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Marianne Erika Oldham · Prevention of Future Deaths report View report

20 Jul 2023 Manchester South A. Mutch

Marianne Erika Oldham was admitted to Tameside General Hospital with vomiting and abdominal pain and was diagnosed with a perforated sigmoid colon after a prolonged delay in clinical assessment and imaging. She deteriorated, was treated conservatively, and died from peritonitis. The report identified concerns about delays linked to Emergency Department demand, staffing shortages, and shortages of radiographers and radiologists.

Josephine Celia BARKER · Prevention of Future Deaths report View report

7 Mar 2022 Surrey J. Russell-Mitra

Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.

ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report View report

27 Jun 2014 Manchester City N. Meadows

Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.

Michael James Francis Bray · Prevention of Future Deaths report View report

22 May 2023 Suffolk P. Taheri

Michael James Francis Bray was at home on 9 and 10 October 2021 after drinking alcohol and contacting a crisis helpline while considering hanging himself; he died by hanging between about 1:50 am and 5:53 am on 10 October 2021. The report identified concerns about prolonged delays in responding to Category 2 ambulance calls, including persistently above-target response times, alongside issues concerning inter-agency communication, police and ambulance responses, and welfare checks.

Dr Kenneth Wilson CULLY · Prevention of Future Deaths report View report

30 Apr 2026 East Riding and Hull L. Harris

Dr Kenneth Wilson CULLY died after a catastrophic, uncontrollable bleed from the foot while taking blood-thinning medication. The report identified a concern that the ambulance service’s newer NHS Pathway system may lack sufficient questions to recognise the seriousness of an uncontrolled bleed, potentially leading to incorrect categorisation and delayed treatment.

Patricia Genders · Prevention of Future Deaths report View report

28 Oct 2025 West Sussex, Brighton and Hove N. Armstrong

Patricia Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.

Adam Ali Hussain · Prevention of Future Deaths report View report

6 Jan 2026 Nottinghamshire E. Didcock

Adam Ali Hussain died on 16 May 2025 at Queens Medical Centre, Nottingham, from complicated appendicitis with perforation, peritonitis, severe intra-abdominal sepsis and multiple organ failure. The report identifies missed opportunities to recognise worsening illness and sepsis and to arrange face-to-face assessment, particularly on 14 May 2025. Concerns include unreliable handling and transfer of clinical information, unclear Category 3 ambulance-call criteria, and inadequate communication with families.

Valerie HILL · Prevention of Future Deaths report View report

13 Jun 2025 South Wales Central G. Hughes

Valerie HILL died on 11 March 2022 at Royal Glamorgan Hospital after a fall at Ty Bargoed Care Home led to a periprosthetic femur fracture; pneumonia, COPD and frailty of old age were also recorded. She waited on the floor for over 14 hours for an ambulance, and concerns were raised about inadequate care-home risk assessments, prolonged ambulance handover times, patient-flow systems and continuing system-wide delays in access to emergency care.

David Michael Lee · Prevention of Future Deaths report View report

28 Jun 2017 Manchester North J. Robertson

David Michael Lee was found unresponsive at home on 18 February 2017 after taking a considerable quantity of diphenhydramine and telling the emergency call handler about this during a 999 call. The call was terminated approximately 30 minutes in, and the report identified a missed opportunity to escalate the response before he became unconscious and died prior to the ambulance’s arrival.

Barbara Patterson · Prevention of Future Deaths report View report

21 May 2015 Northumberland (North) C. Henley

Barbara Patterson suffered a cerebral stroke at home on 1 January 2015, fell from a stair lift, and died at Wansbeck Hospital on 2 January 2015. The substantive concerns included the failure to provide timely CPR advice, a fault in the Pathways system relating to agonal breathing, ambulance dispatch and delayed arrival, and wider ambulance service capacity issues.

Charlotte Louise ALDERSON · Prevention of Future Deaths report View report

18 Jun 2025 Suffolk D. Stewart

Charlotte Louise Alderson became seriously unwell from 17 December 2022 and died on 21 December 2022 after a rapidly progressing beta haemolytic streptococcus infection led to septic shock and multi-organ failure. Concerns were raised about the differing outcomes produced by the CENTOR and FEVERPAIN scoring systems, the need for improved tools to identify sepsis or risk of sepsis early, and failures of the NHS Interoperability Toolkit handover between 111 and 999 services.

