6,433 reports
Information drawn from published reports and official responses.
Brian Lloyd died in hospital on 18 July 2025 from an infection following an injury caused by the insertion of a urethral catheter after unsuccessful catheterisation attempts at his care home. The substantive concern was that after two unsuccessful attempts to insert a replacement catheter, arrangements should be made to take the patient to hospital without delay.
High Meadows
Kathleen Rose WARD, who had terminal mesothelioma, was admitted to Hull Royal Infirmary’s emergency department on 19 February 2025 because no bed was available at Queens Centre. She remained there for 21 hours and died at Hull Royal Infirmary on 20 February 2025; the inquest recorded pneumonia as the immediate cause of death, with mesothelioma, immunotherapy-induced myocarditis and chronic kidney disease contributing. The principal concern was that insufficient specialist end-of-life bed capacity resulted in patients receiving palliative care in unsuitable emergency-department environments, with potential delays to appropriate emergency treatment.
Hull Royal Infirmary
Gloria Simon moved into a care home for respite care and died there from natural causes on 20 September 2025 after her health deteriorated. Concerns included missed opportunities for timely clinical assistance, a GP misunderstanding the care home setting and oxygen saturation reading, and possible insufficient training of non-clinical staff in seeking help and taking and responding to basic observations.
Riversdale Care Home
Gloria Simon moved into a care home for respite on 9 September 2025 and died there from natural causes on 20 September after her condition deteriorated. Concerns included missed opportunities to obtain timely clinical input, the GP’s failure to undertake a face-to-face assessment after misreading oxygen saturation results, and insufficient attention to her medical history and care-home setting.
Marine Lake Medical Practice
Mr Gunaratnam Kannan took an overdose of Metformin and Indapamide tablets on 18 March 2025 and initially refused hospital treatment after being assessed as having mental capacity. He was later found confused, with limited consciousness and lacking mental capacity, was taken to hospital, suffered a cardiac arrest and was pronounced deceased on 19 March 2025. The concerns identified were a lack of joint-agency policy and training on Mental Capacity Act and Mental Health Act assessments, including uncertainty about which service should request or undertake a Mental Health Act assessment.
East Midlands Ambulance Service NHS TrustNottinghamshire Healthcare NHS Foundation TrustRoyal College of General Practitioners
Evan Dandou-Dambelle was at home on the evening of 2 May 2025 while experiencing symptoms of psychosis and command hallucinations. The concerns relate to a change in his mental-health service contact from weekly to fortnightly at the same time that his olanzapine was stopped and risperidone commenced, without the medication change being specifically considered when setting the level of contact. The inquest determined that he died by suicide.
East London NHS Foundation Trust
Raymond LEAKE fell and sustained a head injury in hospital on 13 February 2025. An authorised CT scan was not booked by radiology and was carried out more than 13 hours after the fall, revealing a catastrophic bleed; he died on 16 February 2025. The principal concerns were the failure to complete and audit revised radiology processes, the delayed scan, inadequate communication with his family, and poor record keeping.
Hull Royal Infirmary
Alan Horrocks was admitted to hospital on 19 February 2025 with a suspected stroke, later diagnosed as viral encephalitis. He deteriorated, developing a Hyperosmolar Hyperglycaemic State and an upper gastrointestinal haemorrhage, and died on 17 March 2025 after treatment was withdrawn. The hospital investigation identified that overnight observations were not completed in accordance with escalation guidance and raised concerns about increased ward capacity without a corresponding increase in nursing establishment, alongside gaps in the existing nursing establishment.
Bradford Teaching Hospitals NHS Foundation Trust
Lewis Aubrey Garfield suffered an intracerebral haemorrhage at home on 4 December 2024, fell down the stairs, and was taken to John Radcliffe Hospital, where he died on 8 December 2024. Concerns included delays in clinical review and ambulance attendance, inadequate guidance to the family while awaiting an ambulance, and delays handing patients over from ambulances to hospitals, with wider delays affecting patient flow and ambulance availability.
