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Margaret Clement · Prevention of Future Deaths report View report

14 May 2024 Lancashire and Blackburn with Darwen C. Long

Margaret Clement, aged 92, died at Royal Blackburn Hospital on 15 June 2022 after developing significant rectal bleeding, vomiting blood and an upper gastrointestinal bleed following hospital admission after a fall. Concerns included inadequate nursing records and handovers, ineffective prioritisation of urgent tasks, failure to seek urgent clinical assistance for significant rectal bleeding, and inadequate assessment of compliance with procedural changes.

STEPHANIE DANIELS · Prevention of Future Deaths report View report

13 Dec 2013 Manchester City N. Meadows

Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.

Thomas Wedrychowski · Prevention of Future Deaths report View report

28 Nov 2019 Wiltshire and Swindon N. Rheinberg

Thomas Wedrychowski had paranoid schizophrenia and had been prescribed antipsychotic medication for a number of years. Expert evidence indicated that the medication caused diabetes and contributed to morbid obesity; the medical cause of death was recorded as diabetic ketoacidosis and medication-induced diabetes mellitus. Concerns included whether higher-risk patients should receive more frequent diabetes monitoring and whether physical healthcare findings were adequately shared between primary and secondary care providers.

JILL FELICITY SINSON · Prevention of Future Deaths report View report

23 Aug 2013 West Yorkshire (East) M. Williamson

Jill Felicity Sinson had schizophrenia, an anxiety-related disorder, non-epileptic seizures, and a history of self-harm and suicidal tendencies. She was last seen alive on 3 September 2012 and was found lifeless at her home on 10 September 2012; life was pronounced extinct by paramedics. The concerns included inadequate GP monitoring, failure to review or refer her after a GP surgery consultation, insufficient consideration of her medical history when prescribing medication unsupervised, and failure to act appropriately on correspondence from her Consultant Psychiatrist.

Patricia Edge · Prevention of Future Deaths report View report

10 Dec 2014 Manchester West S. Allen

Patricia Edge died at Royal Bolton Hospital on 20 July 2014 after bowel cancer, bowel obstruction and ischaemic bowel, with paracetamol liver toxicity also identified in the inquest conclusion. An excessive dose of paracetamol was prescribed and dispensed between 14 and 19 July 2014, and the report raised concerns about prescribing and dispensing procedures, review of the dose, and the absence of blood tests.

Andrew James Naylor · Prevention of Future Deaths report View report

4 Jun 2024 County Durham and Darlington J. Richards

Andrew James Naylor was found deceased on 11 October 2022 in Durham City, the day after discharge from hospital following treatment for a drug overdose and alcohol withdrawal. The report identified concerns about inadequate warnings of the risks associated with combining the administered drug with alcohol or drugs, poor communication between services, and insufficient consideration of his homelessness, discharge safety, and available support. The inquest concluded that he died from the combined central nervous system depressant actions of alcohol and two drugs, with cumulative failures contributing more than minimally to his death.

Kenneth John Daly · Prevention of Future Deaths report View report

23 Oct 2019 Inner North London S. Bourke

Kenneth John Daly, who had chronic pain and anxiety and was prescribed multiple medications, was found dead at home on 4 December 2018. The inquest concluded that his death was drug related, involving multi-drug toxicity, after he overdosed on Morphine, Dihydrocodeine and Codeine alongside Pregabalin and benzodiazepine medication. Concerns included unclear guidance about using multiple opioid medications together and the absence of tailored written advice for Mr Daly.

Nadine Brookes-Walker · Prevention of Future Deaths report View report

16 Nov 2015 Manchester North E. Moloney

Nadine Brookes-Walker died after a fentanyl patch prescribed for severe pain was likely damaged while being removed from its packaging, resulting in an excessive release of fentanyl. The principal concern was that the packaging did not make the serious consequences of using damaged patches sufficiently apparent to patients; difficulties removing patches also suggested a possible manufacturing fault in some batches.

Matthew Colin FITTEN · Prevention of Future Deaths report View report

7 Dec 2019 Suffolk N. Parsley

Matthew Fitten was found deceased at home on 17 April 2020, and toxicology identified a toxic quantity of methadone in his blood. During the COVID-19 pandemic, his methadone collection was changed from three times per week to fortnightly, but he received three large bottles without a measuring jug or instructions for accurately measuring his prescribed daily dose. The report identifies concerns that this increased access to methadone and the lack of suitable dosing arrangements contributed to his death.

Carole MCQUINN · Prevention of Future Deaths report View report

19 Jul 2023 North Yorkshire and York C. Cundy

Carole MCQUINN underwent pancreatic surgery in February 2022 and subsequently experienced pancreatic leakage, abdominal collections and prolonged hospital treatment. After discharge without a discharge note, medication or follow-up appointment, concerns about infection were not adequately recorded or escalated, and a positive swab result was not reviewed until several days later. She was later admitted with suspected intra-abdominal sepsis and was found unresponsive in hospital; the inquest concluded that she died from a pulmonary embolism likely related to post-operative infection, inflammation and immobility.

