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Sarah Elizabeth ADAMS · Prevention of Future Deaths report View report

21 Mar 2024 Berkshire A. McCormick

Sarah Adams was found deceased at home on 19 May 2022 after taking a self-administered overdose of prescribed medication with the intention of ending her life. The report identified care and service delivery issues around her discharge from a voluntary inpatient mental health admission, including a misunderstanding about Crisis Team contact and the provision of five days of medication. It also raised concerns about delays in care planning, the response to her deterioration, and staff training in discharge processes, particularly for out-of-area admissions.

Dean Mark Rowland · Prevention of Future Deaths report View report

27 Jun 2017 Staffordshire South M. Jones

Dean Mark Rowland, who had a history of two recent self-harm attempts and depression, was found hanging from a bannister on 21 March 2017, and the inquest concluded that his death was suicide. Concerns included his inability to obtain a GP appointment or telephone consultation for nine days when he wished to discuss increasing his antidepressant medication, and his discharge from the community mental health team after one consultation without a follow-up plan beyond returning to primary care.

Gareth Wycliffe WARBURTON · Prevention of Future Deaths report View report

4 Dec 2019 Worcestershire D. Reid

Gareth Wycliffe Warburton had undergone a double lung transplant and was taking anti-rejection medication when he arrived at HMP Hewell. A prescription error resulted in him receiving half his usual dose, and he died after chronic rejection of his transplanted lungs. The report raised concerns about prescription systems, staffing and the handling of important health-related correspondence at the prison.

Chloe Louise Barber · Prevention of Future Deaths report View report

12 Aug 2025 East Riding and Hull P. Marks

Chloe Louise Barber, who had a history of self-harm and multiple overdoses and had been detained under the Mental Health Act, was found at home on 3 November 2021 and was confirmed dead at 17:05. The report identified concerns about transition pathways between CAMHS and adult psychiatric services, guidance on administering depot antipsychotic preparations, and understanding of section 117 aftercare responsibilities.

Thelma Doris Clarkson · Prevention of Future Deaths report View report

27 Nov 2015 Portsmouth and South East Hampshire D. Horsley

Thelma Doris Clarkson fell at home on 10 February 2015, sustained head injuries, and died in hospital the following day after her condition deteriorated and an inoperable head injury was identified. The concern was that the NICE Head Injury Pathway did not treat Clopidogrel use as a trigger for a CT scan in the same way as Warfarin, despite the risk of increased bleeding from head trauma.

John Albert TARRANT · Prevention of Future Deaths report View report

30 Mar 2026 Berkshire R. Simpson

John Albert Tarrant, aged 84, died at Wexham Park Hospital after an unwitnessed fall while an inpatient on 29 April 2025, sustaining a brain bleed that later became unsurvivable. The principal concerns were inaccurate falls risk assessments and insufficient awareness or prompting regarding the urgency of anticoagulation reversal after a fall.

Joshua Arthur Stafford Delaney · Prevention of Future Deaths report View report

8 Apr 2024 Inner South London D. Manknell

Joshua Arthur Stafford Delaney, aged 19, had a history of mental illness, suicidal ideation and previous suicide attempts. On 19 January 2020, he took a large overdose of Propranolol, was found collapsed, and died despite resuscitation attempts. The principal concern was that GPs may not be aware of the risk of fatal Propranolol overdose and may prescribe quantities to people at risk, potentially causing future deaths.

Mr. Kurnathy · Prevention of Future Deaths report View report

14 Nov 2024 Manchester South A. Morris

Mr. Kurnathy was found unresponsive at home on 9 May 2024 and was pronounced dead; autopsy confirmed acute left ventricular failure, with fentanyl and morphine toxicity contributing to the death. Four fentanyl patches were found on his back, exceeding the prescribed amount. The principal concern was that correspondence reporting excessive fentanyl use was not identified by the surgery and did not trigger a medication review, and that the surgery had no specific procedures for flagging or reviewing concerns about fentanyl abuse.

David John Morris · Prevention of Future Deaths report View report

4 Jul 2024 East London G. Irvine

David John Morris, aged 78, developed oesophageal cancer after delays in diagnosis and treatment, later undergoing gastrostomy surgery. He developed a gastrostomy leak, peritonitis and septic shock, and died in hospital on 16 May 2022 after further surgery. The concerns included delayed recognition and treatment of the leak and sepsis, poor clinical records, deficiencies in the investigation, and ineffective controlled-drug management systems.

Siân Frances HEWITT · Prevention of Future Deaths report View report

21 Aug 2020 Milton Keynes T. Osborne

Siân Frances HEWITT died on 6 April 2019 at Milton Keynes University Hospital after collapsing at the Campbell Centre. The report describes failures to recognise and treat her deteriorating condition, including risks associated with pulmonary embolism, and concerns that the Campbell Centre was not an appropriate placement for people with autism and additional mental health problems.

