6,433 reports
Information drawn from published reports and official responses.
Doreen Turner died on 1 November 2024 after her car entered a canal at South Bank, Chichester, and she drowned. The canal was adjacent to a road with low kerbing, no devices to prevent vehicles entering the water, and evidence that another driver had entered the canal at the same location within the previous five years.
West Sussex County Council
Louise Danielle Rosendale was prescribed long-term opiates for pain following previous surgery and was found unresponsive on 24 September 2024. She died from multiple drug toxicity and pneumonia; concerns included limited review of her long-term opiate prescribing and a lack of detailed planning or oversight for such patients within the practice.
Flixton Road Medical CentreNHS Greater Manchester Integrated Care Board
Richard James Moss attended his general practitioner with intermittent chest discomfort on 15 March 2024 and was later found deceased on 29 May 2024; the recorded cause of death was myocardial infarction due to coronary artery thrombosis. His intended referral to the Rapid Access Chest Pain Clinic had not been actioned, and the practice referral system only alerted colleagues when a practitioner manually selected the alert option.
Townhead Surgery
Jannat was a baby who died shortly after birth from trauma suffered during birth as a result of shoulder dystocia. The report states that her mother’s previous shoulder dystocia was not communicated or recognised, and raises a concern that the shoulder shrug manoeuvre used during the delivery is not included in NICE guidelines.
Royal College of Obstetricians and Gynaecologists
Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.
National Institute for Health and Care ExcellenceNHS EnglandRoyal College of General PractitionersRoyal College of Obstetricians and GynaecologistsSomerset NHS Foundation Trust
Martin Robert Saunders, aged 48, died at the scene after his motorbike collided with a coach making a right turn from a layby on the A4059 New Road, Mountain Ash, on 17 June 2023. The report raised concern that reduced visibility, speed and vehicles turning right across the carriageway from the layby created a risk of future deaths along this route.
Rhondda Cynon Taf County Borough CouncilWelsh Government
Lorraine Parker underwent surgery for sigmoid colon cancer in January 2024 and was discharged with a rising CRP and no post-operative scan. After returning to hospital, an anastomotic leak was initially missed, and she later died at Royal Berkshire Hospital on 30 March 2024 following a sudden deterioration. The principal concerns were the lack of guidance requiring consideration of CT scanning when CRP is high and rising or not decreasing, and reliance on clinical judgement without sufficiently accounting for objective blood-test results.
Department of Health and Social CareRoyal College of Surgeons of EnglandThe Association of Coloproctology of Great Britain and Ireland
Christopher Brazil had physical pain, sciatica and poor mental health, and sourced additional medicines and drugs from unlawful online providers. He died in August 2022 after unintentionally overdosing on benzodiazepines. The concerns included the accessibility and legitimacy of unregulated websites, unsafe or counterfeit medicines, inadequate checks of medical history, dosage guidance, safeguards, age and identity verification, and rapid delivery.
Department for Digital, Culture, Media and SportDepartment for Digital, Culture, Media & Sport (2017 to 2023)Department of Health and Social Care
On 17 August 2024, Raymond Barrie Thomas Mills went into the sea while viewing a shipwreck off Brancaster beach, Norfolk, and was found unresponsive; he died after being airlifted to a local airport. The concerns were that no organisation was clearly responsible for the shipwreck’s management and safety, that owners could not be identified for raising safety concerns, and that there were insufficient warnings about the dangers of the tidal waters.
Department for Transport
Lorraine Parker died on 30 March 2024 after surgery conducted on 23 January 2024; the inquest recorded that her death involved cancer, necessary surgical treatment, and delay in diagnosing and managing an anastomotic leak. The report raises concerns about the Royal Berkshire Hospital’s death investigation processes, including delayed meetings and escalation, poor or defensive structured judgement reviews, unreliable records, and insufficient scrutiny of cases reported to the coroner.
