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Robert Newton Stevenson · Prevention of Future Deaths report View report

6 Jul 2023 West Yorkshire (Western) M. Fleming

Robert Newton Stevenson, a 63-year-old retired consultant cardiologist and general physician, left home on 30 May 2022 and was later found hanging; resuscitation attempts were unsuccessful. The report raised concern about a possible rare link between ciprofloxacin and suicidal behaviour, including whether prescribing doctors were sufficiently aware of and communicating this potential side effect.

David Aughton · Prevention of Future Deaths report View report

12 May 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

David Aughton sustained a severe traumatic brain injury in 1999 that led to epileptic seizures. During a hospital admission for a cystoscopy in December 2015, his anticonvulsant medication was not administered; he subsequently had a grand mal convulsion causing aspiration pneumonia and died on 25 January 2016. The principal concern was that there was no mechanism to ensure essential medications were prescribed, dispensed and administered.

Michael Samuel Ian Anthony · Prevention of Future Deaths report View report

9 Apr 2014 Inner South London A. Harris

Michael Samuel Ian Anthony was found dead in his flat on 8 May 2013 and died from diabetic ketoacidotic coma. He had a very high Gabapentin level, and concern was raised about whether Gabapentin was contraindicated for someone with severe Type 1 diabetes and whether prescribing doctors knew of its rare potential to precipitate diabetic coma.

Ania Sohail · Prevention of Future Deaths report View report

7 Feb 2023 Manchester North C. McKenna

Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.

William Richard STOCKIL · Prevention of Future Deaths report View report

18 Jun 2024 West Sussex, Brighton and Hove J. Andrews

William Richard Stockil was admitted to hospital after being found on the floor at home following a long lie, with rhabdomyolysis and dehydration. An electronic prescription error and ineffective alerts resulted in his antibiotics stopping before further antibiotics were prescribed when signs of infection developed; he died from pneumonia. The report identified a risk that medications may cease when they should be continued if no prescribing clinician accesses the patient’s records.

Joy EBANKS · Prevention of Future Deaths report View report

1 Feb 2024 Bedfordshire and Luton S. Cummings

Joy Ebanks lived alone and was found unresponsive at home on 24 May 2023 after taking prescribed oxycodone and pregabalin for pain; she was pronounced deceased at the scene. The medical cause of death was oxycodone toxicity enhanced by pregabalin intake. The report raised concerns about very prolonged prescribing of two dependency-forming drugs, without evidence of a plan to reduce the dosages, and about the limited evidence for their long-term use in chronic pain.

Louise Sharon Henry · Prevention of Future Deaths report View report

16 Oct 2015 Derby and Derbyshire S. Cartwright

Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.

Susan Jane PERRY · Prevention of Future Deaths report View report

28 Nov 2022 South Wales Central G. Hughes

Susan Jane PERRY had a chronic complex mental ill health condition and was receiving long-term care and support at supported accommodation. She was found deceased in her room on 23 October 2020, and the inquest found that COVID-19 infection and elevated levels of prescription medication contributed to her death. The principal concern was that medication cupboard keys were kept nearby in unsecured locations, creating a risk that a service user could access medication; no evidence was received that practices and procedures across similar accommodation addressed this risk.

Shahida KHAN · Prevention of Future Deaths report View report

24 Apr 2024 Hampshire, Portsmouth and Southampton J. Pegg

Shahida KHAN died on 17 December 2022 at Cloverdale Care Home after being given substantial quantities of prescribed medication, causing toxicity and respiratory depression. She had epilepsy and suffered three seizures immediately before her death. It could not be ascertained how she came to be given toxic and fatal quantities of medication, raising a concern about the risk of recurrence for other people in the care home.

Mr Thompson Elliott · Prevention of Future Deaths report View report

15 Oct 2025 Sunderland D. Place

Thompson Elliott, a care home resident, was admitted to hospital with chest pains and discharged with changed opioid medication. Because the discharge letter could not be located, both old and new opioids were administered, resulting in an overdose; he later contracted influenza A in hospital and died after respiratory failure. The principal concerns were unclear procedures, inadequate medication recording and administration, and inconsistent staff decisions when discharge information was unavailable.

Georgia Dehaney-Perkins · Prevention of Future Deaths report View report

5 Feb 2024 Essex S. Hayes

Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.

