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Gillian PEACOCK · Prevention of Future Deaths report View report

6 May 2024 County Durham and Darlington J. Thompson

Gillian Peacock died at Darlington Memorial Hospital on 8 March 2023 after suffering a cardiac arrest during an admission for a chest infection. She had been prescribed digoxin and clarithromycin, and although a pharmacist recorded a warning about possible digoxin toxicity, no alternative drug was prescribed and monitoring did not occur until 7 March. The principal concern was that important information in medical records was not sufficiently visible or accessible to clinicians involved in the patient’s care.

Thomas William Pearson · Prevention of Future Deaths report View report

4 Jul 2016 South Yorkshire (Eastern) M. Beresford

Thomas William Pearson, a retired coal miner with chronic obstructive pulmonary disease and rheumatoid arthritis, died at Doncaster Royal Infirmary on 11 February 2016 after suffering recurrent pneumonia and debilitating breathlessness. The report raised concern that long-term inhaled fluticasone use increased his risk of pneumonia and may have provided no benefit for patients without a raised eosinophil count, and noted that review of inhaled steroid use would be helpful.

David Squire · Prevention of Future Deaths report View report

25 Jan 2018 Black Country E. Serrano

David Squire, a detained patient at The Priory Lakeside View Care Home, took his own life by hanging in Fibbersley Nature Reserve on 25 July 2018 after leaving escorted off-ground leave for a cigarette and not returning. Concerns were raised that smoke-free hospital guidance required smoking patients who refused nicotine replacement to begin leave off grounds, without the staged observation process used for non-smoking patients, and that the guidance did not adequately account for risks in mental health hospitals.

Jodie Catherine McCann · Prevention of Future Deaths report View report

20 Apr 2023 Nottinghamshire E. Didcock

Jodie Catherine McCann, a 22-year-old woman, developed gallstone pancreatitis, suffered a cardiac arrest, and required critical care and ventilation. After her tracheostomy tube became displaced and could not be replaced, she suffered a prolonged cardiac arrest caused by lack of oxygen and died. Concerns included inadequate planning and preparation for difficult airway management and tracheostomy displacement, equipment and staffing availability, and delays in the serious incident review.

Stephen William Cassidy · Prevention of Future Deaths report View report

19 Sep 2023 Avon S. Fox

Stephen William Cassidy fractured his hip and was admitted to Southmead Hospital, where he was given intravenous Ceftriaxone during anaesthetic induction despite a recorded Ceftriaxone allergy. He suffered a severe anaphylactic reaction and died shortly afterwards. The principal concern was that hospital staff could not routinely or easily access or automatically receive Summary Care Record information, including allergies, creating a risk of avoidable patient harm and death.

Barbara Mary Anne Mayer · Prevention of Future Deaths report View report

23 Mar 2015 Norfolk J. Lake

Barbara Mary Anne Mayer had a history of depression and was found drowned in a nearby pond on 16 November 2014 after leaving her house during the early hours. Concerns included carer fatigue not being followed up, lack of continuity in her care, treatments not being adequately discussed with her, and no urgent mental health assessment being available when she needed help on 14 November 2014.

Luke Mervyn WHITELAW · Prevention of Future Deaths report View report

27 Nov 2023 Inner North London I. Potter

Luke Mervyn Whitelaw, who was known to mental health services, died by suicide; his body was recovered from the River Thames on 17 March 2023. Before his death, his mental health deteriorated and a referral for urgent psychiatric review following his disclosure that he would accept informal hospital admission was not acted on. Concerns included insufficient consideration of historic and current risks, inadequate documentation and exploration of deterioration, and a lack of reassurance that identified learning points would be addressed.

Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report View report

13 Mar 2024 Birmingham and Solihull L. Hunt

Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.

DARREN NEIL TURNER · Prevention of Future Deaths report View report

17 Mar 2025 Essex S. Horstead

Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.

Kathryn Lynda Millard · Prevention of Future Deaths report View report

25 Apr 2022 Mid Kent and Medway I. Brownhill

Kathryn Lynda Millard fell down stairs at a property where she was working on 10 May 2021 and was admitted to hospital with a fractured spine. She later developed green vomit, suffered a cardiac arrest on 13 May 2021, and could not be resuscitated; the jury recorded pulmonary embolism and deep venous thrombosis as the medical cause of death. Concerns included failure to document and implement a senior clinician’s direction, lack of awareness among nursing staff about anti-embolic stockings, and inadequate recording and communication following a review of her deteriorating presentation.

Peter James Michael Unsworth · Prevention of Future Deaths report View report

1 Dec 2020 Surrey C. Topping

Peter James Michael Unsworth had a history of deep vein thromboses and was taking long-term anticoagulant medication before a right hip replacement. After developing an infected hip and undergoing surgery, his anticoagulant dose was reduced following haematological advice that was not recorded in writing; he subsequently developed pulmonary emboli and died at home on 29 July 2018. The principal concern was that the lack of written records may have led to a misunderstanding of the advice given and its significance.

