6,433 reports
Information drawn from published reports and official responses.
Michael Briggs developed infective endocarditis after three dental extractions and died at Royal Derby Hospital on 11 January 2023. The principal concerns were limited guidance for dentists in England and Wales about managing patients at increased risk of infective endocarditis, and conflicting guidance on antibiotic prophylaxis.
National Institute for Health and Care Excellence
Archie Campbell Bruce was found unresponsive in a hotel room in Toulouse, France, on 18 August 2019 after socialising and drinking with fellow players. He died after consuming a fatal quantity of tramadol alongside alcohol, cocaine and buprenorphine; the inquest concluded that his death was an accident. The concerns raised related to drug-use education, training and codes of conduct, particularly the possible relaxation of welfare standards for clubs outside the Super League and the need for consistent guidance across the sport.
Rugby Football League
Thomas Wakefield, aged 79, was admitted to hospital on 22 September 2023 after severe stomach pain and sudden collapse at home, and was found deceased in bed the following day. The report identifies concern that abdominal aortic aneurysm and acute pancreatitis can present similarly and may be misidentified, and that guidance did not specifically require exclusion of abdominal aortic aneurysm when pancreatitis was suspected.
NHS England
Margaret Avril Burman, who preferred to be known as Avril, died on 13 July 2021 after an unwitnessed fall at Salisbury District Hospital caused a head injury and intracranial bleed. The report raises concerns that falls risk assessments and enhanced care arrangements were inadequate, and that staffing shortages meant no Healthcare Assistant was available to monitor the ward bay. It also identifies a broader concern that elderly hospital patients remain at significant risk of traumatic and fatal falls because appropriate falls mitigation measures are unavailable.
Department of Health and Social CareNHS England
Mr Timothy Charles Clayton had alcohol-related brain damage, malnutrition, reduced mobility and fluctuating confusion, and was discharged to live alone despite concerns about his ability to care for himself. His flat was inadequately heated, and he was found profoundly hypothermic after self-neglecting; he died at Epsom General Hospital on 12 December 2022. The principal concerns were inadequate discharge planning, insufficient information sharing and investigation, failure to involve or heed his family, an erroneous reliance on his capacity, and pressure to vacate hospital beds.
NHS EnglandSt George's, Epsom and St Helier Hospital Group
Jade Marie Griffiths-Jones died in hospital on 4 June 2023 after suffering a cardiac arrest caused by coronary artery disease and sustaining severe hypoxic brain injury. An ambulance was not available to attend her earlier chest-pain call within target times, with concerns about ambulance response delays linked to increased demand and hospital handover delays.
Department of Health and Social CareNHS Birmingham and Solihull Integrated Care BoardNHS England
William Erskine died on 26 August 2023 after falling or jumping from the open window of his 16th-floor flat, sustaining multiple injuries. Concerns were raised that the windows could be fully opened because their restrictors could be released, and that current requirements do not require fixed window restrictors in high-rise residential buildings or their retrofitting to windows of this type.
Ministry of Housing, Communities and Local Government
Eleanor Smith suffered an unwitnessed fall, sustaining a left femoral neck fracture, and underwent surgical repair. She developed an infection postoperatively and died in hospital on 24 September 2023. The principal concerns were a significant delay in administering intravenous antibiotics, whether the antibiotics were effectively administered, and whether the medical records accurately documented cannula placement and medication administration.
Northumbria Healthcare NHS Foundation Trust
Edith Jane Alden, a resident assessed at very high risk of falls, left a communal area unnoticed and unsupervised on 13 September 2021, fell in the garden and suffered severe head injuries. She died on 25 September 2021. Concerns included unclear and inconsistent care plans and risk assessments, insufficient supervision and staffing, and the use of unlocked communal-area access for residents at very high risk of falls.
The Limes
Axel Price, who had recently turned 18, died by a ligature at some time between 15 and 23 April 2021 after discharge from hospital and Police custody into temporary accommodation. The report identified concerns about unclear agency responsibility and inadequate support during his transition from child and adolescent mental health services to adult services, including failures relating to discharge planning, risk assessment, capacity assessment and ongoing engagement.
Department of Health and Social Care
Stevyn Carr was found dead at his home on 16 November 2021 after contacting Northumbria Police the previous evening and requesting help. Police did not attend until more than 16 hours after his first contact, following a further call from his family. The principal concerns were the grading and delayed handling of the incident, lack of oversight and alternatives when resources were unavailable, and uncertainty about whether Northumbria Police’s subsequent changes had improved the timeliness of responses.
