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Michael Holyoake · Prevention of Future Deaths report View report

27 Apr 2016 Leicester City and South Leicestershire C. Swann

Michael Holyoake, who was bed bound with a terminal and inoperable brain tumour, died after a fire at his home while he was being cared for there. The fire was thought most likely to have involved his lighter and E45 emollient residue on his bedding and clothing, which acted as an accelerant. The principal concerns were a lack of awareness of E45’s flammability and the absence of fire hazard warnings on its prescription or packaging.

David Nicholas ALMOND · Prevention of Future Deaths report View report

17 Jul 2024 Manchester South A. Mutch

David Nicholas Almond was diagnosed with thrombophilia and deep vein thrombosis but was not placed on lifelong anticoagulation. After developing breathlessness that was investigated with an X-ray, he collapsed and was found to have a massive pulmonary embolism, dying in hospital on 5 January 2024. The principal concerns were incomplete access to and recognition of relevant GP records, and failure to arrange appropriate follow-up after the negative X-ray.

Vilem Bock · Prevention of Future Deaths report View report

28 Apr 2022 Manchester South A. Mutch

Vilem Bock was admitted to Tameside General Hospital with sepsis and suspected pulmonary embolism, but his CTPA was delayed because arrangements for an interpreter were not made. He developed a large retroperitoneal haematoma while receiving anticoagulation, subsequently developed sepsis, and died after further deterioration. The report raised concern about the lack of clear national protocols to prevent language barriers from obstructing access to care.

Connor Nelson · Prevention of Future Deaths report View report

25 Nov 2025 Nottinghamshire E. Didcock

Connor Nelson died at Kings Mill Hospital on 30 November 2024 from hypoxic ischaemic encephalopathy following a prolonged cardiac arrest on 10 November 2024. The report describes an undiagnosed congenital prolonged QT syndrome, a nine-minute delay in administering a necessary shock, and concerns about cardiac-arrest response and processes for identifying and investigating prolonged QTc syndrome.

Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report View report

13 Sep 2022 Worcestershire J. Puzey

Mr Peter Antony Joseph Pearson died at Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia, which was in all probability acquired while he was resident at Corbett House Nursing Home. Concerns included a delay in calling an ambulance despite his critical condition, incomplete nursing and medication records, failures in oral-cavity checks, shortcomings in management oversight, and an ineffective investigation into his death.

Jacqueline Elizabeth Smith · Prevention of Future Deaths report View report

21 Aug 2023 West London L. Brown

Jacqueline Elizabeth Smith took her own life by overdosing on prescribed medication at home and died in Hillingdon Hospital on 12 August 2022. She had poor physical health and considerable anxiety while seeking council assistance with hoarded possessions, and a mental health assessment was not performed after she contacted a crisis telephone service. The inquest identified concerns including insufficient staff training for complex hoarder cases, missing safety assessments, an unsuitable council flow chart, and a lack of clear options after the initial assistance plan failed.

Kevin John McDonnell · Prevention of Future Deaths report View report

7 Aug 2024 Nottinghamshire L. Bower

Kevin John McDonnell was discovered deceased in his prison cell on 29 September 2022, having died by ligature asphyxiation; the inquest concluded that he had died by suicide. The principal concerns included failures to conduct planned ACCT reviews and checks, share identified suicide-risk information, provide necessary mental-health support, and preserve accurate documentary evidence after his death.

William Edward TURNER · Prevention of Future Deaths report View report

15 Oct 2020 County Durham and Darlington C. Oliver

William Edward TURNER, aged 74, died at the scene after a multi-vehicle collision on 8 October 2019, when a vehicle travelling in the opposite direction went out of control and caused a head-on collision. The report raised concern about whether the driving-licence surrender periods for people with epilepsy should be revisited or reviewed in light of the circumstances.

Miss Akua Anokye-Boateng · Prevention of Future Deaths report View report

26 May 2014 Inner South London A. Harris

Miss Akua Anokye-Boateng, who had well-managed sickle cell disease, suffered a three-day illness, collapsed suddenly, and died on 16 January 2013. The inquest recorded acute peritonitis and shock due to a perforated duodenum associated with NSAID ingestion and Helicobacter-associated chronic ulceration. Concerns included uncertainty about best practice and whether guidance or additional precautions are needed when NSAIDs are used in children with sickle cell disease.

EDWIN THOMPSON · Prevention of Future Deaths report View report

22 Dec 2014 Gateshead and South Tyneside T. Carney

Edwin Thompson, a 77-year-old residential care home resident with dementia, was found dead in a bathroom on 8 October 2011. The post-mortem identified a previously undiagnosed cardiovascular disease as the natural cause of death. The report identified concerns about protective measures for a vulnerable resident, delayed medical assistance, loss of contact with a resident prone to wandering, response to a final medical crisis, staff training, and record keeping.

