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Karen Ravenscroft · Prevention of Future Deaths report View report

23 May 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

Karen Ravenscroft fell at home on 11 March 2016 and fractured her left arm and leg. She was assessed as being at high risk of venous thromboembolism but was not prescribed appropriate prophylaxis, subsequently developed a deep vein thrombosis, and died from a fatal pulmonary embolus. Concerns included the absence of thromboprophylaxis, failure to reassess VTE risk or provide mechanical prophylaxis, and limitations in electronically prescribing drugs from the Accident & Emergency Department.

Dr Alan William Kingsbury · Prevention of Future Deaths report View report

8 Jul 2024 West Sussex, Brighton and Hove K. Henderson

Dr Alan William Kingsbury, who was extremely frail, died in hospital on 29 October 2023 after excessive bleeding from a chest lesion excision while taking aspirin and clopidogrel, followed by a fall causing a fractured right neck of femur. The report raised concerns about the robustness of guidance on antithrombotic medication, the absence of preoperative assessment and advanced consent, and the wound-closure technique used to achieve haemostasis.

Roger Edward Humphrey Ballard · Prevention of Future Deaths report View report

24 May 2021 Manchester South A. Mutch

Roger Edward Humphrey Ballard was admitted to hospital with a head injury, and a CT scan showed a contusion and subarachnoid haemorrhage. His anticoagulation medication was not stopped despite neurosurgical advice, and he was later readmitted with a catastrophic bleed. Concerns included unclear reporting and recording of the scan findings and inadequate documentation of clinical decisions, including the decision not to follow specialist advice.

Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report View report

4 Mar 2024 Inner West London F. Wilcox

Lee Martin Hughes was found deceased in his cell at HMP Wandsworth on 25 December 2021 while remanded in custody. The medical cause of death was methadone and benzodiazepine intoxication, and the jury concluded that drug-related misadventure was contributed to by neglect. Concerns included the assessment and prescribing of methadone, failure to respond appropriately to signs of sedation and impaired consciousness, and inadequate communication and escalation between healthcare disciplines.

Jude Daryl Lloyd · Prevention of Future Deaths report View report

4 Oct 2021 Manchester City N. Meadows

Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

Edna Elsie Mary Eden · Prevention of Future Deaths report View report

27 Nov 2013 Berkshire P. Bedford

Edna Elsie Mary Eden, who had been living independently, was admitted to hospital after feeling unwell and reporting recent right-sided chest pain. She remained in A&E and the AMU for approximately fourteen and a half hours before being seen by a doctor, then arrested and could not be revived. The report identified missed opportunities involving delayed medical review, failure to recognise or escalate abnormal findings, inadequate communication, incorrect observation scoring, and lack of antibiotic cover.

Beatrice Florence May DAWKINS · Prevention of Future Deaths report View report

5 Apr 2022 Hampshire, Portsmouth and Southampton J. Pegg

Beatrice Florence May DAWKINS died on 20 September 2020 at Queen Alexandra Hospital after suffering an anaphylactic reaction to chloramphenicol administered for a urinary tract infection. The principal concern was that records of her sensitivity to chloramphenicol were not readily accessible or flagged to clinicians before the medicine was administered, creating a future risk to life.

Jennifer Ann Trigger · Prevention of Future Deaths report View report

1 Mar 2024 North Wales (East and Central) J. Gittins

Jennifer Ann Trigger was admitted to Wrexham Maelor Hospital on 29 January 2020 after suffering an acute stroke and was prescribed beriplex, a time-critical treatment, which was not administered until the following morning. The report identified miscommunication and limitations in the bleep system as contributing to delays in prioritising and administering the treatment, followed by deterioration in her condition and her death on 31 January 2020.

Grace Mary Bates · Prevention of Future Deaths report View report

7 Jan 2014 North London A. Walker

Grace Mary Bates died in hospital on 21 April 2013 from complications associated with poorly managed diabetic episodes. The report raised concern that no specialist diabetic nurse was available at the hospital over the weekend, during which her blood sugar management was poor.

Rita Paton · Prevention of Future Deaths report View report

28 Apr 2015 Inner North London R. Brittain

Rita Paton, who had type 2 diabetes, hypertension, chronic kidney disease and dementia, died on 8 December 2014 from ischaemic and hypertensive heart disease, contributed to by chronic kidney disease and diabetes mellitus. Concerns included the lack of a system to ensure requested blood tests were completed and reported, the absence of a clear process for involving family when a patient lacks capacity to make decisions about appointments, and limited access to patients’ medical and medication information for attending medical crews.

