6,433 reports
Information drawn from published reports and official responses.
Keith John Murphy became physically ill in prison after using SPICE and was later found on his cell floor, where he was pronounced dead on 18 July 2013. The report raises concerns about basic first aid, CPR and defibrillator training for prison staff, and the availability of Healthcare staff outside the hours of 7am to 6.30pm.
HM Prison and Probation ServiceNHS England
Bryan Herbert Whitby had chronic kidney disease and underwent a CT scan while his renal function was deteriorating and he was taking metformin. After the scan, further deterioration was identified, but there were delays and failures in escalating the results, arranging urgent admission, recognising his serious condition, providing treatment, and transferring him to the High Dependency Unit; he died shortly after admission there. The principal concerns included communication and escalation failures, inadequate recognition and treatment of acute illness, and delayed critical-care transfer.
Davyhulme Medical CentreManchester University NHS Foundation Trust
Michael Barry Richardson was admitted to hospital on 24 October 2013 after deterioration in his lung disease and died on 27 October 2013 following an arrest. An ambulance report recorded that he had not eaten for five days, but this information may not have been reviewed during his MUST screening. The concern was that failure to review ambulance and other admission records could lead to missed information and pose a risk of future deaths.
James Paget University Hospitals NHS Foundation Trust
Stuart Megginson BAUMBER died by hanging in his cell at HMP Peterborough between 22:30 on 14 November 2013 and 04:10 on 15 November 2013, after being remanded in custody for arson. The jury found that occasions existed when the ACCT process should have been initiated and that inadequate understanding and training contributed to this not happening. The report also raised concerns about ligature points on cell doors, healthcare screening that did not mention section 136 detentions, and items available to prisoners that could facilitate suicide.
HM Prison and Probation ServiceSodexo
Robert Spring, who had chronic obstructive pulmonary disease and used home oxygen while smoking, died in a fire at his home on 14 March 2014. The fire was attributed to either a cigarette lighter or a dropped cigarette. The principal concerns were that relevant agencies were not fully informed of his smoking-related risk, so he was not assessed for available fire-safety equipment, and that more extensive communication between agencies was needed.
Air Liquide Healthcare LimitedLincolnshire County CouncilNHS Lincolnshire Integrated Care BoardUnited Lincolnshire Teaching Hospitals NHS Trust
Pamela Pattison was admitted to hospital after falling at home and fracturing her hip. Her insulin was intentionally omitted following a mistaken assessment, and concerns were raised about sub-optimal diabetic care, inadequate staff training and escalation, insufficient specialist diabetes support, equipment and resourcing problems, and delay in transferring her to an appropriate ward. The medical cause of death was recorded as aspiration pneumonia following nausea and vomiting consequent upon unstable diabetic control, with brittle diabetes and a fractured neck of femur also recorded.
Stockport NHS Foundation Trust
Elliott Bignall, aged 17, died from multiple injuries after being hit by a train at Langsmead Foot Crossing in Ferring, West Sussex, on 9 September 2014; the death was recorded as accidental. Concerns included poor lighting and inadequate warning signage at the crossing, and the risk that people using headphones or phones might not hear or see an approaching high-speed train.
Network Rail
Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.
South Yorkshire Police
Joseph Allison died after the upper trunnion assembly of his Minivator 2000 stairlift failed, throwing him down the stairs and causing cervical vertebrae and head injuries. He subsequently died from bronchopneumonia. Concerns included inadequate training and equipment for service engineers, the absence of a nationally publicised safety recall, and insufficient communication to the stairlift industry about the risks of unimproved stairlifts.
British Healthcare Trades AssociationSavaria Lifts (UK) Ltd
Barbara Mary Anne Mayer had a history of depression and was found drowned in a nearby pond on 16 November 2014 after leaving her house during the early hours. Concerns included carer fatigue not being followed up, lack of continuity in her care, treatments not being adequately discussed with her, and no urgent mental health assessment being available when she needed help on 14 November 2014.
