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Fred Whittaker · Prevention of Future Deaths report View report

14 Jul 2016 Manchester South A. Bridgman

Fred Whittaker, who had schizophrenia and was known to abuse drugs and alcohol, attended hospital with chest pains and drowsiness after taking codeine, alcohol and methadone, but self-discharged and went home. He was found dead in his flat the following morning; the inquest concluded that he died from developing bronchopneumonia and combined codeine, methadone and alcohol toxicity. A principal concern was that Clonazepam was restarted in error after his psychiatrist had requested that it be stopped, reflecting inadequate recording and procedures for discontinued prescriptions.

David Baddeley · Prevention of Future Deaths report View report

21 Oct 2015 Manchester South J. Kearsley

David Baddeley, who had a history of schizophrenia, died at home on 23 June 2015 after tying a ligature around his neck; the cause of death was recorded as hanging, with schizophrenia also noted. Concerns included delays and gaps in transferring and reviewing medical records, incompatibility between electronic systems, and the failure to identify his psychiatric illness and lack of antipsychotic medication during primary-care handovers and checks.

Margaret HUNTLEY · Prevention of Future Deaths report View report

13 Aug 2024 Teesside and Hartlepool P. Appleton

Margaret Huntley died on 10 December 2022 after deteriorating with multi-organ failure associated with dehydration, lack of exogenous steroids and Covid-19 infection. The report identifies delays in recognising her need for steroid medication and in prescribing and administering it. Concerns included ambulance staff understanding and triage guidance regarding steroid medication, use of Steroid Emergency Cards, and GP awareness of ambulance-service patient alerts.

Maureen Patricia FLYNN · Prevention of Future Deaths report View report

26 Aug 2016 Manchester South A. Bridgman

Maureen Patricia FLYNN was admitted to hospital with a urinary tract infection and later suffered a fall from her bedside chair, fracturing her left hip. She underwent surgery, subsequently developed a chest infection that did not respond to antibiotics, and died on 7 May 2016. Concerns included the incomplete falls risk assessment, staff not being alerted to this, and the Patient Safety Investigation not identifying the omission.

Terence William SULLIVAN · Prevention of Future Deaths report View report

13 Mar 2024 Worcestershire D. Reid

Terence Sullivan underwent surgery to remove a sigmoid colon polyp on 8 August 2023, after temporarily stopping rivaroxaban. He suffered an acute myocardial infarction caused by blockage in a coronary artery stent and died in hospital on 10 August 2023. The principal concern was that NICE and BSG guidance may not reflect best practice for patients with coronary stents taking a single anticoagulant who require therapeutic endoscopy, including whether pre-operative consultation with an interventional cardiologist is needed.

Dafydd Rhys WATTS · Prevention of Future Deaths report View report

29 Apr 2014 Avon T. Moore

Dafydd Rhys WATTS died of eosinophilic pericarditis and DRESS syndrome following treatment with levetiracetam for epilepsy. The report raised concern that the possibility of this exceptionally rare reaction and death was not drawn to physicians’ attention in the drug literature or BNF entry.

Jack Horace BURTON · Prevention of Future Deaths report View report

3 Jun 2026 Worcestershire D. Lakin

Jack Horace BURTON, who had schizophrenia and was prescribed Clozapine, died of Clozapine toxicity after stopping smoking while on holiday in North Yorkshire. Concerns included inconsistent medical accounts about the relevance of reducing smoking and a lack of standardised guidance for asking and recording information about possible medication side effects.

Sophie Holman · Prevention of Future Deaths report View report

29 Jan 2019 London (East) S. Radcliffe

Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.

Zarah RAVN · Prevention of Future Deaths report View report

8 May 2024 Surrey K. Hayes

Zarah Ravn, aged 49, was found deceased at home on 3 September 2023 from mixed drug toxicity after consuming unprescribed oramorph and oxycodone alongside prescribed quetiapine. The substantive concerns included failures to carry out regular mental health, physical and medication reviews, inadequate monitoring of those reviews, and a lack of follow-up after HRT was prescribed following a reported deterioration in her mental health.

Susan Edea Poore · Prevention of Future Deaths report View report

28 Mar 2014 Norfolk J. Lake

Susan Edea Poore was fatally injured after being struck by a train on 3 May 2012, after she was seen standing on the railway line near Thains Lane, East Runton. The report raised concerns about her depression deteriorating after prescribed antidepressant medication and whether the medication warning about worsening depression was sufficient.

