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Samantha Singh · Prevention of Future Deaths report View report

2 Jul 2021 East London G. Irvine

Samantha Singh developed a suspected nut allergy, was assessed as having a mixed nut allergy, and was prescribed an EpiPen. On 25 July 2020, she became unwell at home and suffered a cardiac arrest attributable to anaphylactic shock; she could not be resuscitated. The concerns included the miscategorisation of her test results, prescription of only one EpiPen, and lack of referral to an allergy clinic or follow-up appointment.

Dr Kenneth Wilson CULLY · Prevention of Future Deaths report View report

30 Apr 2026 East Riding and Hull L. Harris

Dr Kenneth Wilson CULLY died after a catastrophic, uncontrollable bleed from the foot while taking blood-thinning medication. The report identified a concern that the ambulance service’s newer NHS Pathway system may lack sufficient questions to recognise the seriousness of an uncontrolled bleed, potentially leading to incorrect categorisation and delayed treatment.

Michael Lobban · Prevention of Future Deaths report View report

4 Oct 2019 London Inner (West) R. Caller

Michael Lobban, who had drug dependency and mental illness, was found dead at home on 23 October 2017 with a significant methadone overdose and other drugs in his body. The report raised concerns about the speed and completeness of Boots’ investigation into missing methadone, the robustness of its controlled-drug audit procedures, and the General Pharmaceutical Council’s reporting and investigative arrangements for discrepancies in controlled drugs.

Kevin Dermott · Prevention of Future Deaths report View report

13 Jun 2016 Cheshire N. Rheinberg

Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his death.

Kathryn Mary Barrow · Prevention of Future Deaths report View report

19 Sep 2019 Manchester South C. Morris

Kathryn Mary Barrow was found dead at her home on 7 March 2019, aged 59, after a long history of mental illness and treatment for bipolar affective disorder. A post-mortem did not establish a medical cause of death, and the inquest recorded an Open conclusion. Concerns related to the prescribing of Diazepam, including inadequate documentation or checks, whether access to the medicine illicitly had been considered, and the practice’s lack of a recent review of its prescribing approach.

Rita Taylor · Prevention of Future Deaths report View report

12 Jun 2018 Surrey K. Henderson

Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.

Lily May Girton · Prevention of Future Deaths report View report

11 Aug 2022 East London N. Persaud

Lily May Girton, who had anxiety, depression and emotional dysregulation, died after taking her own life while suffering from mental illness. The inquest found that her death was contributed to by failures in the community CAMHS team concerning psychiatric assessment, risk management and titration of antidepressant medication. It also raised concerns that inadequate staffing and resources in CAMHS services pose a risk of future deaths of young people.

Lyndsey Holt · Prevention of Future Deaths report View report

29 Mar 2017 South Yorkshire (Eastern) N. Mundy

Lyndsey Holt, who was 37 weeks pregnant, collapsed after a gastric ulcer perforated and caused catastrophic bleeding. She died the following morning after emergency surgery and resuscitation; concerns included the telephone prescribing of methadone without sufficient information, assessment, or early medical review, and the provision of a seven-day supply to a methadone-naïve patient.

Elliott James Harratt · Prevention of Future Deaths report View report

20 Jul 2023 Manchester South A. Mutch

Elliott James Harratt was born at the family home following his mother's early labour, transferred to Tameside General Hospital, and died there on 29 January 2023 from extreme prematurity. The inquest identified concerns that expectant mothers were not given clear, readily accessible information about sensitising events requiring Anti-D treatment or when to contact maternity triage; this matter did not contribute to Elliott's death.

Tripta Rani KUMAR · Prevention of Future Deaths report View report

19 Sep 2013 London Eastern C. Inyama

Tripta Rani KUMAR underwent planned hysterectomy and was discharged, but was readmitted the following day with abdominal pain and a perforated bowel. She developed sepsis, suffered a cardiac arrest on 25 August 2012, and died despite CPR. A principal concern was that penicillin-containing Tazocin was prescribed despite records and a wristband indicating a penicillin allergy, after an unsigned handwritten alteration changed the record to “nil allergies”.

Ronald Richard TILLEY · Prevention of Future Deaths report View report

4 Dec 2020 North East Kent J. Andrews

Ronald Richard Tilley presented to hospital on 16 October 2019 with a right ischaemic leg after anticoagulation had been stopped because of concerns about his capacity to manage medication. An assessment of his memory and capacity was completed, but the GP did not receive the communications because another surgery had amended the GP and correspondence address on the Personal Demographic Service; the principal concern was that such amendments do not notify the existing GP.

