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Lewis Rhys Thomas Petryszyn · Prevention of Future Deaths report View report

31 Jul 2025 South Wales Central P. Morgan

Lewis Rhys Thomas Petryszyn died in his shared cell at HMP Parc on 15 April 2022 after inhaling synthetic cannabinoids without intending to end his life. The principal concern was the absence of specified timeframes for intervention, ongoing support and case-load allocation for prisoners at risk of substance misuse, creating a risk of delayed support and intervention.

Joanne Louise STONES · Prevention of Future Deaths report View report

30 Jul 2025 North Yorkshire and York G. Kane

Joanne Louise Stones, who had Anti-Phospholipid Syndrome and Addison’s Disease, was admitted with abdominal pain and diagnosed with acute cholecystitis with gallstones. Her condition deteriorated and she died in intensive care on 17 September 2023. Concerns included delays in prioritisation, treatment with fluids and antibiotics, recognition of her Addison’s Disease, and consideration of her underlying conditions in her treatment plan.

Joan WHITWORTH · Prevention of Future Deaths report View report

29 Jul 2025 Northumberland A. Hetherington

Joan Whitworth, a resident of Oaks Care Home with advanced dementia and a DNACPR order, died there on 3 March 2023 after choking caused by massive aspiration. Concerns included the adequacy of the speech and language assessment, staff training and induction, delayed intervention when she showed signs of choking, and food being prepared contrary to her diet plan.

Leslie Thompson · Prevention of Future Deaths report View report

29 Jul 2025 Manchester South C. Morris

Leslie Thompson died at Tameside General Hospital on 20 February 2025 following a fall in hospital, which caused a head injury against a background of chronic subdural haematoma and multiple complex health problems. The concern was that he had been assessed as medically fit for discharge but was awaiting physiotherapy, with limited evening and weekend physiotherapy services potentially causing discharge delays and exposing patients to risks associated with remaining in an acute hospital environment.

Azroy Dawes-Clarke · Prevention of Future Deaths report View report

29 Jul 2025 Kent and Medway I. Brownhill

Azroy Dawes-Clarke died in hospital on 10 November 2021 after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and treatment. The substantive concerns included inadequate communication and healthcare involvement, disproportionate and prolonged restraint, delays in recognising the arrest and starting CPR, unsuitable ligature-resistant materials, and gaps in staff training on ACCT procedures, first aid, basic life support, and the legal framework for medical emergencies.

Azroy Dawes-Clarke · Prevention of Future Deaths report View report

29 Jul 2025 Kent and Medway I. Brownhill

Azroy Dawes-Clarke died in hospital on 10 November 2021 after an episode of self-strangulation in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrest during conveyance to hospital. The substantive concerns included disproportionate and prolonged restraint, delays in obtaining healthcare assistance and starting CPR, inadequate communication, and uncertainty about responsibility for acute medical emergencies in custodial settings.

Thomas Oliver HILL · Prevention of Future Deaths report View report

29 Jul 2025 Hampshire, Portsmouth and Southampton J. Pegg

Thomas Oliver HILL died on 28 October 2015 after inhaling a fatal quantity of carbon monoxide from a flue-less liquefied petroleum gas cabinet heater while preparing for a bath. The report identified concerns about the heater being used in an undersized room, the absence of a visible external warning label, and it not being obvious to all users that adequate room dimensions were required for safe use.

Azroy Dawes-Clarke · Prevention of Future Deaths report View report

29 Jul 2025 Kent and Medway I. Brownhill

Azroy Dawes-Clarke died in hospital after self-ligaturing in HMP Elmley, followed by restraint, cardiac and respiratory arrest, and further arrests during conveyance and hospital treatment. The principal concerns included confused communication and unclear command structures among prison staff, healthcare professionals and paramedics, disproportionate and prolonged restraint, delays in obtaining medical assistance and starting CPR, and inadequate consideration of his breathing and positioning.

Gareth Wynne Tatchell · Prevention of Future Deaths report View report

28 Jul 2025 Swansea and Neath Port Talbot A. Gruffydd

Gareth Wynne Tatchell died in hospital on 9 April 2024 from pneumonia, with squamous cell carcinoma contributing to his death. The report identified delays in diagnostic and staging scans and in providing treatment, with the inquest concluding that the delay more than minimally contributed to his death. It also raised concern that ongoing delays in staging scans were affecting survivability and prognoses by making treatable cancers irreversible.

Kaine Regan FLETCHER · Prevention of Future Deaths report View report

25 Jul 2025 South Yorkshire (Western) A. Pountney

Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.

