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Amy Anne June Ganner · Prevention of Future Deaths report View report

24 Jun 2021 Manchester West S. Nelson

Amy Anne June Ganner, who had complex health conditions and chronic pain, inadvertently ingested an excessive amount of prescribed medication before being discovered on 6 January 2021. The report identified concerns about the combined depressant effects of opioid medicines and the unpredictable loss of tolerance after abstinence; the inquest conclusion was misadventure and the medical cause of death was combined drugs toxicity.

Hayley Denise Sheehan · Prevention of Future Deaths report View report

1 Aug 2017 Surrey A. Crawford

Hayley Denise Sheehan collapsed and died at home on 22 November 2016 after unintentionally overdosing on prescription Tramadol; the medical cause of death was Tramadol toxicity. The court found that early requests for repeat prescriptions had not been identified or acted upon, allowing her to obtain a significant amount of excess medication. The principal concern was that the prescription process relied heavily on administrators identifying early requests, while the surgery’s software did not automatically flag them.

James David FLETCHER · Prevention of Future Deaths report View report

1 May 2019 Blackpool and the Fylde T. Holloway

James David Fletcher died in hospital on 14 July 2018 following peritonitis caused by leakage of gastric contents after PEG tube insertion. The report identifies concerns including failure to consider or detect peritonitis, continued use of the PEG tube despite it being contraindicated, inadequate communication and record keeping, insufficient awareness of post-operative PEG risks, and difficulties ensuring essential medication was available.

Ben Buster KING · Prevention of Future Deaths report View report

20 Jul 2021 Norfolk J. Lake

Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

Daniel Joseph McCallum Keane · Prevention of Future Deaths report View report

9 Jun 2014 Manchester West K. McLoughin

Daniel Keane was found dead at home after a period in which he had difficulty managing his Type 1 diabetes and was left without active support apart from his family. The cause of death was recorded as ketoacidosis. The reported concerns included a lack of leadership and coordination, no clear post-discharge care plan, ineffective multidisciplinary meetings, and uncertainty about the GP’s role, including the prescribing of citalopram and failure to respond to concerns about Daniel’s wellbeing.

Jan Goodliffe · Prevention of Future Deaths report View report

14 Jan 2022 Essex M. Brown

Jan Goodliffe died on 15 June 2021 several days after taking his own life, following a recent suicide attempt and a history of mental health problems. The report raises concerns that social workers, rather than medically qualified clinicians, assessed him despite information about his suicide risk and recent restart of medication, and that opportunities to obtain qualified medical advice may have been missed.

Kenneth Michael Adams · Prevention of Future Deaths report View report

22 Mar 2023 Dorset B. Allen

Kenneth Michael Adams suffered a scalp laceration after an accidental fall on 19 October 2021. He experienced persistent bleeding while taking clopidogrel, but an ambulance did not arrive until 11.56am; he later died in hospital. The principal concerns were that the Medical Priority Despatch System did not adequately account for persistent scalp bleeding, the high blood flow in the scalp, or antiplatelet medication when prioritising the ambulance response.

Graham Thomas John SMITH · Prevention of Future Deaths report View report

7 Sep 2023 Birmingham and Solihull S. Brenchley

Graham Smith, who had Myasthenia Gravis, was admitted with suspected biliary sepsis and a chest infection. He received Gentamicin, which was contraindicated for Myasthenia Gravis, and was not prescribed his usual Pyridostigmine; he subsequently developed a myasthenic crisis, respiratory failure and multi-organ dysfunction, and died after further deterioration. The principal concern was that insufficient awareness of Myasthenia Gravis and the interaction between Gentamicin and the condition could persist among clinicians more widely.

Kenneth Foster · Prevention of Future Deaths report View report

12 May 2025 East London G. Irvine

Kenneth Foster, who had epilepsy following a traumatic brain injury in 2012, was admitted to hospital after prolonged seizure activity in September 2024. After interruption of clobazam administration following removal of his naso-gastric tube, his seizures resumed; he was later diagnosed with aspiration pneumonia, which led to his death. The report identified concerns about failures in governance and inadequate incident reporting, morbidity and mortality processes, and Patient Safety Incident Response Framework procedures.

Benjamin Noah Frances Harrison · Prevention of Future Deaths report View report

19 Jul 2024 Mid Kent and Medway P. Harding

Benjamin Harrison died in HMP Rochester on 9 May 2022 after inhaling fumes from a medication heated with a vape pen. The inquest identified concerns including insufficient overnight healthcare cover, failure to inform the night orderly that he appeared to be under the influence, inadequate guidance for monitoring and escalation, and weaknesses in medication briefing and information sharing.

