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David Andrew Bladen · Prevention of Future Deaths report View report

4 Mar 2015 South Yorkshire (Eastern) N. Mundy

David Andrew Bladen ruptured his right quadriceps tendon after falling down stairs and underwent reconstructive surgery. He received thromboprophylaxis during and shortly after surgery but no extended treatment after discharge, and died on 2 September 2014 from a massive pulmonary embolism. The principal concern was the absence of clear guidance on optimum thromboprophylaxis for patients with restricted mobility due to a brace rather than a cast.

Nicola FORSTER · Prevention of Future Deaths report View report

20 Jun 2024 Bedfordshire and Luton E. Whitting

Nicola FORSTER, a Metropolitan Police Service Sergeant, was found hanging by a ligature at her home on 28 September 2022, and her death was confirmed by paramedics. The inquest concluded that she intentionally took her own life following a deterioration in her mental health exacerbated by actions of her employer. The report raised concerns about poor management, institutional defensiveness, and a fear among junior officers of speaking out about management.

Seema Pravin HARIBHAI · Prevention of Future Deaths report View report

7 Jul 2022 Inner North London M. Hassell

Seema Haribhai, who had increasingly disabling psoriatic arthritis, took herbal remedies prescribed by an Ayurvedic practitioner and developed liver failure, dying some weeks later. The investigation determined that she died as a consequence of the administration of Ayurvedic medicines intended to treat psoriatic arthritis. Concerns included the practitioner’s failure to recognise the possible harm from the medicines or advise their immediate cessation, the lack of regulation and evidence of quality control, and shortcomings in the GP’s assessment and response to her symptoms and abnormal blood test.

Peter John WALKER · Prevention of Future Deaths report View report

29 Jun 2023 Suffolk N. Parsley

Peter Walker died after the microlight aircraft he was flying alone crashed in a field adjacent to the runway at Beccles Aerodrome on 24 March 2022. The concerns included shortcomings in the Civil Aviation Authority’s guidance and systems for medical self-declarations, licence revalidation, and managing licence revocation or surrender for older pilots and certain microlight licence holders.

Mrs Margaret Melia · Prevention of Future Deaths report View report

18 Apr 2019 Black Country Z. Siddique

Mrs Margaret Melia was admitted to Dovetail Court Care Home in October 2018, later developed declining food and fluid intake, was admitted to hospital with dehydration and a lower respiratory tract infection, and died on 7 November 2018 while receiving end-of-life palliative care. The inquest identified an inadequate discharge and pre-assessment process between Lakeview Care Home and Dovetail Care Home concerning the requirement for subcutaneous fluids.

Amy Hogan · Prevention of Future Deaths report View report

31 Jul 2020 Manchester South C. Morris

Amy Hogan reported feeling unwell from around September 2019 and attended an out-of-hours doctor on 20 January 2020 with light-headedness, weakness and exhaustion. She became acutely unwell and collapsed at home the following day, dying at hospital aged 23. The principal concerns were that her previous GP records had not transferred and that the out-of-hours GP could not electronically access her regular records, including information that she was prescribed the oral contraceptive pill.

Michael Uriely · Prevention of Future Deaths report View report

22 Mar 2017 Inner West London S. Radcliffe

Michael Uriely had asthma from early childhood, which deteriorated and was uncontrolled in the seven months before his death. The report identified missed opportunities in the management of his asthma, including a lack of coordinated overall responsibility and long-term care planning, failure to assess and optimise treatment consistently, poor communication between services, and failure to refer him to a specialist respiratory service.

Frederick William LE GRICE · Prevention of Future Deaths report View report

29 Sep 2023 Essex S. Simblet

Frederick William LE GRICE had prostate problems and recurrent urinary tract infections treated with nitrofurantoin. After taking the drug for several years, he developed coughing, breathlessness and interstitial lung disease; he later died from pneumonia, with interstitial lung disease and nitrofurantoin toxicity contributing. The concerns relate to limited awareness and unclear guidance for clinicians and patients about nitrofurantoin-associated lung damage and the need to recognise and monitor respiratory symptoms.

Wendy BODDINGTON · Prevention of Future Deaths report View report

3 Mar 2026 Derby and Derbyshire P. Nieto

Wendy BODDINGTON was found deceased at home on 24 March 2025 after friends had been unable to contact her for several days. She had two fentanyl patches on her body instead of the single prescribed patch; toxicology found fentanyl at a fatal level, with prescribed codeine adding to the toxicity. The principal concern was that people receiving long-term, often high-dose opiate and opioid prescriptions for chronic pain may not receive adequate support to reduce, stop, or substitute these medications.

Gary David Ash · Prevention of Future Deaths report View report

15 May 2024 East London N. Persaud

Gary David Ash died at Queen's Hospital on 25 June 2019 after developing serotonin syndrome shortly after receiving a general anaesthetic without valid consent. He subsequently received large amounts of intravenous fluid, developed fluid overload and pulmonary oedema, and suffered a cardiac arrest. The principal concerns included knowledge and management of neuroleptic malignant syndrome and serotonin syndrome, use of Dantrolene, fluid monitoring, and potential drug interactions affecting cardiac contractility.

