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JOHN HENRY OATES known as HARRY OATES · Prevention of Future Deaths report View report

18 Dec 2025 Cumbria K. Gomersal

Harry Oates died instantly on 27 October 2023 after contacting an energised low-hanging 11kV conductor while on a training run in a field. The conductor had been released after the simultaneous failure of two porcelain insulators containing voids in their cement fill, and there was no automatic detection of the low-hanging line at the time. The principal concerns were the previously unknown defects in widely used insulators, the potential for phase-to-phase faults to create low-hanging lines, and the existence of other locations with similar configurations and risks.

Stephen Paul PAGE · Prevention of Future Deaths report View report

18 Dec 2025 Kent and Medway I. Potter

On 17 August 2025, Stephen Page drove alone to the multi-storey car park at Hempstead Valley Shopping Centre and died from traumatic injuries sustained there. The report identified concern that the car park’s operational alarm was visual only, displayed for a few seconds, and could be missed by the CCTV operator, potentially losing an opportunity for staff to intervene. There was no evidence of a delayed response in this particular instance.

Valerie Jane Gibson · Prevention of Future Deaths report View report

17 Dec 2025 Sunderland D. Place

Valerie Jane Gibson died on 29 October 2023 at Monkwearmouth Hospital after being admitted under the Mental Health Act with psychotic symptoms and assessed as being at risk of self-harm and harm to others. The principal concerns were uncertainty and inconsistency in the checking of possessions, dispensing and administration of medication, supervision of nurses, and use of the Omnicell and electronic medication record systems, resulting in unclear records of what medication had been dispensed or administered.

Dorothy Ann MACDONALD · Prevention of Future Deaths report View report

17 Dec 2025 Liverpool and the Wirral D. Lewis

Dorothy Ann MACDONALD sustained a fractured neck of femur in an unwitnessed fall at her nursing home on 11 August 2025 and died in hospital on 22 August 2025 after being placed on palliative end-of-life care. The report raised concerns that her falls risk and the potential impact of a fall were repeatedly underestimated, and that staff training and referrals to the falls team were not consistently effective or used.

Dr Debapriya Ghosh and Mr David Albert Ward · Prevention of Future Deaths report View report

17 Dec 2025 Inner West London F. Wilcox

Dr Debapriya Ghosh and Mr David Albert Ward died at St George’s Hospital after falls causing traumatic head injuries while they were being treated in a busy A&E department. The report raised concerns about insufficient staffing and resources, inadequate nursing risk assessment and supervision, reliance on families to supervise patients, and the resulting risks in overcrowded A&E departments.

Richard Haddock · Prevention of Future Deaths report View report

16 Dec 2025 Devon, Plymouth and Torbay A. Longhorn

Richard Haddock died on 25 June 2023 after using his shotgun. The report identified concerns that the police process failed to notify the Firearms Licensing Department of an Environment Agency prosecution, and that the Department had not checked his PNC record before returning his firearms. The inquest conclusion was suicide.

Phillip Lawrence HOGGARTH · Prevention of Future Deaths report View report

16 Dec 2025 Gwent C. Saunders

Phillip Lawrence HOGGARTH was admitted for a total hip replacement, which was performed on 18 March 2025. He deteriorated post-operatively, suffered a myocardial infarction and died on 25 March 2025. The report raised concerns about inconsistent pre-operative management and administration of iron to chronically anaemic patients, communication between clinicians, and delays related to funding responsibility between health boards.

Walter Perukeno POLLYN · Prevention of Future Deaths report View report

16 Dec 2025 Kent and Medway I. Potter

Walter Pollyn was admitted after an unwitnessed fall and increased confusion, tested positive for Covid-19, and was later placed nil by mouth because of oropharyngeal dysphagia. Water was repeatedly left within his reach, and he aspirated water on 24 July 2024 before his condition deteriorated. He died in hospital on 16 August 2024; the immediate cause was multifactorial pneumonia, including aspiration pneumonia. The principal concerns were repeated staff failure to follow the nil-by-mouth instruction and possible underlying attitudinal and record-keeping issues that allowed unsupervised access to water to persist.

Lee Kenneth Eustace · Prevention of Future Deaths report View report

15 Dec 2025 Devon, Plymouth and Torbay L. Wiltshire

Lee Kenneth Eustace was admitted for treatment of oesophageal cancer and underwent a gastro-oesophagectomy with jejunostomy feeding. He developed abdominal pain, but the feed was increased and continued, and he subsequently developed jejunostomy feeding syndrome and bowel ischaemia, dying in intensive care on 1 May 2022. The report raises concerns about an insufficient and partly un followed feeding protocol, and about failures to investigate the incident, comply with the Duty of Candour, and provide relevant information to the Coroner.

Anthony Jonathon LODGE · Prevention of Future Deaths report View report

15 Dec 2025 County Durham and Darlington R. Sutton

Anthony Jonathon Lodge died from a severe urinary tract infection after a urine sample taken to investigate a suspected infection could not be processed because the specimen bottle was out of date. The concern was that the bottles were not stamped with expiry dates, creating a risk that delays from using out-of-date bottles could contribute to future deaths.

