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Suzanne Julia ELLERBY · Prevention of Future Deaths report View report

14 Nov 2025 Surrey A. Loxton

Suzanne Ellerby was found deceased at her father’s home in Addlestone, Surrey, on 4 January 2025, after a period of mental health deterioration and no contact with mental health or medical practitioners since 13 December 2024. The principal concern was the transfer of vulnerable patients from secondary mental health services to primary care without universal guidance, safety-netting, or arrangements to ensure timely follow-up, leaving patients responsible for arranging care themselves.

John Abrahams (Jack) · Prevention of Future Deaths report View report

14 Feb 2023 Manchester North C. McKenna

Jack Abrahams was 20 years old when he took his own life by self-ligature. He had previously received a six-month course of isotretinoin for acne, but the available evidence did not meet the required standard to show a causative link between the treatment and his suicide. The principal concern was that, more than a year after the Isotretinoin Expert Working Group completed its report, its recommendations had still not been implemented, and a further working group to consider implementation had yet to meet.

Andrew Ronald Hall · Prevention of Future Deaths report View report

12 Mar 2014 Teesside A. Eastwood

Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.

Stephen John Neville · Prevention of Future Deaths report View report

24 Oct 2025 Essex S. Horstead

Stephen John Neville, aged 68, was an informal inpatient at Beech Ward for planned ECT after a history of severe treatment-resistant depression, anxiety, agitation, and repeated suicide attempts. He died by hanging while in hospital. The report identified concerns including failures in risk communication and assessment, abrupt medication changes, inadequate therapeutic observations and engagement, insufficient auditing and quality assurance, and failure to mitigate risks associated with an unlocked shower room.

Alexander Shone BLEWITT · Prevention of Future Deaths report View report

6 Jun 2023 Milton Keynes S. Cummings

Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.

Jennifer Anne Lacey · Prevention of Future Deaths report View report

24 Oct 2018 Inner West London F. Wilcox

Jennifer Anne Lacey was found deceased in a hotel room in Morden on 4 June 2018, having consumed a large amount of alcohol and 210 tramadol tablets. The concerns were that potentially dangerous and addictive drugs were freely available over the internet, could be prescribed without contact with the patient’s regular doctor or access to medical records, and might be dispensed by UK pharmacies without further checks.

Doreen Wood · Prevention of Future Deaths report View report

29 Apr 2015 Nottinghamshire H. Connor

Doreen Wood, who had atrial fibrillation and was taking Warfarin, died on 25 September 2014 from an intracerebral haemorrhage after repeated raised INR results. The report raised concerns that her INR was not checked soon enough and that the surgery’s monitoring system relied on healthcare assistants to volunteer relevant clinical information without routinely using standardised questionnaires.

Sam Antony Crick · Prevention of Future Deaths report View report

25 Aug 2017 Cambridgeshire and Peterborough D. Heming

Sam Antony Crick, aged 24, developed recurrent hydrocephalus and progressively raised intracranial pressure before a catastrophic collapse on 29 February 2016. He underwent emergency neurosurgical intervention but died at Addenbrookes Hospital on 4 March 2016. The concerns included missed radiological and ophthalmological signs of rising intracranial pressure, delays in obtaining and considering important imaging information, and the absence of a serious incident investigation.

John William Day · Prevention of Future Deaths report View report

4 Jun 2014 Isle of Wight C. Sumeray

John William Day, who had COPD, heart failure and respiratory difficulties, was found dead on 6 April 2014 while attached to his oxygen supply. An out-of-hours doctor prescribed Co-Amoxiclav after being unable to access Mr Day’s medical records, although he had a known allergy to the drug; the report states that the medication did not cause his death. The principal concern was that out-of-hours doctors could not access patients’ allergy information in every case.

John Andrew Mellor · Prevention of Future Deaths report View report

14 Feb 2019 Manchester North N. Flanagan

John Andrew Mellor had diabetes mellitus, chronic kidney disease and deep vein thrombosis, and died on 3 October 2018 after collapsing at home following the discovery of a very low blood count requiring urgent transfusion. The report describes repeated difficulties in arranging required blood tests, with responsibility passed between agencies and no clear shared-care or testing arrangement. It also raises concern that communications about referrals and test requests were not sent directly to primary care, relying instead on the patient to pass on vital information.

Amber Grace Walker · Prevention of Future Deaths report View report

21 Oct 2025 Dorset B. Allen

Amber Grace Walker, who had epilepsy and uncontrolled nocturnal tonic-clonic seizures, was found deceased at home on 19 April 2023. A post-mortem examination identified Sudden Unexpected Death in Epilepsy (SUDEP) as the medical cause of death. The concerns were that SUDEP and Amber’s individual risk, including the implications of declining increased medication, were not discussed with her, and that SUDEP discussions and related training for doctors were not consistent or universal.

