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Brian Ingram · Prevention of Future Deaths report View report

10 Aug 2025 Cornwall and Isles of Scilly A. Cox

Brian Ingram, an 85-year-old man with dementia and vascular Parkinsonism, fell and was taken to a minor injuries unit after a delay. His hip fracture was not identified there, and he was discharged before later admission to hospital, where he underwent surgery and died. Concerns included the lack of a physical assessment, failure to identify groin pain and obtain a hip x-ray, assumptions about the ambulance staff’s clinical role, exclusion of his family member, and information-sharing between organisations.

Jessica Lynda Smithson · Prevention of Future Deaths report View report

8 Aug 2025 Manchester North J. Kearsley

Jessica Lynda Smithson, aged 27, died by suicide after contacting a crisis text mental health service following an alleged serious sexual assault. The service did not contact the Metropolitan Police despite messages indicating an immediate risk to her life. The report identified concerns about inconsistent procedures among charity crisis text services and the absence of a commissioned crisis text mental health service in Greater Manchester.

Gareth Ian JACKSON · Prevention of Future Deaths report View report

8 Aug 2025 Inner West London P. Rogers

Gareth Ian JACKSON, who was at high risk of suicide and a voluntary patient in an acute psychiatric ward, was permitted unescorted leave despite a plan requiring escorted leave. He left the hospital and was struck by a train, dying from multiple traumatic injuries on 22 June 2022. The principal concerns were failures to communicate, document and follow his leave-safety plan, inadequate risk assessment, unaligned policies, and insufficient controls over access to the route out of the hospital.

Kenneth Edwards · Prevention of Future Deaths report View report

7 Aug 2025 Manchester South B. Myers

Kenneth Edwards fell twice on 22 and 23 March 2025 and died on 23 March 2025 following traumatic subdural and subarachnoid haemorrhages. The principal concerns were that a subdural haematoma was missed on the first CT scan and that blood-thinning medication was administered while awaiting the results of a second CT scan to identify brain bleeding.

Victor Jackson HUTCHENS · Prevention of Future Deaths report View report

7 Aug 2025 County Durham and Darlington R. Sutton

Victor Jackson HUTCHENS died at Darlington Memorial Hospital on 27 February 2025 as a result of an accidental fall causing a head injury. A week before his death, care rounds were mistakenly reduced from hourly to four-hourly, raising concern that the error could recur and cause or contribute to a future death, although the inquest found it could not be said on a balance of probabilities that the error contributed to his death.

Marion Jones · Prevention of Future Deaths report View report

7 Aug 2025 Manchester South B. Myers

Marion Jones, who had stage 4 lung cancer and required assistance with movement, fell from an unrailed bed at Riverside care home on 23 March 2025, sustaining a head injury. The principal concerns were that no bed-rail assessment was recorded or carried out despite family concerns, and that nursing staff lacked a clear understanding of the required assessment process and timing.

Jacob Matthew WOODERSON · Prevention of Future Deaths report View report

6 Aug 2025 Inner North London S. Bourke

Jacob Wooderson, who was being treated with Elvanse for ADHD, increased his dosage to 70 mg in August 2024 and subsequently experienced poor sleep and exhaustion before collapsing and dying at home on 23 August 2024. The inquest recorded sudden arrhythmic death syndrome, with Elvanse treatment for ADHD as a contributing factor, although the precise cause of the arrhythmia could not be established. Concerns included inadequate monitoring and documentation of heart rate, blood pressure and medication advice, particularly following dosage increases and during remote consultations.

Stephen LAWRENCE · Prevention of Future Deaths report View report

6 Aug 2025 Surrey A. Crawford

Stephen Lawrence, a resident at Eastcroft Nursing Home, sustained an unwitnessed fall on 21 December 2022 and multiple rib fractures, which led to a haemopneumothorax and pneumonia. He died in hospital on 5 January 2023; concerns included unexplained injuries, deficient nursing home records, delayed medical advice, and conflicting evidence from the nursing home manager, with an ongoing risk to current residents.

Daisy May McCoy · Prevention of Future Deaths report View report

5 Aug 2025 Devon, Plymouth and Torbay D. Stewart

Daisy May McCoy was born by Caesarean section on 9 February 2022 after reduced and unusual foetal movement was reported, and died in a children’s hospice on 22 February 2022 following a brain injury and peri-natal asphyxia. The report identified concerns about recognising foetal compromise, communication and escalation between staff, staffing and consultant attendance, professional challenge, and the adequacy and implementation of relevant policies and training.