Sundeep Ghuman · Prevention of Future Deaths report View report

15 Dec 2025 Inner South London D. Manknell

Sundeep Ghuman was a prisoner at HMP Belmarsh who was placed in a triple cell with a prisoner known to have racist and violent behaviour. On 18 February 2020, that prisoner violently assaulted Mr Ghuman with a table leg, and Mr Ghuman died in hospital on 19 February 2020 from a head injury. The principal concerns included failures in the CSRA process and training, inadequate treatment of racism alerts and other risk information, insufficient consideration of risks when allocating cellmates, and wider concerns about violence and drug use at HMP Belmarsh.

Mrs Ashana Charles · Prevention of Future Deaths report View report

11 Dec 2025 South London A. Harris

Mrs Ashana Charles died suddenly in hospital on 20 November 2018 after an unexpected cardiac arrest during intravenous feeding. The inquest concluded that cellulose fibres from inadvertently contaminated intravenous infusions caused acute obstruction of small pulmonary arteries, and that the death would have been prevented by using a 1.2-micron filter, which was not standard practice at the time. Concerns included the failure to retain infusion equipment for forensic investigation, inconsistent guidance and practice on filters, and uncertainty about the adequacy of batch-based visual checks of parenteral nutrition products.

David Paul Langford · Prevention of Future Deaths report View report

11 Dec 2025 North Wales (East and Central) K. Robertson

David Paul Langford died at the scene after his motorcycle collided with a motor vehicle emerging from the Waterloo Hill junction. Concerns included restricted visibility caused by vegetation, the condition and positioning of railings and a visibility mirror, and the national speed limit at the dangerous junction.

Mesut Olgun · Prevention of Future Deaths report View report

10 Dec 2025 Worcestershire D. Reid

Mesut Olgun sustained significant injuries while being arrested and was later seriously injured in his cell at HMP Hewell on 8 June 2018; he died from those injuries at Alexandra Hospital, Redditch, on 14 June 2018. The inquest concluded that he died as a result of suicide. Concerns included the lack of “Safer Cells” outside the Segregation Unit, failures to carry out most required ACCT observations, and failure to call a Code Blue emergency at the earliest opportunity; the inquest found that the latter two failures possibly caused or contributed to his death.

Izzah Fatima Ali · Prevention of Future Deaths report View report

10 Dec 2025 Cornwall and Isles of Scilly A. Cox

Izzah Fatima Ali, a nine-month-old infant, died after developing profound iron-deficiency anaemia associated with consumption of cow’s milk. The report identified concerns about healthcare professionals failing to establish what was in her bottles, insufficient consideration of cultural practices, and the repeated absence of an interpreter during ante- and post-natal visits.

Urielle Mayila Kuyenga · Prevention of Future Deaths report View report

9 Dec 2025 East London G. Irvine

Urielle Mayila Kuyenga, a four-year-old girl with sickle-cell disease, died in hospital on 4 December 2023 from sepsis resulting from bacterial pneumonia. The report identifies failures to ensure administration of prescribed prophylactic penicillin and failures by doctors to identify her sickle-cell diagnosis during three presentations for respiratory infection as contributory factors.

Stella Elizabeth LeClaire · Prevention of Future Deaths report View report

9 Dec 2025 Inner South London C. Williams

Stella Elizabeth LeClaire was found unresponsive in a Southwark hotel room on 30 July 2023 and was pronounced dead after taking a substance with the intention of ending her life. The report raises concerns about increasing requests for toxicological analysis involving the substance and whether blood toxicology should be obtained routinely in coroners’ investigations concerning poisoning.

Katherine Wright, known as Sarah · Prevention of Future Deaths report View report

9 Dec 2025 Oxfordshire N. Graham

Katherine Wright, known as Sarah, was reported missing on 15 December 2023 and was found deceased in her flat on 20 December 2023 after an initial police search did not locate her. The report identified concerns about inadequate guidance and training for searches in missing-person cases, and the lack of protocols for escalating safety concerns that may prevent an adequate search.

Hannah Louise Booth · Prevention of Future Deaths report View report

9 Dec 2025 Derby and Derbyshire S. Evans

Hannah Louise Booth, who had been diagnosed with post-natal depression after giving birth in July 2024, drowned in the Goyt River on 6 January 2025 after sending a message evidencing her intention to take her own life. The report identified concerns about information sharing between services, including different record systems, incomplete records, and relevant information about Hannah being recorded only in her baby’s records. Increasing contact about her baby’s development was not shared with perinatal mental health services or recognised as potentially indicating that Hannah was struggling.

OLIVER MULANGALA · Prevention of Future Deaths report View report

8 Dec 2025 Surrey J. Stevens

Oliver Mulangala was in custody at HMP High Down, had epilepsy and a history of serious seizures, and was found dead in his cell on 13 July 2024 after suffering a drug-induced seizure. The report identifies concerns about the easy availability and use of illicit new psychoactive substances in HMP High Down, including their contribution to drug-related deaths, coercion and risks to prisoners. It also raises concerns about the availability of mobile phones and the use of drones to facilitate the delivery of drugs and other contraband into prisons.