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Christopher Howard SMITH · Prevention of Future Deaths report View report

7 Jul 2023 Nottinghamshire L. Bower

Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.

Harry Glibbery · Prevention of Future Deaths report View report

16 Aug 2016 Plymouth, Torbay and South Devon A. Cox

Harry Glibbery had a chronically infected left hip replacement and underwent a Girdlestone procedure before developing pulmonary emboli. He died on 7 April 2016 after a catastrophic intracerebral haemorrhage while receiving Clexane. The principal concerns were that the Clexane prescription exceeded the Derriford Protocol dose, the error was not identified during pharmacy reviews, and difficulties weighing him may have prevented a dose review as he lost weight.

Valerie Margaret Ellis · Prevention of Future Deaths report View report

16 Jun 2016 West Sussex D. Skipp

Valerie Margaret Ellis, an 83-year-old woman, died at home on 6 September 2015 after a massive gastrointestinal bleed associated with Apixaban. The report identified concerns about inadequate counselling on the medication, communication and call-handling problems in NHS 111, premature closure of an IC24 case, and aspects of ambulance triage.

Joanne Manning · Prevention of Future Deaths report View report

1 Nov 2013 East London N. Persuad

Joanne Manning had a history of poly-substance abuse and methadone treatment, developed asthma and increasing breathlessness, and died from respiratory failure. The inquest conclusion attributed the respiratory failure to the combination of her respiratory disease, methadone, mirtazapine, cocaine and morphine. Concerns included a failure to provide the methadone-prescribing psychiatrist with information about her diagnosis and treatment, and the absence of a procedure ensuring clear communication between general practice and secondary care methadone providers.

SARAH LYNNE REED · Prevention of Future Deaths report View report

28 Jul 2017 London (City) P. QC

Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.

James Robert Quinton · Prevention of Future Deaths report View report

22 Feb 2018 South Yorkshire (Eastern) N. Mundy

James Robert Quinton collapsed after a period of vomiting and abdominal pain, with the inquest recording splenic rupture and combined morphine and methadone toxicity, alongside rivaroxaban therapy, as the cause of death. He did not respond to resuscitation and supportive measures. Concerns included poor-quality nursing and observation records, and noradrenaline intended as an infusion being administered as an intravenous bolus during resuscitation.

Peter Arthur Rowe · Prevention of Future Deaths report View report

29 Jun 2016 Manchester South A. Bridgman

Peter Arthur Rowe was administered the penicillin-based antibiotic co-amoxiclav despite a GP referral letter recording a penicillin allergy. He developed a worsening rash, was admitted to hospital with toxic epidermal necrolysis, and died on 8 February 2016 following deterioration. Concerns included the deletion of recorded allergy information and reliance on allergy answers despite Mr Rowe’s poor memory and his wife’s lack of knowledge of his allergy.

Kellum Paul Thomas · Prevention of Future Deaths report View report

3 Aug 2022 Nottinghamshire E. Didcock

Kellum Paul Thomas, aged thirteen, collapsed at home on 9 June 2021 and died after a cardiac arrest caused by ventricular tachycardia deteriorating into ventricular fibrillation. Concerns included an 18-month gap without a functioning REVEAL heart-monitoring device, delayed replacement processes, and a significantly delayed outpatient letter containing medication and investigation information. The report also identified stretched team capacity and resources and stated that necessary actions to address these issues were not confirmed.

Kate Elizabeth O’Donnell · Prevention of Future Deaths report View report

22 Jan 2024 Teesside and Hartlepool C. Bailey

Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.

Margaret Bernadette WILSON · Prevention of Future Deaths report View report

11 Mar 2019 Manchester City J. Harkin

Margaret Bernadette Wilson was admitted with swelling, pain and bruising, and was provisionally diagnosed with cellulitis and treated with antibiotics without prior blood tests. She later developed chest pain, was diagnosed with endocarditis, did not respond to treatment and died. The report identified concern that the absence of a blood test and the prescribing of antibiotics masked the endocarditis, and stated that earlier diagnosis and treatment would more likely than not have resulted in a different outcome.

Michelle Louise WHITEHEAD · Prevention of Future Deaths report View report

4 Oct 2023 Nottinghamshire L. Bower

Michelle Louise Whitehead died on 7 May 2021 while an inpatient, after acute hyponatraemia caused by psychogenic polydipsia. The report identified failures to follow the Rapid Tranquilisation policy, including inadequate monitoring of consciousness and delays in responding to her deterioration, and raised concerns about staff training, policy clarity, monitoring guidance, and the detection and management of psychogenic polydipsia.

