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Linda Louise Banks · Prevention of Future Deaths report View report

19 Dec 2023 County Durham and Darlington J. Richards

Linda Louise Banks died at the University Hospital of North Durham on 10 April 2022 after taking a paracetamol overdose, against a background of alcohol misuse and deteriorating mental health. The report identified concerns about the quality of mental health assessments, triage, safety planning and record keeping, the underestimation of risk, failure to identify possible learning difficulties and provide reasonable adjustments, and delays in investigating the care provided. It also identified concerns that similar issues found in an earlier thematic review had not been effectively addressed.

Elena WELLS · Prevention of Future Deaths report View report

23 Nov 2020 Brighton and Hove C. Palmer

Elena Wells, who had a history of mental health issues, died after placing a ligature around her neck while alone at home awaiting an urgent mental health admission. The report identified unclear responsibility and communication between the Local Authority and Mental Health Trust, and insufficient out-of-hours support and supervision while she waited for a bed.

Sarah Louise Dunn · Prevention of Future Deaths report View report

12 May 2022 Blackpool and the Fylde L. Rae

Sarah Louise Dunn developed Group A Streptococcus sepsis following an early medical abortion and died in hospital on 11 April 2020 after progressing to toxic shock. The report identified failures to recognise and treat sepsis across primary and secondary care, including delays in assessment, use of sepsis pathways and antibiotics. The principal concern was inadequate awareness and training regarding the risk of sepsis following early medical abortion, creating a risk of avoidable future deaths.

Christopher Howard SMITH · Prevention of Future Deaths report View report

7 Jul 2023 Nottinghamshire L. Bower

Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.

Mrs Marina May Raisbeck · Prevention of Future Deaths report View report

18 Feb 2025 Nottinghamshire E. Didcock

Mrs Marina May Raisbeck died on 7 November 2023 at Doncaster Royal Infirmary from sepsis secondary to a perianal abscess. The report identifies concerns about the lack of systems to prioritise urgent surgical patients awaiting transfer and to monitor their clinical parameters at Bassetlaw District General Hospital.

Emily Kate Harkleroad · Prevention of Future Deaths report View report

5 Feb 2024 County Durham and Darlington R. Sutton

Emily Kate Harkleroad collapsed on 18 December 2022 and died from a pulmonary embolism in the early hours of 19 December 2022. The report states that failures and delays in treatment meant she did not receive anticoagulant treatment that, on a balance of probabilities, would have prevented her death. A further concern was that the Emergency Department’s new computer system lacked the previous clear RAG rating display for quickly identifying critically ill patients, particularly during periods of extreme pressure.

Stephen COSTER · Prevention of Future Deaths report View report

4 Jan 2024 East Sussex R. Redman

Stephen Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare staff.

Margaret Walker · Prevention of Future Deaths report View report

25 Mar 2014 Manchester West J. Leeming

Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.

Manoel Messias Santos · Prevention of Future Deaths report View report

3 Oct 2023 Inner South London J. Goldring

Manoel Messias Santos, a Brazilian national detained in prison and facing immigration detention and possible deportation, was found hanging in his cell in the early hours of 2 November 2020 and was declared dead at 3.30am. The jury found that his understanding of his immigration position made a material contribution to his death and identified failures in notifying him about the IS91 notice and communicating his immigration position. The report also raised concerns about delays in notification and case handling, access to legal advice, communication between agencies, dissemination of learning, and staff understanding of the policy on opening cell doors at night.

Philip Taylor · Prevention of Future Deaths report View report

17 Dec 2020 Manchester South A. Mutch

Philip Taylor, who had Lewy Body Dementia and lived in a residential care home, became severely dehydrated during a chest infection and died in hospital on 6 January 2020 after developing an acute kidney injury. Concerns included failure to recognise and respond to dehydration, delayed ambulance transfer and hospital assessment, inadequate monitoring, and limited national guidance for care home staff and paramedics.

Catherine Mary MORGAN · Prevention of Future Deaths report View report

19 May 2026 Kent and Medway P. Harding

Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ leave.

