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George Marks · Prevention of Future Deaths report View report

17 Feb 2015 Mid Kent and Medway K. Thomas

George Marks was admitted with confusion, immobility and a chest infection, and was later diagnosed with a deep vein thrombosis and a thrombus in the pulmonary artery. After his anticoagulant medication was changed to Rivaroxaban, he was not given it from the evening of 28 February until 4 March, and he died on 6 March 2014. The principal concerns were agency staff’s failures in medication administration, record-keeping and handover procedures.

Master Omarian Brooks · Prevention of Future Deaths report View report

29 May 2020 Inner South London A. Harris

Omarian Brooks, a severely disabled boy, deteriorated after being given antibiotics by his parents and died en route to hospital on 27 May, without having had a GP visit. Concerns included the GP apparently being unaware of his deterioration, the absence of a protocol for managing it, and the lack of a patient-specific emergency care protocol. The report states that earlier GP awareness might have led to hospital admission with a real prospect of successfully treating the infection.

Dorothy Delaney · Prevention of Future Deaths report View report

23 Sep 2015 Manchester West R. Griffin

Dorothy Delaney was found collapsed at her care home on 11 June 2015 after being prescribed Rivaroxaban for atrial fibrillation and Clopidogrel for previous transient ischaemic attacks. She was diagnosed with a large intracerebral haemorrhage and died later that day. The principal concern was that both anticoagulant and antiplatelet medications were prescribed without individual specialist advice, increasing the risk of haemorrhage.

Raymond Horace Watkins · Prevention of Future Deaths report View report

26 Jun 2024 Manchester North J. Kearsley

Raymond Horace Watkins was admitted to hospital, discharged to his care home after his insulin and other medications had been stopped, and subsequently sought to restart them. Administrative errors meant the insulin prescription was not authorised before his readmission, although expert evidence concluded that prescribing insulin would not have been appropriate in this case and would not have changed the outcome. The substantive concern was a breakdown in communication between the GP and District Nurses, alongside the lack of “Time Critical Medicine” guidance for community settings.

Wendy Margaret Wilkes · Prevention of Future Deaths report View report

20 Apr 2020 Manchester South A. Mutch

Wendy Margaret Wilkes was found at her home on 6 August 2019, with toxicology showing a fatal level of ethanol and concomitant use of gabapentin, zopiclone, diazepam and amitriptyline. Concerns were raised about the absence of a clear system for alert notes and follow-up reviews, and about whether prescribers were aware of her high alcohol use and assessed the risks of mixing alcohol with her medication.

Dumile Daniel Thompson · Prevention of Future Deaths report View report

2 Aug 2023 West Yorkshire Eastern J. Wolstenholme

Dumile Daniel Thompson developed Ramipril-induced angioedema, deteriorated after an apparent initial improvement, suffered respiratory collapse causing catastrophic brain injury, and died several days later after life support was withdrawn. The principal concerns included inadequate recognition of the risks and trajectory of ACE inhibitor-induced angioedema, insufficient specialist airway reassessment and monitoring, lack of relevant guidance and training, and limited access to previous medical records affecting medication decisions.

Samuel Lewis Jones · Prevention of Future Deaths report View report

5 Dec 2023 Dorset R. Griffin

Samuel Lewis Jones died on 30 April 2021 after suspending himself by a ligature in his cell at HMP Portland. The concerns identified included the lack of systems and national guidance for recording and flagging significant dates, difficulties accessing key information in prison records, and insufficient national guidance on managing medication held in prisoners’ possession.

Wayne Patrick O'NEILL · Prevention of Future Deaths report View report

26 Oct 2015 Worcestershire A. Cox

Wayne Patrick O'NEILL was a serving prisoner at HMP Long Lartin who collapsed in his cell and died on 2 January 2013. The inquest recorded respiratory failure, bronchospasm following ingestion of propranolol, and asthma as the medical cause of death. Concerns included the prescribing of propranolol despite asthma, the combination of psychotropic medicines with potential cardiac effects, and the failure to undertake an ECG before his death.

Jack Basil Lynn · Prevention of Future Deaths report View report

18 Feb 2014 North Northumberland T. Brown

Jack Basil Lynn, who lived alone and received daily care visits, was found unresponsive at home on 15 October 2013 after a morning visit during which the carer did not check his wellbeing. The concerns were that there was no continuous medication communication sheet and that no safety or wellbeing check was made during the allocated visit, creating a potential risk to future residents despite the inquest finding that Mr Lynn died from natural causes.

