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Sophie Louise TOWLE · Prevention of Future Deaths report View report

24 Oct 2025 Nottinghamshire A. Poutney

Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.

Stephen Anthony Mayoll · Prevention of Future Deaths report View report

25 Nov 2014 Portsmouth and South East Hampshire D. Horsley

Stephen Anthony Mayoll fell from a ladder at work and sustained a right Achilles tendon injury, for which he received outpatient treatment at Queen Alexandra Hospital between 11 and 20 June 2013. He became very unwell at home on 21 June and died in hospital at 03.20 hours on 22 June 2013 from a pulmonary thromboembolism arising from a deep vein thrombosis. Concerns included the lack of reassessment under the hospital’s DVT assessment policy for similar fracture-clinic outpatients and delays in making fracture-clinic doctors’ notes available.

Graham Ian OXLEY · Prevention of Future Deaths report View report

19 Mar 2026 South Yorkshire (Western) C. Fitch

Graham Ian Oxley developed serious toxicity after receiving pembrolizumab immunotherapy following kidney cancer surgery, including inflammation affecting his heart, muscles and nerves. He deteriorated despite hospital treatment and life-sustaining treatment was withdrawn. The investigation identified concerns about delays in urgent oncology advice and the lack of a distinct priority pathway for patients presenting immunotherapy alert cards.

Kenneth Evans · Prevention of Future Deaths report View report

30 May 2017 Black Country Z. Siddique

Kenneth Evans was admitted to hospital after a mechanical fall and fractured pubic ramus, and subsequently developed an extensive pulmonary embolism. He died on 11 March 2017 after cardiac arrest and continued clinical deterioration. The inquest identified that thromboprophylaxis and an effective blood-clot risk assessment had not been arranged, with missed opportunities to administer heparin.

Michael Anthony JAGGS · Prevention of Future Deaths report View report

6 Oct 2021 Inner North London M. Hassell

Michael Jaggs was admitted to hospital on 15 January 2021 and developed hypoglycaemia as a complication of treatment for hyperkalaemia. The agency nurse did not escalate his deteriorating condition for medical attention, and he died from hypoglycaemia. The principal concern was that the agency had not provided additional training or required a reflective statement, raising concern that similar learning was not taking place within the agency.

Wayne AUSTIN · Prevention of Future Deaths report View report

10 Apr 2026 Shropshire, Telford and Wrekin H. Westerman

Wayne Austin became unwell and collapsed at Shrewsbury Probation office on 10 October 2024 after reporting that he had consumed cider; paramedics were subsequently informed that he had consumed crack cocaine. He was treated with CPR, advanced life support and Naloxone, transferred to hospital, and died as a result of combined buprenorphine and alcohol toxicity. Concerns included difficulty locating and applying the appropriate Naloxone guidance, the practical difficulty of complying with dosing guidelines during cardiac arrest, and the number of Naloxone vials carried by ambulances.

Wayne Anthony BAYLEY · Prevention of Future Deaths report View report

31 Oct 2024 Inner North London M. Hassell

Wayne Anthony Bayley died in HMP Pentonville approximately ten hours after a restraint. His death involved acute chest syndrome, hypoxia, chronic sickle cell lung disease and sickle cell disease; the principal concern was that learning and improvements relating to the care of prisoners with underlying health conditions may not have been shared nationally.

CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report View report

24 Dec 2015 Norfolk J. Lake

Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.

Tom Cribley · Prevention of Future Deaths report View report

9 Oct 2018 Liverpool and the Wirral J. Goulding

Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

SAM ROBSON PRINGLE · Prevention of Future Deaths report View report

22 Apr 2020 Manchester South J. Wells

Sam Pringle had a long history of mental health problems and died by suicide by hanging on 3 November 2018. The report raised concern that inconsistent prescribing practices and the shared care protocol could delay or prevent access to Lithium for mentally ill patients, with potentially fatal results.

Mr Ward · Prevention of Future Deaths report View report

5 Feb 2015 Black Country Z. Siddique

Mr Ward, an 85-year-old care home resident taking warfarin, suffered an unwitnessed fall and head injury on 29 November 2014. He was found unresponsive the following morning and died on 11 December 2014 after a CT confirmed a subdural haematoma. Concerns included staff awareness of the increased bleeding risk associated with head injury while taking warfarin, and the lack of clear policy, training, and escalation procedures for such falls.