Liliane Andree BOWDEN · Prevention of Future Deaths report View report

11 Nov 2025 Hampshire, Portsmouth and Southampton H. Charles

Liliane Andree Bowden died at Oak View Care Home on 23 September 2024 from bronchopneumonia, with vascular dementia and recent falls making substantial contributions. The inquest raised concerns about a prolonged ambulance delay following her fall, in the context of ambulance demand and hospital handover delays, particularly for elderly or vulnerable Category 3 patients.

Kevin Patrick Hoey · Prevention of Future Deaths report View report

17 Mar 2015 North and East Cambridgeshire W. Morris

Kevin Patrick Hoey suffered chest pain at home on 14 July 2014 and was initially assessed as suitable to remain at home after ambulance attendance. His condition deteriorated, and he died at home in the early hours of 15 July 2014; the inquest recorded haemothorax and acute aortic dissection as the cause of death. The principal concern was the assessment of whether patients required hospital transfer and the need for training concerning community treatment or hospital transfer.

Steven HART · Prevention of Future Deaths report View report

24 Sep 2025 Bedfordshire and Luton S. Cummings

Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.

Ronald Hartley · Prevention of Future Deaths report View report

17 Jul 2022 Manchester South A. Mutch

Ronald Hartley fell in his garden, fractured his neck of femur, underwent surgery, became increasingly frail, and died in hospital on 22 November 2021. His family reported being told that an ambulance would take approximately six hours to attend, so they transported him to hospital themselves, causing him significant pain and discomfort.

Annette HILL · Prevention of Future Deaths report View report

21 Sep 2018 Avon T. Moore

Annette HILL was transported to the emergency department with increasing breathlessness and was assessed under the sepsis protocol before receiving intravenous antibiotics. She suffered an unexpected reaction and died despite advanced CPR; the concern was an unresolved tension between the Sepsis 6 guidelines and the BTS COPD care bundle, as antibiotics were given although she did not appear to require them based on the available information.

Josh Andrew Smith · Prevention of Future Deaths report View report

15 Jul 2024 East Riding and Hull J. Swift

Josh Andrew Smith had longstanding medical complications following quadriplegia from a 2009 road traffic incident. He was found unresponsive and not breathing on 19 December 2022, was diagnosed with hypoxic brain injury, bronchopneumonia and influenza A, and died on 22 December 2022 despite treatment. Concerns included continuing ambulance response delays and hospital handover delays, with response standards and the 15-minute handover target not being achieved.

Nadeem Ahmed · Prevention of Future Deaths report View report

8 Jul 2021 East London N. Persaud

Nadeem Ahmed lacerated his brachial artery after putting his hand through a glass pane at his home on 8 February 2020. He suffered hypovolaemic shock, later cardiac arrest and multiple organ ischaemia, and died at the Royal London Hospital on 13 February 2020. The principal concerns were incorrect triage of emergency calls and failures to communicate accurate and relevant clinical information to the HEMS team, which denied him the opportunity to receive life-saving treatment before cardiac arrest.

Ms. Kala Michelle Skinner · Prevention of Future Deaths report View report

3 Sep 2015 Avon P. Harrowing

On 17 December 2014, Ms. Kala Michelle Skinner experienced breathing difficulties and, after delays and two ambulance dispatches being recalled, was found in cardiac arrest and died at the scene. The report identified missed clinical red flags, inappropriate advice, insufficient and untimely welfare calls, and concerns about training, mentoring, auditing, and resources for Clinical Advisors.

Kirk Duboise · Prevention of Future Deaths report View report

6 Dec 2013 County Durham and Darlington A. Tweddle

Kirk Duboise arrived at HMP Durham with documents highlighting self-harm risks, but the documents were not seen and an ACCT was not opened. He was found dead in his cell approximately eight hours after arrival; concerns included the failure to identify the relevant forms and a delay in summoning an ambulance.