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Steven HART · Prevention of Future Deaths report View report

24 Sep 2025 Bedfordshire and Luton S. Cummings

Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.

Leonardo Cardoso Machado · Prevention of Future Deaths report View report

23 Sep 2025 Dorset B. Allen

Leonardo Cardoso Machado, aged 17, died on 16 April 2023 after losing control of a motorcycle and colliding with metal railings while fleeing a police traffic stop. Concerns included limited oversight of rented food-delivery licences for children under 18, and the vulnerability and road-traffic risks associated with children working alone at night on motorised vehicles.

Christopher John Bird (“Chris”) · Prevention of Future Deaths report View report

23 Sep 2025 Wiltshire and Swindon D. Ridley

Christopher John Bird died by suicide on 19 September 2024 after placing his head on a railway line near South Marston and being struck by a freight train. The report found that a mental-health response sent to primary care was not received, and that this communication failure meant he was not updated about his referral and more likely than not exacerbated his mixed anxiety and depression. It also raised concern about the reliability of nhs.net email for transmitting important information between mental-health and primary-care services.

Tony Buengo Jackson · Prevention of Future Deaths report View report

23 Sep 2025 East London G. Irvine

Tony Buengo-Jackson, who had progressive multiple sclerosis and lived in a nursing home, died after a PEG tube inserted on 19 November 2024 passed through his transverse colon, causing bowel perforation, peritonitis and sepsis. The report raises concerns that the injury was not detected until 3 December despite an earlier admission, CT scan and surgical consultation, and that poor records and inadequate Trust governance impeded investigation and learning.

Rebekah Arter · Prevention of Future Deaths report View report

19 Sep 2025 South London A. Harris

Rebekah Arter, aged 47, died in a hotel room in Barbados on 28 June 2024 in circumstances involving likely intoxication; the medical cause of death was unascertained and the inquest conclusion was open. The principal concern was that missed opportunities by the IOPC and Metropolitan Police Service may have prevented identification of Rebekah as a victim of domestic abuse and coercive control, and prevented protective action.

Mr Luke John Chatterton · Prevention of Future Deaths report View report

19 Sep 2025 South London A. Harris

Mr Luke John Chatterton had a history of Clozapine-related constipation and developed vomiting, severe pain and suspected intestinal obstruction. He was discharged from the emergency department after an X-ray, later deteriorated and suffered a cardiac arrest, with delays in advanced life support before he died. The principal concerns were the safety and timeliness of resuscitation for detained mental health patients and the identification and escalation of risks associated with suspected obstruction in patients taking Clozapine.

Kwabena Amoateng · Prevention of Future Deaths report View report

18 Sep 2025 East London G. Irvine

Kwabena Amoateng, a 17-year-old boy with congenital central hypoventilation syndrome, became ill on 16 September 2024 and died in hospital on 23 September 2024 after developing severe respiratory complications. A Paediatric Respiratory Action Plan for his condition was mislabelled and misfiled, so it was unavailable to emergency healthcare professionals assessing him. The report identified the absence of a coordinated process for producing and storing such documents in online clinical records as a substantive concern.

Pamela SINGH · Prevention of Future Deaths report View report

18 Sep 2025 South Wales Central G. Knox

Pamela Singh died of pneumonia on 29 May 2022 after signs and symptoms had progressed for three days and were not recognised by family and professional care staff until after she went into cardiac arrest. The principal concerns were delayed recognition and response to acute deterioration in a person with a learning disability, and the absence of a specific practice tool to support recognition, escalation and response.

Keith James Hankin · Prevention of Future Deaths report View report

17 Sep 2025 West Sussex, Brighton and Hove K. Henderson

Keith James Hankin was admitted for an elective optical urethrotomy on 8 September 2023, developed sepsis shortly after the procedure, was transferred to Worthing Hospital, and died there on 11 September 2023. The report identifies concerns about poor clinical governance and lack of integration, oversight and clinician assessment within the Community Urology Service, as well as multiple omissions in his pre-operative, intra-operative and post-operative care at Goring Hall Hospital, including delays in recognising and treating sepsis and transferring him for further management.

Brian Lyn Davies · Prevention of Future Deaths report View report

17 Sep 2025 Swansea and Neath Port Talbot A. Gruffydd

Brian Lyn Davies was pronounced dead at his home on 13 March 2023 after sustaining chest and neck injuries in an explosion. The cause of the explosion could not be determined because material evidence was not preserved during the search and rescue and clean-up operations, and concerns were raised about the lack of guidance or a protocol between the Police and the HSE on preserving evidence from domestic explosions.