Esther Jane Jones · Prevention of Future Deaths report View report

2 Jul 2014 North Wales (East and Central) J. Gittins

Esther Jane Jones died at Maelor Hospital, Wrexham, on 30 March 2013. Her death was recorded as due to natural causes, with concerns about missed medication and the process for conducting and completing Serious Incident Reviews, which was said to pose continuing risks to others and may lead to future deaths.

Michael Blow · Prevention of Future Deaths report View report

12 Aug 2016 Portsmouth and South East Hampshire K. Harrold

Michael Blow was admitted after falling downstairs and sustained chest injuries, including fractured ribs, lung contusions and a pneumothorax. His condition later deteriorated, with blood in the chest drain, an INR of 9, and he died following cardiac arrest; the recorded cause of death included haemothorax, fractured ribs and warfarin treatment. Concerns included a requested INR test not being carried out and warfarin being restarted using an outdated INR result without sufficient account of other treatments and medication.

James Stuart Atkinson · Prevention of Future Deaths report View report

26 Jan 2024 Newcastle and North Tyneside K. Dilks

James Stuart Atkinson, who had a known peanut allergy and asthma, died of anaphylaxis after eating a Chicken Tikka Masala pizza containing peanuts from Dadyal Takeaway Restaurant on 10 July 2020. The report identified concerns about the lack of allergen information from the takeaway, the absence of regular allergy reviews, and the failure to locate his Epi-pen during the reaction.

Mr Valdas Jasiunas · Prevention of Future Deaths report View report

8 Mar 2017 East London N. Persaud

Mr Valdas Jasiunas, who had serious underlying health problems including chronic alcohol liver disease and seizures, was arrested and held in police custody on 1 September 2010. He collapsed in his cell the following morning and died in hospital on 2 September 2010. Concerns included the identification and management of alcohol dependency, erroneous custody-record entries that could provide false reassurance, and communication difficulties where English was not the detainee’s first language.

Pamela George · Prevention of Future Deaths report View report

30 Jan 2026 Devon, Plymouth and Torbay D. Archer

Pamela George, aged 70, died at Derriford Hospital on 30 June 2023 after being urgently admitted with suspected sepsis. The report identified missed opportunities to carry out required blood tests, manage a breast infection, document and escalate a fall and medical concerns, assess and record capacity, and maintain relevant care-home policies and records.

Miss Hannah Enola Angela Ayomipo Jacobs · Prevention of Future Deaths report View report

20 Aug 2024 East London S. Radcliffe

Hannah Jacobs, aged 13, died on 8 February 2023 after consuming a dairy milk hot chocolate despite having severe dairy allergies and developing anaphylaxis. She and her mother were not carrying an adrenaline auto-injector, and the available paediatric injector at the pharmacy was an insufficient dosage. The report identified concerns about arrangements for carrying auto-injectors between home and school and the need to educate schools, patients and parents about carrying them.

Myles Edward Scriven · Prevention of Future Deaths report View report

14 Jul 2025 West Yorkshire (Western) C. Oliver

Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that lack of adjustments for his Autism and Learning Disabilities contributed to incorrect decisions about his care and medication. The principal concern was that existing training, policies and support arrangements were not effectively applied or audited to ensure safe care and medication decisions.

Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report View report

20 Aug 2024 East London S. Radcliffe

Hannah Enola Ayamo Jacobs, aged 13, developed anaphylactic symptoms after being served a dairy hot chocolate despite her reported dairy allergy and later died following cardiac arrest. The concerns included dental staff not recognising excessive salivation as inability to swallow and a sign of anaphylaxis, possible misunderstanding of symptoms by her mother, and the availability and use of adrenaline auto-injectors during shortages.

Thomas Grenville Hammersley Ithell · Prevention of Future Deaths report View report

22 Jan 2024 North Wales (East and Central) K. Robertson

Thomas Ithell, aged 77, died in hospital on 20 November 2022 after prostate cancer progressed and caused his death. He had become lost to follow-up, with PSA monitoring and clinical review not occurring for about 10 months after November 2021. Concerns included the absence of a Datix report and Health Board investigation, lack of assurance about learning or changes, and staff time constraints affecting incident reporting.

Benjamin Thomas Brown · Prevention of Future Deaths report View report

5 Sep 2016 North London A. Walker

Benjamin Thomas Brown was a patient detained under section 2 of the Mental Health Act who was found unresponsive at 8.45am after gaps and inaccurate entries in the required 15-minute observation records. He was recognised as having died at 10.06, and the inquest recorded natural causes, with sudden cardiac death due to cardiac arrhythmia. The substantive concerns related to auditing 15-minute observations, staff resuscitation training, and auditing the prescription and management of clozapine.