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Gary Bradshaw · Prevention of Future Deaths report View report

15 May 2014 Manchester South J. Pollard

Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical records.

Edwin Hooper · Prevention of Future Deaths report View report

16 Jan 2018 Manchester South C. Murray

Edwin Hooper was admitted with multiple serious medical conditions, including decompensated heart failure, kidney disease, sepsis and peripheral vascular disease. After a fall while receiving anticoagulant treatment, he sustained a traumatic intracranial bleed and progressively deteriorated before receiving palliative care and dying on 15 November 2016. The principal concern was whether patients with head injuries who are taking anticoagulants undergo CT scanning in accordance with NICE guidelines, particularly when there are on-site CT scanner service issues.

Daniel John O’Sullivan · Prevention of Future Deaths report View report

21 Oct 2022 Inner South London C. Williams

Daniel John O’Sullivan was found deceased on 27 March 2019 while a voluntary psychiatric patient at St Charles Hospital, after leaving the hospital unescorted and failing to return. The principal concerns were failures to update his self-harm risk assessment, formulate a care and treatment plan, document unescorted leave, and promptly notify police when he did not return. The report also raised concerns that the hospital’s serious incident investigation did not identify or investigate these issues adequately.

Hazel Claire Polkinghorn · Prevention of Future Deaths report View report

26 Feb 2014 Central Lincolnshire S. Fisher

Hazel Claire Polkinghorn, who had a history of mental health difficulties, was found deceased in her flat on 24 April 2013 after taking an overdose of Pentobarbital acquired from the internet. The principal concern was the ease with which she obtained potentially dangerous non-prescribed medication online and the risk of similar deaths unless such websites were screened and closed down.

LAURA-JANE KIRSTEN NICOLE SEAMAN · Prevention of Future Deaths report View report

13 Dec 2024 Essex S. Hayes

Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 following a massive intra-abdominal haemorrhage after a recent vaginal delivery, with subsequent disseminated intravascular coagulation. The principal concerns were failures to recognise and escalate maternal collapse and hypovolaemia, obtain and record vital signs and blood-test results, examine for covert bleeding, activate the major haemorrhage protocol, and provide appropriate senior review. The inquest concluded that her death was avoidable and contributed to by neglect.

Pamela Pattison · Prevention of Future Deaths report View report

23 Mar 2015 Manchester South J. Pollard

Pamela Pattison was admitted to hospital after falling at home and fracturing her hip. Her insulin was intentionally omitted following a mistaken assessment, and concerns were raised about sub-optimal diabetic care, inadequate staff training and escalation, insufficient specialist diabetes support, equipment and resourcing problems, and delay in transferring her to an appropriate ward. The medical cause of death was recorded as aspiration pneumonia following nausea and vomiting consequent upon unstable diabetic control, with brittle diabetes and a fractured neck of femur also recorded.

Ioannis AVGOUSTI · Prevention of Future Deaths report View report

24 Apr 2019 Brighton and Hove V. Hamilton-Deeley

Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.

Yaser Saleh · Prevention of Future Deaths report View report

17 Oct 2014 Inner South London A. Harris

Yaser Saleh, aged 15, died on 13 September 2012 after collapsing with cardio-respiratory arrest from acute asthma. The report raised concerns that electronic systems did not identify asthma patients needing review when they were no longer receiving regular prescriptions, creating a risk of preventable deaths in people with chronic diseases.

Name not published · Prevention of Future Deaths report View report

19 Apr 2022 Manchester City N. Meadows

The deceased had mental illness, illicit and prescribed drug misuse, homelessness and a history of contact with mental health services. She was discharged from hospital to community treatment on 13 January 2021 despite concerns about her readiness, inadequate records, risk assessments and mental state examinations, and lack of fixed accommodation. She was found in cardiac arrest on 30 January 2021 and died in hospital on 31 January 2021; the cause of the cardiac arrest could not be determined. The principal concerns included the discharge decision, incomplete clinical documentation, inadequate risk assessment, and failure to consider safeguarding.

John Anthony Delahaye · Prevention of Future Deaths report View report

18 Dec 2018 Birmingham and Solihull E. Brown

John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.

