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Geoffrey Peter Banks · Prevention of Future Deaths report View report

27 Nov 2020 Stoke-on-Trent and North Staffordshire M. Jones

Geoffrey Peter Banks, aged 64, took 44 co-codamol tablets after pulling open a locked medicine cupboard at his assisted accommodation on 1 January 2020. He was admitted to hospital and died on 8 January 2020 from an acute heart attack; the overdose contributed to his death, although it was not possible to determine whether it was accidental or deliberate. Concerns were raised about the lack of safe medication storage for residents needing supervision and about the apparent investigation being perfunctory and conducted by an untrained staff member.

Anita Graves · Prevention of Future Deaths report View report

20 Jun 2023 Manchester South A. Farrow

Anita Graves, who was aged 92, died on 4 January 2023 after an E. coli urinary tract infection following treatment for hyperthyroidism. The inquest found that she had inadvertently taken more than the prescribed dose of carbimazole, and concerns were raised about the visual similarity of different carbimazole strengths and aspirin, together with the community dispensing process.

Joseph Page · Prevention of Future Deaths report View report

12 Nov 2018 South Wales Central G. Hughes

Joseph Page, who had significant co-morbidities, was admitted to hospital on 15 March 2018 and died on 23 March 2018 after deliberately taking a mixed overdose of prescription medication. His medication was accessible and unsecured, contrary to hospital policies. The report identified concerns about the storage and handling of patients’ own drugs in the Emergency Department and on Ward B5, and about the implementation and communication of revised policies.

Elizabeth Rose CURTIS · Prevention of Future Deaths report View report

11 Jan 2019 Avon M. Voisin

Elizabeth Rose Curtis was admitted to hospital with a urinary tract infection and delirium, was treated with antibiotics and haloperidol, developed aspiration pneumonia, and died on 31 March 2018. The inquest noted that she was prescribed 2.5mg of haloperidol instead of the intended 0.25mg. A substantive concern was how patients’ mobility and frailty should be assessed as indicators of wellbeing and possible deterioration in hospital.

Douglas Hodges · Prevention of Future Deaths report View report

12 Oct 2017 Nottinghamshire H. Connor

Douglas Hodges died in hospital on 3 April 2017 after developing multiple organ failure and systemic sepsis; antibiotics prescribed by his GP had not been dispensed by the pharmacy. The principal concerns were that community pharmacy systems did not communicate prescription urgency at the point of downloading, and that a prescription could be mislaid or accidentally disposed of without detection, creating a risk of future deaths.

Andre Roderick Stewart MICKLEY · Prevention of Future Deaths report View report

17 Jun 2015 South Lincolnshire A. Forrest

Andre Roderick Stewart MICKLEY used heroin and cocaine on 17 February 2015, then collapsed with a massive subarachnoid haemorrhage and died on 23 February 2015 despite neurosurgical intervention. The report raised concern about potentially adverse interactions between cocaine and SSRI drugs, and that prescribing information may not prompt consideration of substance misuse or caution about interactions with drugs of misuse.

Mrs Elsie Leaver · Prevention of Future Deaths report View report

26 Apr 2023 Inner West London F. Wilcox

Mrs Elsie Leaver died on 23 August 2020, aged 89, from multiple organ failure following a mixed drug overdose. The report raised concerns about missing psychiatric history, inadequate psychiatric assessment and risk assessment, failure to access available health information, and the lack of formal psychiatric liaison cover at QMH.

John Paul SKINNER · Prevention of Future Deaths report View report

10 Feb 2022 Hertfordshire G. Danbury

John Paul SKINNER was admitted to Watford Hospital on 15 May 2020 after suffering tonic clonic seizures and was given phenytoin. A verbal communication failure led to 15 mg/kg being heard as 50 mg/kg, resulting in an overdose; he arrested and died. The principal concern was that unclear communication of dosage could lead to foreseeable medication errors in hospitals.

Abdeslam BENELGHAZI · Prevention of Future Deaths report View report

10 Oct 2019 Avon M. Voisin

Abdeslam BENELGHAZI was detained under Section 2 of the Mental Health Act and was prescribed methadone alongside several other medications, including clonazepam. He died on 9 December 2017; the inquest identified concerns about inappropriate combined prescribing, inadequate monitoring and failure to escalate concerns, including after signs of over-sedation or reduced consciousness.

Marion Hilda Prance · Prevention of Future Deaths report View report

15 May 2019 South Wales Central R. Knight

Marion Hilda Prance, aged 82, suffered a head injury after an unwitnessed fall at her care home and was given her usual morning dose of Rivaroxaban on the advice of paramedics. She was later diagnosed with a subdural haematoma, developed a catastrophic brain bleed and died the next day. The principal concerns were paramedic awareness and training regarding Rivaroxaban and the need for caution after head injuries caused by falls.

