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Janet Rice · Prevention of Future Deaths report View report

23 Jul 2024 County Durham and Darlington J. Richards

Janet Rice, aged 65, died in hospital from pulmonary and cerebral embolism after surgery for a hip fracture sustained in an accidental fall. Anti-coagulant medication was inconsistently administered, including during a period when she was experiencing acute delirium; concerns included the absence of a capacity assessment, best-interests decision, escalation, or consideration of alternative treatment. The report also raised concerns about delays and limitations in the Trust’s patient safety investigation and the limited scope of related training.

Philip Allen · Prevention of Future Deaths report View report

27 Oct 2014 Inner South London P. Barlow

Philip Allen, who had vascular dementia, was transferred from The Oaks Care Centre to QEH in September 2012 following a deterioration in his condition and died there. The concern was that Quetiapine continued to be prescribed as a repeat prescription after specialist advice to discontinue it, because the surgery’s system did not prevent this; the inquest evidence was that the further prescriptions did not contribute to his death.

Mohammed Zeeshan Akram (Zee) · Prevention of Future Deaths report View report

27 Nov 2023 Inner North London M. Lee

Mohammed Zeeshan Akram, known as Zee, had a history of suicidal ideation and a psychotic disorder. He died at Whittington Hospital on 21 March 2023 after being found unresponsive at his flat. The principal concern was that GPs were not routinely informed when patients stopped taking prescribed medication, including where suicidal ideation or a risk of stockpiling might be present.

Lyn Maher · Prevention of Future Deaths report View report

3 Feb 2026 South Wales Central R. Knight

Lyn Maher, aged 79, was prescribed clarithromycin while taking simvastatin and was not advised to stop the statin. She was admitted to hospital, where the contraindicated co-ingestion was not identified, the statin continued, and rhabdomyolysis was missed; she died following cardiac arrest due to hyperkalaemia on 23 January 2024. The concerns included confusion among community pharmacists about clinical checks and confidentiality, and their limited access in Wales to relevant drug history and test results.

Eric Albert Gaskell · Prevention of Future Deaths report View report

16 Feb 2016 Manchester West R. Griffin

Eric Albert Gaskell attended Royal Bolton Hospital with chest pain on 6 November 2015 and was discharged with a presumed diagnosis of stable angina. He collapsed while working on 8 November 2015 and died at Salford Royal Hospital; the medical cause of death was ischaemic heart disease, coronary artery thrombus and coronary artery atheroma. The report raised concerns that Royal Bolton Hospital’s prescribing policy and pharmacy opening hours could prevent patients from obtaining medication, including potentially lifesaving medication, outside pharmacy opening times.

Philip David Ashton · Prevention of Future Deaths report View report

14 May 2018 Milton Keynes T. Osborne

Philip David Ashton, a resident of Mallard House, was administered warfarin in error on 13, 14 and 15 October 2017. He was found bleeding from an arteriovenous graft on 17 October, and the report raised concerns about the medication error, the lack of an emergency response and the unavailability of his medical information to ambulance staff; he later died in hospital.

Jamie Lee Poole · Prevention of Future Deaths report View report

15 Mar 2021 Stoke-on-Trent and North Staffordshire E. Serrano

Jamie Lee Poole, who had received a kidney transplant and was taking immunosuppressant medication, was admitted with low magnesium and calcium levels before collapsing in hospital on 28 June 2017. She died on 2 July 2017 after developing significant brain swelling; the recorded causes included cerebral oedema and electrolyte disarray with calcium and magnesium deficiencies. The report raised concern that routine magnesium monitoring for transplant patients varied between healthcare trust areas.

Linda Yvonne Fisher · Prevention of Future Deaths report View report

9 May 2014 Blackpool and the Fylde A. Wilson

Linda Yvonne Fisher was admitted to hospital with knee pain and was treated for a suspected deep vein thrombosis. She was found collapsed on 17 October 2013 and died from a pulmonary embolism. Concerns related to medication dosages being based on inaccurately assessed patient weight and relevant family medical history not being obtained and communicated effectively.

Shaun Daniel Houghton · Prevention of Future Deaths report View report

25 Sep 2023 Manchester West A. Walsh

Shaun Daniel Houghton was found dead in a rural area on 1 December 2022 after self-discharging from Atherleigh Park Hospital against medical advice the previous day. During the inquest, concerns were raised about self-discharge procedures, including the absence of routine referral to a Consultant or Senior Doctor, the lack of a checklist for junior doctors, and medication not being prescribed or dispensed at discharge.

Alexandra Bronte Roberts · Prevention of Future Deaths report View report

2 Jan 2025 Cheshire C. Keighley

Alexandra Bronte Roberts, who had a history of mental health issues, self-harm and Type 1 diabetes, died after intentionally overdosing on her prescribed insulin on 13 May 2023. The principal concern was that insulin could only be prescribed in pre-filled pens containing around 10 days’ supply, enabling access to a large overdose, whereas smaller amounts could have reduced the risk.