Shane Luke West · Prevention of Future Deaths report View report

19 Jul 2023 Swansea and Neath Port Talbot A. Gruffydd

Shane Luke West was pronounced dead on 17 August 2018 at Morriston Hospital after multi-organ failure caused by cardiorespiratory arrest associated with abdominal distention from chronic constipation and fluid build-up from laxative treatment. The principal concerns were inconsistent records of laxative administration, difficulty assessing his condition due to his learning disability, and whether the risks of further abdominal distention and respiratory compromise were sufficiently appreciated when administering laxatives.

Ronald PERRY · Prevention of Future Deaths report View report

14 Nov 2025 Manchester South A. Mutch

Ronald Perry became increasingly frail after discharge to The Lakes Care Home and experienced several falls, including a fall on 25 April 2025 that resulted in a brain bleed and fractures. He deteriorated after surgery and died at Salford Royal Hospital on 30 May 2025. Concerns included poor care and risk documentation, incomplete falls risk assessments, and inconsistent adherence to the policy on seeking medical advice for unwitnessed falls involving residents on anticoagulants.

Calam Atour · Prevention of Future Deaths report View report

12 Oct 2016 Wiltshire and Swindon D. Ridley

Calam Atour died by suicide in his room at Erlestoke House on 13 May 2015, after hanging himself by a ligature from the window. The inquest identified concerns about staffing shortages, medical support and coordination, the ACCT process, and the adequacy of monitoring and responses to suicide risk. The report also raised concerns that staffing levels and the way staffing requirements were assessed could create unsafe conditions for prisoners and prison officers.

Mrs Natalie Billingham · Prevention of Future Deaths report View report

27 Jul 2018 Black Country Z. Siddique

Mrs Natalie Billingham was admitted to hospital with worsening foot pain, later developed necrotising fasciitis, underwent emergency surgery including a through-knee amputation, and died on the evening of 2 March 2018. The report identified concerns about inadequate communication and delays in reviewing abnormal blood results, recognising sepsis, and administering antibiotics.

Marian Grant · Prevention of Future Deaths report View report

17 Sep 2018 Oxfordshire D. Salter

Marian Grant, aged 74, tripped and fell on 14 April 2018 and died from a pulmonary embolism during surgery for a fractured neck of femur on 16 April 2018. The principal concerns were the omission of VTE prophylaxis, particularly for patients placed on non-trauma wards, and the failure of EPR alerts and other checks to ensure that prophylaxis was prescribed and acted upon.

Danyon Robert Chesters · Prevention of Future Deaths report View report

26 Feb 2019 Manchester South A. Mutch

On 2 July 2018, Danyon Robert Chesters went onto a railway line under Trafford Bridge Road and was struck by a train. The inquest heard concerns about delays in accessing mental health services, the resulting use of private therapy, and a lack of joined-up care and information sharing. It also heard concerns that private therapists might not obtain information about prescribed mental health medication and its impact on therapy.

Michael Yemm · Prevention of Future Deaths report View report

2 Feb 2021 Norfolk Y. Blake

Michael Yemm had dementia and complex medical needs and was placed in a residential care home despite concerns that it was unsuitable and unsafe. He experienced several falls, including an in-patient fall that fractured his hip and required surgery, and later died in hospital. The principal concerns were the care-home placement, his discharge back to a home that had said it could not meet his needs, and the management of falls and dementia patients in hospital.

Rose Mary Hollingworth · Prevention of Future Deaths report View report

8 Mar 2024 Inner North London J. Stevens

Rose Mary Hollingworth, a frail woman with significant co-morbidities, was found unresponsive at home on 3 January 2022 after a carer left without carrying out welfare checks or providing care. She was admitted to hospital and died the following day from a spontaneous intracerebral haemorrhage. The concerns included failures to provide suitably trained and competent carers, supervise and manage carers, maintain an accurate care and support plan, and monitor the care agency.

Collin Gary GRIFFITHS · Prevention of Future Deaths report View report

4 Sep 2018 Inner North London M. Hassell

Collin Gary Griffiths received a yellow fever vaccination on 23 March 2018 despite having previously undergone a thymectomy for a thymoma, and subsequently died from yellow fever vaccine-associated viscerotropic disease and multi-organ failure. The concerns identified were reliance on verbal communication to record medical conditions and the lack of auditing of the accuracy of nurses’ records at the travel clinic.