Search PFD Monitor

June Elsie Parkes · Prevention of Future Deaths report View report

23 Mar 2016 West Yorkshire (Western) M. Burke

June Elsie Parkes became unwell with symptoms of an upper gastrointestinal bleed and was admitted to hospital on 14 December 2014. She later deteriorated and died shortly after being transferred to Huddersfield Royal Infirmary on 17 December 2014. The concerns included delays and gaps in systems for urgent or emergency endoscopy and surgery, monitoring and escalation, record keeping, and the transfer of critically ill patients.

Philip Hawkins · Prevention of Future Deaths report View report

18 Jul 2023 North Wales (East and Central) D. Pojur

Philip Hawkins, aged 97, suffered a fall at home on 18 March 2023, was transferred by ambulance to hospital, and died on 23 March 2023. Concerns included delays in being admitted and allocated a bed, insufficient staffing, inability to provide care, gaps in nursing documentation, and failures in aspects of assessment and treatment.

Michelle Whitehead · Prevention of Future Deaths report View report

19 Jan 2022 Nottinghamshire E. Didcock

Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

Dean Ryan CROSSMAN · Prevention of Future Deaths report View report

26 May 2022 Teesside and Hartlepool J. Wharton

On 18 June 2019, Dean Ryan Crossman was found hanging after contact with emergency and crisis mental health services following suicidal behaviour the previous evening. The report identifies ongoing concerns about out-of-hours access to second doctors for Mental Health Act assessments and delays in securing private ambulance attendance.

Ian George Stanton SIMPSON · Prevention of Future Deaths report View report

12 May 2025 Inner North London I. Potter

Ian Simpson fell in August 2024, sustained a traumatic spinal injury, and later required a long-term catheter. He was found unresponsive at Magnolia Court Care Home on 16 December 2024, was taken to hospital after a delay in calling an ambulance, and died that evening from sepsis secondary to a urine infection. The principal concerns were the delay in calling an ambulance and inadequate and inaccurate care-home record-keeping, including retrospective or misleading entries.

Mr Gregory Rekowski · Prevention of Future Deaths report View report

28 Dec 2018 Manchester North J. Kearsley

Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.

Frazer Charlie Williams · Prevention of Future Deaths report View report

31 May 2024 Dorset R. Griffin

Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.

Michael Lee Thorley · Prevention of Future Deaths report View report

7 Jul 2015 Manchester South J. Pollard

Michael Lee Thorley was found at his home after a delay in gaining entry following an emergency ambulance call. The medical cause of death was combined opiate/opioid toxicity, and the pathologist said there was a chance his life might have been saved if naloxone had been administered immediately. The report raised concerns about the delay in entry, the absence of a clear policy for forced entry, shortcomings in searching and investigating the scene, and the failure of a Detective Inspector to attend.

Tammy Mary Louise WATKINS · Prevention of Future Deaths report View report

5 Jan 2024 Nottinghamshire L. Bower

Tammy Mary Louise Watkins died on 6 June 2021 after swallowing a plastic twistable crayon that perforated her bowel while she was detained at Rampton Hospital. The principal concerns were failures to risk-assess and manage foreign-body ingestion, recognise and escalate her deteriorating condition, follow NEWS2 requirements, and coordinate an emergency transfer to hospital. The report also identifies poor-quality acute physical healthcare and confusion about emergency medical calls.

Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report View report

13 Sep 2022 Worcestershire J. Puzey

Mr Peter Antony Joseph Pearson died at Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia, which was in all probability acquired while he was resident at Corbett House Nursing Home. Concerns included a delay in calling an ambulance despite his critical condition, incomplete nursing and medication records, failures in oral-cavity checks, shortcomings in management oversight, and an ineffective investigation into his death.

Mr. Steven John Welch · Prevention of Future Deaths report View report

7 Aug 2018 South Wales Central S. Richard

Mr. Steven John Welch was found at home on 26 December 2017 after a reported fall and head injury, and was later diagnosed with a subarachnoid haemorrhage, hydrocephalus and an aneurysm. His condition deteriorated during delays in assessment, neurosurgical admission and transfer of radiology images for specialist review; he was transferred to Southmead Hospital but died from a pulmonary embolism, with deep vein thrombosis and subarachnoid haemorrhage also recorded in the medical cause of death. The principal concerns included delayed emergency assessment and neurosurgical treatment, lack of interventionist radiology cover, and inadequate facilities for transferring radiological images to hospitals outside Wales.