Mohsin Janjua · Prevention of Future Deaths report View report

5 Aug 2025 West Yorkshire (Western) M. Fleming

Mohsin Janjua died on 02/12/2023 after a fire at his home, caused by the catastrophic failure of an ion-lithium battery charging an e-bike. The report raises concerns about the unregulated online sale of lithium-ion batteries, the responsibility of online marketplaces for product safety and legal compliance, and public awareness of the risks of e-bike batteries in domestic properties.

Maureen Brenda Batchelor · Prevention of Future Deaths report View report

5 Aug 2025 West Sussex, Brighton and Hove J. Andrews

Maureen Brenda Batchelor was admitted to hospital with diarrhoea and vomiting, was diagnosed with gastroenteritis and aspiration pneumonia, and died on 26 February 2025 from septicaemia caused by aspiration pneumonia. The report raised concerns that patients were being treated in the Emergency Department corridor, a non-clinical area, because of insufficient capacity, with this practice continuing and no evidence as to when it would end.

Simon Anthony Moore · Prevention of Future Deaths report View report

5 Aug 2025 Dorset R. Middleton

Simon Anthony Moore, a train driver, died after stepping in front of a moving train on 4 November 2024, following an incident that he knew could lead to the loss of his train driver licence and further assessment. Evidence at the inquest raised concerns that the attending Driver Manager was unaware of an earlier recorded conversation in which Mr Moore expressed concern about losing his job and sounded distressed, and that there was no means for the signaller to relay this information to the train company Control or Driver Manager.

Tracey Ostler · Prevention of Future Deaths report View report

4 Aug 2025 Surrey C. Topping

Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.

John Bell · Prevention of Future Deaths report View report

4 Aug 2025 South Yorkshire (Eastern) S. Tait

John Bell died at St John's Hospice Doncaster on 10 February 2025 after right upper lobe pneumonia contributed to by an infected spinal surgery wound, ischaemic heart disease and localised left renal carcinoma. The report raises concerns that critical renal tumour information was not available to or considered by the spinal surgeons before surgery, and that the incident was not formally investigated or subject to organisational learning for about eight months.

Margaret Dorothy MEDLICOTT · Prevention of Future Deaths report View report

1 Aug 2025 Worcestershire D. Reid

Margaret Dorothy Medlicott, who lived with dementia, sustained a severe head injury after being deliberately pushed by another resident at Haresbrook Park Care Home on 23 April 2020. She died in hospital from complications of that injury on 3 May 2020. Concerns included the admission of residents despite agreed restrictions, failures to complete proper risk assessments and care plans, and whether staff were trained and supported to question unsafe decisions.

Benjamin Thomas Dinan BUCKFIELD · Prevention of Future Deaths report View report

1 Aug 2025 Hampshire, Portsmouth and Southampton N. Walker

Benjamin Thomas Dinan Buckfield died in hospital on 11 August 2024 after collapsing at the Boomtown music festival, where he had purchased and consumed MDMA. The report raises concerns about the open availability and sale of illegal drugs at the festival and about policies allowing some people found with drugs to remain on site, creating a risk of future deaths.

Margaret Ann MCNAUGHTON · Prevention of Future Deaths report View report

1 Aug 2025 Black Country J. Lees

Margaret Ann MCNAUGHTON was admitted to hospital with breathing difficulties and a respiratory infection, with a known penicillin allergy recorded in available clinical records. She was prescribed and given intravenous co-amoxiclav before being seen by a clinician, suffered cardiac arrest from penicillin anaphylaxis, and died in hospital on 13 December 2024 after deteriorating with respiratory failure. The principal concerns were failures to check and document her allergy status before prescribing, and the absence of sufficiently clear and embedded Trust processes and policies for carrying out and recording such checks, with further medication allergy incidents reported.

Suzanne EDWARDS · Prevention of Future Deaths report View report

1 Aug 2025 Milton Keynes T. Osborne

Suzanne EDWARDS became unwell on 29 November 2024, was assessed by her GP and at Milton Keynes Hospital, admitted to Bedford Hospital for surgery to insert a kidney stent, and died there of sepsis on 1 December 2024. The principal concern was that emergency departments lacked reliable access to patients’ primary care records, and the inquest identified a failure to recognise signs of urinary tract obstruction, resulting in a lost opportunity to treat the condition before sepsis developed.

Sidi Chax Bojang · Prevention of Future Deaths report View report

1 Aug 2025 North London A. Walker

On 19 July 2024, Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train. He had recently attended hospital after reporting self-harm and experiencing a “wooshing” sound and flashes of light, and had called an ambulance on the morning of his death after cutting himself. The concerns included that possible serious mental illness and hallucinations were not recognised, that a psychiatrist did not review him before discharge, and that discharge was left to a senior psychiatric nurse.

Brian Thomas RINGROSE · Prevention of Future Deaths report View report

1 Aug 2025 Milton Keynes S. Cummings

Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.