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David Joyce · Prevention of Future Deaths report View report

25 Jun 2026 Devon, Plymouth and Torbay A. Longhorn

David Joyce, who had a history of mental health difficulties, died by suicide at his home on 31 August 2023 after being found having suspended himself. The concerns included a lack of follow-up and consideration of mental health referral after he first sought help, prescribing Quetiapine without specialist input despite his reported symptoms and overdose, and a delay of 15 weeks before a medication review led to a change in treatment.

Joyce Violet Rumming · Prevention of Future Deaths report View report

6 Jun 2017 Wiltshire and Swindon D. Ridley

Joyce Violet Rumming attended the Accident and Emergency Department on 11 December 2016 and was given Amoxicillin and Clarithromycin at 01.45 on 12 December 2016; she died just over half an hour later. The stated cause of death was respiratory failure, and the report says this did not appear to be related to an allergic reaction to Amoxicillin. The principal concern was that information about her recorded Amoxicillin allergy was not effectively communicated between systems and staff, resulting in the antibiotic being administered shortly before her death.

June Patricia Margaret PARLOUR · Prevention of Future Deaths report View report

28 Sep 2020 Essex L. Brookes

June Parlour was an inpatient with disseminated terminal cancer when she received morphine doses exceeding national and hospital guidelines. Her condition deteriorated, and she later died of opiate toxicity; the overdose significantly hastened her death. Concerns included staff awareness of morphine guidance, inaccurate hospital guidance and incident reporting, education and auditing for doctors, unclear prescribing instructions, and communication and escalation failures between staff.

Emily Jane CALDICOTT · Prevention of Future Deaths report View report

23 Mar 2022 Worcestershire D. Reid

Emily Jane Caldicott was admitted to hospital after an overdose and was later found unresponsive after tying a ligature around her neck. She died on 23 March 2020 from pneumonia and cerebral anoxia due to the application of a ligature. The principal concerns were that staff failed to adequately assess her capacity regarding Lorazepam, did not administer it in her best interests, and failed to remove the item used to make the ligature; the jury found these failures probably or possibly contributed to her death and identified a risk of future deaths.

Vijaykumar Girishbhai Gadhavi · Prevention of Future Deaths report View report

28 Feb 2022 East London N. Persaud

Vijaykumar Girishbhai Gadhavi died from a drug overdose while an in-patient at Whipps Cross Hospital under enhanced one-to-one care. The report raised concerns about breaches of the Enhanced Care Policy, the absence of an alert or risk-management plan, inadequate recording of property and medication, insufficient family involvement, and a lack of evidence that learning from earlier self-harming incidents had been implemented.

Alfie Stone · Prevention of Future Deaths report View report

14 Jan 2022 Northamptonshire J. Harkin

Alfie Stone, aged 12, died after prolonged seizures, status epilepticus, hypoxia and multiple organ failure following admission to hospital. Concerns included paramedics’ lack of training in buccal midazolam, inadequate oxygenation, no suction attempt, and insufficient evidence of training following an earlier Serious Incident Report.

Wendy Siobhan EYLES · Prevention of Future Deaths report View report

22 Dec 2025 Northamptonshire H. Shah

Wendy Siobhan Eyles died aged 55 on 31 October 2024 after being struck by a train at Kettering Station; the inquest concluded that appropriate mental health support and intervention had not been provided. Concerns included the absence of a protocol for patients receiving both private and NHS psychiatric care, risks from poor communication about medication changes, and possible lack of NHS awareness of private psychiatric treatment.

Frederick Squires · Prevention of Future Deaths report View report

31 Oct 2016 Milton Keynes T. Osborne

Frederick Squires was involved in a low-impact road traffic collision, sustained a head injury, and was discharged home after his warfarin and other medications were stopped. He was later found unwell, diagnosed with an acute ischaemic stroke, and died on 30 December 2014. The principal concern was the lack of guidance for clinicians on when warfarin should be recommenced after a head injury.

Thomas Paul Arthur JACKSON · Prevention of Future Deaths report View report

13 Nov 2018 Staffordshire South A. Haigh

Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.

Rhian Margaret Roberts · Prevention of Future Deaths report View report

14 Jul 2021 North Wales (East and Central) J. Gittins

Rhian Margaret Roberts was admitted to hospital after being found unresponsive at home following a presumed overdose, with extremely high paracetamol levels identified on admission. ICU clinicians did not become aware of the results until the early hours of the following morning, and she died on 25 November 2020. Concerns included uncertainty about whether a requested toxicology screen was undertaken, delays in approving an updated procedure for communicating life-threatening blood results, and delays in investigating incidents, sharing learning and implementing actions.

