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Amanda Mary Spark · Prevention of Future Deaths report View report

19 Apr 2018 Dorset R. Griffin

Amanda Mary Spark, who suffered with depression, was found collapsed and unresponsive at her home on 3 September 2017 and died from an overdose of prescribed medication. The inquest concluded that her death was suicide. The principal concern was that supervision applied to her mental health medication did not also cover prescribed physical health medication, and that there was no clear policy or communication process addressing this.

Mr John Hay · Prevention of Future Deaths report View report

31 Mar 2026 Northamptonshire H. Shah

Mr John Hay, who lived alone and received domiciliary care, suffered an unwitnessed fall at home on 26 September 2024 and later died from a subdural haemorrhage on 2 October 2024. The report raised concerns about incomplete risk assessment, unclear escalation for medical input after a fall, and unclear processes for addressing missing or spent medication.

Mrs Annie Lloyd · Prevention of Future Deaths report View report

30 Oct 2019 Black Country Z. Siddique

Mrs Annie Lloyd was taking warfarin and appears to have taken a higher-than-intended dose for around two weeks. She was found unconscious on 6 April 2019 with a large subdural haematoma and raised intracranial pressure, and died the same day. Concerns identified during the inquest included inadequate checking of her warfarin dosage and reliance on family members to confirm the required dose.

Evelina Vilkiene · Prevention of Future Deaths report View report

6 Mar 2023 East London N. Persaud

Evelina Vilkiene, who was receiving mental health services, was found hanging at her home on 7 June 2022 and was pronounced dead at the scene. The report identified concerns about the absence of detailed risk assessments and jointly agreed risk-management plans during care transitions and when clonazepam was reduced, as well as the lack of subsequent care-coordinator reviews.

Mildred Horrex · Prevention of Future Deaths report View report

8 Jun 2020 West Sussex P. Schofield

Mildred Horrex suffered an unwitnessed fall while sleeping in a chair at Pelham House on 30 December 2017, sustaining fractures to her C1 and C2 vertebrae, and died in hospital on 18 January 2018. The concerns identified were poor and sometimes inaccurate record keeping, insufficient information for an adequate fall-risk assessment, and discrepancies between medication records and the amount of medication held that were not detected by audits.

Katie Emma Corrigan · Prevention of Future Deaths report View report

17 Feb 2021 Cornwall and Isles of Scilly A. Cox

Katie Emma Corrigan had a history of chronic pain, anxiety and depression, and developed an addiction to pain-relieving medication. She obtained medication from multiple sources, and the report raised concerns that doctors, pharmacists and alert systems did not prevent her from obtaining sufficient opiate medication to cause her death.

Derek HAND · Prevention of Future Deaths report View report

24 Apr 2024 Derby and Derbyshire A. Davies

Derek HAND experienced continued bleeding after a tooth extraction while taking Clopidogrel, lost consciousness, and was admitted to hospital. Although his condition initially improved, he later developed swallowing difficulties and aspiration pneumonia, deteriorated, and died on end-of-life care. The principal concern was whether current guidance should require blood testing before dental procedures for patients taking Clopidogrel to identify a risk of excess bleeding.

David Edward Jackson · Prevention of Future Deaths report View report

24 Oct 2017 West Sussex K. Harrold

David Edward Jackson, a 76-year-old man, fell at home and remained on the floor for about two weeks before he died on 17 July 2017. His death was recorded as accidental, with severe pressure sores associated with sepsis, toxaemia and rhabdomyolysis following prolonged immobility. Concerns included long-term repeat prescribing of Co-dydramol and Soneryl without regular face-to-face medical review, and unclear arrangements for prescription collection or delivery.

Stuart Andrew WALLS · Prevention of Future Deaths report View report

8 Dec 2017 East Riding and Kingston Upon Hull M. Mellun

Stuart Andrew WALLS was found dead in his room on 12 March 2017 after being last seen alive the previous morning. The inquest concluded that he died from drug poisoning caused by the combined effects of prescribed medication, with concern that multiple central-nervous-system medicines could have a synergistic effect on respiration even when taken at prescribed doses.

