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Winifred Mary Redfearn · Prevention of Future Deaths report View report

25 Jun 2020 Wiltshire and Swindon D. Ridley

Winifred Mary Redfearn died after falling down the stairs at home, sustaining head and neck injuries and becoming immobile in hospital. She developed a deep vein thrombosis and pulmonary thromboembolism. The principal concern was that resumption of Dalteparin thromboprophylaxis was delayed for more than two and a half days after the CT report, apparently because of the intervening weekend, and that similar delays could contribute to avoidable premature deaths in other cases.

STEPHANIE DANIELS · Prevention of Future Deaths report View report

13 Dec 2013 Manchester City N. Meadows

Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.

Jake Daniel Taylor · Prevention of Future Deaths report View report

8 May 2026 West London L. Brown

Jake Daniel Taylor, aged 19, suffered a cardiac arrest at his care home on 16 January 2025 and died in Kingston hospital on 20 January 2025. The report identified delays in first aid and concerns about the lack of individual emergency planning, staff training, immediately available equipment, and airway training and equipment.

Hannah Grace Beardshaw · Prevention of Future Deaths report View report

13 Apr 2022 Manchester West R. Syed

Hannah Grace Beardshaw was found hanging at her home on 20 April 2021 after contacting a friend, leaving a note of intent, and researching methods of taking her own life. The concerns identified were delays in escalating and responding to the incident, limited availability of method-of-entry kits, and document-management issues within Greater Manchester Police.

Kyle Ashley Smith · Prevention of Future Deaths report View report

21 Jan 2014 Manchester West J. Leeming

Kyle Ashley Smith was found unresponsive by his wife on 19 October 2013 and was pronounced dead by ambulance staff. A post-mortem found that his death was due to the combined toxic effects of Tramadol, Codeine and Zopiclone; concerns included a delay in an urgent mental-health referral reaching the assessment team, the reason for which had not been investigated and was not known.

Kenton Clete BEASLEY · Prevention of Future Deaths report View report

7 Feb 2025 West Sussex, Brighton and Hove J. Turner

Kenton Clete Beasley was found hanging at an address in Ashurst, Steyning on 19 May 2024 and was confirmed deceased at the scene; third-party involvement was ruled out. The report described delays and communication failures in the renewal of his HGV licence, which prevented him from securing professional employment and contributed to distress and deterioration in his mental health.

Andrea Denise MANN · Prevention of Future Deaths report View report

6 Mar 2025 West Yorkshire (Western) A. Brocklehurst

Andrea Denise MANN was discovered hanging at her home on 10 February 2024 and died in hospital the following day after invasive medical care was withdrawn and palliative care was provided. The inquest identified concerns about limited Community Mental Health Trust involvement, the absence of a requested psychiatric appointment, delays in psychological therapy, and the lack of an overarching tool to scrutinise and measure the care provided.

Elsie Raper · Prevention of Future Deaths report View report

29 Mar 2016 County Durham and Darlington C. Oliver

Elsie Raper, who had osteoporosis and lived in a care home, suffered multiple falls and fractures, including fractures of the left tibia and fibula after a fall on 21 August 2015. These fractures were not diagnosed until 25 August, during which time she was reported to have been in extreme pain; the cause of death included multiple fractures.

Michael Andrew Pollard · Prevention of Future Deaths report View report

5 Mar 2015 Leicester City and South Leicestershire L. Brown

Michael Andrew Pollard, aged 14, collapsed at home on 23 June 2014 and was admitted with an upper gastrointestinal bleed. He became unresponsive before an endoscopy was arranged and died from massive haemorrhage several hours later on 24 June 2014. Concerns included delays in escalation to senior colleagues, lack of early intensive care involvement, inadequate resuscitation with blood products, and an out-of-date on-call rota that delayed contacting the appropriate consultant.

Lindy Lyanne ASTON · Prevention of Future Deaths report View report

8 Dec 2023 Leicester City and South Leicestershire I. Thistlethwaite

Lindy Lyanne Aston underwent a total gastrectomy for stomach cancer and later suffered a ruptured spleen, requiring emergency surgery. She was transferred from Kettering General Hospital to Leicester Royal Infirmary, where she underwent a splenectomy, remained very unwell and died on 18 October 2021. The principal concerns were the decision not to provide immediate surgery at Kettering and inadequacies in the Trust’s investigation and incident-reporting processes, which delayed learning about potential care failures.

