6,433 reports
Information drawn from published reports and official responses.
Donna Neill was found deceased at home on 10 December 2018 after an overdose involving medication prescribed to her husband. The report identified that the risk of her taking medication not prescribed to her was not fully assessed, documented, or managed, and that no risk management plan was put in place.
East London NHS Foundation Trust
Aaron David Edwards, aged 42, died at the scene on 30 August 2020 after his motorcycle collided with a car at a junction in Merthyr Tydfil. The concerns identified were poor visibility at the junction, additional traffic and parked cars near a school during pick-up and drop-off times, and the risk of further deaths if driver speeds were not reduced.
Merthyr Tydfil County Borough Council
Liam Joseph LYES-WATSON was found deceased on 26 October 2021 in Shrewsbury, Shropshire, with no suspicious circumstances or evidence of third-party involvement. He had been struggling with his mental health and had contact with the Access Team before his death. Concerns included the second call handler’s lack of training, the response to information provided by Liam’s step-father, whether more should have been done, and whether incoming calls should be recorded.
Midlands Partnership University NHS Foundation Trust
Sandra Kirk was found unresponsive in the ensuite bathroom of her bedroom at Cygnet Hospital on 2 August 2021 and was declared deceased after resuscitation attempts were unsuccessful. The inquest found that she died from asphyxia due to a ligature around her neck. Concerns included inadequate guidance on identifying and removing potential ligatures, including items of clothing, and the limited risk reduction provided by observation intervals.
NHS England
Zachariah Nathaniel Richardson, aged 18, suffered fatal injuries after being found trapped between a forklift truck and a wall while working alone at a site. Concerns included his limited experience and recent forklift training, overdue examinations and defective or defeated safety devices on the forklift trucks, and wider shortcomings in health and safety systems and competence.
D D Dodds and Son LtdLincs Firwood Co LtdRecipient name withheld
Lewis Robert Begley was admitted to a mental health ward on 12 December 2020 and was found unresponsive in his room on the morning of 15 December 2020 after accessing the medicine room. He was pronounced dead at the scene, and post-mortem examination found a split plastic bag containing tablets in his rectum. Concerns included inadequate recording of medicines held, limited knowledge of what medication may have been taken after patient access, and a lack of fixed training for doctors regarding suspected overdoses.
Norfolk and Suffolk NHS Foundation Trust
Robert Norman Howell, who was susceptible to falls, fell backwards in his room at Elm Tree Court care home on 12 April 2022 and struck his head. He sustained a subdural haematoma and died in hospital on 20 April 2022. Concerns included failures to share vital information about residents’ falls risks and care needs, inadequate access to care plans, and a lack of understanding of falls policies.
Elm Tree Court Care HomeHICA Group
Gary McDonald was found deceased in his cell at HMP Hewell after spending nearly four months on remand awaiting trial; the inquest concluded that he died as a result of suicide. The principal concern was that, despite prison healthcare receiving records showing a history of depression and two previous overdoses, including one seven months earlier, there was no system to follow up discrepancies between a prisoner's disclosed mental health history and community GP records.
Government Legal DepartmentHewell PrisonPractice Plus GroupPrisons and Probation Ombudsman
On 9 September 2018, Nargis Begum was fatally injured after a vehicle in which she was a passenger stopped in a live lane of the M1 motorway and was struck by another vehicle. The principal concerns were limited public understanding of the need to alert National Highways about stationary vehicles and insufficient emphasis and effectiveness of public information campaigns about this responsibility.
National Highways
Colin Andrew Mark SMITH, aged 39, died at a hostel after consuming an excessive quantity of alcohol and returning highly intoxicated. The principal concerns were the absence of structured training for hostel workers to identify the risks and signs of alcohol intoxication and when urgent medical intervention was needed.
