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Steven HART · Prevention of Future Deaths report View report

24 Sep 2025 Bedfordshire and Luton S. Cummings

Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.

Bryan Andrews and Mary Andrews · Prevention of Future Deaths report View report

4 Oct 2024 South Yorkshire (Western) T. Rawden

Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.

David Alan White · Prevention of Future Deaths report View report

11 Nov 2015 Inner North London J. Devonish

David Alan White was admitted to hospital with significant pain from arterial vascular disease and later sustained two unwitnessed falls, the second causing fractures to his right hip and shoulder. He underwent emergency surgery and subsequently remained seriously unwell before dying on 26 June 2015. Concerns included the failure to record or act on reported confusion associated with Heparin, lack of supervision despite identified falls risks, and inadequate review and action on nursing records.

Deidre Harvey · Prevention of Future Deaths report View report

8 Aug 2017 South Wales Central C. Woolley

Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

Thomas Henry SMYTH · Prevention of Future Deaths report View report

28 Oct 2019 Milton Keynes T. Osborne

Thomas Henry Smyth, aged 86, was admitted after a fall and died from a subdural haematoma on 3 August 2019 after anticoagulation medication was inappropriately restarted. The report raised concerns that staff could not access vital information recorded in the electronic notes and records, and about the use, training and effectiveness of the notes system.

Martin Rowland HILL · Prevention of Future Deaths report View report

6 Aug 2014 Shropshire, Telford and Wrekin J. Ellery

Martin Rowland HILL died on 24 April 2014 after an abdominal x-ray taken during an A&E attendance showed small bowel obstruction, but the report was not seen by subsequent doctors and he was treated for constipation. The concerns included the failure to act on the radiology report, which might have led to surgical review and readmission, as well as medication not being provided on discharge and no discharge summary being sent to his GP.

Mrs Jane Jowers · Prevention of Future Deaths report View report

23 Sep 2020 East London N. Persaud

Mrs Jane Jowers, who had advanced Alzheimer’s dementia and was dependent on carers for medication, did not receive her anti-epileptic medication on 21 October 2018. She suffered a seizure the following day, was admitted to hospital, and her health deteriorated before she died in a hospice on 23 November 2018. The report raised concern that there was no statutory procedure for checking criminal convictions outside the UK, which may allow unsuitable people to work with vulnerable adults and children.

Billy Paul Thomas Salton · Prevention of Future Deaths report View report

6 Jan 2014 Manchester South J. Kearsley

Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

Talia Evaniа Phillips · Prevention of Future Deaths report View report

2 Sep 2023 Cornwall and Isles of Scilly S. Covell

Talia Evaniа Phillips died from catastrophic head and neck injuries sustained in a head-on road traffic collision, after likely losing control of her vehicle during a cardiac event associated with a significantly elevated blood level of Fluoxetine. The inquest raised concerns that guidance did not indicate routine Fluoxetine-level testing after palpitations and requested a review of when such blood testing should be advised.

Tracy Frances MCCARTHY · Prevention of Future Deaths report View report

21 May 2024 Inner North London I. Potter

Tracy McCarthy was found deceased at home on 17 July 2023 and died from long-term misuse of amitriptyline; the inquest conclusion was a drug-related death, with amitriptyline toxicity and coronary artery disease recorded. The concerns included prescribing amitriptyline above the maximum suggested dose, failure to flag the overdose risk and stop or appropriately manage the prescription, and changing from daily to monthly prescriptions despite recognised risks.

Danny Jay Anderson · Prevention of Future Deaths report View report

25 Jul 2024 East London N. Persaud

Danny Jay Anderson, who had chronic mental health difficulties and was discharged from hospital to inadequate accommodation without a comprehensive risk assessment or safety plan, was found hanging in his room on 30 March 2023 and pronounced dead at the scene. The report identifies concerns about inadequate risk formulation, over-reliance on Danny’s responses about suicidal ideation, insufficient consideration of his history and circumstances, and the absence of a safety plan before discharge from hospital or community mental health services.

Gareth Idris Johnson · Prevention of Future Deaths report View report

12 Sep 2025 South Wales Central K. Burge

Gareth Idris Johnson attended hospital with a bilateral pulmonary embolism and underwent catheter-directed thrombolysis. He later died at University Hospital of Wales from complications following the procedure. The report identified suboptimal post-operative anticoagulation management, including a lack of clarity about the appropriate heparin level, and raised concerns about transferring critical-care patients to PACU because of building maintenance, capacity pressures and infrastructure risks.

