6,433 reports
Information drawn from published reports and official responses.
Bradley Hooper died after coming off his motorbike during a motocross practice session and being struck by another motorbike at a jump. Concerns included a marshal using a mobile phone and facing away from the riders, and the allocation of an inexperienced 16-year-old marshal to the position.
MC FederationPortsmouth Motocross Club
Paul Coxon died after consuming alcohol and crossing the A189 Redheugh Bridge south-bound slip road, where he was struck by an oncoming vehicle and sustained a traumatic brain injury. The concerns identified were inadequate and unilluminated signage for safe pedestrian crossing points, and whether the 50-mile-per-hour speed limit was appropriate given limited driver visibility and reaction time.
Gateshead Borough Council
Luke Myers was found hanging from a bunk-bed in his prison cell on 4 February 2013 and was pronounced dead after resuscitation attempts were unsuccessful. The report raised concerns about the miscalculation of his sentence, which the inquest jury found was a likely factor in his death, and about the length of time since prison discipline staff had received first-aid training.
HM Prison and Probation Service
Craig Roberts, James Dunsby and Edward Maher were reserve soldiers taking part in a specialist-unit selection test march in the Brecon Beacons in July 2013. The report identifies concerns about heat-illness guidance, training and risk assessment, communication of weather information, medical planning, emergency response, tracking of slow or static candidates, and the failure to implement lessons from previous incidents.
Ministry of Defence
Mr. Masoud Ghaderi, who had severe depression and was an informal inpatient at Lime Unit, was found hanging by a belt from a bathroom door on 10 April 2014 and died on 12 April 2014 after life support was withdrawn. The report identified concerns about inconsistent records of engagement, the absence of overarching responsibility for reviewing risk assessments, and ward-round reliance on brief nursing summaries that could result in errors or omissions.
Avon and Wiltshire Mental Health Partnership NHS TrustCare Quality CommissionWidow of the deceased
Adam Lee Connelly was found deceased beside railway tracks near footbridge 57 between Walkden and Atherton after sustaining injuries consistent with being struck by a train. The principal concern was that the approximately five-foot walls of the steps leading to the footbridge could allow a person of reasonable athletic ability to access the railway track, creating a risk of future fatalities.
British Transport PoliceNetwork Rail
Arthur Lindsay Fry was diagnosed with a glioblastoma and underwent tumour debulking surgery on 14 April 2014. He developed severe neurological complications, including a subdural haematoma and extensive brain infarction, and died on 17 April 2014. The principal concern was a breakdown in communication that led to a planned MRI scan not being carried out, which may have impacted his care.
Royal Stoke University Hospital
Isabella Rosa Drew was a 29-day-old infant who contracted whooping cough in early September 2014 and died on 9 September 2014; the recorded causes of death were severe acute pneumonia and Bordetella pertussis. The report raised concerns that pregnant women were not consistently offered whooping cough vaccination, and that national guidance did not provide sufficient detail on local procedures, auditing, follow-up, and communication between antenatal healthcare providers.
Department of Health and Social CareNHS England
Stanley Oliver, aged 85, died at Salford Royal Hospital after being admitted with abdominal pain and a perforated gall bladder. A drainage procedure was not performed over the weekend because there was no out-of-hours rota for GI Radiologists, and the report raised concerns about the availability, communication arrangements and training needed for urgent procedures of this kind.
Department of Health and Social CareNorthern Care Alliance NHS Foundation Trust
John Christopher Lloyd died at UHW on 27 February 2015 following a second accidental morphine overdose. He had chronic pain after a serious foot injury and had previously been admitted after an overdose. The principal concern was that notification of his first hospital admission was not sent to his GP, and that failures in notifying GPs occurred frequently, potentially affecting continuity of treatment.
University Hospital of Wales
Joyce Hartford, described as a frail woman with pre-existing co-morbidities, suffered a fall causing a fracture that required surgery. Her health deteriorated and she died at home on 23 January 2015; the medical cause of death included pneumonia, an operated right neck of femur osteoporotic fracture, and caecal carcinoma. The inquest identified incomplete or inaccurate nursing tools, assessments, records, associated documentation, and the nursing discharge summary, with concerns that record-keeping standards had not materially improved.
Pennine Acute Hospitals NHS Trust
Karen O’Brien suffered from chronic pain and depression and had disclosed thoughts of self-harm. After a mental health referral, SEPT determined that a face-to-face assessment was not required; she later jumped into the path of an underground train, and the inquest concluded that she killed herself, with multiple injuries as the medical cause of death. The principal concerns were the lack of further inquiry or face-to-face assessment and the basis on which SEPT overrode the GP’s request, including its interpretation of NICE guidance.
Essex Partnership University NHS Foundation TrustNational Institute for Health and Care Excellence
PAULS RICARDS KALNINS, who had a history of depression and had expressed suicidal thoughts, was found hanging in a shed after leaving a location where police had spoken to him. The principal concerns were that the Merlin database did not clearly display key risk information, was difficult to navigate, and that communications officers needed more familiarisation and refresher training.
Metropolitan Police Service
Emma Carpenter was treated as an outpatient by child and adolescent mental health services from February 2004 to November 2006 and died from multi-organ failure caused by severe anorexia nervosa. The report identified insufficient physical-health monitoring, lack of specialist paediatric or physician input, and delay in accessing effective inpatient treatment as concerns.
Department for EducationDepartment of Health and Social CareDoncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustNHS England
Thomas Farrell died after becoming unwell with a chest infection while resident at Springfield Care Home and being admitted to hospital, where he died on 16 July 2014. The principal concern was that the care home had not obtained a full medication record from his GP, resulting in several prescribed medicines not being administered; the report stated this omission did not cause or contribute to his death but posed a clear risk in other circumstances.
Springfield Care Home
Kenneth George Bailey, who had lung cancer and was dependent on oxygen at home, died after dropping a cigarette or ash onto a kitchen roll, causing a house fire and significant smoke inhalation. The report raised concerns about the limited opening hours of the local fire station, delays in emergency-service arrival, and the risk that unqualified members of the public might attempt rescues.
Greater Manchester Fire and Rescue Service
Viktoria Was died on 6 January 2013, aged 13, after being injured in a road traffic collision while travelling as a rear-seat passenger in a Volkswagen Polo. The concerns included insufficient regard for injured third parties at the scene, inadequate evidence that lessons had been learned from police pursuits, and insufficient refresher training for police officers.
Metropolitan Police Service
Douglas Birch was a serving prisoner at HMP Swaleside who was found dead in his cell on 15 May 2013, having died between 19:10 on 14 May and 07:10 on 15 May. The concerns were that officers did not elicit a response when unlocking his cell as required by PSI 75/2011, and that officers may not have received or read relevant Prison Service Orders and Instructions.
Swaleside Prison
Cameron William Laing, a soldier, was crushed between a military lorry and a 4-tonne trailer while attempting to reattach the trailer at Bracken Tor on 29 April 2014. The report raised concerns that soldiers did not understand how reconnecting the air line could release the trailer’s emergency brake, that alternative recovery methods were not taught, and that relevant training was not provided.
Ministry of Defence
Colin Moulton was discovered deceased on 14 February 2013 near the perimeter wall of the Irwell Unit at Fairfield General Hospital, after leaving the Accident and Emergency Department the previous day. Concerns included ineffective communication during handover, incorrect triage, failure to recognise confusion, and the absence of a formal capacity assessment or other documented measures when he attempted to leave. The inquest narrative stated that his death was contributed to by neglect.
Department of Health and Social CareFamily of the deceasedNorth West Ambulance Service NHS TrustWeightmans LLPAccount
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