6,433 reports
Information drawn from published reports and official responses.
On 17 December 2023, Alan Richard LEE choked on a food bolus after being given dinner in his flat and died before the ambulance arrived. Staff who attended did not appear to recognise that he may have been choking, so no lifesaving techniques were attempted.
AbbotswoodCare Outlook LtdManager
Fern Elisabeth Foster died by suicide on 8 July 2020 after consuming a substance she had procured with the intention of ending her life. The report identified concerns about the absence of independent advocacy and physical professional support when Fern received news concerning the intended adoption of her child, and about ambulance response times and access to antidote medication in suspected poisoning cases.
Association of Ambulance Chief ExecutivesEmergency Call Prioritisation Advisory GroupNational Ambulance Resilience UnitNational Ambulance Service Medical DirectorsNHS England
Robert John Fray became unwell with suspected sepsis during a dialysis session on 4 April 2022, and ambulance delays and emergency department failures meant he remained untreated for many hours. He developed multi-organ failure after sepsis and a stroke and died on 9 April 2022. The principal concerns were that repeated 999 calls did not trigger consideration of a more urgent response and that the duplicate-call system failed to identify a further call when his location changed.
NHS EnglandWest Midlands Ambulance Service University NHS Foundation Trust
Anoush Summers, a frail woman living alone, fell at home after her wrist alarm had been reported as broken and was found the following day. She was taken to hospital and died of hypothermia on 14 January 2024. Concerns included the failure to repair or replace the alarm, unclear reporting responsibilities, and inadequate instructions or training for carers regarding alarm faults and care notes.
London Borough of HackneySupreme Care Services Limited
Dominic Mark Chapman sustained a fatal head injury during a charity boxing match organised by Ultra Events Ltd at Tramps nightclub in Worcester on 9 April 2022, and died in hospital on 11 April 2022. The concerns identified included unclear and inconsistently applied criteria for matching opponents by weight, training that did not follow the intended pattern, and inadequate individualised risk assessments for events and medical cover.
Department for Digital, Culture, Media and SportUltra Events Ltd
Bernard Compton developed symptoms of a myocardial infarction, but delays in ambulance response, ECG interpretation, triage, blood-result review and clinical assessment meant that the optimum window for intervention had passed. He later suffered a left ventricular rupture and died on 19 October 2023. The concerns included inadequate oversight of patients and urgent results, unclear systems for repeating and acting on tests, and demand-related delays in ambulance and emergency care.
NHS England
Mohammed Akramuzzaman, aged 39, was found in cardiac arrest beside Euston Station on 8 December 2023 after spending the night outside. His death involved alcohol-related ketoacidosis and hypothermia. Concerns included the adequacy of the British Transport Police assessment, the decision not to return to check on him despite the cold conditions, and the lack of identified organisational learning after his death.
British Transport Police
Andrew James Naylor was found deceased on 11 October 2022 in Durham City, the day after discharge from hospital following treatment for a drug overdose and alcohol withdrawal. The report identified concerns about inadequate warnings of the risks associated with combining the administered drug with alcohol or drugs, poor communication between services, and insufficient consideration of his homelessness, discharge safety, and available support. The inquest concluded that he died from the combined central nervous system depressant actions of alcohol and two drugs, with cumulative failures contributing more than minimally to his death.
County Durham and Darlington NHS Foundation TrustTees, Esk and Wear Valleys NHS Foundation Trust
Nigel Walter Dixon, a 64-year-old man who lived alone, was found dead at home on 13 February 2023 after being unable to be roused. His cause of death was morphine and Zopiclone toxicity. Concerns included his access to morphine after hospital discharge and the online supply of large quantities and dosages of Zopiclone without adequate checks, communication with his GP, or safeguards.
Department for Digital, Culture, Media and SportDepartment of Health and Social CareRecipient name withheld
Susan Edwards died in hospital on 7 October 2023 after a sudden deterioration, with post-mortem examination establishing that the cause was a large pulmonary embolus. The report raised concerns that an instruction for mechanical thromboprophylaxis was not carried out and that Worcestershire Royal Hospital had no apparent system to ensure such instructions were followed, potentially putting patients at risk.