Northumbria Police
Sabina Wood was admitted to hospital with abdominal pain, gallstones and possible bile duct stones, underwent an ERCP, and self-discharged against medical advice. She was found unresponsive at home on 27 January 2023 and her death was recorded as a natural death, with acute haemorrhagic pancreatitis and cholelithiasis stated as the medical cause. The principal concern was that a speculative and inaccurate draft discharge summary, prepared before the ERCP and sent to her GP practice, reflected unsafe processes and could pose a risk to future patients.
Blackpool Teaching Hospitals NHS Foundation TrustDepartment of Health and Social Care
James Ferris Baxter, a passenger-carrying coach driver, died at Junction 15 of the M25 while driving a coach with 25 passengers on board after suffering an acute right coronary artery thrombosis. The coach crashed but was brought to a stop by a passenger, causing minor injuries and vehicle damage. Concerns included the renewal and medical assessment process for his Category D licence, and whether risk-based cardiovascular assessment and relevant diabetes and cholesterol information should be incorporated into driver licensing assessments.
Department for Transport
Scott William James Rider was a prisoner at HMP Woodhill who had been serving an indeterminate Imprisonment for Public Protection sentence for 17 and a half years. On 13 June 2022, he was found hanging in his cell with a ligature around his neck, and the inquest concluded that he died by suicide. The concerns included limited hope of release among IPP prisoners, uncertainty about the continuing length of his sentence, inadequate staffing levels, and the risk of further deaths if IPP prisoners were not reviewed.
HM Prison and Probation ServiceMinistry of Justice
Cariss Lucy Stone was detained in a Psychiatric Intensive Care Unit and self-harmed on multiple occasions, including by attaching a ligature around her neck. During an interval in observations, she applied a ligature with fatal effect, and the healthcare assistant who found her did not have a ligature cutter. The concerns identified were possible inadequate understanding and training regarding observation requirements, including for agency staff, and the lack of routine access to ligature cutters for staff conducting observations.
Somerset NHS Foundation Trust
Paul Dow died on 3 April 2023 after taking an overdose of medication while alone in a hotel room. He had indicated that the overdose might be an attempt to take his own life, but both ambulance calls were coded as category 3, with no clinician involved at the time. There were also concerns that the lack of response to three follow-up calls, potentially indicating loss of consciousness, did not lead to escalation.
Department of Health and Social CareNorth West Ambulance Service NHS Trust
Carole Mather, aged 66, was found dead from hypothermia in an alleyway next to her home on 2 January 2023. She had attended hospital the previous day while intoxicated and complaining of shortness of breath, but discharged herself against medical advice. The principal concerns included the complexity of assessing mental capacity in people with chronic alcohol dependence and the lack of overarching guidance for health and social care practitioners on applying legal frameworks to manage and protect them.
Department of Health and Social Care
Joshua Arthur Stafford Delaney, aged 19, had a history of mental illness, suicidal ideation and previous suicide attempts. On 19 January 2020, he took a large overdose of Propranolol, was found collapsed, and died despite resuscitation attempts. The principal concern was that GPs may not be aware of the risk of fatal Propranolol overdose and may prescribe quantities to people at risk, potentially causing future deaths.
NHS England
Tracey Ann FARNDON was admitted to hospital with diarrhoea, vomiting and severe lower back pain, deteriorated rapidly, suffered cardiac arrest and could not be saved. The post-mortem identified severe pneumonia and a septic spleen, with the medical cause of death recorded as septic shock due to sepsis secondary to community-acquired pneumonia. Concerns included delays in recognising and treating sepsis, failure to respond appropriately to an unrecordable low blood pressure, and emergency department overcrowding and insufficient staffing.
Department of Health and Social CareUniversity Hospitals Birmingham NHS Foundation Trust
Tommy Jay Gillman died on 8 December 2022 at Leicester Royal Infirmary after Salmonella Brandenberg meningitis caused sepsis and multi-organ failure. The report identified missed opportunities at Kings Mill Hospital, including delays in triage, escalation, monitoring, intravenous fluids and antibiotics. Concerns included insufficient paediatric nursing cover, undocumented handovers and an inadequate system for recognising and escalating the care of seriously ill babies.
Sherwood Forest Hospitals NHS Foundation Trust
