6,433 reports
Information drawn from published reports and official responses.
Mia Janin was found deceased at home on 12 March 2021, aged 14, after taking her own life. The report describes bullying behaviour by some male students, including gender-based bullying, and hostile responses to a social media post. Concerns were raised about ongoing gender-based bullying at JFS and whether the school’s initiatives had gained the confidence of some female students.
JFS
On 16 June 2023, Matthew Gregory Price was struck by a train at Cottingley Railway Station and died from multiple injuries; the inquest recorded a short-form conclusion of suicide. The report raised concerns about the impact of ongoing Indeterminate Sentences for Public Protection on the wellbeing of people living in the community, including anxiety about recall and seeking mental-health support.
Ministry of Justice
Joseph Leonard Scott Cattle contacted the Welsh Ambulance Service Trust at 00:44 in a call categorised as requiring an Amber 1 response, followed by two further calls. Paramedics did not attend until approximately 07:20, by which time he was deceased; concerns included the delay in allocating an ambulance, hospital handover delays affecting ambulance availability, and an apparent shortfall in funded ambulances.
Welsh Government
Benjamin David Leonard, aged 16, died after slipping and falling from a cliff while descending the Great Orme during an Explorer Scout trip in North Wales. The report identifies concerns about inadequate planning, risk assessment, briefing, supervision, training, safeguarding, first-aid provision, oversight and the Scouts Association’s response to the death.
Children's Commissioner for WalesDepartment for EducationHealth and Safety ExecutiveOffice of the Children's CommissionerThe Charity CommissionThe Scout AssociationUnity Insurance ServicesWelsh Government
Kim Georgina Stroud was admitted to hospital for a bladder tumour procedure that had previously been cancelled five times, became unwell with a chest infection and later tested positive for covid, and died suddenly on 11 October 2022. Concerns included medication being left unsupervised despite delirium, with tablets signed for as administered, and inadequate personal care when she was found heavily soiled with urine and faeces.
The Queen Elizabeth Hospital, King's Lynn
Mr Oliver Beswetherick, who had a history of depression, bulimia and bipolar affective disorder, was found dead after falling from his flat on 4 September 2020. The report raised concern that mental health crisis teams did not have contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, hindering direct referrals and the sharing of case information.
NHS England
Severine Alexia Kelly, who was detained under the Mental Health Act and accommodated at Wotton Lawn Hospital, choked on a sandwich provided by hospital staff on 1 October 2022 and died at the hospital. Concerns included out-of-date training for some bank staff, inadequate updating of risk assessments after a previous choking incident, difficulties contacting emergency services, delays in paramedic attendance, uncertainty about when to call an ambulance, and an AED with an apparently non-working internal clock.
Gloucestershire Health and Care NHS Foundation Trust
Samuel Curless died in hospital on 24 October 2022 after being found suspended from a ligature and receiving delayed life-support intervention. The concerns included failures to call an ambulance promptly, delays in checking vital signs and removing the ligature, and possible inadequacies in police training and refresher training for responding to hanging casualties.
College of PolicingGreater Manchester Police
Kevin John O'Reilly was injured in a motorway collision on 29 June 2023 after his vehicle ran out of petrol and stopped in lane three. He later developed sepsis and pneumonia, followed by a large intracranial bleed, and died on 6 February 2024 from a traumatic intracranial haemorrhage. The concerns included the lack of stopping areas between designated refuse areas on the all-lanes-open motorway and the absence of monitoring of such motorways.
National Highways
Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.
Cygnet Health Care LimitedDerby City CouncilDerbyshire ConstabularyDerbyshire Healthcare NHS Foundation TrustMinistry of Justice
Rosie Catherine YOUNG died on 8 November 2021 after sustaining a traumatic brain injury when she stepped from the rear door of a moving ambulance while being transported to a psychiatric unit. The inquest identified concerns about failures to record and communicate her previous incidents of jumping from moving vehicles, inadequate risk assessment and transport arrangements, and insufficient staff awareness and training regarding the Mental Health Act Transportation Policy.
