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Marjorie GARTSIDE · Prevention of Future Deaths report View report

12 Mar 2019 Manchester North C. McKenna

Marjorie Gartside, aged 100, fractured her hip in an unwitnessed fall at a residential home and underwent surgery. She was discharged from hospital on two occasions, with concerns about inaccurate information regarding her mobility, unsafe discharge processes, lack of care handover and unclear palliative-care arrangements, and anticipatory medication not being sent with her. She died at the Home on 19 October 2018.

Pauline May Pryor · Prevention of Future Deaths report View report

12 Jan 2018 Cornwall and Isles of Scilly E. Carlyon

Pauline May Pryor, a resident of Trevornor Nursing Home receiving lithium treatment, was found unwell on 9 July 2015 and died in hospital on 13 July 2015. The report identified concerns that required quarterly blood tests were not carried out because of unclear communication between the nursing home and GP surgery, and that psychiatric advice to reduce and stop lithium was not seen or followed up.

Alex Kelly · Prevention of Future Deaths report View report

28 Dec 2014 Mid Kent and Medway P. Harding

Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

Janet Doreen Goodacre · Prevention of Future Deaths report View report

18 Sep 2014 Leicester City and South Leicestershire L. Brown

Janet Doreen Goodacre, aged 88, was admitted to Leicester Royal Infirmary on 1 May 2013 and died there on 21 May 2013 after developing a gastrointestinal bleed while receiving warfarin, deltaparin and aspirin. The report raised concerns that the Trust’s investigation report was factually incorrect and flawed, that its identified root causes were wrong, and that the Trust did not communicate these shortcomings or revisit the report before the inquest.

KEITH RUPERT DIMOND · Prevention of Future Deaths report View report

22 Oct 2022 North East Kent S. Hayes

Keith Dimond died on 24 November 2021 at Queen Elizabeth Queen Mother Hospital following a catastrophic bleed from a ruptured iliac artery aneurysm, with anticoagulation contributing to the excessive bleeding. Concerns included communication failures about the known iliac artery aneurysm, lack of information about bleeding risks when anticoagulation was prescribed, delayed escalation when he deteriorated, and haematology advice on anticoagulation not being followed on two occasions.

Neville Bardoliwalla · Prevention of Future Deaths report View report

26 Nov 2020 North London A. Walker

Neville Bardoliwalla was found at home on 10 March 2020 after hanging himself from two screws in a door frame. Evidence was heard that he had accumulated prescribed controlled medication and that there was no process for collecting and disposing of it.

Hailey Anne Thompson · Prevention of Future Deaths report View report

4 Apr 2025 Manchester West M. Pemberton

Hailey Anne Thompson was found unresponsive at home on 19 December 2022 and died after unsuccessful resuscitation. Her death was attributed to sepsis and pneumonia arising from a Streptococcus A infection. The principal concerns were unclear pathways and guidance for care navigators handling reports of allergic reactions to medication, including referral to an appropriately competent clinician and recording an auditable trail.

George Watson · Prevention of Future Deaths report View report

19 Aug 2016 Coventry R. Brittain

George Watson fell from his bed at approximately 04:30 on 3 September 2014 after being admitted following a fall, and died on 21 October 2014 from a subdural haemorrhage, skull fracture and compound fracture of his left humerus. The principal concerns included supervision and staffing arrangements, raised bed rails, discharge without necessary oral pain relief and inadequate investigatory processes, including cooperation with police inquiries.

Robert Charles Rostron · Prevention of Future Deaths report View report

11 Jul 2019 Manchester West R. Galloway

Robert Charles Rostron, who had Type 1 diabetes and Alzheimer’s disease, became unconscious after an agency nurse administered insulin despite recording a low blood sugar reading of 2.2. He did not recover to his previous baseline and later died in hospital; the inquest found that the insulin administration exacerbated his natural illness. Concerns included the use of agency nurses without formal induction, insufficient knowledge of records and care plans, and an agency nurse being the only qualified nurse in charge of the unit.

Beatrice Wright Herriot Gatt · Prevention of Future Deaths report View report

18 Sep 2014 Northamptonshire A. Pember

Beatrice Wright Herriot Gatt was found unresponsive at home on 18 July 2012 and later died at Kettering General Hospital. The report describes an error in which her clozapine medication was not administered on 6, 7 and 8 May 2012, following which her mental state deteriorated; she later suffered falls, fractured her hip and was found on the floor. The principal concern was the medication-transfer error and the apparent lack of formal training for nursing staff on the medication recording system.

