Reports

Thomas George Smith · Prevention of Future Deaths report View report

9 Jul 2014 Cardiff & the Vale of Glamorgan C. Woolley

Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.

David Reginald Giles · Prevention of Future Deaths report View report

9 Jul 2014 Birmingham and Solihull Z. Siddique

David Reginald Giles was discovered at home on 31 March 2014 with a plastic bag over his head connected to a helium gas canister, and paramedics confirmed his death that morning. The concerns included the unrestricted availability and standard size of helium canisters, the absence of modified control valves, and readily accessible online information about suicide by helium inhalation. The report also noted an increase in deaths mentioning helium in England between 2008 and 2012.

Michael John Harrison · Prevention of Future Deaths report View report

9 Jul 2014 North London A. Walker

Michael John Harrison slipped on black ice in a car park on 20 December 2013, sustaining a serious head injury, and died in hospital on 2 January 2014. The concern was that there were insufficient measures to treat the ice in the car park.

Georgina Lauren Taylor · Prevention of Future Deaths report View report

9 Jul 2014 Manchester North S. Nelson

Georgina Lauren Taylor died following a road traffic collision on the A627(M), in which a vehicle lost control at excessive speed, struck a tree and rolled. The report raised concerns about trees and other roadside features near the carriageway, including whether they were adequately protected or should have been removed, and about the lack of requirements to reassess protection as roadside vegetation developed.

Thomas David Dixon · Prevention of Future Deaths report View report

8 Jul 2014 Sunderland D. Winter

Thomas David Dixon had bladder cancer and died at St Benedict’s Hospice on 29 March 2014 from metastatic transitional cell carcinoma of the bladder. Concerns included failures to arrange follow-up and an urgent procedure, missing referral documentation, and a lack of systems to identify and rectify these problems, with potential implications for other patients.

Muriel Naylor · Prevention of Future Deaths report View report

8 Jul 2014 Manchester North S. Nelson

Muriel Naylor died after a bus made an emergency stop on 19 November 2011, causing her to be projected from a designated priority seat into the wheelchair/tip-up bay and sustain fatal spinal injuries. The principal concern was that the priority seat lacked a restraint or other safety measure to restrict passenger movement, despite priority seating being intended to protect vulnerable users.

Anthony Shane Ponting · Prevention of Future Deaths report View report

8 Jul 2014 Somerset (West) M. Rose

Anthony Shane Ponting, a 34-year-old man, was killed on 11 July 2013 while using an authorised pedestrian crossing over the Bristol to Taunton railway line near Highbridge, Somerset. The inquest jury returned an accidental verdict. A report identified potential risks to other crossing users, including reduced sighting time from vegetation, incorrectly positioned S.H.1 boards, and tripping hazards on the crossing surface.

Harold George de Mello · Prevention of Future Deaths report View report

7 Jul 2014 Inner North London G. Elliman

Harold George de Mello, who had multiple co-morbidities, limited mobility and incontinence, died in hospital on 13 April 2014 after collapsing at home and being treated for bronchopneumonia. The principal concerns were that social-care assessments did not adequately investigate or record the reported incontinence, hygiene problems, care arrangements and differing information, and lacked sufficiently comprehensive guidance and senior review.

Stanley Bere · Prevention of Future Deaths report View report

4 Jul 2014 West Sussex P. Schofield

Stanley Bere, a resident of a nursing home, fell on 31 October 2011 and sustained a fractured ankle that was not identified until 8 November 2011. He later developed an infection and died on 4 June 2012; the inquest recorded congestive cardiac failure and bronchopneumonia, with the fractured ankle and subsequent infection contributing to his death. Concerns included incomplete Cardex records, inadequate follow-up of incident reports, and insufficient cross-referencing or monitoring of records, which meant his injuries were not identified promptly.

Michael Holgate · Prevention of Future Deaths report View report

4 Jul 2014 Stoke-on-Trent and North Staffordshire I. Smith

Michael Holgate fell into the water after the narrow boat he was steering collided with the side of Harecastle Tunnel on 20 May 2014. The concerns included the lack of communication facilities in the tunnel, the absence of a requirement for people on board to wear buoyancy aids, the availability of safety helmets, and the safety information provided to tunnel users.

Nadine Gillian THURMAN · Prevention of Future Deaths report View report

3 Jul 2014 Black Country R. Balmain

Mrs Nadine Gillian Thurman was found hanging at home on 5 November 2012, following recent episodes of paracetamol and vodka misuse and hospital treatment. The concerns related to psychiatric assessment, including the exclusion of a relative from contributing and the reported practice of the crisis team refusing relatives' presence.