Worcestershire Acute Hospitals NHS Trust
Isabella McCreadie, aged 90, suffered a fall at home causing fractures, was admitted to hospital and underwent surgery. She developed low haemoglobin, delirium and a hospital-acquired stage 4 pressure sore, and died of pneumonia at home on 6 June 2023. Concerns included insufficient dietetic staffing, pressure-sore care and training, an unprocessed dietary supplement order, and inadequate training for some agency staff using the hospital’s computer system.
Frimley Health NHS Foundation TrustFrimley Park Hospital
Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.
Association of Police and Crime CommissionersBirmingham and Solihull Mental Health NHS Foundation TrustCollege of PolicingDepartment of Health and Social CareHome OfficeNational Police Chiefs’ CouncilNHS EnglandWest Midlands Police
Sewa Kaur Chaddha was found collapsed at home after taking her husband’s medication instead of her own for several days, including diabetes medication. She died in hospital from hyponatraemia caused by treatment for hypoglycaemia resulting from the accidental ingestion of hypoglycaemic medication. Concerns included the identical appearance of the couple’s dosset boxes, small patient-name labels, and the absence or poor dissemination of guidance for pharmacists supplying medication to people with cognitive impairment.
Community Pharmacy EnglandCommunity Pharmacy Thames ValleyGeneral Pharmaceutical CouncilMedicines and Healthcare products Regulatory AgencyNational Pharmacy AssociationNHS Frimley Integrated Care BoardNHS Specialist Pharmacy ServiceSlough Pharmacy
Glennis CONNELLY died at home on 11 November 2022 from end-stage renal failure due to tubulo-interstitial nephritis caused by tazocin, despite a previously identified allergy to the drug. The principal concerns were that this allergy was not recorded in the hospital records at Queens Hospital Burton upon Trent and that electronic patient records across the same trust did not automatically share allergy information.
Department of Health and Social CareUniversity Hospitals of Derby and Burton NHS Foundation Trust
Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.
Department of Health and Social CareGuys Marsh PrisonHM Prison and Probation ServiceMinistry of JusticeNHS EnglandUnilink Software Limited
Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.
Department of Health and Social CareHome OfficeMinistry of JusticeNHS Norfolk and Suffolk Integrated Care BoardNHS Norfolk and Waveney Integrated Care BoardNorfolk and Suffolk NHS Foundation TrustSuffolk ConstabularySuffolk County Council
Christopher Alistair MacGillivray had a history of drug and alcohol issues, attempted suicide and self-harm, and a brain injury. After being remanded in custody and placed on ACCT procedures following reported thoughts of self-harm, he was released on bail without direct communication to his Probation Officer or Manager about his release and risk. He was found hanging at home two days later. The principal concern was the lack of mandatory procedures for communicating known self-harm risks when remand prisoners are released unexpectedly at short notice.
Ministry of Justice
Hayley Jayne Cowan was detained under Section 3 of the Mental Health Act and absconded during accompanied leave to a local shop on 3 June 2022. She was found deceased the following day after using drugs; concerns included inconsistent definitions and guidance for accompanied and escorted leave, including what staff should do if they needed to use the bathroom while accompanying a patient.
Department of Health and Social CareMinistry of Justice
John Richard Hartey was found dead at home on 20 October 2023. His death was attributed to congestive cardiac failure against a background of hypertensive heart disease and Type 1 Diabetes Mellitus, with acute bronchitis and transplant immunosuppression contributing. The court heard concern that a national shortage of District Nurses and Community Specialist Practitioners could delay patients being seen in accordance with their needs.
Department of Health and Social Care
Elizabeth Sarah Jayne McCann was raped and murdered on 25 August 2022 at the home address of her murderer. The report identifies failures in risk assessment, information sharing, safeguarding, and management of a high-risk offender by the Health and Wellbeing College, Probation, and Greater Manchester Police. It also identifies concerns about excessive caseloads, inadequate staffing, supervision, recording, and organisational learning.
Department of Health and Social CareGreater Manchester PoliceHome OfficeMinistry of JusticePennine Care NHS Foundation Trust
