6,433 reports
Information drawn from published reports and official responses.
Noel Williams fell and sustained a fracture of the neck of the right femur on 2 December 2010, which led to her death despite surgical repair. The inquest identified a failure to communicate recent haemoglobin test results to the anaesthetist and surgeon, potentially affecting assessment of fitness for surgery and treatment planning.
South Tees Hospitals NHS Foundation Trust
Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.
HM Prison and Probation ServiceHM Prison ServiceNorth Tees and Hartlepool NHS Foundation TrustTees, Esk and Wear Valleys NHS Foundation Trust
Wendy Bernadine BROWN had suffered from depression and had been the full-time carer of her severely disabled granddaughter. After a period of approximately 18 months without support or respite, Wendy died by hanging at her home during the late evening of 27 August into the morning of 28 August 2013. The concerns included delays and gaps in adult social care support, the adequacy of signposting and funding information, the timeliness of processing care applications, and the availability of appeal routes.
Swindon Borough Council
Lorna Frances Cullen died after falling from the upper level of a multi-storey car park on 23 December 2012, following attendance at an emergency department where she left before receiving a mental health assessment. The principal concern was the long-term adequacy of liaison psychiatry nurse staffing in hospital emergency departments, as patients requiring assessment were regularly waiting well beyond the standard two-hour period.
NHS Kent and Medway Integrated Care BoardNHS Medway Clinical Commissioning GroupNHS Swale Clinical Commissioning Group
Saleh Ali Dalie was hit by a van while crossing Kyotts Lake Road to attend his local mosque and later died from his injuries in hospital. The report raised concerns about the safety of the residential road, noting several incidents and two fatalities, and that requested road-calming, parking restrictions and crossing measures had not been introduced.
Birmingham City CouncilWest Midlands Police
Christopher Shapley was arrested on 17 September 2013, remanded in custody, and taken to HMP Cardiff after treatment at hospital for alcohol withdrawal symptoms and fitting. He was placed alone in a cell and found hanged during morning checks on 20 September 2013. Concerns included incomplete transfer of information about his hospital treatment and self-harm risks, insufficient assessment of risk factors, inadequate efforts to arrange a shared cell, and inadequate handover and night-time observations.
Cardiff PrisonHome Office
Derrick George Rivers, who had been admitted to full-time care after becoming frail and falling, was mistakenly given a 150mg dose of Clozapine intended for another resident. He was admitted to hospital with altered consciousness and confusion, initially improved, then deteriorated and died on 11 July 2013; the inquest found that he died from natural causes to which the Clozapine may have contributed. Concerns included inadequate medication policies and administration protocols, insufficient auditing and inspection, and incomplete implementation of recommendations intended to reduce the risk of medication errors.
Care Quality CommissionPassmonds House Care HomeRochdale Borough Council
Afifa Qaisar was admitted to Tameside General Hospital on 23 June 2013 with collapse and confusion, initially diagnosed as meningitis with sepsis, and died at 20.30 hours the same day. Concerns included uncertainty about whether drugs recorded as given had actually been administered, unavailability of required resuscitation equipment, failure to notify the RMO, delays in platelet and Hb support, an inappropriate response to an apparently non-running saline infusion, and failure to commence fluid balance monitoring or catheterisation.
Tameside and Glossop Integrated Care NHS Foundation Trust
On 18 May 2013, Craig Marren was riding an off-road motorcycle on Tyersal Lane, Bradford, when he collided with a motorcar travelling in the opposite direction. The concern was that trees and foliage obstructed the sight line around a blind left-hand bend for approaching vehicles.
Recipient name withheldTyersal Farm
Andrei Ciprian Matei was born following an emergency caesarean section and died aged 65 minutes after suffering progressive intrapartum hypoxia. The report identified concerns about the timing and method of delivery, failure to respond to abnormal fetal monitoring and obtain a further fetal blood sample, and the lack of national guidance on interpreters during labour and in theatre.
Department of Health and Social Care
Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.
Partnerships in Care LimitedSouth London and Maudsley NHS Foundation Trust
Nellie Travis was admitted to hospital for anaemia and fell while rising from her bed on 2 October 2013, breaking her hip. The report raised concerns that the hospital’s Falls Risk Assessment tool was completed by a non-Trust bank nurse, was highly subjective, and needed to be replaced by a more objective assessment tool.
Tameside and Glossop Integrated Care NHS Foundation Trust
Mr John Patrick Fox, aged 93, sustained a fractured neck of femur in an accidental fall at home and died on 1 January 2014 after treatment for the fracture and underlying heart problems. The report raised concern that reduced physiotherapy services on bank holidays and weekends could increase the risk of post-operative complications in vulnerable patients.
St George's Hospital
Barry Joseph Dillon was detained under the Mental Health Act at Burnley General Hospital and transferred to Royal Blackburn Hospital following seizures, where he suffered aspiration pneumonias and died on 13 November 2013. The report identified insufficient Speech and Language Therapy resources and a delay in responding to his swallow-assessment referral, with patients considered at risk of aspiration pneumonia that may prove fatal.
East Lancashire Hospitals NHS Trust
Neil James Carter took his own life on 20 November 2012 by jumping in front of a train while he was an inpatient at Priory Hospital Roehampton. The report identified repeated failures to perform basic nursing observations, inadequate staffing and skill mix, poor ward layout and discipline, management failures, and deliberate falsification of the nursing record. The inquest concluded that these failures led to missed opportunities to realise he was missing, search for him early, and offer life-saving interventions.
Care Quality CommissionPriory Group
Ms. Kimberley Parsons, who had a history of mental health problems and suicidal ideation, was found hanging in her room at Sycamore Ward on 16 March 2014 after repeated self-harm during her admission. She was transferred to intensive care but died from her injuries on 24 March 2014. Concerns included serious patient-safety deficiencies at Hillview Lodge, including incomplete observation records, shortcomings in resuscitation equipment and training, and deficiencies in care planning and pathways for patients with emotionally unstable personality disorder.
Avon and Wiltshire Mental Health Partnership NHS TrustCare Quality CommissionMother of the deceasedMother of the deceased
Kathleen Ethel Border, a pedestrian, was struck by a reversing delivery vehicle and sustained numerous fractures before her condition deteriorated and she died in hospital. The substantive concerns were that the vehicle was reversing from a car parking bay rather than using a designated delivery area, and that signage for the parking areas was not prominent or clear.
Northwood Square
On 16 July 2013, Ryan James Pettengell entered a lake at a disused quarry and drowned while attempting to swim to a nearby island. Concerns included continued public access, absent or damaged swimming-prohibition signage, and no action having been taken six months after safety recommendations.
Borough Council of King's Lynn and West NorfolkNorfolk ConstabularyNorfolk County CouncilSibelco UK Limited
Anne-Marie Katherine Element, a corporal, died by suicide outside her accommodation at Kiwi Barracks in Wiltshire on or around 9 October 2011. The inquest identified contributing matters including the lingering mental effects of an alleged rape, workplace bullying, work-related despair, and the effects of a relationship break-up. Concerns included inadequate guidance for responding to an alleged rape by one soldier against another and insufficient training and follow-up training for implementing Suicide Vulnerability Risk Assessments.
Ministry of DefenceRecipient name withheld
Lee Sean MACPHERSON was found dead in a safer custody cell at HMP Wormwood Scrubs on 17 October 2012, after being remanded into custody the previous afternoon. Concerns related to incomplete and inconsistently transferred police risk-assessment and escort handover documentation between the police, SERCO and prison staff.
HM Prison and Probation ServiceMetropolitan Police ServiceSerco Group plcWormwood Scrubs PrisonAccount
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