during an extremely busy and understaffed night in the paediatric emergency department. The report describes failures to conduct serial nursing observations, complete appropriate tests, and obtain specialist advice before Finlay was discharged home. The principal concerns were that missing nursing observations may be a wider issue and that medical staff failed to recognise that the observations had not been carried out.
Royal College of Emergency MedicineRoyal College of NursingRoyal College of Paediatrics and Child HealthWhittington Health NHS Trust
Mr Patrick Viles died after taking an intentional overdose of medication at home, in the context of suicidal ideation and previous overdosing. The report raises concern that medication was prescribed after a psychologist had identified significant concerns about his mental health and the need for urgent psychiatric input. It could not be determined at the inquest where the medication used in the overdose had been obtained.
Complex Spine London
Vera Fortey suffered an unwitnessed fall at her care home, after which her mobility and condition deteriorated. Her fractured hip was not medically identified for approximately two and a half days, and she later underwent surgery, declined despite treatment, and died in hospital. The principal concerns were inadequate recording of the fall, missed opportunities to obtain medical assessment, insufficient auditing of residents’ records, and inadequate staff familiarity with the care home’s records system.
Green Range Limited
Margaret Elizabeth Douglas suffered recurrent falls, a subdural haemorrhage, worsening stroke symptoms and increasing frailty while receiving care, and died after a further deterioration at Holcroft Grange. Concerns included accepting her into care despite being unable to provide the required one-to-one supervision, and using carers whose understanding of her complex needs and ability to communicate effectively were questioned, particularly given her risk of aspiration.
1st Care 4U LtdHolcroft GrangeMinster Care Management Limited
Valerie Hampson died at Willow Wood Hospice on 29 December 2024 as a consequence of Non-Hodgkin’s Lymphoma. The report raises concerns about the progression of a left knee wound while she was under District Nurse care, the absence of a serious incident investigation, and apparent failure to provide recommended fracture-clinic follow-up.
Tameside and Glossop Integrated Care NHS Foundation Trust
Pamela Christine BRAND suffered a fall at her residence on 19 March 2024, sustaining a left hip fracture that was surgically treated. She suffered a cardiac arrest and died in hospital on 2 April 2024; the medical cause of death was pulmonary embolism due to deep vein thrombosis following the recent fall and hip fracture. The report raised concern that hospital records lacked key detail about observations and the rationale for clinical decision-making, potentially affecting future patient care.
West Suffolk Hospital
Charlotte Louise Alderson became seriously unwell from 17 December 2022 and died on 21 December 2022 after a rapidly progressing beta haemolytic streptococcus infection led to septic shock and multi-organ failure. Concerns were raised about the differing outcomes produced by the CENTOR and FEVERPAIN scoring systems, the need for improved tools to identify sepsis or risk of sepsis early, and failures of the NHS Interoperability Toolkit handover between 111 and 999 services.
Department of Health and Social Care
