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Milos JANKOVIC · Prevention of Future Deaths report View report

1 Oct 2025 South Wales Central R. Knight

Milos JANKOVIC had been diagnosed with Barrett’s Oesophagus in 2014 but was lost to follow-up surveillance after bowel cancer took priority. In 2020, he developed symptoms and was found to have brain metastases from primary oesophageal cancer. Concerns included inadequate processes for Barrett’s surveillance, particularly in primary care, and the absence of recall or prescribing prompts to identify patients needing surveillance or endoscopy.

Iris May GRIMWOOD · Prevention of Future Deaths report View report

26 Aug 2014 South Lincolnshire A. Forrest

Iris May GRIMWOOD, aged 80, died at Pilgrim Hospital on 8 October 2013 as a result of progressive neurological disease. Concerns were raised about difficulties providing the nursing care she needed, including errors in using semi-automatic thermometers and an attempted application of an antifungal ointment prescribed for oral thrush to her genital region.

Matthew RUSSELL · Prevention of Future Deaths report View report

27 Nov 2016 Surrey R. Travers

Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.

Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report View report

27 Jan 2020 Inner North London M. Hassell

Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.

Bridget May CAHILL · Prevention of Future Deaths report View report

11 Jun 2014 Black Country R. Balmain

Bridget May CAHILL died in hospital from a morphine overdose after being admitted with unresponsiveness and receiving treatment including naloxone. The principal concern was how a patient prescribed and receiving less than the maximum permitted morphine dose could nevertheless suffer an overdose, including whether dosing should account for factors such as body weight, comorbidities, and possible accumulation during long-term therapy.

Amanda Hesketh · Prevention of Future Deaths report View report

17 Jun 2022 Manchester South C. Morris

Amanda Hesketh, who had a complex health history and was prescribed multiple analgesic medicines, became unresponsive in the Emergency Department after presenting with diarrhoea and vomiting and could not be resuscitated. The report identified concerns about the lack of systematic reviews and individual plans for patients receiving multiple analgesics, limited specialist pain-clinic input, and inconsistent use of practice pharmacists.

Wendy Siobhan EYLES · Prevention of Future Deaths report View report

22 Dec 2025 Northamptonshire H. Shah

Wendy Siobhan Eyles died on 31 October 2024 after being struck by a train at Kettering Station having climbed down from the platform. The report identified concerns about the lack of a protocol for patients receiving both private and NHS psychiatric care, including risks that medication changes and treatment arrangements may not be communicated between services.

Mohammed Abdus Salem · Prevention of Future Deaths report View report

18 Oct 2021 Manchester North J. Robertson

Mohammed Abdus Salem, who had chronic myelomonocytic leukaemia, was admitted to hospital after his condition deteriorated and died after being found unresponsive on 1 April 2021. A further intended dose of Rasburicase was not administered on 1 April despite high urate levels; it was considered more likely than not that giving it would have prolonged his life by up to 48 hours. The Root Cause Analysis did not examine the factors behind the omitted dose or its consequences, raising concerns about the rigour of the review and organisational learning from the death.

Caroline Diane Harris · Prevention of Future Deaths report View report

2 Jul 2024 Oxfordshire N. Graham

Caroline Diane Harris, who had a long-standing diagnosis of severe mental illness, was found deceased at home on 26 July 2023, and a medical cause of death could not be ascertained because of decomposition. Information about her declining mental health, refusal of medication and concerns raised by police was not shared with the Adult Mental Health Team, which limited its ability to supervise and follow her up. The principal concern was that important information was not shared between agencies and that appropriate interventions may consequently not have been made.

Darren John Lawrence · Prevention of Future Deaths report View report

15 Oct 2021 Manchester City N. Meadows

Darren John Lawrence had a history of suicidal thoughts, plans, previous attempts, mental ill health, disengagement from services and medication noncompliance. He was found dead at his home on 29 August 2020, and the inquest conclusion was suicide. Principal concerns included inadequate communication and follow-up between mental health services and the GP practice, failure to ensure that prescribed venlafaxine was issued and collected, insufficient escalation when direct contact with him was unsuccessful, and inadequate systems for managing correspondence and medication.

Kenneth Rippon · Prevention of Future Deaths report View report

19 Jul 2023 County Durham and Darlington J. Richards

Kenneth Rippon had deteriorating mental health, including self-harm, suicidal ideation and command auditory hallucinations, and died on 5 May 2022 after jumping or falling from a viaduct at Durham Train Station. The report identified concerns about inadequate mental health assessments and risk information, insufficient family involvement in safety and discharge planning, and delays and weaknesses in the investigation of the serious incident.