Roy DRAPER · Prevention of Future Deaths report View report

4 Aug 2022 Derby and Derbyshire S. Lomas

Roy Draper, who had mesothelioma linked to occupational asbestos exposure, became unwell after chemotherapy in a clinical trial, later developed bronchopneumonia and suffered a massive stroke, and died in hospital on 13 February 2020. Concerns were raised about the lack of a clear process and responsibility for requesting unblinding when a clinical-trial patient became acutely unwell at another hospital, and about the absence of a formal referral system for reporting adverse events to the trials team.

Susan Marie Karakoc · Prevention of Future Deaths report View report

17 Dec 2024 Nottinghamshire A. Bewley

Susan Marie Karakoc collapsed at home on 1 December 2023 and died in hospital the following day after suffering a hypoxic brain injury. The report states that she obtained prescription medications from online sources selling medicines off-label, and that toxicological examination identified toxicity associated with the chain of events leading to her death. Concerns included the ready availability of such websites through search engines, inadequate monitoring of online medication supply chains, and ineffective detection of financial services supporting criminal enterprises.

Linda Louise Banks · Prevention of Future Deaths report View report

19 Dec 2023 County Durham and Darlington J. Richards

Linda Louise Banks died at the University Hospital of North Durham on 10 April 2022 after taking a paracetamol overdose, against a background of alcohol misuse and deteriorating mental health. The report identified concerns about the quality of mental health assessments, triage, safety planning and record keeping, the underestimation of risk, failure to identify possible learning difficulties and provide reasonable adjustments, and delays in investigating the care provided. It also identified concerns that similar issues found in an earlier thematic review had not been effectively addressed.

Teresa Lonergan · Prevention of Future Deaths report View report

14 Mar 2014 Inner South London A. Harris

Teresa Lonergan, aged 73, was found dead at home on 4 September 2012 after taking an overdose of morphine that she had hoarded. The concerns included large quantities of prescribed morphine being available, repeat prescriptions and no reported monitoring of her consumption of controlled drugs.

WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report View report

8 Dec 2023 Essex S. Hayes

William had poorly controlled asthma and experienced a life-threatening asthma attack on 29 May 2021, followed by respiratory and cardiac arrest and a brain injury not compatible with life. The report identified multiple concerns, including failures to assess, review, escalate and treat his asthma, ambulance treatment and airway-management issues, gaps in investigation and training, and limitations in asthma and emergency-care services.

Darren Edward KING · Prevention of Future Deaths report View report

6 Apr 2019 Suffolk N. Parsley

Darren King died at home after an epileptic seizure while in the bath, with drowning recorded as the medical cause of death. The report identified concerns about inadequate follow-up when a high-risk patient with learning disabilities disengages, the lack of a clear escalation process, and the absence of a structured medication review within the care plan.

Mr Alan Hodgson · Prevention of Future Deaths report View report

3 Mar 2022 Sunderland D. DL

Mr Alan Hodgson died at Sunderland Royal Hospital on 14 January 2021. The report describes failures to recognise the severity of his condition, delays in acting on and reporting imaging, failures to follow the vascular pathway, inadequate communication and continuity of care, and an insufficient review of the circumstances leading to his death.

Paul Christopher REEVES · Prevention of Future Deaths report View report

12 May 2025 Inner North London I. Potter

Paul Christopher Reeves died in hospital on 9 April 2024 after ingesting and aspirating mud following the use of unknown drugs or psychoactive substances, and suffering a cardiac arrest during re-intubation. The principal concerns related to inadequate communication between his supported accommodation and mental health team, uncertainty about staff responsibilities, escalation of concerns about his deteriorating condition, and staff knowledge, skills or training in responding to his behaviour in the community.

Andrew James Tizard-Varcoe · Prevention of Future Deaths report View report

31 Mar 2025 Devon, Plymouth and Torbay P. Spinney

Andrew James Tizard-Varcoe died at home on 11 May 2022 due to the progression of an ear infection, later described at inquest as complications of necrotising otitis externa. Concerns included fragmented care across three hospital trusts, difficulties accessing medical records and establishing responsibility, delayed outpatient follow-up, and discharge without oral antibiotics despite microbiology advice.

Karanbir Singh CHEEMA · Prevention of Future Deaths report View report

10 May 2019 Inner North London M. Hassell

Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.