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Stephen Anthony Mayoll · Prevention of Future Deaths report View report

25 Nov 2014 Portsmouth and South East Hampshire D. Horsley

Stephen Anthony Mayoll fell from a ladder at work and sustained a right Achilles tendon injury, for which he received outpatient treatment at Queen Alexandra Hospital between 11 and 20 June 2013. He became very unwell at home on 21 June and died in hospital at 03.20 hours on 22 June 2013 from a pulmonary thromboembolism arising from a deep vein thrombosis. Concerns included the lack of reassessment under the hospital’s DVT assessment policy for similar fracture-clinic outpatients and delays in making fracture-clinic doctors’ notes available.

Peter Harry Mackie · Prevention of Future Deaths report View report

5 Dec 2014 Buckinghamshire R. Hulett

Peter Harry Mackie, a prisoner at HMP Springhill, was found hanging in the prison chapel on 28 December 2013 and was declared deceased. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the availability and deployment of first aiders and healthcare staff across the prison sites, and a lack of clarity about when CPR should be commenced and what action untrained staff should take.

Samantha Jane BOAZMAN · Prevention of Future Deaths report View report

31 Jan 2023 Leicester City and South Leicestershire F. Butler

Samantha Jane Boazman, who was detained under section 3 of the Mental Health Act and living in a locked rehabilitation ward, was found unresponsive in her bathroom on 22 October 2021 and was pronounced dead later that evening. The report identified concerns about delayed access to emergency equipment and CPR, and about predictable and inadequate recording of patient observations. The inquest jury found gross neglect involving shortcomings including inadequate training, failure to remove ligature risks from bedrooms, and inadequate induction and training of temporary staff.

Dominic Adam Travis · Prevention of Future Deaths report View report

7 Dec 2016 Manchester (North) L. Hashmi

Dominic Adam Travis, an 18-year-old man with mental health problems and regular use of cannabis and other substances, died in hospital on 18 May 2015 after suffering catastrophic injuries when he fell or jumped from a derelict mill following an acute psychotic deterioration and absconding from supported accommodation. The concerns raised included whether specialist inpatient provision adequately met the needs of young adults with mental health problems and whether the NHS Trust’s investigation into his care was sufficiently independent, transparent and timely.

Miss Kirsty Walker · Prevention of Future Deaths report View report

19 Dec 2018 Surrey A. Crawford

Miss Kirsty Walker died in hospital on 27 September 2015 after being found unresponsive in prison with a ligature tied around her neck. She had a history of self-harm and had engaged in 235 acts of self-harm during her imprisonment, including 215 involving ligatures. The report raised concern that prisoners were taking well over 14 days to transfer to secure hospitals under section 47 of the Mental Health Act 1983, presenting a risk of further deaths.

Lauren Rae MORET-DELL · Prevention of Future Deaths report View report

4 Feb 2026 Suffolk D. Stewart

Lauren Rae Moret-Dell developed neurological symptoms, later suffered bilateral embolic strokes, and died on 10 January 2024. Concerns were raised about failures to make timely referrals to the TIA Clinic and about the lack of commissioned stroke consultant input at West Suffolk Hospital out of hours, both of which were considered to give rise to a risk of death.

KATHRYN LOUISE SAWYER · Prevention of Future Deaths report View report

16 Apr 2014 Norfolk J. Lake

Kathryn Louise Sawyer, who had a significant history of mental health issues and was prescribed multiple medications including Methadone, was found collapsed and unresponsive at home on 14 August 2013 and died shortly after arriving at hospital. The medical cause of death was respiratory failure due to an overdose of Methadone in combination with therapeutic levels of other drugs. A principal concern was that, although her medication was reviewed in June 2013, there was no or no detailed record of the discussion and no plan for future medication, particularly any plan to decrease it.

Cyril Cheetham · Prevention of Future Deaths report View report

2 Feb 2021 Manchester South A. Bridgman

Cyril Cheetham, aged 91 and resident in a care home, became unwell on 20.02.19, was admitted to hospital later that day, placed on an end-of-life pathway, and died on 25.02.19. The principal concern was that unclear responsibility between Mastercall and his own GP resulted in no same-day GP attendance, alongside concerns that the ATT service lacked adequate auditing and that its triage arrangements could delay hospital admission and contribute to future deaths.

Anne Taylor · Prevention of Future Deaths report View report

8 Nov 2024 Manchester West M. Pemberton

Anne Taylor sustained a head injury after banging her head on a bedside cabinet and falling from a bed during a holiday. After initially leaving hospital before assessment because of waiting times, she returned the next day and was diagnosed with a traumatic brain injury involving bilateral acute subdural bleeding and midline shift; she deteriorated and died on 31 July 2024. Concerns included the lack of consideration of investigations during the waiting period, the absence of evidence that her capacity to leave was assessed, and uncertainty about a new procedure for patients leaving before clinical assessment.

Chloe Anne Tapp · Prevention of Future Deaths report View report

28 Feb 2024 Essex R. Mundy

Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.

