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Louise Helen Jones · Prevention of Future Deaths report View report

12 Jun 2024 Cornwall and Isles of Scilly G. Davies

Louise Helen Jones was found deceased at home on 1 October 2023. The inquest recorded respiratory depression and opiate drug use, following an unintentional overdose involving morphine and bromazalam alongside other central nervous system depressant drugs. Concerns included the absence of an agreed opioid treatment and end-of-treatment plan, practice policies for long-term opioid prescribing and opioid–benzodiazepine co-prescribing, and warning flags after three months of morphine prescription.

Peter Carr · Prevention of Future Deaths report View report

13 Oct 2023 North London P. Straker

Peter Carr developed a severe rash and was admitted to North Middlesex Hospital, where he was later found to have a drug reaction consistent with Stevens-Johnson Syndrome. The principal concern was that patients with acute, severe skin conditions may not receive consultant dermatology input, timely biopsy, and ongoing dermatological oversight during an inpatient stay.

Michelle Whitehead · Prevention of Future Deaths report View report

19 Jan 2022 Nottinghamshire E. Didcock

Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

Barry HARMER · Prevention of Future Deaths report View report

12 Feb 2026 Buckinghamshire C. Butler

Barry Harmer was found deceased at home on 11 April 2024 after sustaining a neck injury he had likely inflicted upon himself. He had been known to community mental health services, had agreed to voluntary psychiatric admission, and was awaiting a bed while remaining at home. Concerns included inadequate pursuit and communication regarding bed availability and home safety responsibilities, the absence of an earlier face-to-face psychiatric review, and shortcomings in the robustness and timely review of the investigation and learning process.

Joan Osborne · Prevention of Future Deaths report View report

26 Mar 2018 Nottinghamshire J. Gillespie

Joan Osborne, who had diabetes and advanced dementia, died on 25 August 2017 after repeated difficulties obtaining her blood glucose levels and administering her insulin. The concerns included failures by nursing home staff to seek medical assistance or escalate her missed insulin, inadequate records, failure to recognise her deteriorating condition, and inaccurate blood glucose measurement and treatment on 22 August 2017.

Dr Donald Clegg · Prevention of Future Deaths report View report

8 Aug 2018 Manchester North L. Hashmi

Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.

Christiana Betty Dawson · Prevention of Future Deaths report View report

16 Oct 2024 South Yorkshire (Western) T. Rawden

Christiana Betty Dawson, known as Betty, was a resident at Darnell Grange who experienced at least ten falls and died in hospital on 19 March 2024 after surgery for a fractured neck of femur and with frailty. The concerns included the management of her falls risk, her return to residential care despite acknowledged difficulties managing that risk, and agency staff not being provided with home-specific training, policies or procedures about moving residents after a fall.

Pauline Russell · Prevention of Future Deaths report View report

4 Aug 2020 Norfolk Y. Blake

Pauline Russell, a poorly controlled diabetic, was discharged from hospital after her insulin dose was increased, but she and her husband could not read the written discharge instructions. She subsequently received a higher incorrect insulin dose, became unresponsive in a hypoglycaemic coma, and died from aspiration pneumonia. The principal concern was that the hospital did not check patients’ literacy or provide discharge instructions in an accessible alternative format.

Sean Robert Steven Owen · Prevention of Future Deaths report View report

23 Oct 2020 Manchester North C. McKenna

Sean Robert Steven Owen had a history of treatment-resistant paranoid schizophrenia and was recognised as being at significant risk if non-compliant with medication. After medication monitoring arrangements broke down, he self-inflicted a penetrating neck injury on 3 June 2019 and died on 14 June 2019 from his injuries and a chest infection. The report raised concerns that his discharge letter omitted significant information about overdoses, suicidal thoughts and the risks associated with medication non-compliance, and that there was no quality assurance system for such letters.

Ian Allen · Prevention of Future Deaths report View report

17 Aug 2020 Birmingham and Solihull L. Hunt

Ian Allen collapsed suddenly at the nursing home where he resided on 31 December 2019 and died soon after arriving at hospital. The medical cause of death was clozapine toxicity. Concerns included a high clozapine blood level not being acted upon, inadequate monitoring and dose adjustment after smoking cessation, and the absence of a system to escalate blood test results to the consultant.

