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Stephen LAWRENCE · Prevention of Future Deaths report View report

6 Aug 2025 Surrey A. Crawford

Stephen Lawrence, a resident at Eastcroft Nursing Home, sustained an unwitnessed fall on 21 December 2022 and multiple rib fractures, which led to a haemopneumothorax and pneumonia. He died in hospital on 5 January 2023; concerns included unexplained injuries, deficient nursing home records, delayed medical advice, and conflicting evidence from the nursing home manager, with an ongoing risk to current residents.

Reginald Cauthery · Prevention of Future Deaths report View report

4 Oct 2022 Inner North London S. Bourke

Reginald Cauthery was a frail man with limited mobility who lived alone and died in hospital after sustaining extensive burns in a smouldering fire at his flat. The report raised concerns that his telecare service was not reviewed despite his increased fire risk and deteriorating mobility, and that his smoke alarms were not connected to the telecare system, delaying contact with the Fire Brigade.

Kevin John Gilbert · Prevention of Future Deaths report View report

14 Dec 2015 Central and South East Kent R. Redman

Kevin John Gilbert suffered an aortic root dissection on 29 January 2015 and died after cardiac arrest during transfer from William Harvey Hospital to St Thomas’ Hospital. The concerns included confusion about transfer protocols, delay in accepting him for transfer, and refusal to escalate the decision to a consultant; the report stated that his chances of survival would have been greater had the delay been avoided.

Ghulam Mohammad · Prevention of Future Deaths report View report

14 Nov 2022 East London G. Irvine

Ghulam Mohammad, an 89-year-old man, was admitted to hospital after an unwitnessed fall and later sustained a head injury in a further hospital fall. His CT head was delayed for four days, and enoxaparin was prescribed and administered before the extent of any intracranial injury was known. The report also identifies inadequate record keeping and omissions in the initial investigation and consultant statement concerning the use of enoxaparin.

Lauren Victoria Finch · Prevention of Future Deaths report View report

21 Oct 2019 Manchester West R. Galloway

Lauren Victoria Finch, aged 23, died on 24 September 2018 after suspending herself from a bedroom door while detained as a patient at Atherleigh Park Hospital; she suffered a significant brain injury and later died in hospital. The principal concerns included inadequate suicide-risk assessment and review, inappropriate observation levels and practices, failures in the anti-barricade system, and delayed clinical record entries.

Zeeyad Hamadi · Prevention of Future Deaths report View report

13 Jan 2014 County Durham and Darlington A. Tweddle

Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.

Alexander Michael BRAUND · Prevention of Future Deaths report View report

20 Dec 2022 Nottinghamshire L. Bower

Alexander Michael Braund was a 25-year-old remand prisoner at HMP Nottingham who became acutely unwell with an undetected atypical pneumonia and died on 10 March 2020 after cardiac arrest and withdrawal of life support. The principal concerns included failures in NEWS2 assessment and monitoring, the absence of a joint healthcare and prison-staff care plan, delays in entering his cell and calling a medical emergency code, and potential weaknesses in the integrity of amended electronic medical records.

Barry THOMPSON · Prevention of Future Deaths report View report

11 Oct 2016 Blackpool and the Fylde C. Doherty

Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

NICHOLAS OLIVER JAMES GEDGE · Prevention of Future Deaths report View report

11 Mar 2025 West Yorkshire Eastern O. Longstaff

Nicholas Oliver James Gedge was found unresponsive in a police station cell on 14 November 2022 and was pronounced deceased at hospital later that day. The principal concerns were the delay in commencing CPR, the lack of a shared understanding and coordinated roles among detention and medical staff, and uncertainty about protocols for responding to medical emergencies in cells.

Sean Perry WILLIAMS · Prevention of Future Deaths report View report

20 Feb 2026 Inner North London I. Potter

Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.

Chantelle Reed · Prevention of Future Deaths report View report

21 Sep 2023 Cambridgeshire and Peterborough S. Goward

Chantelle Reed, who was 33 and had no significant medical history, attended hospital with back, neck and chest symptoms before returning with worsening breathlessness, chest pain, vomiting and fever. She was managed for suspected pulmonary embolism but died after becoming unconscious in the emergency department; the inquest recorded an undiagnosed Type A aortic dissection. Concerns included limited recognition of aortic dissection symptoms in emergency guidance and delays in radiological review that can leave abnormal findings unidentified until after death.

Stephen Weatherley · Prevention of Future Deaths report View report

25 Aug 2023 Inner South London J. Goldring

Stephen Weatherley died at HMP Thameside from the toxic effects of cocaine and methadone after swallowing a package containing a drug during a prison visit. The report identifies concerns about the visitor being allowed an open visit, inadequate investigation and monitoring after the visit, poor record keeping and data retention, and the absence of written guidance for suspected drug swallows.

Mrs. Evelyn KENNEDY · Prevention of Future Deaths report View report

7 May 2015 Brighton and Hove V. Hamilton-Deeley

Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

Lita SERKES · Prevention of Future Deaths report View report

16 Dec 2016 Inner North London M. Hassell

Lita Serkes underwent surgery at Whipps Cross Hospital on 22 July 2016, suffered a stroke the following morning, was transferred to the Royal London Hospital later that day, and died on 24 July. The concerns included discrepancies in observations and clinical records, delay in transfer for specialist stroke care, undelivered pain relief, and delayed recognition and assessment of a significant bleed.

Leslie Isaac LERNER · Prevention of Future Deaths report View report

28 Oct 2016 Brighton and Hove V. Hamilton-Deeley

Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.

Charlie Mark Jermyn · Prevention of Future Deaths report View report

27 May 2016 Cornwall and Isles of Scilly E. Carlyon

Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.

Lina Piroli · Prevention of Future Deaths report View report

4 Dec 2025 Inner North London M. Lee

Lina Piroli, aged 93, was admitted with an E. coli infection and later suffered an unstable C2 fracture and a stable L1 fracture after a fall down stairs. She remained in A&E for a prolonged period because no elderly care ward bed was available, while experiencing pain, confusion and delirium. The report raises concerns about delayed transfer to a ward and the resulting lack of access to specialist, coordinated care and appropriate symptom management for an elderly, complex patient.

Dr Donald Clegg · Prevention of Future Deaths report View report

8 Aug 2018 Manchester North L. Hashmi

Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.

Mrs Pamela Craigie · Prevention of Future Deaths report View report

27 Sep 2017 West London G. Brannigan

Mrs Pamela Craigie died on 19 March 2017 after falling at Cloisters Nursing Home on 24 February 2017 and sustaining an acute subdural haematoma and head injury. The report raised concerns about inconsistent supervision and adherence to her care plan, unclear criteria and processes for referring residents for urgent 1:1 care, delays in urgent assessments, and how residents’ safety was managed while awaiting additional care.

Ella Louise Murray · Prevention of Future Deaths report View report

7 Feb 2025 Mid Kent and Medway C. Wood

Ella Louise Murray was 13 years old when she died at Kings College hospital on 15 November 2023 following an episode of hanging, after a period of self-harm, suicidal ideation and deteriorating mental health. The report raised concerns about the adequacy of her risk assessment and the failure to take urgent protective action, including removing her from home or convening an urgent multi-agency response. It also identified the lack of shared information and records across health, social care and education services.