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Samantha Ann Hopkins · Prevention of Future Deaths report View report

6 Sep 2016 Portsmouth and South East Hampshire D. Horsley

Samantha Ann Hopkins, who was 36 weeks pregnant, collapsed at home after falling and striking her head. Paramedics initiated the PARAMEDIC 2 Trial and administered one dose of the trial drug, although pregnant women were excluded from the trial. The concern was that the exclusion warning was inside the drug packet rather than prominently displayed on its outside, and that participating ambulance services had not been given guidance on highlighting exclusions.

Natalie Ann Thornton · Prevention of Future Deaths report View report

6 Feb 2017 Manchester North S. Nelson

Natalie Thornton, who had longstanding brittle type 1 diabetes and related complications, began insulin pump therapy in December 2014. On 18 January 2015 she became unwell, collapsed, and died; the inquest concluded that the medical cause of death was diabetic ketoacidosis. Concerns were raised about the adequacy of monitoring and review of blood sugar data after the pump was introduced, including that trends were not analysed, and about variable national support for insulin pump users.

James Edward Mansfield · Prevention of Future Deaths report View report

10 Oct 2013 Cambridgeshire (South and West) Cheney

James Edward Mansfield had multiple rib fractures after a fall and was later admitted with a large right haemothorax; he died on 9 March 2013. Concerns included delayed review of the hospital discharge summary and failure to assess him after stronger painkillers were requested despite his injuries, lung and chest history, and warfarin treatment.

Ricky James MONAHAN · Prevention of Future Deaths report View report

22 Oct 2025 Birmingham and Solihull L. Hunt

Ricky James MONAHAN, a resident of a rehabilitation unit detained under section 37 of the Mental Health Act, died after falling from a height on 18 March 2025. The report identified an unprotected fire escape accessible from the garden and roof, no environmental risk assessment of this access, reliance on individual risk assessments, and a lack of guidelines for protecting fire escapes in rehabilitation settings.

Colin John Ireland · Prevention of Future Deaths report View report

7 Nov 2014 West Yorkshire Eastern D. Hinchliff

Colin John Ireland, a diabetic prisoner at HMP Wakefield, fell and fractured his left hip during exercise in icy weather on 11 February 2012. After surgery and discharge to the prison healthcare centre, he collapsed and died on 21 February 2012; the inquest recorded pulmonary thromboembolism and deep venous thrombosis. Concerns included delay in transferring him to hospital, difficulties with the high-security prison approval system, and the absence of an agreed protocol and training for Governors responding to medical emergencies.

Amarnih Lewis-Daniel · Prevention of Future Deaths report View report

11 Dec 2023 East London N. Persaud

Amarnih Lewis-Daniel, who had experienced mental health difficulties and gender dysphoria, died after sustaining fatal injuries in a fall on 17 March 2021 while awaiting care from a Gender Identity Clinic. The report raised concerns about lengthy waiting lists, limited local support during the wait, unclear responsibility for patients’ wellbeing, limited specialist knowledge in local mental health services, and unclear guidance on prescribing bridging hormones.

Brigitte Dominique FAVRE · Prevention of Future Deaths report View report

2 Dec 2025 Suffolk D. Stewart

Brigitte Dominique FAVRE, who had small cell leukaemia and was receiving chemotherapy, was discharged on 25 January 2025, readmitted the following day after her condition deteriorated, and died on 30 January 2025 from neutropenic sepsis following chemotherapy. Concerns were raised about the lack of oncology input for weekend and out-of-hours discharge planning and about emergency department record management, which meant recent chemotherapy and the need for support medication were not identified promptly.

Paul Hardy · Prevention of Future Deaths report View report

4 Feb 2015 Nottinghamshire S. Haskey

Paul Hardy was a serving prisoner at HMP Lowdham Grange when his local hospital confirmed that he had urological cancer, which was not the immediate cause of his death. The report identified failures to obtain and process blood and urine samples, to facilitate INR monitoring, and to conduct a Significant Event Analysis, with delays and errors causing unnecessary suffering and distress.

Tomasz Nowosad · Prevention of Future Deaths report View report

20 Dec 2019 Manchester City N. Meadows

Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

Mrs Norma Faye Campbell · Prevention of Future Deaths report View report

16 Jun 2025 East London N. Persaud

Mrs Norma Faye Campbell attended Whipps Cross Hospital emergency department on 13 January 2024 with clear signs of sepsis and died there in the early hours of 14 January 2024 after suffering a cardiac arrest. The report identifies delays and omissions in sepsis treatment, monitoring, fluid resuscitation and escalation of care. It also raises concerns about overcrowding, inadequate staffing and facilities, insufficient resuscitation beds, lack of electronic observations and the absence of Critical Care Outreach Team support in the emergency department.

Karen Lesley Peters · Prevention of Future Deaths report View report

17 Apr 2014 Plymouth, Torbay & South Devon A. Cox

Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.

