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Sharon Elizabeth Langley · Prevention of Future Deaths report View report

27 Feb 2023 Essex S. Hayes

Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.

Kyron Marcus HIBBERT · Prevention of Future Deaths report View report

27 Feb 2023 Bedfordshire and Luton E. Whitting

Kyron Marcus HIBBERT, who was unable to swim, entered the water at Stewartby Lakes from a rope swing and became submerged; his death was confirmed by paramedics on 30 July 2022. Concerns included the known use of the location and rope swing by children, limited routine checks, sudden changes in water depth without related signage, and restricted access to life-saving equipment.

Sophie Gwen Williams · Prevention of Future Deaths report View report

27 Feb 2023 North London J. Taylor

Sophie Gwen Williams died at home in the early hours of 20 May 2021 after taking a fatal overdose of prescription medications while in a psychotic or dissociative state. The report identifies concerns about the lack of assessment and management of her overdose and self-harm risk, continuity of care and crisis support, staff training and gender-affirming care, and coordination between mental health and gender-identity services.

Doris Joyce Smith · Prevention of Future Deaths report View report

27 Feb 2023 Essex S. Hayes

Doris Joyce Smith fell on Ruby Ward on 9 October 2020, suffered a traumatic subarachnoid haemorrhage, and died on 14 October 2020. The report identifies concerns about delayed and inaccurate falls risk assessments, inadequate neurological and ward observations, failure to implement physiotherapy advice, poor record keeping, and ineffective communication about the care and observation levels required.

Sharon Elaine Harman · Prevention of Future Deaths report View report

24 Feb 2023 Cornwall and Isles of Scilly A. Cox

Elaine Harman was assaulted by her husband, who breached police bail conditions by attending their home and stabbing her to death on 6 August 2021. The principal concern was an apparent disconnect between policing guidance and available legal powers, including the absence of a power to retain a house key during bail conditions in domestic violence cases.

Anthony John Raymond INGRAM · Prevention of Future Deaths report View report

23 Feb 2023 Suffolk N. Parsley

Anthony Ingram was found deceased at his second home in Suffolk on 29 March 2022, having died by hanging. The report identified poor communication between the Metropolitan Police and Suffolk Constabulary, including failure to share information that he had a rope and a collapsible bicycle, resulting in a missed opportunity to find him earlier. The principal concern was the lack of standardised information-sharing requirements or protocols for cross-border missing-person investigations, including cases involving suicidal missing people.

James Francis PARSONS · Prevention of Future Deaths report View report

22 Feb 2023 Cornwall and Isles of Scilly G. Davies

James Francis PARSONS died by drowning at Porthleven Harbour on 23 April 2022 after falling from the harbour wall into the water. The report identified safety concerns including sheer drops without railings, trip hazards, poor lighting, the absence of access ladders or refuge areas, and the pier being open to the public during the festival.

Jacqueline Sharman CAMPBELL · Prevention of Future Deaths report View report

22 Feb 2023 Milton Keynes S. Cummings

Jacqueline Sharman CAMPBELL was found collapsed at home after living with chronic back pain for more than 20 years and taking multiple prescribed medicines. The inquest concluded that she likely inadvertently overdosed on tramadol, which in combination with other medicines had a synergistic effect causing respiratory depression and death. The principal concern was the safety risk of polypharmacy involving gabapentinoids and opioids, particularly their cumulative and synergistic effects on the central nervous system.

Andrew Mark STILL · Prevention of Future Deaths report View report

21 Feb 2023 Gwent C. Saunders

Andrew Mark Still died at the scene after his motorcycle collided with a VW campervan on the A466 near Tintern on 3 June 2022. The concerns included an overgrown chevron sign, missing chevron markers and a lack of evidence that remedial action had been taken after the relevant authority was alerted.

David Colin Strachan · Prevention of Future Deaths report View report

20 Feb 2023 North Wales (East and Central) K. Sutherland

David Strachan developed sudden chest pain, vomiting, clamminess and shortness of breath at home on 15 March 2022. After multiple 999 calls, an ambulance and paramedics arrived only later that morning; he was diagnosed with an ST elevation myocardial infarction, transferred to hospital and died on 16 March 2022. The principal concern was delayed ambulance attendance associated with resource pressures and handover delays, with the report stating that significant concerns remained.

Molly Ann Sergeant · Prevention of Future Deaths report View report

19 Feb 2023 Essex S. Hayes

Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic suicide risk.

