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Margaret HEAL · Prevention of Future Deaths report View report

6 Dec 2023 County Durham and Darlington J. Thompson

Margaret Heal died at home from a massive pulmonary thromboembolism caused by a deep venous thrombosis after stopping anticoagulant medication for surgery and not resuming it. The inquest found no evidence that she had been given written instructions to restart the medication, and raised concern about ensuring vulnerable or elderly patients living alone receive medication advice clearly.

John LEE · Prevention of Future Deaths report View report

6 Dec 2023 Surrey A. Crawford

John Lee, an 83-year-old man with dementia, died in hospital on 3 September 2022 after choking on food. The inquest recorded that he was not closely monitored or provided with effective mouth care while eating, despite recommendations to check his mouth after meals. The Court was concerned that dementia patients at the Trust may not receive mouth care after each occasion they eat, presenting a risk of future deaths.

Patricia Ann WALTON · Prevention of Future Deaths report View report

5 Dec 2023 Leicester City and South Leicestershire D. Hocking

Patricia Ann Walton fell while visiting her granddaughter on Christmas Day 2022 and was later admitted to hospital with a fractured right ankle and shoulder injury. She subsequently received warfarin and dalteparin without a clear review or stopping plan; the dalteparin was not stopped when her INR rose above 2, and she later developed a haemorrhage, pneumonia and deteriorating health before dying on 9 January 2023. The principal concern was insufficient medical cover to assess patients’ ongoing care needs over the New Year Bank Holiday period.

Samuel Lewis Jones · Prevention of Future Deaths report View report

5 Dec 2023 Dorset R. Griffin

Samuel Lewis Jones died on 30 April 2021 after suspending himself by a ligature in his cell at HMP Portland. The concerns identified included the lack of systems and national guidance for recording and flagging significant dates, difficulties accessing key information in prison records, and insufficient national guidance on managing medication held in prisoners’ possession.

Kyra Ali Aslam · Prevention of Future Deaths report View report

5 Dec 2023 South Yorkshire (Western) A. Combes

Kyra Ali Aslam was admitted to Sheffield Children's Hospital for a planned procedure to reverse a stoma, deteriorated over two days after surgery, and died on 13 August 2022. The substantive concerns relate to whether medics adequately considered the views of parents and nursing staff, and whether junior doctors receive sufficient explanation when overruled by a consultant.

Jonathan Neal Goldstein and 2 others · Prevention of Future Deaths report View report

5 Dec 2023 Inner South London D. Manknell

Jonathan Neal Goldstein, Hannah Louise Goldstein and Saskia Lucia Goldstein died when a light aircraft crossing the Swiss Alps stalled at low altitude and collided with the ground on 25 August 2019. The principal concerns were the lack of compulsory specific mountain-flying training for PPL(A) pilots and the lack of UK guidance on the risks of navigating mountain passes.

Alice LITMAN · Prevention of Future Deaths report View report

5 Dec 2023 West Sussex, Brighton and Hove S. Clarke

Alice Litman, a 20-year-old trans female, was found dead on 26 May 2022 after a descent from height. The report raised concerns about mental-health training and support for transgender people, delays in accessing gender-affirming healthcare, and insufficient clarity and provision of care while awaiting treatment.

Catriona Ellen Martin · Prevention of Future Deaths report View report

4 Dec 2023 Gwent C. Saunders

Catriona Ellen Martin was admitted to hospital with autoimmune encephalitis and died on 25 December 2020 after developing dehydration, acute kidney injury and uncontrolled seizures. The report identified inadequate nursing care, including failures to observe her and administer medication, and noted concerns about reliance on her mother to provide care without clear guidance on delegation and nursing staff support.

Fraser William Moore · Prevention of Future Deaths report View report

4 Dec 2023 Inner South London J. Morris

On 25 March 2020, Fraser William Moore escaped from custody at London Bridge Station, entered the railway track area, and died after contacting a live rail before power could be severed. The report raised concerns that CCTV coverage ended at the station concourse and that footage was not immediately available to Route Control Rooms, with insufficient coverage beyond the platform ends.

Angela Dawn COLLINS · Prevention of Future Deaths report View report

4 Dec 2023 Bedfordshire and Luton E. Whitting

Angela Dawn COLLINS died after taking an overdose of prescription drugs while experiencing severe mental and emotional distress. The report describes limited or no support for vulnerable adults at risk of overdose or mental health crisis despite being under secondary mental health services, alongside missed or unsuccessful contacts before her death.

