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Helen BARKER · Prevention of Future Deaths report View report

19 Nov 2019 Lincolnshire P. Cooper

Helen BARKER, aged 50, called emergency services on 11 November 2018 reporting suicidal feelings and threatening to take an overdose. Although reviews were recorded as having been undertaken, they did not occur, and paramedics attended 6 hours and 35 minutes after the initial call; she was pronounced dead at home on 12 November 2018. The report raised concerns about implementation of an investigation recommendation and whether an emergency category 3 call could be escalated when the ambulance response time was exceeded.

Levi Louis Alleyne · Prevention of Future Deaths report View report

4 Nov 2022 Berkshire K. Thorne

Levi Louis Alleyne, a grab lorry delivery driver, died by electrocution at a building site after raising his lorry’s crane arm beneath overhead power lines. CPR was delayed because it was unclear whether the electricity remained live, and the ambulance control operator had no procedure or readily accessible emergency contact information for the relevant electricity network operator. The report identifies risks of delayed life-saving treatment or people approaching live electrical hazards and notes that similar mitigating procedures may not be adopted across England and Wales.

Sharon Louise Suki Butcher · Prevention of Future Deaths report View report

31 Mar 2015 County Durham and Darlington A. Tweddle

Sharon Louise Suki Butcher died of natural causes, with the inquest recording ischaemic heart disease, coronary artery atheroma, diabetes mellitus and cirrhosis of the liver. The report raised concerns about a 10-minute delay in calling an ambulance after an emergency medical code was broadcast, failure to follow the prison’s local protocol, and recurring lack of clarity in responding to medical emergencies.

John Stephen England · Prevention of Future Deaths report View report

9 May 2025 Cornwall and Isles of Scilly A. Cox

John Stephen England developed abdominal pain and increasing distention while on holiday in Cornwall on 12 March 2023, after a history of recurrent sigmoid volvulus. Delays occurred in ambulance arrival, transfer into hospital, and escalation of the CT findings; he underwent surgery for ischaemic and gangrenous bowel and died in hospital on 15 March 2023 after an acute collapse during placement of a naso-gastric tube. The principal concern was whether the ambulance dispatch system could distinguish surgical emergencies requiring conveyance within an appropriate timeframe.

Morris REDDINGTON · Prevention of Future Deaths report View report

21 May 2021 Nottinghamshire L. Bower

Morris Reddington died from a rare stroke involving basilar artery thrombosis, likely caused by dissection of the right vertebral artery. The report identified delays in diagnosis and concerns that electronic ambulance handover records were not routinely reviewed, as well as limited out-of-hours access to mechanical thrombectomy. It also raised concerns about the risk of future deaths from failures in patient-information handover and geographical disparities in access to thrombectomy.

Charlotte Tetley · Prevention of Future Deaths report View report

14 Sep 2025 Cheshire S. Murphy

Charlotte Tetley died on 24 September 2024 after deliberately sitting on railway tracks and being struck by a train. The report describes concerns about the police and ambulance response after she left hospital on 18 September 2024 despite reported suicidal feelings and professional concerns about her immediate safety. It also identifies concerns about the application of missing-person response policy when the person’s whereabouts are unknown.

Mr Ian McDonald Taylor · Prevention of Future Deaths report View report

8 Jun 2022 Inner South London A. Harris

Mr Ian McDonald Taylor suffered a cardiac arrest after a physical altercation while in police detention and died in hospital. Concerns included the police officer’s assessment and communication of Mr Taylor’s breathing difficulties, access to his inhaler while awaiting an ambulance, and the exceptionally delayed ambulance response.

Andrew Vizard · Prevention of Future Deaths report View report

20 Jul 2023 Nottinghamshire M. Wall

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.

Ester Jane Wood · Prevention of Future Deaths report View report

6 Jun 2018 North Wales (East and Central) D. Pojur

Ester Jane Wood was taken by ambulance to Maelor Hospital and waited in the ambulance from 20.05hrs until 1am before admission. The report identified concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that these problems continued and placed patients' lives at risk.

Gladys May Williams · Prevention of Future Deaths report View report

10 Sep 2018 North Wales (East and Central) J. Gittins

Gladys May Williams fell at her care home on 6 March 2018, was discharged from hospital, deteriorated, and experienced delays in ambulance response and handover on 7 March. The report raises continuing concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that patients’ lives may be at risk.

