6,433 reports
Information drawn from published reports and official responses.
On 3 December 2017, a police van responding to an incident collided with Suleyman Yalcin as he crossed Seven Sisters Road, causing fatal injuries. The substantive concerns were insufficient refresher training in emergency response driving, police under-resourcing, and inadequate terminology to communicate the urgency of the incident.
Metropolitan Police Service
Sarah Kiff experienced repeated consultations for vaginal discharge, urinary symptoms, heavy menstruation and lower abdominal pain before cervical cancer was diagnosed after an urgent referral in July 2013. The cancer had metastasised to the liver and, after treatment and subsequent decline, she suffered a cardiac arrest and died at Fairfield General Hospital on 14 October 2015. The report identified concerns about failure to follow cancer referral guidance, inadequate examination and history-taking, poor record-keeping and communication, lack of continuity of care, reluctance to perform internal examinations, and inadequate processes for reviewing test results.
Stonefield Street Surgery
Austin Allen Ellsum THOMAS died after being struck by a Volvo shovel loader truck while walking on the factory floor at a paper mill on 6 February 2017. The concerns identified were the potential distraction caused by music played at high volume in heavy machinery and the absence of random drug testing for employees operating heavy machinery, particularly drivers.
Haulage Contractors LtdHealth and Safety ExecutiveRecipient name withheld
Beryl Ann Walsh sustained catastrophic head injuries in an unwitnessed fall from her bed at Beechwood Lodge Care Home on 3 June 2018, which led directly to her death. The principal concerns were missed opportunities to identify her as being at high risk of falls, refer her to the falls team, provide falls-prevention equipment, and undertake falls-risk assessments and care plans.
Beechwood Lodge
Sheila Graham was admitted to hospital after a fall causing a complicated ankle fracture, subsequently developed infection and clostridium difficile, and died on 13 October 2017 after an upper gastrointestinal bleed. Concerns included the effects of prolonged isolation on her mental and general wellbeing, inadequate recording and monitoring of nutrition despite weight loss, and delayed referral to mental health and dietetic services.
Midlands Partnership University NHS Foundation Trust
On 2 November 2017, Eleanor Brabant hanged herself while alone in a room at Trinity Ward, Antelope House, Southampton. She had a history of mental illness, and her behaviour and mental state had deteriorated after her compulsory detention was rescinded without a clear care plan in place. Concerns included the application and staff training relating to patient observations, safeguarding and reporting crimes involving vulnerable patients, use of Mental Health Act powers for informal patients, and involving families in care planning when consent had been withdrawn.
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Emmett Alexander Gillah had a history of mental illness and was discharged from mental health services at his own request. He later moved onto railway tracks and died after being struck by a train. Concerns included inadequate discharge information and follow-up arrangements, insufficient communication with his family and GP, and failures to refer him to mental health services when his mental health deteriorated.
Kent and Medway Mental Health NHS Trust
Dawn Patricia Gill, a long-term drug user, died from a methadone overdose after taking illicit drugs while in the Royal London Hospital alongside prescribed medication. Concerns included the absence of a nursing care plan addressing her drug use, the loss of her drug chart, failures to detect her in her room during searches, and confusion about when to alert hospital security after she was thought to be missing.
Barts Health NHS TrustRoyal London Hospital
Richard John Hill died on 17 August 2018 when he was struck by a London North Eastern train near the Cromwell Lane level crossing, also known as the Norwell Lane level crossing, near Newark, Nottinghamshire. The concerns identified were that the crossing had no telephones, no displayed contact telephone for Network Rail, and a possibility of a repeat incident at or near the location in the future.
Network Rail
Kendall James Chadwick died at the scene of a road traffic collision on the A518 at Lower Loxley after losing control of his motorcycle during an unsafe overtaking manoeuvre near a bend. The substantive concerns were the history of another fatality at the bend, the possible need for additional safety measures, and the dirty condition of the chevron boards and potential maintenance issues.
Staffordshire County Council
Matthew Sean Arkle, a 37-year-old man and voluntary patient at the Wedgewood Unit, was granted one hour’s unescorted leave on 4 April 2017 but did not return. He was found hanging beside a tree on 6 April 2017 and was pronounced dead at the scene. The inquest identified concerns including failures in record keeping and communication, delays in recognising and reporting him missing, incomplete information provided to police, and the timing of his release.
Norfolk and Suffolk NHS Foundation Trust
Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.
Department of Health and Social CareMidlands Partnership University NHS Foundation Trust
Joseph Page, who had significant co-morbidities, was admitted to hospital on 15 March 2018 and died on 23 March 2018 after deliberately taking a mixed overdose of prescription medication. His medication was accessible and unsecured, contrary to hospital policies. The report identified concerns about the storage and handling of patients’ own drugs in the Emergency Department and on Ward B5, and about the implementation and communication of revised policies.
Cardiff & Vale University LHB
John Eric Graham was found dead at his home on 26 February 2018. Although carbon monoxide was initially considered and later excluded from the cause of death, the report raised concern that carbon monoxide detectors were not routinely installed in homes rented by Rochdale Borough Housing Limited, creating a risk of future deaths if unremedied.
Borough Housing LimitedRochdale Borough Council
Ryan John James WILLIAMS returned to Sandy Railway Station in the early hours of 27 April 2018 and was run over by a train about an hour later. Concerns were raised that the unmanned station had no staff supervision, including no means of supervising potentially intoxicated members of the public if stations remained open while unmanned.
Network Rail
Gerwyn James Thomas was admitted to hospital after a domestic fall that caused a fractured femur and required surgery. He later developed an infection and died after being readmitted to hospital three times; the inquest recorded sepsis, multi-organ failure and infected hip surgery as the medical cause of death. Concerns included delays in responding to acute dietetic referrals, insufficient staffing, and inadequate training in nutritional assessment.
Glangwili General Hospital
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.
General Medical CouncilThe Broadgate General Practice
Gareth James Jones died on the A422 at Inkberrow after losing control of the car he was driving and colliding with another vehicle. Concerns included previous road traffic deaths at the location, a road surface below the specified standard for three years, and the likelihood that the road surface contributed to the death.
Worcestershire County Council
Daniel Paul Mark Stokes, an inmate at HM Prison Lindholme, died on 30 November 2015 after reportedly taking MDMA, acting erratically, becoming physically agitated and suffering cardiac arrest. A concern was raised that prison healthcare staff possessed diazepam but were not trained or authorised to administer it, indicating a possible failure to have proper systems in place.
NHS England
Patricia Chambers died by suicide on 11 May 2016 after jumping from the ninth-floor communal walkway of her residence, sustaining non-survivable injuries. The inquest identified deficiencies in her mental-health discharge process, communication and continuity of care, as well as inadequate GP record keeping and document control; the report remained concerned that information could be lost or ignored and pose a risk to future deaths.
Shepherds Bush Medical CentreWest London NHS Trust
