6,433 reports
Information drawn from published reports and official responses.
Brogen-Lea, a schoolgirl, was struck by a car while walking home after emerging from a footpath onto the A460 Eastern Way in Cannock on 29 November 2022, and later died from her injuries. The concern was that the busy road and footpath lacked warnings for drivers and pedestrians, measures to prevent pedestrians entering the road, and a safe crossing facility.
Staffordshire County Council
Regan Smith died at Kings College Hospital on 31 January 2023 after previously undiagnosed diabetes led to severe metabolic acidosis, multiorgan failure and acute liver failure. An abnormal blood glucose reading obtained by ambulance staff was not effectively handed over or recorded at hospital, resulting in his discharge without further glucose testing or treatment. The report identifies concerns about incompatible information systems, reliance on verbal handover during a period of high acuity, and the absence of national standards for emergency department handovers and confirmation of basic observations.
Department of Health and Social Care
Megan Ceris Williams developed abdominal pain and repeated vomiting between 1 and 5 May 2022, attended hospital twice, and died at home on 5 May 2022 after becoming breathless and losing consciousness. The inquest identified an undiagnosed small bowel obstruction apparently caused by adhesions from previous abdominal surgery. Concerns included possible missed opportunities for investigation, limited staff knowledge and clarity of the Acute Abdominal Pain Pathway, the lack of a signed self-discharge record, and the hospital investigation process not including information from family members.
East Kent Hospitals University NHS Foundation TrustNational Institute for Health and Care ExcellenceNHS England
Frederick Barrie Dunbavin, who had dementia and periods of confusion, fell from a wooded area at the Treetop Apartments onto a concrete path and sustained multiple injuries that caused his death. Concerns related to open access to the wooded area, the absence of a barrier and warning signage at the drop, and the continuing risk of life-threatening injuries.
Seascape Homes And Property Limited
Nathan Scantlebury, aged 16, died in hospital shortly after being found unresponsive with a ████████ tight around his neck on 25 September 2019. The principal concerns were the lack of suitable placements for children with complex mental health needs and failures relating to the suitability and management of his placement and care arrangements.
Department for EducationDepartment of Health and Social CareNHS England
Janet Rice, aged 65, died in hospital from pulmonary and cerebral embolism after surgery for a hip fracture sustained in an accidental fall. Anti-coagulant medication was inconsistently administered, including during a period when she was experiencing acute delirium; concerns included the absence of a capacity assessment, best-interests decision, escalation, or consideration of alternative treatment. The report also raised concerns about delays and limitations in the Trust’s patient safety investigation and the limited scope of related training.
County Durham and Darlington NHS Foundation Trust
Neil Woodley was found ████████ at 7.25 am on 4 January 2024, and evidence from suicide notes suggested that he had killed himself overnight. A colleague called the police because he had not arrived at work, but an ambulance attended the following day after an alleged communication failure between Surrey Police and the Metropolitan Police. The concern was that failures in communication could result in avoidable fatalities in future cases, although the report states that earlier attendance would not have affected this outcome.
Metropolitan Police ServiceSurrey Police
Omar Abdi Ahmed, who had significant comorbidity and bilateral lower-limb amputations, was found unresponsive and severely hypothermic at home on 15 November 2023 after receiving domiciliary and district nursing care. He died in hospital on 20 November 2023; the inquest concluded that hypothermia, with pneumonia and ischaemic heart disease contributing, was the medical cause of death. Concerns included poor communication between care organisations, shortcomings in district nursing oversight, and domiciliary care arrangements that did not adequately address his personal care, nutrition, cleaning, and heating needs.
Department of Health and Social CareEast London NHS Foundation TrustLondon Borough of NewhamSunlight Care Group
Theodore Riley Bradley was born on 14 September 2023 with no heart rate, breathing effort or movement after prolonged intrauterine hypoxia associated with a partial placental abruption. The report identifies a 37-minute delay before his mother was assessed at the maternity triage unit, and states that relevant maternity triage and antepartum haemorrhage policies were not followed. The principal concerns were a failure to respond promptly to vaginal bleeding in pregnancy and wider concerns about the management of antepartum haemorrhage.