Anita Loi · Prevention of Future Deaths report View report

21 Feb 2020 South London J. Devonish

Anita Loi, who had Type 1 diabetes, suffered a burn to her left leg in April 2019 that developed into an infected wound. Despite repeated referrals, the community nursing teams did not attend to management of the wound, and she later suffered cardiac arrest and died in hospital on 1 July 2019. The principal concerns were the lack of response to referrals and whether appropriate referral policies and procedures were in place.

Sebastian Benjamin OLIVER · Prevention of Future Deaths report View report

30 Oct 2024 Birmingham and Solihull A. Hodson

Sebastian Benjamin Oliver was found unresponsive on 29 November 2023 after sustaining an incised wound to his left hand while climbing a spiked fence under the influence of drugs, and he later died in hospital. The report identified concerns about West Midlands Police closing a safe-and-well-check log after Mr Oliver absconded from hospital, relying on an earlier capacity assessment despite a later assessment that he lacked capacity, and about shortcomings in training and communication with ambulance staff.

Matthew Crowley · Prevention of Future Deaths report View report

17 Feb 2016 Mid Kent and Medway P. Harding

Matthew Crowley, aged 39, presented to Maidstone Hospital acutely unwell with sepsis and multiple organ failure, and died at Pembury Hospital at 06.47 on 10 June 2015 after transfer. The report identified concerns including delays in triage, senior medical review, treatment escalation, decision-making and transfer, as well as inadequate communication with the receiving ITU.

Lee Richard Gaunt · Prevention of Future Deaths report View report

4 Mar 2016 Manchester South J. Pollard

Lee Richard Gaunt went to work a night shift at Stalybridge Fire Station on 17 October 2015 and was later found hanging from a tree at the station. The report raised concerns about limited Occupational Health support, delays in accessing a doctor, additional managerial and emergency-response duties following a colleague’s death, and a general failure to provide support staff in stressful situations.

Oliver Christopher Lindsay · Prevention of Future Deaths report View report

6 Apr 2022 Manchester South A. Mutch

Oliver Christopher Lindsay was identified as having fetal growth restriction before suffering an unexpected placental abruption at home on 6 September 2020. He was born with ambulance support, received advanced paediatric life support, and was transferred to hospital, where he was found to have a severe hypoxic brain injury and died on 12 September 2020. The principal concerns were delays in obtaining a growth scan because of scanning capacity issues and limited understanding of the risks associated with fetal growth restriction.

Patricia Violet PALIN · Prevention of Future Deaths report View report

19 Jun 2018 Shropshire, Telford and Wrekin H. Westerman

Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.

Nancy Carolyn Price · Prevention of Future Deaths report View report

26 Apr 2023 North Wales (East and Central) K. Sutherland

Nancy Carolyn Price, aged 62, presented with sudden loss of movement and sensation in both lower limbs and was diagnosed with limb ischaemia. There were delays in assessing and transferring her for vascular surgery, after which she developed multi-organ failure and died on 1 January 2021. The principal concerns were the delayed Health Board investigation, delayed sharing of learning, and unrealistic or incomplete action plans, which limited the timely identification of learning and training needs.

Terence Ewart JAMES · Prevention of Future Deaths report View report

17 Dec 2019 Central and South East Kent S. Hayes

Terence Ewart JAMES, aged 85, was living in a residential home when he sustained an unwitnessed fall on 17 April 2019 and a further fall on 20 April, resulting in a neck of femur fracture. He underwent surgery but became delirious, did not thrive, and died in hospital on 14 May 2019. Concerns included failures to inform the GP of the first fall, hand over the fall history to care staff, and escalate pain and deterioration for further medical advice.

Edna May Davenport · Prevention of Future Deaths report View report

3 Apr 2020 Black Country J. Lees

Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.

Elsie Gibson · Prevention of Future Deaths report View report

21 Oct 2013 South London R. Palmer

Elsie Gibson, aged 94, slipped from a narrowed pavement while passing an unlicensed scaffold tower in High Street, Bromley, on 4 January 2013. She sustained a fractured hip and died in hospital on 9 January 2013. The concerns included the erection of the scaffold without required formalities and the apparent lack of prompt investigation or enforcement action by the Council after the incident.