Ms Christina Ann Fletcher · Prevention of Future Deaths report View report

13 Oct 2017 Manchester North L. Hashmi

Ms Christina Ann Fletcher was found dead at home after Zomorph, an opiate and controlled drug, was mistakenly delivered to her on 4 August 2016 and the error went undetected. Post-mortem examination found markedly elevated free morphine, which was attributed directly to the cause of death. Concerns were raised about the absence of specific regulatory guidance on pharmacy red-flag systems for similar names and addresses, and on the chain of custody for controlled drugs.

Marcus Dale Hamilton · Prevention of Future Deaths report View report

6 Jan 2018 Manchester South A. Bridgman

Marcus Dale Hamilton was a long-term service user of Trafford Drug Treatment Services and died from the combined respiratory depressive effects of several drugs taken in slight excess; the conclusion was drug related, with no evidence of deliberate intent. A substantive concern was that, despite planning a 51-day trip to India, he received only a 28-day prescription of MXL and was told he could obtain more there, potentially from the illicit market.

Abigail Louise SMITH · Prevention of Future Deaths report View report

27 May 2026 Essex Sonia Hayes

Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after unsuccessfully trying to suspend herself, and was pronounced dead at 00:08 on 16 February 2022 from compression of the neck. The report describes concerns about failures in mental-health care, including inaccurate records and diagnosis information, inadequate adjustments for autism and learning difficulties, medication-management problems, and discharge from detention without an effective plan to mitigate a known and immediate risk of suicide.

Sarah Marie GILBERT-JONES · Prevention of Future Deaths report View report

4 Feb 2022 South Wales Central G. Hughes

Sarah Marie GILBERT-JONES died in the early hours of 29 October 2020 after taking a significant overdose of prescription medication with alcohol. The report raised concerns about delays and inconsistent categorisation in the emergency response, including failure to recognise that treatment was time critical, and about sub-optimal mental health service provision.

Alana Molly CUTLAND · Prevention of Future Deaths report View report

5 Aug 2020 Milton Keynes T. Osborne

Alana Molly CUTLAND, a 19-year-old student, died on 25 July 2019 after opening the door of a light aircraft flying in Madagascar and falling from it. The report states that she had taken doxycycline as an antimalarial and was believed to have experienced a psychotic or delirium event. The principal concern was that the drug information leaflet did not mention this possible reaction and should be reviewed.

Natalie Mortimer · Prevention of Future Deaths report View report

25 Jul 2022 Mid Kent and Medway B. Patel

Natalie Mortimer died on 21 April 2022 at St Thomas' Hospital after an overdose of colchicine tablets prescribed for gout. She developed multiorgan failure. Concerns included that information about a previous overdose was not added to her GP record and that 100 tablets were prescribed because this was the system default, without an alert identifying the previous overdose.

Edna May CLEATON · Prevention of Future Deaths report View report

17 Dec 2015 Birmingham and Solihull L. Hunt

Edna May CLEATON died at home after serious pressure sores became septic. The report raised concern that she had not seen a doctor for over three years while receiving repeat citalopram prescriptions, and that systems were needed to ensure appropriate medical reviews before repeat prescriptions were issued.

Claire COPELAND · Prevention of Future Deaths report View report

8 Mar 2022 County Durham and Darlington J. Chipperfield

Claire Copeland had a break in the continuity of her drug addiction treatment after a physical prescription was delivered unsuccessfully, leaving her unable to obtain medication for the weekend. The inquest concluded that she subsequently consumed drugs, including heroin, and that her death was drug-related. The report identified concerns that the prescription delivery arrangements lacked confirmation, prompt detection of failed delivery, and a fail-safe mechanism to remedy it, creating a risk of discontinuity of important medical treatment.

Melvyn Lee BLOUNT · Prevention of Future Deaths report View report

21 Sep 2023 Derby and Derbyshire S. Evans

Melvyn Blount experienced a rapid deterioration in his mental health, including confusion and delusional thoughts, and died from asphyxiation on 14 January 2023 after tying a ligature. Concerns included the lack of a clear policy for ensuring that drug alerts are communicated when a non-prescriber requests a prescription from a GP who does not see the patient, and uncertainty about responsibility for informing the patient.