6,433 reports
Information drawn from published reports and official responses.
Sheila Rosamund JOHNSON died at Butterfly Hospice on 14 February 2021 after an unwitnessed fall at her care home caused multiple rib fractures and fatal injuries. Concerns included an inadequate generic falls prevention policy, unlocked doors to unoccupied rooms, an unlit night light in common areas, no bell-ringing signage, and inadequate records of nightly observations.
Phoenix Care Centre
James Jones was taken to hospital with abdominal and chest pain, vomiting, reduced bowel movements and reduced urine output, and was later assessed as having a small bowel obstruction. He experienced delays in medical review, scanning and preparation for exploratory surgery, waiting 17.5 hours before being taken to the anaesthetic room, where he suffered a cardiac arrest. The concerns identified were pressures and insufficient staffing in the Accident and Emergency department, potentially leading to delayed reviews and missed opportunities that may prove fatal in similar cases.
Betsi Cadwaladr University LHB
Emma Louise Morrissey travelled to Turkey for gastric sleeve surgery and died on 08 July 2022 after an instrument perforated her abdomen during the operation, causing a massive uncontrolled bleed. Concerns included inadequate pre-operative assessment by the health tourism company, unclear health screening questions, lack of investigation into the death, inadequate embalming for repatriation, discrepancies in the surgical records and the reported cause of death, and the absence of platelets despite continued bleeding.
Regenesis Health Travel Ltd
Talia Evaniа Phillips died from catastrophic head and neck injuries sustained in a head-on road traffic collision, after likely losing control of her vehicle during a cardiac event associated with a significantly elevated blood level of Fluoxetine. The inquest raised concerns that guidance did not indicate routine Fluoxetine-level testing after palpitations and requested a review of when such blood testing should be advised.
BNF PublicationsNational Institute for Health and Care Excellence
Harold Derek Pedley, known as Derek, attended hospital after referral by his GP with abdominal pain and vomiting, but remained in the Emergency Department waiting area for almost two hours without being assessed or spoken to by a medical professional, and died before he was called. The report raised concerns about hospital pressures at OPEL 4, the inability to triage patients and notify expecting doctors, and the risk that patients may arrive expecting prompt assessment when this cannot be provided.
Department of Health and Social CareNHS Lancashire and South Cumbria Integrated Care Board
Stephen Ratcliffe, who had a history of illicit drug and alcohol use and mental health conditions, was found deceased at home on 6 February 2023 after last being contacted when he collected methadone on 10 January 2023. The medical cause of death was recorded as respiratory depression due to combined drug toxicity, with developing liver cirrhosis and anxiety and depression also recorded; the principal concern was that no diabetes test was obtained because of difficult venous access and the absence of a specialist blood-taking service for GPs to refer to.
NHS Greater Manchester Integrated Care Board
Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.
Department of Health and Social CareLondon Borough of RedbridgeNorth East London NHS Foundation Trust
Allison Aules was referred to a child and adolescent mental health service in May 2021 following concerns including self-harm, low mood and anxiety, but her referral was delayed and the eventual assessment was incomplete. She was discharged without a documented risk management plan, and was found suspended in her bedroom on 18 July 2022; the investigation states that she died on 19 July 2022 as a result of suicide, contributed to by neglect. The principal concerns were failings in care and the under-resourcing of CAMHS services, including delays in assessment and concern that continuing under-resourcing amid rising demand could result in similar deaths.
Department of Health and Social CareLondon OfficeNHS EnglandRoyal College of Psychiatrists
Mizanur Rahman died on 9 March 2023 at the Royal London Hospital after being overcome by smoke during a fire at the multi-occupancy flat where he lived. The fire was attributed to a faulty lithium ion e-bike battery, with evidence indicating that the battery and charger probably carried different voltage ratings. The report raised concerns about the absence of British or European standards governing the sale of lithium ion e-bike batteries, chargers and conversion kits, and the resulting risk of further deaths.
Office for Product Safety and Standards
Stephen Weatherley died at HMP Thameside from the toxic effects of cocaine and methadone after swallowing a package containing a drug during a prison visit. The report identifies concerns about the visitor being allowed an open visit, inadequate investigation and monitoring after the visit, poor record keeping and data retention, and the absence of written guidance for suspected drug swallows.