Kathleen McGeary · Prevention of Future Deaths report View report

26 Feb 2019 Nottinghamshire S. Haskey

Kathleen McGeary died on 6 March 2018 from a head injury sustained in a fall at Tuxford Manor Care Home after her discharge from hospital. Concerns included inadequate assessment and treatment before discharge, unclear responsibility for discharge decisions, inadequate discharge documentation and communication, and her leaving hospital without prescribed antibiotics.

James Paul COLTON · Prevention of Future Deaths report View report

20 Mar 2015 Worcestershire G. Williams

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.

Mr Nicky Raymond Reilly · Prevention of Future Deaths report View report

4 Jan 2019 Manchester North J. Kearsley

Mr Nicky Raymond Reilly, also known as Mr Mohamed Saeed-Alim, was an inmate at HMP Manchester after spending six years at Broadmoor High Security Hospital. He was found hanging by a ligature in his cell on 19 October 2016 and was pronounced deceased at 14.43. The report raised concerns about the lack of continuation of the Care Program Approach, incomplete multidisciplinary records and coordination, limited psychological input and record keeping, insufficient staff training, separation of mental health and psychology records, and medication-refusal processes.

Nicos Andreas MICHAEL · Prevention of Future Deaths report View report

14 Apr 2014 North East Kent R. Cobb

Nicos Andreas MICHAEL died in hospital on 1 November 2013 after suffering a cardiac arrest and significant brain injury following an acute anaphylactic reaction to intravenously administered Augmentin. The principal concerns were that allergy information was conflicting or incompletely recorded, a historic hospital record of an Augmentin reaction was not carried forward or passed to the GP, and systems did not reliably make previous allergy information available to treating staff.

Hollie Anne RICHARDSON · Prevention of Future Deaths report View report

10 Jun 2022 Bedfordshire and Luton S. Cummings

Hollie Anne RICHARDSON, who was 26, died at Luton and Dunstable Hospital on 27 November 2019 after suffering a cardiac arrest secondary to a massive pulmonary embolism. She had protein S deficiency and a strong family history of blood clots, including fatal cases. The principal concern was that patients diagnosed with protein S deficiency may not be given sufficient information or surveillance about other factors that could increase thromboembolism risk, leaving them potentially unaware of actions to mitigate that risk.

JORDAN ANTHONY BUCKTON · Prevention of Future Deaths report View report

14 Aug 2013 Dorset S. Payne

JORDAN ANTHONY BUCKTON, aged 20, was found hanging by a ligature in his cell at HMYOI Portland on 28 January 2012. Concerns included failures to share information about his previous self-harm, to follow up after antidepressant medication was prescribed, and to continue an Emotional Wellbeing course after staff absence.

Susan Elizabeth SKILLEN · Prevention of Future Deaths report View report

16 Nov 2022 Liverpool and the Wirral A. Bhardwaj

Susan Elizabeth Skillen, aged 61, was admitted to hospital on 26 May 2022 after being found at home with reduced consciousness, low blood pressure, hypoglycaemia and severe neutropenia, and died later that day. The inquest concluded that she died from neutropenic sepsis, with skin loss associated with phototoxicity considered the most likely source of infection and the combined effects of sun exposure and rheumatoid arthritis medication contributing. The substantive concern was that phototoxicity is an extremely rare side effect of methotrexate but did not appear in the literature provided to patients, and it was unclear whether the patient literature required review.

Chloe Every · Prevention of Future Deaths report View report

25 Oct 2024 East London G. Irvine

Chloe Every died in hospital on 14 May 2019 after complications from a hypoxic cardiac arrest sustained during her admission. The report identified concerns including morphine use without recorded justification, an enema undertaken without informed consent while she was unconscious, inadequate clinical observations, missing records, and failures in incident reporting and governance.

John Kenneth PARRY · Prevention of Future Deaths report View report

27 Jun 2024 Leicester City and South Leicestershire C. Mason

John Parry, aged 72, was admitted to Leicester Royal Infirmary on 4 July 2023 after feeling unwell and later suffered two unwitnessed falls. He died on 7 July 2023 after a spontaneous intracerebral bleed was diagnosed. The inquest raised concerns that neurological observations after the falls were not carried out in accordance with hospital policy, the calculations were inaccurate, and a CT head scan that should have occurred within one hour was not performed. A separate concern concerned communication and information-sharing when prescribing warfarin.