6,433 reports
Information drawn from published reports and official responses.
Sarah Ann Tyler was admitted to the Emergency Department on 8 February 2015 following an overdose of co-codamol and, while awaiting admission, used ECG leads as a ligature, resulting in a hypoxic brain injury. The substantive concerns were delays in hospital admissions due to insufficient beds and more acute bed blocking at weekends because of reduced discharges.
Betsi Cadwaladr University LHB
Jennifer Elisabeth Lestajo CLARK was born after a birthing pool delivery, and the midwife did not recognise that she was unwell until she collapsed about 30 minutes after delivery. She was transferred to Luton & Dunstable Hospital, where she died. Concerns included inadequate neonatal facilities at Watford General Hospital and the associated risk to babies’ lives in the future.
Watford General Hospital
Charles Hugh Rendell, aged 76, underwent a prostate biopsy and was prescribed Ciprofloxacin before being found hanging in a garage on 24 September 2016. The Inquest concluded that he took his own life. The report raises concern that Ciprofloxacin’s potential psychiatric and suicide-related risks, and the symptoms requiring attention, may not be sufficiently communicated to patients and prescribing clinicians.
Bayer plc
David Moran, who had bipolar affective disorder and a history including suicide attempt and suicidal ideation, died after taking a fatal overdose of metformin; the inquest could not determine his intention. Concerns included imprecise referral-priority guidance, the absence of a default urgent response when screening was not possible or the situation was ambiguous, and ineffective communication between administrative and clinical staff.
Mersey Care NHS Foundation Trust
Roseleen Mary O'DONOGHUE fell down the stairs at home on 26 or 27 June 2016 and was pronounced dead at the scene on 27 June 2016 after sustaining a traumatic fatal head injury. The stair lift did not come to rest in the safest possible position at the top of its journey, leaving the step plate suspended over the stairwell and creating a risk of falling; concern was also raised that other properties might have the same risk.
Your Housing Group Limited
Raymond David SHEPHERD had chronic ill health, severely limited mobility and a high risk of falls and self-neglect. In January 2016, care records noted repeated falls, poor appetite and a deterioration in his condition, but referrals to a GP or ambulance service were not made; he later sustained a femur fracture after a further fall and died in hospital on 30 January 2016. The principal concerns were poor care record-keeping, missed care visits, failure to escalate reported or observed falls and deterioration, and the absence of a mental capacity assessment.
The Human Support Group LimitedTrafford Borough Council
Simon Charles was found dead in the sea at Hells Mouth on 3 July 2016 after a concern for welfare search. He had been suffering from depression and had previously made a serious attempt to take his own life. Concerns were raised about the lack of additional preventive measures at Hells Mouth, including suicide-support signage and natural barriers.
The National Trust For Places Of Historic Interest Or Natural Beauty
Dorothea Parr fell from a newly delivered electric riser-recliner chair at home on 21 March 2016, sustained a fractured neck of femur, and died of pneumonia on 28 March 2016. The report raised concerns that the chair was delivered without notifying her family, carers, or district nurses, limiting opportunities for training and risk assessment. It also identified a lack of formal procedures for notifying district nurses about falls, changes in presentation, or new equipment.
Cornwall Partnership NHS Foundation Trust
Michelle Barnes was found dead in her cell at HMP Low Newton on 16 December 2015, five days after giving birth and three days after returning to prison. The report identified concerns that an ACCT was not opened after she was told her child would be taken into care, that the support to be offered was not clearly defined or documented, and that other factors probably contributed to her death according to the inquest.
HM Prison and Probation ServiceNational Offender Management Service Equality, Rights and Decency Group
Mrs Georgina Lewis was discharged from a psychiatric unit on 23 September 2013, went missing from home on 27 September, and was found dead in woods near her home on 30 September 2013. Concerns included discharge without family consultation, no discharge plan or follow-up support, and delayed notification to her GP.
Aneurin Bevan University LHB
On 23 April 2016, Thomas Wallace died at the scene after his motorcycle collided with a car that had pulled out from a lane onto the A682 at Long Preston. Concerns included the restricted visibility at the junction, the wall alongside the road, limited and potentially misleading signage, and the positioning of national speed limit signs.
North Yorkshire CouncilRecipient name withheld
Edwina Rose Moses was admitted to hospital after a fall at home that fractured her left hip. While in hospital, she fell from her bed at a time when she should have been receiving one-to-one nursing care, fractured her right hip, and later died following an upper gastrointestinal bleed; concerns included poor systems for arranging additional nursing cover and inadequate staffing when such cover was unavailable.
Swansea Bay University Local Health BoardWelsh Government
Demi Williams was detained under the Mental Health Act after developing psychotic symptoms and disclosed that she had purchased helium gas intending to kill herself. She was later found deceased in her flat from helium inhalation; the principal concerns were that her specific risk of access to helium was not assessed and that this issue was not reflected in the Trust’s investigation.
North London NHS Foundation Trust
David Bassett Cooper was admitted to hospital after a serious head injury caused by a fall in the community and sustained nine further falls while being transferred between wards. He died from a subdural haematoma caused by the final fall on 5 March 2016. The concerns included inadequate handovers about falls risk, incomplete nursing records, a failure to see the overall pattern of falls, and shortcomings in arranging additional one-to-one nursing care.
Swansea Bay University Local Health BoardWelsh Government
Mr Terence Hawkins, an 88-year-old resident of St. Catherine’s Residential Care Home, became unresponsive after vomiting during the early hours of 12 May 2016 and was pronounced dead at 05:12. The concerns identified were that there was no system for regular medical monitoring of care-home residents and that Mr Hawkins had not been seen by a GP for many months.
Lime Tree Surgery, Leytonstone
Grace Joy Roseman died on 9 April 2015 after being found with her head over the half-lowered side of an NCT Bednest crib. The medical cause of death was amended to pressure on the carotid sinus leading to positional asphyxia. The principal concern was that unmodified cribs remained in use or could be passed on or sold, including where customers were unaware that modification was needed or believed it was optional.
Bednest LimitedDepartment for Business, Energy & Industrial Strategy
Mark LILLIOTT, a 54-year-old inmate at HMP Liverpool, was found unresponsive in his cell on the morning after 22 December 2014 and was pronounced dead at 09:12. The report raised a concern about a short delay in accessing a senior officer with a radio to request emergency assistance, although it stated that Mr LILLIOTT was already dead when discovered and that the delay did not affect the outcome in this case.
Liverpool Prison
Charles Ray Woodward underwent surgery to remove a sigmoid colon tumour and was discharged home after an apparently uneventful recovery. His health then declined, and he died from peritonitis caused by a leaking anastomosis following surgery. The principal concerns were inadequate communication and liaison between the hospital, community care providers and the family, together with insufficiently robust monitoring of his condition after discharge.
Mid Cheshire Hospitals NHS Foundation TrustRecipient name withheld
Mr Edwin Richard Flett drowned after entering the sea at Accra (Rockley) Beach, Barbados, on 21 March 2015; prompt CPR could not save him, and the autopsy found no medical reason for the drowning. The report raised concerns about the beach's history of drownings, currents and riptides, the absence of warning flags or signs, and general rather than beach-specific safety information for tourists.
Foreign, Commonwealth & Development Office
Lita Serkes underwent surgery at Whipps Cross Hospital on 22 July 2016, suffered a stroke the following morning, was transferred to the Royal London Hospital later that day, and died on 24 July. The concerns included discrepancies in observations and clinical records, delay in transfer for specialist stroke care, undelivered pain relief, and delayed recognition and assessment of a significant bleed.
Royal London Hospital