Rachel Morgan · Prevention of Future Deaths report View report

10 Feb 2017 Manchester South A. Morris

Rachel Morgan, who had post-natal depression with psychotic symptoms and was considered at high risk of suicide, was found with a ligature around her neck on 16 April 2016 and died from severe anoxic brain injury on 24 April 2016. The principal concerns were delays in reviewing her medication, failures to update risk assessments after information about her suicide risk was received, insufficient observation levels, and a lack of clarity about observation procedures.

Mr. Isaac BAHAR · Prevention of Future Deaths report View report

15 Jun 2015 Brighton and Hove V. Hamilton-Deeley

Mr. Isaac Bahar was admitted to hospital after a fall caused fractured ribs and a traumatic pneumothorax. Despite known stage four chronic kidney disease, he was prescribed and given codeine in contravention of national and local guidance, and later developed opioid toxicity and died. The inquest found the prescribing error was one of the causes of his death; chronic obstructive pulmonary disease was also deemed a contributory factor.

Margaret Jean Silver · Prevention of Future Deaths report View report

3 Jan 2018 Surrey A. Crawford

Margaret Jean Silver, an 85-year-old resident of a care home, developed pulmonary emboli after Rivaroxaban was discontinued following contradictory medication instructions in her hospital discharge summary. She later experienced reduced mobility, sustained a fractured femur in an assisted fall, developed a chest infection, and died in hospital. Concerns included contradictory discharge medication information, failure to identify that Rivaroxaban had been discontinued, and failures in communicating and implementing recommended discharge support and equipment.

Fallon Leanne ADAMS · Prevention of Future Deaths report View report

29 Dec 2025 Cambridgeshire and Peterborough S. Milburn

Fallon Leanne Adams was found unresponsive and cold in her cell at HMP Peterborough on 9 February 2023 and was declared deceased after CPR and a negative heart trace. The inquest concluded that she died from intoxication by mixed drugs, with illicitly obtained medication having a high probability of causing her death. Concerns included the combined sedative effects of prescribed and non-prescribed medication, a lack of specific warnings about over-sedation and death, and inadequate welfare checks and observations.

Linda Hudson · Prevention of Future Deaths report View report

24 Sep 2013 County Durham and Darlington A. Tweddle

Linda Hudson had been discharged from hospital after a previous suicide attempt and was found dead by hanging in her home two days later, although the exact time of death was unclear. Concerns included the quantity of medication supplied at discharge, failure to notify her family, and a delay in arranging follow-up contact after discharge.

Leslie Edmund Harding (Lez) · Prevention of Future Deaths report View report

8 Apr 2014 Plymouth, Torbay and South Devon A. Cox

Leslie Edmund Harding had a history of multiple sclerosis and recurrent pulmonary emboli, and died after collapsing on 28 September 2013. The report raised concerns about the lack of action after he was assessed with chest pain and suspected pulmonary embolus, gaps in anticoagulation prescribing and follow-up, insufficient efforts to address alleged non-compliance, and the absence of a prompt significant events review.

Roger Knight SMITH · Prevention of Future Deaths report View report

6 Feb 2026 Suffolk D. Stewart

Roger Knight SMITH, who had cerebral amyloid angiopathy and a history of strokes, was readmitted to West Suffolk Hospital in August 2023 and received tinzaparin for venous thromboembolism prophylaxis. He later suffered a cerebral haemorrhage and died on 12 September 2023; the inquest narrative attributed his death to the effects of a stroke brought about by tinzaparin administration. The principal concerns were failures in the electronic records system to flag relevant anticoagulation advice, inadequate communication with the patient and his family, and insufficient timely specialist stroke-team input.

John Ioannou · Prevention of Future Deaths report View report

6 Jan 2015 North London A. Walker

On 4 April 2014, John Ioannou fatally injured himself after jumping from a window at his home. The report identified a concern that there was no guidance for GPs when a patient was not collecting medication required to treat a mental health condition, and that this information was not available to the Mental Health Team.

Ms Cherry Lynne GARLAND · Prevention of Future Deaths report View report

8 Sep 2023 Avon R. Sowersby

Ms Cherry Lynne GARLAND died on 11 October 2022 in the Bristol Royal Infirmary from sepsis and right-sided heart failure after cardiac treatment, vascular injury, Covid and pneumonia. During her transfer from the Cardiac High Dependency Unit to the Cardiac Ward, a transcription error omitted antibiotics from her medication list, although the evidence accepted was that discontinuing them would have been reasonable at that time. The report raises concern that incompatible medication systems, manual transcription and insufficient pharmacist capacity create a known risk of future medication errors and deaths.

Judith Anne SAVILLE · Prevention of Future Deaths report View report

15 Jan 2015 Exeter and Greater Devon A. Cox

Judith Anne Saville, who had a long history of agitated depression and previous psychiatric admissions and ECT treatment, was found deceased at home on 28 January 2014. The inquest concluded that she died from a Zopiclone and Paracetamol overdose and that she had taken her own life. Concerns included the quantity of medication prescribed, the need for warnings about a history of overdose in the practice’s computer system, and implementation and auditing of an action plan.