6,433 reports
Information drawn from published reports and official responses.
Derek Reginald Smith, who was bedbound and unable to manage his care needs, died at home on 21 December 2017 from aspiration pneumonia. He had developed a severe pressure sore, and the report raised concerns about limited communication between district nurses, family members and possibly carers, as well as the availability of nursing records and delays in treatment decisions.
HCRG Care Services Ltd
Andrew Thomas HANAHOE died after walking onto Lindsells Foot Crossing at Biggleswade Railway Station as a train approached on 29 December 2017. Concerns were raised about the crossing’s safety, including its exposure to high-speed trains, inadequate fencing and the absence of measures such as repeater lights or trespass deterrence; the report states that the risk of a future death remained.
Network Rail
Jacob Elliot Brown died at Royal Stoke University Hospital on 7 December 2017 from injuries sustained in a road traffic collision on 11 November 2017. The principal concern was whether compulsory ‘black boxes’ for young drivers could help monitor driving and reduce future deaths.
Department for Transport
Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.
Dr Simon ChappleMr Simon WrightRecipient name withheldSolicitors for familythe Shrewsbury and Telford Hospital NHS Trust
Mr Bryan Allsop died very soon after a light aircraft he was piloting crashed shortly after take-off on 28 May 2017. The inquest found that the aircraft’s fuel vapour return line, use of unauthorised E5 Mogas, warm conditions and the engine’s failure to reach full power were contributory factors. The principal concern was that light-aircraft pilot licences did not mandatorily require instruction and testing for partial loss of engine power scenarios.
Department for Transport
Darren James CARRINGTON died after collapsing with a fatal level of Zopiclone in his blood and did not recover. The inquest concluded that the death was misadventure, being an impulsive overdose while under the influence of alcohol. Concerns included the prescribing of potentially dependency-forming medication, excessive Zopiclone prescribing over 57 days, and the ability of receptionists and clinicians to override computer warnings and other safeguards.
NHS Brighton and Hove Clinical Commissioning GroupNHS Surrey and Sussex Integrated Care BoardNorth Laine Medical Centre
Sneh Lata Chaudhry underwent high-risk coronary artery bypass surgery and developed a systemic candida infection requiring amphotericin. The wrong intravenous preparation, Fungizone rather than Ambisone, was obtained and administered, and the inquest concluded that she died from immediate complications of this incorrect formulation. Concerns included the similar appearance of the drug vials and nursing checks being passive rather than active.
NHS England
Alfred William Meek, an 87-year-old man with dementia and cognitive impairment, suffered falls before and during his hospital admission and died on 13 September 2017. Concerns included missed or delayed Enhanced Care Supervision reviews, failure to provide supervision matching his assessed risk, and no evidence of further action after staff escalated concerns about insufficient resources.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Karen Wiggins died instantly after jumping from an upper floor of the Fleming Way Car Park on 1 December 2017. The report raised concerns about previous suicidal falls from multi-storey car parks in Swindon, including the same car park, and called for a Council investigation into possible preventative measures.
Swindon Borough Council
Keiron Christopher Bould left home on 17 September 2017 after taking his girlfriend’s morphine tablets and was later found in his parked vehicle. He was taken to hospital and pronounced deceased on 18 September 2017; the medical cause of death was recorded as a morphine overdose and the inquest concluded suicide. Concerns were raised about the lack of clear communication over which police force had primacy for the missing-person inquiry and about a four-hour delay in actioning the transfer email.
National Police Chiefs’ CouncilWarwickshire PoliceWest Midlands Police
Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.
Care Quality CommissionEpsom HospitalRoyal College of Physicians
Olive Nutt died at home on 29 January 2018 from heart disease, after waiting up to five hours for an LAS attendance. The concerns were that symptoms were not properly recorded, leading to an incorrect priority decision, and that LAS failed to return a call within its own time guidelines.
London Ambulance Service NHS Trust
Graham William FOX was admitted to hospital after a fall in the community in which he broke both ankles. His condition deteriorated, but NEWS assessment and referral were not correctly implemented overnight, and he was not seen by a doctor as he should have been; he was admitted to the Critical Care Unit the following morning and subsequently died. Concerns included misunderstanding among some nursing staff about whether NEWS responses were mandatory and the use of “re-triggering” under NEWS without expert evidence about its clinical appropriateness.
Bristol NHS Foundation Trust
Kevin Freely, aged 61, died at home on 12 October 2016 after a lighted cigarette caused his bedclothes to catch fire while he was bedbound and unable to escape. The principal concern was that warnings about the fire hazard associated with paraffin-based emollient skin products were not being heeded by patients and care organisations providing care in people’s homes.
Care Quality CommissionHome OfficeSkills for Care Ltd
Marcus Hance died on 13 October 2017 from the synergistic effect of a reckless overdose of illicit and therapeutic drugs, in the context of a history of drug abuse. Concerns included the separation of support for substance misuse from support for associated mental health issues, the approach that substance misuse should be addressed before mental health treatment, and his discharge from the Community Mental Health Team after two missed appointments.
Cornwall Partnership NHS Foundation TrustNHS Cornwall and the Isles of Scilly Integrated Care Board
Ester Jane Wood was taken by ambulance to Maelor Hospital and waited in the ambulance from 20.05hrs until 1am before admission. The report identified concerns about ambulance delays, emergency department admission, resource availability and patient flow, stating that these problems continued and placed patients' lives at risk.
Welsh Ambulance Services NHS TrustYsbyty Gwynedd
William Bartram was born with a chordee and hydrocele and was reported to have an inadequate urine stream from shortly after birth. Raised creatinine results and concerns about his urine output were not acted upon, and he died from septic shock on 12 March 2017 after deteriorating in hospital. The principal concerns were unclear processes for repeat blood samples, failure to highlight or act on abnormal results, and inadequate advice to his parents about what constituted a healthy urine stream.
Barts Health NHS Trust
Carol Metcalfe died from chest and abdominal injuries after being struck by a heavy goods vehicle while crossing the A63 Selby Road near Waterloo Manor Hospital. The principal concern was the need for measures to protect pedestrians, including patients leaving the hospital, when crossing the dual carriageway near the hospital.
Leeds City Council
Rosemary Scott suffered a fall, developed a chest flail segment and pneumonia, and died in hospital on 30 December 2017 after deterioration requiring respiratory support. Concerns included the absence of venous blood gas measurements and a reminder system, and insufficient availability of machines to provide the required positive end-expiratory pressure.
Dorset County Hospital NHS Foundation Trust
John Paul Derwent was referred for cognitive behavioural therapy while the waiting time was 12 months against a six-week target. He expressed suicidal ideation, was admitted and later discharged into the community; on 13 November 2017 he was found suspended from a ligature at home. The report raised concerns about insufficient CBT capacity, the substantial waiting list and escalation mechanisms that did not allow early action.
NHS Greater Manchester Integrated Care BoardPennine Care NHS Foundation Trust
