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Mark Robert Smith · Prevention of Future Deaths report View report

7 Apr 2026 Inner South London J. Goldring

Mark Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.

Ian Paul Wolstenholme · Prevention of Future Deaths report View report

8 Aug 2018 Manchester North L. Hashmi

Ian Paul Wolstenholme was found collapsed at home on 17 December 2017 and died later that day. The medical cause of death was combined drug toxicity, with liver cirrhosis and diabetes mellitus also contributing. The report raised concern about the lack of guidance for prescribing highly addictive and potentially harmful drugs together, particularly in cases of polypharmacy.

Beverley Shaw · Prevention of Future Deaths report View report

10 Jun 2019 Manchester North J. Kearsley

Beverley Shaw was found deceased in her bed at home in Oldham in the early hours of 11 December 2018. The inquest heard that she had multiple prescribed medicines, was receiving methadone, and was using cocaine and butane gas. Concerns included inadequate communication between the substance misuse service and GP practice about her butane gas use, lack of a full medication review, and incomplete transfer of medical records.

Mr Leslie Hurwood · Prevention of Future Deaths report View report

5 Feb 2025 Northamptonshire J. Dixey

Mr Leslie Hurwood died on 13 January 2023 at Kettering General Hospital, having had a history of Type I diabetes and other health conditions, and a recent diagnosis of dementia. During a December 2022 admission after a fall, he experienced multiple episodes of hypoglycaemia. The report raises concerns that nurses at Northampton General Hospital administered insulin after meals rather than before them, and that this practice continued to occur occasionally despite advice and training.

Christine Mary Dickinson · Prevention of Future Deaths report View report

18 Jul 2023 Manchester South C. Morris

Christine Mary Dickinson, who had follicular lymphoma and was receiving Rituximab, became gravely ill after a final hospital admission in October 2022 and died on 15 November 2022. The inquest raised concerns about multiple systems being used to record chemotherapy administration and the absence of a recent audit of record-keeping on the Laurel Unit, particularly after another patient’s details appeared in Mrs Dickinson’s record.

Steven Leslie Rogers · Prevention of Future Deaths report View report

20 Jan 2016 Manchester South J. Pollard

Steven Leslie Rogers was admitted to Stepping Hill Hospital on 20 August 2015 with reduced consciousness and confusion and a history of unstable type 1 diabetes. His long-acting Levemir insulin was accidentally omitted during his admission, and he was discharged by a consultant who had not seen him; he was found dead at home two days later, having died from diabetic keto-acidosis. The substantive concerns were the discharge process and the omission and subsequent alteration of his insulin regimen.

ROSA ANN KING · Prevention of Future Deaths report View report

12 Jul 2019 Cambridgeshire and Peterborough N. Moss

Rosa Ann King, a senior carnivore keeper at Hamerton Zoological Park, died on 29 May 2017 after being attacked by a Malayan tiger while exiting the tiger paddock. She had entered while the tiger slides were open, and the report identified concerns about reliance on keeper reliability, fatigue from night-time hand-rearing work, the absence of air-lock type double gates, and lack of access to conventional firearms. The report also raised concerns about insufficient guidance, risk assessment and inspection of these safety arrangements.

Marie ZARINS · Prevention of Future Deaths report View report

14 Aug 2023 Leicester City and South Leicestershire I. Thistlethwaite

Marie Zarins, aged 42, was reported missing by her family and found suspended in Leicestershire; her death was confirmed at the scene on 24 November 2021. The report raised concerns about flawed multidisciplinary team discussions, inaccurate understanding and documentation of her medication status, failures to prescribe antidepressants and sleeping tablets, and inadequacies in the subsequent serious incident investigation.

Phillip Arthur Pratt · Prevention of Future Deaths report View report

30 Jul 2013 West Sussex E. Bussey-Jones

Phillip Arthur Pratt died on 2 November 2012 at St Richards Hospital after a fall-related fracture, surgery, and a sudden deterioration attributed to bronchopneumonia. The report raised concerns about incomplete medication information, delayed consideration of alcohol detoxification, delayed discontinuation of tramadol after confusion developed, delayed shoulder X-rays, and the unavailability of requested additional nursing staff for a high-risk patient.

Idris HABIB · Prevention of Future Deaths report View report

24 Jan 2022 Mid Kent and Medway P. Harding

Idris Habib was found suspended in his cell at HMP Swaleside after incidents involving self-harm, a cell fire and statements that he was being bullied and wanted to kill himself. The inquest concluded that he took his own life by hanging, although his intention was unclear. Concerns included medication from a previous occupant being found in the cell, a disconnect between local policy and training on roll checks, and the need to ensure welfare checks were conducted and documented.

