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Mr John Dodd · Prevention of Future Deaths report View report

2 Apr 2014 Black Country A. Thompson

Mr John Dodd died from a retroperitoneal haemorrhage at Russells Hall Hospital on 21 April 2013, after being admitted through A&E the previous day. Concerns included that his INR was not checked while he was taking Warfarin, a documented temperature rise was not reported to medical staff before discharge, and there was a delay in his first assessment during his final admission, which was said to have delayed investigation and diagnosis.

Mr Edward Cowey · Prevention of Future Deaths report View report

14 Oct 2020 Derby and Derbyshire E. Serrano

Mr Edward Cowey was admitted to Royal Derby Hospital on 22 January 2020, suffered a fall with a head injury on 23 January, and died on 28 January 2020 from a subdural haematoma, with anticoagulation recorded as a contributing factor. Concerns included fragmented patient information across electronic and paper systems, inconsistent local and national guidance on head injuries, gaps in anticoagulation guidance, and a falls form that did not direct doctors to relevant head-injury guidance.

Brian BEER · Prevention of Future Deaths report View report

21 Oct 2024 Suffolk P. Taheri

Brian Beer died peacefully in hospital on 1 March 2024 from small bowel ischaemia caused by a superior mesenteric artery blood clot, following hip fracture surgery after an unwitnessed fall. The principal concern was whether current NICE guidance on the duration of post-surgical prophylactic anticoagulation adequately reflects emerging evidence about risks after hip-fracture surgery, particularly in immobile and elderly patients.

Theresa Mary Thompson · Prevention of Future Deaths report View report

7 Apr 2017 Cornwall and Isles of Scilly E. Carlyon

Theresa Mary Thompson died on 9 October 2016 after admission with sepsis caused by a Streptococcus pneumonia infection, following a history of splenectomy and recent ventriculo-peritoneal shunt insertion. Concerns were raised that she was not receiving lifelong antibiotic prophylaxis and had no antibiotic cover for the shunt procedure, and that there was no evidence she had been advised or prescribed antibiotics before or after the procedure.

Michael George · Prevention of Future Deaths report View report

9 Jul 2015 Inner South London A. Harris

Michael George died after developing a life-threatening hyperglycaemic condition while receiving long-term Olanzapine treatment. The report identified concerns about inadequate monitoring for diabetes, delays and insufficient urgency in transfer to A&E, incomplete referral information, and gaps in the subsequent oversight and care arrangements for the physical health of mental health inpatients.

THOMAS PATRICK MAHER · Prevention of Future Deaths report View report

5 Jun 2014 Manchester South J. Pollard

Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report View report

5 Jun 2023 Derby and Derbyshire S. Cartwright

Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s investigation.

John HOARE · Prevention of Future Deaths report View report

12 Oct 2023 West Yorkshire (Western) C. Oliver

John Hoare died at Airedale General Hospital on 31 March 2020 after contracting Covid-19 while detained under the Mental Health Act 1983. The principal concern was a gross failure in lithium prescribing and dispensing after his discharge to a care home, which contributed to deterioration in his mental health and his subsequent detention. The report states that the detention was preventable, although it could not be concluded on the balance of probabilities that it caused his death.

Phillip Roy Smith · Prevention of Future Deaths report View report

21 Jan 2015 West Yorkshire (Western) M. Burke

Phillip Roy Smith was diagnosed with a likely pancreatic carcinoma and underwent a percutaneous transhepatic cholangiogram with external drain insertion. He deteriorated overnight with severe pain, vomiting and a subsequent cardiac arrest, and died in intensive care on 15 March 2014 after treatment was withdrawn. The concerns included missing nursing and doctors’ records, undocumented observations, medication, blood gas results and fall details, and the junior doctor’s decision not to seek additional senior support despite concerns about Mr. Smith’s deterioration.

Doris Mary Ridgwell · Prevention of Future Deaths report View report

15 May 2018 Surrey A. Loxton

Doris Mary Ridgwell was admitted to hospital with knee swelling and pain, with an INR of 8.1 that was not successfully communicated to the ward or acted upon before her discharge. She was later admitted with a large subdural haematoma and intraventricular bleed, and the inquest determined that she died as a consequence of over-anticoagulation. Concerns included unclear procedures for communicating abnormal coagulation results, delays in making results available to healthcare professionals, and discharge summaries that did not include blood test results.

Valerie Ann Simmons · Prevention of Future Deaths report View report

20 Oct 2023 Cornwall and Isles of Scilly A. Cox

Valerie Ann Simmons developed a large left-thigh haematoma after receiving Fragmin while receiving anticoagulation therapy, was later admitted to hospital, deteriorated and died on 11 January 2023. Concerns included the absence of recorded observations after a change in her presentation and the need for further training on the risks of hypovolaemia in an anticoagulated patient.