Helena Kathleen Farrell · Prevention of Future Deaths report View report

3 Jul 2014 South and East Cumbria I. Smith

Helena Kathleen Farrell had bulimia, had been sexually assaulted, took an overdose, self-harmed, and wrote letters that appeared to be suicide letters after her death. She died from hanging following a period in which she was not seen by CAMHS until the day before her death, and those dealing with her did not recognise her suicidal feelings and intentions. The concerns included failures in the CAMHS referral and follow-up system, inadequate staffing and training, failure to recognise escalating seriousness, unrealistic demands on the school nurse, and insufficient checking of the school counsellor’s credentials.

Ronald Perry · Prevention of Future Deaths report View report

2 Jul 2014 North Wales (East and Central) J. Gittins

Ronald Perry attended Glan Clwyd Hospital on 17 January 2014, was discharged after examination, then collapsed several hours later and could not be resuscitated after readmission. Evidence at the inquest indicated that a CT scan might probably have detected his aneurysm, and raised concern about inconsistent criteria for requesting CT scans outside normal hours and at weekends, creating continuing risks to patients.

Liam Hardy · Prevention of Future Deaths report View report

2 Jul 2014 South London S. Lynch

Liam Hardy, a 15-year-old schoolboy, died after tying his school tie around his neck at his grandfather’s home on 19 November 2012. The inquest recorded concerns that his complex behavioural and emotional problems were not adequately assessed or managed, that information was not fully shared or accessed, and that the risks associated with self-harm were not adequately managed. A further concern was that the electronic patient record system did not clearly flag or summarise significant events and primary concerns for clinicians.

Esther Jane Jones · Prevention of Future Deaths report View report

2 Jul 2014 North Wales (East and Central) J. Gittins

Esther Jane Jones died at Maelor Hospital, Wrexham, on 30 March 2013. Her death was recorded as due to natural causes, with concerns about missed medication and the process for conducting and completing Serious Incident Reviews, which was said to pose continuing risks to others and may lead to future deaths.

Garry Arthur Colin Daltry · Prevention of Future Deaths report View report

2 Jul 2014 North Wales (East and Central) J. Gittins

Garry Arthur Colin Daltry left a New Year's Eve party, tripped over a low wall on the promenade, and fell onto a beach access ramp. He sustained blunt force injuries to his head and neck and died at the scene; the report identified the tripping hazard as a concern because others could fall and suffer fatal injuries.

Miss Beryl Brinkman · Prevention of Future Deaths report View report

2 Jul 2014 Manchester North L. Hashmi

Miss Beryl Brinkman was involved in a serious road traffic collision on 8 January 2014 after emerging from an un-adopted side road onto the A58 Featherstall Road. She suffered catastrophic injuries and died at Royal Oldham Hospital on 10 January 2014. Concerns included the proximity of parked vehicles to the junction, reduced driver visibility, the risk of harm to road users and pedestrians, the appropriateness of the parking bays, and whether the side road should be adopted.

Farres Ikken · Prevention of Future Deaths report View report

2 Jul 2014 North London A. Walker

Farres Ikken was arrested after stating that he wanted to kill himself, assessed by mental health services, and discharged for follow-up by his GP. Shortly after leaving the hospital, he hanged himself in the hospital grounds; the substantive concern was that hospital staff could not directly refer him to community psychological services on discharge.

Mr Hywel Llewelyn Hughes · Prevention of Future Deaths report View report

2 Jul 2014 North West Wales K. Monaghan

Mr Hywel Llewelyn Hughes was forcibly removed from a nightclub, restrained face down by door staff, and later declared deceased in hospital on 3 May 2003. The inquest concluded that the medical cause of death was traumatic asphyxia and that police actions were inappropriate and more probably than not contributed more than minimally to his death. Concerns included training and monitoring of detainees during restraint and transport, and shortcomings in the licensing, training, auditing and review of door supervisors.

ALBERT FLYNN · Prevention of Future Deaths report View report

2 Jul 2014 Manchester South J. Pollard

Albert Flynn, a resident of Appleton Manor Residential Home, was taken to hospital with a suspected deep vein thrombosis and treated with the blood-thinning drug Enoxaparin. The following night he was left in a chair for approximately 10 hours without food, fluids or prescribed medication, while staff were unable to rouse him. He was suffering from a severe cerebral bleed, which was fatal; concerns included inadequate staff training and failure to recognise the significance of his condition and recent blood-thinning treatment.