6,433 reports
Information drawn from published reports and official responses.
Dr Jeroen Ensink was stabbed to death in a wholly unprovoked attack on 29 December 2015. The report identified multiple concerns involving police recording and information-sharing failures, including failures to identify and communicate possible mental health problems and issues in the handling of evidence and custody records.
Metropolitan Police Service
Matthew Karl Hatfield and Darren Paul Neilson died after a Challenger 2 tank fired while its BVA assembly was absent, causing a breech explosion, intense fire and blast-related injuries. The principal concerns included unclear use and meaning of the Prove The Gun drill, inadequate communication about the condition of tanks and the absence of written procedures for checking, removing and storing the BVA assembly. The report also identified insufficient consideration of the hazard during the gun’s design and manufacture, inadequate communication about the opportunistic experience shoot, and routinely unstowed charges that caused a secondary explosion.
BAE Systems plcMinistry of Defence
Baby Mohamed Rahman was born at 01:45 on 17 February 2018 after an elective feticide procedure and was confirmed dead at 02:48 that day. The principal concerns were that fetal asystole was not unequivocally confirmed before discharge, that the mother and professionals were unprepared for the birth, and that documentation and guidance about confirming fetal demise and explaining the procedure to parents required consideration.
Department of Health and Social CareManchester University NHS Foundation TrustRoyal College of Obstetricians and Gynaecologists
Ellie Mae Knowles attended a dance music event on 5 November 2016, consumed MDMA, became unwell, and later died due to methylenedioxymethamphetamine toxicity. The report identified concerns about event search procedures, record-keeping, staffing and future planning of similar events, including the continued existence of a licence for such events at the premises.
Hoults LimitedNbhd Group Limited
Cpls Matthew Karl Hatfield and Darren Paul Neilson died after a Challenger 2 tank fired while its BVA assembly was absent, causing hot pressurised gases to enter the turret, the breech block to explode and a subsequent fire. The substantive concerns included unclear use and meaning of the Prove The Gun drill, inadequate information about tank status available to the Range Conducting Officer, and insufficient risk assessment of the gun’s ability to fire without the BVA assembly.
BAE Systems plcMinistry of Defence
Graeme Robert Mathieson died following an intentional overdose of prescribed medication. The inquest concluded suicide and identified gross failures to provide basic medical attention while he was in a dependent position, which caused or contributed to the outcome. Concerns included time constraints affecting recognition of his serious psychiatric condition, confusion about mental-health care pathways, and weaknesses in transfer processes.
Devon Local Medical CommitteeLivewell SouthwestNHS England
JJ Wilson died instantaneously after a racing car he was driving during a shakedown test left the track and collided with a tree, causing serious head and neck injuries. The report raised concern that fire-retardant overalls were not required for test-track drivers, creating a potential risk of death or serious injury in a similar crash.
Health and Safety Executive
Mr Leslie Bingham was struck by a police vehicle while crossing the A61 Penistone Road at Owlerton Green on his way to a family celebration. The report identified a significant possibility that pedestrians could be misled by a green pedestrian light and miss a red light prohibiting them from crossing the northbound lanes.
Sheffield City Council
Sheila Winifred Ridgway was treated for arterial disease in both legs and later developed a painful, cold, pulseless right leg after stopping dual antiplatelet therapy before a planned loop ECG recorder procedure. She subsequently developed diarrhoea, deteriorating renal function, low blood pressure and multi-organ failure due to sepsis, and died after escalation of treatment was considered futile. The principal concern was inadequate communication between specialty consultants about ongoing risks and treatment requirements.
Care Quality CommissionManchester University NHS Foundation TrustNHS EnglandStockport NHS Foundation TrustThe Alexandra Hospital
On 15 September 2017, Tyrone Declan EVANS was thrown from a quad bike after it collided with a crash barrier and another vehicle, suffering fatal injuries. The principal concern was that quad bike riders were not legally required to wear crash helmets, despite the pathologist’s view that helmet use may have altered the head injury pattern and potentially reduced its severity. The report identified this absence of a legal requirement as a continuing and potentially avoidable risk of deaths on the roads.
