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Terence COLBY · Prevention of Future Deaths report View report

18 Jun 2025 Suffolk D. Stewart

Terence COLBY died on 27 September 2023 after critical limb ischaemia led to a below-knee amputation, followed by hospital-acquired pneumonia and a pulmonary embolism. The principal concern was that his GP practice failed to undertake a simple vascular examination despite a foot wound and leg pain, which was described as substantially sub-standard practice and contrary to national guidelines.

Edward Joseph CASSIN · Prevention of Future Deaths report View report

18 Jun 2025 Milton Keynes S. Cummings

Edward Joseph Cassin was a 66-year-old man with learning difficulties and dysphagia who was developing aspiration pneumonia while in hospital on 24 June 2023. He was given jelly despite it being contraindicated, was not properly supervised while eating, and experienced hypoglycaemic episodes that were not managed according to hospital guidelines; aspiration and the pneumonia were not recognised. The report raised concerns about staff understanding of aspiration-management policies and siloed working between the two NHS trusts providing services.

Kathleen Mary GREGORY · Prevention of Future Deaths report View report

18 Jun 2025 Suffolk D. Stewart

Kathleen Mary GREGORY was found collapsed in bed at her care home on 29 November 2023 after appearing to choke on food, and her death was verified shortly afterwards. A post-mortem examination confirmed asphyxia caused by food lodged in her airway. The concern raised was that a paramedic interpreted the ReSPECT plan as excluding resuscitation during choking, which was considered inconsistent with the form’s terms where the adverse outcome might be reversible.

Hazel Gambles · Prevention of Future Deaths report View report

17 Jun 2025 South Yorkshire (Eastern) S. Tait

Hazel Gambles was admitted to hospital after a fall at home and was later found to have sustained a brain bleed in an unwitnessed in-patient fall. She died on 27 January 2025, and the report states that the head injury more than minimally contributed to her death. The principal concerns were failures to complete and implement falls assessments and prevention measures, delay in medical review, inadequate communication with her family, failure to report and investigate the fall, and omission of the fall from the discharge letter.

Greta Mary Ann Lewis · Prevention of Future Deaths report View report

17 Jun 2025 Devon, Plymouth and Torbay P. Spinney

Greta Mary Ann Lewis suffered a stroke in March 2020 and was later admitted to hospital after becoming unwell. She died at South Molton Community Hospital on 12 July 2021 due to complications caused by her stroke. The report raised concern about a gap in the availability of the time-critical and potentially lifesaving thrombectomy procedure for patients with severe strokes in the South West.

Upali Meththanananda · Prevention of Future Deaths report View report

17 Jun 2025 North East Kent C. Wood

Upali Meththanananda underwent coronary artery bypass surgery and was later admitted with a large left-sided pleural effusion. He died after a chest drain inserted on 20 October 2023 was followed by hypovolaemia, bleeding and cardiorespiratory arrest; concerns were raised about inadequate documentation of observations, procedures and discussions between clinicians.

Sonia Grace SORE · Prevention of Future Deaths report View report

17 Jun 2025 Suffolk D. Stewart

Sonia Grace SORE, who had significant mobility difficulties and was assessed as at risk of falling from her bed, fell from her bed on 14 October 2023 and again on 20 October 2023. She later developed a subdural haematoma, deteriorated, and died on 8 November 2023. The substantive concern was that staff at North Court Care Home repeatedly failed to implement identified risk-mitigation measures, including securing the right-hand bed rail, suggesting a possible wider cultural problem.

Mrs Norma Faye Campbell · Prevention of Future Deaths report View report

16 Jun 2025 East London N. Persaud

Mrs Norma Faye Campbell attended Whipps Cross Hospital emergency department on 13 January 2024 with clear signs of sepsis and died there in the early hours of 14 January 2024 after suffering a cardiac arrest. The report identifies delays and omissions in sepsis treatment, monitoring, fluid resuscitation and escalation of care. It also raises concerns about overcrowding, inadequate staffing and facilities, insufficient resuscitation beds, lack of electronic observations and the absence of Critical Care Outreach Team support in the emergency department.

Chloe Alicia Ellis · Prevention of Future Deaths report View report

13 Jun 2025 West Yorkshire Eastern O. Longstaff

Chloe Alicia Ellis died on 3 September 2024 after attending an Emergency Department with chest and back pain and breathlessness, where she was diagnosed with a viral illness and discharged. The principal concern was that the outcome of her NHS 111 online assessment, which suspected pulmonary embolism and recorded her oral contraceptive use, was not available to Emergency Department clinicians. The report also raised concern that NHS 111 online assessments were not commissioned to be accessible to clinicians at the relevant hospital, although such access might help obtain a full history and provide a failsafe against inadequate history taking.

Valerie HILL · Prevention of Future Deaths report View report

13 Jun 2025 South Wales Central G. Hughes

Valerie HILL died on 11 March 2022 at Royal Glamorgan Hospital after a fall at Ty Bargoed Care Home led to a periprosthetic femur fracture; pneumonia, COPD and frailty of old age were also recorded. She waited on the floor for over 14 hours for an ambulance, and concerns were raised about inadequate care-home risk assessments, prolonged ambulance handover times, patient-flow systems and continuing system-wide delays in access to emergency care.

