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Susan Margaret Williams · Prevention of Future Deaths report View report

20 Jun 2024 Carmarthenshire and Pembrokeshire P. Bennett

Susan Margaret Williams was admitted to hospital on 14 July 2019 with suspected sepsis and abdominal pain, later deteriorating and dying from cardiorespiratory failure due to lung fibrosis and cor pulmonale. The principal concerns were the lack of recorded medication prescription times, a potential delay in administering antibiotics, and the absence of equivalent medication timing records on the Accident & Emergency Record Card.

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.

Walter Gordon Powley · Prevention of Future Deaths report View report

4 Oct 2013 Leicester City and South Leicestershire D. Coutts-Wood

Walter Gordon Powley died after falling against uncovered radiator pipes and valves at a care and nursing home, sustaining burns to his legs. The report raised concerns about the high temperature of uncovered pipework, the absence of risk assessment of the room’s physical circumstances, and inspection bodies not identifying these issues. The inquest also identified inadequate ongoing risk assessments and failures to adhere to procedures for giving and recording medication as contributing factors.

Trevor Alan MONERVILLE · Prevention of Future Deaths report View report

16 Jan 2024 East Sussex R. Redman

Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.

Natasha Learline CHIN · Prevention of Future Deaths report View report

10 Jan 2019 Surrey C. Topping

Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.

Danielle Monique Christina JONES · Prevention of Future Deaths report View report

27 Oct 2025 Black Country J. Lees

Danielle Jones was found unresponsive at home on 13 May 2025 and was confirmed deceased by paramedics. Post-mortem toxicology found high levels of amitriptyline, excess zopiclone and recent substantial cocaine use; the recorded cause was combined multidrug toxicity. The principal concerns were that, despite reported prescription overdoses and concerns raised by a drug and alcohol service, her repeat prescription medication does not appear to have been reviewed and was continued in large quantities at 28-day frequency.

Sarah Brady · Prevention of Future Deaths report View report

5 May 2021 Black Country J. Lees

Sarah Brady, a 75-year-old woman, was admitted to hospital on 4 August 2020 after being found unresponsive at home following a presumed medication overdose. She deteriorated into multi-organ failure and died in hospital on 8 August 2020. The concerns included prescriptions exceeding the GP’s seven-day limit despite her history of overdose and erratic medication compliance, possible stockpiling of medication, and uncertainty about whether an additional hospital prescription had been fulfilled.

Bency Joseph · Prevention of Future Deaths report View report

7 May 2023 Essex S. Hayes

Bency Joseph died instantly on 27 May 2022 from a traumatic head injury after falling headfirst from an upstairs window at home during a severe psychotic episode. The concerns included delays in prescribing and providing therapeutic medication, failure to act on the family’s attempts to escalate the issue, and shortcomings in the Trust’s investigation, including not involving the family or Senior Pharmacist.

Norman Leadbeater · Prevention of Future Deaths report View report

27 Jun 2024 Manchester North C. McKenna

Norman Leadbeater, who had advanced Parkinson’s disease, vascular dementia and presumed liver cancer, developed aspiration pneumonia after being advised to have thickened fluids and died on 14 January 2024. Concerns were identified that his prescribed thickener was not listed on the Medication Administration Record and that his care plan lacked sufficient detail for staff to administer thickened fluids safely and correctly. A recommended audit of medication records had still not been completed four and a half months later, and no completion timescale was provided at the inquest.

Venetia Clarissa Pierce · Prevention of Future Deaths report View report

19 Aug 2025 Surrey S. Ridge

Venetia Clarissa Pierce, described as an elderly frail lady with recurrent urinary infections, was prescribed nitrofurantoin prophylactically in February 2024 and died in hospital on 30 December 2024. The inquest recorded nitrofurantoin-induced pneumonitis as the medical cause of death, with frailty contributing. Concerns included the absence of an MHRA safety alert on the surgery’s EMIS system and limited awareness among clinicians of the potential for pulmonary damage and respiratory failure from nitrofurantoin in elderly patients.

Tanya Rosemary Marion Oladejo · Prevention of Future Deaths report View report

22 Apr 2014 West London C. Inyama

Tanya Rosemary Marion Oladejo was found collapsed and unresponsive on her bed after a friend had not heard from her for approximately one week; police confirmed there were no suspicious circumstances. The inquest concluded misadventure, with the medical cause of death recorded as amitriptyline intoxication. The principal concern was inadequate communication between the GP practice and the responsible clinician about medication, including unilateral changes to amitriptyline prescribing that were not communicated to the responsible clinician.

