Reports

Terence Vincent Anthony FERNANDES · Prevention of Future Deaths report View report

12 May 2014 Bedfordshire and Luton T. Osborne

Terence Vincent Anthony FERNANDES collapsed on a train on 23 January 2013 after drinking alcohol, suffered cardiac arrest associated with airway occlusion, and died in hospital on 25 January 2013. The report raised concern that the train and station personnel who assisted him had no basic first-aid training and may not have recognised that his airway was partially occluded.

Courtney Jordan Mills · Prevention of Future Deaths report View report

12 May 2014 Portsmouth and South East Hampshire D. Horsley

Courtney Jordan Mills was found unresponsive in bed at home on 19 April 2013 and was pronounced deceased at hospital that morning. The concerns included repeated prescription and communication problems affecting access to Clonodine, which was reported as a medication that should not be stopped abruptly, and the potential risk to other children in similar circumstances. The inquest recorded acute bronchopneumonia in a child with sleep apnoea and cerebral palsy, with death due to natural causes.

Keiran Michael John Toman · Prevention of Future Deaths report View report

12 May 2014 Inner West London F. Wilcox

Keiran Michael John Toman had fixed delusions, withdrew from social and psychiatric support, and subsequently starved himself to death due to paranoia before being found deceased in a hotel. The report raised concerns that psychiatric services did not maintain contact with his family despite his lack of insight and capacity, potentially leaving him isolated and increasing the risk of deterioration and death.

Amanda Richards · Prevention of Future Deaths report View report

12 May 2014 Coventry S. McGovern

Amanda Richards, a wheelchair user with live-in carers for 22 hours per day, died in a fire on 3 December 2013 after apparently dropping a cigarette while she was alone. The report raised concern that domestic sprinkler systems in special accommodation could have made such a death far less likely.

Gianni Khan · Prevention of Future Deaths report View report

9 May 2014 Bedfordshire and Luton T. Osborne

Gianni Khan suffered a catastrophic head injury at a birthday party on 21 December 2013 and died at Addenbrooke’s Hospital on 28 December 2013 after his condition deteriorated and he underwent neurosurgery. The principal concern was that, after reporting a head injury at the hospital, he was streamed to an urgent GP clinic rather than being assessed by a doctor in the Emergency Department, with a failure to recognise the seriousness of the injury and lost opportunities for further medical attention.

Lisa Webb · Prevention of Future Deaths report View report

9 May 2014 Inner South London A. Harris

Lisa Webb died suddenly and unexpectedly at home on 10 March 2012, aged 44. The inquest recorded natural causes, including adult respiratory distress syndrome and lower respiratory tract infection, with sleep apnoea and chronic asthma noted. Expert evidence raised concerns about the general practitioner's assessment and management of her asthma and respiratory symptoms, including the prescription of Diazepam.

MARGARET CONNOR · Prevention of Future Deaths report View report

9 May 2014 Norfolk J. Lake

Margaret Connor, a resident of Heathers Nursing Home, probably suffered a right leg fracture when a wheelchair footplate was misplaced on 3 July 2013. The fracture was not detected until hospital admission and imaging, and she died on 2 August 2013; the post-mortem report stated that debility caused by the fracture was likely to have contributed to her death. Concerns included inadequate checks and maintenance of wheelchair footplates, and doctors being told there had been no trauma despite concerns about an injury.

Linda Yvonne Fisher · Prevention of Future Deaths report View report

9 May 2014 Blackpool and the Fylde A. Wilson

Linda Yvonne Fisher was admitted to hospital with knee pain and was treated for a suspected deep vein thrombosis. She was found collapsed on 17 October 2013 and died from a pulmonary embolism. Concerns related to medication dosages being based on inaccurately assessed patient weight and relevant family medical history not being obtained and communicated effectively.

Miss Abiola Dosunmu · Prevention of Future Deaths report View report

9 May 2014 Inner South London A. Walker

Abiola Dosunmu developed abnormal blood tests, proteinuria and symptoms that were treated as cellulitis, before rapidly deteriorating and being found dead at home on 24 August 2012. The report identified concerns about failures to communicate the proteinuria and abnormal results, inadequate follow-up and monitoring, and a missed opportunity to diagnose and treat SLE earlier.