Winifred Mary Redfearn · Prevention of Future Deaths report View report

25 Jun 2020 Wiltshire and Swindon D. Ridley

Winifred Mary Redfearn died after falling down the stairs at home, sustaining head and neck injuries and becoming immobile in hospital. She developed a deep vein thrombosis and pulmonary thromboembolism. The principal concern was that resumption of Dalteparin thromboprophylaxis was delayed for more than two and a half days after the CT report, apparently because of the intervening weekend, and that similar delays could contribute to avoidable premature deaths in other cases.

Alison June Dallow · Prevention of Future Deaths report View report

3 Aug 2022 Herefordshire H. Bricknell

Alison June Dallow died from a pulmonary thromboembolism due to deep vein thrombosis after a fractured left tibial plateau and reduced mobility associated with the fracture and a knee brace. The concerns included unclear advice about weight-bearing, unclear hospital policy on reducing venous thromboembolism risk for outpatients, and unavailable evidence of information given to the patient.

Isabella MCCREADIE · Prevention of Future Deaths report View report

3 Jun 2024 Surrey K. Hayes

Isabella McCreadie, aged 90, suffered a fall at home causing fractures, was admitted to hospital and underwent surgery. She developed low haemoglobin, delirium and a hospital-acquired stage 4 pressure sore, and died of pneumonia at home on 6 June 2023. Concerns included insufficient dietetic staffing, pressure-sore care and training, an unprocessed dietary supplement order, and inadequate training for some agency staff using the hospital’s computer system.

William Arthur Bows · Prevention of Future Deaths report View report

28 Jul 2015 South Yorkshire (Eastern) 2015-0301

William Arthur Bows, an 85-year-old man, was admitted with increasing shortness of breath, deteriorated despite supportive treatment, and died on 15 January while investigations were ongoing. Concerns were raised about the lack of protocols and guidance for monitoring patients prescribed amiodarone, including liver function, thyroid function, and respiratory difficulties, particularly during the first year of treatment.

Brenda Anne Drew · Prevention of Future Deaths report View report

10 Dec 2019 Dorset R. Griffin

Brenda Anne Drew, who was partially sighted, fell at home in November 2018 and was prescribed Oramorph after sustaining a wrist fracture. She was found collapsed and unresponsive at home on 6 April 2019, and toxicology found a fatal level of morphine in her blood. The principal concerns were that repeat Oramorph prescriptions were issued without a formal review or confirmation of her wishes, including requests made by a pharmacy without consultation with the patient.

Labuben Amarsi Vaghadia · Prevention of Future Deaths report View report

5 Sep 2013 Leicester City and South Leicestershire C. Mason

Mrs Vaghadia developed bleeding after receiving an anticoagulant injection for suspected deep vein thrombosis and died in hospital on 27 August 2012 from haemorrhage and haematoma of the abdominal wall. Concerns included the community nurse administering a further anticoagulant injection without seeking medical advice despite knowing about the bleeding, failing to share that information with other healthcare professionals, and lacking training, experience, and insight into the potential risks of her actions.

Asher Blackman · Prevention of Future Deaths report View report

6 Mar 2026 North London A. Walker

Asher Blackman died in hospital on 21 September 2025 after collapsing at home, where he was found to be profoundly hypoglycaemic. Concerns included the District Nurses’ failure to record next-of-kin details or procedures for inability to gain access, and a no-access policy that did not address police involvement where the patient’s life might be at risk.

Ethel Smith Leese · Prevention of Future Deaths report View report

6 Feb 2014 Staffordshire South A. Haigh

Ethel Smith Leese, aged 94, was admitted to hospital after a fall at her care home on 1 January 2013 and died on 4 January 2013. The inquest concluded that her death was accidental, involving intracerebral and subdural haemorrhage, a fall, warfarin-induced coagulopathy, and other listed conditions. The principal concern was chaotic monitoring arrangements for her warfarin levels, including uncertainty and errors concerning her address and GP practice after she moved to the care home.

David John Lewsey · Prevention of Future Deaths report View report

22 Nov 2023 Cornwall and Isles of Scilly A. Cox

David John Lewsey, aged 68, developed a pulmonary embolus following a left knee replacement and died after collapsing at home on 15 December 2022. Concerns included that severe side pain reported to reception staff was not passed to the advanced nurse practitioner, and that the pain’s location was not explored further. The report also raised whether staff training should better address chest or abdominal pain in recently immobilised post-operative patients.