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Kathleen Cornthwaite · Prevention of Future Deaths report View report

18 Jul 2014 Blackburn, Hyndburn and Ribble Valley M. Singleton

Kathleen Cornthwaite, aged 76, was an inpatient at Pendle Community Hospital when her tramadol prescription was increased after a fall causing a rib injury. The inquest concluded that she died of cardiorespiratory failure due to combined tramadol and fluoxetine toxicity. Concerns included the imprecise tramadol dose recorded, failure to account for her age, size and frailty, and failure to consider interactions with other prescribed medicines.

Jacqueline Sharman CAMPBELL · Prevention of Future Deaths report View report

22 Feb 2023 Milton Keynes S. Cummings

Jacqueline Sharman CAMPBELL was found collapsed at home after living with chronic back pain for more than 20 years and taking multiple prescribed medicines. The inquest concluded that she likely inadvertently overdosed on tramadol, which in combination with other medicines had a synergistic effect causing respiratory depression and death. The principal concern was the safety risk of polypharmacy involving gabapentinoids and opioids, particularly their cumulative and synergistic effects on the central nervous system.

Sally-Ann Few · Prevention of Future Deaths report View report

15 Nov 2022 Mid Kent and Medway C. Wood

Sally-Ann Few was found dead at home on 12 March 2022, after being discharged from hospital the previous day with both slow-release and faster-acting morphine; a post-mortem found that she died as a consequence of morphine toxicity. Concerns included the GP prescribing system not showing that Oromorph had been stopped, a discrepancy between inpatient morphine prescriptions that was not reviewed, and poor medical record keeping that did not document decision-making, discussions, or advice.

Marjory Rosina ELLERY · Prevention of Future Deaths report View report

26 Nov 2014 Surrey S. Wickens

Marjory Rosina Ellery was taken to Frimley Park Hospital with chest pains and was administered medication to which she was known to be allergic. She developed anaphylactic shock and died on 16 January 2014; concerns related to administering medication despite a known allergy and obtaining informed consent in those circumstances.

Tracy Marie BROWN · Prevention of Future Deaths report View report

8 Dec 2022 Hampshire, Portsmouth and Southampton R. Simpson

Tracy Marie BROWN died at home on 5 January 2022 after taking an excessive quantity of some of her prescribed medication. Medication was required to be kept in a locked box because of an identified risk, but a week’s supply was regularly left unsecured and the carers’ digital application did not state that it needed to be stored securely.

Mr. Christopher Summerhayes · Prevention of Future Deaths report View report

22 Aug 2019 South Wales Central S. Richards

Mr. Christopher Summerhayes was found deceased at his home address after a significant medical history including double scoliosis, treatment-resistant schizophrenia and a complex regime of around 12 daily medications. The concerns included the prescription of clozapine alongside other medications, substantial weight gain and possible effects on his cardiovascular system, as well as a possible familial lipid disorder. The inquest concluded that the medical cause of death was ischaemic heart disease, with a narrative determination referring to atypical early-onset coronary artery atherosclerosis and complex prescribed medications.

Marjorie Cybil Bassendine · Prevention of Future Deaths report View report

30 Nov 2016 Surrey K. Henderson

Marjorie Cybil Bassendine, aged 98, suddenly collapsed while eating breakfast at her care home on 2 October 2015 and died despite resuscitation. The inquest recorded cardiac arrhythmia, long QT syndrome and therapeutic drug use as the medical cause of death. The principal concern was that multiple medications capable of prolonging the QT interval had been prescribed without assessment of her cardiac status, including an ECG, or regular ECG monitoring.

SAMANTHA JANE GOULD (Sam) · Prevention of Future Deaths report View report

28 May 2021 Cambridgeshire and Peterborough N. QC

Sam took a very large quantity of prescribed medication at home in the early hours of 2 September 2018 and died within at most a couple of hours. The local pharmacy had not been told about a safety plan under which Sam’s parents were responsible for her medication. The report identified a concern that, without national action to ensure pharmacies are involved in medication safety plans for mental health patients aged 16–17, similar fatalities could occur.

Beryl ELLISON · Prevention of Future Deaths report View report

3 Jan 2023 Sefton, St Helens and Knowsley J. Thompson

Beryl Ellison was receiving end-of-life care at Alexandra Care Home and was found deceased there on 28 June 2022. The inquest concluded that her death resulted from underlying poor health in combination with taking an excessive quantity of prescribed medication. Concerns included unsupervised access to syringe medication, prior family reports about medication being left in her room, and the absence of an explanation for the excessive oxycodone concentration found after her death.

Karl James Willis · Prevention of Future Deaths report View report

24 Aug 2018 Exeter and Greater Devon L. Brown

Karl James Willis was found deceased at home, with toxicology showing amitriptyline at a concentration within the reported fatal range and morphine sufficient to increase its toxicity. The inquest recorded the medical cause of death as aspiration pneumonitis and amitriptyline and morphine toxicity, with a conclusion of misadventure. Concerns included online access to amitriptyline without adequate checks, the ability to provide inaccurate information, and the option not to inform the patient’s GP.