Mark Steven Wright · Prevention of Future Deaths report View report

26 Jun 2023 Surrey A. Crawford

Mark Steven Wright deliberately overdosed on prescribed quetiapine at home during the night of 14 June or early hours of 15 June 2022, and was pronounced deceased after an ambulance arrived. The report identifies delays in the ambulance response, including SECAMBS operating under Stage 4 of its Surge Management Plan, as a significant concern because demand exceeded available resources and calls could not be answered within target timeframes.

Terence Norbert Dooley · Prevention of Future Deaths report View report

10 Apr 2014 Manchester City J. Harkin

Terence Norbert Dooley took a fatal overdose of medication and contacted the ambulance service, reporting his location and symptoms. Attendance was delayed by 2 hours and 38 minutes, and he was later found deceased by the canal. Concerns included the emergency call being coded green, the delay in response, poor communication, and misleading computer-generated codes.

William Robert Raymond Nute · Prevention of Future Deaths report View report

24 May 2016 Cornwall and Isles of Scilly E. Carlyon

William Robert Raymond Nute fell while a car was reversing near a shop on 30 June 2015 and sustained a fractured neck of femur. He later developed pneumonia and died on 2 July 2015. Concerns included delays in ambulance attendance and transfer to hospital, inappropriate triage of emergency calls, and delayed notification of the police, leaving him without effective emergency management while lying on a public highway.

Janet Springall · Prevention of Future Deaths report View report

7 Feb 2026 Blackpool and the Fylde A. Anthony

Janet Springall, who had a learning disability and was immunosuppressed, was taken to hospital with pneumonia and sepsis after being found unresponsive. She remained in an ambulance outside the emergency department for almost six hours amid exceptional pressures, and the report raises concern that delays in clinical assessment, blood testing and treatment may place similarly unwell patients at increased risk.

Shirley Ann Hughes · Prevention of Future Deaths report View report

28 Oct 2024 North Wales (East and Central) J. Gittins

Shirley Ann Hughes collapsed at home on 1 June 2024 and, because no ambulance was available, waited more than fifteen hours on the floor before treatment and hospital admission. The principal concern was whether the Medical Priority Dispatch System remained fit for purpose amid ambulance resource pressures, with the coroner concerned that lives were being put at risk.

Lisa Margaret DAY · Prevention of Future Deaths report View report

23 Feb 2016 Inner North London M. Hassell

Lisa Margaret Day died from cardiac arrhythmia from hyperkalemia, associated with diabetic ketoacidosis and poorly controlled type I diabetes. An ambulance arrived approximately four and a half hours after first being called, and concerns were raised that the 111 service did not discuss alternative transport with the friend who made the call or explain the grave consequences of vomiting illness in a person with diabetes.

Keith David FOORD · Prevention of Future Deaths report View report

2 Dec 2024 East Sussex R. Redman

Keith David FOORD died on 3 May 2022 after suffering an acute type A aortic dissection and undergoing emergency repair. The principal concern was that ambulance transfers for aortic dissection requiring emergency surgery should be categorised as category 1 rather than category 2.

Paul Dow · Prevention of Future Deaths report View report

10 Apr 2024 Manchester North M. Cox

Paul Dow died on 3 April 2023 after taking an overdose of medication while alone in a hotel room. He had indicated that the overdose might be an attempt to take his own life, but both ambulance calls were coded as category 3, with no clinician involved at the time. There were also concerns that the lack of response to three follow-up calls, potentially indicating loss of consciousness, did not lead to escalation.

Carl Lee Thompson · Prevention of Future Deaths report View report

18 Apr 2016 West Yorkshire (Western) M. Fleming

Carl Lee Thompson died from drowning on 10 August 2015 after being overwhelmed by surf and waves while bathing in the sea in Fuerteventura. Concerns included inadequate or defective lifesaving and resuscitation equipment, lifeguards’ lack of training in its use, and delays in obtaining replacement equipment and emergency medical assistance.

Russell Curwen · Prevention of Future Deaths report View report

24 Apr 2020 Lancashire and Blackburn with Darwen J. Newman

Russell Curwen, a volunteer with the North West Blood Bikes, was fatally injured after riding through a traffic light against the lights while transporting blood samples and colliding with another vehicle on 5 May 2018. The concerns included the lack of traceable NHS ambulance service coordination in dispatching blood-bike vehicles, no clear or auditable determination or review of whether courier journeys constituted emergencies, and no statutory training requirements for riders using high-powered motorcycles with emergency lights and sirens.