Herefordshire and Worcestershire Health and Care NHS TrustWest Midlands Ambulance Service University NHS Foundation Trust
Phyllis Christina Hart was admitted to County Hospital in Stafford on 19 March 2023 and developed signs of an ischaemic leg. A vascular specialist review was delayed for four days because there was no vascular team at the hospital; she was subsequently placed on palliative care and died on 8 April 2023. The report raised concern about the absence of an on-site vascular team when urgent vascular opinion was required.
County Hospital, Stafford
Roberto Bottello, who had been experiencing depression, anxiety, panic attacks and later an acute psychotic episode, was detained under section 136 of the Mental Health Act after police found him acutely disturbed. While in a hospital cubicle, he broke the window and fell 25 feet, suffering multiple injuries including a divided axillary vein and artery; his death was announced at 07:27 on 16 September 2020. Substantive concerns included the unsuitability and inadequate safety of the cubicle, communication and information-management failures, insufficient mental-health nursing provision, confusion over his identity, limited access to section 136 suites, and wider concerns about training and psychiatric-care resources.
Central and North West London NHS Foundation TrustMetropolitan Police ServiceNHS England
Sean Benjamin CRAWFORD died on 18 December 2020 in Darlington from the combined toxic effect of alcohol and clozapine, neither being individually at toxic levels. The principal concern was that available guidance and medication packaging warned about alcohol, sedation and potentially dangerous side effects but did not advise that death could result from this combination.
BNF PublicationsDepartment of Health and Social CareMedicines and Healthcare products Regulatory Agency
Thomas Peter LOXTON was found unresponsive at home on 21 September 2023 and was subsequently declared deceased. The post-mortem examination determined that his death was due to an overdose of multiple prescription medications, and the inquest concluded suicide. Concerns included administrative errors that led to clinicians sending contact letters to his family after his death, insufficient collaborative working between two mental health trusts, and outstanding actions intended to reduce the risk of future deaths.
Black Country Healthcare NHS Foundation TrustDudley Integrated Health and Care NHS Trust
Teresa Ann Bennett, who had significant comorbidities and was taking multiple medications including Fentanyl, was found deceased at home on 1 December 2021. The inquest recorded multi-organ failure due to fatty liver and combined drug toxicity, with toxicological analysis identifying Fentanyl in the toxic and fatal range. Concerns included missed regular medication reviews, the absence of a standardised review process, and the risk of inadvertent overdose when medicines that depress the central nervous system are prescribed without regular reviews or specific advice.
Betsi Cadwaladr University LHB
Alfie Anthony Kevin Nicholls, a child with autism and a severely restricted diet, collapsed at home on 17 December 2021 and died at Stepping Hill Hospital despite attempts to resuscitate him. A post-mortem examination found significant malnutrition, and the report identified concerns about poor communication between professionals and the family, limited recognition and understanding of ARFID and medical risk, and insufficient coordinated support and resources.
Department for EducationDepartment of Health and Social CareNational Institute for Health and Care ExcellenceNHS Greater Manchester Integrated Care Board
Joshua Ethan Burgess, who had epilepsy and Lennox-Gastaut syndrome, died at home on 19 November 2022 after vomiting and aspirating during an epileptic seizure. The report identifies concerns about communication and prescribing processes for Brivaracetam, including failures to update the prescription, medication being withheld for several days, and a subsequent increase to 10ml twice daily despite information that 4ml twice daily was appropriate.
Brook Medical CentreGodfrey CareUniversity Hospitals of North Midlands NHS Trust
Michael James Nye attended the Royal Berkshire Hospital with sepsis caused by a Streptococcus A skin and soft tissue infection, but was initially diagnosed with an upper arm DVT. His condition deteriorated and he suffered two cardiac arrests, with his death verified on 15 November 2022. Concerns included delays in blood tests, CT scanning, escalation to the Intensive Care Unit and prescribing antibiotics, as well as overcrowding, inadequate escalation arrangements and training needs concerning atypical sepsis.
Berkshire and Surrey Pathology ServicesRoyal Berkshire Hospital
Nazerine Frances Anderson had a deterioration in her mental health following a Department for Work and Pensions performance review and took a paracetamol overdose on 17 May 2023. She later developed irreversible liver damage and died on 19 June 2023. The report raised concerns about missed opportunities to record her vulnerability, failures to direct communications through her daughter, and the training of DWP staff in supporting vulnerable individuals.
Department for Work and Pensions
