1,410 reports
Information drawn from published reports and official responses.
Michael Longley had an adverse reaction to Rivaroxaban administered after hip surgery. He was admitted to hospital with an unrecordable platelet count and died the same day; the report also identified difficulties in communication between Integrated Care 24 and the District Nursing Service.
Kent Community Health NHS Foundation Trust
Denise Prior died on 6 November 2013 following a cardiac arrest after a fall caused by her underlying medical condition. The report raised serious concerns about record-keeping at St Richards Hospital, including recording and prescribing oxygen and applying the National Early Warning Score system, with a stated risk of future deaths.
University Hospitals Sussex NHS Foundation Trust
Amanda Susan Harris fell at her care home, fractured a bone in her right foot, and died in bed on 1 November 2014 after being unable to get out of bed. Concerns included that she was not seen by a doctor before leaving the Minor Injuries Unit, anticoagulant therapy was not considered, and the effects of potential immobility were not assessed when arranging her fracture-clinic appointment.
Mount Vernon Hospital
Keith Andrew Nottle died on 5 July 2021 after taking an overdose of two prescribed medications, which the inquest concluded was an accident. Concerns included telephone triage practices that could bypass specialist mental health assessment, the apparent lack of care coordination, and unclear decision-making around his discharge and repeated re-referrals to mental health services.
Nottinghamshire Healthcare NHS Foundation TrustTurning Point
Janet Blackman became unwell and was treated for hyperthyroidism and low sodium before being transferred between a medical unit and a psychiatric unit. She died after developing a pulmonary embolus due to deep calf venous thrombosis; the report noted that the psychiatric unit could not administer the prescribed heparin prophylaxis and raised concerns about continuity of physical healthcare and application of DVT prevention policy in psychiatric settings.
Department of Health and Social CareSussex Partnership NHS Foundation TrustUniversity Hospitals Sussex NHS Foundation Trust
Sarah Jane Buckingham died by hanging at her home on 12 August 2019 after a period of depression and a recent voluntary admission to a mental health hospital. The principal concern was that hormonal treatment or hormonal changes associated with perimenopause were not considered by the mental health clinicians treating her depressive illness, despite relevant previous episodes following childbirth.
General Medical CouncilHampshire and Isle of Wight Healthcare NHS Foundation TrustNational Institute for Health and Care Excellence
Graham George Smith died in a house fire at his home on 24 April 2018, after deteriorating during alcohol and benzodiazepine withdrawal and refusing hospital transport on three occasions. The report raised concerns that emergency call handling could not link repeat calls about the same patient and address, and that attending ambulance crews lacked information, senior review and warning of heightened concern.
East Midlands Ambulance Service NHS TrustJoint Royal Colleges Ambulance Liaison Committee
Michelle Roach’s inquest was heard at Reading Town Hall between 6 and 9 November 2018, and the narrative conclusion recorded that natural causes contributed to by neglect in her clinical management from 09:11 on 29 January 2014 until 18:07 on 30 January 2014. Concerns related to GP knowledge of venous thromboembolism, record-keeping and reviews of unexpected deaths, as well as the level of overnight medical registrar cover at the hospital trust.
Royal Berkshire HospitalThe Waterfield Practice
Nuel-Junior Dzernjo, who was receiving high-dose steroids and was immunosuppressed, developed chicken pox and deteriorated after being assessed at hospital on 21 February 2023. He was discharged despite ongoing abnormal observations, inability to mobilise and confusion, then deteriorated at home and died after collapsing the following day. The investigation identified unclear guidance on treatment, including whether intravenous rather than oral Acyclovir was indicated.
National Institute for Health and Care ExcellenceRoyal College of Paediatrics and Child Health
Peter Galea, a 51-year-old man, attended hospital and other agencies repeatedly over a 72-hour period and was assessed as low risk on three occasions. On 11 June, after leaving his GP surgery and threatening to jump from a bridge, his body was found under the Queen Alexandra Bridge and he was pronounced dead. Concerns included limited mechanisms for breaking referral cycles, restrictions on direct GP referral for admission to a place of safety, and whether different action might have prevented the outcome.
