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DAPHNE JOAN PENN · Prevention of Future Deaths report View report

29 Jun 2018 Suffolk P. Dean

Daphne Joan Penn was transferred to Newmarket Community Hospital for rehabilitation and later died after readmission to West Suffolk Hospital, following deterioration. The inquest recorded pneumonia as the cause of death and identified concerns about an inadvertently rapid reduction in her long-term steroid therapy, delays in communicating family concerns, and a prescribing error that caused an additional reduction in the steroid dose.

Roy Joseph Godfrey · Prevention of Future Deaths report View report

31 Mar 2014 London (East) N. Persaud

Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

EMMA LOUISE BRAY · Prevention of Future Deaths report View report

16 Nov 2015 East London L. Johnson

Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

Elise Kay Louise Sebastian · Prevention of Future Deaths report View report

8 Feb 2026 Essex S. Hayes

Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

Louise Danielle ROSENDALE · Prevention of Future Deaths report View report

30 Apr 2025 Manchester South A. Mutch

Louise Danielle Rosendale was prescribed long-term opiates for pain following previous surgery and was found unresponsive on 24 September 2024. She died from multiple drug toxicity and pneumonia; concerns included limited review of her long-term opiate prescribing and a lack of detailed planning or oversight for such patients within the practice.

Rachel Gibson · Prevention of Future Deaths report View report

30 Aug 2024 Cambridgeshire and Peterborough P. Barlow

Rachel Gibson underwent hip replacement surgery in April 2022 and received an excessive dose of Ropivacaine, after which she suffered an unwitnessed cardiac arrest and irreversible brain damage. She died in hospital on 14 July 2022. The principal concerns were unclear responsibilities for prescribing, checking and administering the local anaesthetic, inconsistent prescription units, and wide variation in similar practices nationally.

LISA MARIE THOMPSON · Prevention of Future Deaths report View report

10 Feb 2021 Oxfordshire S. Hayes

Lisa was found unresponsive at home on 14 March 2020 after tying a ligature around her neck, was resuscitated and taken to hospital, where she died from hypoxic brain injury following cardiorespiratory arrest caused by asphyxiation. The inquest concluded that the death was suicide. Concerns included the absence of a clear care plan after an emergency review and failures to update mental-health care plans and risk assessments with material information about her overdoses and subsequent disclosures.

Raymond Charles Woodward · Prevention of Future Deaths report View report

26 Aug 2016 Birmingham and Solihull E. Brown

Raymond Charles Woodward suffered a cardiac arrest and died on 19 February 2016 while undergoing a colonoscopy after Buscopan was administered. The report identified concerns that the risk of adverse reactions to Buscopan in patients with coronary artery disease was not widely known and that existing prescribing information did not specifically address ischaemic heart disease.

Ralph Stephen Goslin · Prevention of Future Deaths report View report

25 Jun 2014 Inner North London M. Hassell

Ralph Stephen Goslin, an inpatient detained under Section 3 of the Mental Health Act, was found unresponsive in a bath on 21 June 2014 and died later that day in hospital. A concern was raised that a junior doctor did not recognise his sodium valproate level as subtherapeutic because of the reference range shown, delaying recognition of his failure to take anti-epilepsy medication.

Malcolm John Rathmell · Prevention of Future Deaths report View report

20 Feb 2019 Nottinghamshire J. Gillespie

Malcolm Rathmell was admitted after a fall and his pelvic fracture was not diagnosed until several days later. He was incorrectly given warfarin intended for another patient, subsequently suffered retroperitoneal bleeding, and died after developing bronchopneumonia. Concerns included failures to identify the incorrect prescription, the absence of a ward-based pharmacy review, and insufficient implemented action to address the risk of future deaths.