Charles Hugh Rendell · Prevention of Future Deaths report View report

11 Jan 2017 Berkshire P. Bedford

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.

ANDREW ETLERED NICHOLS · Prevention of Future Deaths report View report

27 Oct 2023 Worcestershire N. Lane

Andrew Nichols developed acute disseminated encephalomyelitis after vaccination and spent over a year receiving hospital and neuro-rehabilitation care. His anticoagulation medication was not continued when he was discharged to community care, and he subsequently died from deep vein thrombosis and pulmonary embolism. The principal concerns were unclear responsibility for venous thromboembolism risk assessments between hospitals and community organisations, and inadequate pathways for organisations to identify relevant NICE guidance.

Mrs Brenda McWilliams · Prevention of Future Deaths report View report

29 Nov 2019 Manchester North P. Sigee

Mrs Brenda McWilliams, who had Alzheimer's disease and remained immobile after discharge from hospital to a residential care home, died on 3 January 2019. A post-mortem examination found that she died from a pulmonary thromboembolism caused by a deep vein thrombosis associated with her immobility. The principal concern was that medication to minimise the risk of venous thromboembolism was not continued or prescribed after her hospital discharge despite her recognised high risk and the potentially life-threatening consequences.

ANN COLES · Prevention of Future Deaths report View report

13 Apr 2021 Surrey C. Topping

Ann Coles was admitted to Frimley Park Hospital in March 2019 with pneumonia and later developed multi-organ failure, dying on 12 March 2019. The principal concern was that long-term amiodarone can cause lung toxicity and fibrotic changes, while there was no requirement for lung imaging to monitor patients prescribed the medication long term.

Glenn Anthony LOCKWOOD · Prevention of Future Deaths report View report

17 Nov 2023 Inner North London I. Potter

Glenn Anthony Lockwood, a known drug user receiving opiate replacement treatment, was found unresponsive after a suspected overdose on 14 April 2023 and later suffered a cardiac arrest. Despite hospital treatment, he died on 2 June 2023; the inquest concluded that his death was drug related, with mixed drug toxicity recorded as the medical cause. Concerns included whether Pregabalin abuse risks were sufficiently monitored and whether prescribing and record-keeping issues had been fully investigated and addressed.

Lester John STACEY · Prevention of Future Deaths report View report

10 Mar 2017 Staffordshire South M. Jones

Lester John STACEY, who had hypertrophic cardiomyopathy and bipolar affective disorder, was found hanging in a barn at his home on 23 October 2016 and was certified dead at the scene. Concerns included discharge from mental health inpatient care without follow-up appointments, no attempted visit to re-engage him with services, and a change in medication that does not appear to have been monitored.

Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report View report

12 Feb 2015 Northamptonshire B. Cheney

Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.

Mr Edward Hearn · Prevention of Future Deaths report View report

8 May 2019 Inner South London A. Harris

Mr Edward Hearn died in hospital after a cardiac arrest, with the medical cause of death including sepsis, bronchopneumonia and multiple myeloma treated with chemotherapy. The report identified concerns that a high globulin result was not followed up, that he was discharged without a safe care plan to minimise fall risk during chemotherapy, and that cardiac monitoring requirements for Carfilzomib may not have been sufficiently definitive.

Sharon Anne ROBINSON · Prevention of Future Deaths report View report

16 Nov 2021 West Yorkshire (Western) A. Howard

Sharon Robinson died at Airedale Hospital on 7 February 2019 after an antibiotic administered on 27 January induced an anaphylactic reaction. The principal concern was that a possible patient sensitivity to an antibiotic might be disregarded and the antibiotic given despite that risk.

Jennifer Tompkins · Prevention of Future Deaths report View report

28 Apr 2014 Inner South London P. Barlow

Jennifer Tompkins, who was undergoing dialysis while awaiting a kidney transplant, suffered fatal allergic anaphylaxis after receiving an intravenous injection of Tazocin at Kings College Hospital on 6 July 2011. Concerns were raised that Tazocin may have been administered too quickly, indicating possible training issues, and that the early stopping of a vancomycin infusion was not recorded in drug administration records.