Search PFD Monitor

Tracey Elizabeth Rose · Prevention of Future Deaths report View report

17 Oct 2023 East Riding and Hull P. Marks

Tracey Elizabeth Rose suffered a right tibial plateau fracture and was discharged with a recommendation for six weeks of dalteparin, but missed up to three doses because of a dispensing issue. She was later admitted with a confirmed pulmonary embolism and died on 25 January 2023 after an embolectomy; the concern was that the missed anticoagulant doses may have significantly contributed to the pulmonary embolism.

Jerome Alexander Peat · Prevention of Future Deaths report View report

4 Feb 2021 Avon S. QC

Jerome Alexander Peat was found dead from an overdose of morphine at his student accommodation on 12 December 2019. The report identifies inadvertent duplication of morphine prescriptions, after the medical record failed to alert a practice that he had already registered with another GP, resulting in significantly more morphine being prescribed than intended.

Lisa Webb · Prevention of Future Deaths report View report

9 May 2014 Inner South London A. Harris

Lisa Webb died suddenly and unexpectedly at home on 10 March 2012, aged 44. The inquest recorded natural causes, including adult respiratory distress syndrome and lower respiratory tract infection, with sleep apnoea and chronic asthma noted. Expert evidence raised concerns about the general practitioner's assessment and management of her asthma and respiratory symptoms, including the prescription of Diazepam.

Pamela Margaret Hands aka Horner · Prevention of Future Deaths report View report

18 Dec 2017 Cornwall and Isles of Scilly E. Carlyon

Pamela Margaret Hands, also known as Horner, fell at home and was admitted to hospital with a periprosthetic femur fracture. After receiving opioid analgesia and a local anaesthetic nerve block, she was not adequately observed, was found unresponsive, and died on 1 December 2015. The principal concerns were inadequate monitoring after the block, insufficient recognition of relative opioid toxicity, and the absence of national guidance on post-procedure monitoring and related risks.

Michele Brenda Duckworth · Prevention of Future Deaths report View report

12 Feb 2021 Stoke-on-Trent and North Staffordshire S. Murphy

Michele Brenda Duckworth, who had paraplegia, end stage renal failure and a renal transplant requiring immunosuppression, was admitted with profuse diarrhoea and low blood pressure and later deteriorated with sepsis. She died on 23 February 2020, with the post-mortem finding death due to Escherichia coli bacteraemia of unknown source. The principal concern was that Tazocin was prescribed and continued despite previous ESBL colonisation, contrary to the trust guideline.

Dyllon Shaun Graham Milburn · Prevention of Future Deaths report View report

21 May 2021 Manchester City Z. Golombeck

Dyllon Shaun Graham Milburn died on 8 October 2019 in the garden of his home in Manchester from asphyxiation using a ligature made from a scarf. He had been prescribed Sertraline and had periods of non-compliance. The report raised concern that the repeat-prescription system did not allow automated alerts to remind patients to request and collect their medication.

Michalla Jane SWEETING · Prevention of Future Deaths report View report

21 May 2018 Avon M. Voisin

Michalla Jane Sweeting was a remand prisoner undergoing detoxification who was found unresponsive in her cell at 07.00hrs on 2nd June 2016. The medical cause of death was aspiration of gastric content in association with methadone toxicity. Concerns included inadequate response to reported over-sedation, unsatisfactory handover between shifts, inadequate clinical observations, and failures in communication and assessment.

Michael John Drewell · Prevention of Future Deaths report View report

30 Aug 2018 West Yorkshire Eastern P. Holden

Michael John Drewell fell from his bike while travelling to work on 16 November 2017, sustained a hip fracture, and underwent surgery. He later suffered a cardiac arrest at home and died on 22 December 2017 from a pulmonary thromboembolism, likely a complication of the hip surgery. The concerns were that a Senior Clinician’s advice for six weeks of Tinzaparin was not followed and was not recorded in the electronic notes, resulting in a four-week prescription that ended two days before his death.

Robin Keith Brett · Prevention of Future Deaths report View report

11 Jan 2016 Wiltshire and Swindon C. Balysz

Robin Keith Brett, an 18-year-old man with congenital adrenal hyperplasia, died on 14 June 2014 after being admitted with severe constipation and an addisonian crisis. He did not receive his prescribed steroids, and the concerns identified were that nursing staff failed to notice the missed dose and that prescribing systems lacked an alert for patients taking long-term steroids.

Mr. Alun Walters · Prevention of Future Deaths report View report

9 Jul 2015 Powys, Bridgend and Glamorgan Valleys S. Jane-Richards

Mr. Alun Walters, who was prescribed Warfarin following receipt of a metallic heart valve, died after a gastro-intestinal haemorrhage in circumstances of suspected elevated Warfarin levels and failed INR monitoring. His prescriptions continued despite no INR tests after November 2013, and 51 prescriptions were provided without dosage assessment. Concerns included failures by the medical practice in monitoring, prescription systems and notifying the pharmacy that Warfarin had been withdrawn, while the pharmacy supplied Warfarin without a valid prescription.