MRS KERRY JACOBS · Prevention of Future Deaths report View report

21 Mar 2014 West Sussex B. Dolan

Mrs Kerry Jacobs died on 8 July 2013 from a pulmonary embolism arising from a deep vein thrombosis in her right calf. Concerns included the prescription of a steroid dose outside usual ENT practice and BNF guidelines without adequate documentation or confirmation with the consultant, and the lack of a protocol requiring discussion between pharmacists and clinicians when prescriptions are queried.

Federica Cavenati · Prevention of Future Deaths report View report

25 Oct 2023 Inner West London P. Malhotra

Federica Cavenati died on 18 October 2021 after sustaining multiple traumatic injuries from a fall from height while receiving treatment at Chelsea and Westminster Hospital. The report identified contributing service-delivery issues including the absence of recent mental health review, removal of 1:1 mental health observations, and inconsistent antidepressant medication. A substantive concern was the absence in the United Kingdom of intravenous antidepressant medication for patients unable to take it orally for physical reasons.

Marie Hilda Millward Winter · Prevention of Future Deaths report View report

15 Jan 2019 Manchester City R. Galloway

Marie Hilda Millward Winter fell at a nursing home on 19 August 2017, sustained a head injury and developed an intracranial bleed. The report states that Apixaban was administered after the fall and that this worsened the bleed and contributed to her death at hospital on 2 September 2017. The principal concern was the administration of anticoagulant medication after a head injury, reportedly on the advice of or in the presence of ambulance technicians.

Mr George Arthur Cheese · Prevention of Future Deaths report View report

6 Jun 2017 Berkshire P. Bedford

Mr George Arthur Cheese, an 18-year-old man, was found hanging in woodland near his home on 9 April 2015. He had anxiety and depression with suicidal thoughts, and concerns were raised about the amount of Fluoxetine prescribed and the absence of a flag to limit repeat medication supplies.

Kumbulani MTOMBENI · Prevention of Future Deaths report View report

16 Aug 2021 West London L. Brown

Kumbulani Mtombeni was found deceased at his home on 25 January 2021, with evidence indicating that he intended to take his own life; the inquest conclusion was suicide and the recorded cause of death was methadone toxicity. The principal concerns were how methadone prescribed to another person came into his possession, whether medication audits identified missing medication, and his access to residents’ prescribed medicines through his work as a senior carer.

Percy Jacks · Prevention of Future Deaths report View report

27 Jul 2017 South Wales Central A. Barkley

Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.

Mr Barry Clive Loxston · Prevention of Future Deaths report View report

12 Nov 2025 Inner West London F. Wilcox

Mr Barry Clive Loxston died at St George’s Hospital on 30 July 2023 after complications following renal transplant surgery, including electrolyte imbalance and delayed graft function. The report identifies concerns about failures to recognise his unfitness for surgery, inadequate patient handling, unsupervised medication administration, insufficient investigation, incomplete review of blood tests, and gaps in systems for assessing transplant-list suitability and communication between nephrology teams.

Leonardus Adrianus VRIES · Prevention of Future Deaths report View report

9 Mar 2015 Worcestershire G. Williams

Leonardus Adrianus Vries apparently obtained medical-grade drugs from his workplace and injected himself at his family home, where he died; the inquest concluded that his death was accidental, involving respiratory depression and combined toxicity of bupivacaine, morphine and diamorphine. The principal concern was inadequate documentation and auditing of medication, particularly non-controlled medication, at the Royal Orthopaedic Hospital, creating an opportunity for abuse or theft.

Karen Jane Winn · Prevention of Future Deaths report View report

22 Oct 2020 Suffolk N. Parsley

Karen ‘Jane’ Winn died at West Suffolk Hospital after developing bilateral pulmonary emboli and deep venous thromboses in the context of haemolytic anaemia. Although prophylactic anticoagulation was identified as necessary, it was not administered during most of her admission, and the report states that this contributed to her death. Concerns included a lack of early haematology consultant involvement, repeated manual overriding of the automated VTE assessment warnings, and inadequate electronic flagging of the anticoagulation decision.