Matthew Marc GROOM · Prevention of Future Deaths report View report

12 Nov 2015 Inner North London M. Hassell

Matthew Marc Groom stood in front of a lorry after spending seven hours in the emergency unit of Whittington Hospital, where he was seen by emergency medicine and mental health staff. Concerns included delays in his mental health assessment, prescribed diazepam not being administered, inadequate planning for his possible departure, failure to seek urgent hospital security assistance, and incomplete communication with police.

Michael Leslie PEGG · Prevention of Future Deaths report View report

26 Jan 2024 Worcestershire D. Reid

Michael Leslie Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after two significant seizures and died there on 15 January 2023 following deterioration and pneumonia. The report raised concerns that steroid treatment fell far short of relevant NICE guidelines, that staff awareness and application of the guidelines were insufficient, and that crowded treatment areas created difficulties in providing appropriate care.

Raymond JENNINGS · Prevention of Future Deaths report View report

6 Mar 2025 West Yorkshire (Western) S. Eccleston

Raymond JENNINGS, aged 84, was admitted to hospital with sepsis due to community-acquired pneumonia and died on 7 March 2023. His care home failed to promptly administer prescribed antibiotics or seek further medical advice when initial attempts to obtain them were unsuccessful. The report raised a concern that other vulnerable residents may be at future risk if prescribed medications are not administered promptly.

Graham Philip Jones · Prevention of Future Deaths report View report

18 Apr 2019 Gloucestershire K. Skerrett

Graham Philip Jones, a 63-year-old man with significant medical conditions, was admitted to hospital with vomiting and abdominal pain and underwent repair of a perforated duodenal ulcer. He suffered several falls in hospital, including a fall that caused a significant head injury; the injury was diagnosed after a delay, and he died on 13 April 2018. The principal concerns related to falls prevention, adherence to the post-falls protocol, review of medication after a fall, and the handover of safety information between wards.

Steven Bowker · Prevention of Future Deaths report View report

2 Dec 2023 Manchester South C. Murray

Steven Bowker fell from garden ladders in 2016 and subsequently developed dependence on prescribed opioid medication. He was found unresponsive at home and pronounced dead on 1 December 2021; the report expressed concern about the dangers of prolonged prescription and use of opiate medication.

Maureen Waterfall · Prevention of Future Deaths report View report

30 Dec 2019 Manchester South A. Farrow

Maureen Waterfall fell at home on 12 July 2019 while taking the anticoagulant Edoxaban and sustained a head injury that led to a subdural haematoma. She died at Willow Wood Hospice on 26 July 2019. Concerns included the lack of a licensed specific antidote for Edoxaban, uncertainty about treatment effectiveness and timing, the absence of national guidance, and the storage of antidote supplies away from the resuscitation unit.

Paul Michael Clark · Prevention of Future Deaths report View report

16 Oct 2024 Manchester South A. Mutch

Paul Michael Clark was found unresponsive at home on 12 May 2024 and died from drug toxicity; the inquest concluded that the death was accidental. The principal concern was that opioid painkillers were prescribed despite his documented previous heroin addiction, without evidence that the risks of reintroducing opioids were considered or monitored, and he subsequently became addicted and took increasing amounts, including non-prescribed opioids.

Mrs Vivien Brunning · Prevention of Future Deaths report View report

12 Oct 2021 East London G. Irvine

Mrs Vivien Brunning was admitted to hospital with sepsis and treated for a kidney stone, during which prescribed Clexane was temporarily held and then omitted on 13 and 14 July 2020. She developed a right brachial artery thrombosis, suffered a stroke during emergency thrombolysis, and died on 25 July 2020. Concerns included missed venous thromboembolism reviews, omitted anticoagulant doses, and failure to report the initial omission through the Trust’s incident reporting system.

Kim Jeannette ROBINSON · Prevention of Future Deaths report View report

31 Jan 2025 Suffolk N. Parsley

Kim Robinson died at home in Suffolk on 12 May 2024 after toxicological analysis identified a significantly toxic level of a medication obtained from an online pharmacy. The report identified concerns that the online prescriber could not access her GP records, the ordering process used incorrect details, and the medication was delivered in a quantity that gave her direct access to a fatal amount. The report stated that the online prescription system needed review.

PATRICIA PRISCILLA CHAMBERS · Prevention of Future Deaths report View report

4 Nov 2018 West London R. Furniss

Patricia Chambers died by suicide on 11 May 2016 after jumping from the ninth-floor communal walkway of her residence, sustaining non-survivable injuries. The inquest identified deficiencies in her mental-health discharge process, communication and continuity of care, as well as inadequate GP record keeping and document control; the report remained concerned that information could be lost or ignored and pose a risk to future deaths.