Lucy KILVERT · Prevention of Future Deaths report View report

15 Oct 2013 Black Country R. Balmain

Lucy KILVERT was taken to hospital on 14 June 2013 after falling at home on 10 June and subsequently deteriorating; she had hit her head and was taking blood-thinning medication. The principal concern was that she did not initially receive a head CT scan, which was performed about eight hours after hospital presentation and revealed an intracranial bleed; the report also noted possible shortcomings in how the significance of blood-thinning medication was emphasised in the relevant guidelines.

Thomas George Jordan · Prevention of Future Deaths report View report

10 Aug 2016 West Yorkshire Eastern D. Hinchliff

Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac symptoms and was admitted to hospital on 6 August 2015. His condition deteriorated, and he died following cardiac arrest at 1955 hours that day; the inquest recorded natural causes. The concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication when he was discharged from hospital, although the report stated there was no evidence that the drug error materially caused or contributed to his death.

Derek LEE · Prevention of Future Deaths report View report

14 Feb 2017 Brighton and Hove V. Hamilton-Deeley

Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

Songul BOZDAG · Prevention of Future Deaths report View report

26 Jul 2017 Inner North London M. Hassell

Songul Bozdag, who had schizophrenia and other mental health conditions, died after jumping from a tenth-floor window on 9 February 2017. Concerns included missed mandatory reviews, incomplete recording of consultations, failure to record a required care plan approach, an incorrect drug card that left her under-medicated, and the absence of a system safety net to identify these errors.

Theresa Robertson · Prevention of Future Deaths report View report

6 Aug 2020 East London G. Irvine

Theresa Robertson was found deceased outside 90 Greengate Street on the evening of 18 September 2019, after being captured on CCTV in the area two days earlier. The medical cause of death was recorded as Amitriptyline and Zopiclone toxicity and hypothermia. Concerns included missing records of important telephone calls and a consultation, prescriptions exceeding the surgery’s seven-day limit for high-risk patients, and the absence of assurance that other patients’ prescriptions had been audited.

Stephen George Coulson · Prevention of Future Deaths report View report

27 Oct 2017 Manchester City R. Sohail

Stephen George Coulson was discharged from Manchester Royal Infirmary after an increased Fentanyl patch was applied, with no record that the previous patch had been removed and despite confusion and agitation requiring further observation under hospital policy. He was found in cardiac arrest at home in the early hours of 1 January 2016 and died in intensive care later that day. The principal concerns were controlled-drug administration and documentation, failure to escalate the need for observation and review before discharge, and the Trust’s investigation failing to identify lessons.

Natalie Jane Edgington · Prevention of Future Deaths report View report

11 Jan 2021 Manchester North C. McKenna

Natalie Jane Edgington, aged 28, died at her mother’s address on 24 February 2020. She died from the effects of an accumulated dose of methadone, which she was unable to properly eliminate because of impaired liver function. Concerns included prescribing methadone without sufficient information about her liver disease or an up-to-date liver function test, and the absence of evidence that a lower starting dose was considered.

Jennifer Ann Midgley · Prevention of Future Deaths report View report

5 Oct 2017 West Yorkshire Eastern D. Hinchliff

Jennifer Ann Midgley had chronic obstructive pulmonary disease, malnutrition, non-alcoholic fatty liver disease and cirrhosis. After fracturing her left femur and undergoing surgery, she received intravenous paracetamol that was not adjusted for her weight, and this was described as contributing to organ failure and her death. The concerns included unclear drug administration charting distinguishing oral from intravenous paracetamol and the lack of a recorded patient weight for intravenous dosing.

James Forryan · Prevention of Future Deaths report View report

18 Mar 2022 Inner North London E. Buckett

James Forryan died aged 29 after deliberately taking a poisonous quantity of pentobarbital medication at a London hotel. Evidence indicated that he had accessed an internet forum promoting suicide, which provided information about drugs, methods and obtaining medication. The principal concerns were the accessibility of suicide-promoting websites and forums and the apparent lack of sufficient regulation or enforcement action against them.

Urmila Patel · Prevention of Future Deaths report View report

26 Feb 2026 East London G. Irvine

Urmila Patel, aged 78, was admitted to hospital with suspected sepsis and later fell in a ward toilet on 29 June 2025. She subsequently deteriorated and died in hospital on 7 July 2025 after a CT scan identified a significant subdural haematoma. The concerns included inadequate falls-risk assessment, mobility care planning, supervision, assessment for intracranial bleeding, timely CT referral, and review of her warfarin after the fall.