6,433 reports
Information drawn from published reports and official responses.
Wilfred Roy Breakell died at Royal Bournemouth Hospital from multiple cervical spine fractures sustained when he fell into a storm drain while riding his bicycle. The report raised concern that there was still no barrier between the highway and the storm drain, creating a risk to cyclists and vehicles leaving the highway.
Bournemouth, Christchurch and Poole Council
Neil Challinor-Mooney was admitted to hospital under the Mental Health Act after an acute relapse in his mental health. After disclosing suicidal thoughts and a plan to hang himself using his shoes, his trainers were not removed, and he was later found suspended by their laces; he died on 18 November 2018. Concerns included failures by nursing staff to follow risk assessment and management policy, and delays and amendments affecting the integrity of electronic medical records.
North East London NHS Foundation Trust
Liam Kenyon was found unconscious in his supported housing accommodation on 17 July 2020 after a suspected opioid overdose, refused hospital admission, and was later found deceased on 18 July 2020. The concerns included unclear responsibilities for supported housing staff, failure to conduct agreed hourly checks and other welfare and risk-management actions, inadequate escalation of staffing difficulties, and a deficient Serious Incident Review process.
Adullam Homes Housing Association Limited
Richard Burgess died at Holy Cross Nursing and Residential Care Home, Sunderland, on 30 November 2018 after being punched three times in the head by another patient on 31 August 2018. The principal concerns related to dementia care, including multidisciplinary staffing, proactive assessment and risk management, family engagement, person-centred care, and converting policy into practice.
Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustDepartment of Health and Social Care
Callum Rhys EVANS, aged 17, died after falling onto the live rail at Hinton Admiral Railway Station while intoxicated with alcohol. The report identified insufficient signage communicating the presence of the live rail and the risk to life, particularly from the station entrance and central part of the platform.
Network Rail
Todd James Salter was released from prison on licence in July 2019 and later experienced difficulties obtaining housing, drug support and mental health support. On 1 October 2019, he hanged himself outside Doncaster police station. The concerns included inadequate probation knowledge of available services, poor engagement and collaborative working between agencies and family, and the apparent progression toward criminal acts to obtain treatment and support.
National Probation ServiceProbation Service
Juliet Saunders, a 25-year-old woman with Cornelia De Lange Syndrome and a profound learning disability, attended hospital on 7 March 2020 with abdominal pain and vomiting and died at home the following day. The report identified concerns including misinterpretation of abdominal x-rays, failure to diagnose intestinal obstruction, inadequate escalation and supervision, departures from transfer and discharge procedures, lack of safety-netting advice, and insufficient support for patients with learning disabilities at weekends.
Barking, Havering and Redbridge University Hospitals NHS TrustQueen's Hospital, Romford
Lola Sheldrake died aged 13 days on 23 December 2019 from severe anaemia caused by haemolytic disease of the newborn, which developed untreated after her discharge from hospital. The report raised concern that there were no national guidelines for monitoring and treating infants at risk, particularly following acute treatment after birth or discharge.
British Association of Perinatal MedicineNational Institute for Health and Care Excellence
Lynne Lawrence tripped on an uneven pavement on 21 September 2020 and sustained a head injury that was not initially diagnosed on scan. She later collapsed, suffered an intracerebral haemorrhage worsened by warfarin, and died in hospital on 23 September 2020; the report raised concern about the condition of the pavement and potential risks to people, especially those with reduced mobility.
Blaenau Gwent County Borough Council
Stephen Thurm died at the scene on 5 February 2020 after being found suspended by a rope from a tree, with the medical cause of death recorded as hanging. The concerns included family information about self-harm risk not being taken into account in care planning and risk assessments, no designated time for care coordinators to write detailed notes contemporaneously, and insufficient consideration of the mental health and care needs of his main carers.
Greater Manchester Mental Health NHS Foundation TrustNHS England
Sarah Margaret Clarke, a 23-year-old university student with significant mental health difficulties, was found deceased in her university accommodation on 21 November 2019 after sending an email indicating that she intended to end her life. The concerns included inadequate follow-up after she became extremely distressed, insufficiently robust systems for managing and safeguarding students at high risk of self-harm, and failure to implement relevant national guidance or provide adequate oversight and learning.
