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Thomas Warren · Prevention of Future Deaths report View report

14 Aug 2014 Inner South London A. Harris

Thomas Warren, a child with cerebral palsy, died after receiving a 25 microgram fentanyl patch for pain and subsequently developing symptoms before suffering a cardiac arrest. The report identified concerns about prescribing an opiate to an opiate-naïve child without hospital admission, missed opportunities to stop dispensing the drug and provide parents with adequate monitoring information, and gaps in checks on the fitness to practise of a locum doctor.

Francis James Lea · Prevention of Future Deaths report View report

15 Dec 2016 Leicester City and South Leicestershire L. Brown

Francis James Lea, who was living in a care home, was transferred to a new GP without his family being informed. After a hospital admission for a seizure, his prescribed anti-epileptic medication was not continued because the new GP was unaware of the admission and prescription. The report raised concerns about involving next of kin, recording the rationale and consent or capacity assessment for changing GP, and ensuring a safe transfer of care between the care home and GP surgeries.

Ricky Barcock · Prevention of Future Deaths report View report

21 Sep 2019 West Yorkshire (Western) M. Fleming

Ricky Barcock was admitted to a recovery centre for detoxification and rehabilitation and was later found unresponsive in his room after sleeping for several hours. He was found to have died from morphine toxicity, with methadone and diazepam use also recorded. The principal concern was whether resident wellbeing checks should include regular physical checks and rousing clients when necessary.

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 information indicating the need for an urgent ambulance response was not obtained, no ambulance was available for several hours, and his family transported him to hospital. The principal concerns included limited awareness and monitoring of excessive salbutamol use, ambulance handover delays affecting emergency availability, risks when families transport critically unwell patients, and unclear NHS Pathways triage wording.

Anthony Paul Nixon · Prevention of Future Deaths report View report

16 Aug 2024 County Durham and Darlington J. Richards

Anthony Paul Nixon, aged 45, was found deceased at his home on 12 June 2023 after a drug overdose involving a combination of substances. The report identified concerns that a pharmacy supplied additional doses of a controlled drug in advance and contrary to the supervised-consumption prescription, leaving him in possession of multiple doses without notifying his drug treatment provider. The inquest concluded that the death was drug related and that the pharmacy’s actions contributed more than minimally by supplying the additional doses.

Ian Anthony Charles Miller · Prevention of Future Deaths report View report

5 Jan 2022 Gwent C. Saunders

Ian Anthony Charles Miller was serving a term at HMP Usk and died by suicide in the prison on 21 September 2019 after being told he could not live at the family home or with his father-in-law, could not have unsupervised contact with his children, and might be homeless. The report raised concerns that prisoners were trading prescribed medication at HMP Usk and that unprescribed medication was being ingested, putting other prisoners’ lives at risk.

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 attempting to suspend herself; resuscitation was unsuccessful and she was pronounced deceased at 00:08 on 16 February 2022. The report identifies concerns about inadequate trained staffing and observation, unsuitable care arrangements, access to ligature materials, insufficient risk assessments and care plans, communication adjustments for autism and learning disability, and an unsafe discharge from hospital.

Marian DAY · Prevention of Future Deaths report View report

25 Sep 2020 Nottinghamshire E. Didcock

Marian Day died at Kings Mill Hospital on 18 November 2019 after a sudden collapse caused by a massive intra-abdominal haemorrhage. Warfarin was continued and administered despite suspected bleeding and an earlier plan to withhold it; the inquest found that this prescription error made a contribution to the haemorrhage. The report raises concerns about muddled prescribing systems, insufficient senior review, and unclear anticoagulant management plans.

Daniel Onley · Prevention of Future Deaths report View report

19 Sep 2013 Gloucestershire T. Osborne

Daniel Onley, a resident at Orchard House, was found face down in his bath on 22 June 2012 and was concluded to have died from sudden unexplained death in epilepsy. Concerns included insufficient support for taking anti-convulsant medication, inadequate management of medication-related risks, and insufficient evening supervision.

Alec James MATHIAS · Prevention of Future Deaths report View report

26 Jun 2015 Exeter and Greater Devon E. Earland

Alec James Mathias developed drug-induced jaundice after receiving Flucloxacillin in 2008, but this reaction was not communicated to his GP or highlighted in the hospital records. He was prescribed Flucloxacillin again in 2014 for an infected finger and died after developing Flucloxacillin-induced cholestatic liver injury and liver failure. The principal concerns were failures to send discharge information to the GP and to record the drug sensitivity in the hospital notes.

