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Dominic Martin PHILIP · Prevention of Future Deaths report View report

14 Mar 2025 Northamptonshire H. Shah

Dominic Martin Philip died at Kettering General Hospital on 3 February 2023 from an anaphylactic reaction to contrast medium injected for an abdominal CT scan. Concerns included whether potential allergies to contrast medium could be identified before injection, the unexplained presence of Lidocaine in his blood despite his disclosed Lidocaine allergy, and controls over the storage and removal of Lidocaine.

Stanley Alfred Babbs · Prevention of Future Deaths report View report

6 Nov 2020 East London N. Persaud

Stanley Alfred Babbs, who had chronic kidney disease, diabetes and heart failure, became unwell after receiving contrast for a CT scan and was diagnosed with contrast-induced acute kidney injury. He was later admitted to hospital and died from sepsis arising from a urinary tract infection on 16 February 2016. The report raised concerns that contrast, a prescription-only medicine, could be administered without a formal prescription, individualised risk/benefit assessment, careful dose consideration or a clearly identified responsible clinician, particularly for patients at high risk of acute kidney injury.

David Gary Chatburn · Prevention of Future Deaths report View report

18 Mar 2014 Manchester North L. Hashmi

David Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health services.

Rafal Delezuch · Prevention of Future Deaths report View report

27 Mar 2015 Leicester City and South Leicestershire M. Gotheridge

Rafal Delezuch was seen behaving bizarrely and showing paranoia in Leicester before being restrained by police under section 136 of the Mental Health Act and taken to hospital. The inquest concluded that he died from amphetamine-induced delirium in association with prolonged struggle. Concerns included staff awareness and training on restraint, lack of familiarity with the dangers of prolonged prone restraint, difficulties obtaining and selecting medication for rapid tranquillisation, and an overlooked warning about diazepam in NICE guidance.

James Ralph COCHRANE · Prevention of Future Deaths report View report

5 Sep 2025 Rutland and North Leicestershire R. Connell

James Ralph Cochrane, who had schizoaffective disorder with fluctuating mood and psychosis, died on 17 November 2023 after jumping from an overbridge into the carriageway and being struck by a vehicle. The report raises concerns about how carers’ views and video evidence are considered and used in safety planning, and about the support provided to carers assisting mental health patients at home.

Vauna LEEMING · Prevention of Future Deaths report View report

17 Jan 2025 Worcestershire D. Reid

Vauna Leeming was admitted to hospital after an accidental fall at home that caused a fractured right neck of femur. After surgery, her condition deteriorated, she tested positive for Covid-19, suffered a pulmonary embolism and died in hospital. Concerns included incomplete documentation of anticoagulation and compression-stocking measures, failures to report omissions, and insufficient awareness among employed and agency nurses of these duties.

ELEANOR ROSE MURPHY-RICHARDS · Prevention of Future Deaths report View report

11 Jul 2021 Mid Kent and Medway S. Hayes

Ellis died on 30 September 2020 after jumping from a footbridge onto a railway track in front of an oncoming train, intending to end his life. Concerns included gaps in the safety plan, a deviation from it without an updated risk assessment, incomplete sharing of information about a recent failed hanging attempt, and advice that did not account for the risk of Ellis leaving the centre.

Kimberley Sampson and Samantha Mulcahy · Prevention of Future Deaths report View report

17 Sep 2023 Central and South East Kent C. Wood

Kimberley Sampson and Samantha Mulcahy died after developing disseminated herpes simplex infections acquired before or around delivery, with both progressing to multi-organ failure despite intensive treatment. The principal concerns were delays in recognising a viral cause and commencing antiviral therapy, alongside a lack of national guidance on antiviral treatment for women presenting with systemic infection in the postpartum or peripartum period. The investigation also found uncertainty about testing staff who had treated both women and was unable to establish whether they had a common source of infection.

William Antony Northcott · Prevention of Future Deaths report View report

27 Jan 2025 Devon, Plymouth and Torbay L. Wiltshire

William Antony Northcott, who had treatment-resistant schizophrenia, was found deceased on 13 July 2021 after suffering a sudden fatal cardiac arrhythmia. The report raised concerns about the adequacy and consistency of information on clozapine side effects and cardiac warning signs, the detection of cardiomyopathies in patients taking clozapine, and communication between agencies and care teams.

