6,433 reports
Information drawn from published reports and official responses.
Ian Sidney Martin fell on wet, slippery and worn steps on a canal bridge while travelling from Skipton Bus Station to meet his wife, sustaining a head injury from which he died in hospital later that day. The principal concerns were the dangerous condition of the steps and poor lighting around the bridge.
Canal & River TrustRecipient name withheld
Elizabeth Jayne Cooper had Factor V Leiden mutation and died after a holiday involving air travel; the inquest recorded pulmonary thromboembolism and deep vein thrombosis, with a conclusion of natural causes. The principal concerns were conflicting or unclear advice about precautions for air and long-distance travel, the lack of a clear pathway for informing family members, and the absence of information leaflets about the risks and consequences of untreated DVT and Factor V Leiden mutation.
General Medical CouncilNational Institute for Health and Care Excellence
Darren Arnoup was found hanging in the garage of his home on 27 October 2013 and was declared deceased at the scene. The report raises concern that correspondence containing information about a patient's suicide risk or self-harming behaviour might not be brought to a GP's attention, because it may be treated as information-only correspondence and filed without medical review.
Mundesley Medical CentreNHS Norfolk and Suffolk Integrated Care BoardNHS North Norfolk Clinical Commissioning Group
Beryl French was a resident at Landmere Nursing Home who developed respiratory difficulties while receiving personal care. Nursing staff did not initiate active interventions because they believed a completed DNACPR form was in place, but no such form existed. The concerns included staff understanding of DNACPR forms and insufficient end-of-life care planning.
Sycamore Horizon Ltd
Sukhir Singh RANA and Mandip SINGH died following a road traffic collision on Park Lane, Handsworth, Birmingham, involving the car in which both men were travelling. The principal concerns were whether the 60-mile-per-hour speed limit was appropriate for a poorly lit, bend-filled country lane and whether the bend's theoretical maximum speed contributed to excessive speeds.
Sandwell Borough Council
Mary Wanya died after falling through a hospital window on 1 November 2011 while in an acutely confused and agitated state. The window restrictor was defective, allowing the window to be fully opened. Concerns included delays in psychiatric assessment, the assessment and treatment of mental illness on the Medical Admissions Unit, her earlier diagnosis and discharge, and the inadequacy of the Trust’s investigation report.
Leeds Teaching Hospitals NHS Trust
Miss Samiyo Sahra Shih Farah, who had depression and a history of self-harm, was found unresponsive with a ligature around her neck on 30 December 2012 and was pronounced dead. The principal concerns were the lack of national guidance on observation of children and adolescents in specialist mental health units, inadequate formal protocols for communication during transfers between private and NHS providers, and inconsistent referral arrangements following her attendances at A&E.
Affinity Healthcare LimitedDepartment of Health and Social CareGreater Manchester Mental Health NHS Foundation TrustManchester University NHS Foundation TrustRoyal College of Psychiatrists
Stephen Anthony Allardice Widman had a history of rectal carcinoma and was repeatedly catheterised. An inappropriately placed catheter was considered likely, infection developed, and he became weakened by pneumonia before dying from sepsis associated with a urinary tract infection and pyelonephritis. Concerns included delays in treating neutropenic sepsis in Accident and Emergency and frequent catheterisation without urological management.
Department of Health and Social CareTorbay Hospital
Dafydd Rhys WATTS died of eosinophilic pericarditis and DRESS syndrome following treatment with levetiracetam for epilepsy. The report raised concern that the possibility of this exceptionally rare reaction and death was not drawn to physicians’ attention in the drug literature or BNF entry.
BNF PublicationsUCB Pharma
Janet Blackman became unwell and was treated for hyperthyroidism and low sodium before being transferred between a medical unit and a psychiatric unit. She died after developing a pulmonary embolus due to deep calf venous thrombosis; the report noted that the psychiatric unit could not administer the prescribed heparin prophylaxis and raised concerns about continuity of physical healthcare and application of DVT prevention policy in psychiatric settings.
