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3 Nov 2025 East Riding and Hull L. Harris

Kathleen Rose WARD, who had terminal mesothelioma, was admitted to Hull Royal Infirmary’s emergency department on 19 February 2025 because no bed was available at Queens Centre. She remained there for 21 hours and died at Hull Royal Infirmary on 20 February 2025; the inquest recorded pneumonia as the immediate cause of death, with mesothelioma, immunotherapy-induced myocarditis and chronic kidney disease contributing. The principal concern was that insufficient specialist end-of-life bed capacity resulted in patients receiving palliative care in unsuitable emergency-department environments, with potential delays to appropriate emergency treatment.

5 May 2023 East Sussex M. Spencer

Joshua Asprey, aged 19, died on 14 June 2021 from multiple injuries after deliberately jumping from a cliff; the inquest recorded a conclusion of suicide. The report raised concern about inconsistencies between the sertraline patient information leaflet and the British National Formulary regarding the risk of suicidal behaviour, and the potential for prescribers to be unaware of or fail to discuss that risk.

7 May 2021 Stoke-on-Trent and North Staffordshire S. Murphy

Alex Louise Shaw, who had methylmalonic aciduria and chronic kidney failure, died on 22 October 2018 after developing fluid overload, pulmonary oedema and respiratory failure during hospital treatment. The principal concerns were poor communication and documentation of her clinical observations and telephone advice between clinicians at Royal Stoke University Hospital and Birmingham Children’s Hospital, including failure to communicate her rising heart rate.