6,433 reports
Information drawn from published reports and official responses.
Ondrej Suha, a serving prisoner, was found hanging in his cell on 21 December 2015 and died in hospital on 25 December 2015. Concerns included the lack of specific night-shift training for the responding prison officer and the absence of first-aid training enabling initial staff to attempt resuscitation.
HM Prison and Probation Service
John Clarke Jaundoo, aged 24, was found with multiple stab wounds under Garston Bridge in the early hours of 15 April 2010 and died later in hospital. Three men who lived in the same supported living accommodation were subsequently convicted of his murder, and the inquest concluded that he died as a result of unlawful killing. The inquiry identified concerns about the referral and accommodation of high-risk offenders, failures to provide accurate and up-to-date information and review risk assessments, and missed oversight opportunities by Liverpool City Council.
HM Prison and Probation ServiceLiverpool City Council
Beryl Yvonne Foster underwent an endoscopic ultrasound examination on 8 December 2015, became unwell after discharge, was readmitted on 11 December 2015, and died on 2 January 2016. The concern was that posting, rather than emailing, the endoscopy discharge summary meant her GP practice was unaware of the procedure when she contacted it after becoming unwell, creating a risk in similar circumstances.
Portsmouth Hospitals University NHS Trust
Lyndsey Holt, who was 37 weeks pregnant, collapsed after a gastric ulcer perforated and caused catastrophic bleeding. She died the following morning after emergency surgery and resuscitation; concerns included the telephone prescribing of methadone without sufficient information, assessment, or early medical review, and the provision of a seven-day supply to a methadone-naïve patient.
Dinnington Group PracticeYorkshire Ambulance Service NHS Trust
Olive Daynes, described as an 86-year-old lady, presented to hospital with an altered mental state and a suspected fall after earlier treatment for painful or sore legs and ulcers. The report identified concerns about Warfarin being prescribed with antibiotics, inadequate monitoring, communication between the hospital and GP surgery, and a subsequent INR increase to over 9 before she passed away.
United Lincolnshire Teaching Hospitals NHS Trust
John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.
Care UKHM Prison and Probation ServiceNHS EnglandPentonville Prison
Michael Brennan developed bleeding during a bronchoscopy to investigate a suspected lung cancer, deteriorated after a transfer to a satellite hospital could not be arranged because no beds were available, and died after transfer to intensive care. The principal concern was that the backup transfer plan relied on bed availability that was not known to clinicians, creating a risk of similar future deaths without a system to provide current bed-status information across the Trust’s sites.
University College London Hospitals NHS Foundation Trust
Steven Fone died on 31 October 2016 following consumption of a fatal combination of tramadol, cocaine, amitriptyline, methadone, pregabalin and heroin. The concern raised was that a pharmacy allowed customers to collect one another’s prescriptions, potentially enabling stockpiling of medicines with a risk of harm or death.
Adams Pharmacy
Grant Richards died by suicide on 19 October 2016 after ejecting himself from a tenth-floor window and suffering catastrophic injuries. The report identified failures to act on an A&E request for chest-clinic follow-up, failures in contingency and audit systems, omissions in GP reporting, and failures to act on mental-health service fax communications. It noted that anxiety about possible lung cancer may have prolonged or exacerbated his depression leading to his suicide.
Wanstead Place Surgery
Ralph Ian Brazier, a 52-year-old man, died after his bicycle struck a pothole next to a drainage gully cover on the A317 on 1 March 2016, throwing him onto the road. The concern was that Surrey County Council’s defect categorisation and repair priorities did not sufficiently account for cyclists using highways, particularly the nearside section of the road.
Surrey County Council
Antony Miles Abbott was arrested on 23 October 2015 and held in a cell at Benidorm Police Station, Spain, where he was found with a soft loose ligature around his neck after no officer presence was observed for 18 minutes. The jury concluded that he died by hanging and recorded misadventure, with his death contributed to by neglect. Concerns included the lack of CCTV and an audible means of attracting attention in the cell, the failure to implement prior recommendations for custody surveillance and cell safety, and the absence of CPR training for custody officers.
Father of the deceasedForeign, Commonwealth & Development OfficePartner of the deceased
Patricia Yvonne Donovan was admitted after a fall causing a fractured neck of femur and was scheduled for total hip replacement. Shortly after receiving a general anaesthetic, she suffered an adverse reaction causing cardiac failure and died; the report raised concerns about emergency trauma surgery arrangements where specialist skills are needed.
Aneurin Bevan University LHB
Marian Dale injured both legs in separate accidents, developed cellulitis in both legs, and was admitted to Stepping Hill Hospital. She developed sepsis and died there on 17 November 2016. The report raised concerns that the District Nursing Team could not evidence the condition of her legs and treatment because records were not held centrally or retrieved after her death.
Stockport NHS Foundation Trust
Michael Uriely had asthma from early childhood, which deteriorated and was uncontrolled in the seven months before his death. The report identified missed opportunities in the management of his asthma, including a lack of coordinated overall responsibility and long-term care planning, failure to assess and optimise treatment consistently, poor communication between services, and failure to refer him to a specialist respiratory service.
National Institute for Health and Care ExcellenceNHS England
Scott Douglas Hooper, aged 46, died on 22 March 2016 after sustaining complex pelvic fractures in an unwitnessed workplace forklift accident and later suffering a pulmonary embolism and deep vein thrombosis. The principal concerns were that his weight was incorrectly recorded, affecting the prescribed anticoagulant dose, and that a decision to withhold a dose was not recorded with the decision-maker identified.
Southampton General HospitalUniversity Hospital Southampton NHS Foundation Trust
James Aran Spencer died from multiple drug toxicity after self-injecting illegal street drugs following a prolonged period of abstinence. He was found in a drug-related collapse, but a support officer did not seek emergency medical assistance, and the report raised concerns about inadequate first-aid, drug-awareness and mandatory training for staff.
Stonham BASS
Trevor John CURRY died within 48 hours of admission to a psychiatric hospital. The concerns were that information about his heart problems was not recorded in his admitting note and that the trust did not obtain his full physical medical history until after his death, with particular concern about timely access to medical histories for psychiatric patients unable to provide them.
Sussex Partnership NHS Foundation Trust
Stephen McDermott was found deceased at home on 25 May 2015, having died sometime earlier as a result of the intentional application of a ligature; the inquest recorded the medical cause of death as hanging and concluded suicide. In the preceding months, he had presented repeatedly after overdoses and being recovered from train tracks, but was discharged without mental health follow-up. The principal concerns included fragmented and poorly used records, incomplete assessments and record keeping, insufficient consideration of overlapping mental health and substance misuse issues, missed opportunities for face-to-face assessment, limited information sharing between services, and an incomplete incident review.
Lancashire & South Cumbria NHS Foundation Trust
Derek Wynne Turnbull, a resident at the ICAR Unit with a recognised risk of falls and taking Warfarin, suffered an unwitnessed fall with facial injuries on 9 August 2016 and was taken to hospital after an ambulance was summoned 63 minutes after he was found. He was diagnosed with a large acute-on-chronic subdural haemorrhage and died at Sunderland Royal Hospital on 10 August 2016; the principal concern was the delay in summoning an ambulance despite the known risk factors and head injury.
Gateshead Health NHS Foundation Trust
Clive Davies, who was generally in poor health and had a history of falls, fell down the stairs at home on 22 August 2016 and sustained serious head and neck injuries. He died in hospital on 30 August 2016; concerns included failures in routine NEWS and neurological observations, including an incorrectly calculated NEWS score and missed observations.
Cwm Taf Morgannwg University Local Health BoardOffice of the Chief CoronerWelsh Government
