Reports

Katie Louise Davies · Prevention of Future Deaths report View report

6 Jun 2014 Manchester West A. Walsh

Katie Louise Davies died in hospital on 26 December 2012 after developing Cerebral Venous Sinus Thrombosis and suffering a cardiac arrest. The report raised concerns about blind spots in hospital bleeper systems delaying clinicians’ responses and about differing policies for managing and transferring patients with Cerebral Venous Thrombosis to regional neuroscience centres.

James Edward Boylan · Prevention of Future Deaths report View report

6 Jun 2014 South and East Cumbria I. Smith

James Edward Boylan, who had a history of anxiety and was admitted to a mental health unit, died by hanging using a phone charger cord and a bathroom rail. The concerns included removable bathroom rails creating a ligature point, insufficient searching of patients’ property, access to a cord, and failures in recognising and communicating the escalation of his condition.

Archie Hames · Prevention of Future Deaths report View report

5 Jun 2014 Surrey M. Fleming

Three-year-old Archie Hames, who had CHARGE syndrome and relied on a tracheostomy, was found unresponsive at home on 15 January 2012 after the tracheostomy tube had become displaced. He was resuscitated and taken to hospital, but died of cerebral hypoxia on 19 January 2012; testing indicated that the attaching Velcro strap had worn the tube’s silicone eyelet, contributing to detachment and airway obstruction.

Sophie Allen · Prevention of Future Deaths report View report

5 Jun 2014 Sunderland D. Winter

Sophie Allen, aged 2 years, was found at home with a blind cord wrapped around her neck and was pronounced dead on 26 April 2014 after hospital transfer. The report highlighted the continuing risk of blind cords to young children, including risks from existing cords in homes and the need for wider public awareness.

THOMAS PATRICK MAHER · Prevention of Future Deaths report View report

5 Jun 2014 Manchester South J. Pollard

Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

John William Day · Prevention of Future Deaths report View report

4 Jun 2014 Isle of Wight C. Sumeray

John William Day, who had COPD, heart failure and respiratory difficulties, was found dead on 6 April 2014 while attached to his oxygen supply. An out-of-hours doctor prescribed Co-Amoxiclav after being unable to access Mr Day’s medical records, although he had a known allergy to the drug; the report states that the medication did not cause his death. The principal concern was that out-of-hours doctors could not access patients’ allergy information in every case.

Private Robert WOOD and Private Dean HUTCHINSON · Prevention of Future Deaths report View report

3 Jun 2014 Wiltshire and Swindon D. Ridley

Private Robert Wood and Private Dean Hutchinson died on 14 February 2011 from inhalation of products of combustion and severe burns. The report raised concerns about fire risk assessments, training on electrical appliance overloading, identification of sleeping in office accommodation, and the effectiveness of random overnight checks.

Private Robert WOOD and Private Dean HUTCHINSON · Prevention of Future Deaths report View report

3 Jun 2014 Wiltshire and Swindon D. Ridley

Private Robert Wood and Private Dean Hutchinson died on 14 February 2011 from inhalation of products of combustion and severe burns. The report raised concerns about fire risk assessments, training on electrical appliance overloading, identification of sleeping in office accommodation, and the effectiveness of random overnight checks.

Denise PRIOR · Prevention of Future Deaths report View report

2 Jun 2014 West Sussex M. Kendall

Denise Prior died on 6 November 2013 following a cardiac arrest after a fall caused by her underlying medical condition. The report raised serious concerns about record-keeping at St Richards Hospital, including recording and prescribing oxygen and applying the National Early Warning Score system, with a stated risk of future deaths.

Essa Shah · Prevention of Future Deaths report View report

2 Jun 2014 Bedfordshire and Luton T. Osborne

Essa Shah, aged eight weeks, went to sleep in the same bed as his mother following a feed and was later found unresponsive. The report raised concern that hospital literature about the dangers of co-sleeping was available only in English.

