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Patricia Margaret Thomas · Prevention of Future Deaths report View report

7 Mar 2016 Swansea and Neath Port Talbot P. Bennett

Patricia Margaret Thomas died at Morriston Hospital on 30 October 2013 after suffering an intracerebral haemorrhage, following an episode of unresponsiveness and left-sided weakness. The report identified a potential interaction between Miconazole Gel and Warfarin, a lack of awareness of this interaction among health professionals, and possible difficulties locating clear interaction-checking resources.

Thelma Joyce · Prevention of Future Deaths report View report

23 Aug 2019 Oxfordshire D. Salter

Thelma Joyce commenced chemotherapy for gall bladder cancer, developed a severe reaction, was admitted to hospital and died on 14 February 2019. The principal concern was whether updated guidance and routine testing for DPD deficiency should be introduced for patients due to receive Capecitabine or 5FU chemotherapy.

Mrs. Evelyn KENNEDY · Prevention of Future Deaths report View report

7 May 2015 Brighton and Hove V. Hamilton-Deeley

Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

Rachel Alicia Elizabeth RYAN · Prevention of Future Deaths report View report

15 Nov 2024 Birmingham and Solihull S. Brenchley

Rachel Alicia Elizabeth RYAN was treated for a sacral pressure ulcer that became infected and developed into osteomyelitis, alongside deep vein thrombosis and pulmonary embolism. She deteriorated and died on 21 June 2024; the stated medical cause of death was osteomyelitis due to an infected sacral pressure sore, with frailty of old age also recorded. The principal concern was delay and lack of collaboration between specialist teams in arranging a deep tissue biopsy to guide antibiotic treatment.

Mr Luke John Chatterton · Prevention of Future Deaths report View report

19 Sep 2025 South London A. Harris

Mr Luke John Chatterton had a history of Clozapine-related constipation and developed vomiting, severe pain and suspected intestinal obstruction. He was discharged from the emergency department after an X-ray, later deteriorated and suffered a cardiac arrest, with delays in advanced life support before he died. The principal concerns were the safety and timeliness of resuscitation for detained mental health patients and the identification and escalation of risks associated with suspected obstruction in patients taking Clozapine.

Thomas Rawnsley · Prevention of Future Deaths report View report

9 Dec 2020 South Yorkshire (Western) A. Combes

Thomas Rawnsley, a residential nursing home resident, developed a chest infection, later collapsed at the home and died in hospital on 4 February 2015. Concerns included the quality of safety-netting advice, the risks of telephone consultations and incomplete information during clinical triage, and inaccuracies or omissions when paramedic advice was transferred to patient information leaflets.

William Howard DOWLING and Victoria Elaine ROSE · Prevention of Future Deaths report View report

21 Jan 2014 Wiltshire and Swindon D. Ridley

On 2 March 2013, William Howard Dowling shot Victoria Elaine Rose twice in the head before shooting himself in the head. The report raised concerns about information sharing between general practitioners and firearms licensing authorities, the wider public-safety implications of confidentiality, and the independence and transparency of firearms licensing decisions involving current or former police employees.

John Trevor WINSWORTH · Prevention of Future Deaths report View report

29 Sep 2023 Norfolk J. Lake

John Trevor Winsworth, aged 92, was found on the floor at his home on 14 February 2023 and later died in hospital on 21 February 2023 after a traumatic intracranial bleed following a fall. The report raises concerns about delays in ambulance attendance, delays in admission to the Accident and Emergency Department, and continuing delays by the ambulance service in responding to calls.

Rebekah Juliet Mills · Prevention of Future Deaths report View report

15 May 2023 Manchester South A. Mutch

Rebekah Juliet Mills suffered a knee injury in an accidental skiing fall, underwent surgery, collapsed at home several days later, and died from a pulmonary embolism. The inquest identified unclear clinical guidance about reducing the risk of DVT in young, immobile patients taking oral contraception who require surgery, with differing approaches and insufficient recognition of the potential fatal risk.

Gordon Bernard Hendley · Prevention of Future Deaths report View report

14 Jul 2022 Cumbria N. Shaw

Gordon Bernard Hendley, who had lymphoma and recent lung infection and pulmonary embolism, developed a severe rash most likely caused by Stevens-Johnson Syndrome and died in hospital on 23 January 2022 after maximal treatment. The report identified concerns about delays in medical assessment and treatment, failure to escalate significant blood-test results, lack of specialist dermatology input and prognostic scoring, and the robustness of systems for monitoring and supporting severely ill patients.