Phyllis Kerry · Prevention of Future Deaths report View report

23 Oct 2014 Nottinghamshire H. Connor

Phyllis Kerry, who was taking long-term Warfarin, was admitted with symptoms suggestive of stroke and found to have a haemorrhagic stroke. She deteriorated and died after the intracerebral bleed increased. The principal concerns were uncertainty about which specialty was responsible for deciding on immediate Warfarin reversal, the absence of clear guidelines, and inadequate communication of relevant guidelines to staff.

Andrew Ewin-Ripp · Prevention of Future Deaths report View report

2 Apr 2024 East London N. Persaud

Andrew Ewin-Ripp, who had epilepsy, suffered a fit at home on 1 November 2022, was found in cardiac arrest, and died in hospital on 4 November 2022. The reported cause of death was sudden unexpected death in epilepsy (SUDEP). Concerns included lengthy waits for neurology care, the absence of clear guidance and systems for monitoring, discharge information, and urgent review after seizure recurrence.

Matthew John LYNCH · Prevention of Future Deaths report View report

4 Mar 2025 Birmingham and Solihull L. Hunt

Matthew John Lynch was attacked in the garden of his supported living accommodation in Birmingham on 11 July 2023 and was killed by decapitation. The concerns included whether medication non-compliance and a change of address had been adequately followed up, the quality of mental health assessments, and information sharing and training between mental health services, the council, housing providers and support workers.

Amanda Richardson · Prevention of Future Deaths report View report

9 Sep 2024 West Yorkshire Eastern K. McLoughlin

Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.

Kinga Cieciorska · Prevention of Future Deaths report View report

13 Jun 2016 Black Country Z. Siddique

Kinga Cieciorska, a 16-year-old girl with complex medical needs, was taken to hospital with abdominal pain and distension. She was diagnosed with constipation and discharged, but deteriorated overnight and died after being returned to hospital on 11 March 2016; the stated cause of death was peritonitis from a perforated gastric ulcer. Concerns included failure to investigate tachycardia and an abnormal ECG, failures in recording and transmitting clinical information, and failure to consider the significance of her medication.

David RILEY · Prevention of Future Deaths report View report

7 May 2024 Warwickshire L. Lee

David Riley developed a pericardial effusion after atrial fibrillation ablation and later suffered a stroke before dying on 10 June 2023. Concerns included inconsistent decisions about pausing Apixaban, delays in restarting it, inadequate communication and continuity of care, and difficulties using computerised clinical records.

Ruth Diane Eggleton · Prevention of Future Deaths report View report

3 Jul 2024 Nottinghamshire A. Bewley

Ruth Diane Eggleton fell in her garden on 2 April 2023 and sustained a head injury with a small subdural haemorrhage. She was taking Rivaroxaban, which was not withheld or reversed, and she was discharged from hospital; the report identified concerns about the lack of an evidence-based protocol for managing DOAC anticoagulation.

Hana Aisha Abd Elhamid · Prevention of Future Deaths report View report

13 May 2015 North London A. Walker

Hana Aisha Abd Elhamid was being treated with Clozapine for a mental health condition and developed diabetes, which was likely not identified because routine fasting blood tests were not carried out. She later required intubation for a diabetic coma, self-extubated and sustained airway injury, and died after subsequent breathing difficulties and treatment for a narrowed airway. The principal concerns were the failure to perform routine blood sugar testing and the resulting airway injury during treatment.

Phyllis Eleanor Barlow · Prevention of Future Deaths report View report

29 Jan 2015 Cardiff & Vale of Glamorgan C. Woolley

Phyllis Eleanor Barlow, who was taking warfarin, fell and struck her head in a GP surgery car park on 29 September 2014 but was not admitted to hospital. She fell again at home the following day, sustaining a subdural haemorrhage and hip fracture, and died on 8 November 2014; the concern was that GP surgeries were not sufficiently aware of NICE guidance requiring hospital admission and CT scanning after a head injury in a person taking warfarin.

Ann Corfield · Prevention of Future Deaths report View report

29 Mar 2019 Manchester City A. Mazzag

Ann Corfield was admitted to hospital with a urinary tract infection, low sodium levels and deteriorating mental health, later developing severe psychotic depression, poor oral intake and dehydration. She suffered a cardiac arrest and died after transfer between hospitals. Concerns included inadequate handover about anticoagulation, failure to administer prescribed prophylactic anticoagulation, poor completion of fluid balance charts, and the lack of suitably qualified staff to administer intravenous fluids at Park House.