Harry Peter DUNN · Prevention of Future Deaths report View report

4 Jul 2024 Northamptonshire A. Pember

Harry Peter Dunn, aged 19, died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The report raises concern that paramedics cannot access nasal or buccal analgesics that may assist with potentially lifesaving pre-hospital treatment or faster patient extraction when time is critical.

Mr Frederick White · Prevention of Future Deaths report View report

3 Jun 2015 Black Country Z. Siddique

Mr Frederick White suffered a fall at a retirement home on 29 March 2015, sustaining a traumatic spinal cord injury, and died on 2 April 2015. The report identified concerns about failures to recognise symptoms of spinal injury and to immobilise him initially and at hospital, with the inquest finding that these collective failures contributed to his death.

Mr Luke John Chatterton · Prevention of Future Deaths report View report

19 Sep 2025 South London A. Harris

Mr Luke John Chatterton had a history of Clozapine-related constipation and developed vomiting, severe pain and suspected intestinal obstruction. He was discharged from the emergency department after an X-ray, later deteriorated and suffered a cardiac arrest, with delays in advanced life support before he died. The principal concerns were the safety and timeliness of resuscitation for detained mental health patients and the identification and escalation of risks associated with suspected obstruction in patients taking Clozapine.

John Howe · Prevention of Future Deaths report View report

25 Jun 2024 Manchester South L. Costello

John Howe, an 81-year-old man with diabetes and peripheral vascular disease, underwent an amputation for diabetic foot sepsis and later died in hospital on 28 May 2023 from hospital-acquired pneumonia against a background of necessary surgery and wound haemorrhage. Concerns included his late discharge home, which resulted in him being left outside while access was addressed, continuing late discharges despite a policy change, ambulance service awareness of discharge timings, and delays and factual inaccuracies in the Serious Incident Review.

Linda Oldland · Prevention of Future Deaths report View report

14 Aug 2023 Surrey A. Crawford

Linda Oldland died at Hydon Hill Nursing Home on 3 January 2022 from a urinary tract infection that infected both kidneys and resulted in sepsis. Concerns included failures to share information about positive urine tests and the GP’s treatment plan, delayed antibiotics, failure to recognise cardiac arrest, and incorrectly informing ambulance staff that a valid DNAR form was in place.

Kevin Anthony Forster · Prevention of Future Deaths report View report

28 Oct 2015 County Durham and Darlington A. Tweddle

Kevin Anthony Forster died in his prison cell at HMP Durham on 14 September 2014 after taking drugs he had hidden within his body. Staff identified that he was under the influence of an unknown substance, but no thorough or clinical assessment was undertaken. The principal concerns included inadequate policies, training, assessment, observation, treatment planning, communication and emergency response to prisoners who may have overdosed.

Dorothy Lilian REID · Prevention of Future Deaths report View report

4 Feb 2025 North East Kent C. Wood

Dorothy Reid, a 91-year-old woman, suffered spinal fractures after a fall and later died from a pulmonary embolism on 3 April 2024. Concerns included delays and poor conditions in the emergency department, the impact of hospital bed shortages on emergency care, and patients’ reluctance to attend hospital because of long waiting times.

Fern-Marie CHOYA · Prevention of Future Deaths report View report

31 Jul 2019 Inner North London M. Hassell

Fern-Marie Choya died from hypovolaemic shock caused by massive intra-abdominal bleeding following rupture of the abdominal gravid uterus during a monochorionic diamniotic pregnancy. Concerns included failure to communicate her pregnancy during the pre-hospital alert and on hospital arrival, a 16-minute delay in recognising the pregnancy and calling the obstetric team, and treatment focused on possible pulmonary embolism before free fluid was identified.

Louis James Rogers · Prevention of Future Deaths report View report

28 Mar 2023 Surrey K. Henderson

Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.