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Tracey Oldfield · Prevention of Future Deaths report View report

11 Nov 2025 Cornwall and Isles of Scilly A. Cox

Tracey Oldfield underwent an elective fistula revision procedure on 17 October 2024 and was admitted after developing low oxygen saturations and low blood sugars. She became drowsy and unresponsive after receiving opiate pain relief that was contraindicated in end-stage renal failure, while her CPAP device was unavailable and there was no senior medical review. She suffered a cardiac arrest, developed a hypoxic brain injury, and died on 24 October 2024. A continuing concern was the timely prescription of patients’ usual medication after unexpected admission, including appropriate pain relief.

John Malcolm FISHER · Prevention of Future Deaths report View report

19 Mar 2026 West Sussex, Brighton and Hove K. Taylor

John Malcolm Fisher was admitted to hospital on 22 April 2025 with persistent focal seizures that developed into status epilepticus, and he died on 4 May 2025 after the seizures could not be controlled. The report raises concerns about inaccurate or incomplete medication information during transfers between community services and the omission of sodium valproate from the care agency’s medication record, resulting in six days without that medication.

Tania Salekovna Hristova · Prevention of Future Deaths report View report

28 Sep 2015 Wiltshire and Swindon C. Balysz

Tania Salekovna Hristova had depression and received Citalopram by repeat prescription for five and a half years. She was found hanging by a ligature at home after becoming distressed, and the inquest concluded that her death was suicide. The concerns identified were inadequate review of her medication and mental health, and failure to offer counselling or CBT.

Frances Claire ANDRADE · Prevention of Future Deaths report View report

28 Jul 2014 Surrey R. Travers

Frances Claire Andrade died after taking an overdose of fluoxetine and insulin, following a period involving repeated overdoses and increasing distress around criminal proceedings. The report raised concerns about advice and support for vulnerable witnesses, explanations of trial directions, and securing medication prescribed to another family member after repeated overdoses.

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.

Nancy Hughes · Prevention of Future Deaths report View report

12 Jun 2015 North Wales (East and Central) J. Gittins

Nancy Hughes, who had Alzheimer’s disease and was receiving Risperidone, fell at a care home and later suffered a further unwitnessed fall in hospital before dying on 3 January 2014. The concerns were that her medication was not reviewed as required and that there was insufficient cohesion between mental health and medical treatment, potentially affecting care for vulnerable patients.

DAVID WAYNE BENNETT · Prevention of Future Deaths report View report

17 Feb 2025 Essex S. Hayes

David Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.

Graham Earl · Prevention of Future Deaths report View report

30 Sep 2019 Manchester South A. Mutch

Graham Earl had pulmonary fibrosis diagnosed while receiving Amiodarone therapy and was not referred back to the cardiologist. He later developed influenza, deteriorated, and died at Stepping Hill Hospital on 16 February 2019. The principal concerns were that the link between Amiodarone and pulmonary fibrosis was not recognised promptly, the medication was amended without reference to secondary care, and there was insufficient awareness of escalation procedures for side effects.

Evan Amon DANDOU-DAMBELLE · Prevention of Future Deaths report View report

29 Oct 2025 Inner North London M. Hassell

Evan Dandou-Dambelle was at home on the evening of 2 May 2025 while experiencing symptoms of psychosis and command hallucinations. The concerns relate to a change in his mental-health service contact from weekly to fortnightly at the same time that his olanzapine was stopped and risperidone commenced, without the medication change being specifically considered when setting the level of contact. The inquest determined that he died by suicide.

Mr Harold Goulding · Prevention of Future Deaths report View report

14 Jul 2016 London (East) N. Persaud

Mr Harold Goulding suffered two falls at a care home on 5 and 6 November 2015, followed by a subdural haematoma, seizure and cardiac arrest; he died on 10 November 2015. The concerns included communication failures between the anticoagulation clinic, GP and care home, and the GP not checking the care home’s medication administration record, meaning he was unaware that Mr Goulding was receiving warfarin.

