6,433 reports
Information drawn from published reports and official responses.
Stephanie Louise Augusta Marks died from untreated hypokalaemia, in a setting of anorexia nervosa and hypokalaemia. The report identified inconsistent systems for passing blood results to GPs and no evidence that staff checked each evening that GP messages had been countersigned as received or acted on.
Clevedon Medical Centre
Michael Guy Hutchence broke his lower leg after slipping on an icy pavement and died in hospital on 28 January 2016. The report raised concerns about repeated ward moves, staffing and record-keeping, weight-based anticoagulant dosing and inconsistent weight recording, inadequate equipment for leg elevation, and delays to surgery after two operation kits were found to be non-sterile. The stated medical cause of death included bronchopneumonia, deep vein thrombosis and pulmonary embolus, and fractured tibia and fibula.
Stockport NHS Foundation Trust
Mr Zawdie Qounseye Bascom developed severe abdominal pain, was assessed and discharged from A&E with a presumed diagnosis of gastritis, and later collapsed and died on 12 May 2014. The post-mortem cause of death was peritonitis due to rupture of an inflamed vermiform appendix. Concerns included inadequate recording and systematic assessment of pain, lack of documented pain relief before discharge, and insufficient attention to persistent severe pain that was unusual for gastritis.
Barts Health NHS Trust
Valerie Margaret Ellis, an 83-year-old woman, died at home on 6 September 2015 after a massive gastrointestinal bleed associated with Apixaban. The report identified concerns about inadequate counselling on the medication, communication and call-handling problems in NHS 111, premature closure of an IC24 case, and aspects of ambulance triage.
Integrated Care 24South East Coast Ambulance Service NHS Foundation TrustUniversity Hospitals Sussex NHS Foundation Trust
On 2 December 2015, 18-year-old Mr Reece Atkinson sustained fatal head injuries when his car left the road and collided with a tree on the A25 Sheer Road in Albury. The inquest identified wet soil and sandy deposits near the Albury Sandpit entrance, which may present a risk to drivers.
Surrey County Council
Christina O'Brien died by suicide on 17 September 2015 after hanging herself outside her flat; she also had injuries to her arms and legs. She had a long-term mental illness and was receiving treatment and care from SLAM. The principal concern was that community respite options for people experiencing mental health crises were limited, particularly after the withdrawal of Dove House, a non-hospital respite facility that had previously benefited her.
Department of Health and Social CareOffice of the Chief CoronerSouth London and Maudsley NHS Foundation Trust
The circumstances of Andrew Gus Peebles’s death are said to be set out in the attached summing up, jury findings and conclusion; the inquest concluded on 18 May 2016. The substantive concerns included failures to record or undertake mental-health assessments and referrals, inadequate review of relevant documentation, and insufficient evidence of supervision or retraining after the concerns were identified.
Lancashire & South Cumbria NHS Foundation Trust
Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his death.
Department of Health and Social CareNHS England
Laura McRory, who had a history of anxiety, depression and alcohol misuse, was assessed at hospital on 20 June 2015 after deterioration in her mental state and increased alcohol consumption. She was discharged without immediate follow-up or continued observation and was found unresponsive the following day; she died from alcohol and mixed drug consumption. The principal concerns were the adequacy of the discharge safety plan and the lack of a clear process for referring NELFT staff seeking mental healthcare to another Trust when they were unwilling to share information with colleagues.
North East London NHS Foundation Trust
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.
Parents of Kinga CieciorskaWalsall Healthcare NHS Trust
Matthew Joseph Gunn fell from height while using a staff staircase at a supermarket on 25 September 2014. The jury found the fall was probably caused by an epileptic event, and he died in hospital on 7 October 2014 from injuries sustained in the fall. The report raised concern that observed or reported epileptic events involving an employee at work were not recorded.
Dwf LLPTewkesbury Borough CouncilWm Morrison Supermarkets plc
Mrs Clarke “Betty”, also identified as Gwendoline Betty Clarke, sustained multiple fractures and other injuries during a significant incident at her care home on 28 December 2014. She was admitted to hospital, subsequently deteriorated with respiratory failure and sepsis, and died on 31 December 2014; concerns were that staff did not report the injury or promptly escalate her allegation that a member of staff had hurt her.
ADL PlcCare Quality Commission
Stephen Alan Hunt, a firefighter, died after entering a fire at Paul's Hair and Beauty World in Manchester on 13 July 2013. He was found inside the premises after suffering heat exhaustion and hypoxia. The principal concerns included failures in communication and handover, misinterpretation of instructions, loss of telemetry and radio communications, inadequate fire risk assessments and fire safety measures, and decisions affecting firefighter safety.
Chief Fire and Rescue AdviserHome Office
Peter Seale had occupational asbestos exposure, pleural plaques identified in 2011, and a persistent cough in 2013, but no further tests were conducted before he was diagnosed with terminal lung cancer in 2015. The principal concern was the absence of national guidance for follow-up and monitoring of patients with pleural plaques, creating inconsistent approaches and a risk of patients being lost to follow-up where earlier diagnosis or treatment might be possible.
Department of Health and Social CareRoyal College of Physicians
Anthony Benjamin Patrick Fraser had terminal multiple myeloma and died at Doncaster Royal Infirmary on 24 September 2015 after his condition significantly progressed and palliative care was initiated. The report identified the absence of a robust system for conveying summary medical information to receiving A&E departments when inmates are transferred with an acute illness, which could delay diagnosis for other inmates.
Lindholme Prison
Nadim Muzzfar BUTT died on 5 September 2014 after complications following laparoscopic gastric bypass surgery, including small bowel obstruction, systemic inflammatory response syndrome and multi-organ failure. The report raised concerns that the hospital review was not escalated to a serious untoward incident or root cause analysis, and that no consultant-led out-of-hours on-call rota was in place for postoperative patients.
Royal Stoke University Hospital
On 23 October 2015, Ezh arul Islam fell and struck his head as a 191 bus moved away from a bus stop, possibly while he was sitting down. The principal concern was that there was no system to alert passengers that the bus was about to move; the inquest recorded a narrative conclusion and a medical cause of death involving aspiration pneumonia and treatment following chronic subdural haematoma.
Transport for London
Tracey Lynch, who had emotionally unstable personality disorder, died by suicide after hanging herself in her room at Oswald House on 9 October 2015. The report identified concerns about the lack of a final discharge meeting, familiarisation visits and appropriate escorted transport, and about the absence of adequate assessments and care planning after her presentation changed and she was transferred between services.
Lancashire & South Cumbria NHS Foundation Trust
Steven Trudgill was found hanging in his cell at HMP Highpoint on 9 January 2014 while on an open ACCT document. The report described a longstanding and complex mental health history, the absence of standardised treatment programmes for fire setters within HM Prison Service, and a suggested Therapeutic Community option that was not taken forward before his death. The inquest jury concluded that his death was suicide.
Ministry of Justice
Clarice Beverley Hilton, who had depression and anxiety, was admitted to a psychiatric unit after refusing food, fluids and prescribed medication. She refused physical observations after the first evening, became unresponsive following a deterioration in her physical health, and died on 23 January 2016 after transfer to hospital. The principal concern was the absence of policy or guidance for monitoring and responding when psychiatric patients refuse physical observations and MEWS assessment.
Mersey Care NHS Foundation Trust
