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Teresa Ann Bennett · Prevention of Future Deaths report View report

14 Feb 2024 North West Wales S. Riley

Teresa Ann Bennett, who had significant comorbidities and was taking multiple medications including Fentanyl, was found deceased at home on 1 December 2021. The inquest recorded multi-organ failure due to fatty liver and combined drug toxicity, with toxicological analysis identifying Fentanyl in the toxic and fatal range. Concerns included missed regular medication reviews, the absence of a standardised review process, and the risk of inadvertent overdose when medicines that depress the central nervous system are prescribed without regular reviews or specific advice.

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.

Edward John Devlin · Prevention of Future Deaths report View report

22 Jul 2014 County Durham and Darlington C. Oliver

Edward John Devlin was found dead in his cell at HMP Durham on 17 July 2011, having died from the effects of dihydrocodeine. The report raised concerns that medication, including potentially dangerous drugs, may have been slid under locked cell doors without confirming receipt or administration, creating risks of diversion, inaccurate medication records, stockpiling and potentially lethal overdose. It also found that his physical condition on the night before his death warranted medical assessment, but no such assessment was carried out.

Graham Martin SAFFERY · Prevention of Future Deaths report View report

18 Sep 2019 Bedfordshire and Luton E. Whitting

Graham Martin SAFFERY was found deceased at home on 19 June 2018 after taking prescribed oxycodone and amitriptyline. The inquest conclusion stated that the combination carried a risk of sudden death and that his prescription remained unchanged despite signs of over-sedation. A substantive concern was that the BNF did not appear to provide the caution and monitoring advice given by other pharmacological guidance for simultaneous prescribing of these medicines.

Mary Nelson · Prevention of Future Deaths report View report

24 Feb 2020 Cumbria N. Shaw

Mary Nelson, aged 75, was found deceased on her sofa at home after what appeared to be a sudden death during the night. The inquest concluded that she died from a combination of hypertensive heart disease and the toxic effect of a properly prescribed medication. Concerns included the very high post-mortem Fluoxetine level, possible accumulation during treatment, whether dosage guidance should be revised for older people, and the death not having been reported through the Yellow Card system.

Kathleen Ludmila Neville · Prevention of Future Deaths report View report

7 Aug 2015 Cardiff and the Vale of Glamorgan C. Woolley

Kathleen Ludmila Neville was admitted to hospital after an accidental fall that fractured her femur and later died following complications after surgery and a prolonged hospital stay. Her regular thyroid medication was omitted for five weeks because it was not recorded on the drug chart and the hospital lacked a Medication Reconciliation Policy; this contributed to lassitude and confusion but not to her death. The principal concern was that the absence of such a policy could allow medication errors to persist and potentially contribute to future deaths, particularly with medicines whose omission could be fatal.

Jacqueline Anne CARREY · Prevention of Future Deaths report View report

26 Oct 2023 Milton Keynes T. Osborne

Jacqueline Anne CARREY was admitted to Milton Keynes University Hospital with severe pancreatitis pain, discharged with an excess of medication, and found deceased at home on 25 May 2023; the inquest conclusion was drug related. The principal concern was that risks of medication abuse may not have been clearly recorded or flagged before discharge, raising concerns about medication distribution and patient-record procedures.

Valerie Jane Gibson · Prevention of Future Deaths report View report

17 Dec 2025 Sunderland D. Place

Valerie Jane Gibson died on 29 October 2023 at Monkwearmouth Hospital after being admitted under the Mental Health Act with psychotic symptoms and assessed as being at risk of self-harm and harm to others. The principal concerns were uncertainty and inconsistency in the checking of possessions, dispensing and administration of medication, supervision of nurses, and use of the Omnicell and electronic medication record systems, resulting in unclear records of what medication had been dispensed or administered.

KATHRYN LOUISE SAWYER · Prevention of Future Deaths report View report

16 Apr 2014 Norfolk J. Lake

Kathryn Louise Sawyer, who had a significant history of mental health issues and was prescribed multiple medications including Methadone, was found collapsed and unresponsive at home on 14 August 2013 and died shortly after arriving at hospital. The medical cause of death was respiratory failure due to an overdose of Methadone in combination with therapeutic levels of other drugs. A principal concern was that, although her medication was reviewed in June 2013, there was no or no detailed record of the discussion and no plan for future medication, particularly any plan to decrease it.

Sally Mills · Prevention of Future Deaths report View report

14 Oct 2024 Berkshire P. Malhotra

Sally Mills choked on prescribed medication at home on 23 July 2023 after experiencing difficulty swallowing during its administration, and died later that day in hospital. The principal concerns were gaps in first-aid understanding for an unresponsive person and failures to appropriately escalate difficulties encountered during medication administration.