Moses Andrew Arthur McDonald · Prevention of Future Deaths report View report

2 Dec 2014 Inner South London L. Tagliavini

Moses Andrew Arthur McDonald, who had paranoid schizophrenia and was taking Clozapine, was found deceased at home on 2 April 2013 after experiencing frequent urination and extreme thirst. He had not undergone glucose testing since May 2012. The principal concern was the lack of mandatory and regular glucose testing by the Clozapine clinic while he was receiving antipsychotic medication; the inquest concluded that diabetic ketoacidosis contributed to his death.

Heather Beatrice Planner · Prevention of Future Deaths report View report

13 Dec 2008 Buckinghamshire C. Butler

Heather Beatrice Planner died at Wycombe Hospital on 1 April 2019 from a gastrointestinal bleed in the context of large bowel ischaemia. The report states that she had not received her prescribed apixaban anticoagulation at home for two days before admission, and identifies concerns about medication administration, communication and record-keeping processes for carers, as well as the subsequent investigation.

Jane Elizabeth ALLISON · Prevention of Future Deaths report View report

7 Mar 2022 County Durham and Darlington C. Oliver

Jane Elizabeth ALLISON died in hospital on 20 November 2021 after being admitted with severe type 1 respiratory failure. She had received a 10-day course of nitrofurantoin for a urinary tract infection, and the inquest concluded that she died from the effects of prescribed medication. The principal concern was that BNF guidance did not sufficiently alert clinicians to the risk of sudden pulmonary deterioration or provide adequate monitoring advice in this circumstance.

Dylan Jay Henty · Prevention of Future Deaths report View report

8 Oct 2019 Cornwall and Isles of Scilly A. Cox

Dylan Jay Henty had a complex medical history including schizophrenia, a cerebral tumour, communication difficulties and seizures. He went missing after declining prescribed medication on 17 February 2018, and his body was found at Fistral beach on 21 February 2018; the cause of death was recorded as multiple injuries, with no evidence explaining the apparent fall or how he entered the sea. Concerns included an unsupervised seizure in a bath, inadequate awareness of hoarding, medication compliance, inconsistent reporting of absconding incidents, and arrangements for monitoring residents at risk of absconding.

Amy Jade BUTCHER · Prevention of Future Deaths report View report

26 Nov 2024 Suffolk N. Parsley

Amy Jade Butcher was declared deceased on 14 May 2023 after suspending herself with a ligature around her neck during a heightened anxiety crisis. The inquest identified concerns about a confusing, fragmented system for prescribing mental health medication, and about the decision not to prescribe Lorazepam despite its previous effectiveness for Amy.

Mr Devindar Lal Seth · Prevention of Future Deaths report View report

26 Feb 2016 East London N. Persaud

Mr Devindar Lal Seth, aged 94, suffered a fall, fractured his hip and underwent surgery before developing opiate toxicity after postoperative pain treatment. The opiate toxicity was not identified by ward staff until family members raised concerns, and there was also a delay in ventilation after he suffered aspiration. The report identified a lack of clear guidance for ward staff about the risks and side effects of opiate medication in older orthopaedic patients.

Resmije Ahmetaj · Prevention of Future Deaths report View report

12 Aug 2025 Essex S. Hayes

Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.

Margaret HEAL · Prevention of Future Deaths report View report

6 Dec 2023 County Durham and Darlington J. Thompson

Margaret Heal died at home from a massive pulmonary thromboembolism caused by a deep venous thrombosis after stopping anticoagulant medication for surgery and not resuming it. The inquest found no evidence that she had been given written instructions to restart the medication, and raised concern about ensuring vulnerable or elderly patients living alone receive medication advice clearly.

Andrew Craig · Prevention of Future Deaths report View report

25 Jun 2018 Dorset R. Griffin

Andrew Craig, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell on 16 September 2016. The inquest concluded that the medical cause of death was the toxic effects of buprenorphine and diazepam, with a conclusion of misadventure. The principal concerns were illicit drug use at the prison and weaknesses in the dispensing and monitoring of medication, which could facilitate the redistribution of prescription drugs.

George Stone · Prevention of Future Deaths report View report

20 Aug 2014 Portsmouth and South East Hampshire D. Horsley

George Stone suffered from long-term depressive illness and ended his own life on 19 November 2012 after a grand mal seizure following treatment with Venlafaxine. The concern was that severe seizures are a rare side effect of Venlafaxine and similar antidepressants, but the national warning guidelines did not then include the risk of severe seizures.

Derek Larkin · Prevention of Future Deaths report View report

19 Jan 2023 Dorset S. Nicholls

Derek Larkin was found deceased at home on 2 June 2021 after returning from a care home, and a post-mortem examination demonstrated an overdose of prescription morphine. The report raises concerns that Adult Social Care did not have sufficient information about his prescribed medication, medication management, or concerns raised by family and healthcare professionals, including because its computer system could not communicate with the NHS SystemOne system.