6,433 reports
Information drawn from published reports and official responses.
Mr Viswambaran, aged 27, was found dead at home on 18 September 2018 after overdosing on co-dydramol tablets. The report raises concerns about lengthy waiting times for IAPT therapy and difficulties contacting the IAPT service, which could contribute to deterioration or disengagement from mental health support.
North East London NHS Foundation Trust
Gail Bailey, who was nine weeks pregnant, developed abdominal discomfort while on holiday on 5 August 2017. An ambulance was called but arrived after a delay, and she was declared deceased at Boston Pilgrim Hospital later that evening. The report raised concerns about emergency communication and preparedness, including pre-alert calls that were not dated or signed and the apparent lack of advance warning to obstetric and gynaecology staff.
United Lincolnshire Teaching Hospitals NHS Trust
Tyrone Givans, who was homeless, profoundly deaf and had a history of alcohol and drug use, was remanded into custody at HMP Pentonville after being arrested for assault. The jury concluded that he hanged himself in his cell, although his intentions were unclear. Principal concerns included Spice use in prison, duplicated prison and healthcare records that prevented access to earlier assessments, and inadequate recognition and support of his deafness and disabilities.
Care UKHM Prison and Probation ServicePentonville Prison
Ann Swoffer died on 02/09/18 after an oesophageal perforation developed following dilatation during naso-jejunal tube insertion. The report identified concerns about the procedure being contrary to accepted practice, delayed recognition and treatment of the perforation, inadequate escalation to senior staff at the weekend, and inconsistent practices and protocols across hospital sites.
University Hospitals Birmingham NHS Foundation Trust
Neil Antony Black was remanded into HMP Birmingham on 8 March 2018 after disclosing extensive alcohol and intravenous drug use and a DVT in his right leg. He became increasingly unwell in prison, was admitted to hospital on 12 March with suspected sepsis, and was diagnosed with infective endocarditis and lung abscesses before deteriorating to multi-organ failure and dying on 31 March 2018. The report identified concerns about inconsistent physical observations, inadequate interaction between prison healthcare teams, unclear responsibilities, and the lack of examination of his leg and injection sites.
Birmingham and Solihull Mental Health NHS Foundation TrustBirmingham Community Healthcare NHS Foundation Trust
Robert Irwin Norton sustained fatal injuries in a motorcycle collision at a roundabout on 5 April 2018. The concerns identified were the poor legibility of road markings and potential confusion about the correct lane for exiting onto the M62 slip road.
Calderdale Borough Council
Norman Joseph Pirie died on 5 October 2018 following a major haemorrhage and cardiac arrest after open surgery was required when an endovascular cuff device failed to deploy during an elective procedure. The device had been used at a 68-degree angle, beyond the manufacturer’s maximum permitted angle of 60 degrees. The principal concern was that such devices were being used outside manufacturer instructions in non-emergency procedures, increasing the risk of deployment failure and urgent open surgery with a high risk of death.
Royal London Hospital
Mylon Sheppard hanged himself at home and was found on 3 October 2018. The report identified concerns about oversight of duty workers' decisions, waiting-list management, non-attendance processes, family involvement in care planning, and the identification of GP and geographical boundaries for local mental health services.
Coventry and Warwickshire Partnership NHS Trust
Mark Harris was found deceased with a rope around his neck at the home of his ex-partner on 11 January 2016, after expressing suicidal thoughts following his release from police custody. The report identified communication and information-sharing problems between the ambulance service, police control room and attending officers, including the deceased’s name being mis-spelt and uncertainty about the purpose of the police attendance.
East of England Ambulance Service NHS TrustMelbourne Ambulance StationNorwich Emergency Operations Centre
George Foster Thompson, who had multiple chronic health problems and lived in a residential care home, became unwell on 21 August 2018, deteriorated despite receiving antibiotics, and died in hospital on 23 August 2018. The substantive concern was that only one doctor was on duty at the practice, with no resource for a home visit that afternoon even if the doctor considered one indicated.