Nathaniel Luke Phillips · Prevention of Future Deaths report View report

13 Oct 2015 Manchester South J. Kearsley

Nathaniel Luke Phillips died at Tameside General Hospital after an acute asthma attack; the inquest recorded hypoxic brain injury due to the attack. Concerns included the cost of regular asthma prescriptions, his apparent loss to adult asthma services, and delays in ambulance availability during his final emergency.

Kaiya Sonja Campbell · Prevention of Future Deaths report View report

30 Sep 2019 Manchester South A. Mutch

Kaiya Sonja Campbell was born at Tameside General Hospital on 28 September 2019 following her mother’s extensive bleeding and early rupture of the membranes. She lived briefly and died soon after birth, with the medical cause recorded as extreme prematurity at 19 weeks and 6 days’ gestation. Concerns included gaps in records of her mother’s anticonvulsant prescriptions, failure to seek urgent neurology guidance, and the offering of a routine rather than appropriately identified high-risk consultant appointment.

Jane Elizabeth Wadsworth · Prevention of Future Deaths report View report

17 Jul 2023 Manchester South A. Mutch

Jane Elizabeth Wadsworth became seriously unwell after elective hip surgery, developing a deep vein thrombosis, cellulitis, sepsis, acute kidney injury and liver failure, and died on 31 December 2022 despite intensive care treatment. Concerns included missed antibiotic doses, limited consultant input, unclear escalation and doctor-to-doctor discussion about intensive care, unavailable Critical Care Outreach support, and no evidence that specialist liver advice was obtained.

Jessica Hodgkinson · Prevention of Future Deaths report View report

26 May 2023 Derby and Derbyshire M. Kewley

Jessica Hodgkinson died on 14 May 2021 at Chesterfield Royal Hospital shortly after giving birth, following a pulmonary embolism arising from a deep vein thrombosis and acute anaphylaxis of unknown cause. The inquest identified failures to communicate and follow up the plan for prophylactic tinzaparin until birth, and concerns about consideration and documentation of her Klippel-Trenaunay Syndrome during pregnancy.

Janice HOPPER · Prevention of Future Deaths report View report

28 Nov 2022 Norfolk J. Lake

Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.

Lee Jay Bonsall · Prevention of Future Deaths report View report

31 Jan 2014 Carmarthenshire and Pembrokeshire J. Layton

Lee Jay Bonsall was found hanging from a bannister rail at his home on 3 March 2012, and the inquest recorded the medical cause of death as asphyxia by hanging, with intent unclear. Concerns related to citalopram being prescribed on repeat and the ten-month waiting time for psychotherapy.

Sebastian Harry DANIELS · Prevention of Future Deaths report View report

22 Sep 2023 Hampshire, Portsmouth and Southampton R. Simpson

Sebastian Harry Daniels, who had paranoid schizophrenia and was treated with clozapine, developed severe hypertriglyceridemia and necrotising pancreatitis before dying from multiple organ failure on 4 July 2021. Concerns included the failure to escalate abnormal triglyceride results, unclear communication of required GP actions in hospital discharge summaries, delays in addressing identified deficiencies, and the requirement for patients taking clozapine to attend separate appointments for some blood tests.

Leslie Clewarth · Prevention of Future Deaths report View report

10 Nov 2020 West Yorkshire Eastern K. McLoughlin

Leslie Clewarth died in hospital from natural causes, with the Inquest recording aspiration pneumonia, small bowel obstruction, adhesions within the peritoneal cavity, and ischaemic heart disease. Concerns included the loss of his NG tube, an empty syringe driver, an injection administered after death, lack of treatment for a severe coronary condition, and missing or inadequate medical records. The principal substantive concern was that inadequate records made it impossible to corroborate the care and medication provided and created a risk that essential care could be omitted or duplicated.

Sadik Miah · Prevention of Future Deaths report View report

26 Jun 2014 Inner South London A. Harris

Sadik Miah, who had schizophrenia and was detained in hospital, collapsed suddenly and died in Lambeth Hospital on 15 October 2011 despite resuscitation. Concerns included the monitoring of ECG abnormalities and antipsychotic-related arrhythmia risk, delays in obtaining specialist advice about hyponatraemia, and the lack of regular physician support for psychiatric in-patients with physical health problems.