Susan Jill Hammond · Prevention of Future Deaths report View report

4 Nov 2013 Central Lincolnshire S. Fisher

Susan Jill Hammond, who had a known penicillin allergy, was admitted to hospital after becoming ill and was administered intravenous Augmentin despite allergy warnings. She suffered a cardiac arrest and died on 3 July 2009. The principal concerns were that allergy warnings were not sufficiently noticed and that the handover between departments did not communicate her penicillin allergy.

Sidra Aliabase · Prevention of Future Deaths report View report

21 Jan 2026 Inner West London F. Wilcox

Sidra Aliabase was born prematurely at Chelsea and Westminster Hospital and later died there aged 3 weeks after being wrongly prescribed sodium acid phosphate instead of sodium chloride at approximately five times the recommended neonatal dose. The report describes concerns about communication between paediatric cardiology and hospital teams, delayed planning and diagnosis for long QT syndrome, reliance on appropriate cardiology advice, and prescribing systems that may contribute to errors involving similarly named drugs.

Lee Hollman · Prevention of Future Deaths report View report

26 Mar 2014 West Sussex K. Henderson

Lee Hollman, who had a long history of intermittently severe mental ill-health, died after taking an overdose of Quetiapine, Trazodone and alcohol on 28 February 2014. The report identified concerns about inaccurate and outdated medical records, the repeat-prescription system, and failure to review patients in line with relevant guidelines.

Craig Stuart Hamilton · Prevention of Future Deaths report View report

13 Jun 2017 South Yorkshire (Eastern) N. Mundy

Craig Stuart Hamilton died on 8 December 2016 from acute tramadol toxicity after taking excess Tramadol to relieve chronic pain and sleep before working the next day. The principal concerns were the absence of clear procedures for managing patients who obtain or take more medication than prescribed, and insufficient exploration of medication regimes, alternative pain management, and discussions about exceeding prescribed dosages.

Theresa Margaret Feehan · Prevention of Future Deaths report View report

27 Feb 2019 Inner West London F. Wilcox

Theresa Margaret Feehan, who had severe oxygen- and steroid-dependent allergic asthma, was found deceased at home on 12 March 2018. The court recorded aspiration pneumonia and ingestion of amitriptyline and dihydrocodeine as the medical cause of death, with natural causes combined with side effects of prescribed medication. Concerns included inadequate medication review, incomplete medical-history recording, poor correlation between medication and problem lists, insufficient systems for identifying harmful medication interactions, and inadequate supervision of administrative work.

Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report View report

17 May 2024 Greater Lincolnshire J. Wilkes

Jonathan Paul Szczepanski had been prescribed Naproxen regularly for several years without a corresponding proton pump inhibitor or medication reviews addressing the risks of long-term NSAID use. He was admitted with symptoms indicative of a gastrointestinal bleed, did not respond to treatment, and subsequently died. The inquest concluded that he died from a duodenal ulcer, to which Naproxen treatment without a corresponding PPI made a contribution. Concerns included a lack of local prescribing guidance, prescribing software without specific NSAID warning flags, and discharge documentation without relevant warnings.

Liane Davenport · Prevention of Future Deaths report View report

10 Oct 2019 Cumbria K. Cheema

Liane Davenport had chronic schizophrenia treated with high doses of two antipsychotic medicines, alongside significant coronary artery disease and left ventricular dysfunction, and died at home in Cumbria on 4 December 2019. The principal concern was whether blood-level monitoring should be considered for patients receiving long-term high-dose antipsychotic treatment, particularly as they become older and more frail.

Pauline Meredith · Prevention of Future Deaths report View report

10 Jan 2014 Staffordshire South M. Jones

Pauline Meredith, aged 42, was found dead in her flat on 30 August 2013. Her death was attributed to mixed drug toxicity, including a fatal level of morphine, excessive levels of tramadol and propranolol, and alcohol. Concerns included the amount and review of prescribed medication, the addition of morphine alongside existing medication and alcohol dependence, the response to family concerns, the absence of team meetings, and delays in involving community mental health services.

Jacqueline Marie Elliott · Prevention of Future Deaths report View report

11 Jan 2019 Manchester South A. Mutch

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.

Jason Ricardo White · Prevention of Future Deaths report View report

19 Dec 2025 South Yorkshire (Eastern) N. Mundy

Jason Ricardo White died on 10 December 2024; the cause of death is redacted in the supplied text, and the inquest conclusion was suicide. The principal concerns were the abrupt cessation of olanzapine, failure to follow the planned daily monitoring, and the resulting risk of relapse and serious deterioration in mental health.