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Nora Jane Foulkes · Prevention of Future Deaths report View report

14 Apr 2022 North Wales (East and Central) J. Gittins

Nora Jane Foulkes, an 87-year-old resident of a residential home, was admitted to hospital on 11 April 2021 and died on 16 April 2021. Her untreated hypothyroidism was contributory to her death, which was due to cardiorespiratory failure resulting from bronchopneumonia and an existing cardiac condition. Concerns included the failure to restart and subsequently monitor her hypothyroidism treatment, and the lack of routine medication review during ANP visits because of time constraints.

Bethany Victory Shipsey · Prevention of Future Deaths report View report

15 Feb 2018 Worcestershire G. Williams

Bethany Victory Shipsey, a young woman with significant mental health difficulties, died by suicide on 15 February 2017 after deliberately ingesting tablets containing dinitrophenol purchased over the Internet. The report identified significant failings in hospital monitoring and supportive care, and raised concern that dinitrophenol was extremely toxic, had no known antidote, and was freely available online.

Christopher Thomas Ace Ryan · Prevention of Future Deaths report View report

22 Jul 2022 West London L. Brown

Christopher Thomas Ace Ryan was detained under section 3 of the Mental Health Act and absconded from escorted leave on 23 December 2020. He obtained and smoked heroin, developed laboured breathing, lost consciousness, and died despite CPR. Concerns included repeated absconding during escorted leave, access to illicit drugs, unclear boundaries around escorted leave, and the security and smoking arrangements at the hospital car park.

Mr Luke Alexander Worrell · Prevention of Future Deaths report View report

21 Feb 2025 London South A. Harris

Mr Luke Alexander Worrell, who had treatment-resistant schizophrenia and was taking Clozapine, developed persistent vomiting, dehydration and an ileus before suffering a ruptured oesophagus and dying in hospital on 2 January 2021. The report identified concerns about clinical staff failing to recognise the potentially fatal gastrointestinal side effects of Clozapine and about the inappropriate use of a community treatment order instead of continued detention under a mental health section. The inquest narrative also described failures to recognise the need for face-to-face psychiatric assessment after his deterioration following discharge.

Katie Overd · Prevention of Future Deaths report View report

15 Oct 2025 Manchester North J. Kearsley

Katie Overd, aged 46, died at home on 20 March 2025. The inquest concluded that she died from an unintended overdose of prescribed medication against a background of longstanding inappropriate prescribing and delayed medication reduction. The report raised concern that the lack of proactive public communication about the Right Care Right Person process could delay families seeking assistance in emergencies.

James Duncan STEWART · Prevention of Future Deaths report View report

4 Dec 2014 Bedfordshire and Luton T. Osborne

James Duncan STEWART, a resident of Manton Heights Nursing Home, was admitted to hospital with decreased mobility and responsiveness after his Parkinson’s medication had apparently not been provided. He was discharged to Airedale Nursing Home for end-of-life care and died on 21 April 2014. The principal concerns were the absence of a system to check medication details with a previous GP practice and uncertainty about responsibility for confirming the correct medication prescription.

Astonn Mitchell-Male · Prevention of Future Deaths report View report

26 Jul 2018 Manchester North L. Hashmi

Astonn Mitchell-Male, who had schizophrenia/psychosis and was living in supported accommodation, was found deceased on 1 November 2016 after police and ambulance services had been delayed in responding to a welfare concern the previous evening. The jury found that he died from multiple self-inflicted stab and incise wounds on or around the evening of 31 October 2016 following a deterioration in his mental state. Concerns included the absence of a Trust policy on medication monitoring and compliance, and poor or non-existent record keeping affecting patient safety.

Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report View report

29 Apr 2015 Manchester West A. Walsh

Jorge Emanuel Mousinho Assabay E Castro died at home on 16 October 2014 after being found collapsed and unresponsive. He had post-traumatic epilepsy but had not received sodium valproate after 3 July 2014, despite attending his GP practice three times without the medication issue being reviewed. The principal concerns were the lack of systems to identify uncollected prescriptions and to alert GPs to medication-adherence concerns, particularly for vulnerable patients.