Department of Health and Social CareEast Midlands Ambulance Service NHS TrustSouth Central Ambulance Service NHS Foundation TrustUniversity Hospitals of Northamptonshire NHS Group
Patricia Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.
Department of Health and Social CareNHS England
Danielle Jones was found unresponsive at home on 13 May 2025 and was confirmed deceased by paramedics. Post-mortem toxicology found high levels of amitriptyline, excess zopiclone and recent substantial cocaine use; the recorded cause was combined multidrug toxicity. The principal concerns were that, despite reported prescription overdoses and concerns raised by a drug and alcohol service, her repeat prescription medication does not appear to have been reviewed and was continued in large quantities at 28-day frequency.
Your Health Partnership – Regis Medical Centre
Shannon Lee Jordan was admitted to hospital after her mental health deteriorated and she reported plans to run in front of cars. While detained and subject to observations, she was found unresponsive after tying a ligature around her neck and was pronounced deceased on 1 March 2023. The principal concern was confusion about whether 15-minute observations could be completed within a 15-to-30-minute range, with no national standard for observation intervals.
Black Country Healthcare NHS Foundation TrustFamily of Shannon Lee Jordan
Louisa Walker’s head was impacted in her mother’s pelvis during a caesarean section, and she suffered skull fractures and intracranial bleeding during manoeuvres to disimpact her head. She was born on 25 May 2024 and died on 28 June 2024. The principal concern was that, despite an action plan for training arising from the incident, 83% of the trust’s obstetricians had not undergone that training by the inquest.
Royal Berkshire Hospital
Louisa Walker was born on 25 May 2024 and died on 28 June 2024 after her head became impacted in her mother’s pelvis during a caesarean section. She suffered skull fractures and intracranial bleeding during attempts to disimpact her head. The principal concerns were the absence of national guidance for impacted fetal head at caesarean section, uncertainty and potentially inadequate training, and the increasing frequency of this emergency.
Royal College of Obstetricians and Gynaecologists
Alexander Rhys Lewis, a motorcyclist, died from chest injuries following a road traffic collision while being pursued by police. The report raises concerns that a pursuing officer had to undertake multiple tasks alone, limiting communication of dynamic risk assessments and causing vital information about risks, including a red-light contravention, to be missed. Evidence also indicated that double-manning the pursuit crew would be safer, although this would reduce the number of available trained units.
Home OfficeSouth Wales Police
Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.
Department of Health and Social CareNottinghamshire Healthcare NHS Foundation TrustSherwood Forest Hospitals NHS Foundation Trust
Stephen John Neville, aged 68, was an informal inpatient at Beech Ward for planned ECT after a history of severe treatment-resistant depression, anxiety, agitation, and repeated suicide attempts. He died by hanging while in hospital. The report identified concerns including failures in risk communication and assessment, abrupt medication changes, inadequate therapeutic observations and engagement, insufficient auditing and quality assurance, and failure to mitigate risks associated with an unlocked shower room.
Essex Partnership University NHS Foundation Trust
Caitlin Rachel Imber (“Caiti”) died on 13 December 2022; the recorded cause of death was hanging. The report raises concern about a 42-day delay in progressing a CAMHS referral after missing contact information was not followed up, although it states that this was not contributory to Caiti’s death.
Betsi Cadwaladr University LHBYsbyty Gwynedd
Mr Saranveer Singh Sihota, known as Sunny, was a detained patient at a mental health unit who left without permission and died from injuries sustained after falling approximately 70 feet. The report identifies concerns about the relatively low perimeter wall at the location, the risk of fatal falls, and the possibility that others experiencing suicidal thoughts might use the location.
Chesterfield Borough Council
Dr Mark Ryan Foster, who had experienced breathlessness since December 2023, collapsed at home on 17 February 2024 and died despite resuscitation. Post-mortem examination found a pulmonary embolism. The report identified missed opportunities for in-person assessment and hospital referral, and raised concerns about the practice’s leadership and governance and its method of investigating incidents.
Castlegate & Derwent SurgeryAccount
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