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William James Moody · Prevention of Future Deaths report View report

25 Sep 2019 Hampshire S. Marsh

William James Moody, aged 85, intentionally entered the River Itchen from the banks of his home on 19 April 2019 and could not be revived after being taken to Southampton General Hospital. The report raises concerns that Hampshire’s 999 call-handling system may cause delays, missed triage opportunities and inadequate information-sharing between emergency services during mental health crises involving suicidal ideation.

Liam Stephen Allan · Prevention of Future Deaths report View report

30 Jan 2025 West London A. Van Dellen

Liam Stephen Allan was arrested alongside the River Thames on the evening of 26 August 2022, entered the river, and drowned. The report identified concerns about inadequate lighting and visibility of riverside buoyancy aids, and about delays in alerting the London Fire Brigade because notification was made by telephone rather than through the faster CAD-mediated system.

James William Francis · Prevention of Future Deaths report View report

19 Jun 2019 West Sussex P. Schofield

James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.

Kirsty Michelle Hendry · Prevention of Future Deaths report View report

20 Oct 2023 Manchester South A. Mutch

Kirsty Michelle Hendry developed headache and vomiting, later deteriorated, and died at Salford Royal Hospital on 11 April 2023. The report describes a subarachnoid haemorrhage caused by a burst aneurysm that was not identified until severe vasospasm and neurological compromise had developed. The principal concerns were limited awareness of the key symptoms in primary care, delayed referral and imaging, and an incorrectly reported CT scan.

William Thomas Anderson · Prevention of Future Deaths report View report

17 Oct 2014 West Yorkshire Eastern M. Williamson

William Thomas Anderson died in his cell at HMP Wealstun on 19 September 2010 after taking prescription medication belonging to others and drinking hooch, having appeared intoxicated or under the influence of alcohol or drugs the previous afternoon. The concerns included insufficient vigilance around inmate gatherings involving drugs and alcohol, incomplete staff training and recording of observations, failure to use an emergency code, and delay in summoning paramedic assistance.

Joanne Louise STONES · Prevention of Future Deaths report View report

30 Jul 2025 North Yorkshire and York G. Kane

Joanne Louise Stones, who had Anti-Phospholipid Syndrome and Addison’s Disease, was admitted with abdominal pain and diagnosed with acute cholecystitis with gallstones. Her condition deteriorated and she died in intensive care on 17 September 2023. Concerns included delays in prioritisation, treatment with fluids and antibiotics, recognition of her Addison’s Disease, and consideration of her underlying conditions in her treatment plan.

Barbara Wingate · Prevention of Future Deaths report View report

10 Feb 2026 Kent and Medway C. Wood

Barbara Wingate, a 71-year-old woman, fell at home on 18 May 2025, sustained multiple pelvic fractures, suffered a cardiac arrest and died on 21 May 2025 following multiple organ failure. The inquest identified avoidable delays in diagnosing and treating her pelvic fractures. The report also raised concerns about emergency department capacity, delayed discharge of medically fit patients, and insufficient timely community care or alternative placements, creating risks for other critically ill patients.

Ronald James JEPSON · Prevention of Future Deaths report View report

11 Mar 2024 Coventry D. Henry

Ronald James Jepson, who resided at a mental healthcare facility and had a known risk of choking, suffered an unwitnessed choking episode after being provided with supper and died in hospital on 15 March 2023. Concerns included delayed and suboptimal CPR, staff calling 111 rather than 999, and infrequent and ineffectual emergency training for care home staff.

Nimo OSMAN · Prevention of Future Deaths report View report

12 Aug 2024 Inner North London I. Potter

Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

Sarah Ann Tyler · Prevention of Future Deaths report View report

13 Jan 2017 North Wales (East and Central) J. Gittins

Sarah Ann Tyler was admitted to the Emergency Department on 8 February 2015 following an overdose of co-codamol and, while awaiting admission, used ECG leads as a ligature, resulting in a hypoxic brain injury. The substantive concerns were delays in hospital admissions due to insufficient beds and more acute bed blocking at weekends because of reduced discharges.

Michael HUGGON · Prevention of Future Deaths report View report

8 Jul 2024 Cumbria N. Shaw

Michael Huggon, who had declining health and profound anaemia, became seriously unwell on 6 February 2024. After delays in obtaining urgent medical assistance and a hospital admission was declined, he collapsed in cardiac arrest shortly after midnight and died in hospital on 7 February 2024. The principal concerns were delays and an inadequate handover in responding to the urgent request for help, with concern that earlier assessment and admission might have enabled a blood transfusion and prevented his death.

