6,433 reports
Information drawn from published reports and official responses.
Brian Anthony Gillard, who had asbestosis and required ambulatory oxygen, died at Royal Bolton Hospital on 20 March 2015 after collapsing and suffering a cardiac arrest while using the toilet. The concerns included a lack of handover about his oxygen requirement, transfer to the toilet without oxygen, and leaving him unsupervised in a toilet without an emergency pull-cord.
Royal Bolton Hospital
Alec James Mathias developed drug-induced jaundice after receiving Flucloxacillin in 2008, but this reaction was not communicated to his GP or highlighted in the hospital records. He was prescribed Flucloxacillin again in 2014 for an infected finger and died after developing Flucloxacillin-induced cholestatic liver injury and liver failure. The principal concerns were failures to send discharge information to the GP and to record the drug sensitivity in the hospital notes.
Royal Devon University Healthcare NHS Foundation Trust
Summer Leigh Robertson and Alice Rebecca Barnett died in the sea off Woody Cape, South Africa, on 4 December 2014 after entering the water and being caught in a rip current. The principal concerns were that the people entering the sea and Lattitude were unaware of the rip-current risk, and that there was no specific risk assessment or adequate warning about rip currents.
Lattitude Global Volunteering
Richard Anthony Marshall Turner was struck by a reversing Mercedes Sprinter van in Cherry Tree Square on 13 November 2014 and died later that day after collapsing while being assisted home. The report raised concerns about significant blind spots behind light goods vehicles and the absence of reversing aids, noting evidence that a rear-facing camera system could have prevented the fatality and that similar incidents may be underreported.
Department for Transport
Lottie Reid, aged 95, was readmitted to hospital with haematemesis and melaena and died on 29 January 2015. The inquest concluded that she died from bleeding duodenal ulcers on a background of other significant natural disease, with her death probably accelerated by bleeding exacerbated by anticoagulant therapy. Concerns were raised that the medication administration chart at the intermediate care centre did not mirror the hospital discharge documentation and that there was no clear protocol for checking discrepancies, particularly at weekends.
Good Hope HospitalUniversity Hospitals Birmingham NHS Foundation Trust
Alice Mead was known to mental health services and was receiving care under the Care Programme Approach. The inquest concluded that she took her own life on 20 January 2015. Concerns included the failure to replace her care co-ordinator, inadequate response to her requests for a medication review, delayed action following urgent concerns, and a lack of documented review of her risk assessment.
Sussex Partnership NHS Foundation Trust
Mr. Anthony Geerts sustained a fractured neck of femur, underwent surgery and was transferred for rehabilitation before being moved to a nursing home. He later returned to hospital with hospital-acquired pneumonia and a possible urinary tract infection, and died on 21 November 2014. The concerns included inadequate rehabilitation, incomplete records and monitoring, poor communication and discharge planning, and failures in managing his continence, fluid restriction and possible chest infection; the inquest concluded that neglect at Princess Royal Hospital contributed to his death.
Princess Royal Hospital, Haywards HeathUniversity Hospitals Sussex NHS Foundation Trust
Steven Curtis fell from a telescopic ladder while inspecting a roof and was admitted to hospital, where he underwent treatment before complications and subsequent death. The principal concern was the safety and origin of the ladder, including whether it was one of approximately 43,000 N19KJ ladders sold by Maplin before withdrawal and whether further investigation could establish its source.
Derbyshire County Council
Kathleen Eaton fell in her bedroom on 26 January 2015 and was lifted using a blow-up ‘hoist’ before being left awaiting her regular carers. She was later taken to hospital, where she was found to have damage to and around her brain; the inquest recorded subdural and subarachnoid haemorrhage, recurrent falls, and other medical conditions. Concerns included inadequate training and procedures for assessing head injuries and uncertainty about when to summon an ambulance, as well as the distance between the care service base and the deceased’s home.