Christopher John Llewellyn Roberts · Prevention of Future Deaths report View report

5 Oct 2017 Swansea and Neath Port Talbot A. Gruffydd

Christopher John Llewellyn Roberts was pronounced dead at his home on 19 October 2015 after an overdose involving prescribed opiate medication. He was receiving treatment for mental illness, and his medication use was described as chaotic. The report raised concerns that a care plan review was not recorded, including whether a recent overdose attempt had been considered, and that nomad trays may be unsuitable for some patients.

DAVID ERNEST MASON · Prevention of Future Deaths report View report

19 Apr 2023 Worcestershire N. Lane

David Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.

Mark Jarvis · Prevention of Future Deaths report View report

19 Sep 2019 Suffolk N. Parsley

Mark Jarvis was found apparently deceased in his cell at HMP Warren Hill on 30 December 2015 and was later pronounced dead. The inquest concluded that the death resulted from a cardiac event precipitated by ingestion of a New Psychoactive Substance, with ischaemic heart disease recorded as the medical cause of death. Concerns included difficulties with the prison prescription system, including the inability to readily verify current and previous prescriptions, and the potential misuse of medications.

Francis Xavier Cooney · Prevention of Future Deaths report View report

10 Aug 2020 Birmingham and Solihull E. Brown

Francis Xavier Cooney fell at home, underwent surgery for a scalp laceration, developed delirium during his hospital stay, and was discharged home after an occupational therapy assessment. Following discharge he became more confused and anxious about changes to his medication, and on 27 January 2020 he was found hanging from the bannister and declared deceased. The principal concern was that medication changes were not communicated directly to his daughter and next of kin, who held lasting power of attorney, leaving her unable to explain the changes or reassure him; the report also raised concern about the lack of a root cause analysis or similar investigation into the communication breakdown.

Katharine Eva Stamp · Prevention of Future Deaths report View report

18 Dec 2019 West Sussex J. Healy-Pratt

Katharine Eva Stamp died while detained under the Mental Health Act from sudden cardiac arrhythmia due to hypoxia, with the hypoxia described as involving aspiration pneumonia, probable sleep apnoea, obesity, smoking and clozapine effects. The report raised concerns that clozapine side effects, particularly in relation to smoking and pneumonia, were under-appreciated and that the BNF did not provide sufficient clarity to prescribers; it also stated that the lack of an effective national weight-gain monitoring programme for mental health inpatients was causally linked to her obesity and probable sleep apnoea.

Irene Whittingham · Prevention of Future Deaths report View report

28 Feb 2020 Manchester West R. Syed

Irene Whittingham died at The Royal Bolton Hospital on 31 July 2019 from the toxic effects of a Vitamin D overdose. An incorrect discharge prescription recorded Vitamin D as twice daily, and no monitoring advice was provided while she was taking high doses in the community. Concerns included conflicting guidance on blood-level monitoring and software dropdown options that permitted a potentially unsafe dosage.

Jonathan Earp · Prevention of Future Deaths report View report

8 May 2018 Gloucestershire C. Saunders

Jonathan Earp died at Gloucester Royal Hospital on 10 July 2017 from the effects of prescribed and non-prescribed drugs. Concerns included the management and disposal of Fentanyl patches and the possibility that additional Fentanyl was taken alongside illicit drugs without staff considering the combined effects.

Sean Benjamin CRAWFORD · Prevention of Future Deaths report View report

15 Feb 2024 County Durham and Darlington C. Oliver

Sean Benjamin CRAWFORD died on 18 December 2020 in Darlington from the combined toxic effect of alcohol and clozapine, neither being individually at toxic levels. The principal concern was that available guidance and medication packaging warned about alcohol, sedation and potentially dangerous side effects but did not advise that death could result from this combination.

PETER MARTIN AARON FLEMING · Prevention of Future Deaths report View report

14 Jul 2023 Birmingham and Solihull J. Bennett

Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.

Raymond Claude Woodhouse · Prevention of Future Deaths report View report

21 Oct 2020 Cornwall and Isles of Scilly A. Cox

Raymond Claude Woodhouse had severe Parkinson’s disease and underwent a total knee replacement, after which he developed infections in his elbow and knee and died on 11 February 2019. Concerns included difficulties obtaining staff attention, poor cleanliness, a potential delay in antibiotics, and multiple late or omitted doses of prescribed Parkinson’s medication.

Laurence Boyens · Prevention of Future Deaths report View report

22 Apr 2015 Inner South London A. Harris

Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.