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DAVID ERNEST MASON · Prevention of Future Deaths report View report

19 Apr 2023 Worcestershire N. Lane

David Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.

James O’Brien · Prevention of Future Deaths report View report

13 Mar 2017 Inner South London P. Barlow

James O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.

Sharon Louise Kelly · Prevention of Future Deaths report View report

24 Nov 2020 Essex C. Beasley-Murray

Sharon Louise Kelly, who had a long history of mental health and alcohol problems and frequent suicide attempts, informed a family member that she would kill herself on the anniversary of her baby son’s death. On 27 June 2019, an ambulance attended her property but did not enter while awaiting delayed police attendance; when services eventually entered, Ms Kelly was deceased. The concerns included delays and communication between ambulance and police services, risk assessment and police response procedures, and arrangements for urgent mental health assessments.

Rafe Robbie Angelo · Prevention of Future Deaths report View report

27 Nov 2017 Portsmouth and South East Hampshire K. Harold

Rafe Robbie Angelo was born at 17:30 on 23 September 2014 after his mother was transferred from the Blake Birthing Centre to hospital during labour. He was born pale and floppy, without breathing or a heart rate, and died after 37 minutes of resuscitation. The principal concerns included delays in recognising the need for urgent delivery and communication failures between the birthing centre, ambulance service and hospital, including failure to request a time-critical transfer and a non-urgent ambulance stop.

Eric Harold Bird · Prevention of Future Deaths report View report

10 Feb 2021 Black Country J. Lees

Eric Harold Bird, a 91-year-old man with dementia and assessed as being at high risk of falls, suffered seven falls during a four-week period in a specialist care centre. After a fall on 21/11/20, he sustained a subdural haematoma and died in hospital on 30/11/20. The principal concerns included failures to follow procedures after head injuries, delays in contacting emergency services and gaining ambulance access, and inadequate updating and review of his falls risk documentation and care plan.

Jackson Yeow · Prevention of Future Deaths report View report

17 Jan 2025 South Wales Central D. Regan

Jackson Yeow, aged 16, became seriously unwell with abdominal pain and vomiting and later developed diabetic ketoacidosis and other complications. He waited approximately 9½ hours for an ambulance after his family called 999, and died on 9 April 2022. Concerns included delays in ambulance handovers associated with emergency department overcrowding, corridor care, and delayed discharge of medically fit patients.

Bernard Lyon · Prevention of Future Deaths report View report

9 Apr 2025 Manchester South A. Mutch

Bernard Lyon, who had dysphagia and was living at Hyde Nursing Home, developed sepsis and aspiration pneumonia and died at Tameside General Hospital on 30 January 2024. The report describes concerns about the nursing home's management capacity, staffing and adherence to his modified diet plan, as well as multi-agency oversight, communication with families, ambulance handover delays and delays in administering antibiotics in a very busy emergency department.

Paul David Whitehead · Prevention of Future Deaths report View report

14 Dec 2015 West Yorkshire Eastern K. McLoughlin

Paul David Whitehead sustained severe crush injuries after becoming trapped between the moving conveyors of a packing machine at work and subsequently died in hospital. Concerns were raised that the workplace emergency response, including first aid provision and contacting and directing emergency services, was not sufficiently efficient or effective.

Jack Alfie Charlie HUBBARD · Prevention of Future Deaths report View report

28 Jan 2019 Inner North London M. Hassell

Jack Hubbard, aged 18, ingested MDMA at Egg Nightclub in London on the evening of 24/25 August 2018; the investigation recorded the medical cause of death as MDMA toxicity. A concern was raised that the nightclub’s ambulance-calling protocol required the duty manager to be called and a second set of observations to be taken first.

Mitica Marin · Prevention of Future Deaths report View report

12 Mar 2020 East London G. Irvine

Mitica Marin, aged 35, was found unresponsive at home on 11 April 2019 and died in hospital after prolonged resuscitation attempts. The cause of death was unascertained. The LAS investigation identified a four-minute delay in delivering the first defibrillator shock while Mr Marin was in a shockable rhythm, associated with the defibrillator being used in manual rather than automatic mode.