Clive Mark Hyman · Prevention of Future Deaths report View report

22 Jan 2026 Inner North London S. Bourke

Clive Mark Hyman, who was taking apixaban, fell and hit his head on 1 August 2025 but did not seek medical advice because he felt well. He later developed a sudden severe headache, became unresponsive, and was found to have a subdural haemorrhage and extensive brain injury; he died in hospital on 10 August 2025. The concerns relate to guidance for people taking apixaban after head trauma, including the absence of clear advice in reviewed patient leaflets to seek medical attention after such an injury.

Freda Weston · Prevention of Future Deaths report View report

23 Feb 2016 Manchester South J. Pollard

Freda Weston was treated for septic arthritis in a replacement knee and died in hospital on 29 April 2015. The report states that Septrin led to disseminated intravascular coagulation and identifies concerns including delays in antibiotics, insufficient time to assess whether the new drug suited her, inadequate staffing, and failures in communication and escalation procedures.

Somtera Bibi · Prevention of Future Deaths report View report

2 May 2026 East London N. Persaud

Somtera Bibi, aged 80, died from fatal stab wounds to the chest at her home on 2 April 2022. The report identified concerns about the absence of robust community mental-health risk management, including relapse prevention, family safety planning, DASH risk assessments, safeguarding referrals and multi-agency involvement, despite known risks posed by the family member who inflicted the injuries.

Dayle BATES · Prevention of Future Deaths report View report

8 Feb 2024 Cumbria R. Cohen

Dayle Bates, aged 39, was found dead at his home on 31 August 2023 after ambulance staff were unable to revive him. A post-mortem examination attributed his death to the combined effect of heroin, bromazolam, protonitazene, xylazine and alcohol. The report raises concerns that Recovery Steps were not promptly informed when he stopped collecting methadone, and that pharmacies lacked a direct reporting route and were not obliged to report wider welfare concerns.

Alan CRABTREE · Prevention of Future Deaths report View report

20 Feb 2026 Cheshire E. Wheeler

Alan Crabtree was prescribed methotrexate on 3 February 2025, developed rapid-onset pancytopenia, was admitted to hospital on 18 February, and died of pneumonia on 1 March 2025. The report identified concerns that the methotrexate dosing guidance was outdated and that its advice about which healthcare professional patients should contact for signs of toxicity was ambiguous, potentially delaying appropriate treatment.

Lucasz Lewandowski · Prevention of Future Deaths report View report

15 Oct 2014 Manchester (North) L. Hashmi

Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.

Mrs. Mary Patricia James · Prevention of Future Deaths report View report

4 Sep 2015 Powys, Bridgend and Glamorgan Valleys S. Richards

Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.

Conrad Richard James Colson · Prevention of Future Deaths report View report

26 May 2023 East London N. Persaud

Conrad Colson, who had severe body dysmorphic disorder and a previous serious suicide attempt, was found deceased at home on 2 March 2022 after friends became concerned for his welfare. The inquest concluded that he took his own life while accessing aesthetic dermatology treatment, without therapeutic medication or professional mental health support, and after discharge without a robust risk assessment or relapse risk-management plan. Concerns included insufficient liaison and information sharing between mental health services, inadequate consideration of risks associated with aesthetic dermatology treatment, and training and resource gaps relating to body dysmorphic disorder.

Mr Harbans SINGH · Prevention of Future Deaths report View report

15 Oct 2021 Warwickshire S. McGovern

Mr Singh was admitted to Warwick Hospital with severe hypothyroidism on 23 April 2021 and died the following day. Concerns included failures in the discharge process, omission of his new diagnosis and medication from the discharge summary, and significant thyroid blood-test results not being flagged or acted upon.

Sheila Elizabeth Steggles · Prevention of Future Deaths report View report

10 Feb 2022 Norfolk Y. Blake

Sheila Elizabeth Steggles, who had reduced mobility and several risk factors for thrombosis, collapsed on 5 November 2019 and died in an ambulance after suffering a cardiac arrest. The cause of death was recorded as acute pulmonary embolus arising from deep vein thrombosis. Concerns included the absence of a documented VTE risk assessment, insufficient consideration of reduced mobility and past DVT, inadequate staff training, and missed opportunities to provide prophylactic heparin.

Thomas Farrell · Prevention of Future Deaths report View report

14 Jul 2015 Nottinghamshire S. Haskey

Thomas Farrell died after becoming unwell with a chest infection while resident at Springfield Care Home and being admitted to hospital, where he died on 16 July 2014. The principal concern was that the care home had not obtained a full medication record from his GP, resulting in several prescribed medicines not being administered; the report stated this omission did not cause or contribute to his death but posed a clear risk in other circumstances.