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MARY MARGARET WHITLOCK · Prevention of Future Deaths report View report

17 Dec 2024 Essex S. Hayes

Mary Margaret Whitlock died at Broomfield Hospital on 23 August 2023 after sustaining cervical fractures in a fall and subsequently suffering aspiration following assisted feeding while experiencing swallowing difficulties. The report identified concerns about delayed provision of a recommended collar, inadequate planning and communication regarding swallowing and oral intake, medication administration despite recorded opioid allergies, understaffing, and the absence of discharge and safety-netting advice to her care home.

Anthony Binfield · Prevention of Future Deaths report View report

17 Dec 2024 Nottinghamshire L. Bower

Anthony Binfield died from ligature asphyxiation inside his cell at HMP Lowdham Grange on 6 March 2023. Prison staff delayed entering the cell for 11 minutes after finding the observation panel covered and receiving no response. The principal concerns were unsafe and policy-inconsistent management of covered cell observation panels, an embedded staff practice of delaying entry, and repeated notices failing to address the issue.

Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report View report

16 Dec 2024 West Sussex, Brighton and Hove P. Schofield

Matthew Zak Sheldrick (Matty), who identified as non-binary, attended A&E in crisis on 3 November 2022 following deteriorating mental health and intense suicidal thoughts. After being assessed under the Mental Health Act and not detained, Matty left the hospital and was found suspended by a ligature in the hospital grounds. The report identified concerns including the lack of suitable inpatient beds, the unsuitability of A&E for neurodivergent patients, gaps in service provision, and shortcomings in the mental health assessment and discharge care planning.

Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report View report

16 Dec 2024 West Sussex, Brighton and Hove P. Schofield

Matthew Zak Sheldrick (Matty), who identified as non-binary, had a history of mental health difficulties and was admitted to A&E in crisis on 3 November 2022 after a previous 26-day wait for a psychiatric bed. After being assessed under the Mental Health Act and not detained, Matty left hospital and was found hanging in the hospital grounds. Concerns included shortages and long waits for mental health beds, the unsuitability of A&E for neurodivergent patients, gaps in services and discharge planning, and shortcomings in the mental health assessment.

Anne Patricia Leake · Prevention of Future Deaths report View report

16 Dec 2024 Staffordshire and Stoke-on-Trent D. Ritchie

Anne Patricia Leake suffered cardiac arrest and arrhythmia, underwent heart valve surgery, and was released from hospital without the planned ICD being fitted. Three days later, she suffered a cardiac arrhythmia and died. The report identified concerns about hospital teams using inaccessible ward-based notes, the absence of a shared electronic records system, and continued reliance on manual transcription of treatment decisions.

Susan EVANS · Prevention of Future Deaths report View report

13 Dec 2024 Hampshire, Portsmouth and Southampton S. Olsen

Susan Evans underwent elective gastric bypass surgery on 11 July 2023, developed abdominal pain, was discharged without review by the specialist bariatric team or a senior doctor, and was later readmitted with abdominal sepsis from an anastomotic leak. She died at Queen Alexandra Hospital on 12 August 2023. The principal concern was that the hospital’s written and informal policies for specialist review and escalation of pain were not followed, which the inquest found contributed more than minimally to her death.

LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report View report

13 Dec 2024 Essex S. Hayes

Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.

Timothy Robert DE BOOS · Prevention of Future Deaths report View report

13 Dec 2024 Suffolk N. Parsley

Timothy Robert DE BOOS was declared deceased at his home in Ipswich on 6 February 2024 after a self-inflicted domestic fire, with the medical cause of death recorded as smoke inhalation and severe burns. The report raises concerns about the lack of available Mental Health Unit inpatient beds and about the admission process when the patient, family, and an experienced mental health professional considered voluntary admission necessary.

Jean LANGAN · Prevention of Future Deaths report View report

13 Dec 2024 Devon, Plymouth and Torbay I. Arrow

On 4 March 2022, Jean Langan fell and struck her head when the downwash from a landing helicopter affected her in a public car park at Derriford Hospital; she suffered a serious head injury and died shortly afterwards. The concerns identified included the safe landing of hospital helicopters without endangering people nearby, and the need for a real-time database of hospital helicopter landing sites and contact details for the relevant site managers.

Huw Irwin ERASMUS · Prevention of Future Deaths report View report

12 Dec 2024 Gwent C. Saunders

Huw Irwin Erasmus died at Aderyn Unit in Pontypool after consuming a large quantity of Yew leaves while detained under Section 3 of the Mental Health Act. Concerns were raised about the absence of documentary evidence of post-leave assessments, confusion among staff about assessment and documentation requirements, and the failure to identify and manage risks associated with ingesting Yew leaves.

