412 reports
Information drawn from published reports and official responses.
On 3 March 2014, RHYS TUDOR WILLIAMS was put to bed at Sunrise Senior Living and was found deceased between his bed and the wall at 1.40 am. The report raised concerns about inadequate staff training, incorrect bed positioning, failure to apply bed brakes, insufficient staffing and communication, pre-completed care notes, and possible delays in calling an ambulance.
Sunrise Senior Living Limited
Corin Bonaparte, a young man aged 23, was found hanging in his cell at HMP Dartmoor on 28 February 2017 after his former partner ended contact with him during a telephone call. Resuscitation efforts were unsuccessful. Concerns included the failure to open an ACCT after he disclosed deliberate self-harm, suggesting inadequate training, and an eight-minute delay in an ambulance leaving the prison because an escort was being sought.
Dartmoor Prison
Emma Victoria Sanders died on 19 March 2023 after being found unresponsive in a hospital toilet with a ligature fashioned from nasal cannula tubing around her neck. The report raised concerns about delays in accessing hospital records and care plans, particularly when patients are placed in cohorting areas, and about the absence of care-plan information from Summary Care Records.
NHS Dorset Integrated Care BoardNHS England
Oscar was born with a pelvi-ureteric junction obstruction and later developed a bacterial infection after prescribed antibiotics were not received. On 26 June 2024, he was taken to hospital after a call to NHS 111 about breathing difficulties, was found to have sepsis, and died the same day. Concerns included inadequacies in the algorithm for assessing ill newborns, reliance on the algorithm without early clinical input, and delay or lack of direction in obtaining clinical assessment.
NHS EnglandSouth Central Ambulance Service NHS Foundation Trust
Liam Sutton became unconscious at home after discharge following a total knee replacement with increased opioid medication, and was subsequently treated for suspected opioid toxicity, pneumonia or sepsis, respiratory complications and acute kidney injury. After intensive care treatment involving ventilation and repeated extubation attempts, he suffered an unresuscitable cardiac arrest during reintubation and died. The principal concerns were prolonged occupancy of the emergency department resuscitation area and hospital bed-blocking linked to delays in discharge and access to appropriate community or care placements.
Department of Health and Social CareKent County CouncilMedway CouncilNHS Kent and Medway Integrated Care Board
James Jones was taken to hospital with abdominal and chest pain, vomiting, reduced bowel movements and reduced urine output, and was later assessed as having a small bowel obstruction. He experienced delays in medical review, scanning and preparation for exploratory surgery, waiting 17.5 hours before being taken to the anaesthetic room, where he suffered a cardiac arrest. The concerns identified were pressures and insufficient staffing in the Accident and Emergency department, potentially leading to delayed reviews and missed opportunities that may prove fatal in similar cases.
Betsi Cadwaladr University LHB
Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.
Department for EducationDepartment of Health and Social CareLondon Ambulance Service NHS TrustLondon North West University Healthcare NHS TrustRoyal College of Paediatrics and Child HealthThe British Society For Allergy & Clinical ImmunologyViatris Inc.William Perkin Church of England High School
Kenneth Rippon had deteriorating mental health, including self-harm, suicidal ideation and command auditory hallucinations, and died on 5 May 2022 after jumping or falling from a viaduct at Durham Train Station. The report identified concerns about inadequate mental health assessments and risk information, insufficient family involvement in safety and discharge planning, and delays and weaknesses in the investigation of the serious incident.
Care Quality CommissionTees, Esk and Wear Valleys NHS Foundation Trust
Carlington Maurice Spencer, a detainee at Morton Hall IRC, suffered a right middle cerebral artery infarction after being found unwell and was later confirmed deceased on 3 October 2017. The report identifies concerns about confirmation bias relating to presumed drug use, inadequate monitoring and record keeping, poor communication and escalation between discipline and healthcare staff, failures to recognise stroke symptoms, and delays in emergency treatment.
Morton Hall PrisonNottinghamshire Healthcare NHS Foundation Trust
Elizabeth Anne Watson attended the Humber Bridge on 5 December 2022 and jumped from it, landing on Cliff Road; she was declared dead at the scene. The concerns included a lack of structured training, including input from trained mental-health professionals, for bridge security staff identifying and responding to people in mental-health distress, as well as delays in emergency and mental-health support responses.
Humber Bridge Board
On 1 July 2017, Mavis Jeanne Reves pulled her Careline cord because she had a dry mouth and was struggling to breathe. Paramedics reached her flat after delays involving the building’s automated entry system and key safe, and performed CPR. The concerns included limitations of the analogue Careline system, delays in emergency access and connection time, and difficulties identifying the master key.
FirstPort Retirement Property Services Limited
Reginald George KEY underwent surgery and was discharged from hospital on 1 December 2016. He was reportedly very unwell when delivered home after a delay in patient transport and was readmitted on 4 December with sepsis. He underwent further procedures and died on 10 December 2016; concerns were raised about his discharge condition, the delay in transport, and whether his deterioration could have been identified or whether paramedics could have returned him to hospital.
NHS Staffordshire and Stoke-on-Trent Integrated Care Board
Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.
Cwm Taf Morgannwg University Local Health BoardNational Institute for Health and Care ExcellencePrince Charles Hospital (Merthyr Tydfil)
Annette KRASINSKY-LLOYD died at Royal Surrey County Hospital on 20 April 2016 after an unwitnessed fall caused a pelvic fracture and retro-peritoneal haemorrhage, resulting in hypovolemic shock. The report identified inadequate A&E governance and delays in consultant involvement, investigations, reversal of anticoagulation and blood transfusions, as well as inadequate monitoring that contributed to poor intravenous access.
Royal Surrey NHS Foundation Trust
Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.
Care Quality CommissionDHU 111 (East Midlands) CICFamily of Alexander DavidsonNational Institute for Health and Care ExcellenceNHS EnglandNHS PathwaysRoundwood SurgerySherwood Forest Hospitals NHS Foundation Trust
Matthew Alexander Flatman died at Queen Alexandra Hospital, Portsmouth, on 5 July 2013 after experiencing chest, jaw and arm pain, followed by a cardiac arrest. The inquest recorded that he had taken MDAI, a so-called legal high, the previous evening, and concluded that its consumption precipitated a myocardial infarction and subsequent cardiac arrest in the context of severe coronary artery disease. The report raised concerns about the fatal risk posed by MDAI and the slow process of proscribing it as an illegal drug.
Home Office
Student A was found unresponsive in his student accommodation on 28 July 2024 and paramedics verified his death shortly thereafter; the medical cause was asphyxiation and the inquest conclusion was suicide. The principal concerns were delays in carrying out the welfare check and calling emergency services, limited assessment of Student A’s condition, failure to provide basic assistance or first aid, and possible inadequacy or ineffectiveness of staff training and procedures.
The Unite Group PLC
Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.
Essex Partnership University NHS Foundation Trust
Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.
Greater Manchester PoliceGreen Surgery ManchesterMedacs Healthcare Limited
Sandra Phillpott died on 31 October 2023 after developing sepsis and multi-organ failure following E. coli O157 and pneumococcal infections. The report identifies delays in recognising suspected sepsis and providing antibiotics and intravenous fluids, with attention initially focused on ruling out pulmonary embolism and deep vein thrombosis.
Blackpool Teaching Hospitals NHS Foundation Trust