Jeff David ANTWIS · Prevention of Future Deaths report View report

13 Nov 2017 Shropshire, Telford and Wrekin J. Ellery

Jeff David ANTWIS, a 14-year-old teenager with Asperger’s syndrome and a history of self-harm and suicide attempts, was struck by a train at Harlescott level crossing on 30 January 2017 and died later that day. The principal concern was that, despite indicating that he wished to die, he was given a routine medical review appointment for 17 March rather than an urgent review, alongside concerns about risk assessment, referral mechanisms and recognition of how his conditions may have affected the presentation of suicidal ideation.

Margaret Gertrude Kelly · Prevention of Future Deaths report View report

9 Oct 2023 North Wales (East and Central) J. Gittins

Margaret Gertrude Kelly underwent elective hernia repair on 28 March 2022, after which her bowel was probably damaged. She attended the Emergency Department the following day but was not seen by a surgical doctor for several hours; emergency surgery was undertaken on 30 March, and she died at Glan Clwyd Hospital on 31 March 2022. The report raises concerns about unsustainable pressure on staff, delays in treatment, and insufficient or ineffective strategic planning and support to reduce pressures within the department.

Ronald Henry SPENCER · Prevention of Future Deaths report View report

23 Apr 2024 Birmingham and Solihull A. Hodson

Ronald Henry Spencer had an oesophageal stent placed on 13 November 2023, which migrated into the small bowel and caused a suspected bowel perforation. He underwent surgery to remove the stent and repair the bowel, initially recovered, then deteriorated and died on 2 December 2023. The report raised concerns about significant staffing issues and resulting delays in treatment, as well as inadequate cohesive planning for short- and long-term staffing pressures; it stated there was no direct evidence that the delays caused or contributed to his death.

Raisa Cristina Iordan · Prevention of Future Deaths report View report

31 Mar 2026 West Yorkshire Western C. Keighley

Raisa Cristina Iordan became less responsive and developed seizures and severe neurological symptoms after returning to Dewsbury District Hospital with a suspected viral illness. She was later transferred to Sheffield Children’s Hospital, where imaging showed catastrophic and irreversible brain herniation, and her death was confirmed on 30 November 2023. Concerns included missed escalation of care, inaccurate interpretation of imaging by an external general radiologist without paediatric radiology experience, and delays in scanning and intubation.

Tyla Katherine Joan COOK · Prevention of Future Deaths report View report

17 Sep 2019 Norfolk J. Lake

Tyla Cook had a complex mental health history and took 24 paracetamol tablets on 9 November 2017. After delayed treatment and subsequent deterioration, Tyla suffered a cardiac arrest and died at Queen Elizabeth Hospital on 15 November 2017. Concerns included delays in specialist assessment, the absence of an up-to-date written care and crisis plan, and the failure to organise a planned multi-disciplinary learning event addressing emergency response skills.

Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report View report

8 Jun 2023 Inner North London E. Buckett

Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.

Mohammad Ismaeel Ashraf · Prevention of Future Deaths report View report

1 Sep 2017 Birmingham and Solihull L. Hunt

Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.

Madhumita Mandal · Prevention of Future Deaths report View report

8 Dec 2015 South London S. Lynch

Madhumita Mandal became unwell and attended Croydon University Hospital on 7 September 2013, where the inquest recorded multiple organ failure due to sepsis associated with a ruptured endometriotic ovarian cyst. The principal concerns were delays in assessment and treatment, including initial streaming by a receptionist without medical training, and failures in clinical supervision. The report also raised concerns about differing assessment based on whether patients arrived by ambulance.

Charley Ann Patterson · Prevention of Future Deaths report View report

19 Oct 2022 North and South Northumberland A. Hetherington

Charley Ann Patterson had experienced low mood, anxiety, bullying and previous self-harm. She attended hospital for support in May 2020, but the planned referral to the Northumberland (Early Help) Hub was not made and there was an absence of communication with other services and professionals. She later died by suicide on 1 October 2020. The concerns included increased demand for children’s mental health support following the Coronavirus pandemic and delays in receiving treatment and early support.