James Robert Michael ALDERMAN · Prevention of Future Deaths report View report

12 Dec 2024 West London L. Brown

Jimmy was being breastfed in a baby carrier worn by his mother when he collapsed after five minutes. He died three days later in hospital from accidental suffocation after his airway was occluded while he was not held in a safe position. The report identified insufficient information and guidance for parents about safe positioning of young babies in carriers or slings, particularly when breastfeeding, and raised concerns about the need for industry safety standards.

Nonie Atshiki · Prevention of Future Deaths report View report

12 Dec 2024 Inner North London M. Hassell

Nonie Atshiki, aged 35, was found dead in the stairwell of the hostel where she lived shortly after 4am on 13 July 2024. Her medical cause of death was acute cardiac failure associated with cocaine use and long-term alcohol excess. The report raised concerns that the hostel’s night concierge had no first aid training from St Mungo’s, there was no defibrillator, and no cardiopulmonary resuscitation was attempted after her discovery.

Jean MULLEN · Prevention of Future Deaths report View report

12 Dec 2024 South Yorkshire (Eastern) N. Mundy

Jean Mullen, an 87-year-old woman, was found collapsed and unresponsive at the bottom of the stairs at home after her pendant alarm was triggered on 22 June 2024; the inquest concluded that her death was accidental, involving a fall from height, fracture of the neck and subdural haemorrhage. Concerns included the failure to provide a recommended grab rail, failure to escalate a fall in the shower or reassess her mobility and equipment needs, and incomplete recording of stair-related risks.

THOMAS ADRIAN BURROUGHS · Prevention of Future Deaths report View report

12 Dec 2024 Essex S. Hayes

Thomas Burroughs was a 35-year-old learning disabled man with cerebral palsy, scoliosis, pressure ulcers and PEG feeding who died in hospital on 22 February 2024 after recurrent aspiration pneumonia and prolonged admissions. Concerns included a split Hickman Catheter that was not reported through the required Datix process, remained in situ after advice that it should be removed, and was later surgically removed on 30 January 2024; he also developed tachycardia and a raised temperature while it remained in place.

Fehim AHMET · Prevention of Future Deaths report View report

11 Dec 2024 Inner North London M. Hassell

Fehim Ahmet was sitting in a café when a man fell through a skylight from the flat roof above and struck him. He died a fortnight later from his injuries; concerns included the lack of guidance for estate agents about recording and passing on hazards, and the failure to follow up reports that tenants were accessing the roof.

CHARLES GEORGE EDWARD DEVOS · Prevention of Future Deaths report View report

10 Dec 2024 Cornwall and Isles of Scilly G. Davies

Charles George Edward Devos died at home on 9 January 2021 from an acute bowel condition after delayed clinical assessment following two 999 calls. The inquest found that the delay was a missed opportunity for potentially lifesaving treatment amid extreme operational pressure on ambulance services. The principal concerns were unallocated 999 calls, excessive ambulance delays, and reliance on measures such as self-conveyance, taxis and unattended emergency department drop-offs.

Peter McCarthy · Prevention of Future Deaths report View report

10 Dec 2024 Surrey C. Topping

Peter McCarthy fell from his wheelchair at home on 25 November 2023, was found the following morning, and was taken to hospital with rib fractures and a subdural hematoma. He deteriorated and died on 30 November 2023 from heart failure and pneumonia. The principal concern was the absence of a protocol governing whether anticoagulant medication should be given to a client after a fall without medical oversight.

Karen Lesley Day · Prevention of Future Deaths report View report

10 Dec 2024 West Yorkshire Eastern E. Mather

Karen Lesley Day sustained a leg laceration in 2021 and received care from her GP practice and district nursing team. She was later admitted to hospital extremely unwell, did not respond to active treatment, and died on 14 July 2022. Concerns were raised that the lower limb framework was not followed consistently, referrals and escalation were inadequate, and the practice lacked adequate systems for timely internal investigation of patient safety incidents.

Karen Pamela DACK · Prevention of Future Deaths report View report

10 Dec 2024 Leicester City and South Leicestershire D. Hocking

Karen Pamela Dack had worsening bowel stricture and obstruction, and planned surgery was delayed or cancelled on several occasions. Her bowel subsequently perforated, she developed sepsis and died despite further operations. The principal concern was the repeated cancellation of surgery because of limited theatre availability and the risk that similar delays could lead to further deaths.

Craig Brendon SPIBY · Prevention of Future Deaths report View report

10 Dec 2024 Manchester West T. Brennand

Craig Brendon SPIBY, who had a condition that made him susceptible to choking, died on 13 July 2024 after choking on a sandwich while eating lunch unsupervised at an assisted living facility. The principal concerns were inconsistent understanding and use of monitoring and supervision requirements, inadequate clarity in care-plan terminology, insufficient professional curiosity when he was believed to be asleep, limited confidence in choking-related first aid, and a lack of training addressing confirmation bias.