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David Stables · Prevention of Future Deaths report View report

6 Dec 2024 South Yorkshire (Western) M. Whittle

David Stables had a history of mental health issues and attended his GP in February and March 2024 with anxiety, sleep difficulties and poor appetite. The inquest concluded that he died by suicide, with bilateral transection of the ulnar arteries and incised wounds to the wrists. The principal concern was that no mental health or medication reviews were recorded between April 2020 and February 2024, and it was unclear whether reviews had taken place but were not recorded or had not taken place when they should have.

Margaret Kagure Pauline REECE · Prevention of Future Deaths report View report

13 May 2025 West Sussex, Brighton and Hove J. Andrews

Margaret Kagure Pauline Reece died on 7 March 2023 after being found hanging at her home address. The principal concern was that inadequate information-sharing between mental health services and the GP could result in patients receiving no medication or excessive medication due to duplicitous prescribing.

Margaret Ann MCNAUGHTON · Prevention of Future Deaths report View report

1 Aug 2025 Black Country J. Lees

Margaret Ann MCNAUGHTON was admitted to hospital with breathing difficulties and a respiratory infection, with a known penicillin allergy recorded in available clinical records. She was prescribed and given intravenous co-amoxiclav before being seen by a clinician, suffered cardiac arrest from penicillin anaphylaxis, and died in hospital on 13 December 2024 after deteriorating with respiratory failure. The principal concerns were failures to check and document her allergy status before prescribing, and the absence of sufficiently clear and embedded Trust processes and policies for carrying out and recording such checks, with further medication allergy incidents reported.

Nathan John COOKE · Prevention of Future Deaths report View report

17 Apr 2019 Isle of Wight C. Sumeray

Nathan John COOKE was found dead at home after being prescribed Methadone and Clomipramine and supplementing these with illicit medication. The inquest concluded that the death was drug related, with the medical cause recorded as cardio-respiratory failure, severe central nervous system depression, and Methadone and Clomipramine overdose. A principal concern was that the known risk associated with QTc prolongation was not adequately addressed through clinical monitoring and medication management.

Avery Jake Hall · Prevention of Future Deaths report View report

2 Feb 2026 Sunderland D. Place

Avery Jake Hall died at Sunderland Royal Hospital on 13 November 2024, aged four days, after developing global hypoxia and diffuse alveolar damage following his birth. The report was concerned that his mother continued taking Candesartan during pregnancy because she was not given clear and definitive advice to stop it, and that the medication remained available on repeat prescription without warnings identifying her pregnancy.

Thomas Henry Robin Kingston · Prevention of Future Deaths report View report

7 Jan 2025 Gloucestershire K. Skerrett

Thomas Henry Robin Kingston, a 45-year-old man, died after sustaining a self-inflicted shotgun wound to the head at his parents’ property on 25 February 2024. The report raises concerns about communication of suicide risks associated with SSRI medication and whether guidance to continue or switch SSRI medication is appropriate when there is no benefit or adverse side effects are experienced.

ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report View report

27 Jun 2014 Manchester City N. Meadows

Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.

Derrick Twaite · Prevention of Future Deaths report View report

29 Feb 2016 South Lincolnshire M. Spittal

Derrick Twaite swallowed a Finasteride tablet that remained in a sharp-edged bubble-pack segment, causing a gut perforation that led to his death. The report raised concern that tablets were still being snipped from unit-dose packs and placed in multi-dose compliance aids despite advice from relevant professional bodies.

Terence Norbert Dooley · Prevention of Future Deaths report View report

10 Apr 2014 Manchester City J. Harkin

Terence Norbert Dooley took a fatal overdose of medication and contacted the ambulance service, reporting his location and symptoms. Attendance was delayed by 2 hours and 38 minutes, and he was later found deceased by the canal. Concerns included the emergency call being coded green, the delay in response, poor communication, and misleading computer-generated codes.

Audrey King · Prevention of Future Deaths report View report

22 Aug 2023 Cornwall and Isles of Scilly G. Davies

Audrey King was admitted for femoral hernia obstruction and underwent repair on 6 November 2022. Her apixaban was suspended for surgery and not restarted; she suffered a severe stroke on 11 November and died four days later. The principal concerns were inconsistent record keeping between specialties, inadequate alerting when important handwritten notes were made, and no EPMA alert requiring review of the ongoing medication suspension.