HT Practice
John Preece, who had early onset dementia and was prone to seizures, suffered a witnessed seizure and fall on 9 September 2015, sustaining a serious head injury. He was not closely monitored and received incomplete and inappropriate physical and neurological observations before being admitted to hospital, where he died in the early hours of 10 September 2015. The principal concerns were inadequate falls management and neuro-observation knowledge and training, lack of forward planning and monitoring, and delayed medical assistance for medically unwell mental health patients.
Cardiff & Vale University LHBNursing and Midwifery Council
Marie Hilda Millward Winter fell at a nursing home on 19 August 2017, sustained a head injury and developed an intracranial bleed. The report states that Apixaban was administered after the fall and that this worsened the bleed and contributed to her death at hospital on 2 September 2017. The principal concern was the administration of anticoagulant medication after a head injury, reportedly on the advice of or in the presence of ambulance technicians.
North West Ambulance Service NHS Trust
Ms Catherine Anne Horton, a patient with paranoid schizophrenia detained under section 3 of the Mental Health Act 1983, died by hanging in July 2017, with the death occurring sometime between 16 and 24 July. The report identified failures in ward observation, recording and risk assessment, leadership, the police information pack, and the execution of a section 135(2) warrant. It also raised concerns about a missing-person investigation being incorrectly closed before a Safe and Well check, in the context of staff shortages and pressure of work.
Metropolitan Police Service
Jacqueline Marie Elliott, who had a long-standing history of back pain, was found deceased at home on 9 August 2018. Post-mortem and toxicology findings identified reduced liver function and significant toxicity from a combination of drugs. Concerns included inaccurate prescription records, insufficient clinical notes and medication-review detail, prescribing of 100 tramadol tablets despite a recorded history of non-compliance and self-medication, and a lack of continuity of care.
Delamere Medical PracticeDepartment of Health and Social CareNHS Greater Manchester Integrated Care Board
Ricardo Wayne Holgate was found dead in his cell at Birmingham Prison on the morning of 26 March 2018. The post-mortem recorded coronary artery thrombosis and atherosclerosis, with the combined effects of synthetic cannabinoid and codeine. The inquest identified significant concerns about the supply and use of illicit substances, staffing levels, staff training and experience, and inconsistent management and reporting of prisoners affected by such substances.
G4SHM Prison and Probation ServiceMinistry of Justice
Ruth Gregory had reduced mobility after a fall that led to a total knee replacement and subsequently developed an infected knee. After vomiting suggestive of an upper gastrointestinal bleed, she was readmitted to hospital, deteriorated due to aspiration pneumonia and died on 2 July 2018. The inquest heard that residents were regularly left unsupervised in communal areas, with no detail available about how this risk was managed or how supervision was ensured.
Reinbek
Elizabeth Rose Curtis was admitted to hospital with a urinary tract infection and delirium, was treated with antibiotics and haloperidol, developed aspiration pneumonia, and died on 31 March 2018. The inquest noted that she was prescribed 2.5mg of haloperidol instead of the intended 0.25mg. A substantive concern was how patients’ mobility and frailty should be assessed as indicators of wellbeing and possible deterioration in hospital.
NHS England
Richard John Lockley had throat and neck cancer and sustained falls that resulted in cervical spine fractures. He died in hospital on 11 September 2018, with suitable feeding not arranged before his death. The concerns were poor communication during a proposed transfer between County Hospital and Royal Stoke University Hospital, and difficulties finding a gastroenterology bed at Royal Stoke.
Royal Stoke University HospitalUniversity Hospitals of North Midlands NHS Trust
Natasha Learline Chin died in her cell at HMP Bronzefield on 19 July 2016 after profuse vomiting associated with undertreated opiate and alcohol withdrawal. The report identified concerns about delayed medication, inadequate monitoring and escalation, failures in record-keeping and governance, and insufficient auditing and training.
Care Quality CommissionHM Inspectorate of PrisonsMinistry of JusticePrisons and Probation OmbudsmanSodexo
Christopher Michael Seal died by suicide on 30 November 2017 at playing fields at Bath Spa University, having been found suspended from rugby posts. In the five days before his death, he was assessed as high risk by mental health services, but concerns included underestimation of his condition, failures to escalate after missed contact and a police welfare check, inadequate information sharing with his family, and weaknesses in records, policies and staff processes.
Avon and Wiltshire Mental Health Partnership NHS Trust
