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ALBERT FLYNN · Prevention of Future Deaths report View report

2 Jul 2014 Manchester South J. Pollard

Albert Flynn, a resident of Appleton Manor Residential Home, was taken to hospital with a suspected deep vein thrombosis and treated with the blood-thinning drug Enoxaparin. The following night he was left in a chair for approximately 10 hours without food, fluids or prescribed medication, while staff were unable to rouse him. He was suffering from a severe cerebral bleed, which was fatal; concerns included inadequate staff training and failure to recognise the significance of his condition and recent blood-thinning treatment.

Mathew Christopher Moore · Prevention of Future Deaths report View report

9 Aug 2022 Dorset S. Nicholls

Mathew Christopher Moore died on 7 August 2021 in Bournemouth, Dorset, having attached a rope as a ligature. The report records concerns about the combined use of prescribed medication and excess alcohol, including potentially unsafe prescribing, a lack of documented communication of concerns to Mr Moore, and the need for clearer policies, dosage review, follow-up, and information-sharing within the surgery.

Mr Christopher Granville Bradbury · Prevention of Future Deaths report View report

11 Mar 2025 Staffordshire and Stoke-on-Trent E. Serrano

Christopher Granville Bradbury fell at home, sustained a cut to his right foot, and was admitted to hospital several days later with diarrhoea, vomiting, collapse, and swelling of the right leg. He was diagnosed with a severe invasive soft tissue infection and underwent a below-the-knee amputation, but died the following day. Concerns included a lack of national knowledge and guidelines for these infections, ineffective training and learning measures, and the absence of an audit trail when medication was omitted because it was unavailable or for another reason.

Scott Douglas Hooper · Prevention of Future Deaths report View report

20 Mar 2017 Portsmouth and South East Hampshire D. Horsley

Scott Douglas Hooper, aged 46, died on 22 March 2016 after sustaining complex pelvic fractures in an unwitnessed workplace forklift accident and later suffering a pulmonary embolism and deep vein thrombosis. The principal concerns were that his weight was incorrectly recorded, affecting the prescribed anticoagulant dose, and that a decision to withhold a dose was not recorded with the decision-maker identified.

Adam Connolly Stuyvesant · Prevention of Future Deaths report View report

6 Oct 2023 Wiltshire and Swindon I. Singleton

Adam Connolly Stuyvesant was involved in a minor road traffic collision on 17 August 2022 and sustained an ankle injury that was immobilised with a plastic boot. He collapsed on 22 August 2022 and died despite resuscitation efforts; the post-mortem confirmed pulmonary embolus arising from deep vein thrombosis associated with lower-limb immobilisation. The report raised concerns that the hospital’s DVT risk assessment did not account for immobilisation when considering anti-clotting medication.

Eleanor Smith Deceased · Prevention of Future Deaths report View report

17 Apr 2024 Northumberland A. Hetherington

Eleanor Smith suffered an unwitnessed fall, sustaining a left femoral neck fracture, and underwent surgical repair. She developed an infection postoperatively and died in hospital on 24 September 2023. The principal concerns were a significant delay in administering intravenous antibiotics, whether the antibiotics were effectively administered, and whether the medical records accurately documented cannula placement and medication administration.

Lilian Margaret BOARD · Prevention of Future Deaths report View report

5 Oct 2023 Lincolnshire P. Cooper

Lilian Margaret BOARD, aged 91, died at Lincoln County Hospital on 1 February 2023 after intentionally ingesting tablets the previous day; a note of intent was left. The principal concern was that both her GP and the hospital had prescribed the same medication, raising a question about checks to prevent duplicate prescriptions.

Louis Robert SAUNDERS · Prevention of Future Deaths report View report

27 Feb 2026 East Sussex L. Bradford

Louis Robert Saunders, who had been diagnosed with ADHD and experienced suicidal ideation as a side effect of medication, travelled to the East Sussex coast on 9 October 2024 and was found dead at the base of a cliff the following morning. The principal concern was insufficient communication and continuity of care between the private ADHD clinic and NHS GP, resulting in concurrent prescribing of different ADHD medications and a risk of duplicate prescriptions or confusion about treatment.

Tony Montana Duncan · Prevention of Future Deaths report View report

15 Oct 2025 City of London A. Hewitt

Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.

Simon HOCKENHULL · Prevention of Future Deaths report View report

12 Jun 2025 Cheshire E. Wheeler

Simon Hockenhull died at home on 5 December 2024 after contracting lobar pneumonia, with underlying diabetes and diabetic gastro-enteropathy reducing his resilience. The report raises concerns that inconsistent interpretations of a 28-day supply as a “month” can delay repeat prescriptions for diabetic medication and devices, potentially leading to inconsistent medication use and serious health effects including diabetic ketoacidosis.