Patrick Stephen Moran · Prevention of Future Deaths report View report

5 Jan 2018 Inner North London J. Devonish

Patrick Stephen Moran was admitted with severe peripheral vascular disease, left foot gangrene and ongoing leg pain. During angiography and angioplasty, he suffered an iliac artery rupture; his left leg became non-viable and was amputated, while his right leg later deteriorated. The report identified concerns about a tenfold insulin dosing error involving use of a standard syringe, the lack of mandatory diabetes and insulin-device training, and the absence of an organisation-wide process to review compliance with safety alerts.

Paul Leslie HYDE · Prevention of Future Deaths report View report

5 Dec 2014 Brighton and Hove V. Hamilton-Deeley

Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.

Miriam Tighe · Prevention of Future Deaths report View report

4 Jul 2019 Manchester South R. Galloway

Miriam Tighe became a resident of Edge Hill Residential Home in August 2016 and later received hospital and residential nursing care before passing away on 28 February 2017. The report identified concerns that promazine and other sedative or antipsychotic medication continued to be prescribed and administered despite advice to stop promazine, and that communication between GPs and a psychiatrist was insufficient, leading to unsafe prescribing. The investigation recorded that her death followed naturally occurring disease, with high levels of sedation and immobility in the preceding months worsening her frailty.

Darren Linfoot · Prevention of Future Deaths report View report

9 Mar 2015 Berkshire P. Bedford

Darren Linfoot was found unresponsive in his room at Broadmoor Hospital on 18 December 2011 and was declared deceased at Frimley Park Hospital. A post-mortem examination found lobar pneumonia as the cause of death, with dihydrocodeine toxicity contributing. Concerns included inadequate auditing of some potent medications, inconsistent four-hourly patient observations, and inconsistent understanding of the radio nurse’s duties.

Gemima CHRISTODOULOU-PEACE · Prevention of Future Deaths report View report

22 Jul 2024 Suffolk N. Parsley

Gemima Christodoulou-Peace was found suspended by her neck from a ligature and died from suspension hanging, with the inquest noting insufficient evidence that she intended her death at all material times. The report raises concerns about the absence of a single reference point for identifying medications associated with increased suicidal behaviour, limited recording and accessibility of mental-health telephone calls, and delays in access to prescribing mental-health support. Gemima had requested a medication review, but had not seen a prescribing mental-health practitioner before her death.

Lacey Carole Anne HEATH · Prevention of Future Deaths report View report

28 May 2026 Essex S. Hayes

Lacey Carole Anne HEATH died on 16 February 2025 after collapsing at home and suffering cardiac arrest en route to hospital. The death followed thrombosis and complete stenosis of her mechanical aortic valve in the context of sub-therapeutic anticoagulation. Concerns included difficulty maintaining therapeutic anticoagulation, lack of access to affordable at-home monitoring, absence of a funding application, insufficient medical review or haematology referral, and inadequate clinical records.

Alex Grady · Prevention of Future Deaths report View report

18 Nov 2019 Manchester North C. McKenna

Alex Grady was found deceased in his bed on 26 February 2019 and died from combined toxicity involving prescribed and non-prescribed medication and illicit drugs. Concerns included the adequacy of support and follow-up when alcohol detoxification is managed solely by a GP, and the accessibility of complete prescription information to healthcare practitioners.

Roshen Abbas Ladak-Ebrahim · Prevention of Future Deaths report View report

5 May 2013 North London A. Walker

Roshen Abbas Ladak-Ebrahim, aged 22, was found having hanged himself at home on the evening of 11 October 2012. The report raised concerns about assessing and recording immediate risk of self-harm, ensuring patients at risk were not left alone, and requiring appropriate medical consultation and follow-up when prescribing medication associated with increased self-harm risk.

Victoria HARRILD-JONES · Prevention of Future Deaths report View report

17 Nov 2021 Suffolk N. Parsley

Victoria Harrild-Jones died at home on 27 December 2019 after developing a pulmonary embolism following gastric bypass surgery, with peritonitis, reduced mobility and thrombosis identified in the account of her death. The principal concern was that she was not prescribed prophylactic anti-coagulation medication after discharge, unlike the treatment described as required for UK-based patients under NICE guidance, potentially resulting in care below the standard expected in the UK for military personnel and dependants treated overseas.

Patricia Ann Mellor · Prevention of Future Deaths report View report

12 Nov 2014 Nottinghamshire J. Gillespie

Patricia Ann Mellor suffered a cardiac arrest during general anaesthesia in 2004, resulting in a hypoxic brain injury and severe disability. She died from aspiration pneumonia on 24 January 2014. The investigation identified acquired Long QT Syndrome associated with a combination of citalopram, nortriptyline and ranitidine, and concerns were raised about the need to identify and manage this risk before anaesthesia.