Haydar Jefferies · Prevention of Future Deaths report View report

20 Dec 2024 Surrey C. Topping

Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.

Edna Marina Collett · Prevention of Future Deaths report View report

28 Nov 2017 Staffordshire South A. Haigh

Edna Marina Collett was admitted to hospital on 10 March 2017 and remained there until her death on 19 May 2017. The report identified delays in arranging a suitable community care package, meaning she stayed in hospital for more than two months despite being fit for discharge, and raised concerns about improving the system for moving patients on from hospital.

Michael Anthony Tarratt · Prevention of Future Deaths report View report

14 Mar 2014 Leicester City and South Leicestershire L. Brown

Michael Anthony Tarratt, who had a history of poly-drug and alcohol abuse and was receiving methadone treatment, was found deceased at home from multiple drug toxicity. The concerns included a lack of contact between drug and alcohol services and his GP for 18 months, and the prescription of tramadol to an opioid-dependent patient without routine information-sharing between services.

Kyle Nicholas James Hurst · Prevention of Future Deaths report View report

26 Oct 2021 North Wales (East and Central) J. Gittins

Kyle Nicholas James Hurst was admitted to Glan Clwyd Hospital on 24 January 2021 after taking an undisclosed quantity of a substance and died there later the same day despite treatment. Concerns included the lack of an adopted protocol for accelerated administration of N-Acetylcysteine and delays in implementing procedures intended to mitigate risks from failures to act on diagnostic results.

Doreen Willis · Prevention of Future Deaths report View report

11 Jul 2017 Plymouth, Torbay and South Devon I. Arrow

Doreen Willis, who had a history of strokes due to clotting, was admitted to hospital after a stroke and later discharged to Belle Vue Care Home for end-of-life care, where she died on 9 June 2015. The inquest found that her risk of stroke was mitigated by Rivaroxiban, which she did not receive for a period of time, and that its absence may have contributed to her death. The report also refers to key learning from a Root Cause Analysis Report and concerns about future inspections of care homes.

Cameron William LAING · Prevention of Future Deaths report View report

10 Jul 2015 Exeter and Greater Devon E. Earland

Cameron William Laing, a soldier, was crushed between a military lorry and a 4-tonne trailer while attempting to reattach the trailer at Bracken Tor on 29 April 2014. The report raised concerns that soldiers did not understand how reconnecting the air line could release the trailer’s emergency brake, that alternative recovery methods were not taught, and that relevant training was not provided.

Patrick Joseph Carrick · Prevention of Future Deaths report View report

9 Oct 2015 Newcastle upon Tyne K. Dilks

Patrick Joseph Carrick underwent laparoscopic high anterior resection for colorectal cancer on 23 January 2012 and subsequently deteriorated, later dying from a rare but recognised complication of the surgery. Concerns included a significant unexplained departure from his management plan during rapid deterioration, failure to action blood analysis results, inadequate monitoring, delays in administering antibiotics, and inadequate completion of nursing and medical notes.

Naomi Clare Sourbut · Prevention of Future Deaths report View report

26 Feb 2018 Exeter and Greater Devon J. Tomalin

Naomi Clare Sourbut, who had a history of anxiety, depression, self-harm and bulimia, self-administered an overdose of medication, most probably Venlafaxine, and died after developing hypoxic brain injury. Concerns included whether recommendations from a root cause analysis had been considered and implemented, and whether protective factors were put in place after she reported suicidal intent and access to medication.

Mark PRYOR · Prevention of Future Deaths report View report

6 Feb 2024 Derby and Derbyshire P. Nieto

Mark Pryor died at the emergency department of Royal Derby Hospital on 5 September 2020 after suffering an alcohol-withdrawal-related seizure and cardiorespiratory arrest while in police custody. The inquest jury found deficiencies in the health care professionals’ assessment and treatment of his alcohol withdrawal that probably made more than a minimal contribution to his death. The report raises concerns that health care professionals may not receive sufficient training to practise effectively and safely in police custody suites.

Philip David Taylor · Prevention of Future Deaths report View report

2 Feb 2024 North Wales (East and Central) K. Robertson

Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.