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Peter STOJILJKOVIC · Prevention of Future Deaths report View report

14 Mar 2018 Manchester South A. Mutch

Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.

Terence Douglas Thornton · Prevention of Future Deaths report View report

3 Apr 2019 Plymouth, Torbay and South Devon A. Cox

Terence Douglas Thornton was admitted to hospital after a fall in which he struck his head, while receiving warfarin. A subtle subdural haemorrhage was missed on the initial CT scan; after discharge and administration of enoxaparin, the haemorrhage expanded catastrophically and he died on 19 September 2017. The concerns included radiology staffing shortages and work pressures, with a consequent risk of similar fatalities.

Patricia Anne HOLMES · Prevention of Future Deaths report View report

2 Jul 2015 Central and South East Kent R. Redman

Patricia Anne Holmes was diagnosed with fractured ribs at William Harvey Hospital on 1 February 2015 and, despite information that she was receiving anticoagulation therapy with an INR of 6, no action was taken to reverse its effect. She returned in a state of collapse on 2 February and died two days later; the principal concern was that the treating A&E doctor did not consider the risk of internal bleeding associated with her trauma, rib fractures and anticoagulation therapy.

John Keith Edwards · Prevention of Future Deaths report View report

10 Jan 2018 Staffordshire South M. Jones

John Keith Edwards, aged 64, was admitted to a care home for respite and subsequently suffered falls, seizures, reduced mobility, pressure sores and a rapid decline before dying in a nursing home on 19 December 2016. Concerns included inadequate care-home policies and care, failures to seek medical assistance and recognise deterioration, poor record-keeping, and inappropriate placement for his complex needs.

Mrs Jean James · Prevention of Future Deaths report View report

13 Mar 2014 Sunderland D. Winters

Mrs Jean James was admitted to the Acute Medical Unit on 24 December 2013, where prophylactic Dalteparin was intended but not prescribed. A pharmacy query was not effectively communicated, and the omission was not subject to effective review. Mrs James died on 8 January 2014; the post-mortem identified bilateral pulmonary thromboembolism due to deep venous thrombosis, and the inquest concluded: “Natural Causes Contributed to by Neglect”.

Patricia Ann Cleghorn · Prevention of Future Deaths report View report

25 Jul 2016 Birmingham and Solihull L. Hunt

Patricia Ann Cleghorn, who had suicidal ideation and was awaiting an inpatient mental health bed, was found collapsed at home after receiving diazepam and was declared dead by paramedics on 14 December 2015. The concerns were the lack of an available inpatient bed, allowing her to self-medicate with potentially dangerous drugs despite repeated statements that she intended to overdose, and the absence of a formal risk assessment.

Catherine Mary McNamara · Prevention of Future Deaths report View report

13 Dec 2019 Manchester South A. Mutch

Catherine Mary McNamara was found dead at home on 11 May 2019, having probably died in the early hours of 9 May 2019. She had been prescribed high levels of opiates over a number of years, and the inquest heard that prescribed opiate toxicity, in combination with over-the-counter medication, contributed to her death; efforts to reduce the dosage had been challenging.

Jessica de Souza · Prevention of Future Deaths report View report

16 Jul 2024 Surrey C. Topping

Jessica de Souza, who had bipolar disorder, developed depression after a family bereavement and took her own life by hanging at home on 1 February 2023. Concerns included that aripiprazole was prescribed as monotherapy for both polarities of bipolar disorder, although expert evidence stated it was not effective prophylaxis against depressive relapse. The expert also considered that the guidance relied on by clinicians may have been misleading.

Alan Vaughan Jones · Prevention of Future Deaths report View report

18 Feb 2015 Swansea and Neath Port Talbot P. Bennett

Alan Vaughan Jones had Addison’s disease and became unable to take his steroid medication after developing gastroenteritis. His condition deteriorated, and he died at 08.50 hours on 8 April 2011; the inquest concluded that Addison’s Disease resulted from neglect. Concerns included inadequate training in the use of electronic patient-record software and failures of the software to highlight important diagnosed conditions as alerts.

Clive Miles · Prevention of Future Deaths report View report

16 Dec 2019 Manchester South A. Mutch

Clive Miles was found dead at his home on 31 May 2019. Toxicology found toxic amounts of morphine, codeine and sertraline, and the pathologist concluded that the combination caused his death. The principal concern was that his prescriptions had been changed from weekly to monthly despite limited evidence of assessment of the risk, leaving him with a significantly increased quantity of medication.