Bonnie Rose WEBSTER · Prevention of Future Deaths report View report

25 Nov 2022 Norfolk J. Lake

Bonnie Rose Webster was born by emergency caesarean section in a poor condition on 9 February 2022, required resuscitation and neonatal treatment, and died the following day after her condition deteriorated. Concerns included communication with her parents about the seriousness of the situation, a delay in giving prescribed antibiotics, and paediatric staff being alerted on foot rather than through the emergency bleep system.

Marcus William George McGuire · Prevention of Future Deaths report View report

23 Jun 2019 Birmingham and Solihull E. Brown

Marcus William George McGuire died at HMP Birmingham on 24 April 2018 after being found in his cell with a ligature around his neck. The inquest concluded that his suicide was possibly contributed to by failures to carry out a mental health assessment, respond to missed anti-psychotic medication, involve mental health services in the ACCT process, assess his risk using all relevant information, and properly manage the ACCT.

David Glyn Price · Prevention of Future Deaths report View report

1 Jun 2015 Manchester South J. Pollard

David Glyn Price suffered a heart attack in early June 2011 and underwent surgery at Wythenshawe Hospital, during which a swab was inadvertently left inside his body attached to his heart; this gradually formed an abscess. Concerns included continued warfarin prescribing despite missed anticoagulation appointments, poor handwritten clinical records, failure to act on imaging showing a foreign body, and inadequate swab-count procedures.

Barry THOMPSON · Prevention of Future Deaths report View report

11 Oct 2016 Blackpool and the Fylde C. Doherty

Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

Luke Owen ASHCROFT · Prevention of Future Deaths report View report

20 Mar 2026 Greater Lincolnshire P. Smith

Luke Ashcroft was admitted to Lincoln County Hospital from HMP Lincoln after being found unconscious in his cell in the Care and Separation Unit. His death was confirmed on 1 July 2020, with the post-mortem finding hypoxic brain injury consistent with ligature application. The inquest identified concerns about missed healthcare opportunities, inadequate information sharing and risk mitigations, shortcomings in the ACCT plan, and failures to carry out required observations; it also raised concerns about the safety and availability of corded telephone access in the unit.

Timothy Simon Jones · Prevention of Future Deaths report View report

24 Nov 2016 Birmingham and Solihull L. Hunt

Timothy Simon Jones, who had Down syndrome, epilepsy and dementia and required PEG feeding, was admitted to hospital with breathing difficulties and aspiration pneumonia, was discharged and readmitted the same day, and died on 17 July 2016. Concerns included incomplete GP record keeping, unclear communication and documentation of requests for home visits, lack of GP clinical assessment despite deteriorating health and complex needs, a home-visit policy that did not address residents with complex chronic conditions, and antibiotic prescribing for aspiration pneumonia.

Gordon Frank Thornhill · Prevention of Future Deaths report View report

4 Dec 2017 South Yorkshire (Eastern) N. Mundy

Gordon Frank Thornhill, a 61-year-old man, developed abdominal pain, attended A&E twice, and collapsed and died at home on 13 April 2017. The report identified incomplete VTE risk assessment, failure to identify that omission, undocumented consultant assessment, and a delay of more than 24 hours in providing thromboprophylaxis; the inquest conclusion was natural causes, with death from pulmonary embolism following DVT development.

Joseph David POWELL · Prevention of Future Deaths report View report

17 May 2025 Cheshire S. Murphy

Joseph David POWELL, aged 28, was found suspended at his home on 6 September 2024 and did not respond to resuscitation. The principal concern was that requiring patients with mental health difficulties to book their own GP follow-up may result in missed reviews and no further medication.

Roy Elton TRAVERS · Prevention of Future Deaths report View report

8 Nov 2022 Inner North London M. Hassell

Roy Travers died on 6 June 2022 from a spontaneous cerebral bleed after admission to Whittington Hospital on 2 June, where he was not initially scanned and the bleed was not diagnosed. Concerns included delayed review after melaena was noted, failure to withhold apixaban, uncertainty about whether identified learning actions took place, and concerns about the treatment of Mr Travers and the late disclosure of the hospital’s review to the coroner and family.