1,410 reports
Information drawn from published reports and official responses.
Peter PETTITT, aged 86, died on 11 September 2023 after developing sepsis due to bronchopneumonia and acute pyelonephritis. The report raised concerns about inadequate care records, gaps in medication and catheter support, and insufficiently assured training and management arrangements for the commissioned care provided to him.
Multi-Care Community Services Suffolk
Aaron Atkinson was found deceased at his home on 20 April 2023, and the death was unexpected. The inquest conclusion was unascertained, with medical evidence considering seizure and positional asphyxia, or cardiac arrhythmia associated with prescribed medication. The principal concern was that annual reviews for people taking long-term antipsychotic medication may not consistently include ECGs despite recognised risks of QT interval prolongation and lethal cardiac arrhythmias.
National Institute for Health and Care ExcellenceNHS Derby and Derbyshire Integrated Care Board
Kenneth Edwards fell twice on 22 and 23 March 2025 and died on 23 March 2025 following traumatic subdural and subarachnoid haemorrhages. The principal concerns were that a subdural haematoma was missed on the first CT scan and that blood-thinning medication was administered while awaiting the results of a second CT scan to identify brain bleeding.
Stockport NHS Foundation Trust
Feni Lee, who had Behçet’s syndrome, took an excessive quantity of colchicine over a two-week period in September 2017 and died in hospital on 17 September 2017 after developing severe side effects, including liver necrosis. The concerns included the thoroughness of the medication review, the failure to address her loss to hospital follow-up, and delays and ineffective processes for redirecting correspondence between two GP practices.
Bexley Medical Group
John Alfred Roberts, aged 78, was admitted with vomiting and retching and was found to have an inoperable perforated sigmoid colon. He was discharged home for palliative care and died there on 26 June 2021. The substantive concerns related to an inadvertent reduction in his prednisolone dosage at Royal Cornwall Hospital and the adequacy of medication-error arrangements, as well as omissions in NICE’s BNF guidance about the risk of bowel perforation associated with corticosteroids in people with diverticular disease.
National Institute for Health and Care ExcellenceRoyal Cornwall Hospitals NHS Trust
Terence Bradfield entered Derriford Hospital on 1 December 2013 with gastric bleeding and died on 17 December 2013, primarily from the consequences of his gastrointestinal bleed. The report raised concerns that his long-term steroid medication was not given or adequately managed, including when he was vomiting, and about staff training and the absence of policies for steroid management and “Nil by Mouth” patients with co-morbidities.
University Hospitals Plymouth NHS Trust
Eirwen Rebecca Hollister, who had a history of mental health issues and overdoses of prescribed medication, was found deceased at home on 10 May 2022. Evidence at the inquest identified that prescriptions continued after overdoses, and that there was no process to prevent further prescriptions before a full review.
Heathview Medical Practice
Doris Daisy Laura Clark fell at home on 3 November 2018 and remained on the floor for around six hours before being taken to hospital with a suspected fractured neck of femur. She received multiple doses of morphine, including an intravenous dose that was not titrated, and was not monitored in accordance with Trust policy; concerns included inconsistent use of millilitres and milligrams between pre-hospital and hospital services when recording opiate medication.
Barking, Havering and Redbridge University Hospitals NHS Trust
Peter McCarthy fell from his wheelchair at home on 25 November 2023, was found the following morning, and was taken to hospital with rib fractures and a subdural hematoma. He deteriorated and died on 30 November 2023 from heart failure and pneumonia. The principal concern was the absence of a protocol governing whether anticoagulant medication should be given to a client after a fall without medical oversight.
Care4u Health Care Limited
Michael John Vince, a patient of the community mental health team receiving treatment for schizo-affective disorder, was found deceased at home on 19 June 2021 after apparently taking an overdose. The concerns included prolonged prescribing of medication for insomnia, lack of meaningful prescription review, failure to share evidence of dependence, and failure to monitor the frequency of PRN administration.
