6,433 reports
Information drawn from published reports and official responses.
Sam Molyneux, a prisoner at HMP Liverpool, was found hanging from a ligature in his cell on 1 April 2016 and was pronounced dead at 22:55. The inquest identified a failure to open an ACCT, concerns about the response to assaults and possible bullying, and a delay in accessing him because the cell door could be barricaded.
HM Prison and Probation Service
Bronwyn Williams died on 23 May 2017 from a retropharyngeal abscess after attending hospital and a dentist with severe restricted mouth opening and malaise. The concerns included the use of postal referral for an urgent maxillofacial appointment and the failure to provide an appointment within two weeks; the appointment was ultimately scheduled nearly seven weeks after referral and Ms Williams died before being seen.
Homerton Healthcare NHS Foundation TrustKindandental
Frances Elizabeth Greenhalgh died on 10 April 2017 after taking a substantial overdose of Mirtazapine and Dihydrocodeine, following a recent hospital admission after an overdose and discharge with a mental health care plan. The principal concern was that the GP surgery did not promptly record or act on the RAID Team’s faxed notification and treatment plan, so the plan was not available to the GP at the deceased’s appointment.
Heaton Medical Centre
Mr Brian MacLean died on 19 March 2016 from smoke inhalation contributed to by alcohol toxicity after a fire started while he was smoking on his sofa. The report raised concerns about insufficiently proactive social services involvement, failure to identify and refer him as being at risk of fire, and the absence of automatic processes for fire-risk assessment, referrals, sprinklers and other preventive measures.
Great Places Housing AssociationManchester City CouncilNHS Greater Manchester Integrated Care Board
Henry Prow died at the scene after his car collided with a roundabout while he was returning from a medical appointment. A medical event before the collision could not be excluded. Concerns were raised about mechanisms for medical review of drivers with deteriorating or fluctuating health, the potential impact of licence surrender, and whether required vehicle modifications remained appropriate and were being used.
Department for TransportDriver and Vehicle Licensing Agency
Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.
East London NHS Foundation Trust
On 20 February 2017, a short-circuiting Electrium Miniature Circuit Breaker caused a small smouldering fire at Brian David Betterton’s home, releasing carbon monoxide. He died in his bedroom from carbon monoxide exposure. The report raised concerns that the product recall did not reach the deceased and was dependent on identifying purchasers, who were often professional electricians not required to keep records or notify suppliers of end users.
Department for Business, Energy & Industrial Strategy
Mr John Griffiths had a history including ischaemic heart disease and presented with worsening shortness of breath and other symptoms before suffering a cardiac arrest at home and dying in hospital on 8 April 2016. The substantive concerns included failures to complete and process a cardiology referral, inadequate review of previous emergency-department records and investigations, and the absence of a system to identify relevant recent attendances or admissions.
Manchester University NHS Foundation Trust
Geoffrey Frank Taylor, aged 75, died from fatal injuries sustained in a road traffic collision while driving in Cornwall on 8 August 2016. Concerns were raised about the criteria and processes for issuing and surrendering driving licences after medical events, including potential conflicts for GPs and difficulties faced by elderly drivers who may be reluctant to report health problems or surrender their licences.
Department for TransportDriver and Vehicle Licensing Agency
Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following discharge.
NHS LothianOffice of the Chief Coroner
Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following discharge.
NHS LothianOffice of the Chief Coroner
Terence Ryan died on 14 November 2016 after a road traffic collision caused a left leg fracture and he later self-discharged from hospital without anticoagulation medication. The report identified concerns about a consultant-prescribed anticoagulant not being added to his repeat prescriptions and the absence of a hospital protocol for patients, particularly vulnerable patients, who self-discharge without necessary medication.
Grasmere SurgeryWrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Patricia Forshaw fell at home, sustaining a full-thickness wound to her right leg, which developed signs of infection. She died in hospital after suffering a cardiac arrest at home. Concerns included unclear discharge information and telephone advice, failures to record or communicate clinical information, lack of routine observations and blood investigations, and inadequate escalation for review.
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
David Michael Sewell was found in the bath at his home in the early hours of 5 June 2017 with injuries to his arms and holding a razor. He had a history of mental health difficulties, including previous self-harm and an overdose, and the inquest concluded that the cause of death was transection of the left brachial artery and recorded a conclusion of suicide. The principal concern was the apparent lack of a robust system to ensure that people with mental health problems were seen and appropriately cared for, including further efforts to re-engage Mr Sewell after he did not respond to a letter.
Cwm Taf Morgannwg University Local Health Board
Glenys Pollitt was admitted to Stepping Hill Hospital with community acquired pneumonia, but surgical emphysema and an oesophageal rupture were not identified on an initial x-ray and subsequent reviews. She underwent emergency surgery after the rupture was identified, deteriorated, and died from multi-organ failure on 16 February 2017. Concerns included inconsistent use of high-resolution x-ray screens, unclear reinforcement of clinical learning, and unclear escalation processes to consultant and critical care levels.
Stepping Hill Hospital
Brandon Singh Rayat, aged 15, died in hospital on 10 August 2016 after being discovered hanging at home the previous day. The report identified a concern that there was no provision of long-term mental health care for children in Leicestershire whose anxiety prevented them from attending hospital for treatment.
Department of Health and Social CareNHS Leicester, Leicestershire and Rutland Integrated Care Board
Anthony William McCormack became unwell and collapsed while an aircraft was taxiing at Manchester Airport, later suffering cardiac arrest and dying after resuscitation attempts at Wythenshawe Hospital. The report identified concerns about Emirates staff recognising cardiac arrest and agonal breathing, starting CPR promptly, and procedures when the Tempus system could not provide assistance. It also raised concerns about ambulance response targets and the availability of only one paramedic at Manchester Airport.
Department of Health and Social CareEmiratesManchester Airports Group plcNorth West Ambulance Service NHS Trust
Francis Mortimer LANGLEY fell from a step ladder in November 2016, sustained thoracic spinal fractures and a thoracic cord injury, and became paralysed from the waist down. He later developed hospital-acquired pneumonia and died on 30 April 2017; the principal concern was the assessment and non-use of bedrails despite identified risks and apparently contradictory assessment responses before a subsequent fall from bed.
Great Western Hospitals NHS Foundation Trust
Liam Thomas died on 28 August 2016 after being found in a shower room at Littlemore Hospital with plastic bags over his head; he was pronounced dead at hospital, and the cause of death was asphyxiation. The principal concerns were access to plastic bags and other items posing a personal risk, the effectiveness of environmental safety checks, and communication between hospital staff and Liam’s family about information and elevated risk.
Oxford Health NHS Foundation Trust
Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.
Birmingham City CouncilBirmingham Community Healthcare NHS Foundation TrustCater Link LimitedThe Olive School, Small HeathAccount
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