Department for TransportDriver and Vehicle Licensing Agency
Adam James Carter died on 10 September 2017 after absconding from The Harbour mental health facility during escorted leave and falling from the fifth floor of a car park. The principal concern was inadequate record keeping about Adam’s risks, leave arrangements, leave authorisation and assessment before leave, which could affect staff decisions about patient safety.
Lancashire & South Cumbria NHS Foundation Trust
Rita Elizabeth GILES underwent an endoscopic retrograde cholangiopancreatography after delays and was reported not to have recovered, dying a few days later. The concerns included unnecessary transfers without supporting paperwork, failure to follow the Trust’s Transfer Policy, limited ERCP capacity, and failure to recognise the urgency associated with her sepsis; it was suggested that earlier transfer to the Royal Sussex County Hospital might have enabled urgent treatment.
University Hospitals Sussex NHS Foundation Trust
Bartholomew Patrick Coleman accessed a railway track near his home, lay on the track as a train approached, and died after being struck. Concerns included that the track was easily accessible from a bridge used by schoolchildren and that there appeared to be no warning about the dangers of accessing the area.
British Transport PoliceNetwork Rail
Eugeniusz Niedziolko, who was heavily intoxicated and vulnerable, was left alone in an unheated public lavatory after police and ambulance staff decided he did not require hospital care. He was found unresponsive several hours later and died from acute alcohol toxicity and hypothermia. The report identifies concerns about failures to follow protocols, assess and communicate critical information, provide appropriate training, and consider available options for keeping him safe and monitored.
College of PolicingDyfed-Powys PoliceSouth Western Ambulance Service NHS Foundation TrustWiltshire Police
Doris McCarthy, a resident of Baycroft Orpington, had recurrent falls and was involved in two incidents where she slid from a chair without the sensor system alerting staff. The principal concerns were continuing sensor system outages and the steps taken to safeguard residents known to slide when seated in chairs; the inquest concluded that she died from natural causes resulting from a pulmonary embolism, with an underlying subdural haemorrhage caused by recurrent falls.
Pemberley Manor Care and Nursing Home
Robert Andrew Power, a 49-year-old man living in a neurological care home, had a chronic brain condition and experienced recurrent aspiration pneumonia and seizure activity. He died on 17 May 2017 after being discharged for palliative care following admission with aspiration pneumonia. The principal concern was that, while treated by the trust, he was lost to outpatient follow-up between 2007 and 2015, creating a risk that future deaths may occur unless patients are not lost to follow-up care.
Bristol NHS Foundation Trust
David Chandler died at the scene on 9 November 2016 during work to remove a dormant compressor at the Carlsberg Brewery, following a high-pressure escape of gaseous ammonia. The concerns included reliance on an isolation from earlier work, inadequate review of the isolation standard, unclear responsibilities between organisations, and an incorrectly completed Permit To Work that did not refer to hazardous substances.
CMBC Supply Limited
Kathleen Margaret Allen died at Birmingham Heartlands Hospital on 20 March 2018 from the effects of aspiration pneumonia caused by small bowel obstruction, after she was initially diagnosed with gastroenteritis. The report states that delayed investigation, insufficient monitoring and lack of senior medical review meant the severity of her condition was not identified promptly, and that her death was preventable. A principal concern was the inconsistent application of MEWS escalation procedures in the Emergency Department, with staff receiving different instructions and a risk to patient safety.
University Hospitals Birmingham NHS Foundation Trust
On 28 January 2018, Yunis Malik Hadi choked and collapsed while eating a snack at a Sunday school, and could not be resuscitated despite CPR efforts. The concerns included inadequate first-aid training for volunteers, lack of emergency medical equipment such as a defibrillator, and insufficient oversight of training, supervision and child safeguarding.
London Borough of LambethSouth London Islamic Centre
Daphne Joan Penn was transferred to Newmarket Community Hospital for rehabilitation and later died after readmission to West Suffolk Hospital, following deterioration. The inquest recorded pneumonia as the cause of death and identified concerns about an inadvertently rapid reduction in her long-term steroid therapy, delays in communicating family concerns, and a prescribing error that caused an additional reduction in the steroid dose.
Newmarket Community HospitalRookery Medical CentreWest Suffolk Hospital
