6,433 reports
Information drawn from published reports and official responses.
Steven Duquemin, a vulnerable man, died after choking on a large piece of raw chicken that he attempted to eat overnight while no carer staff were present. The report identified inconsistent care-record entries and an under-appreciation of his choking risk, with concern that necessary preventative measures might not be implemented promptly for other vulnerable service users.
Northern Care Ltd
Andrew Vizard, aged 58, died from a pulmonary embolism on 14 July 2022 after suffering cardiac arrests while detained in hospital under section 2 of the Mental Health Act 1983. The report identified delays in obtaining monitoring equipment, a ward doctor attending, and calling an ambulance when concerns arose about his breathing. It also raised concern that existing staff training and emergency-response systems may not ensure an immediate and effective response in similar life-threatening situations.
Nottinghamshire Healthcare NHS Foundation Trust
Elliott James Harratt was born at the family home following his mother's early labour, transferred to Tameside General Hospital, and died there on 29 January 2023 from extreme prematurity. The inquest identified concerns that expectant mothers were not given clear, readily accessible information about sensitising events requiring Anti-D treatment or when to contact maternity triage; this matter did not contribute to Elliott's death.
NHS Greater Manchester Integrated Care Board
Marianne Erika Oldham was admitted to Tameside General Hospital with vomiting and abdominal pain and was diagnosed with a perforated sigmoid colon after a prolonged delay in clinical assessment and imaging. She deteriorated, was treated conservatively, and died from peritonitis. The report identified concerns about delays linked to Emergency Department demand, staffing shortages, and shortages of radiographers and radiologists.
NHS England
Peter John Harris was admitted with stage 4 metastatic lung cancer and recurrent pericardial effusion, suffered a cardiac arrest during treatment, developed multi-organ failure, and died on 10 June 2022. The principal concerns were that two scans with concerning findings were not seen and acted upon in a timely manner, including a 2020 scan indicating possible lung metastases and a 2022 scan suspicious for lung cancer. Ongoing concerns remained about whether unexpected or expected cancer findings would be appropriately highlighted and whether optional read receipts would adequately identify unread reports.
Barking, Havering and Redbridge University Hospitals NHS Trust
Carole MCQUINN underwent pancreatic surgery in February 2022 and subsequently experienced pancreatic leakage, abdominal collections and prolonged hospital treatment. After discharge without a discharge note, medication or follow-up appointment, concerns about infection were not adequately recorded or escalated, and a positive swab result was not reviewed until several days later. She was later admitted with suspected intra-abdominal sepsis and was found unresponsive in hospital; the inquest concluded that she died from a pulmonary embolism likely related to post-operative infection, inflammation and immobility.
Leeds Teaching Hospitals NHS TrustYork Hospital
Bernhard John Marek sustained an accidental fall, suffered a fractured neck of femur, and died in hospital on 6 January 2023 after developing pneumonia. Concerns included prolonged ambulance waits for frail elderly patients with hip fractures and delays in ambulances offloading patients at emergency departments.
Department of Health and Social CareNHS Greater Manchester Integrated Care Board
Shane Luke West was pronounced dead on 17 August 2018 at Morriston Hospital after multi-organ failure caused by cardiorespiratory arrest associated with abdominal distention from chronic constipation and fluid build-up from laxative treatment. The principal concerns were inconsistent records of laxative administration, difficulty assessing his condition due to his learning disability, and whether the risks of further abdominal distention and respiratory compromise were sufficiently appreciated when administering laxatives.
Swansea Bay University Local Health Board
Evelyn Mary Dutton, who had severe systemic sclerosis, was admitted after an accidental fall that caused a fractured neck of femur. Her nutritional status remained compromised, and she developed complications including electrolyte imbalance, vomiting blood and duodenal ulcers before deteriorating and dying in hospital on 13 August 2022. The report raised concerns about prolonged ambulance and hospital transfer delays for elderly frail patients with hip fractures.
NHS England
Sylvia Pollitt, an elderly resident, raised a concern about her boiler, but the subcontractor could not contact her and the situation was not escalated. She was found at home on 1 December 2022 and the post-mortem found that she had died from complications of hypothermia. The inquest identified that welfare checks were not carried out and that the Housing Association lacked systems to monitor non-escalation and referral outcomes.