Department of Health and Social CareSussex Partnership NHS Foundation TrustUniversity Hospitals Sussex NHS Foundation Trust
Joanne Elizabeth Oliver, aged 31, was transferred by air ambulance after treatment for H1N1 influenza and ECMO, but her condition deteriorated after arrival at Manchester Royal Infirmary. She developed severe metabolic acidosis with high carbon dioxide and potassium levels, suffered cardiac arrest, and died. The report identified an unacceptable delay in obtaining blood gas analysis and monitoring, and raised concerns about the lack of detailed guidance and risk assessment for transferring critically ill patients.
Faculty of Intensive Care MedicineThe Intensive Care Society
Miss Yasmin Mary Richards died at the scene after her Ford Ka crossed into the opposing carriageway and collided with a Range Rover on the A46 on 2 November 2013. The inquest heard that worn and under-inflated tyres contributed to the collision, alongside the vehicle’s speed and the driver’s inexperience. Concerns were raised about repeated collisions on the same section of road and the adequacy of the speed limit, signs, carriageway markings and other measures at the bends.
National Highways
Mr Robert Anthony Perkins, who had terminal cancer, was admitted after a fall and was found to have a cervical spine fracture. Despite neurosurgical instructions, a cervical collar was not fitted while he was on the ward, and a suitable collar was difficult to obtain before his transfer to a hospice, where he died. The report raised concerns that inadequate immobilisation placed him at risk of serious or fatal injury and that suitable collars were not readily available.
Bristol NHS Foundation Trust
Jennifer Tompkins, who was undergoing dialysis while awaiting a kidney transplant, suffered fatal allergic anaphylaxis after receiving an intravenous injection of Tazocin at Kings College Hospital on 6 July 2011. Concerns were raised that Tazocin may have been administered too quickly, indicating possible training issues, and that the early stopping of a vancomycin infusion was not recorded in drug administration records.
King'S College Hospital NHS Foundation Trust
Stephen Goodhall fell at home on 19 October 2013, fractured his lumbar spine, developed recurrent hospital-acquired pneumonia and deteriorating physiological and kidney function, and died two days after being taken to ITU. The report identified concerns about the absence of a clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff.
Manchester University NHS Foundation Trust
Tanya Rosemary Marion Oladejo was found collapsed and unresponsive on her bed after a friend had not heard from her for approximately one week; police confirmed there were no suspicious circumstances. The inquest concluded misadventure, with the medical cause of death recorded as amitriptyline intoxication. The principal concern was inadequate communication between the GP practice and the responsible clinician about medication, including unilateral changes to amitriptyline prescribing that were not communicated to the responsible clinician.
Central and North West London NHS Foundation TrustNHS West and North London Integrated Care Board
Audrey Wakefield suffered a stroke, later fell at a care home, deteriorated after hospital admission, and died at a hospice on 11 April 2013. The principal concern was inadequate communication of discharge information from the hospital to her GP, particularly for practices outside the usual local communication system.
University Hospitals of North Midlands NHS Trust
Michael Harry Worrall had longstanding mental health issues and was admitted to secure forensic units before being discharged to community services in July 2013. He died after falling from a bridge in October 2013. The principal concern was the limited availability of psychological therapy at Avesbury House and the possible adverse consequences of discontinuing psychological input before discharge into the community; the report states there was no evidence that this lack of treatment contributed to his death.
North London NHS Foundation Trust
Paul Millis died after riding his motorbike through the junction of Troon Way and Nicklaus Road in Leicester and colliding head-on with a car on 3 December 2013. The principal concerns were the short distances over which two lanes merged and opposing traffic joined, potentially causing delayed lines of sight, together with the acute movement of one lane into the carriageway.
Leicester City Council
Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.
Royal Cornwall Hospitals NHS Trust