Susan Warby · Prevention of Future Deaths report View report

25 Sep 2020 Suffolk N. Parsley

Susan Warby was admitted to hospital with a perforated bowel and underwent emergency surgery. An incorrect intravenous fluid attached to an arterial line, combined with incorrect blood-sampling technique, produced erroneous results that led to unnecessary insulin treatment, hypoglycaemia and a brain injury; her death followed multi-organ failure, septicaemia and disseminated aspergillus pneumonia. The principal concerns were the lack of distinctive labelling for fluids used with arterial lines and inadequate blood-sampling technique and training.

Courtney Jordan Mills · Prevention of Future Deaths report View report

12 May 2014 Portsmouth and South East Hampshire D. Horsley

Courtney Jordan Mills was found unresponsive in bed at home on 19 April 2013 and was pronounced deceased at hospital that morning. The concerns included repeated prescription and communication problems affecting access to Clonodine, which was reported as a medication that should not be stopped abruptly, and the potential risk to other children in similar circumstances. The inquest recorded acute bronchopneumonia in a child with sleep apnoea and cerebral palsy, with death due to natural causes.

Margaret Hions · Prevention of Future Deaths report View report

12 Feb 2016 Carmarthenshire and Pembrokeshire J. Layton

Margaret Hions was admitted to Glangwili Hospital on 1 July 2013 and later transferred to Prince Philip Hospital, where she died on 27 August 2013. During her admission, a large bruise rapidly expanded after warfarin was replaced with tinzaparin. Concerns were raised about tinzaparin prescribing, monitoring of blood levels, and monitoring creatinine clearance, with the inquest identifying shortcomings in the management of her care at Glangwili Hospital.

Captain James Michael Bedford · Prevention of Future Deaths report View report

18 Oct 2016 South Yorkshire (Western) C. Dorries

Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.

Yemisi Cielto-Opaleye · Prevention of Future Deaths report View report

18 Nov 2024 Inner North London E. Buckett

Yemisi Cielto-Opaleye, a psychiatric inpatient at St Pancras Hospital, died on 13 December 2023 after receiving an Olanzapine depot injection and developing Olanzapine toxicity. The report identified concerns about inadequate pre- and post-injection vital-sign monitoring, unclear staff responsibilities, insufficient escalation and contingency planning, and failures to obtain required approval and provide adequate information about risks.

Jamie Francis O'Connor · Prevention of Future Deaths report View report

21 Oct 2021 Leicester City and South Leicestershire D. Hocking

Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.

Michael James Robert ROLFE · Prevention of Future Deaths report View report

7 Sep 2022 Lincolnshire P. Cooper

Michael James Robert ROLFE, a 72-year-old man, was admitted on 23 August 2019 with decreasing consciousness and a cerebellar haemorrhage with intraventricular extension, and died the following day after treatment was considered not possible. The report raises concern that prescribing Rivaroxaban in the context of liver impairment, low platelets and impaired renal function may have increased bleeding risk and may have contributed to the rectal bleeding and cerebral haemorrhage.

Christine Marie Stevenson · Prevention of Future Deaths report View report

10 Mar 2016 Manchester South J. Kearsley

Christine Marie Stevenson, who had a history of illicit drug use and multiple medical issues, died at home on 21 July 2015. The inquest recorded the cause of death as combined drug toxicity from prescribed and illicit drug use. Concerns were raised about the lack of control over Oramorph prescribing, including the issue of 500 ml, equivalent to 1000 mg, without controls despite evidence that 50 ml could pose a risk to life in a naïve user.

David Charles Martin · Prevention of Future Deaths report View report

8 Oct 2024 Cornwall and Isles of Scilly A. Cox

David Charles Martin, an 83-year-old man with progressive heart failure, was admitted to hospital, underwent PCI, collapsed later that day, and died in hospital on 17 September 2022. The principal concerns were inadequate induction for a locum doctor unfamiliar with the Trust’s DAPT policy and multiple missed opportunities to identify and act on the fact that he had been prescribed Aspirin only.

Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report View report

24 Jul 2019 Manchester South A. Mutch

Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.