High Street SurgeryNorth East London NHS Foundation Trust
Kevin Lapwood, aged 63, was acting as a volunteer safety diver at Wraysbury Dive Centre on 12 February 2022 after failing an HSE medical in October 2021. He got into difficulty in very cold water and died at Wexham Park Hospital the next day; the recorded cause of death was immersion pulmonary oedema, hypertension and coronary artery disease. Concerns included medical requirements and awareness for volunteer divers, awareness of immersion pulmonary oedema risks, the guidance on shore support, and potential ambiguity in HSE legislation and guidance concerning volunteers.
British Diving Safety GroupHealth and Safety Executive
Lewis James Doyle, who had multiple medical conditions including coronary artery disease and recurrent depressive illness, died on 8 January 2019 after developing worsening respiratory illness and pulmonary oedema following traumatic injuries sustained when he fell in front of a train. The principal concern was that discharge letters, including information about suspended or stopped medication, should be sent to all current medical attendants across primary, secondary and tertiary care.
Department of Health and Social CareNHS England
Betty Addison fell while walking for a bus, sustained a fracture to her right femur, underwent surgery, and later died after collapsing at a care home on 2 December 2015. She was given five additional Dalteparin injections beyond those prescribed, raising concerns about the control and monitoring of medication administration at Alexandra Court Care Home, although the report states that the additional medication was not causative or contributory to her death.
Cuerden Care Homes
Thomas Theo Charles Thurling, who had increasing depression, anxiety and suicidal ideation, was found dead at home on 28 October 2014 after he did not respond to visits. The inquest concluded that he took his own life, with medical cause of death recorded as asphyxiation. Concerns included medication changes not being adequately monitored, a prolonged absence of his Care Co-ordinator without alternative cover or review, and staff shortages.
Norfolk and Suffolk NHS Foundation Trust
Carol Ann Gibson, aged 65, died at home on 8 August 2012 following an adverse reaction to nitrofurantoin, which had been prescribed despite an alert in her medical records about a previous adverse reaction. The concerns included failure to heed and appropriately investigate the alert, and possible weaknesses in the practice’s systems and staff understanding for managing patient safety alerts.
Castlefields Health CentreNHS England
Maureen Anne Campbell-Scott died from multiple injuries after falling from a ledge at the Exchange Shopping Centre car park on 16 June 2017. The report identified concerns about delays and errors in mental health referrals, delayed communication of medication changes, prescribing that did not always follow specialist directions, and a lack of joint working between mental health services and the GP practice.
Medical CentreNorth East London NHS Foundation Trust
Susan Ann Gladstone was admitted to Lister Hospital with pyelonephritis and an extremely elevated INR after taking warfarin and recently prescribed tramadol. She died on 8 January 2021; the principal concern was a potentially fatal interaction between tramadol and warfarin that caused exceptional thinning of her blood and brain bleeding.
Recipient name withheld
Kim Georgina Stroud was admitted to hospital for a bladder tumour procedure that had previously been cancelled five times, became unwell with a chest infection and later tested positive for covid, and died suddenly on 11 October 2022. Concerns included medication being left unsupervised despite delirium, with tablets signed for as administered, and inadequate personal care when she was found heavily soiled with urine and faeces.
The Queen Elizabeth Hospital, King's Lynn
Paul Geoffrey Mullen died at his home in Wigan on 22 June 2017. He had been receiving daily methadone but did not collect it for three consecutive days before his death. The report raised concerns that the pharmacy’s failure to report the missed collections promptly to his designated Key Worker, and the three-day reporting threshold, may have delayed checks on his welfare.
Greater Manchester Mental Health NHS Foundation TrustHindley Health Centre Pharmacy
Alan Mitchell was admitted to hospital on 8 March 2025 with evidence of an upper gastro-intestinal bleed. On 12 March 2025, he suffered a heart attack, became unresponsive and died shortly afterwards. The report raised concern that software could remove a lifelong repeat prescription without notifying or obtaining a choice from the GP, creating a risk that patients may not receive needed medication.
Optum