Sheldon Lawrence Jeans · Prevention of Future Deaths report View report

25 Jul 2025 Dorset R. Griffin

On 13 November 2022, Sheldon Lawrence Jeans, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell. The inquest recorded that he died following an idiosyncratic response to alcoholic intoxication and medicinal drugs, combined with partial postural asphyxia. The report raised concerns about the lack of guidance on illicitly brewed alcohol and the governance, storage and return of medication held by prisoners.

Michael Pugh · Prevention of Future Deaths report View report

25 Jul 2025 Kent and Medway P. Harding

Michael Pugh was found dead in his prison cell on 29 June 2024 while subject to an ACCT. No observations were carried out between 07.22 and 09.57 on the day he was discovered, and the record was completed retrospectively; concerns also included new officers’ incomplete understanding of the ACCT observation and recording requirements.

Robert Grey English · Prevention of Future Deaths report View report

25 Jul 2025 North London A. Walker

Robert Grey English, aged 32, was electrocuted after entering a railway track at night, and was subsequently run over by a train searching the track. The report identifies concerns about failures to follow the process for switching the rail power back on and about inadequate lighting and equipment for locating a person on the railway at night.

Samantha Kate YOUNG · Prevention of Future Deaths report View report

25 Jul 2025 Hampshire, Portsmouth and Southampton H. Charles

Samantha Young died at home on 20 November 2023 after intentionally taking her own life by hanging. She had a history of mental health difficulties, previous suicide attempts, and worsening condition amid significant stress. The concerns included insufficient training for agency staff in risk assessments and inadequate contact and communication with patients’ families and friends.

Evelyn Veronica Chancellor · Prevention of Future Deaths report View report

25 Jul 2025 North London A. Walker

Evelyn Veronica Chancellor fell from her chair in a supervised care-home lounge when the supervising person turned away to collect cups. She was taken to hospital, discharged without a CT scan, later developed symptoms of serious head injury, and died the next day from its consequences. The report raises a concern about having sufficient staff to ensure residents’ safety when staff are distracted by other activities.

Jordan Michael BABB · Prevention of Future Deaths report View report

25 Jul 2025 Milton Keynes T. Osborne

Jordan Michael BABB had chest pain and attended an urgent care centre on 13 September 2024, where he was assessed and discharged without investigation for a possible pulmonary embolism. He collapsed on 16 September 2024 and died of a pulmonary embolism. Concerns included failure to escalate abnormal observations, lack of a structured pulmonary embolism risk assessment, unclear use of clinical decision tools, and a risk of similar failings recurring.

James Alexander SCOTT · Prevention of Future Deaths report View report

24 Jul 2025 Hampshire, Portsmouth and Southampton R. Rhodes-Kemp

James Alexander Scott died at the scene after his Vauxhall Corsa lost control on standing water during a road traffic collision on the A33 on 5 July 2024. The standing water was identified as a contributory factor, with concerns about the known flood risk, blocked drainage gullies, maintenance frequency, and the presence of only a temporary warning sign.

Isaac Arlan Ingle-Gillis · Prevention of Future Deaths report View report

22 Jul 2025 Gwent C. Saunders

Isaac Arlan Ingle-Gillis, who was suffering from depression, died at the Ty Hotel in Magor on 9 February 2025 from the effects of an intentional overdose. The concern was that the Crisis Resolution and Home Treatment Team did not have access to GP records, and that information recorded by the GP might be vital in future assessments.

Robyn Anne Chambers · Prevention of Future Deaths report View report

22 Jul 2025 Gwent C. Saunders

Robyn Anne Chambers was born prematurely at 23 weeks gestation and developed significant physical and neurological problems, including ongoing respiratory problems. She developed a chest infection on 26/10/2024 and died on 2/11/2024 at Ty Hafan Hospice. The report noted concerns about the estimated eight-hour ambulance response and delays in releasing ambulances from hospital emergency departments, although these were stated not to have affected Robyn’s care or outcome.

Madeline Reding · Prevention of Future Deaths report View report

21 Jul 2025 East London G. Irvine

Madeline Reding, a 79-year-old nursing-home resident with advanced vascular dementia, became unwell after lunch on 17 May 2024, regurgitated food, developed an upper-airway obstruction and respiratory arrest, and died that afternoon. The inquest identified delayed and disorganised staff responses, including a failure to sound the emergency alarm or make an immediate 999 call, delayed CPR, and ineffective first aid.