6,433 reports
Information drawn from published reports and official responses.
Ernest Smith died in hospital from sepsis associated with hospital-acquired pneumonia and an infected haematoma, which developed after prophylactic anticoagulation. Concerns included delays in medical and consultant reviews, delayed antibiotics for the infected haematoma, and failure to follow the Sepsis Protocol.
the Princess Alexandra Hospital NHS Trust
Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.
Department of Health and Social CareMinistry of Housing, Communities and Local GovernmentNHS Greater Manchester Integrated Care Board
Terence Sullivan underwent surgery to remove a sigmoid colon polyp on 8 August 2023, after temporarily stopping rivaroxaban. He suffered an acute myocardial infarction caused by blockage in a coronary artery stent and died in hospital on 10 August 2023. The principal concern was that NICE and BSG guidance may not reflect best practice for patients with coronary stents taking a single anticoagulant who require therapeutic endoscopy, including whether pre-operative consultation with an interventional cardiologist is needed.
British Society Of GastroenterologyNational Institute for Health and Care ExcellenceNHS England
Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.
Birmingham and Solihull Mental Health NHS Foundation TrustG4SHM Prison and Probation ServiceSwansea Bay University Local Health BoardWest Midlands Police
Alan William Rowland Smith developed severe leg swelling associated with venous insufficiency and probable venous thrombosis, followed by an infected leg and rapid deterioration. He died at Stepping Hill Hospital on 17 September 2023. The concerns included delayed recognition of the severity of his condition, late referral to vascular and district nursing services, poor communication across services, and failure to follow advice about a dermatology referral.
NHS Greater Manchester Integrated Care Board
Elizabeth Jane Brown had severe respiratory disease and was diagnosed with mesothelioma, which was attributed on the balance of probabilities to asbestos exposure; she died at Stepping Hill Hospital on 23 January 2023. The inquest heard concerns about lengthy delays in immunology follow-up, linked to a significant national shortage of qualified and trained staff and high vacancy levels.
NHS England
Peter Beresford contacted the North West Ambulance Service with chest pain on 25 September 2023 and was found deceased when an ambulance arrived at his home. The report raised concerns that delays in attending Category 2 calls persisted because of staff and emergency vehicle shortages, and that ambulance resources could not be fully utilised because of delays clearing Accident and Emergency departments.
Department of Health and Social Care
Jason Brown died at his home on 6 September 2022 after taking an overdose of his prescribed medication; the inquest concluded suicide, with the medical cause recorded as cardiac arrhythmia and drug overdose. The report raises concern that original-pack dispensing requirements for Zuclopenthixol dihydrochloride could provide a patient with suicidal risk and previous overdose attempts with a large quantity of medication.
General Pharmaceutical CouncilLundbeck LimitedMedicines and Healthcare products Regulatory AgencyNational Pharmacy Association
Giuseppe Tabone and Andrew Evans died at HMP Lewes after intentionally inhaling isotonitazene, a synthetic opioid. Prison staff failed to carry out required roll checks at 7.30pm and 8.45pm on 27 June 2022, and the report raises concerns about staff compliance with, understanding of, and monitoring of required prisoner checks.
HM Prison and Probation Service
Keith Smith experienced worsening back and chest pain in early July 2023 and sought help from his GP on 3, 4 and 5 July. GP call-backs did not occur, and on 5 July his family contacted 111, after which an ambulance diagnosed a myocardial infarction; he suffered cardiac arrest and died shortly after midnight on 6 July 2023. The principal concern was that the GP surgery could not provide persuasive evidence that procedures, staffing and training had improved the recording and escalation of calls or the monitoring of GP call-backs.
Church Elm Lane Medical Practice
Ronald James Jepson, who resided at a mental healthcare facility and had a known risk of choking, suffered an unwitnessed choking episode after being provided with supper and died in hospital on 15 March 2023. Concerns included delayed and suboptimal CPR, staff calling 111 rather than 999, and infrequent and ineffectual emergency training for care home staff.