Stefan Kluibenschadl · Prevention of Future Deaths report View report

19 Feb 2023 North East Kent C. Wood

Stefan Kluibenschadl was found hanging at home on 20 March 2022 and died in hospital on 26 March 2022. He had autism and had experienced a decline in mental health. The report raised concern that he did not have a case manager or key worker to help him and his family navigate available support services, and that many autistic young people may similarly lack access to such support.

Rachelle Naomi Ross · Prevention of Future Deaths report View report

17 Feb 2023 Newcastle upon Tyne and North Tyneside C. Henley

Rachelle Naomi Ross, aged 34, had not undergone a smear test before being diagnosed with squamous cell carcinoma in November 2020. Despite treatment, the cancer metastasised and she died at home on 20 April 2022. The report raised concerns that GP systems did not automatically flag patients who failed to attend smear tests, potentially requiring manual recording of warnings.

Mr Twm Bryn · Prevention of Future Deaths report View report

17 Feb 2023 North West Wales S. Riley

Mr Twm Bryn died on 4 October 2021 in a shipping container near his home after suspending himself by the neck with a ligature. He had experienced mental health difficulties and was awaiting counselling after an assessment that identified a mild risk of suicide. The report raises concerns about delays and lengthy waiting lists for primary mental health support, and the lack of interim contact, monitoring or support for low-risk patients who are waiting for counselling.

Jamie Paul Woods · Prevention of Future Deaths report View report

17 Feb 2023 Dorset B. Allen

Jamie Paul Woods, a farm worker, died at the scene on 30 January 2021 after an upper pre-cast concrete panel came away from its fixing and caused multiple injuries. Concerns included the use of weaker fixings, insufficient recognition of the associated risks during farm inspections, and a lack of understanding among farm workers about securing such panels safely.

Raniya Rizwan Khan · Prevention of Future Deaths report View report

15 Feb 2023 Berkshire H. Connor

Raniya Rizwan Khan was born on 9 May 2020 and died at Great Ormond Street Hospital on 28 May 2020 after her condition deteriorated; the recorded cause of death was multi-organ failure and severe arterial pulmonary hypertension of unknown cause. Concerns included failures in labour monitoring and escalation by an agency midwife, and the reported non-completion of trust undertakings concerning placenta retention, related procedures and staff training.

Natalie Ann Young · Prevention of Future Deaths report View report

15 Feb 2023 Somerset S. Marsh

Natalie Ann Young, a 92-year-old woman, was knocked over by a mobility scooter in a supermarket on 9 March 2022 and suffered a humeral fracture. Following immobility and a subsequent lower respiratory tract infection, she died at Musgrove Park Hospital on 13 April 2022. The principal concern was the lack of regulation governing who may operate mobility scooters and the absence of legal registration or ownership records, which was considered capable of contributing to further deaths.

Stephen Geoffrey Preston · Prevention of Future Deaths report View report

14 Feb 2023 West Yorkshire (Western) M. Fleming

Stephen Geoffrey Preston fell down stairs at the Earlsheaton Conservative Club on 6 May 2022, striking his head on glazing in double doors and dying before paramedics could assist him. The report raised concerns that the glazing was not safety glass and that the doors were too close to the bottom step and did not comply with relevant requirements.

John Abrahams (Jack) · Prevention of Future Deaths report View report

14 Feb 2023 Manchester North C. McKenna

Jack Abrahams was 20 years old when he took his own life by self-ligature. He had previously received a six-month course of isotretinoin for acne, but the available evidence did not meet the required standard to show a causative link between the treatment and his suicide. The principal concern was that, more than a year after the Isotretinoin Expert Working Group completed its report, its recommendations had still not been implemented, and a further working group to consider implementation had yet to meet.

HANNAH WARREN · Prevention of Future Deaths report View report

13 Feb 2023 Swansea Neath Port Talbot E. Ramsay

Hannah Warren was reported missing on 3 February 2016 after leaving London by car while expressing delusional thoughts, and her body was found in Port Talbot harbour the following morning. The inquest concluded that she died from drowning and a head injury. Concerns included shortcomings in the missing-person investigation, including delayed or insufficient use of the ANPR Bureau, communication failures, failure to contact family, and the use of a low-priority vehicle stop despite a medium risk assessment; the report also identified a lack of formal guidance, training, or protocols linking these systems.