Glennis CONNELLY · Prevention of Future Deaths report View report

31 May 2024 Staffordshire and Stoke-on-Trent A. Barkley

Glennis CONNELLY died at home on 11 November 2022 from end-stage renal failure due to tubulo-interstitial nephritis caused by tazocin, despite a previously identified allergy to the drug. The principal concerns were that this allergy was not recorded in the hospital records at Queens Hospital Burton upon Trent and that electronic patient records across the same trust did not automatically share allergy information.

Andrew Peter McCall · Prevention of Future Deaths report View report

1 Jul 2019 Stoke-on-Trent and North Staffordshire A. Barkley

Andrew Peter McCall was found face down and unresponsive in supported living accommodation on 18 September 2018. A post-mortem examination and toxicology attributed his death to gastric aspiration associated with Pregabalin and Methadone use. The report raised concern that his GP was unaware of his Methadone prescription and could therefore prescribe medications that might be unsuitable or potentially harmful.

MARY NABILIA GWANYAMA · Prevention of Future Deaths report View report

21 Apr 2021 Surrey C. Topping

Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.

Rohid SHERGILL · Prevention of Future Deaths report View report

12 Oct 2016 Nottinghamshire H. Connor

Rohid Shergill, who had Duchenne’s muscular dystrophy and was fed through a nasogastric tube, died on 14 March 2016 after the tube was inserted into his lung and was used for feeding and medication. The principal concerns included inadequate checking of the tube position, uncertainty about parental understanding of pH testing, insufficient information-sharing between trusts, unclear care coordination, and possible contamination from repeated syringe use.

Jason Edward Lawson · Prevention of Future Deaths report View report

9 Jan 2015 Rutland and North Leicestershire R. Chapman

Jason Edward Lawson, who had epilepsy and schizophrenia, was found dead in his prison cell at HMP Stocken on 17 March 2013; the time of death was uncertain but likely late on 16 March or early on 17 March. Concerns included welfare checks that did not establish that he had died, systems that did not reliably identify medication non-attendance or lapsed prescriptions, access delays to healthcare, and the absence of a specific policy for 24-hour medical observation where constant medical supervision was unavailable.

Dean Ronald Edmund BOLAND · Prevention of Future Deaths report View report

25 Nov 2015 Birmingham and Solihull L. Hunt

Dean Ronald Edmund Boland was found unresponsive in his cell at HMP Birmingham on 17 April 2015 and was pronounced dead shortly afterwards. Post-mortem examination confirmed multiple drugs in his system, and the inquest concluded that he died from mixed drug toxicity. The principal concerns included inadequate awareness, communication, monitoring, searching and security measures relating to drug use within the prison.

Hayley Christine Clark · Prevention of Future Deaths report View report

12 Apr 2016 South Yorkshire (Eastern) M. Beresford

Hayley Christine Clark, aged 36, was admitted to Rotherham General Hospital with electrolyte imbalance and received an unadjusted standard adult dose of paracetamol despite her extremely low body weight. Her condition deteriorated and she died on 24 May 2015; the inquest recorded severe multifactorial malnutrition among the causes of death. The substantive concern was that staff failed to recognise the need to reduce the paracetamol dosage for her low body weight.

Patrick McGagh · Prevention of Future Deaths report View report

28 Apr 2016 Manchester South J. Pollard

Patrick McGagh died at his care home from natural causes; the medical cause of death was recorded as pneumonia, coronary artery atheroma and hypertensive heart disease. After discharge from hospital, no discharge information or prescribed antibiotics were provided to his GP or care staff, who were therefore unaware that he should have been taking them.

Russell Charles ROBB · Prevention of Future Deaths report View report

22 Dec 2017 Manchester South A. Mutch

Russell Charles ROBB died at Manchester Royal Infirmary on 9 April 2016 after taking a fatal combination of prescribed and non-prescribed drugs with alcohol. The report identified inadequate monitoring and lack of regular medication reviews, no apparent guidelines to limit the quantity of drugs available, and limited information sharing between agencies involved in adult safeguarding.

Robert Lee Evans · Prevention of Future Deaths report View report

20 Oct 2022 Swansea and Neath Port Talbot K. Heaven

Robert Lee Evans, a prisoner at HMP Swansea, was found deceased in his cell in the early hours of 14 January 2018 after tying a ligature around his neck, shortly after arriving at the prison and while undergoing alcohol detoxification. The concerns included inadequate assessment and monitoring of his suicide and self-harm risk, failures relating to prescribed antidepressant and detoxification medication, and failures to promptly capture evidence from prison staff witnesses after his death.