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Julie Sheila Beasley · Prevention of Future Deaths report View report

28 May 2025 Essex S. Hayes

Julie Sheila Beasley was found deceased at home on 16 March 2023 and died from multiple drug misuse involving a fatal amount of morphine and concomitant prescribed medications. She had deteriorating mental health, increasing suicidal thoughts and plans, and repeatedly requested mental health assessment and a medication review. The report identifies failures to complete required assessments and medication review, inadequate communication and record keeping, and insufficient exploration of information she sought to share about her risks.

Zulfiqar HUSSAIN · Prevention of Future Deaths report View report

24 Nov 2023 Manchester North J. Mitchell

Zulfiqar Hussain, who was 48 years old, was found dead at home on 2 April 2023 from combined drug toxicity causing significant respiratory depression, compounded by pneumonia. The report identified concerns that incoming correspondence was not reliably brought to clinicians’ attention and that adverse medication markers were not being added to electronic medical records, creating a risk that contraindicated medicines could be prescribed.

Redmond Johnson · Prevention of Future Deaths report View report

20 Jun 2014 Suffolk P. Dean

Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.

Philip Richard David BREATNACH · Prevention of Future Deaths report View report

15 Sep 2016 Brighton and Hove V. Hamilton-Deeley

Philip Richard David Breatnach's circumstances are referred to in the Record of Inquest. The concerns relate to online applications for medication, inadequate checking of answers and failure to contact his GP, and the prescribing of Dihydrocodeine by a prescriber who had not seen him, including concerns about the quantity, suitability for migraine, and dosing instructions. The inquest concluded with a finding of MISADVENTURE (DEPENDENCE ON DRUGS).

Mary Ann LINCOLN · Prevention of Future Deaths report View report

2 Aug 2021 West Yorkshire Eastern L. Harris

Mary Ann LINCOLN was admitted to Pinderfields General Hospital on 18 May 2020 and was discovered deceased on the floor of her room on 21 May 2020, with an open fracture of the tibia and fibula. The concerns identified included inadequate overnight checks for vulnerable patients at risk of falls and weaknesses in the circulation and understanding of the bedrails policy.

Cain Alex River Donald · Prevention of Future Deaths report View report

5 Jun 2025 Oxfordshire N. Graham

Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.

Lynn POYSER · Prevention of Future Deaths report View report

23 Jul 2015 South Lincolnshire A. Forrest

Lynn POYSER had impaired kidney function and was prescribed Lisinopril while already taking Spironolactone. She was admitted to hospital with severe hyperkalaemia and suffered a cardiac arrest from which she could not be resuscitated. The principal concern was whether guidance on co-prescribing these medicines sufficiently emphasised caution, review, and monitoring of renal function and electrolytes.

Name not published · Prevention of Future Deaths report View report

5 Nov 2018 London Inner South H. QC

The deceased died at St Thomas’s Hospital on 22 November 2017 from brain damage sustained after he hanged himself at home on 20 November 2017. Concerns included changes and prescribing of psychiatric and sedative medication, inadequate clinical records and review of past records, failure to make an urgent psychiatric referral, and uncertainty about the medication found after his death and what he had taken.

Ghulam Mohammad · Prevention of Future Deaths report View report

14 Nov 2022 East London G. Irvine

Ghulam Mohammad, an 89-year-old man, was admitted to hospital after an unwitnessed fall and later sustained a head injury in a further hospital fall. His CT head was delayed for four days, and enoxaparin was prescribed and administered before the extent of any intracranial injury was known. The report also identifies inadequate record keeping and omissions in the initial investigation and consultant statement concerning the use of enoxaparin.

Wayne Lee Millett · Prevention of Future Deaths report View report

18 Feb 2020 Manchester South C. Morris

Wayne Lee Millett, a detained patient at The Priory Hospital, Cheadle, had treatment-resistant schizophrenia treated with Clozapine and died there on 13 February 2019 after escalating abdominal symptoms, collapse and complications including pseudo-obstruction of the small bowel. The report raised concerns that the Care Plan was not followed, that the Priory’s investigation and quality-assurance processes were inadequate, and that care-plan compliance and Clozapine-related monitoring had not been sufficiently reviewed.

