6,433 reports
Information drawn from published reports and official responses.
Rowan Lloyd died after colliding with a traffic signal pole while cycling home from school and falling under the wheels of a trailer at a busy junction. Concerns related to the lack of pedestrian crossing facilities, barriers, and dedicated cycling infrastructure at the junction, particularly given its use by school-age pedestrians and cyclists.
Dorset Highways Department
Christopher Lewis McGUFFIE stood on the rails at Chester-le-Street station and was struck by a London to Edinburgh service. The report raised concerns about the lack of immediate and effective means to alert railway staff to people on the line, and the lack of alternative detection and response systems.
Arriva Rail North Limited
Abigail Hall died at home on 23 September 2015 from aspiration pneumonitis and viral gastro-enteritis. Evidence at the inquest showed that there was no defibrillator at the premises and Derwent staff were not first aid trained; this position apparently still persisted.
Derwent Facilities Management Limited
Simon Healey underwent right hemi-colectomy on 1 August 2017 and died on 10 August 2017 after an anastomotic leak led to faecal peritonitis, E. coli septicaemia and organ failure. The principal concerns were missed opportunities to detect the leak and sepsis earlier, inadequate escalation of care under NEWS protocols, the suitability of private hospitals’ staffing and facilities for such procedures, and an inadequate hospital investigation.
Independent Healthcare Providers NetworkRamsay Health Care UK
John Michael KIRBY took his own life, according to the conclusion of the inquest. The concerns included delays in his care, the handling of an ADHD diagnosis and Concerta prescribing, inadequate monitoring, and failures to respond appropriately to information about suicidal thoughts, a reported suicide attempt, substance use and an A&E admission.
Sussex Partnership NHS Foundation Trust
Veronica Gregory, who was 83 and living in a nursing and care home, suffered an unwitnessed incident followed by a delayed recognition of pain and a fractured neck of femur. She underwent surgery, developed pneumonia and died on 23 November 2017. The principal concerns included inadequate falls-risk care planning and review, incomplete observation and clinical records, insufficient staffing and supervision, and failures to seek medical assistance promptly.
Zinnia Healthcare Limited
Mrs Sylvia Mitchell, a 90-year-old woman, died at Good Hope Hospital on 23 May 2018 after developing urosepsis associated with a fistula caused by an impacted Gellhorn pessary. The report identified inadequate communication and failures to adequately monitor and review the pessary, with delays in its removal contributing to her death.
Medical CentreSandwell and West Birmingham Hospitals NHS TrustThe Oaks Medical Centre
Mr Bradley Fraser Brown was a serving prisoner who died in prison on 14 August 2017 after being found suspended by a ligature from a cell light fitting. The report identifies concerns about his late weekend transfer, limited access to healthcare records and assessments, reduced weekend healthcare provision, and the absence of national guidance on late prison transfers.
Ministry of JusticeNHS England
Thomas Nicol, a serving prisoner at HMP The Mount, was found hanging in his cell on 21 September 2015 and died in hospital on 25 September 2015. The report raised concern that the weeks-to-months taken to transfer prisoners in acute mental health crisis to suitable secure hospitals potentially puts lives at risk.
Ministry of JusticeNHS England
Luke John Saxton was struck by a motor car while walking along the A59 in darkness on 23 June 2018 and died at the scene from his injuries. The principal concern was that the collision location and nearby bus stops had no street lighting, despite the area being near a popular wedding venue.
North Yorkshire CouncilRecipient name withheld
John Lea was admitted to hospital for management of heart failure and was later found collapsed on the ward after the bay-tagging nurse temporarily left without arranging monitoring. Resuscitation was unsuccessful and his death was confirmed on 12 June 2017; the report considered a sudden cardiac-related event more likely than not. Concerns included incomplete risk assessments, poor communication, gaps in documentation, failure to escalate a change in oxygen saturations, incorrectly calculated NEWS scores, and failures to follow relevant policies and protocols.