Aimee Sarah VARNEY · Prevention of Future Deaths report View report

2 Jun 2014 Bedfordshire and Luton T. Osborne

Aimee Sarah VARNEY died following a seizure from Sudden Unexpected Death in Epilepsy at her home address. The report identifies a concern that NICE guidance on referring patients with suspected epilepsy to a Specialist Tertiary Centre was not followed, and states that this represented a lost opportunity to diagnose and further treat her condition.

Jennifer Morrison · Prevention of Future Deaths report View report

2 Jun 2014 Wirral A. Wilson

Jennifer Morrison had significant breathing difficulties, fell at home on 30 December 2012, was admitted to hospital, deteriorated despite treatment, and died following a cardiac arrest on 9 January 2013. Concerns included missing hospital observation records and whether staffing pressures and delays in early January affected the care provided, including delays in transfer to a High Dependency Unit and in restarting fluids.

Richard Edward Anthony Jaeger-Fozard · Prevention of Future Deaths report View report

30 May 2014 Buckinghamshire R. Hulett

The supplied text records an investigation into the death of Richard Edward Anthony Jaeger-Fozard, but does not provide the circumstances of the death. It identifies ongoing differences of professional opinion about the proper steps to prevent similar occurrences.

Matthew Thomas Purser · Prevention of Future Deaths report View report

30 May 2014 Swansea and Neath Port Talbot P. Rogers

Matthew Thomas Purser hanged himself in his cell at Swansea Prison on 13 June 2012, after being remanded there and placed on self-harm monitoring. The report identified concerns about inadequate ACCT training, insufficiently objective recording and review of trigger events and significant interactions, and unclear arrangements for obtaining community mental health records.

Mark Duggan · Prevention of Future Deaths report View report

29 May 2014 London (North) K. CBE

On 4 August 2011, Mark Duggan was shot by an armed police officer during an enforced vehicle stop in London and was pronounced dead at the scene. The report raises concerns about intelligence sharing and operational decisions before the shooting, the investigation and preservation of evidence at the scene, the recording of the operation, and the coordination and access to intelligence during the investigation and inquest.

Stephen Anthony WARD · Prevention of Future Deaths report View report

29 May 2014 Inner North London M. Hassell

Stephen Anthony Ward, who had a long history of depression and other mental health problems, was found hanging by a close friend on 28 February. The principal concern was that, after the crisis team contacted police to request a welfare check, nobody followed up when police did not call back within one or two hours; the police later said they could not locate his flat, by which time Mr Ward had been found hanging.

Magdalen Bernadette Dwerryhouse · Prevention of Future Deaths report View report

29 May 2014 Manchester West A. Walsh

Magdalen Bernadette Dwerryhouse, who lived alone and was being assessed for a paranoid mental illness, died at home on 25 November 2013 after a kitchen fire; she was found collapsed and unresponsive at the bottom of the stairs. Concerns included the arrangements for appointments with vulnerable people, the response to a failed home visit and the lack of partnership working between the mental health trust and the fire service regarding fire-risk prevention.

Loui Aspinall · Prevention of Future Deaths report View report

29 May 2014 Manchester West A. Walsh

Loui Aspinall died after walking into a swimming pool at a hotel resort in Tunisia and becoming submerged. The concerns included the apparent absence of obvious resuscitation and rescue equipment, uncertainty about lifeguard provision and first-aid training, and gaps in tour-operator best-practice guidance on pool safety and emergency procedures.

Laura Page · Prevention of Future Deaths report View report

28 May 2014 Leicester City and South Leicestershire L. Brown

Laura Page experienced social stresses, sought medical support, and later took overdoses requiring psychiatric care. She died on 4 December 2012 after taking a substantial overdose. Concerns included failed community-team home visits, inadequate escalation and welfare-check thresholds, incomplete discharge arrangements, and poor inter-agency communication.

Arnold SOULSBY · Prevention of Future Deaths report View report

28 May 2014 Black Country R. Balmain

Arnold SOULSBY was killed when a lorry moved off at traffic lights and knocked him down while he was crossing the road. The concern was that forward-facing mirror requirements for lorries were not retrospective, leaving many older lorries without this facility and potentially limiting drivers’ visibility of pedestrians.