Tyne Housing Association Limited
Harper DENTON, aged one month, was unlawfully killed by her father, who had previously been convicted of violent offences against a two-year-old child. The inquest found that failures by state agencies to manage the continuing risk he posed contributed to her death. Concerns included police information-sharing and risk-management practices, the absence of an offender register for people convicted of cruelty offences against children, and the non-mandatory nature of full safeguarding assessments by health visitors.
College of PolicingDepartment of Health and Social CareHome OfficeMetropolitan Police ServiceNational Police Chiefs’ Council
Diane Margaret Austin-Martin was a vulnerable adult with multiple sclerosis and significant care needs who was found severely underweight, with multiple pressure ulcers, in filthy and squalid living conditions on 22 March 2021. The report identified concerns about failures to notify Stockport Social Services of her move, the absence of adequate quality assurance for private care, and her becoming unseen by agencies after an initial benefits claim and GP visit.
Department of Health and Social Care
Lilian SHEARING died in Lincoln County Hospital on 29 September 2019 after admission for unrelated medical treatment. Before her hospital admission, poor fluid intake was recorded at her care home, but no risk assessment was undertaken and omissions were made from the fluid intake chart; her intake was later estimated to have been approximately 25% of the expected level due to dehydration.
Tanglewood Cloverleaf
Adam Gallagher, aged 30, died on 18 October 2021 after being found at around 9am, following communication of suicidal ideation while under the influence of alcohol. The report identifies a missed opportunity for urgent intervention, including limited assessment, no clinical input and no ambulance dispatch, and raises concerns about learning, retraining and mental-health incident protocols.
North East Ambulance Service NHS Foundation Trust
Irene Annie Davies had multiple underlying health issues, including congestive cardiac failure and an infected nephrostomy associated with renal stones. After an accidental fall at home on 1 March 2022, she waited more than an hour for a Category 2 ambulance response, was taken to hospital, and was found unresponsive there on 2 March 2022. The substantive concerns included delays to renal stone surgery and delays in ambulance attendance due to service capacity and availability issues.
Department of Health and Social Care
Maureen Harrop, a care home resident, suffered an accidental fall resulting in a fracture to the neck of her femur. She experienced prolonged waits in the Emergency Department and for surgery, which was delayed because of limited bed and theatre capacity. She later developed a urinary tract infection, deteriorated, and died from urosepsis; the report raised concerns about the impact of these delays on her condition.
NHS England
Mr Peter Antony Joseph Pearson died at Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia, which was in all probability acquired while he was resident at Corbett House Nursing Home. Concerns included a delay in calling an ambulance despite his critical condition, incomplete nursing and medication records, failures in oral-cavity checks, shortcomings in management oversight, and an ineffective investigation into his death.
Care Quality CommissionCorbett House Nursing HomeRecipient name withheldWorcestershire County Council
Delina Etienne, who had schizo-affective disorder and was an inpatient receiving treatment, was found unresponsive in bed on 7 May 2021 and was declared deceased at the scene. The report identifies concerns about the chaotic response to her cardiac arrest, including failure to follow resuscitation procedures and an erroneous assumption that a DNACPR order was in place. It also identifies concerns about failures to escalate raised blood pressure and chest pain, assess VTE risk, and disclose the resuscitation error.
Department of Health and Social CareEast London NHS Foundation Trust
Daniel Robert Nelson had a history of schizophrenia, drug dependency, homelessness and imprisonment. After discharge from mental health care with inadequate planning and without required section 117 support, he was placed in unsuitable emergency accommodation with access to drugs and died from an accidental heroin overdose; concerns included the absence of Trust protocols, policies or adequate procedures for section 117 discharges.
Greater Manchester Mental Health NHS Foundation Trust
Robert Graham Taylor suffered significant facial fractures and a subdural haematoma after a fall, developed epistaxis, then deteriorated and died at Southampton General Hospital on 5 June 2021. The concern was that bleeding following epistaxis or facial fractures may continue in the back of the throat and that the importance of checking this was not widely known in the Emergency Department and Trauma Admission Unit.
University Hospital Southampton NHS Foundation TrustAccount
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