Lottie Reid · Prevention of Future Deaths report View report

25 Jun 2015 Birmingham and Solihull M. Jones

Lottie Reid, aged 95, was readmitted to hospital with haematemesis and melaena and died on 29 January 2015. The inquest concluded that she died from bleeding duodenal ulcers on a background of other significant natural disease, with her death probably accelerated by bleeding exacerbated by anticoagulant therapy. Concerns were raised that the medication administration chart at the intermediate care centre did not mirror the hospital discharge documentation and that there was no clear protocol for checking discrepancies, particularly at weekends.

Susan Nora Elizabeth YOUNG · Prevention of Future Deaths report View report

24 Jun 2025 Norfolk Y. Blake

Susan Nora Elizabeth Young was admitted to hospital after taking overdoses of prescription medication on 22 and 23 August 2024. She was transferred to a ward with directions for cardiac monitoring, but no clinical handover or monitoring instructions were provided. She was later found unresponsive and not attached to monitoring, and resuscitation failed; unused medication was subsequently found among her belongings.

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.

Oliver James Billings · Prevention of Future Deaths report View report

28 Nov 2024 Devon, Plymouth and Torbay L. Nicholson

Oliver James Billings, aged 22, was found deceased at home on 6 December 2023 after consuming possibly as many as 266 prescribed 75mg tablets. The report describes concerns that a second prescription was issued without confirming the status of the first, that rapid dispatch limited opportunities to identify or correct the error, and that Oliver was expected to remedy the problem when Pharmacy2U could not be contacted.

Chloe Elizabeth Burgess · Prevention of Future Deaths report View report

4 Mar 2025 Hampshire, Portsmouth and Southampton N. Walker

Chloe Elizabeth Burgess was found deceased at home on 8 September 2023. The report states that interactions between amitriptyline, paroxetine and ivabradine, together with an episode of sleep apnoea, contributed to severe cardiac arrhythmia and sudden cardiac death. The principal concerns were that the potential dangers of this medication combination were not widely appreciated and did not trigger alerts in prescribing software, and that prescribers of ivabradine should have a full understanding of the potential interaction.

Paolino AMICO · Prevention of Future Deaths report View report

17 Nov 2025 Essex S. Hayes

Paolino Amico, who had metastatic bladder cancer and advanced clinical frailty, was admitted with severe bilateral pneumonia and died in hospital on 12 June 2024. He received multiple overdoses of slow-release morphine following a prescription error, with concerns also raised about medication administration, delayed emergency escalation, oxygen provision after discharge, and the management of morphine reversal and pain relief.

Colin Vincent GREENWAY · Prevention of Future Deaths report View report

18 Jul 2023 Norfolk Y. Blake

Colin Vincent Greenway became ill with gastroenteritis after returning from Cyprus and was admitted to hospital with acute kidney injury and infection. He was prescribed enoxaparin at half the usual dose despite documented risk factors and renal function above the threshold for dose reduction, and he later died from a pulmonary embolism. The concerns included incorrect junior prescribing, incomplete VTE assessments, inadequate senior oversight and continuity of care, and limited pharmacy checking.

Sarah Julie MITCHELL · Prevention of Future Deaths report View report

8 Jan 2024 Suffolk D. Stewart

Sarah Julie MITCHELL, who had a history of chronic back pain, medication dependence, and previous overdoses, was found deceased at her residence on 22 September 2022. The post-mortem found multiple drug toxicity from prescribed medication. The principal concerns were that she received 28 days’ worth of medication in less than 48 hours despite known overdose and hoarding risks, and that emergency department staff had no process for accessing relevant medication records and dispensing information.

Paula Doreen Hughes · Prevention of Future Deaths report View report

14 Oct 2025 Inner South London L. Field

Paula Doreen Hughes was admitted to hospital after a fall and received paracetamol in excess of the recommended dose because paracetamol was prescribed alongside co-codamol. The overdose was not recognised until she had developed fulminant acute liver failure, and timely treatment was not provided. The principal concerns included preventing duplicate paracetamol prescriptions and administration, recognising and managing therapeutic excess, accurately assessing confusion, recording over-the-counter medicines, mitigating confirmation bias, and providing guidance for virtual patient reviews.

Daniel Young · Prevention of Future Deaths report View report

26 Jul 2018 Inner West London S. Radcliffe

Daniel Young, a fit and healthy university lecturer, was randomly attacked on his way to work on 19 January 2016 and sustained a fatal stab wound to the abdomen. The report raised concerns that GP surgeries did not routinely monitor whether psychiatric patients collected their antipsychotic medication, despite the risk that stopping treatment could lead to relapse and harm to others.