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Michelle Julie Marie Michaela MASON · Prevention of Future Deaths report View report

2 Jun 2025 Lancashire and Blackburn with Darwen C. Long

Michelle Julie Marie Michaela MASON died on 1 June 2024 at Royal Infirmary, Lancaster, after sudden onset of lack of vision, vomiting and severe pain. She was reviewed around six hours later, when thrombolysis was no longer possible; thrombectomy was considered but no local service was available and transfer was considered too late. Concerns included the absence of a 24/7 thrombectomy service in Lancashire, limited understanding among non-stroke specialists about thrombectomy availability, and a lack of regional mutual aid.

Colin David Lovett · Prevention of Future Deaths report View report

30 May 2025 Dorset R. Griffin

On 29 October 2022, Colin David Lovett was found collapsed and unresponsive in his room at HMP The Verne. The report raised concerns about prison staff’s lack of awareness and training regarding diabetes, limited out-of-hours healthcare access, and the support available to prisoners with insulin-dependent diabetes. It also identified concerns about telephone-call monitoring, access to medication, and the adequacy of risk management and support at HMP The Verne.

Eric Swaffer and 4 others · Prevention of Future Deaths report View report

30 May 2025 Leicester City and South Leicestershire C. Mason

On 27 October 2018, a helicopter crashed shortly after departing Leicester's King Power Stadium, killing pilots Eric Swaffer and Izabela Lechowicz and passengers Vichai Srivaddhanaprabha, Nusara Suknamai and Kaveporn Punpare. The report states that Ms Lechowicz died from head and chest injuries, while the other four died from inhaling combustion products. The principal concerns relate to EASA's handling of recommendations about helicopter component design, certification, life limits, post-service assessment, load-spectrum standards and system-level failure analysis.

Jeanette Sidlow Beech · Prevention of Future Deaths report View report

29 May 2025 North Wales (East and Central) K. Robertson

Jeanette Sidlow Beech, who had a history of alcohol withdrawal-related seizures, became unwell at home on 2 August 2024 and died there on 3 August 2024 after suffering a seizure and cardiac arrest. An ambulance took 15 hours and 13 minutes to attend, by which time resuscitation efforts were unsuccessful. The report raises concerns about ambulance response and hospital handover delays, linked to wider pressures involving hospital capacity, social care and community hospital provision.

Callum James Hargreaves · Prevention of Future Deaths report View report

29 May 2025 Cornwall and Isles of Scilly A. Cox

Callum James Hargreaves, who had a history of substance misuse and housing instability, was found dead in the sea on 20 January 2024 after being removed from a cliff edge and assessed under the Mental Health Act the previous day. The principal concerns were that the rationale for not pursuing a short-term admission was not recorded, and that clinicians did not further explore or test Callum’s refusal to allow his mother to be informed of his discharge. The report also noted that the Nearest Relative’s details appeared not to have been completed on the MH 1.

Julie Sheila Beasley · Prevention of Future Deaths report View report

28 May 2025 Essex S. Hayes

Julie Sheila Beasley was found deceased at home on 16 March 2023 and died from multiple drug misuse involving a fatal amount of morphine and concomitant prescribed medications. She had deteriorating mental health, increasing suicidal thoughts and plans, and repeatedly requested mental health assessment and a medication review. The report identifies failures to complete required assessments and medication review, inadequate communication and record keeping, and insufficient exploration of information she sought to share about her risks.

Samuel Anthony Donald STEWART · Prevention of Future Deaths report View report

28 May 2025 West London L. Brown

Samuel Stewart was found deceased in his cell at HMP Wormwood Scrubs on 15 July 2023, with drugs paraphernalia in the cell. His death was due to drugs in combination with long-term cardiac damage. A positive drug test on 6 March 2023 was not followed by discussion, support, or a multidisciplinary meeting, and the pathways after a positive result were unclear or not followed.

Callum Hargreaves · Prevention of Future Deaths report View report

28 May 2025 Cornwall and Isles of Scilly A. Cox

Callum Hargreaves died after his body was recovered from the sea in Newquay on 20 January 2024, having suffered multiple injuries consistent with a fall from height; the inquest recorded suicide. The principal concern was the response to suspected cuckooing of his social-housing flat, including uncertainty about who caused substantial damage, a period of homelessness, and the decision to serve a Notice Seeking Possession shortly before his death.

Callum James Hargreaves · Prevention of Future Deaths report View report

28 May 2025 Cornwall and Isles of Scilly A. Cox

Callum James Hargreaves, who had substance misuse issues and was sleeping rough, was removed from a cliff edge on 19 January 2024 and underwent a mental health assessment before being discharged to emergency accommodation. His body was recovered from the sea the following day, and the inquest concluded that he died from suicide due to multiple injuries. Concerns included unrecorded reasons for not detaining him, insufficient exploration of his wish not to inform his mother, incomplete nearest-relative details, and gaps in record keeping.

Callum James Hargreaves · Prevention of Future Deaths report View report

28 May 2025 Cornwall and Isles of Scilly A. Cox

Callum James Hargreaves died after his body was recovered from the sea in Newquay on 20 January 2024, following multiple injuries consistent with a fall from height; the report recorded a conclusion of suicide. Concerns included unresolved responsibility between the Council and a social housing provider for addressing safeguarding alerts about cuckooing and housing Callum, despite seven safeguarding conferences, as well as conflicting views about whether a social tenancy disqualified someone from making a homelessness application.