Gary Richards · Prevention of Future Deaths report View report

9 May 2014 Inner South London A. Harris

Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.

Ernest Charles Harper · Prevention of Future Deaths report View report

9 May 2014 Bedfordshire and Luton I. Pears

Ernest Charles Harper fell from the tailgate lift of a small minibus while returning from the Goldington Day Care Centre, sustaining injuries including a right subdural and subarachnoid haemorrhage. Concerns were raised that a passenger could fall between the safety barrier and the back of the vehicle, and that mobility information used for risk assessment depended on voluntary information rather than a formal assessment.

Ann Bennett · Prevention of Future Deaths report View report

9 May 2014 West Yorkshire Eastern D. Hincliff

Ann Bennett, aged 61, underwent emergency laparoscopic cholecystectomy on 18 April 2012, which resulted in a perforated bowel. Her death was confirmed on 20 April 2012 after multi-organ failure, septic shock and peritonitis. The report identifies concerns about poor post-operative care, including failure to act on important symptoms and deteriorating observations, and describes the death as potentially avoidable.

Frank POPE · Prevention of Future Deaths report View report

8 May 2014 Inner North London R. Brittain

Frank Pope had ischaemic heart disease, peripheral vascular disease and an abdominal aortic aneurysm, and was admitted to hospital several times in 2013 for ischaemic colitis. He died on 12 December 2013 after rapidly deteriorating from a further episode of ischaemic colitis; concerns were raised that patients who lack capacity to manage follow-up appointments may miss them when family members are not included in correspondence, with no clear backup process identified.

Sopeluwa Babatunde Peters · Prevention of Future Deaths report View report

8 May 2014 County Durham and Darlington A. Tweddle

Sopeluwa Babatunde Peters died by drowning in the River Wear on 30 October 2013, after likely falling into the river while descending steep steps in Drury Lane, Durham City, while under the influence of alcohol. Concerns included poor illumination, the absence of a handrail, the steepness of the steps, and a low riverside wall that provided limited safety protection.

Anthony Lapping · Prevention of Future Deaths report View report

8 May 2014 Newcastle upon Tyne K. Dilks

Anthony Lapping died after a fire at his home, following the ignition of a cooker and the rapid spread of fire to an adjacent fridge freezer. The principal concern was that highly flammable insulation in fridge freezers could cause rapid fire spread, reducing opportunities for escape and increasing the risk of further deaths.

Rajesh Parkash · Prevention of Future Deaths report View report

8 May 2014 Surrey R. Travers

Rajesh Parkash, a 43-year-old dentist, died after his motorcycle collided with an ambulance parked in lane 3 of the southbound A3. The report identified concerns about the ambulance’s dangerous position, inadequate risk assessment and failure to follow safety guidance, as well as issues involving staff communication, training and supervision.

Emma Isabel Lifsey · Prevention of Future Deaths report View report

7 May 2014 Nottinghamshire H. Connor

Emma Lifsey, a four-year-old passenger in a car, died after the car entered the path of a train at Beech Hill level crossing on 4 December 2012. The concerns included glare affecting the visibility of the crossing lights, the poor brightness of old-style filament bulbs, and the time being taken to replace them with LED lights and research the effects of glare.

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.

Neil Andrew Blood · Prevention of Future Deaths report View report

5 May 2014 Stoke-on-Trent and North Staffordshire I. Smith

Neil Andrew Blood died shortly after falling from his bicycle under a passing van and its rear wheel while cycling in St Helier, Jersey, on 31 July 2013. The report raised concerns about the oversight, control, legislation, risks and warnings associated with the supply of pedal cycle cleats and shoes.

Donald Spooner · Prevention of Future Deaths report View report

5 May 2014 West Sussex K. Henderson

Donald Spooner died after being thrown from a motorised bicycle when it caught the edge of a parked vehicle. He was not wearing a protective helmet, and the report raised concerns that helmet use was not compulsory for motorised bicycles capable of speeds over 15 MPH and that protective headgear might have reduced his injuries.