Department of Health and Social Care
Miss C died at Northampton General Hospital on 5 October 2021. The primary underlying causes were recent weight loss with nutritional deficiencies and interstitial pneumonia. During her deterioration, a doctor’s review was delayed, representing a missed opportunity for enhanced supportive care and an earlier peri-arrest call. Concerns also included the out-of-hours availability of Resuscitation Officers and aspects of the cardiac-arrest management, including inconsistent records of dextrose administration.
Northampton General Hospital NHS TrustResuscitation Council UK
Reginald Cauthery was a frail man with limited mobility who lived alone and died in hospital after sustaining extensive burns in a smouldering fire at his flat. The report raised concerns that his telecare service was not reviewed despite his increased fire risk and deteriorating mobility, and that his smoke alarms were not connected to the telecare system, delaying contact with the Fire Brigade.
Care Quality CommissionDepartment of Health and Social CareHome OfficeLondon Telecare LimitedThe Community Equipment Code of Practice Scheme C.I.C.TSA – The Voice of Technology Enabled Care
Kirsty Elizabeth Tolley had several health problems and was admitted to Queen Elizabeth Hospital with severe anaemia and a high temperature. She was later found unresponsive in bed on 19 November 2017 and was declared dead despite resuscitation. Concerns included blood tests not being carried out daily as required, incomplete Early Warning Score monitoring, and a lack of documented escalation or additional observations when scores reached 3; the medical cause of death was unascertained.
the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Ann Margaret Smith was admitted to Princess Alexandra Hospital, suffered an unwitnessed fall the following day, sustained a head injury and died four days later. The principal concern was uncertainty about managing anticoagulation after the fall, including the lack of a local protocol for patients over 65 on anticoagulants who sustain head trauma.
Princess Alexandra Hospital
Mr James Mc Manus was admitted with acute lower limb ischaemia requiring thrombolysis and subsequently developed bleeding and hypovolaemic shock. He died on 3 November 2013 following recognised but rare complications of medical intervention; concerns included failures to follow protocols for managing thrombolytic-associated bleeding and massive blood loss.
Pennine Acute Hospitals NHS Trust
Linda Rose Lloyd was found at home after complaining of a headache and was taken to hospital, where she was assessed, underwent a CT scan confirming an acute subdural haemorrhage, and died on 3 January 2014. The report raised concerns that treatment was delayed and that hospital procedures and staffing levels were insufficiently robust to minimise the risk of similar deaths.
Blackpool Teaching Hospitals NHS Foundation Trust
Karen Ann Thorne died at Salford Royal Hospital on 13 June 2016 following complications associated with Natalizumab treatment for Multiple Sclerosis and subsequent Plasma Exchange treatment for Progressive Multifocal Leukoencephalopathy. PML identified on scans in May and October 2015 was not reported or diagnosed until February 2016, with delays in reporting and treatment adversely affecting her response and prognosis. The report raised concerns about delays in neuroradiology reporting and the national shortage of Radiologists and training positions.
Department of Health and Social Care
Karena Wickings, aged 58, died at home in Brampton, Cumbria on 5 February 2023 from pulmonary embolism following a prolonged hospital admission for surgery and postoperative complications. Her mobility remained significantly restricted at discharge, when anticoagulant prophylaxis stopped. The report raises concern that discharge planning did not consider whether ongoing anticoagulant prophylaxis was indicated for patients who had not regained full mobility.
North Cumbria Integrated Care NHS Foundation Trust
Ms Jennifer McKoy underwent laparoscopic cholecystectomy in August 2018 and later developed disseminated gallbladder adenocarcinoma, with a retrospective review finding that carcinoma had been present in the original histology but was not identified. She died on 17 May 2019 after developing pulmonary venous thrombo-embolism, deep phlebo-thrombosis and disseminated gallbladder adenocarcinoma. Concerns included inadequate audit of non-suspicious samples and limited evidence of a protocol for managing anticoagulation or prophylaxis for community patients with identifiable risk factors for complications.
Black Country Pathology ServicesWalsall Manor Hospital
Charlotte Louise Alderson became seriously unwell from 17 December 2022 and died on 21 December 2022 after a rapidly progressing beta haemolytic streptococcus infection led to septic shock and multi-organ failure. Concerns were raised about the differing outcomes produced by the CENTOR and FEVERPAIN scoring systems, the need for improved tools to identify sepsis or risk of sepsis early, and failures of the NHS Interoperability Toolkit handover between 111 and 999 services.
Department of Health and Social Care
