Search PFD Monitor

Laura Eve PARSONS · Prevention of Future Deaths report View report

3 Sep 2020 County Durham and Darlington J. Thompson

Laura Eve Parsons was found dead at home on 5 November 2019, after consuming a fatal amount of liquid morphine prescribed for breakthrough cancer pain. She had previously been admitted to hospital following an accidental morphine overdose, but a repeat prescription was later issued without the electronic prescribing system directing the prescriber to review the prominent medical-record information about that overdose.

Rohan Dayal Singh · Prevention of Future Deaths report View report

30 Apr 2021 East London G. Irvine

Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.

Michael John Spencer · Prevention of Future Deaths report View report

5 Feb 2018 South Yorkshire (Western) A. Forrest

Michael Spencer died from a fatal midbrain haemorrhage while being treated with Rivaroxaban as part of a clinical trial. The concern was that Andexanet alfa, a specific reversal agent for Factor Xa inhibitor anticoagulants, was not available in the UK, although the evidence stated that its availability would not have changed the outcome in Mr Spencer’s case.

Deborah Chapman · Prevention of Future Deaths report View report

1 Aug 2019 Manchester South A. Farrow

Deborah Chapman, who had COPD, chronic pain, and continued to misuse heroin and crack cocaine, was found unresponsive at home on 3 March 2019 and was pronounced dead at 7.06am. The post-mortem attributed her death to the combined toxic effects of heroin, oxycodone and pregabalin, together with COPD. Concerns included whether her ongoing illicit drug use and the risks of combining prescribed and illicit drugs had been adequately assessed and recorded when prescribing oxycodone and pregabalin.

Name not published · Prevention of Future Deaths report View report

1 Apr 2022 Manchester City N. Meadows

The deceased had chronic mental health problems, serious self-neglect and infected wounds, and was detained in hospital under the Mental Health Act. After readmission, a VTE risk assessment, monitoring, records, management plan and further capacity assessments were not undertaken; she suffered a pulmonary thromboembolism and died following a cardio-respiratory arrest on 23 February 2020. The principal concerns included inadequate safeguarding and clinical oversight, failures to implement and audit the VTE policy, and insufficient staff training.

Michael BRIGGS · Prevention of Future Deaths report View report

18 Apr 2024 Derby and Derbyshire S. Loman

Michael Briggs developed infective endocarditis after three dental extractions and died at Royal Derby Hospital on 11 January 2023. The principal concerns were limited guidance for dentists in England and Wales about managing patients at increased risk of infective endocarditis, and conflicting guidance on antibiotic prophylaxis.

Dean Emrode Elie · Prevention of Future Deaths report View report

6 Jan 2015 North London A. Walker

Dean Emrode Elie was found dead at home on 27 February 2013, having died in his sleep. He had missed several GP appointments for medication review, diabetic review and blood tests, and concerns were raised about the lack of a way to ensure his attendance; the report identified consideration of further legislation on this issue.

Edward Thomas WILSON · Prevention of Future Deaths report View report

5 Jun 2025 Cheshire J. Devonish

Edward Thomas Wilson was attended by paramedics at home and later transported to hospital after worsening breathing difficulties; he suffered cardiac arrests during transit. The principal concern was that paramedics did not take his significant heart failure into account when administering salbutamol nebulisers, which lowered his blood pressure.

Carol Ann DIVALL · Prevention of Future Deaths report View report

14 May 2024 East Sussex R. Redman

Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.

James Colin Day · Prevention of Future Deaths report View report

7 Feb 2024 Manchester South A. Mutch

James Colin Day, who had developed severe post-traumatic stress disorder after serving in Afghanistan, collapsed and died on Malvern Road on 6 May 2023. The report describes concerns that mental health support for service personnel with severe PTSD, both during service and after discharge, was patchy and difficult to access, and that he used alcohol and prescribed medication to cope with his symptoms.

Khalid Abiaz · Prevention of Future Deaths report View report

20 Jun 2022 Swansea and Neath Port Talbot K. Heaven

Khalid Abiaz, a prisoner at HMP Swansea, died in the early hours of 13 September 2016 after being found suspended by a ligature. The report identified concerns that an ACCT was not opened despite suicide warning markers and relevant historical information, and that prison and bank nursing staff may not have received sufficiently frequent or up-to-date ACCT training.

