6,433 reports
Information drawn from published reports and official responses.
Wesley Dennis Rowlands died by suicide through ligature hanging in his cell at HMP Garth, using a fixed television bracket. The principal concern was that redundant television brackets remained installed in cells, including his, creating gross and obvious ligature points until removed.
Garth Prison
Brian Richard Murphy had congestive cardiac failure and significant coronary artery narrowing, deteriorated suddenly after being referred to cardiology, and died at Stepping Hill Hospital on 17 February 2020 following an acute myocardial infarction. The inquest heard that delays in the cardiology test referral system delayed tests and referrals to cardiology clinics.
NHS Greater Manchester Integrated Care Board
Daphne Ann McKenna died after an accidental fall of approximately 40 metres from a public footpath near a viewing point at Hells Rock Cliff on 13 July 2020. The principal concern was that the footpath passed close to a severe drop and that safety-related signage might alert members of the public to the danger.
Calderdale Borough Council
Joseph Michael Cheetham suffered an unwitnessed accidental fall, underwent surgery for a dislocated prosthetic hip, and later died in hospital on 22 January 2020 after pneumonia, dysphagia and respiratory deterioration. Concerns included prolonged waiting in the Emergency Department because of bed shortages and discharge home before a care package was in place, while he was frail and vulnerable and had lost weight in hospital.
Department of Health and Social CareGreater Manchester Health and Social Care PartnershipHealth Services Safety Investigations Body
Mavis May Lawrence, who had severe dementia and required full nursing care, was admitted to hospital with dehydration, deep ungradable pressure sores and a buttock abscess, and later died on 28 February 2019. The inquest concluded that she died from natural causes exacerbated by infected pressure sores. Concerns included gaps in pressure-area checks and care documentation, a pressure mattress being turned off, lack of escalation and pain-relief evidence, insufficient GP involvement, and district nurses not involving tissue viability nurses.
Beech Dene Residential Care HomeLeek Health CentreMidlands Partnership University NHS Foundation Trust
Mollie Matilda Gifford was struck by a large goods vehicle while crossing a road and later died in hospital after sustaining severe traumatic injuries and complications. The principal concern was that standard class 5 and 6 lorry mirrors create an avoidable risk that drivers will not see pedestrians and other road users close to the cab when stationary; the cause of death and the role of the collision remained unknown.
Department for TransportDriver and Vehicle Standards Agency
June Parlour was an inpatient with disseminated terminal cancer when she received morphine doses exceeding national and hospital guidelines. Her condition deteriorated, and she later died of opiate toxicity; the overdose significantly hastened her death. Concerns included staff awareness of morphine guidance, inaccurate hospital guidance and incident reporting, education and auditing for doctors, unclear prescribing instructions, and communication and escalation failures between staff.
East Suffolk and North Essex NHS Foundation Trust
Mr William Ivan McKibbin died at Trafford General Hospital on 20 August 2018 following complications of a traumatic brain injury sustained in an unwitnessed fall in hospital. The report raised concerns about bed-rail and bed-brake checks, the culture of openness and candour, communication between specialists and hospital sites, incident investigations, and the process for learning from deaths.
Care Quality CommissionDepartment of Health and Social CareManchester University NHS Foundation TrustNHS England
Marian Day died at Kings Mill Hospital on 18 November 2019 after a sudden collapse caused by a massive intra-abdominal haemorrhage. Warfarin was continued and administered despite suspected bleeding and an earlier plan to withhold it; the inquest found that this prescription error made a contribution to the haemorrhage. The report raises concerns about muddled prescribing systems, insufficient senior review, and unclear anticoagulant management plans.
Sherwood Forest Hospitals NHS Foundation Trust
Susan Warby was admitted to hospital with a perforated bowel and underwent emergency surgery. An incorrect intravenous fluid attached to an arterial line, combined with incorrect blood-sampling technique, produced erroneous results that led to unnecessary insulin treatment, hypoglycaemia and a brain injury; her death followed multi-organ failure, septicaemia and disseminated aspergillus pneumonia. The principal concerns were the lack of distinctive labelling for fluids used with arterial lines and inadequate blood-sampling technique and training.