Pennine Acute Hospitals NHS Trust
Michelle Roach’s inquest was heard at Reading Town Hall between 6 and 9 November 2018, and the narrative conclusion recorded that natural causes contributed to by neglect in her clinical management from 09:11 on 29 January 2014 until 18:07 on 30 January 2014. Concerns related to GP knowledge of venous thromboembolism, record-keeping and reviews of unexpected deaths, as well as the level of overnight medical registrar cover at the hospital trust.
Royal Berkshire HospitalThe Waterfield Practice
Ronald Houchin died on 5 September 2017 after an unwitnessed fall at Rosehill House Care Home, having sustained a subdural haematoma; the recorded medical cause of death was aspiration pneumonia caused by the haematoma. The report identified concerns that falls risk assessments and care plans were not reviewed regularly or followed, despite Mr Houchin having fallen seventeen times.
Rosehill House
Jack Riding collapsed while playing football after a genetic heart condition caused his heart to stop, and he was declared dead in hospital on 15 August 2018. The report raised concerns about delays in deploying a defibrillator and directing ambulance personnel to the pitch, as well as the adequacy of emergency medical risk assessments, first-aid training, and related procedures. The report stated that these delays could not be said to have contributed to Mr Riding’s death but presented a risk of future death.
Goals Soccer Centres PLCRecipient name withheldThe Football Association
Matthew Gerard Craven was found dead at home on 19 April 2018 after consuming pregabalin in excess of his prescribed amount; toxicology showed a fatal dose of pregabalin. Concerns included repeated rejected referrals for psychiatric assessment, the absence of a challenge or escalation process, no agreed timescales for routine appointments, limited documentation of referral decisions, and inadequate sharing and review of mental health information.
Pennine Care NHS Foundation Trust
Savannah-Rose Michelle Owen was a healthy baby born on 16 February 2018 who fell asleep on a nursing pillow on a sofa at home on 22 April 2018 and later became unresponsive. Resuscitation attempts were unsuccessful, and the post-mortem found no cause of death, with the death recorded as due to natural causes. Concerns included the lack of specific safety regulation for multi-purpose nursing pillows, potentially misleading imagery and warnings, the warning label not being attached to the pillow, and uncertainty about whether community health professionals were highlighting the risks of unsupervised sleeping on such pillows.
Department for Business, Energy & Industrial StrategyDepartment of Health and Social Care
Karen Moran was found at home on 7 April 2018 and died after unsuccessful resuscitation attempts at Tameside General Hospital. Toxicology showed raised levels of prescribed dihydrocodeine and gabapentin, and the inquest heard that her recognised addiction to prescribed medication was not addressed through referral while repeat prescriptions continued to provide access to significant amounts of medication.
NHS Greater Manchester Integrated Care Board
Roy Burgess, aged 87, was admitted after a fall at home that caused a left femoral fracture and was transferred for surgery. The report identified missed opportunities to recognise and escalate his deteriorating condition, inadequate clinical record-keeping, and untimed ward-round notes entered non-chronologically. The inquest concluded that it was unlikely that intervention would have altered the outcome.
Department of Health and Social CareDoncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
On 22 January 2018, 11-year-old Ursula Niamh MacEochaigh Keogh left school, got off the bus early and jumped from North Bridge in Halifax; she was later found in the river and pronounced deceased. The inquest heard concerns about inconsistent advice and communication between health and education professionals regarding referral for assessment of Ursula’s self-harm, as well as preventative measures at North Bridge.
Calderdale Borough CouncilDepartment of Health and Social CareNHS West Yorkshire Integrated Care Board
Ben Walmsley died by suicide at his home on 4 February 2018, by hanging. Before his death, he searched school computers for suicide-related content, but the school had no mechanism to be alerted to blocked high-risk searches; the report raised concern about whether similar monitoring functionality was mandatory or available across schools and software providers.
Department for Education