Emily Kate Harkleroad · Prevention of Future Deaths report View report

5 Feb 2024 County Durham and Darlington R. Sutton

Emily Kate Harkleroad collapsed on 18 December 2022 and died from a pulmonary embolism in the early hours of 19 December 2022. The report states that failures and delays in treatment meant she did not receive anticoagulant treatment that, on a balance of probabilities, would have prevented her death. A further concern was that the Emergency Department’s new computer system lacked the previous clear RAG rating display for quickly identifying critically ill patients, particularly during periods of extreme pressure.

Edward Muwanga · Prevention of Future Deaths report View report

24 Apr 2026 Inner West London P. Rogers

Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.

Bathsheba Shepherd · Prevention of Future Deaths report View report

28 Mar 2021 London (West) S. Cummings

Bathsheba Bianca Kay Shepherd, known as Kay, was fatally stabbed by her housemate at some point between 10 and 11 November 2015 and was pronounced deceased on 11 November 2015. The report identified concerns about her being housed with a dangerous and vulnerable housemate, failures in risk assessment and rehousing, and her lack of GP registration and associated support.

Benjamin Robert Compton · Prevention of Future Deaths report View report

19 Mar 2025 Devon, Plymouth and Torbay P. Spinney

Benjamin Robert Compton, who had autism, experienced a deterioration in his physical and mental wellbeing and escalating distress. In the early hours of 1 February 2022, he left his supported accommodation and was hit by a lorry on the M5. The substantive concerns included gaps in support for autistic people in crisis and the inability of the Special Allocation Scheme to meet Benjamin’s needs.

Laura Jane Medcalf · Prevention of Future Deaths report View report

23 Mar 2022 Manchester South A. Mutch

Laura Jane Medcalf died on 17 February 2021 after being found unresponsive in her mental health ward bed, following a period of repeated self-harm incidents and signs of deteriorating mental health. The investigation concluded that her death was suicide, contributed to by failures to recognise her deteriorating mental health and increased risk, and to take effective steps to reduce that risk. Concerns also included shortages of mental health beds and staffing challenges affecting services.

Ms. Amy Jo Cross · Prevention of Future Deaths report View report

20 Oct 2025 Avon P. Harrowing

Ms. Amy Jo Cross was arrested on 9 June 2023, experienced reported drug and alcohol withdrawal symptoms, and died in a prison cell on 10 June 2023 after being found unresponsive before prescribed medication was administered. The report identified concerns about the transfer of healthcare information, including recent medication administration and physical observations, between police, court and prison healthcare providers, and the absence of a shared medical records system.

Jamie Stuart Funnell · Prevention of Future Deaths report View report

13 Oct 2025 East Sussex R. Redman

Jamie Stuart Funnell died at HMP Lewes on 16 December 2023 while withdrawing from alcohol and drugs. The inquest concluded that his death was due to the effects of drug and alcohol withdrawal, exacerbated by omissions by healthcare and prison staff. Concerns included failures in withdrawal assessment and monitoring, communication, CPR response, staff training, equipment maintenance, and updating relevant procedures.

Sarah Elizabeth READ · Prevention of Future Deaths report View report

17 Nov 2023 Lancashire and Blackburn with Darwen C. Long

Sarah Elizabeth Read had a mechanical mitral valve replacement and required intense anticoagulation. During pregnancy, anticoagulation was adjusted and interrupted following a stroke and a decision to terminate the pregnancy; she then suffered another stroke three days later and did not recover. Evidence raised concern that thrombectomy was unavailable in Lancashire after 5pm, with no regional coordination to ensure access to this urgent treatment.

Amirah KHALIFA · Prevention of Future Deaths report View report

27 Nov 2023 Liverpool and the Wirral A. Bhardwaj

Amirah Khalifa was admitted to hospital in December 2022 after feeling generally unwell and deteriorated despite active treatment, dying on 31 January 2023. The report states that multiple organ failure caused by sepsis and intestinal haemorrhage was more likely than not related to long-term steroid therapy. Principal concerns included failures to document, monitor and review the steroid treatment, recognise its complications, and ensure that its clinical indication and intended duration were communicated to primary care; the SCR also did not automatically flag long-term steroid use or record the clinical indication for prescribed drugs.