Department for EducationNHS EnglandUniversity of Surrey
Steven James Oscroft was killed instantly when a piece of concrete fell from an oncoming lorry and smashed through his windscreen while he was driving on 7 July 2020. The concerns included the practice of mounding loads above the sides of tipper lorries and using sheeting systems that could leave material uncovered and liable to fall or be blown from the vehicle.
Driver and Vehicle Licensing AgencyDriver and Vehicle Standards AgencyPaul Wainwright Construction Services Limited
Mary Anne Mellor died at Stepping Hill Hospital from a ruptured thoracic aortic aneurysm caused by a leak from an aortic stent. The leak was not identified on CT scans in 2019 and 2020 because 3D reconstruction was not used. Concern remained that other patients with aortic stents could be at risk of leaks not being identified, potentially depriving them of elective surgical management before life-threatening complications occurred.
Liverpool Heart and Chest HospitalLiverpool Heart and Chest Hospital NHS Foundation TrustMedica Reporting Limited
Paul Steven Reynolds died on 16 February 2017 after being restrained by the neck and placed in a prone position at Pontins Pakefield in Lowestoft. The principal concerns included inadequate monitoring of his breathing, failure to place him in the recovery position, insufficient staff training, unclear responsibilities, and poor sharing of information with police.
Britannia Hotels Group LimitedBritannia Jinky Jersey LimitedNational Police Chiefs’ CouncilNorfolk ConstabularySuffolk Constabulary
Coral Amy O’Donnell developed severe pneumonia after presenting with cough and cold-like symptoms and died in hospital on 17 May 2019 after prolonged intensive care. Concerns included failure to consider PVL Staphylococcus aureus promptly, limited awareness of relevant guidance and internal systems, problematic communication between critical care and microbiology teams, and insufficient microbiology staffing.
Blackpool Teaching Hospitals NHS Foundation TrustNHS Lancashire and South Cumbria Integrated Care Board
Charlotte Lucy Swift was found unresponsive at her parents’ home on 9 April 2020 and was pronounced deceased at 19.43 hours. She had an eating disorder and urgently needed specialist inpatient treatment, but no bed became available before her death; the report also describes a national shortage of placements and an administrative error that meant she did not receive an expected update from her Consultant.
NHS England
Paris Alan George Lapper, aged 19, was found deceased in his room at the Wolsey Hotel on 13 August 2020 and was declared deceased at 1125hrs. The post-mortem recorded respiratory depression due to opiate and benzodiazepine toxicity. The report raised concerns that he obtained duplicate prescriptions from multiple providers because providers lacked a central record or mechanism to check prescriptions issued elsewhere, creating a risk of medication misuse and fatal outcomes.
NHS England
John Lott underwent surgery to form a defunctioning ileostomy and subsequently became seriously unwell, including inadequately treated hypoglycaemia, myocardial ischaemia and infarction. He died on 8 November 2020 after two occasions when transfer from the private hospital to an NHS hospital with appropriate critical care facilities was considered necessary but did not occur. Concerns included missed transfer opportunities, inadequate management of hypoglycaemia, and a lack of contact with the on-call anaesthetist when the consultant was unavailable.
Consultant orthopaedic surgeonNuffield HealthNuffield Health Brighton Hospital
Eva Hayden, aged four, developed neutropenia following an illness and later became seriously unwell with fever-like symptoms. She collapsed on 10 January 2020 and died in the emergency department on 11 January 2020; the inquest found sepsis and bone marrow hypoplasia. Concerns included missed follow-up of her neutropenia, inadequate communication between hospitals, and insufficient communication with her parents about infection risks.
Mersey and West Lancashire Teaching Hospitals NHS TrustSouthport and Ormskirk Hospital NHS Trust
Macaulay Wilson had a long-term indwelling urinary catheter that was not changed for almost a year, despite the catheter reportedly needing replacement every 12 weeks. The inquest determined that the failure to change it caused urosepsis. Concerns included failures by the hospital urology department to risk assess and arrange appropriate catheter changes, district nurses not enquiring about catheter changes, and unclear communication by the GP practice.
Lower Clapton Group Practice