Abu RAHMAN · Prevention of Future Deaths report View report

31 Mar 2025 Inner North London H. Lambert

Abu Rahman, aged 88, suffered a traumatic fall causing a fractured hip and underwent hemi-arthroplasty before deteriorating with pneumonia on a background of end stage renal failure. Concerns included delays in obtaining Naloxone when supplies ran out and limited awareness of opioid toxicity or accumulation in patients with kidney impairment or failure.

Sasha Drysdale · Prevention of Future Deaths report View report

18 Jul 2024 Manchester South C. Morris

Sasha Drysdale died on 28 March 2023 in hospital as a consequence of acute myeloid leukaemia transformed from myelodysplastic syndrome. She had previously been prescribed clozapine for treatment-resistant schizoaffective disorder and was detained under section 3 of the Mental Health Act 1983 at the time of her death. The concern raised was that further research is needed to establish whether clozapine materially increases the risk of certain blood cancers.

Billie Diane WICKS · Prevention of Future Deaths report View report

13 Mar 2025 Inner North London M. Hassell

Billie Wicks, aged 16, was brought to hospital with an asthma attack and was discharged without adequate repeat observations or senior clinical review. The report states that her asthma was not diagnosed or treated and that she died from infective exacerbation of asthma. Concerns included understaffing and inadequate observations, delayed antibiotic treatment, lack of awareness of adult-onset asthma, and the limitations of safety-netting advice after her parents had already sought hospital care.

Mrs Ruth Ellen Edwards · Prevention of Future Deaths report View report

18 Dec 2018 South Wales Central R. Knight

Mrs Ruth Ellen Edwards died at home on 31 August 2018 after hanging herself from an attic ladder, following a long history of mental health problems and previous suicide attempts. Concerns included her discharge after a drug overdose without psychiatric liaison assessment, inadequate risk assessment and inaccurate communication about the overdose, and potentially insufficient medication reviews despite access to many medications at home.

Douglas OWENS · Prevention of Future Deaths report View report

19 Oct 2020 Blackpool and the Fylde T. Holloway

Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

Nigel Handscomb · Prevention of Future Deaths report View report

1 Aug 2018 Inner South London P. Barlow

Nigel Handscomb was admitted to University Hospital Lewisham after being diagnosed with pneumonia and possibly having suffered a stroke. He was not reviewed by a doctor for 48 hours, opportunities to escalate his care were missed, and he later suffered a cardiac arrest; the inquest concluded that natural causes, including aspiration pneumonia, bronchopneumonia and severe ketoacidosis, involved neglect. Concerns included incomplete and inaccurate GP records, delayed recording, and missing information about examinations, medication and swallowing difficulties.

Aarav Pal CHOPRA · Prevention of Future Deaths report View report

13 Jan 2025 Birmingham and Solihull L. Hunt

Aarav Pal CHOPRA died on 22 November 2023 after an intercostal artery was damaged during a liver biopsy, causing a haemothorax, cardiac arrest and hypoxic brain injury. The report identified concerns about inadequate planning and communication, delayed recognition and treatment of the haemothorax, unclear decision-making, trainee competence, consent, patient risk factors, prophylactic antibiotics, learning from deaths and access to complete electronic records.

Mr Turner · Prevention of Future Deaths report View report

14 Jan 2026 Staffordshire and Stoke-on-Trent E. Serrano

Mr Turner was a 63-year-old man who was found deceased at his home on 18 April 2025; a postmortem identified citalopram toxicity as the cause of death. The concern raised was that there was no local or national guidance on what steps to take when a high serum level is returned in patients monitored while taking clozapine.

Michael Paul Barry · Prevention of Future Deaths report View report

12 Jun 2025 Essex S. Horstead

Michael Paul Barry died at Broomfield Hospital from fatal complications of community-acquired pneumonia, with excessive codeine use contributing to his death. The principal concern was the lack of a commissioned specialist service to help patients and GPs safely reduce or withdraw from prescribed dependency-forming medication, creating a risk of avoidable future deaths.

Elaine Michelle Inns · Prevention of Future Deaths report View report

26 Aug 2021 Manchester South A. Mutch

Elaine Michelle Inns was found dead at her home on 18 January 2021. The inquest heard that she continued to be prescribed powerful painkillers despite significant alcohol use and use of liquid morphine without clearly following dosage instructions; the medical cause of death involved the combined toxic effects of ethanol and prescribed medicines.