6,433 reports
Information drawn from published reports and official responses.
Stanley Sampey, an in-patient at George Eliot Hospital, choked on a food bolus while eating in bed on 5 March 2016. Staff found that both the wall-mounted suction device and a portable suction unit were not working, and concerns included the lack of working suction equipment and inadequate checking procedures.
George Eliot Hospital
Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.
Department of Health and Social CareGreater Manchester PoliceNHS EnglandNorth West Ambulance Service NHS Trust
Mrs Freda Cordy, a 93-year-old woman with dementia and a history of falls, was admitted to a care home after a fall but received checks only every two hours despite an identified need for constant supervision. She suffered two further falls from her bed, sustaining head injuries and a subdural haematoma, and died in hospital on 1 November 2015. The principal concerns were the lack of constant supervision, the absence of a specific falls risk assessment, and limited consideration of preventative equipment.
Northampton General HospitalTemplemore Care Home
Jonathan Lewis Fry was admitted after an unwitnessed fall and was diagnosed with an L1 compression fracture. He later became increasingly unwell and was found unresponsive on 20 April 2015; the post-mortem cause of death was recorded as pulmonary embolism due to deep venous thrombosis. The principal concerns were the absence of senior Consultant review, inadequate follow-up of tests and results, and inconsistent or incomplete medical records.
Medway NHS Foundation Trust
Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.
Care Quality CommissionCircle Health Group LimitedGeneral Medical CouncilRoyal College of RadiologistsRoyal Surrey County Hospital
Sheldon Woodford was found hanging in his prison cell on 9 March 2015 and subsequently died in hospital on 12 March 2015 after sustaining a significant hypoxic brain injury. The report identified concerns about the identification of the SASH document during reception, ACCT process training, staffing levels, and the unstructured application of the ACCT process, including inadequate integration between prison staff and healthcare.
Winchester Prison
Ronnie Olliffe collapsed in his cell at HMP Rochester on 1 October 2014 and was later confirmed dead at the scene; the medical cause of death was anabolic steroid-related cardiac hypertrophy. Concerns included failures to issue a required Code Blue, inadequate understanding that this would summon an ambulance, and failure to consider or use an available defibrillator.
Rochester Prison
Geoffrey Ellis was admitted for a left-sided laparoscopic nephro-ureterectomy, which was completed by open laparotomy. He died in hospital on 8 September 2015; the inquest concluded that misadventure contributed to by neglect contributed to his death. The principal concern was that illegible clinical records or incomplete important documents could cause communication breakdown and misinformation in a patient’s care pathway.
Stockport NHS Foundation Trust
Harold James Davies, aged 91, died in a road traffic collision on the evening of 8 November 2015 after his Volvo collided with a Jaguar at the junction of Station Road and the A.46 in Nottinghamshire. The principal concern was that this was the third fatality at the junction since 2010, with concerns about the absence of a date for funding or commencing proposed remedial safety work and the potential need for additional warning signs and a lower speed limit.
A-One+National HighwaysNottinghamshire County Council
Mrs Constance Pridmore, who was living independently, fell accidentally on 3 May 2015 and was admitted to hospital with pneumonia. She died on 7 May 2015 from a haemothorax associated with fractured ribs, during insertion of a chest drain. The principal concern was that rib fractures and the associated haemothorax were not identified promptly because her admission chest X-ray was not reviewed by a radiologist until after her death, amid a shortage of radiologists.
Department of Health and Social CareUniversity Hospitals of Morecambe Bay NHS Foundation Trust
James Hall, a Lincoln University student, returned to Ipswich and later left in the family car before being found beneath Orwell Bridge; efforts to resuscitate him were unsuccessful, and he was pronounced dead on 24 November 2015. The report raised concerns about the bridge’s easy access, low concrete walls, lack of deterrents to climbing, and absence of handholds or footholds to prevent or recover from a fall.
Suffolk County Council
David Aughton sustained a severe traumatic brain injury in 1999 that led to epileptic seizures. During a hospital admission for a cystoscopy in December 2015, his anticonvulsant medication was not administered; he subsequently had a grand mal convulsion causing aspiration pneumonia and died on 25 January 2016. The principal concern was that there was no mechanism to ensure essential medications were prescribed, dispensed and administered.
East Lancashire Hospitals NHS Trust
Mia Gibson was born in very poor condition after her mother suffered a sudden placental abruption on 16 November 2015 and died later that day. The report identifies delays in ambulance availability and transfer to hospital, alongside concerns about recognition of the risk to the baby, ambulance crew availability and meal-break planning.
Association of Ambulance Chief ExecutivesEast Midlands Ambulance Service NHS TrustNHS Derby and Derbyshire Integrated Care BoardNHS England
Gillian Rose Taylor had a lengthy history of mental health issues and repeated suicide attempts. After being detained under the Mental Health Act and treated away from Powys because no acute bed was available locally, she remained under community mental health care until her death by hanging at home on 3 January 2016. The concerns included the lack of an acute treatment facility in Powys, resulting patient transfers, lack of continuity of treatment, and the possible adverse effect of this experience on her engagement with mental health professionals and risk of self-harm or suicide.
Daughter of the deceasedDepartment of Health and Social CareOffice of the Chief CoronerPowys Teaching Local Health Board
Sally Ann Tooze Froggatt died on 6 April 2015 at Royal Lancaster Infirmary following multiple missed opportunities to treat her high risk of venous thromboembolism. Concerns included failures in the Duty of Candour, inadequate staff training, potentially contradictory pharmacy guidance, and failure to raise known risk factors with consultants.
Circle Health Group Limited
On 27 September 2015, Peter William Richardson was working beneath a car on a two-post vehicle lift when the car became dislodged and fell onto him, causing fatal head injuries. The substantive concerns included the absence of formal guidance on safe tolerances and torque levels for safety-critical lift components, inadequate recording and training arrangements, and the practice of placing foreign objects between lift pads and vehicles to provide clearance.
Department for Work and PensionsHealth and Safety ExecutiveHsb Engineering Insurance Services LimitedLiftmaster LimitedRecipient name withheldThe Garage Equipment Association LimitedThe Safety Assessment FederationWest End Garage (Woking)
Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying patient.
University Hospitals Sussex NHS Foundation Trust
Carole Rita Lovett, a patient under Section 3 of the Mental Health Act 1983, was transferred to Northwick Park Hospital after becoming unwell and developing myocarditis associated with Clozapine medication. She deteriorated in the Acute Assessment Unit, was found unresponsive, resuscitated and transferred to Critical Care, where she died; concerns included staff competence and training in use of the NEWS system, communication, responses to monitoring alarms and consideration of alternative monitoring.
North Middlesex University Hospital
Lee James Nauman died after losing control of his motorcycle on Lee Lane and colliding with an oncoming vehicle, sustaining fatal head injuries. Evidence at the inquest identified a crumbling road edge, a pothole and leaf and soil debris across the road; although these were not shown to have caused the loss of control, a contributory effect could not be discounted. The concern was to review the road conditions and consider whether remedial action was appropriate.
Bradford City Council
Jack was a 17-year-old boy who developed a drug-related psychotic episode after taking cannabis and ecstasy, was detained by police and taken to hospital, and was discharged after assessment. His condition deteriorated after discharge; he later entered a river while being pursued by police and drowned. The principal concern was that the hospital did not communicate to his family the expected recovery, warning signs of recurrence, or when and how to seek urgent professional help.
East London NHS Foundation TrustAccount
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