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Angela Maguire · Prevention of Future Deaths report View report

1 Jun 2022 West London L. Brown

Angela Maguire deteriorated after being referred for investigation of suspected malignancy and died in Kingston Hospital on 8 April 2021 following an upper gastrointestinal bleed. The report identified the lack of a shared regional system for accessing radiology images, which meant Kingston Hospital could not access previous images from Queen Mary's Hospital; this resulted in missed opportunities for diagnosis and palliative care, although it did not affect the outcome in this case.

Andrea Denise MANN · Prevention of Future Deaths report View report

6 Mar 2025 West Yorkshire (Western) A. Brocklehurst

Andrea Denise MANN was discovered hanging at her home on 10 February 2024 and died in hospital the following day after invasive medical care was withdrawn and palliative care was provided. The inquest identified concerns about limited Community Mental Health Trust involvement, the absence of a requested psychiatric appointment, delays in psychological therapy, and the lack of an overarching tool to scrutinise and measure the care provided.

John Paul Pace · Prevention of Future Deaths report View report

13 Nov 2023 Essex J. Mellani

John Paul Pace was serving a prison sentence at HMP Chelmsford and was receiving methadone as part of a drug detoxification programme. He stopped taking methadone before completing the programme and was found unresponsive at the prison on 22 July 2020; the post-mortem examination concluded that the likely medical cause of death was synthetic cannabinoid misuse. The principal concern was that a new discharge pathway for prisoners who stopped or completed methadone detoxification had not been documented in policies or procedures, creating a risk that monitoring and support would not be provided consistently.

Oliver Marc Robinson · Prevention of Future Deaths report View report

4 Feb 2026 Manchester North C. McKenna

Oliver Robinson was 34 when his body was discovered at home on 24 November 2023. The Court found that he died by self-ligature tied during acute emotional dysregulation, in the context of multiple psychosocial stressors and cannabis dependence. The principal concerns were that Cureleaf prescribed medicinal cannabis despite incomplete information, insufficient relevant psychiatric expertise and treatment options not being exhausted, failed to liaise with treating psychiatrists, and that continued prescriptions obstructed appropriate psychiatric and addictions care.

Vivienne Greener · Prevention of Future Deaths report View report

18 Dec 2023 North Wales (East and Central) D. Pojur

Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.

Zachary Victor TAYLOR-SMITH · Prevention of Future Deaths report View report

14 Mar 2024 Derby and Derbyshire S. Evans

Zachary Taylor-Smith was born preterm after an induced labour and died aged 14 hours at Royal Derby Hospital on 17 November 2022. The inquest found that he contracted an infection and that his death was contributed to by neglect, including failures relating to prophylactic antibiotics, recognition of the duration since rupture of membranes, and treatment of signs of early-onset infection. Concerns included staff understanding of infection indicators, communication between maternity and neonatal teams, systems for ensuring reviews were completed, and the safety of planned inductions given service capacity.

Kirabo Kiwanuka · Prevention of Future Deaths report View report

3 Mar 2014 Inner South London A. Harris

Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.

Michael John NEWELL · Prevention of Future Deaths report View report

13 Apr 2017 Preston and West Lancashire J. Adeley

Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management issues.

Sharon Louise Henshall · Prevention of Future Deaths report View report

20 Aug 2015 Preston and West Lancashire C. Hammond

Sharon Louise Henshall sustained a fractured ankle while skiing in Italy and died in the early hours of 18 February 2015 after collapsing from a pulmonary embolus. The report raised concerns that there was no venous thromboembolism risk-assessment tool or interim process for patients discharged with lower-limb immobilisation, and that access to prophylaxis varied between hospitals.

Lauren Louise MURDOCK · Prevention of Future Deaths report View report

4 May 2022 Inner North London M. Hassell

Lauren Murdock died from a myocardial infarction at age 27. Concerns included a significantly elevated blood pressure reading that was not recorded in her medical record or brought to the GP’s attention, and errors in assessing clot and cardiovascular risks when prescribing the combined contraceptive pill. She died ten days after the elevated blood pressure reading was taken.

Euphemia Lumsden Aldred · Prevention of Future Deaths report View report

18 Feb 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

Euphemia Aldred fell at home, sustained fractures to her left leg and ankle, and was treated in hospital with a plaster cast. After discharge, she was no longer prescribed low molecular weight heparin, developed a deep vein thrombosis and pulmonary embolism, and died; the report identified that the relevant Trust policy did not comply with NICE guidance on venous thrombo-embolism prevention.

