6,433 reports
Information drawn from published reports and official responses.
Peter John Buckle was injured at work when a post propping open a trailer tailgate slipped, causing the tailgate to fall. He was airlifted to Addenbrooke's Hospital and died later that day from his injuries. Concerns included the failure to reassess the risks when the original work method became unavailable and an apparent lack of a health and safety culture at ground level.
Wayland Farms Limited
On 26 January 2015, Jacqueline Williams was taken to Royal Blackburn Hospital and assessed as being at moderate risk of self-harm, but a referral to the Mental Health Liaison Team was not accepted because of a communication breakdown. She subsequently hanged herself in an emergency department cubicle; concerns related to referral errors and systems that did not make missed or unaccepted referrals readily identifiable and rectifiable.
East Lancashire Hospitals NHS TrustLancashire & South Cumbria NHS Foundation Trust
Connor Sparrowhawk died on 4 July 2013 at STATT after drowning following an epileptic seizure while in the bath; the jury found that neglect contributed. The report raises concerns about whether sight or sound observations during bathing can effectively prevent drowning in patients with epilepsy, and whether RIO adequately captures and makes accessible patients’ epilepsy histories.
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Steven David Jackson attended Southend Hospital on 5 March 2014, was later taken there by ambulance after collapsing, and died at 14:26. The inquest recorded acute epiglottitis as the cause of death and identified very serious failings in the care provided by ambulance staff. Concerns also included an out-of-hours general practitioner’s apparently outdated knowledge of epiglottitis in adults.
Bevan Brittan LLPEast of England Ambulance Service NHS TrustGeneral Medical CouncilIrwin Mitchell LLPSouthend University HospitalWeightmans LLP
Jean Dorothy Gillespie was residing in a care home for respite care when her prescribed Pyridostigmine ran out, with the last dose administered on 25 April 2015. She developed symptoms attributable to myasthenia gravis, was taken to hospital, and died on 8 May 2015. The report raised concerns that care staff did not know about her condition or the urgency of replacing the medication, and that care home records did not document the condition, its symptoms, or the medication's purpose.
Alexandra Court - Cleveleys
Marie Quinn fell at home on 20 May 2015, sustained a fractured right neck of femur, underwent surgery, and died in hospital on 13 July 2015 after becoming unwell. The report identified concerns about sub-optimal deep venous thrombosis prophylaxis and medication management at Richmond House Nursing Home, including inaccurate instructions and unaccounted-for excess medication.
Hc-One Limited
Richard Scott Green was found hanged in his cell at Haverigg Prison on 9 May 2014, using a ligature made from a torn bed sheet. The jury found that bullying and debt had contributed to his death but was not satisfied that he intended to kill himself. The report raised concerns that his documented history of self-harm and apparent suicide attempts was not recognised or acted upon by prison medical professionals, with missed opportunities to assess and manage the risk he presented.
HM Prison and Probation ServiceMinistry of Justice
Dennis Peter Stark, who was detained at a rehabilitation unit, was found unresponsive in his second-floor bedroom on 27 May 2014 and later died after developing pneumonia and hypoxic brain injury. The report raised concerns that the absence of a lift and the difficulty of removing a person of his size from the second floor could delay emergency treatment and pose a risk to future patients requiring urgent medical attention.
Cygnet Newton House
Mary Catherine Bloom, who had dementia and reduced oral intake, was admitted with probable left-leg ischaemia and died in hospital on 4 February 2014. Concerns included failures to record her weight, consult haematology, obtain baseline and follow-up blood tests, and make the heparin administration guidance sufficiently visible. There was also no discussion with her next of kin before a DNAR order was placed.
Barking, Havering and Redbridge University Hospitals NHS Trust
Hilda Haughton was admitted to hospital with pneumonia and an acute exacerbation of COPD, and was injured when a fire door was electronically released during a power failure and struck her. The concerns included a subsequent fall from her bed when cot sides had not been raised, alleged lack of candour by hospital staff, and whether the response to the speed and power of electronically released fire doors was adequate.
Department of Health and Social CareTameside and Glossop Integrated Care NHS Foundation Trust
Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.
Farnham Medical CentreNational Institute for Health and Care ExcellenceNHS EnglandNHS North East and North Cumbria Integrated Care BoardSouth Tyneside and Sunderland NHS Foundation Trustthe Newcastle Upon Tyne Hospitals NHS Foundation Trust
Florence Margaret Lowe, aged 85, died from multiple chest injuries after being struck by a vehicle while attempting to cross the A519 Clayton Road on 18 November 2014. The substantive concerns related to the road’s 60 mph statutory limit despite nearby residential properties and busy facilities, and the lack of a pedestrian crossing on the south side of a nearby roundabout.
Staffordshire County Council
Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.
G4SHM Prison and Probation ServiceNational Offender Management Service Equality, Rights and Decency Group
Christopher John Smith died instantaneously after jumping from Barton Bridge on 15 July 2015. The principal concern was a 12-minute delay in contacting the ambulance service, caused by a communication breakdown about which service was responsible for making the call, although this did not affect the outcome in this case.
Greater Manchester Police
Ms. Scarlett Jukes was thrown from a horse during a trail hunting event after the horse lost its footing, and her head struck the road after her riding hat came off. She suffered a severe traumatic head injury, underwent surgery, and died in hospital on 14 February 2015. The principal concerns were that participants and hunt staff were not required to wear protective headgear complying with recognised safety standards, and that hunt staff could choose to wear non-compliant traditional hunt caps.
Health and Safety ExecutiveMasters of Foxhounds AssociationPartner of the deceased
Mr. George Hines, who lived in sheltered accommodation, died from carbon monoxide toxicity following a fire at his home on 23 October 2014. The concerns included an unconnected bedroom pull-cord, lack of regular inspection and maintenance of alarm and smoke-detector systems, smoke detection that did not alert the emergency control room or communal areas, and resident fire instructions that prioritised pulling the cord over calling 999.
Bristol City Council
On 15 November 2014, a vehicle carrying Bartosz Bortniczak, Blake Cairns, Jordanna Goodwin, Arapad Kore and Megan Storey collided with an oncoming vehicle after entering a bend on the A630 at about 73 mph. All five occupants suffered fatal injuries. The report raised concern that the 60 mph speed restriction before and through the bend contributed to an ongoing risk of further deaths, given the history of incidents on that stretch of road.
City of Doncaster Council
Charlotte Emily Bevan, who had schizophrenia and an undiagnosed psychotic relapse following childbirth, left hospital with her four-day-old daughter Zaani and went to the Avon Gorge cliff top; both died from injuries. The inquest identified failures including the absence of multidisciplinary care planning, insufficient psychiatric involvement, and failures to diagnose and manage Charlotte’s relapse.
Avon and Wiltshire Mental Health Partnership NHS Trust
Barry Thraves, who had schizoaffective disorder and lived alone, took his own life after a relapse in May 2015; the time of death was unknown and his body was discovered on 29 May 2015. The report identified concerns about delayed psychiatric follow-up, lack of community mental-health support, inadequate risk consideration, and poor communication between services and Barry’s family and GP.
Leicester City CouncilLeicestershire Partnership NHS Trust
Allan Richard Beasley, who had vascular dementia, was admitted to a care home after he could no longer manage at home and experienced multiple falls. Following a further fall, he was diagnosed with cervical spine fractures, developed a chest infection, deteriorated and died. Concerns included inadequate falls-risk assessment, failures to record and escalate falls, inaccurate observation records, and incomplete monitoring and review.
Sunrise Care HomeAccount
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