Mr Zawdie Qounseye Bascom · Prevention of Future Deaths report View report

20 Jun 2016 London (East) N. Persaud

Mr Zawdie Qounseye Bascom developed severe abdominal pain, was assessed and discharged from A&E with a presumed diagnosis of gastritis, and later collapsed and died on 12 May 2014. The post-mortem cause of death was peritonitis due to rupture of an inflamed vermiform appendix. Concerns included inadequate recording and systematic assessment of pain, lack of documented pain relief before discharge, and insufficient attention to persistent severe pain that was unusual for gastritis.

Dorothy June MACEY · Prevention of Future Deaths report View report

13 Nov 2019 Mid Kent and Medway S. Hayes

Dorothy June MACEY sustained leg injuries when her legs went through a glass door and was later discharged home with district nurse dressing care. Antibiotics prescribed in September were not received promptly, and concerns were raised about wound assessment, information sharing, record-keeping, sepsis checks, medication monitoring, care planning and a missed visit. She was admitted to hospital for sepsis on 28 September 2018, developed gangrene in her left lower leg, and died at Medway Maritime Hospital on 7 October 2018.

Melanie Ruth Pinnell · Prevention of Future Deaths report View report

26 Mar 2026 Suffolk D. Sharpstone

Melanie Ruth Pinnell had a history of depression and recently described suicidal thoughts and ideation. No follow-up was arranged by the GP practice after February 2025, and a psychiatrist’s recommendation to start Sertraline was not actioned. Melanie was found hanging at home on 4 May 2025. The report identified these matters as significant risks to patient safety.

Name not published · Prevention of Future Deaths report View report

22 Dec 2022 Manchester City N. Meadows

The deceased suffered serious traumatic injuries in an accidental fall in Pakistan, including flail chest and a subdural haemorrhage that were not initially diagnosed, and later deteriorated during her flight to the United Kingdom. She was admitted to hospital in Manchester, but despite medical management her condition deteriorated and she died on 26 July 2019. The substantive concerns included inconsistent oxygen prescribing and documentation, wider risks from over- or under-oxygenation, and the absence of guidance addressing fitness to fly after trauma with respiratory implications.

Joanna Clare Alice Flynn · Prevention of Future Deaths report View report

14 Nov 2019 Essex C. Beasley-Murray

Joanna Clare Alice Flynn, aged 31, was found slumped over her bed on 26 May 2019 after last being seen on 23 May 2019. The inquest returned an Open conclusion against a background of long-standing prescribed opiate addiction, with concerns about the lack of specialised support and referral pathways for patients needing help to withdraw from addictive prescription drugs, as well as GP training and education.

Yousef Al-Kharboush and 2 others · Prevention of Future Deaths report View report

15 Nov 2024 Inner South London J. Morris

Aviva Otte died in January 2014 after receiving TPN provided and compounded by an NHS establishment; the TPN was, on balance, contaminated with Bacillus cereus. Oscar Barker and Yousef Al-Kharboush died in June 2014 after receiving TPN compounded by a commercial provider that was also contaminated with Bacillus cereus. The principal concerns were unclear or absent requirements for section 10 exempt entities to report adverse-event findings and uncertainty about reporting thresholds and wider dissemination of information that could help other providers assess risks.

Shona Christine Michaela Campbell · Prevention of Future Deaths report View report

1 Jul 2022 Manchester City N. Meadows

Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.

Frederick Sutton · Prevention of Future Deaths report View report

27 Aug 2015 Manchester South J. Pollard

Frederick Sutton fell and broke his hip at home on 3 February 2015, may have suffered a myocardial infarction, and died approximately 12 hours after admission to hospital. The concerns included hospital staffing levels, escalation procedures, failures to read nursing notes, incompatible computerised record systems, inadequate staff training, response to cardiac arrest, medication administration, and inaccurate next-of-kin information.

MARTIN ARNOLD HILL · Prevention of Future Deaths report View report

22 Aug 2014 Brighton and Hove V. Hamilton-Deeley

MARTIN ARNOLD HILL arrived at A & E on 28 March 2014 after approximately three days of confusion, abdominal pain and vomiting, with raised inflammatory markers. The concerns included delayed antibiotics, failures to refer him to the Critical Care Outreach Team when his NEWS was elevated, inadequate withdrawal treatment, failures in managing constipation, poor handover and communication, and serious omissions in the Medical Administration Record.

Barry Myers · Prevention of Future Deaths report View report

12 Mar 2025 West Sussex, Brighton and Hove L. Milner

Barry Myers died at Royal Sussex County Hospital on 28 January 2024 after suffering an ischaemic cerebral artery stroke. The report describes that a mechanical thrombectomy was not available outside departmental operational hours, and notes insufficient funding for urgent thrombectomy provision between 4 pm and 8 am, as well as missed opportunities for transfer to another centre.