Sherwood Forest Hospitals NHS Foundation Trust
Russell Ian Irvine took his own life by hanging in his prison cell at HMP Durham on 7 November 2022, three days after entering custody. He had reportedly told reception healthcare staff that he had refused food and fluids for the previous two days, but this information was not escalated and his intake was not adequately monitored. The report identified concerns about failures in reception screening, healthcare compliance with relevant policies, and the absence of a formal policy for monitoring whether prisoners collected meals.
Recipient name withheldRecipient name withheld
Gemima Christodoulou-Peace was found suspended by her neck from a ligature and died from suspension hanging, with the inquest noting insufficient evidence that she intended her death at all material times. The report raises concerns about the absence of a single reference point for identifying medications associated with increased suicidal behaviour, limited recording and accessibility of mental-health telephone calls, and delays in access to prescribing mental-health support. Gemima had requested a medication review, but had not seen a prescribing mental-health practitioner before her death.
Department of Health and Social Care
Rita Howells was transferred to Bromyard Hospital for rehabilitation and discharge planning, later became confused and agitated, fell from her bed, and was found to have an intracerebral haemorrhage. The concerns identified were that bed rails were routinely erected before a falls assessment, contrary to policy, and that procedures for establishing whether a call bell was working were unsatisfactory.
Hereford County Hospital
Benjamin Harrison died in HMP Rochester on 9 May 2022 after inhaling fumes from a medication heated with a vape pen. The inquest identified concerns including insufficient overnight healthcare cover, failure to inform the night orderly that he appeared to be under the influence, inadequate guidance for monitoring and escalation, and weaknesses in medication briefing and information sharing.
Oxleas NHS Foundation TrustRochester Prison
On 2 December 2020, Tony Williams died at the scene after two hay bales fell on him while he was unloading an HGV in Cheshire. The report raised concern that guidance and support materials did not contain clear images to assist drivers loading and unloading bales.
Health and Safety Executive
Noura Hardy died at Royal Sussex County Hospital on 14 March 2023 of a cardiac arrest following a septal ablation procedure complicated by perforation of a coronary artery. The report raised concerns that a nine-month wait for heart treatment, alongside long-term steroid use, may have weakened her heart muscles and contributed to the fatal perforation, and identified excessive waiting lists for heart treatment as a national concern.
Recipient name withheldRecipient name withheld
Paul Anthony Roberts took an overdose and inflicted multiple stab wounds in February 2023, after which he received no further mental health support. On 14 August 2023, he attended an emergency department because of deteriorating mental health, but psychiatric assessment was delayed and he left before it took place; he subsequently harmed himself and died on 15 August 2023 from a knife injury to the heart. The substantive concerns were failures in mental health referral and emergency-department care, insufficient accountability for staff actions or omissions, and delays in implementing identified safety measures.
Betsi Cadwaladr University LHB
Deborah Jane Cooper, aged 61, was found dead at her home after apparatus apparently constructed using instructions from an internet publication was found at the scene, alongside notes indicating an intention to end her life. The principal concern was that the publication, which provided instructions for making the apparatus, was available for direct sale by Amazon UK, with an apparent legislative gap regarding the effectiveness of measures to prevent such material being marketed to the public and children.
Department for Science, Innovation and Technology
Anna Vivien Elliott, who had severe recurrent depression with psychotic features and autism spectrum disorder, was detained under the Mental Health Act after having thoughts and plans to end her life. She was found deceased in her room on 24 November 2021 after safe and supportive observations were missed and her safety plan was ended without an adequate risk assessment. Concerns included inadequate handover and staffing, missed and falsified observation records, poor record keeping, and uncertainty about the management of safety plans.
East London NHS Foundation Trust
Sasha Drysdale died on 28 March 2023 in hospital as a consequence of acute myeloid leukaemia transformed from myelodysplastic syndrome. She had previously been prescribed clozapine for treatment-resistant schizoaffective disorder and was detained under section 3 of the Mental Health Act 1983 at the time of her death. The concern raised was that further research is needed to establish whether clozapine materially increases the risk of certain blood cancers.
Britannia Pharmaceuticals LimitedLeyden Delta LimitedNational Institute for Health and Care ExcellenceViatris UK Healthcare Limited
Pauline Spedding, who had a history of falls and was assessed as being at high risk, suffered a fall in hospital on 24 March 2023, developed a large subdural haematoma and died later that morning. The report identifies concerns about multiple ward moves, incomplete falls-risk and care documentation, failure to notify the Falls Response Team, and hospital capacity pressures involving escalation beds.
Department of Health and Social Care
