6,433 reports
Information drawn from published reports and official responses.
Amy Chiverall, a resident of Royley House Care Home, had an unwitnessed fall on 1 July 2020 and was later found to have multiple rib fractures and a traumatic pneumothorax. The concerns included that her fixed call bell was out of reach, medical attention was not sought in a timely manner, and post-fall observations were not conducted in line with care home policy.
RochCare (UK) Ltd
Richard John Dyson and Simon Brian Midgley were guests at the Cameron House Hotel when a fire broke out on 18 December 2017. They were found unresponsive by firefighters and pronounced dead later that morning; the inquest concluded that both were unlawfully killed as a result of inhalation of smoke and fire gases and the hotel fire. The principal concerns were the lack of a readily accessible and accurate guest list and the resulting delay in identifying that the two men were missing, which impeded rescue efforts.
Department for Business, Energy & Industrial Strategy
Ann Coles was admitted to Frimley Park Hospital in March 2019 with pneumonia and later developed multi-organ failure, dying on 12 March 2019. The principal concern was that long-term amiodarone can cause lung toxicity and fibrotic changes, while there was no requirement for lung imaging to monitor patients prescribed the medication long term.
Royal College of General PractitionersRoyal College of Physicians
Anthony Wilkinson died on 4 April 2018 after choking, with the inquest concluding that he was unlawfully killed as a result of foreign body obstruction of the airway. The report identifies concerns about the failure to incorporate Speech and Language Therapy advice on diet and supervision into care plans, risk assessments and staff communications, alongside wider concerns about care-provider governance and regulatory oversight.
Care Quality CommissionSouth West Yorkshire Partnership Teaching NHS Foundation TrustStars Social Support Limited
Natasha Jennifer Irene Crabb died at Princess Gardens, Woking, on 29 June 2018 after continuing to inhale butane gas following her self-discharge from hospital. The substantive concerns were that inhaling butane was lawful, there were no legal powers to prevent a person with capacity from inhaling it or to remove it from them, and there was no restriction on the amount of butane that could be purchased.
Department of Health and Social CareHome Office
Gary Day underwent an endoresection operation for choroidal melanoma at Moorfields Eye Hospital on 15 December 2020 and died the following day after becoming severely unwell from an air embolus. The concerns identified were that the risk of death from air embolism was not explained, no post-operative check for air embolus was carried out, and he was discharged without an overnight stay or access to his earlier medical notes when transferred to another hospital.
Moorfields Eye Hospital NHS Foundation Trust
Hannah Elizabeth Browning, who was receiving treatment for mental health issues and had a history of self-harm and suicidal thoughts, expressed an intention to end her life on 10 October 2018. She subsequently placed a ligature around her neck and sustained a hypoxic brain injury, dying at Wrexham Maelor Hospital on 12 October 2018. The principal concern was that inadequate arrangements and insufficient efforts were made by Mental Health Services to protect her and contact her after she indicated an immediate risk of harm.
Betsi Cadwaladr University LHBWrexham County Borough Council
Mina TOPLEY-BIRD, who had a severe and enduring mental illness and a history of suicide and self-harm attempts, was admitted to West Park Hospital after attempting to run into traffic and stab herself. On 8 May 2019, after being told that no bed was available for her in London, she said words to the effect of “I may as well kill myself”; she was later found hanging in her room and pronounced dead. Concerns included incomplete access to historic medical records, inability to print and share documents across NHS Trust systems, uncertainty about ligature-point assessments, limited bed-management coverage, and incomplete risk-assessment and safety-summary processes.
Care Quality CommissionDepartment of Health and Social CareSouth London and Maudsley NHS Foundation TrustTees, Esk and Wear Valleys NHS Foundation Trust
Janet Willcock, aged 61, was diagnosed with critical aortic stenosis and underwent surgery on 17 November 2020. She suffered a major stroke on 19 November and died on 21 November 2020; a principal concern was that her chest was not auscultated during two earlier hospital attendances, representing a missed opportunity to diagnose and treat the aortic stenosis earlier.
University Hospitals Sussex NHS Foundation Trust
Raphael Maximilian Kolbe was delivered at term after an uneventful pregnancy, but a cord prolapse during delivery was not recognised until fetal compromise had occurred. He died six weeks later in Kingston Hospital after transfer for palliative care. The concerns identified included inadequate monitoring during induction labour and epidural re-siting, unclear staff roles, and differences between hospital policy and practice.