Bertram Theophilus HAMILTON · Prevention of Future Deaths report View report

26 Feb 2014 Black Country R. Balmain

Bertram Theophilus HAMILTON was a long-term care-home resident who died shortly after receiving insulin despite a recorded blood sugar level of 1.6. Concerns included the nurse appearing not to know that insulin should not be given when blood sugar was so low, and concerns about the nurse's account of events not being supported by contemporaneous documentation.

Paul Byron Holmes · Prevention of Future Deaths report View report

27 Jun 2024 Cornwall and Isles of Scilly S. Covell

Paul Byron Holmes sustained fractured ribs and a fractured sternum in a road traffic collision on 4 April 2022, followed by hospitalisation, delirium, dehydration and declining health. He died at home on 29 May 2022 after returning for palliative care. Concerns included inadequate doctor-to-doctor handover and recording of the treatment plan during a hospital transfer, and a prescription error that delayed intravenous fluids.

Brian Leonard Bicat · Prevention of Future Deaths report View report

29 May 2018 West Yorkshire (Western) M. Fleming

Brian Leonard Bicat sustained severe burns at home on 22 September 2017 when his dressing gown caught fire while he was smoking a cigarette. He died later that day from his extensive cutaneous burns, with evidence indicating that paraffin-based emollient creams and ointments increased the speed and intensity of the fire. The principal concerns were that low-paraffin emollients may pose a fire hazard, that warnings were not displayed consistently on packaging or communicated by healthcare professionals, and that related prescribing alerts and incident data were inconsistent or incomplete.

Rhys Lennon Hill · Prevention of Future Deaths report View report

15 Jan 2024 Manchester South A. Mutch

Rhys Lennon Hill underwent spinal surgery and was discharged from Royal Preston Hospital on 30 January 2023. He collapsed at home on 9 February 2023 and attempts to resuscitate him were unsuccessful; a post-mortem examination found that he died from a pulmonary embolus due to a deep vein thrombosis. The principal concerns included failure to escalate his refusal of Dalteparin or assess the associated risk, failure to provide required VTE information at discharge, and wider problems with communication, documentation, medication reconciliation, and discharge processes.

Hireiti Kufletsion · Prevention of Future Deaths report View report

23 Oct 2015 Birmingham and Solihull E. Brown

Hireiti Kufletsion died at Queen Elizabeth Hospital Birmingham on 20 November 2014 from thrombosis of a mechanical mitral valve during the first trimester of pregnancy. The report identified failures to adequately investigate the valve, seek specialist cardiology advice and prescribe adequate doses of clexane, with concerns that pregnant women with mechanical heart valves may be at risk from insufficient anticoagulation and inadequate clinical understanding of the associated thrombosis risk.

Pamela June Conway · Prevention of Future Deaths report View report

26 Aug 2016 North Wales (East and Central) J. Gittins

Pamela June Conway developed an infected knee and experienced cumulative delays, including around 21 hours before receiving antibiotics, during which she went into irrevocable septic shock. The concerns included the absence of a finalised care pathway for patients with an infected prosthesis and an almost two-hour delay between knee aspiration and antibiotic administration. The inquest recorded that her death was due to natural causes exacerbated by delayed medical treatment.

Dorothy Joan ROBINSON · Prevention of Future Deaths report View report

13 Aug 2014 Avon M. Voisin

Dorothy Joan Robinson developed pneumonitis after Busulphan was prescribed despite a previous recorded intolerance and died after being admitted to hospital severely unwell. The principal concern was the continuing risk of prescribing errors because previous drug intolerances, reactions or allergies may not be adequately identified across the Trust.

Jamie Harding · Prevention of Future Deaths report View report

29 Oct 2024 Essex S. Horstead

Jamie Harding attended Basildon Hospital on 3 June 2022 in crisis, with worsening psychotic symptoms, suicidal ideation and several days without sleep. He was discharged home rather than admitted as an inpatient and took his own life within hours after falling from a window. The substantive concerns included failures in assessment, follow-up, medication review, multidisciplinary working, risk assessment, record keeping and communication, alongside weaknesses in systems supporting the First Response Team and access to the Dual Diagnosis pathway.