JOHN JAMES JACKSON · Prevention of Future Deaths report View report

16 Oct 2013 Black Country R. Balmain

JOHN JAMES JACKSON was found dead at his home, and life was pronounced extinct at 12 noon on 2 May 2013. Evidence indicated that he was a compulsive user of Hero Energy Mints and had more than twice the blood caffeine level reported as capable of producing a fatality. The concerns included limited information about the product’s caffeine content and the dangers of consuming large quantities, and its position between medication and sweets.

Michael Guy Hutchence · Prevention of Future Deaths report View report

20 Jun 2016 Manchester South J. Pollard

Michael Guy Hutchence broke his lower leg after slipping on an icy pavement and died in hospital on 28 January 2016. The report raised concerns about repeated ward moves, staffing and record-keeping, weight-based anticoagulant dosing and inconsistent weight recording, inadequate equipment for leg elevation, and delays to surgery after two operation kits were found to be non-sterile. The stated medical cause of death included bronchopneumonia, deep vein thrombosis and pulmonary embolus, and fractured tibia and fibula.

Lucy Jane PHELAN · Prevention of Future Deaths report View report

1 Apr 2026 Worcestershire D. Reid

Lucy Jane Phelan was found unresponsive at home after taking prescribed medications with a significant amount of alcohol and was later treated in hospital for likely aspiration pneumonia. She subsequently vomited, suffered cardiopulmonary arrest, and died shortly after midnight on 14 May 2025; the inquest concluded that her death was contributed to by neglect. The principal concern was that latching on Emergency Department monitoring equipment may contribute to alarm fatigue and hinder recognition of new alarms, with its use in other hospitals in England and Wales unknown.

Jordan George James Fogg Howarth · Prevention of Future Deaths report View report

1 May 2024 Manchester South A. Mutch

Jordan George James Fogg Howarth, a fit and healthy 25-year-old, was admitted to hospital on 3 April 2023 with an unexplained and deteriorating condition. He was not escalated for critical care review as required, and although a later review identified that he needed urgent ICU admission, this was delayed; he suffered a cardiac arrest on 6 April 2023 and could not be resuscitated. The principal concerns included inadequate coordination and continuity of care, failure to follow escalation policy, insufficient documentation of clinical decisions, and a lack of multidisciplinary discussion.

Kalila Elizabeth Griffiths · Prevention of Future Deaths report View report

18 Dec 2020 East London N. Persaud

Kalila Elizabeth Griffiths, who had complex medical conditions including asthma, developed worsening breathing problems in January 2019 and died on 1 February 2019 from a pulmonary embolism, with asthma contributing to her death. The report states that she was discharged from hospital on 19 January despite severe respiratory deterioration and required observation and respiratory physician assessment. Concerns included the management of asthma patients nationally, inconsistent clinical guidelines, uncertainty over which guidelines should be used for acute asthma attacks, and insufficient training.

Charles Andrew STONLEY · Prevention of Future Deaths report View report

20 Aug 2025 Liverpool and the Wirral A. Bhardwaj

Charles Andrew Stonley, who had severe depression with psychotic features, attended hospital with suicidal ideations and psychotic and paranoid symptoms while awaiting a mental health bed. After repeatedly leaving the Emergency Department, he was found deceased hanging in a wooded area. The report raises concerns about limited legal powers and resources for managing mental health patients in Emergency Departments and shortages of mental health beds, which can leave vulnerable patients at increased risk of self-harm and death.

Mr Ronald Francis Bonfield · Prevention of Future Deaths report View report

11 Sep 2015 Powys, Bridgend and Glamorgan Valleys G. Hughes

Mr Ronald Francis Bonfield sustained a head injury at home on 29 September 2014, was admitted to Prince Charles Hospital on 1 October, and died there on 2 October 2014. The inquest recorded that he was taking Warfarin, was over-anticoagulated, and that his INR levels were not being monitored as required. The substantive concerns related to inconsistent procedures for monitoring delegated INR testing and the risk of unmonitored over-anticoagulation.

Sarah YOUNG · Prevention of Future Deaths report View report

10 Feb 2020 Bedfordshire and Luton E. Whitting

Sarah YOUNG was admitted to Bedford Hospital on 9 April 2019 with headaches, confusion, immobility and fluctuating consciousness, and was later declared to have suffered brain-stem death on 12 April 2019 after an extensive cerebral sinus thrombosis. The principal concerns were delays in medical and neurological review, diagnosis and treatment, including difficulties with the referral system. The Inquest heard that earlier treatment may have increased her chances of survival, but could not be said to have contributed to her death.

Colleen Alice FLETCHER · Prevention of Future Deaths report View report

20 Jul 2022 Rutland and North Leicestershire F. Butler

Colleen Fletcher, who was insulin-dependent and cared for in a residential care home, experienced progressively rising blood glucose levels, collapsed into a diabetic coma and died on 29 January 2021. The report raises concerns about the availability of rapid-acting insulin for patients whose glucose levels were previously stable, and the potential delay before increased insulin could be administered or ambulance assistance considered necessary.