6,433 reports
Information drawn from published reports and official responses.
Claire Elizabeth Homer, aged 46, was found dead at home on 5 May 2023. The cause of death was unascertained. Concerns were raised about a delayed response to a GP’s email regarding Claire’s worsening condition and whether more robust protocols were needed when staff or key contacts are on leave.
North London NHS Foundation Trust
Graham Ian COOMBE entered the water from the lower level of Eastbourne Pier on 1 May 2022 and was rescued by lifeboat after attempts to reach him were delayed by access and lifesaving-equipment issues. He died at Royal Sussex County Hospital Brighton on 4 May 2022 as a result of drowning. Concerns included a locked access gate, an inaccessible and poorly visible lifesaving ring, a rope that was too short to reach the water at low tide, and the number of lifesaving rings on the pier.
Eastbourne Pier
Christopher Richard Allum had escalating mental health issues and a history of deliberate self-harm before being admitted to the Langford Centre on 14 May 2022. He was found unresponsive in his room on the evening of 15 May 2022, and death was confirmed at 23:01; the inquest concluded that he died as a result of suicide. The concerns identified included gaps in obtaining and recording previous methods of self-harm and relevant family information at referral and admission, and difficulties accessing NHS notes in private healthcare settings.
NHS EnglandThe Langford Centre
Frances Ann Newbury was found unconscious and not breathing at home on 20 May 2023 after reportedly taking drugs the previous evening; the inquest recorded acute poly drug toxicity, substance misuse disorder and chronic lung disease as the medical causes of death. The principal concern was that paramedics did not administer Naloxone despite being informed of illicit drug use and observing signs associated with drug use, which may affect outcomes in other cases.
London Ambulance Service NHS Trust
Mason Williams was struck by a car while crossing Trinity Road, Piccadilly, in darkness on 30 November 2022 and died in hospital three days later. The substantive concern was that the street lighting was not illuminated because of a fault with underground cabling, which may have been damaged in an earlier road traffic collision.
Warwickshire County Council
Elizabeth Anne Watson attended the Humber Bridge on 5 December 2022 and jumped from it, landing on Cliff Road; she was declared dead at the scene. The concerns included a lack of structured training, including input from trained mental-health professionals, for bridge security staff identifying and responding to people in mental-health distress, as well as delays in emergency and mental-health support responses.
Humber Bridge Board
Alfie was born on 13 June 2022 and died in cardiac arrest at 01.50 on 14 June 2022 after intensive treatment. The postmortem cause of death was severe congenital pneumonia and meningitis, with suspected acute chorioamnionitis. The report identifies that antibiotics were not administered after concerning observations at 03.55, and raises concerns that electronic risk assessment did not fully map national guidance and that the NEWTT2 chart was not available on BadgerNet.
Clevermed Limited
Christopher Hart became unwell at home and an ambulance was requested, but no ambulance was immediately available because of high service demand and hospital off-loading delays. He was later found unresponsive and could not be resuscitated; the report states that his cardiac condition caused his death and that the ambulance delay directly contributed to it. The principal concern was continuing and regular ambulance non-availability in Suffolk and the wider East of England region, with insufficient ambulance resources potentially leading to future loss of life.
Department of Health and Social Care
Luca Yates was born by emergency caesarean section on 23 January 2022 after fetal bradycardia was detected, and died the following day after difficult resuscitation. The inquest found that he died from complications of asphyxia around the time of birth, with concerns including failure to recognise established or transitioning labour, absence of hospital monitoring, and non-use of 100% oxygen during part of resuscitation. The report also raised concerns about future paediatric doctors having reduced experience in neonatal resuscitation.
Royal College of Paediatrics and Child Health
Lee Bowman was last seen on 31 October 2021 after being reported as having injuries consistent with an assault, and his body was found on 3 January 2022. The medical cause of death was unascertained. The principal concerns were assumptions about his whereabouts and reasons for not contacting family, insufficient weight given to information from his family, and shortcomings in the police handling and risk assessment of the missing-person reports.
College of Policing
Leva Amra Adris was pronounced deceased on 18 March 2023 after suffering a fitting episode, and post-mortem testing identified toxicity following an overdose of medication used for anxiety. The report raised concerns that a GP referral requesting secondary mental health assessment was not considered by secondary services, that the GP was not informed it had been rejected, and that the significance of worsening mental health symptoms may have been underestimated.
