6,433 reports
Information drawn from published reports and official responses.
Joseph was driving on Brow Lane on 20 October 2023 when his vehicle collided with a wall, and he was pronounced deceased at the scene. The report raises concerns about the absence of legal restrictions on young or newly qualified drivers and the carrying of young passengers, noting the potential for further similar deaths.
Department for TransportRecipient name withheld
Aarav Pal CHOPRA died on 22 November 2023 after an intercostal artery was damaged during a liver biopsy, causing a haemothorax, cardiac arrest and hypoxic brain injury. The report identified concerns about inadequate planning and communication, delayed recognition and treatment of the haemothorax, unclear decision-making, trainee competence, consent, patient risk factors, prophylactic antibiotics, learning from deaths and access to complete electronic records.
Birmingham Women'S and Children'S NHS Foundation TrustDepartment of Health and Social Care
Mr Warren James Green, who was receiving care in an acute hospital following a serious attempt on his life, died on 20 August 2024 after jumping through a gap in a four-storey stairwell and sustaining a skull fracture and traumatic subdural haemorrhage. The concerns identified included delays in securing a psychiatric bed, inadequate supervision and safeguarding for a patient at high risk of self-harm, patients being able to leave the acute ward without appropriate assessment or staff awareness, and unclear escalation to consultant psychiatric oversight.
Essex Partnership University NHS Foundation TrustMid and South Essex NHS Foundation Trust
Ava Grace HODGKINSON died in cardiac arrest at Ormskirk District General Hospital on 14 December 2022, following overwhelming sepsis caused by Group A Streptococcus infection. A delay in receiving antibiotics occurred because the prescribed strength was unavailable and the pharmacy could not issue a different strength that would have provided the same dose without an amended prescription.
Department of Health and Social Care
Jan Michael Raciborski, who had longstanding mental health issues and a brain injury, died at home on 5 February 2024 after hanging himself. The principal concern was that records of contacts with the Adult Mental Health Team contained no written risk assessments, creating risks of inadequate information sharing, misleading records, and difficulties investigating whether risks to life had been identified.
Oxford Health NHS Foundation Trust
Eden Anna Street, aged 13, was found suspended by her sister and could not be revived; she was declared deceased on 27 June 2021. The report describes concerns that information provided by parents of autistic children through a Trust telephone helpline was not fed back to the Trust’s weekly audit meeting, meaning potentially worsening information might not reach those able to alter clinical priorities.
Humber Teaching NHS Foundation Trust
Joshua James David Forsdyke, aged 19, died after jumping into the River Thames following the use of ketamine, tramadol and alcohol; his body was recovered near Butlers Wharf on 31 August 2024. The report raised concern that ketamine was easily and openly available to students through activity connected with student halls of residence.
Fresh Property Group LtdUniversity of the Arts London
Mark-Anthony Summerset attended Worthing Hospital Emergency Department on 5 February 2024 after expressing suicidal thoughts, but left before triage or assessment and was found deceased in his car in Arundel on 7 February 2024. The principal concern was insufficient recording, information flow and information sharing between the agencies involved, including failures to notify Police that he had left the Emergency Department, which may have limited efforts to locate, contact and urgently treat him.
University Hospitals Sussex NHS Foundation Trust
David Vincent Tighe, a 59-year-old man receiving chemotherapy for cancer, was admitted to hospital with chemotherapy-induced enterocolitis. During his treatment, bile aspiration occurred after insufficient monitoring and displacement of a Ryles tube, contributing to bronchopneumonia and sepsis, from which he died. The principal concerns were the absence of a specific Ryles tube policy and the use of a narrowly focused structured review that could miss care or procedural problems.
Oxford University Hospitals NHS Foundation Trust
John Michael Liddle was cycling on the A694 when he was hit by an overtaking minibus and suffered unsurvivable head injuries. The substantive concern was that the 40 miles per hour speed limit was unsafe for that stretch of road, which was residential, included bends and junctions, and had previously experienced other collisions involving cyclists, pedestrians and motor vehicles.
Gateshead Borough Council
Maria Simpson died on 24 August 2022 from massive recurrent pulmonary thromboembolism and deep vein thrombosis. The report states that referrals concerning anticoagulation were returned or not accessed before her death, and that this probably made more than a minimal contribution to her death. It also identifies concerns about non-uniform electronic record systems, delays when transferring records, and difficulty accessing historic referral information.
