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Tom Sweeting · Prevention of Future Deaths report View report

19 Jan 2024 West London L. Brown

Tom Sweeting experienced a sudden deterioration in his mental health in August 2021 and was assessed by liaison psychiatry after reporting suicidal thoughts. On 20 August 2021, he was found suspended by a ligature at home after locking himself in the garage, and resuscitation attempts were unsuccessful. Concerns included incomplete clinical assessment documentation, failures in discharge communication and treatment-plan communication, delegation of family collateral information gathering to a junior trainee, and a lack of evidence that new training and procedures had been effectively audited.

Norma Ann Patricia Tellam · Prevention of Future Deaths report View report

2 Dec 2024 Cornwall and Isles of Scilly S. Covell

Norma Ann Patricia Tellam suffered a fall causing a proximal femoral fracture and underwent surgery, followed by rehabilitation and further surgery after problems developed with the metalwork. She later suffered an upper gastrointestinal bleed and died on 16 April 2023. Concerns included transfers between hospitals that did not give sufficient weight to continuity of clinical care and did not return her to the hospital responsible for her orthopaedic follow-up.

Mrs. Hilda May Harris · Prevention of Future Deaths report View report

24 Apr 2015 Powys, Bridgend and Glamorgan Valleys S. Richards

Mrs. Hilda May Harris, aged 86, suffered a cerebral infarction with an intracerebral haemorrhage on 04.01.15 after an additional INR test was not undertaken while she was taking Warfarin alongside medication for gout. The report identified unreliable systems for booking community INR tests and for notifying or acting on omissions.

BETTY ANNIE TADMAN · Prevention of Future Deaths report View report

1 Feb 2021 Mid Kent and Medway S. Hayes

Betty Annie Tadman died after an unwitnessed fall at home caused a pelvic fracture with extensive local haemorrhage. She was treated for suspected urosepsis and deep vein thrombosis, but no imaging was conducted despite signs of possible injury, and the pelvic fracture and internal bleeding were not diagnosed. Concerns were also raised that the Trust did not investigate the death or review it through its morbidity and mortality processes.

Stephanie Anne Barkley Link · Prevention of Future Deaths report View report

23 Apr 2026 Birmingham and Solihull S. Brenchley

Stephanie Anne Barkley Link attended hospital with acute pancreatitis, later developing malnutrition, sepsis, acute liver injury, aspiration and multi-organ failure. She died in intensive care after a cardiac arrest on 30 June 2024. The principal concern was the absence of an effective multidisciplinary approach and an agreed, documented care pathway for complex acute pancreatitis across hospital sites, alongside missed opportunities for specialist transfer and continued paracetamol despite deteriorating liver biochemistry.

Liam Ryan Wayne Bentley · Prevention of Future Deaths report View report

3 Jul 2023 Mid Kent and Medway P. Harding

Liam Ryan Wayne Bentley was a serving prisoner at HMP Swaleside who had a history of self-harm and expressed fears about other prisoners and suicidal thoughts. He later took his own life, although his intention was unclear. The report identified concerns about inadequate psychological support, failures in self-harm monitoring and care planning, ineffective communication, and staff shortages and training gaps.

Philip Laurence Justin MALONE · Prevention of Future Deaths report View report

23 Nov 2023 Birmingham and Solihull J. Bennett

Philip Laurence Justin Malone, who had treatment-resistant schizophrenia and had deteriorated significantly in late June 2023, was found deceased in his supported accommodation on 3 July 2023. The inquest concluded that his death was the consequence of suicide. The principal concern was inadequate psychiatric bed capacity in Birmingham and Solihull, after clinicians sought to admit him but no inpatient bed was available, creating an ongoing risk of future deaths.

IAN JAMES WEEKS · Prevention of Future Deaths report View report

12 Mar 2020 South Wales Central G. Williams

Ian Weeks was remanded into custody at HMP Cardiff and was later found to have hung himself from the shower rail in his cell, sometime between 20 and 21 October 2017. The concerns included that healthcare staff did not check records showing a recent suicide attempt or notice that he had been prescribed antidepressants, and that there was no effective process for reviewing System 1 records or a suicide and self-harm warning flag.

Christine Margaret Cumbers · Prevention of Future Deaths report View report

16 Jun 2023 Essex J. Mellani

Christine Margaret Cumbers was admitted to hospital after developing a skin eruption following treatment with Carbimazole for hyperthyroidism. She developed sepsis during the admission, which was belatedly diagnosed and treated due to a lack of continuity of care caused by multiple ward moves, and this more than minimally contributed to her death. The GP practice also identified shortcomings in earlier care but had not implemented the learning from its review by the date of the inquest.

Maria De Oliveria Alva LOPES · Prevention of Future Deaths report View report

11 Jul 2014 Surrey K. Henderson

Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.