Royal Berkshire NHS Foundation Trust
Mary Frances Cunningham, Grace Foulds, Anne Elizabeth Ferguson and Peter Anthony Westwell died in separate road traffic collisions involving drivers whose eyesight was below the legal standard for driving. The report raises concerns about the UK licensing system, including reliance on self-reporting, the lack of periodic visual checks, and the limitations of the number-plate test. It states that the DVLA continued to license the drivers involved despite their impaired vision.
Department for Transport
Linda took her own life on 11 November 2023 after prolonged strain associated with caring for her husband, who had significant physical and mental health problems. Adult Social Care did not substantively respond to safeguarding and carer assessment referrals or the family’s escalating concerns before her death. The report raises concerns about inadequate oversight and the risk that urgent referrals could be inappropriately downgraded or insufficiently reviewed, potentially contributing to future deaths.
Essex County Council
Sheila Margaret Edwards was a front-seat passenger in a car whose driver became unresponsive, leading to a head-on collision on 8 January 2023. The report identified concerns that drivers with dementia and other conditions may not recognise or report them to the DVLA, creating risks to other road users, and that such conditions may be under-recorded in collision data.
Department for Transport
Iris Joan CARTER had a fall at home on 1 October 2024 and sustained a left distal femur fracture, which was surgically stabilised. After rehabilitation treatment, including treatment for a Grade 4 pressure sore on her left heel, she developed pneumonia and died in hospital on 8 November 2024. The principal concern was that the pressure sore may not have been properly inspected or that inspections were not adequately recorded during her admission at the Queen Elizabeth Hospital.
University Hospitals Birmingham NHS Foundation Trust
Abdulrahman AlAjmi died at the London Clinic on 7 August 2024 from multiorgan failure after arriving in the UK for medical treatment in a substantially poorer condition than had been reported. The report found that the flight probably contributed to his death by exacerbating serious pre-existing medical conditions. Concerns included the absence of uniform systems for accepting and transferring overseas patients, ensuring that receiving services have accurate and up-to-date medical information, and safely treating patients who arrive more unwell than anticipated.
Department of Health and Social CareForeign, Commonwealth & Development OfficeHome OfficeNHS England
Sarah Alison Cunningham jumped onto the northbound track at Chalk Farm London Underground Station while intoxicated by alcohol, cocaine and ketamine, and was killed by a train on 2 November 2024. The principal concern was that TfL’s corporate planning may not sufficiently address the risks posed to intoxicated passengers, with learning from its investigation described as aspirational and lacking a concrete plan.
Transport for London
On 16 October 2024, Freddie Slater died at the scene after his Smart car collided with two other vehicles on the M20 and an adjoining slip road in Kent. The report raised concerns that the grass verge separating the roads had no physical barriers, allowing an uncontrolled vehicle to cross into traffic travelling in the opposite carriageway and creating a risk of high-speed collisions and fatalities.
Kent PoliceNational Highways
Samuel Joseph Brookes was discharged home after a hospital admission following a fall and long lie, but his required care was not rearranged. He was immobile, lived alone, and was left unattended for two weeks without access to his pendant alarm or mobile phone; he was then found unresponsive and deceased. The principal concerns were the failure to arrange and document his care, the lack of a process requiring confirmation of his safe return, and his inability to raise an alarm or call for help.
Russells Hall Hospitalthe Dudley Group NHS Foundation Trust
Patricia Ann Catterall’s care was transferred to a nursing home on 11 June 2024 after 207 days at Mold Community Hospital. Her blood sugar levels, previously checked three times daily, were checked once daily at the nursing home; her condition deteriorated and she was admitted to hospital on 19 June with HHS and sepsis, dying a few days later. The principal concern was that the nursing home’s pre-transfer assessment was not sufficiently robust and did not identify all relevant care information, including the frequency of her blood sugar monitoring.
Betsi Cadwaladr University LHBHighfield Care Home, Wrexham
Susan Marion Lakin, a 72-year-old woman with progressive mobility and memory decline, died after sliding beneath an armchair lap belt that became caught around her neck. The report raises concerns that high-risk lap belts were available to purchase online without adequate warnings about risks such as strangulation or guidance from a healthcare professional.
Department of Health and Social CareMedicines and Healthcare products Regulatory Agency