Cheshire Peaks & Plains Housing Trust Limited
Kian Singh GILL, aged 15, died at the scene of a road traffic accident while cycling into the path of a car at a junction in Gilmorton, Leicestershire, on 5 May 2015. Concerns included overgrown hedgerows obscuring visibility, a lack of junction signage, and the national speed limit remaining in place despite the junction.
Leicestershire County Council
Jan McLean was arrested at a flat in Guildford where drugs were being used, became unwell in a police van, and died in hospital on 14 August 2013. The inquest found drug-related death from cocaine, amphetamine and butylone toxicity, after he swallowed an unknown quantity of unknown drugs while in police custody. The principal concern was that police officers may not have received adequate training to fully interrogate warning markers on the Police National Computer.
Surrey Police
Elizabeth Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated between agencies.
Avon and Wiltshire Mental Health Partnership NHS TrustRoyal United Hospitals Bath NHS Foundation TrustWiltshire Council
Christopher Tandy died after his bicycle veered across London Bridge and he was struck by a southbound motor car. Concerns included inadequate prominent signage for the 20 mph speed limit and the lack of a separate cycle lane on the bridge.
Transport for London
Benjamin John William Bartle, aged 71, died on 26 August 2014 after complications following elective laparoscopic colon surgery, including bowel obstruction, infection and an acute cardiac event. His family raised concerns about staffing levels, delayed interventions, nutritional support, pain control and communication from nursing staff.
Recipient name withheld
Andrew John Nickolls was discharged from Torbay Hospital on 12 September 2013 and was later found by police officers in his flat after concerns were raised. The report identified concerns about information sharing and continuity of primary care for a vulnerable adult who may have been neglecting himself; the medical cause of death was unascertained and the inquest conclusion was open.
Devon County CouncilNHS Devon Integrated Care BoardNHS South Devon and Torbay Clinical Commissioning GroupPlymouth City CouncilTorbay Council
Andre Roderick Stewart MICKLEY used heroin and cocaine on 17 February 2015, then collapsed with a massive subarachnoid haemorrhage and died on 23 February 2015 despite neurosurgical intervention. The report raised concern about potentially adverse interactions between cocaine and SSRI drugs, and that prescribing information may not prompt consideration of substance misuse or caution about interactions with drugs of misuse.
Medicines and Healthcare products Regulatory Agency
Mr. Isaac Bahar was admitted to hospital after a fall caused fractured ribs and a traumatic pneumothorax. Despite known stage four chronic kidney disease, he was prescribed and given codeine in contravention of national and local guidance, and later developed opioid toxicity and died. The inquest found the prescribing error was one of the causes of his death; chronic obstructive pulmonary disease was also deemed a contributory factor.
University Hospitals Sussex NHS Foundation Trust
Marie Gretta Harding, who had chronic obstructive pulmonary disease, was admitted with breathlessness and a left-sided pneumothorax requiring chest drains. A chest drain inserted on 12 October 2014 more likely than not penetrated her left lung, after which she deteriorated and died on 14 October 2014. The inquest identified a lack of Trust guidelines and up-to-date training for chest drain insertion, and unawareness of the availability of an on-call interventional radiologist.
NHS England
Sidney Barnett, a care home resident whose health was gradually declining, was found inadequately clothed and cared for, struggling to eat alone and unattended, and later died in hospital from pneumonia on 3 January 2015. The principal concerns were inadequate observation and general welfare, unclear rules about open windows, and inadequate and insufficiently structured safeguarding investigations.
Berrycroft ManorStockport Borough Council
Nancy Hughes, who had Alzheimer’s disease and was receiving Risperidone, fell at a care home and later suffered a further unwitnessed fall in hospital before dying on 3 January 2014. The concerns were that her medication was not reviewed as required and that there was insufficient cohesion between mental health and medical treatment, potentially affecting care for vulnerable patients.
Betsi Cadwaladr University LHBYsbyty GwyneddAccount
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