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KENNETH HEARD · Prevention of Future Deaths report View report

23 Nov 2023 Cornwall and Isles of Scilly G. Davies

Kenneth Heard suffered a major heart attack on 10 July 2022, but the ambulance responding to his 999 call arrived about eight hours later. He suffered a cardiac arrest at Royal Cornwall Hospital on 11 July 2022 and resuscitation was unsuccessful; the court found it more likely than not that he would have survived without the ambulance delay. The principal concerns were ambulance response and hospital handover delays, linked to pressure on services and insufficient social care provision, with continuing risks to life from these delays, particularly during winter demand.

Jake Kieran Hartwright · Prevention of Future Deaths report View report

5 Jan 2026 Nottinghamshire E. Didcock

Jake Kieran Hartwright developed severe illness associated with bowel ischaemia and had a cardiac arrest at home on 16 January 2025. He died at Queens Medical Centre in the early hours of 17 January 2025 from multiple organ failure secondary to extensive bowel ischaemia. The report identified serious issues in the urgent care pathway, including missed opportunities to arrange a Category 2 ambulance and problems with clinical information transfer and management of Category 3 calls.

Glenys Roberts · Prevention of Future Deaths report View report

24 Oct 2022 North West Wales K. Sutherland

Glenys Roberts was found on the floor by her front door on 23 August 2021 with leg pain and loss of sensation, and was diagnosed with a complete occlusion of the distal aorta. An ambulance transfer for vascular surgery did not take place in a timely manner or at all before she became too frail to be conveyed; she was certified deceased at 07.39 on 24 August 2021. Concerns included slow progress on intra-hospital transfers, the vascular emergency transfer pathway, and an ambulance handover plan intended to improve ambulance availability.

Liam Martin Coleman · Prevention of Future Deaths report View report

25 May 2014 North London A. Walker

Liam Martin Coleman collapsed at home in the early hours of 3 October 2012 and died after London Ambulance Service crews provided advanced life support. The principal concern was that insufficient ambulances were available to cover Red 1 and Red 2 calls during that period; the report states that the delay did not more than minimally or trivially contribute to his death.

Julie Ann Robertson · Prevention of Future Deaths report View report

16 Jul 2014 Essex E. McGann

Julie Ann Robertson died on 11 May 2013 from complications following an operation for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. The inquest narrative described delays in escalation, obtaining blood and starting surgery, as well as poor record keeping and unclear timings. The report raised concerns that matched blood was not immediately available on the ward and that there was insufficient formal training in record keeping.

Natalie Gray · Prevention of Future Deaths report View report

13 Jan 2017 Mid Kent and Medway P. Harding

Natalie Gray died after leaving Priority House, where she was an informal patient, and jumping in front of a train at Barming railway station on 21 April 2015. The principal concerns included insufficient risk assessments, inadequate handovers and failures in procedures for informal patient leave, communication of risk, recording third-party information and reporting her absence to police.

Albert Dovey · Prevention of Future Deaths report View report

21 Jul 2023 Manchester South A. Mutch

Albert Dovey suffered an accidental fall at home and was admitted to hospital with rhabdomyolysis, acute kidney injury, heart failure and a fractured clavicle. He became gravely frail and died at Tameside General Hospital on 4 February 2023. The inquest heard concerns about delays in ambulance attendance, ambulance processing at hospital and clinical assessment, with evidence that delays in treating elderly frail patients after a fall increased the risk of death.

Amelia Alexandra Anuszka RIDOUT · Prevention of Future Deaths report View report

11 Feb 2025 Cambridgeshire and Peterborough E. Gray

Amelia Ridout, a six-year-old girl with suspected aplastic anaemia, died after a bone marrow aspirate and trephine procedure under general anaesthetic caused internal bleeding from an iliac artery injury. Despite prolonged resuscitation and emergency surgery, the bleeding could not be stopped. The concerns identified were the development and publication of national guidelines and a standard operating procedure for these procedures, including recommended methodology, and the development of a database to record procedures and outcomes.

Paul Alexander Murray · Prevention of Future Deaths report View report

13 May 2015 North London A. Walker

Paul Alexander Murray died on 8 February 2015 after developing myocarditis, suffering a cardiac arrest, and later dying in hospital despite treatment. The report identified insufficient ambulance resources following a second call as a concern, with delayed attendance and hospital arrival described in the circumstances.

Lachlan Charles Campbell · Prevention of Future Deaths report View report

28 Feb 2025 Cornwall and Isles of Scilly A. Cox

Lachlan Charles Campbell was found unconscious outside a railway station after taking drugs and died in hospital on 1 November 2022 following hypothermia, bronchopneumonia and combined drug intoxication. The report identifies concerns about delayed ambulance attendance, delays in hospital handovers, inadequate care by responding police officers, and information sharing between police and ambulance services.