London & Quadrant Housing Trust
Kenneth Rippon had deteriorating mental health, including self-harm, suicidal ideation and command auditory hallucinations, and died on 5 May 2022 after jumping or falling from a viaduct at Durham Train Station. The report identified concerns about inadequate mental health assessments and risk information, insufficient family involvement in safety and discharge planning, and delays and weaknesses in the investigation of the serious incident.
Care Quality CommissionTees, Esk and Wear Valleys NHS Foundation Trust
Michael Kevin Amesbury had extensive cardiac disease and became increasingly unwell while awaiting assessment for severe mitral regurgitation. He died in hospital after becoming unresponsive and undergoing cardiopulmonary resuscitation; post-mortem examination identified bilateral bronchopneumonia and aspiration of gastric contents, with heart failure contributing to reduced physiological reserves. The concerns included delays and problems in referrals between secondary and tertiary services, information-sharing and transfer of clinical records and images, and delays in cardiology assessment and trans-oesophageal echocardiography due to resource and appointment constraints.
NHS Greater Manchester Integrated Care Board
Thelma Mary Radmore was taken to hospital after a prolonged wait for an ambulance and then waited over 26 hours in the Emergency Department before transfer to a ward. She developed an unstageable sacral pressure ulcer and contracted Influenza A and Covid-19 in hospital, deteriorating rapidly before her death. The report identified concerns about delays caused by demand for ambulance, Emergency Department and bed capacity, and the effect of those delays on pressure-ulcer prevention.
Department of Health and Social Care
Colin Vincent Greenway became ill with gastroenteritis after returning from Cyprus and was admitted to hospital with acute kidney injury and infection. He was prescribed enoxaparin at half the usual dose despite documented risk factors and renal function above the threshold for dose reduction, and he later died from a pulmonary embolism. The concerns included incorrect junior prescribing, incomplete VTE assessments, inadequate senior oversight and continuity of care, and limited pharmacy checking.
The Queen Elizabeth Hospital, King's Lynn
Ronald Scott Ashdown died from aspiration pneumonia on 15 August 2021, following severe disability caused by a hypoxic brain injury after a cardiac arrest in 2013. Concerns included failures in basic personal hygiene while he was dependent on hospital staff, and a flawed investigation that failed to consider photographic evidence and contributed to subsequent safeguarding investigations being undermined.
Mid and South Essex NHS Foundation Trust
Christine Mary Dickinson, who had follicular lymphoma and was receiving Rituximab, became gravely ill after a final hospital admission in October 2022 and died on 15 November 2022. The inquest raised concerns about multiple systems being used to record chemotherapy administration and the absence of a recent audit of record-keeping on the Laurel Unit, particularly after another patient’s details appeared in Mrs Dickinson’s record.
Stockport NHS Foundation Trust
Philip Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.
Betsi Cadwaladr University LHBWelsh Ambulance Services NHS Trust
Ross Stephen Ballatine, Carl Stephen McGrath and Alan Wallace Minard died from immersion/drowning after the fishing vessel Nicola Faith capsized off the coast of North Wales on 27 January 2021. The principal concerns were that the Maritime and Coastguard Agency had not established or applied a clear threshold for requiring full stability assessments after significant vessel modifications, relied too heavily on the skipper's assurances and informal visual assessments, and did not give sufficient weight to earlier rescue incidents.
Maritime and Coastguard Agency
Jane Elizabeth Wadsworth became seriously unwell after elective hip surgery, developing a deep vein thrombosis, cellulitis, sepsis, acute kidney injury and liver failure, and died on 31 December 2022 despite intensive care treatment. Concerns included missed antibiotic doses, limited consultant input, unclear escalation and doctor-to-doctor discussion about intensive care, unavailable Critical Care Outreach support, and no evidence that specialist liver advice was obtained.
NHS EnglandTameside and Glossop Integrated Care NHS Foundation Trust
Sean Anthony Heeney was found unresponsive at Bridgewood House on 22 September 2019 and died in hospital on 26 September 2019 after suffering cardiac arrest during efforts to extricate him from the building. The principal concerns were delays caused by the lack of a clear extrication plan, the building’s restrictive layout, and the absence of a plan for evacuating a person unable or unwilling to leave during a medical emergency. The inquest narrative also stated that the initial emergency call was incorrectly categorised and that ambulance staff did not properly appreciate the seriousness and urgency of his condition.
HM Prison and Probation ServiceAccount
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