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Sophie Ann Louise Cotton · Prevention of Future Deaths report View report

27 May 2025 County Durham and Darlington R. Sutton

Sophie Ann Louise Cotton had a long history of mental health problems and previous suicide attempts. On 6 January 2025, after she failed to attend important family contact and could not be contacted, four calls were made to the police requesting a welfare check; shortly afterwards, her family found her hanging by a ligature at home. The principal concerns were refusals or delays in police attendance under the “Right Care, Right Person” procedure, including where callers expressed a real and immediate risk to life and where mental health services could not enter locked premises.

Alan Christopher NIPPARD · Prevention of Future Deaths report View report

24 Jul 2023 Avon M. Voisin

Alan Christopher Nippard was admitted to hospital after a fall and developed a sacral pressure sore during his admission, followed by infection and deterioration. He died on 6 July 2022 after surgery was considered unsuitable. The report identified concerns that the pressure sore was preventable and that basic nursing care, including risk assessment, skin care, repositioning and personal care, was not provided adequately.

Lucy Anne Walles · Prevention of Future Deaths report View report

22 Jun 2023 Berkshire H. Connor

Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.

Stephen Frederick DULLING · Prevention of Future Deaths report View report

14 Oct 2024 North Yorkshire and York C. Cundy

Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.

THOMAS PATRICK MAHER · Prevention of Future Deaths report View report

5 Jun 2014 Manchester South J. Pollard

Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

Patricia Margherita WEBB · Prevention of Future Deaths report View report

20 Apr 2017 Brighton and Hove V. Hamilton-Deeley

Patricia Margherita WEBB was an 86-year-old woman who was admitted to hospital after which she experienced six falls, fracturing her hip in the sixth fall. The report raised concerns about fall prevention, observation and meaningful activity, footwear and mobility, staffing and ward layout, handover arrangements, resources, and delays in discharge.

John Frederick Doyle · Prevention of Future Deaths report View report

12 Nov 2024 Coventry and Warwickshire L. Lee

John Frederick Doyle, a kidney transplant recipient, was admitted with rectal bleeding and a persistent cough and was later diagnosed with a severe cytomegalovirus infection after delays in testing, diagnosis and transfer to specialist care. He deteriorated to multiple organ failure and died on 30 December 2023. Concerns included unclear arrangements for contacting specialist centres, sharing information, accessing renal guidance, initiating transfers and coordinating care between specialist and non-specialist hospitals.

Kimberley Lauren Lindfield · Prevention of Future Deaths report View report

2 Feb 2015 Manchester City N. Meadows

Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.

Floyd Everton CARRUTHERS · Prevention of Future Deaths report View report

5 Jan 2023 Birmingham and Solihull I. Dreelan

Floyd Everton Carruthers was detained at HMP Birmingham and died in hospital on 14 June 2021 after developing infective endocarditis, cardiac tamponade, and multi-organ failure. The report raises concerns about inadequate safeguarding training and escalation processes, insufficient record keeping and handover, and failures to refer him to healthcare despite missed meals and not leaving his cell. The jury concluded that his death was contributed to by neglect.

Brian Thomas RINGROSE · Prevention of Future Deaths report View report

1 Aug 2025 Milton Keynes S. Cummings

Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.

Michael Folley · Prevention of Future Deaths report View report

21 Jun 2017 Central Hampshire K. Harrold

Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.

Nichola Jane Lomax · Prevention of Future Deaths report View report

17 Dec 2021 Manchester North J. Kearsley

Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.