Steven Terence Allen · Prevention of Future Deaths report View report

2 Jun 2021 Manchester South A. Mutch

Steven Terence Allen was found unresponsive at home on 25 October 2020, and toxicology found a fatal level of prescribed medication; the medical cause of death was recorded as combined drug toxicity. Concerns included prescribing oxycodone and other medications despite a history of addiction, self-harm and poor use of substances, with telephone consultations during Covid-19 and additional replacement prescriptions sometimes issued with little challenge.

Joshua Ethan BURGESS · Prevention of Future Deaths report View report

13 Feb 2024 Staffordshire and Stoke-on-Trent D. Howe

Joshua Ethan Burgess, who had epilepsy and Lennox-Gastaut syndrome, died at home on 19 November 2022 after vomiting and aspirating during an epileptic seizure. The report identifies concerns about communication and prescribing processes for Brivaracetam, including failures to update the prescription, medication being withheld for several days, and a subsequent increase to 10ml twice daily despite information that 4ml twice daily was appropriate.

Chloe Anne Tapp · Prevention of Future Deaths report View report

28 Feb 2024 Essex R. Mundy

Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.

Fiona May Humberstone · Prevention of Future Deaths report View report

28 Jun 2021 Essex S. Horstead

Fiona May Humberstone, who had longstanding mental health conditions, alcohol misuse and chronic pain, died at home from an inadvertent overdose of prescribed Oromorph taken with other medication. The concerns included mental health clinicians relying solely on patients’ accounts of their medication and inadequate access to accurate, up-to-date prescribing information between primary and secondary care.

Nicholas J D’Ourou · Prevention of Future Deaths report View report

11 Feb 2025 Inner North London R. Brittain

Nicholas J D’Ourou, who had been admitted to Highgate Acute Mental Health Centre as a voluntary patient, was found on 15 April 2024 with a ligature around his neck and died from asphyxiation. The report raises concerns about inconsistent practice and limited guidance for cross-titrating psychiatric medication, and about the lack of patient observation, including electronic monitoring, in psychiatric wards.

Ms Karen Redding · Prevention of Future Deaths report View report

18 Nov 2021 Black Country Z. Siddique

Ms Karen Redding died after drinking an excess of Oramorph, becoming increasingly drowsy and suffering a fatal overdose. During the inquest, concern arose that care staff handed her the medication without checking the box contents, and that she was not seen by a doctor after disclosing that she had taken too much.

Rachel Holly Edwards · Prevention of Future Deaths report View report

27 Feb 2018 Suffolk N. Parsley

Rachel Holly Edwards died on 8 May 2017 after an overdose of multiple prescription medicines, following a period of severe and unbearable pain. Concerns identified at the inquest included unclear quantities of discharge medication, inadequate communication of prescriptions to her GP, record-keeping weaknesses, and the absence of a formal patient advocate system to support her when pain-management news and treatment administration increased her hopelessness.

Mr Patrick Viles · Prevention of Future Deaths report View report

20 Jun 2025 Inner North London R. Brittain

Mr Patrick Viles died after taking an intentional overdose of medication at home, in the context of suicidal ideation and previous overdosing. The report raises concern that medication was prescribed after a psychologist had identified significant concerns about his mental health and the need for urgent psychiatric input. It could not be determined at the inquest where the medication used in the overdose had been obtained.

Julia Jane MacPherson · Prevention of Future Deaths report View report

1 Apr 2018 South London S. Hayes

Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.

Viktor John Anthony Scott-Brown · Prevention of Future Deaths report View report

20 Aug 2020 County Durham and Darlington O. Longstaff

Viktor John Anthony Scott-Brown, aged 23, was found hanging at his home overnight on 14/15 December 2018 and pronounced dead at the scene; the inquest concluded that his death was suicide. He had been prescribed Lamotrigine without being warned about its potential association with thoughts of self-harm or suicide, and concerns were raised that reputable prescribing resources were inconsistent or silent about this potential side effect.