HCA Healthcare UK The Portland Hospital
Pauline BRUMFITT died on 15 April 2020 after a fall at a care home led to hospital admission and diagnosis of an intracranial bleed. The concerns were that falls risk assessments, prevention measures and referrals were not implemented after her previous falls, and that the incident was not promptly reported or investigated.
Care Quality CommissionMr John Brumfitt (son)Office of the Chief CoronerWidnes Hall
Imre Paul Thomas died at HMP Garth on 12 September 2019 after an overdose involving tramadol and other prescription medication obtained illicitly. The report raised concern that repeated cancellations of hospital appointments placed vulnerable prisoners at risk, and identified the possibility of prison clinics for visiting hospital consultants as an issue for investigation.
NHS England
Steven Charles Costello attended the Princess Royal Hospital on 3 October 2019 after disclosing suicidal thoughts and having a rope at home. He remained in A&E overnight because no hospital bed was available, and was found hanging at home on 4 October after leaving the department. The substantive concerns included inadequate documentation and review of his care and condition in A&E, including the failure to update his paper notes at the required intervals.
University Hospitals Sussex NHS Foundation Trust
Joan Mavis COLEY, who had end stage renal failure requiring dialysis, diabetes and an infected right foot, suffered a cardiac arrest after air entered her central dialysis line while blood was being taken. She was resuscitated but subsequently developed sepsis and died on 27 November 2020. The principal concerns were inadequate training, supervision, competency assessment and handover for junior doctors taking blood from central lines, together with the absence of a clear standard operating procedure.
Aston Medical SchoolBirmingham Medical SchoolDepartment of Health and Social CareGeneral Medical CouncilSandwell and West Birmingham Hospitals NHS TrustUK Foundation Programme
Nicholas Hugh Winterton developed Mycobacterium chimaera infection after aortic valve replacement surgery involving a heater-cooler unit in May 2016. The infection led to endocarditis, sepsis and multi-organ failure, and he died on 29 September 2018. The principal concerns were that the nationally reported infection risk was based on outdated and incomplete data, and that equipment use was not recorded and cleaning was performed less frequently than recommended by the manufacturer.
College of Clinical Perfusion ScientistsNational Institute for Cardiovascular Outcomes ResearchPublic Health EnglandSociety for Cardiothoracic Surgery in Great Britain and Ireland
MOHAMMED BILAL ZEB, aged 18, drowned after jumping into the River Wharfe at Linton Falls on 31 July 2020; he could not swim and became unresponsive. Concerns included the absence of flotation or rescue aids, difficult access and conditions for rescuers, and a lack of apparent safety warnings about hazards including cold water, water flow and underwater obstructions.
North Yorkshire CouncilYorkshire Dales National Park AuthorityYorkshire Water Services Limited
Raymond Alfred POWELL became increasingly frail, moved into Cole Valley Nursing Home, and suffered falls on 3 November 2020 that caused an acute subdural haematoma. He later developed an infection and seizure and died on 5 December 2020. Concerns included failures to record a preceding fall, update his falls risk assessment, accurately document observations, formally review the circumstances, and comply with court orders for evidence, creating an ongoing risk to other residents.
Cole Valley Care Limited
Roy Morris was found deceased in Birch Wood on 30 June 2019, having probably hanged himself there on the night of 26/27 May 2019. At the time, he was under the care of community mental health services after discharge from inpatient care. The substantive concerns were the absence of a detailed written care plan, the late allocation of a care coordinator, and insufficient opportunity for his family to engage with the inpatient team.
Oxford Health NHS Foundation Trust
Nicholas Rousseau attended Milton Keynes University Hospital on 3 and 5 October 2019 and died at home on 9 October 2019, aged 47. During his first attendance, his lactate level was 3.9 and he was discharged. The report identified conflicting views among senior Accident and Emergency staff about the significance of elevated lactate and whether it should be repeated, with concern that disregarding the NICE guidelines posed a threat to patients with sepsis and elevated lactate levels.
Milton Keynes University Hospital
Bathsheba Bianca Kay Shepherd, known as Kay, was fatally stabbed by her housemate at some point between 10 and 11 November 2015 and was pronounced deceased on 11 November 2015. The report identified concerns about her being housed with a dangerous and vulnerable housemate, failures in risk assessment and rehousing, and her lack of GP registration and associated support.
Central and North West London NHS Foundation TrustNHS England
