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HARRY RICHFORD · Prevention of Future Deaths report View report

2 Mar 2020 North East Kent C. Sutton-Mattocks

Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.

Helen Margaret McLean · Prevention of Future Deaths report View report

3 Mar 2021 Liverpool and the Wirral A. Rebello

Helen Margaret McLean was without Edoxaban from 5 November 2020 after medication and discharge information were not correctly transferred between hospital, GP practices and her nursing home. She was admitted to hospital with an ischaemic stroke on 18 November 2020 and died on 21 November 2020; the report found it more likely than not that Edoxaban may have prevented the fatal event. A substantive concern was that the discharge summary was not received by the GP practice and contained an incorrect GP practice identifier, with medication-transfer processes also failing to identify the omission.

Andrew BIDDLECOMBE · Prevention of Future Deaths report View report

25 Feb 2021 Hampshire, Portsmouth and Southampton J. Pegg

Andrew BIDDLECOMBE died on 10 July 2020 after the motor car he was driving collided with a sign-post and rolled over, causing fatal head and neck injuries. It could not be ascertained whether he suffered a medical episode or whether poor eyesight and mobility hindered him in avoiding the collision. The concerns included that he had not been advised about the impact of his medical conditions on safe driving or the legal requirement to notify the DVLA, and that the practice did not inform the DVLA of relevant medical conditions.

Sammi Higgins · Prevention of Future Deaths report View report

13 Dec 2019 East London N. Persaud

Sammi Higgins had mental health conditions and a deteriorating mental state, including voices telling her to harm herself. On 3 February 2018, after presenting to mental health services following an overdose and self-harm and being discharged without weekend mental health support, she ingested a fatal combination of alcohol and tablets. Concerns included the absence of an overarching care plan or key-worker, failures in communicating and implementing a medication change, and lengthy delays in accessing psychotherapy.

George Boulton · Prevention of Future Deaths report View report

7 Aug 2015 Leicester City and South Leicestershire L. Brown

George Boulton developed an intracerebral bleed at home on 12 February 2015 and died on 14 February 2015 at Leicester Royal Infirmary. The report identified delays in arranging emergency transfer and failures to communicate or recognise the need to withhold dalteparin, which materially contributed to the continuing bleed.

JULIA SHEEREN DELL · Prevention of Future Deaths report View report

17 Jan 2014 Cornwall A. Cox

Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.

Peter John Keep · Prevention of Future Deaths report View report

14 Oct 2016 Surrey K. Henderson

Peter John Keep, an 82-year-old man, was admitted after a fall and underwent pacemaker insertion for Mobitz type 2 heart block. During the difficult procedure he received several sedative and analgesic doses, lost his airway, and suffered cardiac tamponade from perforation of the right ventricle; he later had a cardiac arrest and died in intensive care. The principal concerns included inappropriate and inconsistent sedation, inadequate sedation policies and training, and a lack of action plans for procedure intolerance, airway loss, or difficulty placing the pacemaker wire.

Thomas Charles TAYLOR · Prevention of Future Deaths report View report

1 Sep 2014 Inner North London M. Hassell

Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

Charlotte Emily BEVAN and Zaani Bevan Malbrouck · Prevention of Future Deaths report View report

27 Oct 2015 Avon M. Voisin

Charlotte Emily Bevan, who had schizophrenia and an undiagnosed psychotic relapse following childbirth, left hospital with her four-day-old daughter Zaani and went to the Avon Gorge cliff top; both died from injuries. The inquest identified failures including the absence of multidisciplinary care planning, insufficient psychiatric involvement, and failures to diagnose and manage Charlotte’s relapse.

David Morley Sargeant · Prevention of Future Deaths report View report

25 Oct 2018 Cornwall and Isles of Scilly G. Davies

David Morley Sargeant died on 16 June 2017 from the toxic effects of an intentional overdose of prescribed and controlled drugs, with suspension by a ligature around his neck also recorded. He had a history of chaotic illicit substance misuse and had been referred for assessment of possible ADHD, but specialist services in Cornwall or out of county were unable to diagnose and treat him. The principal concern was the lack of access to specialist ADHD assessment and treatment, including the absence of suitable ongoing medication oversight arrangements.

Ronald William Lowe · Prevention of Future Deaths report View report

3 Apr 2019 Birmingham and Solihull E. Brown

Ronald William Lowe collapsed at home on 26 October 2018 and died after being found in cardiac arrest. A pulmonary embolus identified on a CT scan was not treated with anticoagulation because reporting was delayed by individual and systemic omissions. The report raised concerns about systems for ensuring radiographers had seen and understood relevant CT standard operating procedures and that their training records were complete and up to date.