Barbara Joan Howard · Prevention of Future Deaths report View report

27 Nov 2017 West Sussex J. Andrews

Barbara Joan Howard fell at home on 19 July 2017, experienced delays in ambulance response and backup, and was taken to hospital, where she died from injuries sustained in the fall on 20 July 2017. The concerns included ambulance and clinician staffing shortages, failure to make a priority-assessment call when the response exceeded the target time, and ambulance-call auditing below the stated target.

Wendy HAMMON · Prevention of Future Deaths report View report

30 Jul 2024 Surrey A. Crawford

Mrs Wendy Hammon was admitted to hospital on 30 August 2022 with abdominal pain, vomiting and a small bowel obstruction caused by adhesions from previous surgery. She developed mesenteric ischaemia and multi-organ failure and died on 9 September 2022. The court was concerned that rising CRP was not recognised, fluid input and output charts were inadequate, and NEWS2 scores were often incomplete, with no reassurance that these matters had been addressed.

Neal Terence Saunders · Prevention of Future Deaths report View report

15 Dec 2022 Berkshire H. Connor

Neal Terence Saunders was restrained by police for 58 minutes, including 14 minutes in a prone position, after police attended his address following an assault report and concerns about recent cocaine use and paranoid behaviour. He suffered a cardiac arrest while being transported to hospital and died there on 4 September 2020. Concerns included inadequate guidance and training about prolonged restraint, ambulance response expectations, prone transportation, and coordination and training between police and ambulance services.

Hubert Kelly · Prevention of Future Deaths report View report

19 Sep 2018 Black Country L. Nash

Hubert Kelly was taken to hospital on the evening of 13 November 2017 after his health deteriorated and waited for four hours in a wheelchair in the emergency department with his family. Nursing staff later found that he had died, and concerns included patients waiting in corridors without meaningful interaction or permanent medically qualified staff, with waits of up to seven hours for clinical assessment.

Lee Dryden · Prevention of Future Deaths report View report

2 Aug 2023 South Yorkshire (Western) A. Combes

Lee Dryden had a displaced tracheotomy tube associated with emphysema, and critical scan findings on 15 December 2021 were not followed by successful contact or timely review. He suffered a cardiac arrest on 16 December 2021, resulting in a hypoxic brain injury, and died on 12 January 2022. The principal concerns were failures in communicating and acting on critical imaging findings and the delayed ambulance response to his mother's call.

Ellame FORD-DUNN · Prevention of Future Deaths report View report

3 Feb 2026 West Sussex, Brighton and Hove J. Andrews

Ellame FORD-DUNN, aged 16, was detained on an acute paediatric ward because no Tier 4 Paediatric Mental Health bed was available. She absconded from the ward during a toilet visit and died following her absconding. The principal concerns included insufficient Tier 4 beds, inadequate security and risk management, inconsistent handovers and unclear procedures for responding to absconsion, and poor coordination between agencies.

Thomas Mark Anthony Moffett · Prevention of Future Deaths report View report

22 Jan 2022 Lancashire and Blackburn with Darwen N. Rheinberg

Thomas Mark Anthony Moffett had probably suffered from diarrhoea and vomiting for up to three weeks before dying from natural causes following a cardiac arrest due to metabolic acidosis. Failures included an unlabelled blood sample, omission of an ECG, and inadequate communication of the patient’s condition and emergency level to ambulance control. The report raised concerns about communication arrangements between healthcare staff, prison control rooms and ambulance control, including the possibility of a wider national problem.

Jean Thomas · Prevention of Future Deaths report View report

4 Mar 2024 Swansea and Neath Port Talbot A. Gruffydd

Jean Thomas fell at home and remained on the floor for approximately 14 hours while waiting for an ambulance, during which a sacral pressure sore began to develop. The sore was exacerbated by a further delay in offloading her from the ambulance and by delays in obtaining an appropriate anti-pressure sore mattress; it later became infected, and she died at Morriston Hospital. The report raises concerns about pressure sores developing or worsening when vulnerable patients experience delays in ambulance response and hospital offloading.

Jeanette Sidlow Beech · Prevention of Future Deaths report View report

29 May 2025 North Wales (East and Central) K. Robertson

Jeanette Sidlow Beech, who had a history of alcohol withdrawal-related seizures, became unwell at home on 2 August 2024 and died there on 3 August 2024 after suffering a seizure and cardiac arrest. An ambulance took 15 hours and 13 minutes to attend, by which time resuscitation efforts were unsuccessful. The report raises concerns about ambulance response and hospital handover delays, linked to wider pressures involving hospital capacity, social care and community hospital provision.

Roman Louie BARR · Prevention of Future Deaths report View report

4 Mar 2026 Coventry L. Lee

Roman Louie Barr suffered an asthma attack on 14 December 2023 and died after no ambulance was available for several hours, leading his family to transport him to hospital. The principal concerns were limited awareness and follow-up of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks to families transporting critically unwell patients, and unclear NHS Pathways triage wording.