Mrs Christine Forbes · Prevention of Future Deaths report View report

23 Sep 2020 Derby and Derbyshire E. Serrano

Mrs Christine Forbes, a 72-year-old woman with a history of oxycodone stockpiling and misuse, died on 2 February 2020 after taking oxycodone and zolpidem. The principal concern was that patients registering with GP surgeries may be prescribed medication before their medical notes and relevant history are available.

Sean Perry WILLIAMS · Prevention of Future Deaths report View report

20 Feb 2026 Inner North London I. Potter

Sean Williams died in the back of a Serco van outside Thames Magistrates’ Court after suffering a fit during transport and then a cardiac arrest. Concerns included gaps in his custody healthcare assessment and treatment, inadequate Serco first-aid training and competence assessment, failure to provide timely first aid, unclear emergency procedures, and insufficient emphasis on preserving life.

Marlin Burrows · Prevention of Future Deaths report View report

30 Apr 2024 Liverpool and the Wirral N. Rheinberg

Marlin Burrows was found collapsed in his cell at HMP Garth on 15 August 2022 and died in the early hours of 16 August 2022 after being semi-conscious for nearly 15 hours. The inquest concluded that he died from multi-organ failure due to serotonin syndrome and drug toxicity, including amitriptyline toxicity. Concerns included unclear welfare-sheet purposes and guidance, poor communication of entries to medical staff, and insufficient joint consideration of the sheet by prison and healthcare services.

Winnie Harrop · Prevention of Future Deaths report View report

19 Mar 2025 Manchester South J. Gill

Winnie Harrop collapsed at a care centre on 12 August 2024, was treated in hospital after sustaining facial fractures, and was discharged back to the care centre with a new oxygen requirement but without oxygen. She became drowsy and unresponsive, was readmitted on 13 August, and died in hospital on 16 August 2024. The principal concerns were unclear health and social care guidance about discharge to a care home, discharge while overly sedated, and a discharge letter that did not record the sedation level or new oxygen requirement.

Maria Patricia Kelly · Prevention of Future Deaths report View report

27 Sep 2024 Inner North London M. Lee

Maria Patricia Kelly, who lived alone and was in poor health, was found deceased at home by police on 15 May 2024 after concerns were raised by neighbours and a housing officer. The report identifies prolonged lack of contact with primary care and mental health services, numerous failed encounters, and no welfare check until the neighbours’ concerns were raised; the inquest determined natural causes.

Jonathan Harris · Prevention of Future Deaths report View report

20 Mar 2024 Surrey A. Crawford

Jonathan Harris died in the early hours of 27 June 2022 after deliberately suspending himself while suffering a relapse of paranoid schizophrenia. The inquest concluded that his relapse followed reductions in antipsychotic medication and that an inpatient psychiatric bed was unavailable when an assessment was required. The court was concerned about the vacant consultant psychiatrist post and the shortage of inpatient psychiatric beds, which it considered presented a risk of future deaths.

Lee Terence Curran · Prevention of Future Deaths report View report

25 Feb 2014 Manchester West J. Leeming

Lee Terence Curran died on 3 May 2011 while in custody at Forest Bank Prison, with naturally occurring ischaemic heart disease identified as the prime cause of death. Before his death, he experienced multiple episodes of transient loss of consciousness that were not diagnosed, and concerns were raised that recommended investigations and follow-up were not provided. Further concerns included incomplete implementation of recommendations, potentially misleading medical-note entries, and inadequate awareness or application of relevant clinical guidelines.

Mohammad Ismaeel Ashraf · Prevention of Future Deaths report View report

1 Sep 2017 Birmingham and Solihull L. Hunt

Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.

JASON JAMES CLEMENS · Prevention of Future Deaths report View report

2 Jul 2025 Cornwall and Isles of Scilly G. Davies

Jason James Clemens died on 23 March 2024 after a seven-hour delay in administering antibiotics prescribed for immediate use following a medical episode at the renal unit. The report identified four missed opportunities to administer the antibiotics and stated that the delay likely hastened his death and more than minimally contributed to his cause of death. It also raised concerns about the absence of implemented procedures for managing worsening renal-unit patients and uncertainty about the appropriate admission pathway.

Joan Hanratty · Prevention of Future Deaths report View report

9 May 2018 Manchester South C. Morris

Joan Hanratty, who had a complex medical history including heart failure, ischaemic heart disease and moderate to severe Chronic Obstructive Pulmonary Disease, developed a chest infection and was prescribed antibiotics and steroids. She collapsed and suffered a cardiac arrest on 28 January 2018 and died in hospital later that day. The principal concern was that the prescribing system did not explicitly advise patients to seek medical advice if their condition did not significantly improve within a specified period after starting treatment.