George Edward GRIFFITHS · Prevention of Future Deaths report View report

28 Jun 2023 Herefordshire H. Bricknell

George Edward GRIFFITHS was admitted to hospital with acute kidney injury, gastritis, poorly controlled diabetes and infected toes, and later developed sepsis, COVID, delirium and a significant pressure sore during his prolonged admission. The report states that doctors believed the hospital-acquired pressure sore contributed to his death. Concerns included prolonged time in the emergency department without footwear removal, inadequate pressure-area prevention and delayed reassessment and pressure-relieving measures.

Master Ruben Bousquet · Prevention of Future Deaths report View report

18 Dec 2020 Inner South London A. Harris

Master Ruben Bousquet died after consuming popcorn that had become cross-contaminated with milk protein, causing acute anaphylaxis. The report raised concerns about timely sharing and registration of fatal food-allergy incidents, and about whether food businesses should have access to adrenaline auto-injectors.

Mary Jones · Prevention of Future Deaths report View report

30 Sep 2019 Manchester South A. Mutch

Mary Jones had an accidental unwitnessed fall, was treated surgically and transferred for rehabilitation, and died on 3 March 2019 after developing acute pneumonia alongside congestive heart failure and acute kidney injury. Concerns included an out-of-hours transfer and admission, delayed falls-risk assessment, poor fluid-chart documentation, loss of records during an IT merger, absent or untraceable nutrition-related referrals, and no clear clinical review of fluid-chart outcomes.

Kristina CROSS · Prevention of Future Deaths report View report

2 Jan 2018 Lancashire and Blackburn with Darwen J. Newman

Kristina Cross, aged 72, was admitted on 28 August 2016 after an unwitnessed fall and was later found to have a displaced fracture of the neck of the femur. The fracture was initially misdiagnosed, delaying surgical fixation; she subsequently suffered wound complications and joint dislocations, deteriorated after further surgery, and died on 20 November 2016. The principal concerns were unfilled consultant radiologist posts and delays, or failures, in reporting radiological investigations needed for diagnosis and clinical decision-making.

Sarah YOUNG · Prevention of Future Deaths report View report

10 Feb 2020 Bedfordshire and Luton E. Whitting

Sarah YOUNG was admitted to Bedford Hospital on 9 April 2019 with headaches, confusion, immobility and fluctuating consciousness, and was later declared to have suffered brain-stem death on 12 April 2019 after an extensive cerebral sinus thrombosis. The principal concerns were delays in medical and neurological review, diagnosis and treatment, including difficulties with the referral system. The Inquest heard that earlier treatment may have increased her chances of survival, but could not be said to have contributed to her death.

Lynsey Sarah Smalley · Prevention of Future Deaths report View report

8 Sep 2023 North West Wales K. Robertson

Lynsey Sarah Smalley, aged 42, set fire to her bed at home during an acute psychotic episode on 8 April 2021. She suffered inhalation injuries, was admitted to intensive care, and died at Ysbyty Gwynedd, Bangor on 16 May 2021. The substantive concerns were conflicting investigation reports, disjointed patient-safety and governance processes, delays in completing actions, and risks arising from paper-based medical records that may impede continuity of care.

Tyler Jay Ryan · Prevention of Future Deaths report View report

17 Oct 2023 Newcastle upon Tyne and North Tyneside C. Henley

Tyler Jay Ryan, aged 11, was found collapsed in his bedroom on 12 February 2021 and died after resuscitation attempts. Genetic testing identified two RYR2 variants associated with CPVT, following earlier differing pathological opinions. The report raised concerns about delays in paediatric pathology reporting and the delayed identification of families who may need genetic testing, as well as the need for wider use of molecular autopsy and revision of the SUDIC Protocol.

Eleanor Emily SHERMAN · Prevention of Future Deaths report View report

26 Nov 2020 Warwickshire S. McGovern

Eleanor Emily SHERMAN died at Warwick Hospital on 20 August 2020 after collapsing at home; a CT scan confirmed a subarachnoid haemorrhage. The report identified two misdiagnoses, failure to read the GP referral letter, and systemic problems with access to the GP’s electronic records and the scanning of notes.

Richard Mark WHELAN · Prevention of Future Deaths report View report

9 Apr 2026 West Yorkshire (Western) P. Merchant

Richard Mark Whelan died on 15 December 2024 from exsanguination caused by incised wounds to both wrists after a deliberate act intended to end his life. In the preceding weeks, his mental health had deteriorated, and a referral to the Mental Health Trust Single Point of Access made on 11 December had not been acted on by the time of his death. The principal concern was that non-urgent referrals could take up to 14 days to be triaged, with a further plan only devised after triage.

Alison Jean Shirley Jeanes · Prevention of Future Deaths report View report

7 Oct 2020 Manchester South A. Mutch

Alison Jean Shirley Jeanes was admitted to hospital after an accidental fall at a care home while taking anticoagulation, with a head injury and high INR. She later developed a progressing bleed, was placed on palliative care, and died in hospital. The report raised concerns about delays in neurosurgical input, CT scanning, and further haematology advice, and about unclear responsibility for follow-up.