Norfolk and Suffolk NHS Foundation Trust
James Bateley was admitted to Worthing Hospital with severe pressure sores and died on 6 June 2014; the stated cause of death included bronchopneumonia, sepsis, necrotising fasciitis and a pressure wound. The report raised concern that nursing homes and community nurses did not have ready access to necessary dressings, which could take up to 14 days to arrive and meant that, in Mr Bateley’s case, staff borrowed dressings from another resident.
NHS Surrey and Sussex Integrated Care BoardSussex Community NHS Foundation Trust
Kingsley Burrell died on 31 March 2011 after being restrained and transported between mental health and hospital settings following an acute mental health disturbance. The inquest found that the covering over his head, unreasonable periods of restraint, delay in resuscitation and neglect contributed to his death. Concerns included inconsistent national understanding of acute behavioural disturbance, the absence of a nationally implemented crisis-team system, and non-nationally consistent policies for managing patients between services during a crisis.
Association of Ambulance Chief ExecutivesDepartment of Health and Social CareNational Police Chiefs’ Council
James Paul COLTON was a serving prisoner who became critically unwell on 29 August 2013 after a period of deteriorating health and died two days later in hospital. Concerns included failure to revisit his diagnosis or escalate treatment, inadequate analgesia, poor continuity and communication of care, and an extremely heavy workload affecting healthcare provision.
Herefordshire and Worcestershire Health and Care NHS Trust
Brenda Leyland was found deceased in a hotel room on 4 October 2014 after buying helium canisters to end her life; the inquest concluded suicide. The concerns were the free availability of helium canisters, the lack of controls on purchase quantities, their large volume, and the absence of a modified control valve to restrict gas release.
Department of Health and Social Care
Elsie May Hayward was admitted to hospital after a fall at home and was being treated for sepsis. During her admission, she sustained four falls, including a likely fall from her bed that caused a head injury and subdural haematoma; her condition deteriorated and she died three days later. Concerns included overstretched staffing, inadequate post-head-injury observations, and omissions and inconsistencies in clinical records and communication.
Cardiff & Vale University LHBOffice of the Chief CoronerSon of the deceased
Valerie WALTON was struck by a bus while using a Zebra crossing on Remembrance Road, Coventry, on 29 September 2014. Evidence was heard that the crossing’s position on the apex of a sharp bend was contributory, and that a crossing on the straight section or controlled by traffic lights might have prevented the death.
Coventry City Council
Mrs Anne Elizabeth Fowler died in a house fire. A dust cover had been left over the smoke alarm nearest the fire and the deceased, preventing it from sounding as early as it otherwise would have; the report also raised concern that alarms may be inaccessible to elderly or immobile occupiers and that protective covers should be removed before properties are occupied.
Home Office
Anais Chantal Thouvenot was knocked from her bicycle by a passing vehicle at a road junction in Leicester on 9 November 2014, sustained a serious head injury, and died at Queens Medical Centre, Nottingham, on 16 November 2014. Concerns were raised about the junction’s safety, including visibility, inadequate or absent filter lanes, heavy traffic, and the road contour, with reported near misses involving cyclists.
Family of Anais ThouvenotLeicester City CouncilLeicester Cycling Campaign GroupOffice of the Chief Coroner
Grant Thomas Benson and Gordon Nicky Davidson were travelling in a motor vehicle that crashed into a tree. The passenger died at the time of the collision or soon afterwards, while the driver survived the impact but died in the ensuing fire. The report identified shortcomings in emergency call handling and cross-boundary coordination, which delayed the dispatch of emergency services, although the evidence was that a prompt local response would not have changed the driver’s outcome in this case.
Yorkshire Ambulance Service NHS Trust
Kevin Patrick Hoey suffered chest pain at home on 14 July 2014 and was initially assessed as suitable to remain at home after ambulance attendance. His condition deteriorated, and he died at home in the early hours of 15 July 2014; the inquest recorded haemothorax and acute aortic dissection as the cause of death. The principal concern was the assessment of whether patients required hospital transfer and the need for training concerning community treatment or hospital transfer.
East of England Ambulance Service NHS Trust