Christian James Gabriel Hobbs · Prevention of Future Deaths report View report

7 Apr 2025 Cambridgeshire and Peterborough D. Heming

Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.

CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report View report

31 Oct 2014 Inner South London S. Ormond-Walshe

Christopher Toke Ajayi, who had schizo-affective disorder and insulin-dependent type II diabetes, was discharged into unsupported accommodation and was found decomposed there on 17 September 2012 after apparently receiving no professional or carer visits for about a month. The report identified concerns about discharge planning, lack of supported accommodation and GP care, failures to communicate his medical needs, and failure to follow up missed appointments, medication and insulin treatment. The inquest found the cause of death to be hyperosmolar non-ketotic coma associated with diabetes mellitus, with neglect contributing.

Vasilis KTORAKIS · Prevention of Future Deaths report View report

19 Oct 2015 Inner North London M. Hassell

Baby Vasilis was born in an extremely poor condition following a long labour at Whittington Hospital on 23 May 2015 and died shortly thereafter. The report identified concerns about the timing of Syntocinon, inadequate recording of a management plan, a registrar’s decision regarding passive descent, and failures to involve staff in the investigation and communicate its findings for learning.

Maureen Woods · Prevention of Future Deaths report View report

24 Jul 2019 Nottinghamshire L. Bower

Maureen Woods died on 26 January 2019 while a patient at the Emergency Department of Bassetlaw District General Hospital after experiencing symptoms consistent with a cardiac event and subsequently suffering cardiac arrest. The report identified concerns about delays in ambulance dispatch for category 2 calls involving possible cardiac events and the failure to administer Amiodarone. It stated that these failings prevented her from having the best possible chance of survival, although it could not be concluded that either caused or contributed to her death.

Francoise Simone Annabel SNAPE · Prevention of Future Deaths report View report

13 Feb 2013 Worcestershire G. Williams

Mrs Snape was admitted to Worcestershire Royal Hospital on 2 August 2014 after an infarcted stroke and later developed a massive pulmonary embolus. Thromboembolic medication caused a catastrophic bleed resulting in her death. Concerns included the absence of a VTE assessment and failure to consider relevant NICE guidance on mechanical anti-DVT devices, which represented a lost opportunity for informed care and may have changed the outcome.

Regan Edwin James SMITH · Prevention of Future Deaths report View report

24 Jul 2024 Suffolk N. Parsley

Regan Smith died at Kings College Hospital on 31 January 2023 after previously undiagnosed diabetes led to severe metabolic acidosis, multiorgan failure and acute liver failure. An abnormal blood glucose reading obtained by ambulance staff was not effectively handed over or recorded at hospital, resulting in his discharge without further glucose testing or treatment. The report identifies concerns about incompatible information systems, reliance on verbal handover during a period of high acuity, and the absence of national standards for emergency department handovers and confirmation of basic observations.

Christopher Brazil · Prevention of Future Deaths report View report

23 Apr 2025 Ceredigion L. Corcoran

Christopher Brazil had physical pain, sciatica and poor mental health, and sourced additional medicines and drugs from unlawful online providers. He died in August 2022 after unintentionally overdosing on benzodiazepines. The concerns included the accessibility and legitimacy of unregulated websites, unsafe or counterfeit medicines, inadequate checks of medical history, dosage guidance, safeguards, age and identity verification, and rapid delivery.

Ross REEVES · Prevention of Future Deaths report View report

29 Mar 2018 Brighton and Hove V. Hamilton-Deeley

Ross REEVES died after taking more than one week’s worth of Gabapentin, Zomorph and Mirtazapine, which caused profound stupor and respiratory depression; he subsequently developed lobar pneumonia. The principal concern was that his transfer to a new GP was likely unsafe and that better handover information might have led to different prescribing arrangements.

Janet Alison Anderson · Prevention of Future Deaths report View report

9 May 2025 Manchester South A. Mutch

Janet Alison Anderson, who had schizophrenia, Lewy Body Dementia and Parkinsonism symptoms, was admitted to Manchester Royal Infirmary with a suspected infection and remained there after she was medically optimised for discharge. She subsequently declined, developed repeated infections, and died on 28 October 2024 from bilateral pneumonia. Concerns included the prolonged hospital stay, lack of joined-up working and discharge planning between trusts, poor documentation of key decisions, and the resulting unavailability of an acute hospital bed.

Julie Louise Hancock · Prevention of Future Deaths report View report

15 May 2023 Cornwall and Isles of Scilly A. Cox

Julie Louise Hancock underwent a right total knee replacement on 2 March 2022, was discharged on 5 March 2022, and died at home on 28 March 2022. Her post-mortem cause of death was pulmonary embolus due to deep vein thrombosis, with immobility following the knee replacement. The concerns included apparent prescription of low-risk thrombosis prophylaxis despite her being assessed as high risk, an unidentified doctor’s prescription of dalteparin that was stopped after one dose, and possible discrepancies between summary and full thrombosis-prevention guidance.