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Kore Elizabeth Padgett · Prevention of Future Deaths report View report

28 Aug 2025 West Yorkshire (Western) C. Keighley

Kore Elizabeth Padgett was admitted to hospital after an accidental fall down the stairs, sustaining an unstable neck fracture requiring immobilisation in a hard collar. The collar affected her swallowing, contributed to pressure sores, and limited chest physiotherapy; she later developed recurrent aspiration pneumonia and died on 23 October 2024. The concerns included inadequate staff training in fitting the collar, insufficient communication and multidisciplinary consideration of treatment options, and a lack of opportunity for Kore to make an informed decision about the risks and benefits of continued collar use.

Anne Lorraine Dyson · Prevention of Future Deaths report View report

26 Aug 2025 Sunderland D. Place

Anne Lorraine Dyson died at St Benedict's hospice on 24 February 2025 after metastatic lung cancer was diagnosed in November 2024, following investigation for lung disease since September 2021. An incorrect interpretation of a CT scan in March 2024 significantly delayed diagnosis, by which time the cancer had progressed to a terminal stage. Concerns included inconsistent and limited clinical information provided to radiologists, potentially leading to restricted scan interpretation and delayed diagnosis and treatment.

Gabriella Omolabake Torisheju JAYIESIMI · Prevention of Future Deaths report View report

26 Aug 2025 Inner North London M. Hassell

Gabriella Omolabake Torisheju Jayiesimi suffered seizures and a cardiac arrest at a Tesco supermarket on 24 January 2025 and died a month later from the hypoxic brain injury sustained during the arrest. The concerns included the absence of effective first aid and CPR, failure to recognise that she had stopped breathing, failure to check her pulse or use a defibrillator, and inadequate first-aid training and preparedness among relevant Tesco and security staff.

Lee James STAMMERS · Prevention of Future Deaths report View report

22 Aug 2025 South Yorkshire (Eastern) L. Slater

Lee Stammers attended Doncaster Royal Infirmary on 10 February 2025 with chest pain, shortness of breath and nausea, suffered a cardiorespiratory arrest later that day, and was pronounced deceased at 20:00 hours. The report identified missed opportunities to detect myocardial ischaemia, including incomplete or unreported electrocardiography and blood tests not being performed. Concerns also included poor documentation, communication and systems for tracking investigations, and the ability of unidentified staff to cancel tests without rationale or accountability.

Nicholas Paul MURPHY · Prevention of Future Deaths report View report

21 Aug 2025 Hampshire, Portsmouth and Southampton R. Simpson

Nicholas Paul MURPHY reported taking an overdose on 29 December 2023, declined further assessment and hospital transfer, and was later found deceased at home on 9 January 2024 after a further welfare concern. The principal concerns were that ambulance outcome codes did not record refusal of treatment or transfer, and that recording the outcome as “Advice only” or “advice given” could mislead staff and result in critical safeguarding information being missed.

Charles Andrew STONLEY · Prevention of Future Deaths report View report

20 Aug 2025 Liverpool and the Wirral A. Bhardwaj

Charles Andrew Stonley, who had severe depression with psychotic features, attended hospital with suicidal ideations and psychotic and paranoid symptoms while awaiting a mental health bed. After repeatedly leaving the Emergency Department, he was found deceased hanging in a wooded area. The report raises concerns about limited legal powers and resources for managing mental health patients in Emergency Departments and shortages of mental health beds, which can leave vulnerable patients at increased risk of self-harm and death.

Masood Hamid · Prevention of Future Deaths report View report

20 Aug 2025 Manchester North J. Kearsley

Masood Hamid, who had dementia and multiple physical health conditions, died on 24 December 2024 shortly after being transferred under restraint from Shawside Care Home to hospital. The report identified concerns about inadequate planning for the transfer, ineffective communication between GMP and NWAS that delayed assistance, and an ineffective investigation into his death.

Mary Anne FITZPATRICK · Prevention of Future Deaths report View report

20 Aug 2025 Inner North London M. Hassell

Mary Anne Fitzpatrick was discharged from hospital on 29 January 2025 and received district nursing care. A sacral pressure sore progressed from category 2 to category 4, leading to readmission on 27 February, deconditioning and her death. Concerns included the frequency and adequacy of wound dressing visits, the development and treatment of the pressure sore, and insufficient reflection by the district nursing team after her death.

Ricky O'Connell · Prevention of Future Deaths report View report

20 Aug 2025 Manchester South A. Mutch

Ricky O'Connell's overnight symptoms deteriorated and his partner called an ambulance, but it had not arrived by the time he collapsed. He was treated by his family and ambulance staff, transported to hospital, and died there on 27 January 2025. The principal concerns were significant ambulance delays, including delays caused by prolonged hospital handovers, high demand, and limited vehicle availability, with evidence that an ambulance should have arrived before he collapsed.