Marjorie Walker · Prevention of Future Deaths report View report

15 Jun 2022 Manchester South A. Mutch

Marjorie Walker was found unresponsive in hospital on 27 May 2020 after receiving prescribed gabapentin, morphine and buprenorphine, with post-mortem toxicology finding gabapentin above the therapeutic level. The report describes concerns about an incorrectly completed DNA CPR form, delays in specialist pain-clinic access, and insufficient recognition and monitoring of kidney function when prescribing gabapentin and other pain medication.

Kimberley Holden · Prevention of Future Deaths report View report

4 Apr 2017 Nottinghamshire E. Didcock

Kimberley Holden, who had a chronic neurological condition and chronic pain, died from Oxycodone toxicity on 26 November 2014 after a dose significantly higher than intended was prescribed. The concerns included unsafe prescribing of controlled drugs and poorly coordinated management and prescribing between healthcare providers.

Abbigail Louise SMITH · Prevention of Future Deaths report View report

27 May 2026 Essex Sonia Hayes

Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

James Owen DELANEY · Prevention of Future Deaths report View report

25 Jun 2019 Norfolk J. Lake

James Owen DELANEY was a resident at Sapphire House Care Home and had insulin-controlled diabetes. He refused insulin on 25 and 26 July 2018 and was unwell on 27 July; he was found unresponsive and pronounced dead on 28 July 2018. Concerns included insufficient regular refresher training on policies and inconsistent procedures for contacting a GP when medication was refused.

Clare Louise BAIN · Prevention of Future Deaths report View report

5 Aug 2014 Exeter and Greater Devon E. Earland

Clare Louise BAIN, who was prescribed Methadone and Valium, was found collapsed after ingesting a fatal quantity of prescribed and non-prescribed Methadone and Valium. She initially responded to Naloxone but later suffered cardiac arrest and died. The concerns were that paramedics may have treated the incident as a heroin overdose and that insufficient repeat Naloxone could fail to counteract the longer respiratory-depressant effects of Methadone.

Christopher Paul Davies · Prevention of Future Deaths report View report

29 Sep 2014 North Wales (East and Central) J. Gittins

Christopher Paul Davies was found unresponsive at home on 5 February 2014 and was verified dead that day; the inquest recorded accidental death, with the cause stated as clozapine poisoning. Concerns were raised that information about possible interactions between clozapine, caffeine and changes in smoking, and about warning signs of toxicity, had not been communicated to the deceased or Community Mental Health Team staff.

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.

Peter John BROOKES · Prevention of Future Deaths report View report

7 May 2014 Inner North London R. Brittain

Peter John Brookes was admitted to hospital after complications following catheterisation and later experienced problems with the administration of his Parkinson’s disease medication. After an episode of agitation and rapid breathing was not reviewed by ward doctors, he suffered a respiratory arrest on 19 August 2013, was found to have had a heart attack, developed bronchopneumonia and died on 27 August 2013. The concerns identified included inconsistent administration of Parkinson’s medication, limited availability of doctors for non-emergency weekend reviews, and an unexplained hospital pharmacy dispensing error.

Martin Glyn Baker · Prevention of Future Deaths report View report

3 May 2018 Plymouth, Torbay and South Devon A. Cox

Martin Glyn Baker, who had longstanding mental health difficulties and a history of suicide attempts, died following a prescription drug-related death. The inquest identified concerns about inadequate communication with his family, a shortage of care coordinators, and a risk assessment that did not address his periodic impulsivity.

Daniel Davey · Prevention of Future Deaths report View report

16 May 2019 Oxfordshire D. Salter

Daniel Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.

Claire Nicole Briggs · Prevention of Future Deaths report View report

8 Dec 2023 Manchester South A. Farrow

Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.

Carol Ann Robinson · Prevention of Future Deaths report View report

30 Mar 2023 East London N. Persaud

Carol Ann Robinson died at Queen's Hospital on 8 May 2022 after taking an overdose of medication and being diagnosed with mixed drug toxicity. The principal concerns were that she was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multidisciplinary discussion, or communication with her domiciliary care agency and family about the withdrawal of support.