Jason Mark BAYLEY · Prevention of Future Deaths report View report

17 Oct 2023 Birmingham and Solihull V. McKinlay

Jason Mark BAYLEY, who had chronic constipation while detained for treatment at St. Andrew's Healthcare, developed intestinal pseudo-obstruction and died at hospital on 28 December 2022. Concerns included repeated inaccurate recording of medication adherence in the Rio notes, which stated that all medication had been taken when doses of lactulose had been refused, creating a risk that staff might misunderstand whether medication had been taken and fail to plan appropriate care.

Richard Philip WHITE · Prevention of Future Deaths report View report

28 Feb 2014 County Durham and Darlington C. Oliver

Richard White was a resident at Hope House who took an overdose of cyclizine and zopiclone on 9 June 2013 and subsequently died from cyclizine toxicity. The concerns were that Hope House’s medication policy was not made known to the prescriber or others involved, was not set out in a protocol or policy statement, and that no such document was available.

Maureen Leaver · Prevention of Future Deaths report View report

27 Jan 2014 West Sussex K. Henderson

Maureen Leaver, who had dementia and severe delusions, was admitted for assessment in July 2010 and later transferred to hospital with profound hypothermia. She died on 6 October 2010; the report identified concerns about inadequate medical supervision and systems for investigating and managing acutely ill elderly patients, as well as understanding of legal duties when changing her patient status.

Lee Derek Jamie ADAMS · Prevention of Future Deaths report View report

20 Mar 2025 Inner South London J. Morris

Lee Derek Jamie ADAMS was at home alone after taking an excessive number of propranolol tablets, intending to take his own life, and was pronounced dead at 03.39 on 24 July 2020. The report highlights concerns about propranolol’s toxicity at relatively small doses, the absence of a specific antidote, and the need for doctors, particularly GPs, to be aware of the consequences of excess ingestion.

Donna Neill · Prevention of Future Deaths report View report

28 Sep 2022 East London N. Persaud

Donna Neill was found deceased at home on 10 December 2018 after an overdose involving medication prescribed to her husband. The report identified that the risk of her taking medication not prescribed to her was not fully assessed, documented, or managed, and that no risk management plan was put in place.

Ronald Maurice Brewer · Prevention of Future Deaths report View report

19 Oct 2017 Gloucestershire K. Skerrett

Ronald Maurice Brewer was an 87-year-old man with significant medical conditions who was admitted to hospital, discharged to a care home for end-of-life care, and died shortly after receiving prescribed palliative and anticipatory medication. The substantive concern related to the administration, documentation, and dispensing of palliative medications.

Cuthbert Anthony Stanley Hingert · Prevention of Future Deaths report View report

1 Aug 2018 Isle of Wight C. Sumeray

Cuthbert Anthony Stanley Hingert was admitted to hospital with shortness of breath and possible acute coronary syndrome, during which duplicate doses of antiplatelet and anticoagulant medications were given. He later became confused, fell and sustained a subdural haematoma, skull fracture and subarachnoid haemorrhage, dying in hospital on 5 March 2017. Concerns included failures to check the medicines database, inappropriate or potentially inappropriate prescribing, delayed documentation, inadequate staff training and failure to report a medication incident according to protocol.

Karen Moran · Prevention of Future Deaths report View report

22 Nov 2018 Manchester South A. Mutch

Karen Moran was found at home on 7 April 2018 and died after unsuccessful resuscitation attempts at Tameside General Hospital. Toxicology showed raised levels of prescribed dihydrocodeine and gabapentin, and the inquest heard that her recognised addiction to prescribed medication was not addressed through referral while repeat prescriptions continued to provide access to significant amounts of medication.

Eileen Brindley · Prevention of Future Deaths report View report

24 Sep 2020 Black Country J. Lees

Eileen Brindley, aged 97, was admitted to New Cross Hospital on 28 August 2020 after being found struggling to breathe and died shortly afterwards from anaphylaxis. The concerns included prescribing a penicillin-type antibiotic despite a recorded adverse reaction to Flucloxacillin, without evidence that the prescribing clinician had noted the reaction or explained the prescription, and insufficiently highlighted medical-record entries.

William Stephen GREEN · Prevention of Future Deaths report View report

28 Feb 2025 Shropshire, Telford and Wrekin H. Westerman

William Stephen Green was admitted to hospital after a seizure and was prescribed Lamotrigine. He was later readmitted with a collapse and rash, developed Stevens-Johnson Syndrome, and died on 9 July 2023 from toxic epidermal necrolysis secondary to Lamotrigine, with alcohol dependent disease contributing to his death. The concerns were that patients were not given or recorded as receiving counselling about drug side effects and complications, and that there was no provision to record what should happen when a patient lacked capacity to understand such an explanation.