Kelly Marie STEVENS · Prevention of Future Deaths report View report

24 Sep 2024 Worcestershire D. Reid

Kelly Stevens, who had profound learning and physical disabilities and received nutrition, hydration and medication via a PEG tube, was admitted to hospital on 28 December 2023. She suffered a seizure on 3 January 2024 caused by an excessively low, unrecognised sodium level, aspirated vomit, developed aspiration pneumonia and died in hospital later that night. Concerns included the absence of clear overall consultant responsibility, failure to monitor electrolytes and record fluid intake and output properly, and the copying of outdated care plans in her notes.

Michael Kevin Amesbury · Prevention of Future Deaths report View report

19 Jul 2023 Manchester South A. Mutch

Michael Kevin Amesbury had extensive cardiac disease and became increasingly unwell while awaiting assessment for severe mitral regurgitation. He died in hospital after becoming unresponsive and undergoing cardiopulmonary resuscitation; post-mortem examination identified bilateral bronchopneumonia and aspiration of gastric contents, with heart failure contributing to reduced physiological reserves. The concerns included delays and problems in referrals between secondary and tertiary services, information-sharing and transfer of clinical records and images, and delays in cardiology assessment and trans-oesophageal echocardiography due to resource and appointment constraints.

Ms. Kimberley Parsons · Prevention of Future Deaths report View report

4 Mar 2014 Avon P. Harrowing

Ms. Kimberley Parsons, who had a history of mental health problems and suicidal ideation, was found hanging in her room at Sycamore Ward on 16 March 2014 after repeated self-harm during her admission. She was transferred to intensive care but died from her injuries on 24 March 2014. Concerns included serious patient-safety deficiencies at Hillview Lodge, including incomplete observation records, shortcomings in resuscitation equipment and training, and deficiencies in care planning and pathways for patients with emotionally unstable personality disorder.

Alice MEAD · Prevention of Future Deaths report View report

24 Jun 2015 Brighton and Hove V. Hamilton-Deeley

Alice Mead was known to mental health services and was receiving care under the Care Programme Approach. The inquest concluded that she took her own life on 20 January 2015. Concerns included the failure to replace her care co-ordinator, inadequate response to her requests for a medication review, delayed action following urgent concerns, and a lack of documented review of her risk assessment.

Haik Patrick NIKOLYAN · Prevention of Future Deaths report View report

15 Aug 2023 Buckinghamshire C. Butler

Haik Patrick NIKOLYAN committed suicide and was found unresponsive in his cell at HMYOI Aylesbury in the early hours of 11 March 2019. The inquest identified concerns including failures to protect him from harm, withdrawal of depression medication without documented risk assessment or enhanced monitoring, bullying and exploitation, ineffective safeguarding and communication, and inadequate consideration of his Autism Spectrum Disorder.

Jeffrey MARSHALL · Prevention of Future Deaths report View report

13 Aug 2023 Surrey A. Loxton

Jeffrey Marshall died at St Peter’s Hospital in Chertsey on 13 December 2023 after suffering an ischaemic stroke caused by thrombosis of the basilar artery, following a fall and subdural haematoma. His anticoagulation had been withheld for 47 days. The principal concern was the lack of national guidance on when to recommence anticoagulation after a head injury and the lack of guidance on discussing the risks and benefits of withholding it with patients.

Patricia Lilian Parker · Prevention of Future Deaths report View report

24 Jul 2017 Milton Keynes T. Osborne

Patricia Lilian Parker suffered a cardiac arrest after sedation for an endoscopy on 5 January 2017 and died on 8 January 2017 despite resuscitation. The report identified a failure to follow the Trust’s intravenous sedation policy and BNF recommendations on titrating sedation, and raised concerns about clinicians’ awareness and training regarding sedation, particularly for older people.

Annette KRASINSKY-LLOYD · Prevention of Future Deaths report View report

7 Apr 2017 Surrey D. Stewart

Annette KRASINSKY-LLOYD died at Royal Surrey County Hospital on 20 April 2016 after an unwitnessed fall caused a pelvic fracture and retro-peritoneal haemorrhage, resulting in hypovolemic shock. The report identified inadequate A&E governance and delays in consultant involvement, investigations, reversal of anticoagulation and blood transfusions, as well as inadequate monitoring that contributed to poor intravenous access.

LORRAINE JOYCE BIRD · Prevention of Future Deaths report View report

10 Aug 2015 Bedfordshire and Luton T. Osborne

Lorraine Joyce Bird fractured her ankle after a fall and later attended a plaster room with numbness in her foot. The report identifies concerns that a developing deep vein thrombosis was not recognised or medically reviewed, that there was no adequate assessment protocol, and that she had not received low molecular weight heparin. The inquest concluded that this resulted in a lost opportunity for further treatment and that she died on 13 September 2014.