Sally Burr · Prevention of Future Deaths report View report

13 Jun 2025 West Sussex, Brighton and Hove J. Turner

Sally Burr, who had a history of mental health difficulties and repeated serious self-harm attempts, was detained under section 3 of the Mental Health Act and admitted to Meadowfield Hospital. While detained, she used internet access to research and obtain toxic plant material and needles, which she consumed on 30 May 2024 with fatal results. The principal concern was that detained adult patients’ internet access could enable them to obtain means and methods to cause serious self-harm, while staff lacked practical ways to monitor or control internet use without restricting privacy and communication.

Valerie HILL · Prevention of Future Deaths report View report

13 Jun 2025 South Wales Central G. Hughes

Valerie HILL died from pneumonia following a fall that caused a periprosthetic femur fracture, with COPD and frailty of old age contributing. She had remained on the floor for over 14 hours awaiting an ambulance after falling at Ty Bargoed Care Home. The report raised concerns about the identification, documentation and mitigation of falls risks, staff training, completion and oversight of risk assessments, and ambulance handover and patient-flow systems.

Michael Paul Barry · Prevention of Future Deaths report View report

12 Jun 2025 Essex S. Horstead

Michael Paul Barry died at Broomfield Hospital from fatal complications of community-acquired pneumonia, with excessive codeine use contributing to his death. The principal concern was the lack of a commissioned specialist service to help patients and GPs safely reduce or withdraw from prescribed dependency-forming medication, creating a risk of avoidable future deaths.

Carol Taylor · Prevention of Future Deaths report View report

12 Jun 2025 Essex S. Simblet

Carol Taylor, aged 75, was a detained psychiatric patient found unresponsive in her bed on a ward for elderly patients, and resuscitation efforts were attempted. The report raised concerns that staff who were not compliant with mandatory training, including basic life support training, could work on in-patient wards, particularly wards treating elderly patients.

Oscar Michael Thomas Keenan · Prevention of Future Deaths report View report

12 Jun 2025 Oxfordshire J. Leach

Oscar was born with a pelvi-ureteric junction obstruction and later developed a bacterial infection after prescribed antibiotics were not received. On 26 June 2024, he was taken to hospital after a call to NHS 111 about breathing difficulties, was found to have sepsis, and died the same day. Concerns included inadequacies in the algorithm for assessing ill newborns, reliance on the algorithm without early clinical input, and delay or lack of direction in obtaining clinical assessment.

Simon HOCKENHULL · Prevention of Future Deaths report View report

12 Jun 2025 Cheshire E. Wheeler

Simon Hockenhull died at home on 5 December 2024 after contracting lobar pneumonia, with underlying diabetes and diabetic gastro-enteropathy reducing his resilience. The report raises concerns that inconsistent interpretations of a 28-day supply as a “month” can delay repeat prescriptions for diabetic medication and devices, potentially leading to inconsistent medication use and serious health effects including diabetic ketoacidosis.

Maureen POWELL · Prevention of Future Deaths report View report

11 Jun 2025 Nottinghamshire G. Clow

Maureen Powell died from severe frailty after a prolonged period of ill health, hospitalisation and transfer to a nursing home. A serious pressure ulcer developed and worsened in the nursing home and contributed to her death. Concerns included inadequate recording and implementation of repositioning, failure to record skin inspections, delayed equipment and specialist referral, poor record-keeping, inaccurate reporting, and insufficient communication with her family.

Lila Airelle Marsland · Prevention of Future Deaths report View report

11 Jun 2025 Manchester South C. Morris

Lila Marsland became unwell with headache, fever, lethargy and neck pain and was discharged from hospital with a diagnosis of viral tonsillitis. She was found to have died at home around six and a half hours after discharge; the inquest recorded that she died as a consequence of undiagnosed and untreated pneumococcal meningitis. Concerns included the embedding of the Child Sepsis Screening Tool, implementation of relevant NICE guidance, the adequacy and recording of clinical assessments, and fragmented storage and sharing of clinical information.

Amy Anne Levy · Prevention of Future Deaths report View report

10 Jun 2025 Avon R. Sowersby

Amy Anne Levy, a 22-year-old student, took an overdose of prescription drugs on 18 June 2023 and later died in hospital on 22 June 2023. Police and ambulance services did not know her address for over two hours despite knowing that her condition was deteriorating and that the case required an immediate response. The principal concern was that police officers and call handlers did not leave voicemail messages when attempting to contact her parents, potentially delaying the discovery of her location; the inquest jury identified a catalogue of missed opportunities to obtain her correct address.

Andrew James CONNOLLY · Prevention of Future Deaths report View report

10 Jun 2025 Manchester South A. Mutch

Andrew James Connolly died after being struck by a train having entered the track at a railway station on 26 November 2024. Concerns included telephone GP appointments despite his mental health not improving, no opportunity for family input into his clinical assessment, and a lack of guidance or mechanism for these arrangements; the inquest heard that his risk was not recognised.