Department of Health and Social Care
Anthony Paine died at the scene after being struck by a car while crossing the A361 in Banbury on 24 March 2023. Concerns were expressed that the 30 mph speed limit may be too high for the road’s characteristics and pedestrian volume, and that a slower vehicle speed might have allowed more time to react or reduced the severity of the impact.
Oxfordshire County Council
Matthew Brierley died in the car park of Buttermere Court Hotel on 24 April 2024, after being arrested, bailed and placed under conditions that prevented him from living at home or having unsupervised contact with his children and stepdaughter. The inquest concluded that his death was suicide. Concerns included the potentially prolonged period before decisions were made about his devices and case, the use of standard bail conditions without an apparent specific risk assessment, and the lack of proactive follow-up support after his release on bail.
College of PolicingMinistry of JusticeNational Police Chiefs’ Council
Sheila Ann Nicholls died after choking on food during respite care at Mandeville Grange Nursing Home on 19 November 2023. Her family had warned the nursing home about her swallowing difficulties, but important information was not recorded or shared, and she was given food that was unsuitable or insufficiently prepared. The report raised concerns about policy management, emergency response training, and the investigation and learning from adverse incidents.
Mandeville Grange Nursing Home
Thomas Henry Robin Kingston, a 45-year-old man, died after sustaining a self-inflicted shotgun wound to the head at his parents’ property on 25 February 2024. The report raises concerns about communication of suicide risks associated with SSRI medication and whether guidance to continue or switch SSRI medication is appropriate when there is no benefit or adverse side effects are experienced.
Medicines and Healthcare products Regulatory AgencyNational Institute for Health and Care ExcellenceRoyal College of General Practitioners
Alexandra Bronte Roberts, who had a history of mental health issues, self-harm and Type 1 diabetes, died after intentionally overdosing on her prescribed insulin on 13 May 2023. The principal concern was that insulin could only be prescribed in pre-filled pens containing around 10 days’ supply, enabling access to a large overdose, whereas smaller amounts could have reduced the risk.
NHS England
Peter Good, a resident of Hilltop Hall Nursing Home, was admitted to hospital on 26 December 2023 with a blocked gastrostomy tube and was described on admission as being in poor condition, with concerns about his hygiene, wounds and oral care. He deteriorated despite antibiotic treatment and died on 9 January 2024 from pneumonia and complications associated with a previous cerebral infarction, Parkinson’s disease and skin ulceration. The principal concern was that Harbour Healthcare had not investigated how he was cared for at the nursing home, including potential ongoing risks to other residents and learning for staff and managers.
Harbour Healthcare Ltd.
Victor William Knowles was admitted to a nursing home for short-term care planning while at high risk of dehydration and malnutrition. He lost 5kg, had very low fluid intake, and later required hospital treatment for severe dehydration and malnutrition, acute kidney injury, hypernatremia and osmotic demyelination syndrome before dying on 20 January 2024. Concerns included inaccurate or incomplete information being shared with healthcare professionals, failures to obtain timely medical treatment, and limited investigation, reflection and learning from his care and death.
Henning HallSpringcare Limited
Joseph Forbes Black was found deceased at his home on 9 August 2023, having died from acute polydrug toxicity involving heroin adulterated with protonitazene and metonitazene. The report’s principal concern was that naloxone kits were not permitted to be provided by the supported accommodation provider or mental health NHS Trust to known drug users, while access was concentrated through substance misuse services with which many drug users were not engaged. The concern was considered potentially nationwide and heightened by the increased incidence of heroin adulterated with potent synthetic opioids.
Department of Health and Social CareNHS England
Morgan Rose Betchley had a history of mental health difficulties, self-harm and attempts to take her life, and was receiving inpatient care before she died after hanging herself in hospital grounds while awaiting a discharge meeting. The report identified a lack of policy or guidance for assessing risks posed by hospital fixtures and fittings. The inquest also described failures concerning admission, diagnosis, risk management, record keeping, family involvement, discharge planning, staff conduct and the quality of observations and interactions.
NHS EnglandSussex Partnership NHS Foundation Trust