Phillip Lawrence HOGGARTH · Prevention of Future Deaths report View report

16 Dec 2025 Gwent C. Saunders

Phillip Lawrence HOGGARTH was admitted for a total hip replacement, which was performed on 18 March 2025. He deteriorated post-operatively, suffered a myocardial infarction and died on 25 March 2025. The report raised concerns about inconsistent pre-operative management and administration of iron to chronically anaemic patients, communication between clinicians, and delays related to funding responsibility between health boards.

Joanne Louise STONES · Prevention of Future Deaths report View report

30 Jul 2025 North Yorkshire and York G. Kane

Joanne Louise Stones, who had Anti-Phospholipid Syndrome and Addison’s Disease, was admitted with abdominal pain and diagnosed with acute cholecystitis with gallstones. Her condition deteriorated and she died in intensive care on 17 September 2023. Concerns included delays in prioritisation, treatment with fluids and antibiotics, recognition of her Addison’s Disease, and consideration of her underlying conditions in her treatment plan.

Joanna Sarah Louise Orpin · Prevention of Future Deaths report View report

31 Dec 2019 Isle of Wight C. Sumeray

Joanna Sarah Louise Orpin experienced severe, treatment-resistant agitated depression before leaving home on 13 February 2018 and disappearing near Culver Cliff. Her body was found on mudflats at Bosham Quay on 18 February 2018, and the inquest concluded that she killed herself. The substantive concerns included recurring incidents involving people in mental distress at Culver Cliff and the apparent absence of suicide-prevention signs there.

Linda Oldland · Prevention of Future Deaths report View report

14 Aug 2023 Surrey A. Crawford

Linda Oldland died at Hydon Hill Nursing Home on 3 January 2022 from a urinary tract infection that infected both kidneys and resulted in sepsis. Concerns included failures to share information about positive urine tests and the GP’s treatment plan, delayed antibiotics, failure to recognise cardiac arrest, and incorrectly informing ambulance staff that a valid DNAR form was in place.

Sandra Brotherton · Prevention of Future Deaths report View report

8 Dec 2016 Manchester South J. Kearsley

Sandra Brotherton was killed at her home on 31 December 2014, shortly after returning from hospital. The inquest heard that she had been the predominant and effectively sole carer for a person with a dual diagnosis of paranoid schizophrenia and Asperger’s Syndrome, who had been alone at home during her hospital stay. Concerns included the lack of a clearly discussed contingency plan, inadequate documentation and sharing of care-plan information with the Personal Assistant, difficulty obtaining an urgent psychiatric appointment, and insufficient follow-up after Sandra requested that he be rehoused immediately.

Mrs Ann Patricia Ellen Schuetz · Prevention of Future Deaths report View report

24 Nov 2020 Northamptonshire H. Shah

Mrs Ann Patricia Ellen Schuetz died at Northampton General Hospital on 26 June 2018 following an allergic reaction to Ramipril. The report identifies concerns that her known allergy was not recorded across relevant electronic systems, which allowed Ramipril to be restarted and continued to be prescribed.

Greg Revell · Prevention of Future Deaths report View report

28 Apr 2015 Leicester City and South Leicestershire L. Brown

Greg Revell was found hanging in his cell at HM YOI Glen Parva, and resuscitation was unsuccessful. The concerns included that a previous ligature self-harm attempt did not lead to an ACCT, uncertainty among prison officers about when to open an ACCT, insufficient consideration of recorded risk factors, and weaknesses in capturing healthcare information and obtaining a GP summary.

Sheldon Gary Farnell · Prevention of Future Deaths report View report

25 Mar 2021 Sunderland D. DL

Sheldon Gary Farnell, aged 4 years, died at Sunderland Royal Hospital on 26 November 2018 after presenting very unwell and being admitted to hospital. He was discharged before antibiotics could be given for adverse blood test results, and he could not be recalled. The concerns included sepsis recognition and training, the timely prescribing of antibiotics, and providing families with contact details at admission and discharge.

Antony Williamson · Prevention of Future Deaths report View report

20 Dec 2024 Manchester South A. Farrow

Antony Williamson experienced chronic pelvic pain and associated mental health difficulties, including increasing suicidal thoughts, before leaving home on 19 December 2023 and entering cold water. His body was found in the River Mersey on 17 March 2024, and the inquest concluded that he died from dry drowning and took his own life while experiencing hopelessness about the investigation and treatment of his pelvic pain. The report identified a lack of liaison and communication between the medical and mental health specialties involved in his care, with no formal framework to facilitate inter-specialty communication in complex cases.