Department of Health and Social CareMedicines and Healthcare products Regulatory Agency
Vaidotas Gerbutavicius, aged 21, ingested slimming pills containing 2,4-dinitrophenol after drinking alcohol and died in hospital on 10 March 2018. The report raised concerns that DNP remained readily available online, that existing legislation was inadequate, and that protections preventing its internet sale were absent.
Home Office
Zak Miles Joe Walter Paul Farmer, a 23-year-old man, died on 21 July 2019 after being found hanging. Concerns included a lack of clarity about the meaning of “urgent” referrals to the Access and Assessment Team and shortcomings in guidance for community mental health service users disengaging from prescribed treatment plans.
CRG Medical ServicesEssex Partnership University NHS Foundation Trust
June Mavis Winterbottom, aged 90, lived alone in sheltered accommodation and was found semi-conscious in her own faeces and vomit, covered in pressure sores, after an urgent Adult Social Care referral received no contact. She was taken to hospital and treated for urosepsis, but died later that day. The report identified ineffective urgent-referral handling, unclear accountability, and no safety net for calling an ambulance when Adult Social Care could not respond promptly.
Wakefield City Council
Eileen Brindley, aged 97, was admitted to New Cross Hospital on 28 August 2020 after being found struggling to breathe and died shortly afterwards from anaphylaxis. The concerns included prescribing a penicillin-type antibiotic despite a recorded adverse reaction to Flucloxacillin, without evidence that the prescribing clinician had noted the reaction or explained the prescription, and insufficiently highlighted medical-record entries.
Tettenhall Medical Practice
Mrs Jane Jowers, who had advanced Alzheimer’s dementia and was dependent on carers for medication, did not receive her anti-epileptic medication on 21 October 2018. She suffered a seizure the following day, was admitted to hospital, and her health deteriorated before she died in a hospice on 23 November 2018. The report raised concern that there was no statutory procedure for checking criminal convictions outside the UK, which may allow unsuitable people to work with vulnerable adults and children.
Disclosure and Barring Service
Brett Anthony Marrs, a long-term drug user, was found collapsed in his prison cell after morning unlock on 4 September 2018. The inquest concluded that he died as a result of synthetic cannabinoid and morphine toxicity. Concerns included inadequate first-aid and resuscitation training for prison officers and failures to conduct welfare checks during morning cell unlocks.
Wymott Prison
Mrs Christine Forbes, a 72-year-old woman with a history of oxycodone stockpiling and misuse, died on 2 February 2020 after taking oxycodone and zolpidem. The principal concern was that patients registering with GP surgeries may be prescribed medication before their medical notes and relevant history are available.
Clinical Commissioning Groups (England)NHS Derby and Derbyshire Integrated Care BoardNHS EnglandPrimary Care Support England
Andres Roberts suffered a large stroke and was taken to Morriston Hospital after four emergency calls, with the ambulance arriving 2 hours and 20 minutes after the incident was reported. He received thrombolysis and later suffered a large intracranial bleed before dying at the hospital. Concerns included the grading of acute stroke patients, whether a specific response-time target should be set, and whether additional ambulance resources were needed.
Department of Health and Social CareWelsh Ambulance Services NHS Trust
Paul Vincent Reynolds underwent finger surgery under general anaesthetic after presenting to hospital with a swollen hand and a necrotic finger. He suffered a loss of blood pressure and a hypoxic period following the anaesthetic, and died from the hypoxic event on 31 December 2019. The concerns identified included the unavailability of his full hospital notes and an incomplete understanding of his underlying medical condition, leading to an inappropriate choice of monitoring and anaesthetic.
Derriford Hospital
Baby Frederick Joseph Terry was delivered by caesarean section after a failed forceps attempt on 16 November 2019, and death was confirmed after 40 minutes of resuscitation attempts. The stated cause of death was hypovolaemic shock due to skull fracture, scalp laceration and haemorrhage arising from birth trauma. Concerns included risk assessment and forceps delivery, excessive force and traction, staff training and levels, communication, record keeping, resuscitation equipment and procedures, and neonatal unit support.
Mid and South Essex NHS Foundation Trust