Alice Jean FOX · Prevention of Future Deaths report View report

9 Jun 2023 Derby and Derbyshire P. Nieto

Alice Jean FOX, known as Jean, died in hospital on 1 July 2021 from severe infection resulting from bacterial infection of the surgical site following partial hip replacement after a fall. Concerns included her lengthy wait in the discharge lounge and late arrival at rehabilitation, which meant usual admission assessments were not completed, and delays in reviewing blood results and referring her back to hospital despite signs of infection.

Malcolm Bennett · Prevention of Future Deaths report View report

22 Jun 2016 Manchester South J. Pollard

Malcolm Bennett, a resident of a care establishment, sustained injuries in falls and altercations with other residents. After an alleged assault on 15 December 2015, he was taken to hospital several hours later and died the following day from a head injury; the principal concern was the delay in arranging hospital treatment despite his care plan.

Sandra Bodrožič’ · Prevention of Future Deaths report View report

24 Nov 2014 Inner North London M. Hassell

Sandra Bodrožič’ died after running to the attic, saying goodbye and jumping from a window, landing three storeys below. She had previously been detained under the Mental Health Act and treated in hospital and the community. The substantive concerns included delays in finding a hospital bed, arranging a Mental Health Act assessment, and the absence of clear urgency or timeframe protocols for such assessments.

Barry John TUCKER · Prevention of Future Deaths report View report

17 Jan 2018 Brighton and Hove V. Hamilton-Deeley

The supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.

Marlene McCabe · Prevention of Future Deaths report View report

11 Jun 2023 Blackpool and the Fylde T. Holloway

Marlene McCabe was unlawfully killed in her own home on 4 September 2019 after being struck repeatedly on the head and face with a doorstop, causing catastrophic injuries. The concerns included urgent mental-health referral processes, inconsistent access to and sharing of mental-health records, the risk of substance misuse obscuring mental-health diagnoses, non-communication of material information, and delayed assessment of apparently intoxicated patients.

Kristian Edward Allen · Prevention of Future Deaths report View report

26 May 2026 West Sussex, Brighton and Hove G. Jones

Kristian Edward Allen, who had complex mental health issues and a history of drug and alcohol abuse, died at Millview Hospital on 16 February 2025 after taking heroin, cocaine and alcohol. The report identifies concerns about inappropriate authorisation of leave, inadequate searches and observations, poor communication, and a delayed and ineffective response to his cardiac arrest. The concerns also include staff being insufficiently trained to manage cardiac arrests and drug overdoses in acute mental health wards.

John Michael Matthews · Prevention of Future Deaths report View report

29 Jan 2015 Manchester South J. Pollard

John Michael Matthews died from natural causes, with the medical cause recorded as aspiration pneumonia associated with haemorrhagic hydrocephalus and spontaneous subarachnoid haemorrhage. Concerns included triage without the ambulance Patient Report Form, a locum doctor’s inability to access the complete computerised system, failure to institute neurological observations, and an unnecessary and partly unexplained delay in obtaining a head CT scan.

Beryl Dandridge · Prevention of Future Deaths report View report

12 Jun 2024 Oxfordshire N. Graham

Beryl Dandridge fell at her nursing home on 23 January 2024 and sustained a periprosthetic hip fracture. Her ambulance attendance and surgery were delayed, including a delay while an echocardiogram was considered necessary; she underwent surgery on 27 January and died on 28 January 2024. Concerns related to conflicting clinical views about the need for echocardiography, responsibility for expediting it, and the subject expertise involved in the structured mortality review.

Carol Leeming · Prevention of Future Deaths report View report

25 Sep 2023 Newcastle and North Tyneside G. Nolan

Carol Leeming had several medical conditions and had repeatedly sought advice from her GP. On the afternoon before her death, she called an ambulance requesting help and hospital admission, but the out-of-hours GP believed an ambulance had been requested through an electronic system when no such facility existed, so no ambulance was requested. The principal concerns were the lack of required induction before the GP started work, the absence of online induction for those unable to attend in person, staff confusion about call-centre systems, and regular turnover of short-term GPs.