HM Inspectorate of PrisonsHM Prison and Probation ServiceMinistry of JusticeThameside Prison
Miss C died at Northampton General Hospital on 5 October 2021. The primary underlying causes were recent weight loss with nutritional deficiencies and interstitial pneumonia. During her deterioration, a doctor’s review was delayed, representing a missed opportunity for enhanced supportive care and an earlier peri-arrest call. Concerns also included the out-of-hours availability of Resuscitation Officers and aspects of the cardiac-arrest management, including inconsistent records of dextrose administration.
Northampton General Hospital NHS TrustResuscitation Council UK
Christopher James Locke sustained a cardiac arrest at a public house on 21 October 2021 and died at Morriston Hospital on 29 October 2021 from hypoxic ischaemic encephalopathy caused by the arrest. The concerns included that emergency services did not instruct the caller to begin chest compressions, and that public-house staff may lack CPR training needed to provide lifesaving treatment when appropriate.
J D Wetherspoon PLC
On 12 August 2021, Jonathan Paul Bost Mann and Margaret Jean Costa were involved in a plane crash after weather conditions deteriorated while Mr Mann was flying above cloud, which he was not qualified to do. Both suffered catastrophic injuries incompatible with life. The principal concerns were that the Distress and Diversion Cell did not obtain or share critical information about the pilot, aircraft and weather, and that incorrect assumptions, misunderstandings and miscommunications with Exeter Air Traffic Control limited the assistance provided.
Civil Aviation AuthorityMilitary Aviation Authority
On 2 March 2023, a human body was found near the railway line in the Askam-in-Furness area after a train driver reported seeing it. The inquest concluded that Gordon Alexander John RODGER died by suicide, with multiple injuries consistent with being struck by a train; concern was raised that the line may be readily accessible to individuals wishing to harm themselves.
Network Rail
Audrey King was admitted for femoral hernia obstruction and underwent repair on 6 November 2022. Her apixaban was suspended for surgery and not restarted; she suffered a severe stroke on 11 November and died four days later. The principal concerns were inconsistent record keeping between specialties, inadequate alerting when important handwritten notes were made, and no EPMA alert requiring review of the ongoing medication suspension.
Royal Cornwall Hospitals NHS Trust
Lawson Bond was attacked and mauled by an adult Rottweiler at his home on 28 March 2022 and died from his injuries at Birmingham Children’s Hospital on the morning of 30 March 2022. The report raised concerns that Worcestershire Regulatory Services did not take a sufficiently proactive approach to identifying unlicensed dog breeders, creating a continuing risk from puppies and dogs offered for sale by such breeders.
Wychavon District Council
Jacqueline Elizabeth Smith took her own life by overdosing on prescribed medication at home and died in Hillingdon Hospital on 12 August 2022. She had poor physical health and considerable anxiety while seeking council assistance with hoarded possessions, and a mental health assessment was not performed after she contacted a crisis telephone service. The inquest identified concerns including insufficient staff training for complex hoarder cases, missing safety assessments, an unsuitable council flow chart, and a lack of clear options after the initial assistance plan failed.
Central and North West London NHS Foundation TrustLondon Borough of HillingdonThe Forward Trust
David Joseph Celino, aged 16, took tablets sold as an illicit drug at Leeds Festival in August 2022, developed an adverse reaction, and died after being treated at the festival field hospital and in hospital. The concerns included inadequate information about the number of under-18 attendees, the absence of national oversight and reliable data on drug-related casualties at music festivals, insufficient action to deter drug supply, and a failure by festival staff to identify and assist David as his condition deteriorated.
Department for Culture, Media and SportDepartment for Digital, Culture, Media and SportFestival Republic LimitedHome OfficeLeeds City CouncilWest Yorkshire Police
Juanita Boate Nti had complex congenital diseases and was receiving palliative care at home. She received twenty times the intended morphine dose after the prescription and symptom control plan failed to clearly specify the volume, and the prescription contained two different concentrations. She suffered respiratory arrest and died following an accidental morphine overdose, with concerns also identified about the EMIS prescribing system not offering the relevant morphine strength.
NHS England
Louis Steven James THOROLD died in hospital after being struck by a van that left the road following a collision on the A10 Ely Road. The report raised concern that drivers over 70 could continue driving through an online self-certification process without independent medical scrutiny, including where undiagnosed dementia may affect their ability to perceive hazards.
Cambridgeshire County CouncilDepartment for Transport