Terence Ryan · Prevention of Future Deaths report View report

8 Sep 2017 Manchester West A. Walsh

Terence Ryan died on 14 November 2016 after a road traffic collision caused a left leg fracture and he later self-discharged from hospital without anticoagulation medication. The report identified concerns about a consultant-prescribed anticoagulant not being added to his repeat prescriptions and the absence of a hospital protocol for patients, particularly vulnerable patients, who self-discharge without necessary medication.

Paris Alan George Lapper · Prevention of Future Deaths report View report

10 May 2021 West Sussex P. Schofield

Paris Alan George Lapper, aged 19, was found deceased in his room at the Wolsey Hotel on 13 August 2020 and was declared deceased at 1125hrs. The post-mortem recorded respiratory depression due to opiate and benzodiazepine toxicity. The report raised concerns that he obtained duplicate prescriptions from multiple providers because providers lacked a central record or mechanism to check prescriptions issued elsewhere, creating a risk of medication misuse and fatal outcomes.

Karen Lesley SUTTON · Prevention of Future Deaths report View report

4 Sep 2013 Leicester City and South Leicestershire L. Brown

Karen Lesley Sutton, who had primary antibody deficiency disorder and had undergone a splenectomy, was readmitted on 11 October 2012 with severe sepsis and died that evening after cardiac arrest. Concerns included the Immunology team not being notified of her hospital admissions, discontinuation of her prophylactic antibiotics on discharge, and inadequate arrangements for follow-up and communication between departments.

John Joseph SINGLETON · Prevention of Future Deaths report View report

16 Nov 2023 Cheshire K. Ainge

John Joseph Singleton, who was serving a prison sentence at HMP Risley, was found hanging in his locked cell on 1 September 2019 and later died in hospital on 10 September 2019. The report identifies concerns about sporadic medication compliance and the difficulty of detecting non-collection of medication, including the lack of an automated warning flag in the SymStone system. These issues were stated not to have caused or contributed to his death.

Marie Quinn, otherwise known as Marie Pearson Quinn · Prevention of Future Deaths report View report

2 Nov 2015 Manchester West R. Griffin

Marie Quinn fell at home on 20 May 2015, sustained a fractured right neck of femur, underwent surgery, and died in hospital on 13 July 2015 after becoming unwell. The report identified concerns about sub-optimal deep venous thrombosis prophylaxis and medication management at Richmond House Nursing Home, including inaccurate instructions and unaccounted-for excess medication.

Alan Charles Peck · Prevention of Future Deaths report View report

14 Oct 2014 Manchester South J. Pollard

Alan Charles Peck had been an inpatient at Tameside Hospital for approximately six weeks, underwent a hemi-colectomy, and was then discharged to Willow Wood Hospice. Concerns were raised that his syringe driver was not connected while he was on the surgical ward and that he was deprived of medication during transfer to the hospice.

Larry Stephen SPRIGGS · Prevention of Future Deaths report View report

22 Dec 2023 Surrey D. Stewart

Larry Stephen Spriggs died after falling from the window of his room at Farnham Road Hospital on 27 May 2021. The inquest identified concerns about the assessment and management of inpatient risk, the use of anti-anxiety medication, communication between staff, and the implementation and management of intermittent observations. The death was recorded as contributed to by neglect and caused or more than minimally contributed to by failures in implementing intermittent observations.

David Michael Potts · Prevention of Future Deaths report View report

26 Nov 2019 Norfolk Y. Blake

David Michael Potts fell at home while prescribed apixaban and was admitted with an acute subdural haematoma. Beriplex was prescribed to reverse the apixaban but was not given in a timely manner, and staff did not confirm that it had been administered or establish where he was. His bleed extended; after transfer to a local unit, he declined and died seven days later.

Joan Wright · Prevention of Future Deaths report View report

28 Dec 2018 Manchester South A. Mutch

Joan Wright, who had poor mobility and was unable to communicate verbally, died at Belmont Residential Home on 16 September 2017; the post-mortem found extensive coronary artery atheroma. The report raised concerns about the incorrect administration and handling of Oramorph, medication management at a care home rated inadequate, and failures to recognise and address safeguarding risks after the medication incident.

Mary Bertha Johnson · Prevention of Future Deaths report View report

1 Feb 2019 Herefordshire H. Bricknell

Mary Bertha Johnson died at County Hospital, Hereford, on 25 July 2018 after falling on 20 July 2018 and sustaining a periprosthetic fracture of the femur. Concerns included poor communication about feeding and medication before surgery, and the suggestion that porter availability affected the hospital theatres’ ability to carry out operations.