Jean Dorothy Gillespie · Prevention of Future Deaths report View report

2 Nov 2015 Blackpool and the Fylde A. Wilson

Jean Dorothy Gillespie was residing in a care home for respite care when her prescribed Pyridostigmine ran out, with the last dose administered on 25 April 2015. She developed symptoms attributable to myasthenia gravis, was taken to hospital, and died on 8 May 2015. The report raised concerns that care staff did not know about her condition or the urgency of replacing the medication, and that care home records did not document the condition, its symptoms, or the medication's purpose.

Jason Brown · Prevention of Future Deaths report View report

12 Mar 2024 Sunderland D. Place

Jason Brown died at his home on 6 September 2022 after taking an overdose of his prescribed medication; the inquest concluded suicide, with the medical cause recorded as cardiac arrhythmia and drug overdose. The report raises concern that original-pack dispensing requirements for Zuclopenthixol dihydrochloride could provide a patient with suicidal risk and previous overdose attempts with a large quantity of medication.

Sarah Rhiannon Keen · Prevention of Future Deaths report View report

4 Mar 2024 Mid Kent and Medway P. Harding

Sarah Keen, who had a history of mental health difficulties and required support with daily activities, died after being discharged from hospital to supported accommodation. A post-mortem examination determined the medical cause of death to be multi-drug toxicity involving fluoxetine and dihydrocodeine in the presence of cocaine. The principal concerns were inadequate communication to carers about her risks and medication, insufficient guidance about discharge medication, and use of an abbreviation that was not universally understood.

Samuel Martin BROWN · Prevention of Future Deaths report View report

4 Dec 2025 South Yorkshire (Eastern) A. Combes

Samuel Martin BROWN, a 29-year-old male, was found deceased at Elliott Court, Rotherham, on 30 March 2025; the inquest conclusion was drug-related death due to drug intoxication. The principal concern was that primary care prescribing did not identify potential addiction and drug-seeking behaviour or adequately review whether medications were still required.

Anna Maria Burns · Prevention of Future Deaths report View report

19 Nov 2025 Wiltshire and Swindon G. Davies

Anna Maria Burns was found unresponsive on 12 January 2024 after taking more than her prescribed amounts of medication, including methadone, and was declared deceased that day. The inquest concluded that she died from multidrug toxicity involving methadone, zopiclone and pregabalin, while her intent remained unclear. The principal concern was that the methadone prescribing authority was not informed of her November 2023 opioid overdose and hospital admission, limiting its ability to review overdose risks and prescribing arrangements.

Matthew William Thomas Power · Prevention of Future Deaths report View report

26 Jun 2023 Surrey S. Ridge

Matthew William Thomas Power, a 33-year-old man living in supported accommodation, died at a house in Redhill after taking illicit and prescribed drugs over the previous 36 hours; the medical cause of death was recorded as mixed drug toxicity. The concerns identified related to the EMIS prescribing system, including cancelled prescriptions remaining pending, prescriptions being grouped in a way that obscured prescribing history, and difficulty determining what had been prescribed and issued.

Anita Mandalia · Prevention of Future Deaths report View report

9 Jul 2021 East London G. Irvine

Anita Mandalia took an overdose of prescribed medications at home on 7 February 2021 and died in hospital on 11 February 2021 from complications of the overdose. Concerns included prescribing beyond recommended guidance, failure to re-refer her to mental health services when concerns arose, and prescribing pain medication that gave her access to an excess of medication despite overdose-risk mitigation measures.

Kathleen Gabrielle Bamforth · Prevention of Future Deaths report View report

20 Jul 2018 West Yorkshire (Western) M. Fleming

Kathleen Gabrielle Bamforth was found unresponsive at home on 28 May 2017 and was confirmed to have died after resuscitation attempts. The cause of death was recorded as the effects of clomipramine toxicity, although the circumstances of the toxicity remained unclear. The substantive concerns were about reviewing prescribing guidelines for clomipramine and considering routine blood screening for patients receiving it long term.

Olivia Amy RUSSELL · Prevention of Future Deaths report View report

14 Dec 2023 Cheshire V. Davies

Olivia Russell had a history of anxiety, started citalopram in November 2020, stopped taking it without consulting a GP around June 2021, and restarted it in August 2021 after a relapse. She took her own life on 19 September 2021. Concerns included a lack of recorded evidence that risks associated with stopping medication or initially feeling worse had been discussed, uncertainty about consistent adherence to relevant guidance, and delay in carrying out a significant event review after her death.

Gemma Louise Macdonald · Prevention of Future Deaths report View report

5 Dec 2019 Suffolk J. Devonish

Gemma Louise Macdonald died on 22 July 2019 after taking a massive overdose of medication at home, including medicines purchased online. The report raised concerns about the availability of large quantities of medication online, whether purchaser suitability was assessed, and whether transactions were limited by quantity and ordering frequency.