Meadow House
Isaac Onyeka, a 3-year-old boy with Down’s Syndrome, developed chicken pox followed by painful swellings and signs of sepsis. He became unresponsive at home and died in hospital on 31 May 2023. Concerns included missed clinical information and risk factors during NHS111 and GP assessment, limited access to background diagnoses for NHS111 health advisers, gaps in awareness of the immune deficiency associated with Down Syndrome, and a lack of central resources to help families recognise sepsis in patients with darker skins.
NHS England
Linda Heath was discharged from hospital with a sacral sore, but the discharge information did not include a required district nursing referral and no referral was made. Her condition worsened, she was admitted to hospital, and she died on 31 March 2022 from sepsis caused by an infected sacral sore. The substantive concerns included inadequate discharge information, failure to arrange district nursing care, insufficient follow-up after discharge, and over-reliance on private domiciliary carers without sufficient enquiry into their remit.
Care Quality CommissionCity Health Care Partnership CICHull University Teaching Hospitals NHS TrustNHS EnglandNursing and Midwifery CouncilSt Andrews Surgery
Rose Mary Hollingworth, a frail woman with significant co-morbidities, was found unresponsive at home on 3 January 2022 after a carer left without carrying out welfare checks or providing care. She was admitted to hospital and died the following day from a spontaneous intracerebral haemorrhage. The concerns included failures to provide suitably trained and competent carers, supervise and manage carers, maintain an accurate care and support plan, and monitor the care agency.
Care Quality CommissionHomedotcare LimitedIslington Social Services
David Louis Siirak was a detained inpatient who suffered unsurvivable injuries after being seriously assaulted by another patient on 1 March 2020 and died on 4 March 2020. The principal concern was that ward staff response was described as chaotic and panicking, with evidence of inadequate training in unexpected simulation exercises to manage such emergencies.
Central and North West London NHS Foundation Trust
Adrian Michael James died after falling from the fourth-floor balcony of his block of flats while experiencing severe and enduring mental illness, including paranoia and a high background risk of suicide. The principal concerns were that he was not assessed by a consultant, proactive care was not considered during his mental health crisis, insufficient attention was given to impulsive suicide risk, no follow-up assessment occurred after a police-interrupted treatment session, and communications between services were inadequate.
Central and North West London NHS Foundation TrustNHS England
Richard Andrew Collins, who had bipolar affective disorder, was struck by an articulated lorry after walking into the eastbound carriageway of the A421 on 9 February 2022, and his death was confirmed despite resuscitation attempts. The report raises concerns that, after his mental health deterioration and hospital admission, his driving fitness and duty to notify the DVLA were not revisited by medical professionals, and that similar missed opportunities may occur nationally.
Department of Health and Social CareNHS England
Nicola Raynor was found hanging on 6 June 2023 and later died at Addenbrookes Hospital from a hypoxic brain injury. The report raises concerns about the lack of available informal mental health inpatient beds locally and nationally, including continuing insufficient bed capacity for patients awaiting admission.
Department of Health and Social Care
Mr Iain Hughes became submerged approximately 11 hours and 35 minutes into a channel swim on 19 June 2023 and was not recovered despite rescue attempts; he was subsequently found in Belgian waters on 4 July 2023. The concern was a lack of clarity about who should decide when to abort a swim and how that decision should be communicated, potentially causing delay and increasing risk.
Channel Swimming & Piloting FederationPilot of the Anastasia
John Patrick MacGREGOR fell at a care home on 2 April 2023 and was not admitted to hospital until 13 April 2023, by which time he was profoundly unwell. He was treated for a hydropneumothorax, fractures and infection, but deteriorated and was placed on an end-of-life pathway; concerns included the quality and completion of care-home documentation and procedures for escalation or non-escalation after a fall.
Credenhill Court Rest Home