Darrell Lee DEVLIN · Prevention of Future Deaths report View report

23 Nov 2021 Cumbria N. Shaw

Darrell Lee Devlin died at home on 23 February 2021 after being unwell with a chest infection and while receiving methadone treatment. The inquest record reported active bronchopneumonia and an extremely high level of Flubromazolin in his bloodstream. Concerns focused on reliance on telephone contacts, the absence of in-person assessment and drug testing, and the resulting difficulty in assessing and supporting him while receiving treatment.

Mrs Ashana Charles · Prevention of Future Deaths report View report

11 Dec 2025 South London A. Harris

Mrs Ashana Charles died suddenly in hospital on 20 November 2018 after an unexpected cardiac arrest during intravenous feeding. The inquest concluded that cellulose fibres from inadvertently contaminated intravenous infusions caused acute obstruction of small pulmonary arteries, and that the death would have been prevented by using a 1.2-micron filter, which was not standard practice at the time. Concerns included the failure to retain infusion equipment for forensic investigation, inconsistent guidance and practice on filters, and uncertainty about the adequacy of batch-based visual checks of parenteral nutrition products.

David Wade · Prevention of Future Deaths report View report

6 Sep 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

David Wade, who was receiving Warfarin therapy for atrial fibrillation, developed severe headaches, vomiting and collapse on 14 June 2016. A CT scan showed a non-survivable cerebellar haemorrhage; the report identified concern that there was no system for providing anticoagulant patients with information about brain-bleed symptoms and what action to take.

Mary Barbara Ryder · Prevention of Future Deaths report View report

27 Sep 2018 Manchester South A. Mutch

Mary Barbara Ryder underwent surgery for bladder cancer and was discharged after receiving Clexane, with reduced mobility and no further clinical review regarding Clexane. She later deteriorated, was diagnosed with a pulmonary embolism and died on 21 August 2017. The inquest raised concerns that guidance did not address whether some patients with ongoing reduced mobility might require longer treatment or emphasise review after discharge.

Audrey Lily Kelly · Prevention of Future Deaths report View report

8 Apr 2014 Manchester South J. Pollard

Audrey Lily Kelly complained of abdominal pain on 17 November 2013, was prescribed Trimethoprim by an out-of-hours doctor who could not access her GP medical notes, and was found deceased at home two days later. The investigation concluded that she died from natural causes. The principal concern was that out-of-hours services and hospital emergency departments could not access patients’ GP notes, including allergy information, which was considered a serious procedural lapse that could put lives at risk.

Marta Elena Vento · Prevention of Future Deaths report View report

11 Mar 2025 Dorset R. Griffin

Marta Elena Vento was working alone as a hotel receptionist in Bournemouth when she was fatally beaten in an unprovoked attack on 9 December 2020. The report raises concerns about the sharing of remand prisoners’ risk information with sentencing courts, continuity of mental healthcare after release from prison, risk assessment of violent offenders managed by MOSOVO units, and access to patient information through the National Record Locator.

Norma Bradbury · Prevention of Future Deaths report View report

27 Jan 2021 Manchester City A. Bridgman

Norma Bradbury underwent aortic valve replacement on 15 February 2019, was discharged home on 22 February, and was found deceased beside her bed on 3 March 2019. The report identified concern that the discharge letter, which required GP involvement within one week to check bloods and blood pressure and restart and titrate Losartan, was not received until 25 February. The medical cause of death was recorded as intracerebral haemorrhage, with systemic hypertension and oral anticoagulation for atrial fibrillation contributing.

Sheridan Tate Pickett · Prevention of Future Deaths report View report

19 Mar 2025 Manchester South J. Gill

On 9 August 2024, Sheridan Tate Pickett sustained fatal injuries after falling from a height out of a window; the inquest concluded that the death was suicide. The concern was that information about an overdose and advice not to recommence ADHD medication was not shared with the private ADHD provider, and that there were no current guidelines governing information sharing between private psychiatry providers and NHS services involved in parallel care.

Michael Roy Mahon · Prevention of Future Deaths report View report

15 Mar 2017 Manchester South A. Mutch

Michael Roy Mahon was found dead at home on 13 September 2016 after a period of deteriorating health and obesity while prescribed clozapine. The inquest heard that he had not received an annual test required for people prescribed clozapine, and that there was no system to identify the missed test or that it had not been noticed during monthly checks. The recorded cause of death was dilated cardiomyopathy, with obesity and clozapine therapy, and alcohol use also listed.