Colm MCCABE · Prevention of Future Deaths report View report

31 Jan 2022 Berkshire H. Connor

Colm McCabe, aged 79, was admitted to hospital with hyperglycaemia after his blood sugar levels were not monitored and insulin administration was not clarified at the care home. He was transferred to hospital on 22 March 2021 and died there on 24 March 2021; the inquest concluded that natural causes were contributed to by neglect. Concerns included staff recruitment, training and appraisal, ineffective auditing, failures to clarify and monitor diabetes care, and the candour and completeness of investigations by the care home.

Myles Edward SCRIVEN · Prevention of Future Deaths report View report

14 Jul 2025 West Yorkshire (Western) C. Oliver

Myles Edward Scriven died at Huddersfield Royal Infirmary on 16 April 2023. The report states that he had several contacts with Dalton Surgery while suffering from an ongoing pulmonary embolism, none of which resulted in referral to secondary care, and that the handling of his care contributed to his death. Concerns also included insufficient adjustments and understanding of his autism and learning disabilities, failure to record numeric observations properly, and failure to undertake a rigorous internal review.

Denise Sharon Parramore · Prevention of Future Deaths report View report

19 May 2014 South Yorkshire (Western) D. Coutts-Wood

Denise Sharon Parramore, who had a lengthy history of mental ill health and previous self-harm, died from respiratory depression after taking Tramadol in excess of the prescribed level in combination with other medication. The concerns were that psychiatric services were unaware of the Tramadol prescription and that primary and secondary care should have open two-way communication and access to each other's documentation.

Sandra Dawne Scott · Prevention of Future Deaths report View report

6 Nov 2019 South Yorkshire (Western) D. Urpeth

Sandra Dawne Scott was prescribed treatment for a urinary infection, but the prescription was not available for collection after changes were made to the electronic prescribing system. She was admitted to hospital with worsening symptoms on 22 April 2019, deteriorated, and died on 23 April 2019. Concerns included the failure to act on hospital urine-test results and the lack of awareness among healthcare professionals of the electronic prescribing system issue; the evidence was that receiving the prescribed or indicated medication would have meant she did not die when she did.

Arthur Brockett-Deakins · Prevention of Future Deaths report View report

25 Feb 2014 Inner South London A. Harris

Arthur Brockett-Deakins was born in poor condition on 16 December 2007 after complications during labour and suffered severe disabilities resulting from acute profound perinatal hypoxic-ischaemic encephalopathy. He died at home on 18 October 2011 from respiratory problems. The report identified concerns about failure to escalate an abnormal CTG, administration and monitoring of Syntocinon, CTG interpretation and display of the maternal heart rate, and the organisation and support of a private midwifery-led service.

LUKE OWEN JACKSON · Prevention of Future Deaths report View report

21 Feb 2020 Mid Kent and Medway S. Hayes

Luke Owen Jackson, who had Becker’s Muscular Dystrophy and a chest infection, was admitted to hospital on 4 December 2019 and suffered a cardiac arrest on 6 December before being transferred to the Evelina Children’s Hospital. He later died on palliative care from hypoxic ischaemic encephalopathy following prolonged cardiac arrest. The principal concerns included recognition and treatment of total-body potassium depletion in a child with myopathy, and the limitations of monitoring oxygen saturation when assessing deterioration.

VAN THAI TUYEN · Prevention of Future Deaths report View report

22 Feb 2022 Inner North London J. Stevens

Van Thai Tuyen was admitted to hospital for stroke treatment and, after a nasogastric tube was misplaced into his right lung, approximately 300ml of liquid feed was administered through it. He died from cavitating necrotising pneumonia. The principal concerns were the use of misplaced nasogastric tubes, the recurrence of such incidents, and the absence of a unified approach to preventing avoidable deaths from this problem.

Patricia Violet PALIN · Prevention of Future Deaths report View report

19 Jun 2018 Shropshire, Telford and Wrekin H. Westerman

Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.

Barry Jack Gordon Liffen · Prevention of Future Deaths report View report

17 Dec 2019 Inner West London F. Wilcox

Barry Jack Gordon Liffen, who had dementia and other chronic illnesses and was taking anticoagulants, fell at his sheltered accommodation on 10 March 2019 and sustained a head injury causing subdural bleeding. His condition later deteriorated, and he died in hospital on 11 May 2019 after developing recurrent pneumonia. The concerns identified were the need for clinical assessment after falls and when staff observe deterioration in frail residents at Glebelands.

Ricky Anderson · Prevention of Future Deaths report View report

9 Sep 2013 Mid Kent and Medway P. Harding

Ricky Anderson was admitted to hospital with command hallucinations and suicidal thoughts, was discharged, and was later found suspended from a tree at Chatham Cemetery on 21 May 2012. Concerns included failures to inform his GP of his hospital admissions, reliance on family information when assessing his wellbeing after discharge, and the lack of contact with the Access team and a care plan before his death.