Jennifer Cahill and Agnes Cahill · Prevention of Future Deaths report View report

5 Nov 2025 Manchester North J. Kearsley

Jennifer Cahill died in hospital on 4 June 2024 after post-partum haemorrhage, a fourth-degree perineal tear and cardiac arrest following a home birth. Her daughter, Agnes Cahill, was born on 2 June 2024, required resuscitation after complications during birth, and died in neonatal intensive care on 7 June 2024. The report identified concerns including failures in antenatal planning, fetal monitoring, resuscitation and post-birth care, as well as the absence of national guidance and a robust framework for supporting higher-risk home births.

Peggy COPEMAN · Prevention of Future Deaths report View report

28 May 2021 Norfolk J. Lake

Mrs Peggy Copeman became unresponsive and was declared dead at the scene while being transported by ambulance on the M11. Concerns included delayed recognition of her deterioration, delay in calling emergency services, ineffective CPR because of her position, and inadequate CPR training among the transporting staff.

Oliver James WINSON · Prevention of Future Deaths report View report

20 Dec 2024 Norfolk S. Goward

Oliver James Winson, a 33-year-old man with a history of drug misuse and a referral for adult ADHD assessment, was found deceased at home on 10 June 2024. Toxicology confirmed cocaine use before death, and the medical cause of death was cocaine toxicity. The principal concern was that lengthy adult ADHD waiting lists left at-risk patients without treatment or monitoring, potentially allowing deterioration, harmful behaviour and death.

Nicholas James Megginson · Prevention of Future Deaths report View report

11 Sep 2014 Powys, Bridgend and Glamorgan Valleys A. Barkley

Nicholas James Megginson was found unresponsive at home on 22 May 2014 after fracturing his left ankle and undergoing surgery earlier that month. A post-mortem examination found that he died from a pulmonary embolism. The report raised concern that patients discharged after surgery were not consistently advised, orally or in writing, about venous thromboembolism risks and warning signs requiring urgent treatment.

Teresa Auriemma · Prevention of Future Deaths report View report

14 Nov 2024 Worcestershire D. Reid

Teresa Auriemma was admitted to hospital after becoming unwell and was treated for aspiration pneumonia, dehydration, acute kidney injury and deranged electrolytes. She received intravenous potassium based on an out-of-date and inaccurate blood test, was given further intravenous potassium without the required monitoring, and subsequently collapsed and died from a fatally high potassium level. The principal concerns were failures to monitor potassium and other electrolytes and to ensure that doctors understood and complied with relevant monitoring policies.

Elizabeth Jayne Cooper · Prevention of Future Deaths report View report

1 May 2014 Cumbria (South & East) P. Sharp

Elizabeth Jayne Cooper had Factor V Leiden mutation and died after a holiday involving air travel; the inquest recorded pulmonary thromboembolism and deep vein thrombosis, with a conclusion of natural causes. The principal concerns were conflicting or unclear advice about precautions for air and long-distance travel, the lack of a clear pathway for informing family members, and the absence of information leaflets about the risks and consequences of untreated DVT and Factor V Leiden mutation.

Beryl WALTERS · Prevention of Future Deaths report View report

11 Nov 2014 Black Country A. Thompson

Beryl Walters presented to A&E with atypical chest pain and a posterior myocardial infarction. After receiving Cyclizine for nausea, she became hypotensive and tachycardic and suffered a cardiac arrest from which she could not be resuscitated; the substantive concern was the use of Cyclizine in acute coronary events despite an available alternative antiemetic and evidence advising against its use in these circumstances.

Edward Joseph CASSIN · Prevention of Future Deaths report View report

18 Jun 2025 Milton Keynes S. Cummings

Edward Joseph Cassin was a 66-year-old man with learning difficulties and dysphagia who was developing aspiration pneumonia while in hospital on 24 June 2023. He was given jelly despite it being contraindicated, was not properly supervised while eating, and experienced hypoglycaemic episodes that were not managed according to hospital guidelines; aspiration and the pneumonia were not recognised. The report raised concerns about staff understanding of aspiration-management policies and siloed working between the two NHS trusts providing services.

Mr Keith James Harwood · Prevention of Future Deaths report View report

16 Jan 2018 Blackpool and the Fylde A. Wilson

Mr Keith James Harwood underwent elective cardiac surgery in July 2014 and subsequently suffered a cardiac arrest and hypoxic brain injury, leaving him in a persistent vegetative state. He later died on 29 December 2016 from the combined effects of bronchopneumonia and a sub-phrenic abscess. Concerns included inadequate recognition of the complexity of his Parkinson’s disease and uncertainty about how hospital staff could obtain timely specialist neurological advice for patients with complex conditions.