Gemma May Weeks · Prevention of Future Deaths report View report

19 Aug 2025 Dorset B. Allen

Gemma May Weeks, a long-term ketamine user, was found deceased on 26 January 2025 after consuming high levels of ketamine and another substance; the combined effects caused her death. The report raises concerns that the acute and chronic risks of ketamine, including addiction and severe bladder damage, are not well understood by the public, potential first-time users, and groups at greatest risk of starting to use it.

Venetia Clarissa Pierce · Prevention of Future Deaths report View report

19 Aug 2025 Surrey S. Ridge

Venetia Clarissa Pierce, described as an elderly frail lady with recurrent urinary infections, was prescribed nitrofurantoin prophylactically in February 2024 and died in hospital on 30 December 2024. The inquest recorded nitrofurantoin-induced pneumonitis as the medical cause of death, with frailty contributing. Concerns included the absence of an MHRA safety alert on the surgery’s EMIS system and limited awareness among clinicians of the potential for pulmonary damage and respiratory failure from nitrofurantoin in elderly patients.

Emily · Prevention of Future Deaths report View report

18 Aug 2025 Nottinghamshire E. Didcock

Emily died at Bassetlaw DGH on 6 May 2024 after developing unrecognised dehydration, acute kidney injury, ileus and sub-acute small bowel obstruction following bowel surgery for Crohn’s disease. She experienced vomiting, aspiration pneumonitis and cardiac arrest, with the report identifying concerns about inadequate hydration assessment, fluid-balance recording, recognition of deterioration, clinical assessment and escalation, and response to family concerns. The report also raises concerns about clinical assessment in the Emergency Department before mental health referral or discharge home.

Margaret Taylor · Prevention of Future Deaths report View report

12 Aug 2025 Gloucestershire R. Ollivere

Margaret Taylor, who had dementia, dysphagia and a severe risk of choking, died after choking on chicken brought to her care home on 8 November 2024. Concerns included her removal from a soft-food diet without a documented rationale or further SALT assessment, and staff not checking food brought in by her husband for suitability in accordance with the home's policy.

Chloe Louise Barber · Prevention of Future Deaths report View report

12 Aug 2025 East Riding and Hull P. Marks

Chloe Louise Barber, who had a history of self-harm and multiple overdoses and had been detained under the Mental Health Act, was found at home on 3 November 2021 and was confirmed dead at 17:05. The report identified concerns about transition pathways between CAMHS and adult psychiatric services, guidance on administering depot antipsychotic preparations, and understanding of section 117 aftercare responsibilities.

Resmije Ahmetaj · Prevention of Future Deaths report View report

12 Aug 2025 Essex S. Hayes

Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.

Robert Tom Duke SIMPSON · Prevention of Future Deaths report View report

12 Aug 2025 Birmingham and Solihull A. Samuel

Robert Tom Duke SIMPSON underwent a hemicolectomy for colonic cancer on 4 June 2024, developed hospital-acquired pneumonia and an anastomotic leak, and was discharged home on 28 June while awaiting drainage. He deteriorated after discharge, was admitted as an emergency on 1 July, and died on 9 July 2024 after further treatment and two peri-arrests. Concerns included the provision of medication that did not belong to him, missed antibiotic doses because the drug was out of stock, and a lack of evidence about how these medication failures occurred or were managed.

James William Rownsley · Prevention of Future Deaths report View report

12 Aug 2025 South Yorkshire (Eastern) N. Mundy

James William Rownsley died at home on 20 February 2025 after his clothing caught fire when he was sitting close to a gas fire. Emollient cream on his clothing was identified as a significant factor, contributing to the intensity and rapid development of the fire. The principal concerns were inadequate awareness and communication among professionals and the public about the ignition risks of emollient creams, and weaknesses in reporting deaths involving such creams.

Charlotte NOORDAM · Prevention of Future Deaths report View report

12 Aug 2025 Birmingham and Solihull A. Samuel

Charlotte NOORDAM died on 8 March 2025 after her motorbike collided with a car at the junction of Frederick Road and St James Road in Edgbaston. The report raises concerns about the junction's safety, noting at least 27 other road traffic incidents there and an ongoing risk to life despite existing signage and road markings.

Paul Pidgeon · Prevention of Future Deaths report View report

11 Aug 2025 Surrey A. Crawford

Paul Pidgeon was found deceased at home on 20 March 2022 after deliberately overdosing on paracetamol the previous day. His death was caused by paracetamol toxicity, with coronary artery disease and hepatic steatosis contributing. The Coroner was concerned that Booker in Wimbledon, and potentially Booker more widely, may have sold bulk quantities of medicinal products to customers not authorised or entitled to supply them to the public, creating a risk of future deaths.

QUY THI PHAM · Prevention of Future Deaths report View report

11 Aug 2025 Essex S. Hayes

Quy Thi Pham died at Basildon Hospital on 3 September 2024 after an extremely rare and rapidly progressing early-stage cervical cancer caused metastatic pulmonary hypertension and irreversible cardiac arrest. She had been advised to wait until 12 weeks post-partum for cervical screening, and a later appointment was cancelled because of staff shortages and not rebooked. Concerns were raised about the application of national cervical screening guidance to post-partum women and whether it may exclude some women from timely diagnosis.