Carol Patricia Cole · Prevention of Future Deaths report View report

2 Feb 2022 Dorset R. Griffin

Carol Patricia Cole was found collapsed and unresponsive at home on 15 May 2020 after being prescribed medication and having a history including depression, unstable personality disorder and previous overdoses. The inquest concluded that her death was suicide. Concerns were raised that processes for sharing Public Protection Notices in the Dorset Council area may have resulted in the GP not receiving information about concerns regarding her mental health, creating a missed opportunity for assessment, support or treatment.

Lauren Amelia Rose SANDELL · Prevention of Future Deaths report View report

25 Jun 2018 London (East) N. Persaud

Lauren Sandell became unwell with headaches, vomiting, aches and pains on 29 September 2016 and became unresponsive at home on 2 October 2016, when her life was pronounced extinct by paramedics. The inquest concluded that she died from meningococcal sepsis (serogroup W135) and fell within the cohort requiring MenACWY vaccination. Concerns included confusion over responsibility for vaccinating children not covered by the school programme, uncertainty about GP responsibilities, and the lack of auditing of systems to identify and protect unvaccinated children before university.

Christopher Byron · Prevention of Future Deaths report View report

5 Nov 2019 Manchester North J. Kearsley

Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

James Stephen KEEN · Prevention of Future Deaths report View report

2 Jan 2025 West London L. Brown

James Stephen KEEN was found deceased in his room at supported accommodation on 8 December 2023. He had a history of severe mental ill-health and substance abuse, and the inquest conclusion recorded a drug-related death involving the cardiotoxic effects of methamphetamine and sildenafil. Concerns included confusion and inadequate documentation about physical health observations by untrained support workers, a broken thermometer, and a lack of evidence of appropriate training or competency checks.

Colin Bailey · Prevention of Future Deaths report View report

29 Mar 2019 Manchester South C. Murray

Colin Bailey was admitted to hospital following a stroke and later transferred for rehabilitation. After falling and hitting his head while taking anticoagulant medication, he suffered an extensive subarachnoid haemorrhage and died at Tameside General Hospital on 10 April 2018. The concern was that national guidance did not require a CT scan in this situation for all types of anticoagulant medication, although clinicians indicated that scanning should be undertaken regardless of the type used.

Helen Jayne SHEATH · Prevention of Future Deaths report View report

27 Jan 2020 Bedfordshire and Luton E. Whitting

Helen Jayne Sheath, who had a recent history of self-harm and suicidal ideation, ingested a fatal dose of sodium nitrate at home and died in hospital on 20 August 2018. Concerns included the initial ambulance call being coded as Category 3 rather than Category 2, subsequent delays in ambulance attendance, and the Community Mental Health Team leaving her home before gaining access despite being alerted to her threats to self-harm.

Deborah Michelle HEADSPEATH · Prevention of Future Deaths report View report

18 Nov 2019 Suffolk N. Parsley

Debbie Headspeath died suddenly at home on 28 July 2017 from aspiration pneumonitis caused by pancreatitis, which was linked in the report to long-term codeine use. The principal concerns were the lack of a central database for prescription-only medicines, uncoordinated access to codeine from multiple online suppliers, and the ability of some suppliers to operate outside the CQC regulatory regime.

Carly Marie GORDON · Prevention of Future Deaths report View report

4 Aug 2017 Exeter and Greater Devon G. Tomalin

Carly Marie GORDON was admitted to hospital after a failed attempt on her own life and was later found hanging at home on 27 May 2016 after being discharged to her mother's care. The inquest concluded that she took her own life while suffering from depressive disorder and benzodiazepine withdrawal; concerns related to the long-term prescribing and review of benzodiazepines.

Darren John Goddard · Prevention of Future Deaths report View report

9 Mar 2020 South Wales Central S. Richards

Darren John Goddard underwent an elective trans-rectal ultrasound of the prostate and subsequently developed sepsis, becoming acutely unwell and dying on 18 April 2019. The principal concerns included delayed recognition and treatment of sepsis, delays in triage, antibiotics, fluids and critical care, and the information provided about sepsis risks and symptoms following the procedure.

Maureen Chatterley · Prevention of Future Deaths report View report

8 Oct 2015 Manchester West A. Walsh

Maureen Chatterley died at Royal Bolton Hospital on 24 December 2014 after a fall causing a right hip fracture, subsequent dislocations and multiple surgical procedures. The report raised concerns that a possible excess dose of lorazepam was not investigated and that medication stock in patient drawers and ward cupboards was not recorded or controlled, although the Inquest accepted that any excess dose did not contribute to her death.