1,410 reports
Information drawn from published reports and official responses.
John Michael KIRBY took his own life, according to the conclusion of the inquest. The concerns included delays in his care, the handling of an ADHD diagnosis and Concerta prescribing, inadequate monitoring, and failures to respond appropriately to information about suicidal thoughts, a reported suicide attempt, substance use and an A&E admission.
Sussex Partnership NHS Foundation Trust
Jonathan Richard McCarthy was admitted to hospital with confusion, aspiration pneumonia, sepsis, acute kidney injury and swallowing difficulties, and later deteriorated with another aspiration pneumonia and hyperglycaemia. The stated concerns were failures to correctly monitor blood sugar and ketones, administer the correct insulin dose, and provide adequate nursing care and escalation to the medical team.
Maidstone and Tunbridge Wells NHS Trust
Jayden Andrew Booroff died after absconding from The Linden Centre and being struck by a train on 23 October 2020. The report identified concerns about risk assessments, observation levels, ward security, absconsion procedures, record keeping, medication, and communication between healthcare professionals and emergency services.
Essex Partnership University NHS Foundation TrustEssex Police
Mohammed Shabol Ahmed, a long-term illicit drug user with schizophrenia and a learning disability, was found deceased in his prison cell the morning after being returned from hospital following a drug-related collapse. Concerns included the possible interaction between olanzapine and Spice, failures in information-sharing between the prison, healthcare and hospital, and inadequate prison training for drug-related incidents and their aftermath.
Department of Health and Social CareNHS England
Edna Bulmer, who had a history of falls, suffered an unwitnessed fall on 10 September 2013 and was later found unconscious in bed. She died in hospital on 15 September 2013 after sustaining a serious intracranial haemorrhage. The concerns identified were inconsistent recording of her falls risk, delays in providing the identified pressure mat and pendant, and the apparent absence of a clear process for reviewing her risk assessment after further falls.
Dovecote Lodge
Eileen Cooke, an 80-year-old woman with dementia, frailty, contractures and a fractured left ankle, died in Pinderfields Hospital on 21 December 2017. Concerns included the lack of a best-interests multidisciplinary meeting, her discharge to a nursing home with unresolved medical and care needs, inadequate preparation for wound dressing and pain control, and the risk posed to other patients by precipitously arranged hospital discharges.
Mid Yorkshire Teaching NHS Trust
Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.
Hampshire and Isle of Wight Healthcare NHS Foundation TrustNHS EnglandNHS Hampshire and Isle of Wight Integrated Care Board
Darren Jones had chronic kidney disease and a renal transplant, and later died from massive left-sided pleural and mediastinal haemorrhage associated with thoracic aortic perforation and invasive aspergillosis. The report raised concerns about protocols for seeking renal advice for transplant patients and the availability of immunosuppressant medication at short notice.
University Hospitals of Derby and Burton NHS Foundation Trust
John Cogdon underwent coronary artery bypass graft surgery on 26 June 2023 and deteriorated before dying on 4 August 2023. Evidence at the inquest raised concern that different hospital wards and departments used fragmented, poorly integrated record-keeping and prescribing systems.
South Tees Hospitals NHS Foundation Trust
Viola Burke, aged 80, died on 5 January 2015 after developing a productive cough and shortness of breath, receiving a diagnosis of chest infection, and later collapsing at home. Concerns included reliance on an asthma pump despite no recorded asthma diagnosis, the absence of a care plan that would have provided Out of Hours clinicians with fuller medical records, and questions about the implementation and accessibility of the care plan system.
City & Hackney Integrated Primary Care C.I.C.Recipient name withheldThe Lawson Practice
Linda McLaughlin was treated for chronic myeloid leukaemia with nilotinib and later developed interstitial lung disease, probably as a consequence of the treatment. She was admitted with bronchopneumonia and died at Tameside General Hospital on 27 October 2023. Concerns included limited awareness of this rare complication, consent processes that may not mention it, and a lack of clear guidance on stopping treatment when patients are in remission.
NHS England
Bryan Herbert Whitby had chronic kidney disease and underwent a CT scan while his renal function was deteriorating and he was taking metformin. After the scan, further deterioration was identified, but there were delays and failures in escalating the results, arranging urgent admission, recognising his serious condition, providing treatment, and transferring him to the High Dependency Unit; he died shortly after admission there. The principal concerns included communication and escalation failures, inadequate recognition and treatment of acute illness, and delayed critical-care transfer.
Davyhulme Medical CentreManchester University NHS Foundation Trust
Jade Michelle Hart died on 9 July 2018 after giving birth, following a uterine inversion caused by inappropriate management of the third stage of labour. She suffered massive uterine haemorrhage and multiple cardiac arrests, with delayed recognition and management of the bleeding, and the inquest concluded that her death was contributed to by neglect. The report raised concerns about the Trust’s serious incident investigation and insufficient support for newly appointed obstetric consultants.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Lee Francis Grimes, who was known to misuse cocaine and had schizophrenia, was found collapsed and unresponsive at home on 21 March 2016. Before his death, he disclosed on two occasions that he had taken an overdose of prescribed medication, but the disclosures did not result in assessment or treatment, and a message to the Community Mental Health Team was not followed up or acted upon. The report raised concerns about failures in responding to overdose disclosures and referral messages, and about staff training and procedures.
Mersey Care NHS Foundation TrustNext Stage "A Way Forward" Ltd
Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.
Essex Partnership University NHS Foundation Trust
Frances Elizabeth Greenhalgh died on 10 April 2017 after taking a substantial overdose of Mirtazapine and Dihydrocodeine, following a recent hospital admission after an overdose and discharge with a mental health care plan. The principal concern was that the GP surgery did not promptly record or act on the RAID Team’s faxed notification and treatment plan, so the plan was not available to the GP at the deceased’s appointment.
Heaton Medical Centre
Mr Yusuf Seyit had been in hospital since January and, after developing suspected urinary and chest infections, deteriorated into septic shock. He died on 3 July 2019. The concerns were uncertainty about whether there was a plan for timely antibiotic treatment, and uncertainty about when Amikacin was administered despite evidence that it was needed within an hour in septic shock.
University Hospital Lewisham
Robert Day died on 15 January 2025 after taking a significant overdose of prescription medication and refusing treatment after an ambulance and police response. The principal concern was the absence of national guidance for frontline emergency services dealing with complex, time-critical situations involving mental health concerns, which the report said risks the lives of others.
Department of Health and Social CareHome Office
Margaret Crooks attended Stepping Hill Hospital after being diagnosed with a stroke and received intravenous thrombolysis. She developed a large bleed attributed to the thrombolysis, and died at Salford Royal Hospital on 20 February 2025. The report identified confusion about the level of overnight specialist stroke support and concern that time-critical treatment advice was not provided promptly or with stroke consultant input.
NHS Greater Manchester Integrated Care Board
Mark Richard HINTON attended A&E with right calf pain and swelling after being advised to attend because of a possible clot. He was discharged before a markedly raised D-Dimer result became available; the inquest recorded pulmonary embolus due to deep vein thrombosis and bleeding duodenal ulcer, with a conclusion of “Preventable Natural Cause”. Concerns included failures in recording and communicating the D-Dimer request and result, delayed testing, inadequate documentation, and other system and process failures.
the Shrewsbury and Telford Hospital NHS Trust