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 and other medical problems and died in hospital after suffering cardiac arrest on 6 August 2015. Concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication between the hospital and prison, although the report stated there was no evidence that the drug error materially caused or contributed to his death.

Lee Derek Jamie ADAMS · Prevention of Future Deaths report View report

20 Mar 2025 Inner South London J. Morris

Lee Derek Jamie Adams died after taking an excessive number of propranolol tablets on 24 July 2020, following extensive online gambling and in the context of depressive illness. The substantive concerns included the rapid absorption and high toxicity of propranolol, the lack of a specific antidote, and the need for GPs to consider patients’ gambling habits and the risks of excess propranolol ingestion.

Nigel Walter DIXON · Prevention of Future Deaths report View report

4 Jun 2024 Rutland and North Leicestershire I. Thistlethwaite

Nigel Walter Dixon, a 64-year-old man who lived alone, was found dead at home on 13 February 2023 after being unable to be roused. His cause of death was morphine and Zopiclone toxicity. Concerns included his access to morphine after hospital discharge and the online supply of large quantities and dosages of Zopiclone without adequate checks, communication with his GP, or safeguards.

Jake Robinson · Prevention of Future Deaths report View report

9 Dec 2015 Manchester South J. Kearsley

Jake Robinson died at home on 23 August 2015 after taking his own life; the recorded cause of death was hanging and illicit drug use. Concerns included failures to share information about prescribing diazepam, the failure to identify this issue in the review of his death, fragmented substance-misuse services, and the unexplained rearrangement of a Community Mental Health Team appointment shortly before his death.

Lesley Julie BRASS · Prevention of Future Deaths report View report

27 May 2020 Avon R. Sowersby

Lesley Julie BRASS fell at home, sustained a head injury, and was admitted to hospital after her wound became infected. While an inpatient, she developed severe hyperkalaemia but did not receive the required emergency treatment within the specified timeframe, and she suffered a fatal cardiac arrest. The report raises concerns about failures to recognise, escalate and treat the condition, and about the Plastic Surgery department’s subsequent investigation, openness and willingness to acknowledge mistakes.

George Edward James Haldenby · Prevention of Future Deaths report View report

21 May 2026 Dorset Rachael Griffin

George Edward James Haldenby was a serving prisoner with severe heart failure who collapsed at HMP The Verne on 29 January 2022 and died that day at Dorset County Hospital. The report identifies delays in receiving an increased dose of Furosemide, and a delay in recognising the collapse and starting CPR, as substantive concerns. It also raises concerns about the absence of regular refresher training in first aid and CPR and the lack of a clear process for handling hospital prescriptions issued outside prison healthcare hours.

Tung Thanh Tran · Prevention of Future Deaths report View report

11 May 2026 Inner North London R. Brittain

Tung Thanh Tran, who had a renal transplant and chronic hepatitis B, died after Entecavir was inadvertently discontinued following a change to home medication delivery. He developed acute liver disease from hepatitis B reactivation, was too unwell for a liver transplant, and died on 12 September 2025. Concerns included a lack of national guidance on responsibility for monitoring and prescribing hepatitis B reactivation prevention, and insufficient specialised commissioning to maintain engagement with some patients diagnosed through Emergency Department screening.

Mr Maurice Macdonnell · Prevention of Future Deaths report View report

14 Jun 2017 Inner South London A. Harris

Mr Maurice Macdonnell had advanced liver cancer and participated in a clinical trial of Nivolumab. After developing ptosis and fatigue, he received a second dose before the cause of the ptosis had been diagnosed, later becoming progressively weaker and dying after cardiac arrest; the inquest recorded myocarditis and myositis associated with an immune-related adverse reaction. The principal concern was a potential conflict of interest where the doctor deciding whether to administer the treatment was also the research investigator.

Kalma RAM-HENMAN · Prevention of Future Deaths report View report

23 Oct 2018 Brighton and Hove V. Hamilton-Deeley

Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned treatment.

Mary Catherine Bloom · Prevention of Future Deaths report View report

30 Oct 2015 East London N. Persaud

Mary Catherine Bloom, who had dementia and reduced oral intake, was admitted with probable left-leg ischaemia and died in hospital on 4 February 2014. Concerns included failures to record her weight, consult haematology, obtain baseline and follow-up blood tests, and make the heparin administration guidance sufficiently visible. There was also no discussion with her next of kin before a DNAR order was placed.