Thomas Alexander Ferdinand MAYHEW (known as Ned) · Prevention of Future Deaths report View report

23 Apr 2026 East Sussex L. Bradford

On 6 May 2024, 16-year-old Ned Mayhew was found hanging in a wooded area after leaving school and was taken to hospital, where his death was confirmed on 9 May 2024 following brain stem testing. The principal concern was that routing an emergency call reporting an apparently deceased person to the police before the ambulance service may result in valuable minutes being lost during the limited period in which treatment might prevent death.

Karen Lesley Peters · Prevention of Future Deaths report View report

17 Apr 2014 Plymouth, Torbay & South Devon A. Cox

Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.

Robyn Anne Chambers · Prevention of Future Deaths report View report

22 Jul 2025 Gwent C. Saunders

Robyn Anne Chambers was born prematurely at 23 weeks gestation and developed significant physical and neurological problems, including ongoing respiratory problems. She developed a chest infection on 26/10/2024 and died on 2/11/2024 at Ty Hafan Hospice. The report noted concerns about the estimated eight-hour ambulance response and delays in releasing ambulances from hospital emergency departments, although these were stated not to have affected Robyn’s care or outcome.

Gail Bailey · Prevention of Future Deaths report View report

23 Jan 2019 Lincolnshire P. Smith

Gail Bailey, who was nine weeks pregnant, developed abdominal discomfort while on holiday on 5 August 2017. An ambulance was called but arrived after a delay, and she was declared deceased at Boston Pilgrim Hospital later that evening. The report raised concerns about emergency communication and preparedness, including pre-alert calls that were not dated or signed and the apparent lack of advance warning to obstetric and gynaecology staff.

Joshua Harry Smith · Prevention of Future Deaths report View report

2 Dec 2016 North Northumberland T. Brown

Joshua Harry Smith, aged 16, fell from cliffs near Spittal Beach and was later swept out to sea while clinging to a rock. He was rescued unconscious and died at Wansbeck General Hospital. The report identified delays in locating him, unclear overall command and coordination, and failure to follow JESIP principles.

Max Carlton-Smith · Prevention of Future Deaths report View report

14 Jan 2015 Inner South London A. Harris

Max Carlton-Smith died after taking MDMA at an illegal rave and collapsing when emergency medical assistance was not summoned immediately. The rave had no on-site medical assistance, inadequate ventilation, and unregulated fire exits and procedures; the report also raised concerns about delays in calling an ambulance and the authorities’ ability to intervene at the squatted commercial premises.

Kaine Regan FLETCHER · Prevention of Future Deaths report View report

25 Jul 2025 South Yorkshire (Western) A. Pountney

Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.

Marion Hilda Prance · Prevention of Future Deaths report View report

15 May 2019 South Wales Central R. Knight

Marion Hilda Prance, aged 82, suffered a head injury after an unwitnessed fall at her care home and was given her usual morning dose of Rivaroxaban on the advice of paramedics. She was later diagnosed with a subdural haematoma, developed a catastrophic brain bleed and died the next day. The principal concerns were paramedic awareness and training regarding Rivaroxaban and the need for caution after head injuries caused by falls.

Colin Richard BROWN · Prevention of Future Deaths report View report

23 Dec 2025 North Yorkshire and York G. Kane

Colin Richard Brown attended York Hospital Emergency Department on 28 March 2025 and choked on food provided by the hospital, leading to a cardiac arrest and transfer to intensive care. He died on 31 March 2025. The concerns were that his care plan was not transported to hospital and that information about his choking risk might not be reliably communicated or checked during the handover period.

Michael Nestor WYSOCKYJY · Prevention of Future Deaths report View report

24 May 2022 Norfolk J. Lake

Michael Nestor WYSOCKYJY became unwell on 20 September 2021 and was taken to Queen Elizabeth Hospital, where delays occurred before a chest x-ray was performed. A large right-sided pneumothorax was identified shortly before he suffered cardiac arrest and was pronounced dead. Concerns related to delays in ambulance offloading and the lack of clear escalation arrangements to ensure requested x-rays were completed in a busy emergency department.