Elvon Paul Randolph Morton · Prevention of Future Deaths report View report

13 May 2024 East London G. Irvine

Elvon Paul Randolph Morton, a 38-year-old man with extensive co-morbidity, was admitted to hospital on 6 December 2022 with abdominal pain, vomiting, diarrhoea, dizziness and shortness of breath. He deteriorated and went into cardiac arrest while awaiting a CT scan under sedation; the inquest concluded that his death was caused by the combined effects of septic shock, oxycodone and lorazepam. Concerns included poor documentation of critical decisions, a flawed decision to sedate him, failures to manage workload pressures safely, and inadequate Trust processes for identifying and reviewing serious incidents.

Lee Mark Anthony Bates · Prevention of Future Deaths report View report

17 Sep 2015 Inner South London A. Harris

Lee Mark Anthony Bates died at 01.18 on 24 February 2014 in Cambian Churchill London Clinic after ingesting a potentially fatal overdose of Zopiclone in conjunction with benzodiazepines while under one-to-one eyesight observation. The principal concerns were inadequate staff training in one-to-one observation and insufficient coordination between psychiatric and sleep-apnoea specialists about CPAP use, sedative medication risks, and monitoring of patients with severe obstructive sleep apnoea.

Matthew John Evans · Prevention of Future Deaths report View report

18 May 2022 Surrey K. Henderson

Matthew John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.

Alphonso Alexander Shearer · Prevention of Future Deaths report View report

28 Apr 2022 Manchester South A. Mutch

Alphonso Alexander Shearer, who had oesophageal cancer and poor swallowing, was discharged with a catheter after treatment for acute urinary retention. He developed symptoms consistent with a urinary tract infection, was prescribed antibiotics he could not swallow, and later collapsed and died while being transferred to an ambulance; post-mortem examination confirmed urosepsis. Concerns included the lack of a system to identify the need for liquid antibiotics, difficulties with the ASK MY GP communication system, and the absence of a face-to-face GP assessment before his deterioration was recognised.

Audrey Margaret Lambert · Prevention of Future Deaths report View report

5 Nov 2024 Manchester South A. Mutch

Audrey Margaret Lambert suffered an accidental fall at home on 25 March 2024, fractured her right proximal femur, underwent surgery and subsequently had significantly reduced mobility while receiving care at Brinnington Hall. She was found unresponsive on 28 May 2024 and died from pulmonary thromboembolism due to deep vein thrombosis. The concern was that there was no national guidance to help primary care clinicians assess whether anticoagulation should be prolonged for elderly, immobile patients after the standard post-operative course.

KIMBERLY ANNA LIU · Prevention of Future Deaths report View report

21 Dec 2023 Inner North London I. Potter

Kimberly Anna Liu, who had become addicted to sedative and other medications, was found unresponsive at home on 7 February 2023 and was pronounced dead. The inquest concluded that this was a drug-related death caused by mixed drug toxicity. The principal concern was that unregulated websites supplied prescription-only sedative medications without prescriptions or adequate checks, potentially exploiting vulnerable people with medication addictions and providing means for suicide or self-harm.

Caroline Victoria Forte · Prevention of Future Deaths report View report

27 Apr 2023 West Sussex, Brighton and Hove P. Schofield

Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS services.

Frank Raymond STOCKTON · Prevention of Future Deaths report View report

27 Jun 2019 Blackpool and the Fylde T. Holloway

Frank Raymond Stockton was admitted to hospital with shortness of breath and collapse, later experienced recurrent nosebleeds while receiving oxygen therapy and Warfarin, and died on 22 July 2018 after developing melena and haematemesis. The principal concern was that the risks of epistaxis causing or contributing to death, particularly in patients receiving oxygen therapy or Warfarin or with impaired lung or heart function, may not be generally recognised by clinicians, and that maintaining the INR within its target range may not prevent this risk.

Urielle Mayila Kuyenga · Prevention of Future Deaths report View report

9 Dec 2025 East London G. Irvine

Urielle Mayila Kuyenga, a four-year-old girl with sickle-cell disease, died in hospital on 4 December 2023 from sepsis resulting from bacterial pneumonia. The report identifies failures to ensure administration of prescribed prophylactic penicillin and failures by doctors to identify her sickle-cell diagnosis during three presentations for respiratory infection as contributory factors.

Catriona Ellen Martin · Prevention of Future Deaths report View report

4 Dec 2023 Gwent C. Saunders

Catriona Ellen Martin was admitted to hospital with autoimmune encephalitis and died on 25 December 2020 after developing dehydration, acute kidney injury and uncontrolled seizures. The report identified inadequate nursing care, including failures to observe her and administer medication, and noted concerns about reliance on her mother to provide care without clear guidance on delegation and nursing staff support.