Callum James Hargreaves · Prevention of Future Deaths report View report

28 May 2025 Cornwall and Isles of Scilly A. Cox

Callum James Hargreaves, who had experienced homelessness, substance misuse issues and mental health concerns, was found deceased in the sea on 20 January 2024 after suffering multiple injuries consistent with a fall from height. The principal concern was the difficulty in securing suitable accommodation, with evidence that long periods of homelessness and frustrations about his housing situation contributed to his mental state at the time of his death.

Mr Dean Bradley · Prevention of Future Deaths report View report

28 May 2025 Teesside and Hartlepool C. Bailey

Mr Dean Bradley was found deceased by hanging in his hostel flat on 15 October 2021, after earlier suicidal behaviour and expressions of paranoid and persecutory beliefs while apparently under the influence of drugs. Concerns included whether current resources adequately safeguard people with mental health concerns while intoxicated, and failures to contact mental health services and to relay the details of his crisis to hostel staff.

Sophie Ann Louise Cotton · Prevention of Future Deaths report View report

27 May 2025 County Durham and Darlington R. Sutton

Sophie Ann Louise Cotton had a long history of mental health problems and previous suicide attempts. On 6 January 2025, after she failed to attend important family contact and could not be contacted, four calls were made to the police requesting a welfare check; shortly afterwards, her family found her hanging by a ligature at home. The principal concerns were refusals or delays in police attendance under the “Right Care, Right Person” procedure, including where callers expressed a real and immediate risk to life and where mental health services could not enter locked premises.

Abdirahman Afrah · Prevention of Future Deaths report View report

27 May 2025 East London N. Persaud

Abdirahman Afrah developed severe chest pain and attended A&E, but left without being seen by a doctor after a prolonged wait. He later collapsed at home and died in hospital on 4 June 2024 from bleeding caused by a pulmonary vascular malformation. The concerns included prolonged A&E waits, lack of timely medical triage, unclear communication about the urgency of returning to hospital, failure to discuss this directly with a responsible parent, and failure to send results to his GP in time.

Keith Ineson · Prevention of Future Deaths report View report

27 May 2025 Blackpool and the Fylde A. Cousins

Keith Ineson, a resident at Glenroyd Care Home, suffered an unwitnessed fall on 26 April 2024 and was subsequently treated for a fractured hip. Following surgery, he suffered a choking episode, developed aspiration pneumonia and died at Blackpool Victoria Hospital on 6 May 2024. The principal concern was that observation scores taken after the fall were not all recorded, leaving gaps in the information available to assess whether escalation to medical services was needed and creating a risk of further death.

Sarah Kathleen Hill · Prevention of Future Deaths report View report

26 May 2025 Cumbria M. Taylor

Sarah Kathleen Hill was admitted for an elective ERCP to remove gallstones and developed worsening pancreatitis, perforation, multi-organ failure and cardiac arrest before dying in the early hours of 8 November 2024. Concerns included inadequate falls-risk assessment and reporting, insufficient documentation and monitoring, poor observability in a side room, and understaffing despite escalation.

Paul Andrew Alexander · Prevention of Future Deaths report View report

25 May 2025 West Yorkshire (Western) P. Merchant

Paul Andrew Alexander, who had a long-standing history of mental illness and was under the care of community mental health services, entered the water at Aspley Marina on 4 February 2024 and died from cold-water immersion. A welfare call to police was redirected to the ambulance service, which did not attend, and no emergency services were dispatched. The principal concern was a gap in how emergency services respond to welfare calls under the Right Care Right Person framework.

George Kenneth Fraser · Prevention of Future Deaths report View report

23 May 2025 East London N. Persaud

George Kenneth Fraser, aged 37, was found deceased at his home after mental health services had been unable to contact him and his family had last contacted him several weeks earlier. The cause and date of death were uncertain. Concerns included the absence of a clear care plan and robust risk assessment, and inadequate action and communication following failed contact and concerns raised by a friend and family.

Matthew Joseph O’Reilly · Prevention of Future Deaths report View report

23 May 2025 Manchester West T. Brennand

Matthew Joseph O’Reilly was found collapsed and unresponsive in his locked student accommodation room on 25 September 2020 and was pronounced dead after attempted resuscitation. Postmortem testing found recently ingested, significant and fatally toxic levels of a substance, and the inquest concluded that he died following deliberate self-ingestion, although his intentions remained unclear. The report raised concerns about gaps in guidance and oversight for the sale of a reportable poison, particularly through online marketplaces, and about public access to websites promoting poison-based suicide methods.

William James Armstrong · Prevention of Future Deaths report View report

23 May 2025 Manchester West T. Brennand

William James Armstrong, aged 24, died after deliberately self-administering a significant quantity of a toxic substance following its internet purchase. He was found unresponsive in a hotel room after an ambulance response delay, and the report states that the consequence of the delay cannot be established. Concerns included gaps in guidance and training for sellers of the substance, the assessment of small-quantity purchases as legitimate use, and public access to websites promoting poisons and suicide methods.