Martin COLLINS · Prevention of Future Deaths report View report

17 Sep 2025 Suffolk P. Taheri

Martin Collins, a 66-year-old male serving a prison sentence, died by suicide after being found suspended in his cell at HMP Highpoint on 25 November 2023. The report raises concerns that the prison telephone system could not automatically identify unusually high call volumes and alert staff or healthcare, potentially missing opportunities to identify risk triggers and intervene.

John Franklin · Prevention of Future Deaths report View report

16 Sep 2025 Worcestershire S. Murphy

John Franklin, who lived alone and was at high risk of falls, suffered a fall after discharge home, followed by dehydration, reduced mobility, contractures and pressure ulcers. He deteriorated despite treatment and died on 16 October 2024; the inquest concluded that death was due to complications of recent falls contributed to by frailty syndrome. The principal concern was that he was discharged home before a careline/lifeline pendant was provided, although the records later indicated that one was installed.

John Franklin · Prevention of Future Deaths report View report

16 Sep 2025 Worcestershire S. Murphy

John Franklin, who was frail and at high risk of falls after hip surgery and prolonged hospitalisation, was found on the floor at home after a long lie and subsequently developed pressure ulcers and a deteriorating hip wound. He died on 16 October 2024; the inquest concluded that death was due to complications of recent falls contributed to by frailty syndrome. A substantive concern was that he was discharged home before a careline/lifeline pendant was provided, with uncertainty about whether it had been installed when he was found on the floor.

Christian Barry · Prevention of Future Deaths report View report

16 Sep 2025 West Yorkshire Eastern L. Benyounes

Christian Barry, who had recent alcohol withdrawal and worsening mental health symptoms, was found hanging in a bathroom at a respite facility on 6 January 2025 and was pronounced dead at the scene. The principal concern was the lack of a formal system for communication, information sharing and handover between the respite facility and the clinical service responsible for his care, including after a planned 48-hour review was missed.

Mohammed Ismail KHAN · Prevention of Future Deaths report View report

16 Sep 2025 Birmingham and Solihull E. Brown

Mohammed Ismail Khan sustained a catastrophic brain injury during a breech delivery at 35 weeks and 2 days gestation on 6 September 2022, after his mother had been discharged from hospital earlier that day despite antenatal risk factors. He later died following a respiratory infection, with the medical cause of death recorded as respiratory failure due to parainfluenza virus infection, with hypoxic-ischaemic brain damage. The investigation identified delayed and suboptimal emergency care, failure to adhere to breech-delivery guidance, and the absence of mandatory paramedic training in obstetric emergencies as substantive concerns.

Linda Janet Sharp · Prevention of Future Deaths report View report

15 Sep 2025 East Riding and Hull P. Marks

Linda Janet Sharp had repeated presentations to healthcare professionals with symptoms consistent with thromboembolic disease before suffering a cardiac arrest at home and dying on 21 November 2023. The principal concern was that a low Wells score was treated as excluding deep vein thrombosis or pulmonary embolism, without further testing or empirical anticoagulation; expert evidence stated that a Wells score on its own does not exclude either condition.

Charlotte Tetley · Prevention of Future Deaths report View report

14 Sep 2025 Cheshire S. Murphy

Charlotte Tetley died on 24 September 2024 after deliberately sitting on railway tracks and being struck by a train. The report describes concerns about the police and ambulance response after she left hospital on 18 September 2024 despite reported suicidal feelings and professional concerns about her immediate safety. It also identifies concerns about the application of missing-person response policy when the person’s whereabouts are unknown.

Charlotte Tetley · Prevention of Future Deaths report View report

14 Sep 2025 Cheshire S. Murphy

Charlotte Tetley died after deliberately sitting on railway tracks and being struck by a train on 24 September 2024. The report describes concerns that she was removed from the inpatient bed list before an appropriate mental health review had taken place, despite previous documented reviews stating that inpatient admission was required.

Gareth Idris Johnson · Prevention of Future Deaths report View report

12 Sep 2025 South Wales Central K. Burge

Gareth Idris Johnson attended hospital with a bilateral pulmonary embolism and underwent catheter-directed thrombolysis. He later died at University Hospital of Wales from complications following the procedure. The report identified suboptimal post-operative anticoagulation management, including a lack of clarity about the appropriate heparin level, and raised concerns about transferring critical-care patients to PACU because of building maintenance, capacity pressures and infrastructure risks.

Michael Leonard MOORE · Prevention of Future Deaths report View report

11 Sep 2025 Norfolk S. Goward

Michael Leonard Moore had recurrent, advanced urothelial carcinoma after a biopsy was delayed for approximately eight months while he remained on a waiting list. He was considered too frail for active treatment and died at home on 17 September 2024. The principal concern was that insufficient NHS capacity and lengthy waiting lists caused delays in diagnosing cancer recurrence and accessing treatment.