Michelle Jeffries · Prevention of Future Deaths report View report

22 Nov 2021 Manchester South C. Morris

Michelle Jeffries had a complex medical history involving chronic, debilitating pain and had been prescribed large quantities of analgesic medication, including opiates. The report raised concern about the absence of local guidance on safely overseeing high-dose multiple analgesic prescriptions in the community and on when referral to a pain specialist should be required.

Nasar AHMED · Prevention of Future Deaths report View report

12 May 2017 Inner North London M. Hassell

Nasar died following an anaphylactic reaction contributed to by asthma while he was in the internal exclusion room at school. The concerns included delayed or inappropriate advice about using his adrenaline auto-injector, discrepancies and gaps in asthma and allergy care planning, unsuitable emergency inhaler equipment, inadequate medication review systems, and shortcomings in staff awareness, training and emergency procedures.

Edward Angus Mallen · Prevention of Future Deaths report View report

7 Sep 2016 Cambridgeshire and Peterborough B. Cheney

Edward Angus Mallen, who was suffering from depression and had disclosed suicidal thoughts, died after lying across a railway line and being struck by a train on 9 February 2015. The concerns included unclear responsibility for his care, advice from a non-prescriber about medication, lack of information about possible worsening symptoms and increased suicidal feelings, and inadequate awareness of routes to further psychiatric advice.

Doreen Elma STAPLETON · Prevention of Future Deaths report View report

24 Feb 2017 Inner North London M. Hassell

Doreen Stapleton died at Whittington Hospital on 15 September 2016 from a pulmonary thromboembolism, after previously being diagnosed with pulmonary emboli. Following discharge, district nurses were intended to administer daily tinzaparin injections, but the referral was not received because an obsolete email address was used. The principal concern was that Doreen and her sons were not given sufficiently explicit advice about the potentially fatal consequences of missed medication and were not given the district nursing team’s telephone number or told to call if nurses did not attend.

Stephen James Morris · Prevention of Future Deaths report View report

29 Aug 2014 Blackpool and the Fylde A. Wilson

Stephen James Morris, who had previously been diagnosed with bipolar affective disorder, was found deceased in the bath at his flat on the morning after 16 June 2013. A post-mortem found high levels of mood-stabilising and antidepressant medication, whose combined effects proved fatal; the inquest concluded that he took his own life. The principal concerns were that Mirtazapine was prescribed despite awareness of his diagnosis and its suitability concerns, based on the patient's verbal account rather than confirmation from the mental health team.

DESGRAE REGINA TUCKER · Prevention of Future Deaths report View report

23 Jan 2014 Gwent W. James

Desgrae Regina Tucker was admitted with abdominal pain, underwent gall bladder removal surgery, was discharged home, and died at home six days later. Concerns included inadequate recording and consideration of anti-embolic stockings and no anti-coagulant medication being prescribed on discharge.

John Hills · Prevention of Future Deaths report View report

11 Aug 2015 West Sussex C. Wilkinson

John Hills, a resident of a nursing home, suffered fatal burns after his clothing and blankets caught fire while he was smoking in the conservatory. The report raised concerns about the failure to ensure he was wearing his fire-retardant apron and about insufficient awareness, communication and prevention of the fire risks associated with paraffin-based emollient creams such as Cetraben, particularly in community care settings.

Olive DAYNES · Prevention of Future Deaths report View report

28 Mar 2017 South Lincolnshire P. Cooper

Olive Daynes, described as an 86-year-old lady, presented to hospital with an altered mental state and a suspected fall after earlier treatment for painful or sore legs and ulcers. The report identified concerns about Warfarin being prescribed with antibiotics, inadequate monitoring, communication between the hospital and GP surgery, and a subsequent INR increase to over 9 before she passed away.

Aaron John Peter McCaffrey · Prevention of Future Deaths report View report

16 Jun 2017 Manchester South R. Galloway

Aaron John Peter McCaffrey had a history of addiction to loperamide and regularly took large quantities. After taking around 250 tablets on 13 January 2017, he collapsed, was admitted to hospital, and died on 19 January 2017; the recorded conclusion was a drug-related death. The principal concern was that there was no apparent limit on the amount of loperamide that could be purchased from a single store, facilitating large-quantity purchases and creating a risk of overdose and death.

Mohammed Khalid HUSSAIN · Prevention of Future Deaths report View report

12 Jul 2023 Birmingham and Solihull L. Hunt

Mohammed Khalid HUSSAIN was found collapsed on the bathroom floor at his home on 28 November 2022 and was confirmed deceased shortly afterwards. The medical cause of death was determined to be sudden cardiac death in schizophrenia. Concerns included inadequate systems for monitoring, communicating and acting on high clozapine levels and medication changes, as well as deficiencies in internal investigation, understanding of clozapine and pharmacy resourcing.