6,433 reports
Information drawn from published reports and official responses.
Keith John Charles Harper was struck by a Renault Clio while exiting a footpath crossing the central reservation of the A132 Southmayne and died in hospital on 2 December 2015. Concerns related to limited warning and visibility of the pedestrian crossing for drivers, and obscured carriageway markings caused by resurfacing work and road debris.
National Highways
Mary Walker, who had dementia and had been admitted to hospital after a stroke before being discharged to a care setting, was found dead on 10 October after overnight checks. She had died of bronchopneumonia. Concerns were raised about the lack of detail recorded during night-time checks and unclear procedures for Care Assistants escalating health concerns.
Belong LimitedCare Quality Commission
Christopher Harold Brand, a 53-year-old patient at Broadmoor Hospital, became unresponsive after returning from treatment at Frimley Park Hospital and could not be revived despite resuscitation attempts. Concerns included failures to follow observation procedures, failure to check that he was alive when his room was unlocked, and a delay in starting CPR.
Broadmoor Hospital
Richard Paul Martin Grant was found deceased in his car in his garage on 7 January 2016 following inhalation of helium gas. He had previously self-harmed and threatened suicide, but his counselling referral was sent to the wrong team and an appointment was arranged for 22 February 2016. The report identified concerns about delays and failures in referring him to the appropriate mental health service and in informing his GP about the assessment and its outcome.
Black Country Healthcare NHS Foundation Trust
Derrick Edward ROSE-FOWLER was found hanging by his neck from his prison cell window on 5 June 2015 and was pronounced dead after being transferred to hospital. The concerns included the first attending prison officer not being first-aid trained, the handling of alleged bullying, and the failure to raise concerns about the deceased at a MASH meeting despite several relevant factors.
Ministry of JusticeStoke Heath Prison
Angus Jonathan Labofski WEST was born on 24 January 2015 and became unwell shortly afterward, developing severe hypoxic-ischaemic encephalopathy. His death was confirmed at Martin House Children’s Hospice on 20 February 2015. The principal concern was that the placenta was not retained, limiting possible pathological examination into factors that might have contributed to his death.
York and Scarborough Teaching Hospitals NHS Foundation Trust
Ronald Hamer, an elderly man living independently at home, fell in his bathroom on 8 February 2016 and remained immobilised on the floor for over 13½ hours before being found. He was taken to hospital after a delayed ambulance response and died there on the morning of 10 February 2016. Concerns included the ambulance response time, the lack of timely follow-up contact with the family, and inadequate planning and direction during periods of very high call volumes.
Daughter of the deceasedHealthcare Inspectorate WalesOffice of the Chief CoronerWelsh Ambulance Services NHS TrustWelsh Government
Helen Elizabeth Patton developed infection, respiratory failure and a fast heart rhythm after a right lobectomy, and underwent a mini tracheostomy to remove secretions. During the procedure, performed on an intensive care ward without ultrasound guidance, a small thyroid artery was damaged, causing catastrophic bleeding and her death; concerns were raised about the continuing risk of mortality and the absence of national guidance for such procedures.
Department of Health and Social Care
On 6 March 2015, a vehicle collision on the A470 near the Storey Arms, Brecon resulted in the deaths of Rhodri Dafydd Miller-Binding, Corey Bailey Price, Alesha Marie O’Connor and Margaret Elizabeth Challis. The principal concern was that the challenging bend lacked an advance warning sign, which the inquest evidence indicated could help reduce the risk of similar fatal collisions.
FamilyOffice of the Chief CoronerPowys County Council
On 6 March 2015, a vehicle collision on the A470 near the Storey Arms, Brecon resulted in the deaths of Rhodri Dafydd Miller-Binding, Corey Bailey Price, Alesha Marie O’Connor and Margaret Elizabeth Challis. The principal concern was that the challenging bend lacked an advance warning sign, which the inquest evidence indicated could help reduce the risk of similar fatal collisions.
FamilyOffice of the Chief CoronerPowys County Council
On 6 March 2015, a vehicle collision on the A470 near the Storey Arms, Brecon resulted in the deaths of Rhodri Dafydd Miller-Binding, Corey Bailey Price, Alesha Marie O’Connor and Margaret Elizabeth Challis. The principal concern was that the challenging bend lacked an advance warning sign, which the inquest evidence indicated could help reduce the risk of similar fatal collisions.
FamilyOffice of the Chief CoronerPowys County Council
On 6 March 2015, a vehicle collision on the A470 near the Storey Arms, Brecon resulted in the deaths of Rhodri Dafydd Miller-Binding, Corey Bailey Price, Alesha Marie O’Connor and Margaret Elizabeth Challis. The principal concern was that the challenging bend lacked an advance warning sign, which the inquest evidence indicated could help reduce the risk of similar fatal collisions.
FamilyOffice of the Chief CoronerPowys County Council
Leslie William Carswell was admitted to hospital following a transcatheter aortic valve implantation, was assessed as being at high risk of falls, and suffered a serious brain bleed after falling while going to the toilet. The report raised concern that technical difficulties transmitting CT scans delayed review and treatment planning, with potential to delay lifesaving treatment for patients with urgent conditions.
Sandwell and West Birmingham Hospitals NHS TrustUniversity Hospitals Birmingham NHS Foundation Trust
Doreen Mattinson, an 80-year-old resident of Acorn Care Home with dementia and other comorbidities, deteriorated rapidly with laboured breathing on 12 November 2015. Concerns were raised about the administration of oxygen, including the flow rate, her supine position, and the absence of evidence of training for the registered nurse who administered it.
Acorn Lodge Care CentreLodge Care Home
Carl Lee Thompson died from drowning on 10 August 2015 after being overwhelmed by surf and waves while bathing in the sea in Fuerteventura. Concerns included inadequate or defective lifesaving and resuscitation equipment, lifeguards’ lack of training in its use, and delays in obtaining replacement equipment and emergency medical assistance.
Ayuntamiento de La Oliva
Adele Blakeman, who had a history of mental health difficulties and self-harming behaviour, died after taking her own life at Gateley Railway Station on 28 September 2015. The substantive concerns included failures in police information recording and access, classification and escalation of the call, timely allocation of resources, and understanding of the role of the Missing Persons Unit.
Greater Manchester Police
Luke Christie AYRES, aged 24, died on 27 September 2015 while serving a custodial sentence as an inpatient at Raeside Clinic. He was found hanging by a ligature in his bedroom and could not be resuscitated. Concerns included delays and communication risks in contacting the ambulance service, and the absence of staff to escort paramedics from reception to the ward.
Birmingham and Solihull Mental Health NHS Foundation Trust
Helen Jennifer Turner was admitted with diarrhoea and vomiting and was diagnosed with a sigmoid colon obstruction. She later developed sepsis, colonic perforation and peritonitis, underwent surgery and further procedures, and died after her condition deteriorated. The report identified delays in confirming the obstruction, arranging stenting and operating to remove it; expert evidence stated that these delays diminished her chances of survival.
East Kent Hospitals University NHS Foundation Trust
Dennis Bennett had dementia and was admitted under the Mental Health Act before receiving end-stage palliative care on a mental health ward, where he died of natural causes on 7 February 2016. Concerns included an urgent deprivation of liberty application made while he was already detained under Section 3, uncertainty about the application’s continuation, confusion about place-specific authorisations, and limited consideration of whether the application was needed while he was compliant and receiving palliative care.
Greater Manchester Mental Health NHS Foundation TrustTrafford Borough Council
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.
the Rotherham NHS Foundation Trust