Paul Perrott · Prevention of Future Deaths report View report

2 Dec 2023 Plymouth, Torbay and South Devon D. Archer

Paul Perrott, an inpatient detained under the Mental Health Act, died on 31 July 2020 after attempting to hang himself on Ashcombe Ward. Concerns included inadequate recording of his 15-minute observations, unclear responsibility for checking observation charts, insufficient staff awareness of his recent and historical suicide risk, and a focus on immediate rather than historical and contextual risks.

Steven Bowker · Prevention of Future Deaths report View report

2 Dec 2023 Manchester South C. Murray

Steven Bowker fell from garden ladders in 2016 and subsequently developed dependence on prescribed opioid medication. He was found unresponsive at home and pronounced dead on 1 December 2021; the report expressed concern about the dangers of prolonged prescription and use of opiate medication.

Anthony Eric Williams · Prevention of Future Deaths report View report

1 Dec 2023 Manchester South A. Mutch

Anthony Eric Williams was diagnosed with advanced colorectal cancer after presenting with abdominal pain and later developing a bowel mass, spinal cord compression and brain spread. He died at Stamford Court on 28 April 2023. The concerns included national delays in specialist scanning, compliance with the two-week cancer pathway, and access to treatment, which were described as contributing to poorer outcomes and reduced chances of successful treatment.

Ms Samantha Jade Shillito · Prevention of Future Deaths report View report

1 Dec 2023 West Yorkshire Eastern K. McLoughlin

Ms Samantha Jade Shillito was significantly unwell when admitted to hospital and underwent an ascitic tap procedure that perforated an artery, causing intra-abdominal bleeding. She deteriorated over the following weekend without medical review or further investigations and died on 27 February 2022. Concerns included missed opportunities to respond to her deterioration, inadequate information about the risks of the procedure and shortcomings in communication with her family.

David John Briggs · Prevention of Future Deaths report View report

1 Dec 2023 South Yorkshire (Western) H. Berry

David John Briggs died at the Northern General Hospital, Sheffield, on 15 November 2022 after developing urosepsis associated with urinary tract obstruction and a long-term catheter. His carers made several emergency calls as his breathing deteriorated, but the ambulance arrived at 0044 after the first call at 2049. Concerns included insufficient ambulance service resources, delays in responding to the Category 2 call, and hospital offloading delays that reduced ambulance availability.

Donna Marie Donnellan · Prevention of Future Deaths report View report

30 Nov 2023 Manchester North J. Kearsley

Donna Marie Donnellan had a long-standing history of disordered eating, severe weight loss and peripheral neuropathy. She was found deceased at home on 10 October 2022, and the investigation recorded death from complications arising from malnutrition likely due to an undiagnosed atypical eating disorder. Concerns included unclear roles between acute clinicians and the Mental Health Liaison Team, and a lack of understanding about referral pathways to specialist eating disorder services.

Katherine Sarah FLYNN · Prevention of Future Deaths report View report

30 Nov 2023 Liverpool and the Wirral A. Bhardwaj

Katherine Sarah Flynn, aged 34, underwent surgery for a malignant brain tumour and subsequently became dependent on an external ventricular drain. She died on 6 March 2022 after the drain stopped draining, hydrocephalus developed, and the drain was found to have dislodged. Concerns included failures to escalate reduced drainage and leakage to the medical team, and unclear guidance on escalation when a drain stopped draining but continued to oscillate.

Julia MURPHY · Prevention of Future Deaths report View report

30 Nov 2023 Sefton, St Helens and Knowsley J. Goulding

Julia Murphy, known as Sheila, died in hospital on 9 April 2023 after a fall in her care home caused a hip fracture and her condition deteriorated. The report raises concerns about repeated falls, incomplete or inaccurate referrals to the falls prevention team, inadequate escalation, and failure to formally seek one-to-one supervision funding where appropriate.

Ann Dorothy PEARCE · Prevention of Future Deaths report View report

28 Nov 2023 West Sussex, Brighton and Hove J. Andrews

Ann Dorothy Pearce was discharged from hospital on 28 March 2022 after treatment for a tibial spine fracture, having been immobilised in a brace and only partially weight bearing. No venous thromboembolism assessment was undertaken during her admission or on discharge, and she died from a massive pulmonary embolism on 1 April 2022; the inquest also identified that the relevant policy did not cover patients attending hospital without being admitted.

Glyn Ackerley · Prevention of Future Deaths report View report

27 Nov 2023 Cheshire V. Davies

Glyn Ackerley became unresponsive at home on 4 September 2022 after reporting that he had swallowed medication; the cause of death could not be determined. The report raised concern that the NHS Pathways process in place at the time did not distinguish between high-risk and low-risk overdoses, potentially delaying treatment for a potentially fatal overdose.