Birmingham and Solihull Integrated Care SystemBirmingham and Solihull Mental Health NHS Foundation Trust
Owen Garnett, a 19-year-old student with severe learning difficulty, swallowing problems and Pica, died after choking on a significant amount of blue paper towel while unsupervised at school. The principal concerns were that carers’ repeated concerns were not acted on, that required supervision was not provided despite the risk assessment, and that the school’s subsequent action plan lacked clear guidance and oversight.
Health and Safety ExecutiveUnity Multi Academy Trust
Gina Marie Bywater became unwell with vomiting, shortness of breath and later chest pains, but an ambulance was not available for nearly 10 hours despite repeated 999 calls. She was found in cardiac arrest and subsequently died from a heart attack. The principal concern was the continuing lack of sufficient ambulance resources in Suffolk and the wider East of England, resulting in delays that the report states contributed to her death.
Department of Health and Social Care
Michael John Vincent died in hospital on 20 December 2022 after falling at home and remaining on the floor for many hours while awaiting an ambulance response. He later suffered a cardiac arrest and died from a combination of undiagnosed bronchopneumonia, severe coronary artery disease and a long lie. The principal concern was the substantial delay in responding to an appropriately categorised emergency call, with concern that another frail elderly person could have the same experience.
Association of Ambulance Chief ExecutivesEast of England Ambulance Service NHS TrustNHS EnglandRoyal College of Emergency Medicine
Terri Liz Harris, her children John-Paul Bennett and Lacey Bennett, and their friend Connie Gent were discovered deceased at Terri’s home on 19 September 2021. They had been murdered by Terri’s partner, Damien Bendall, who inflicted severe head injuries on all four; the report also states that he raped Lacey. The deaths were contributed to by acts and omissions in offender supervision and electronic monitoring, including concerns about risk-recording, domestic abuse and child-safeguarding checks, reporting of threats, and notification of missed treatment appointments.
Capita PLCDerbyshire Healthcare NHS Foundation TrustMinistry of JusticeProbation Service
Irene Joy White, who had dementia and became immobile after a fall and hip-fracture surgery, was discharged to a nursing home without further thromboprophylaxis and was not mobilised beyond regular repositioning. She died of a pulmonary embolism, and concerns were raised about the nursing home's failure to identify and manage her DVT risk, including the absence of a DVT policy.
Frome Care Village
Mr Kevin Conrad Gale died at home on 4 March 2022; the inquest concluded that his death was suicide following deliberate self-suspension. He had a history of severe depression and anxiety and remained anxious about his Universal Credit application. The report raised concerns that DWP procedures, including lengthy forms, telephone queues and travel requirements, may be impractical or exacerbate symptoms for people with mental health illness.
Department for Work and Pensions
Ms. Madeleine Lawrence suffered a traumatic hip dislocation while playing rugby and later developed sepsis and necrotising myositis after her hospital admission. Her condition deteriorated, but observations were not performed or escalated in a timely manner, and prompt treatment for presumed sepsis was not initiated; she died in hospital on 25 March 2022. The concerns identified included serious deficiencies affecting patient safety and the adequacy of staff training on recognising and treating deteriorating patients and sepsis.
Bristol NHS Foundation TrustCare Quality CommissionParents of the deceased
Adam Johnson, a professional ice hockey player, sustained an incised neck wound caused by another player's skate during a game on 28 October 2023 and later died in hospital from his injury. The report raised concern that future deaths may occur because neck guards or protectors are recommended but not required for players over 18.
Elite Ice Hockey LeagueIce Hockey UKThe English Ice Hockey Association Limited
Musa Sidique Konteh went missing after hiring a jet ski alone at a beach resort in Sierra Leone on 19 March 2023; his body was found in the water on 22 March 2023. Concerns included the reported lack of health and safety procedures for jet-ski users, including no emergency engine cut-off instructions, no guidance about submerged rocks, and no supplied lifejackets, as well as travel advice that did not warn that local health and safety standards might be lower than those experienced in the UK.
Foreign, Commonwealth & Development Office
