Reports

Lee Terence Curran · Prevention of Future Deaths report View report

25 Feb 2014 Manchester West J. Leeming

Lee Terence Curran died on 3 May 2011 while in custody at Forest Bank Prison, with naturally occurring ischaemic heart disease identified as the prime cause of death. Before his death, he experienced multiple episodes of transient loss of consciousness that were not diagnosed, and concerns were raised that recommended investigations and follow-up were not provided. Further concerns included incomplete implementation of recommendations, potentially misleading medical-note entries, and inadequate awareness or application of relevant clinical guidelines.

Kenneth Gerald Aldridge · Prevention of Future Deaths report View report

24 Feb 2014 Berkshire P. Bedford

Kenneth Gerald Aldridge, aged 68, died after the car he was driving collided with another vehicle on the A4 near Woolhampton and then crashed into a tree. The principal concern was the appropriateness and potential danger of access to a service road from a 70-mile-per-hour dual carriageway, including vehicles turning into or pulling out of the service road.

Graham James Sutton · Prevention of Future Deaths report View report

24 Feb 2014 North London A. Walker

On 10 July 2013, Graham James Sutton fell five feet from a ladder while cutting a hedge, struck his head on concrete, and later died after being taken to hospital and transferred to a Trauma Centre. The concern was that the London Ambulance Service did not automatically link the fall, his age over 50, and his use of the anti-clotting medication Clopidogrel to a response within eight minutes.

Mark Andrew Burgess · Prevention of Future Deaths report View report

24 Feb 2014 Blackburn, Hyndburn and Ribble Valley M. Singleton

Mark Andrew Burgess died after losing control of his vehicle on the M65 while under the influence of alcohol and probably using a mobile phone, colliding with the nearside vehicle restraint system and sustaining fatal injuries. The report raised concerns that the road lighting had been decommissioned and was not operating during hours of darkness, leaving debris and damaged vehicles difficult to see and contributing to further collisions in which up to eleven other people were injured.

Benjamin James Carroll · Prevention of Future Deaths report View report

20 Feb 2014 Gwent W. James

Benjamin James Carroll was taking part in an open-road cycle event when his cycle crossed into the opposite carriageway and collided with an oncoming van; he later died from his injuries. The report raised concern that the road remained open to traffic while cyclists were grouped together and sprinting towards the finish line, despite accredited marshals being present.

Simon William McAndrew · Prevention of Future Deaths report View report

19 Feb 2014 South London R. Palmer

Simon William McAndrew died in hospital on 3 July 2011 after being found hanging from a tree at the residential home where he lived and subsequently suffering severe brain injury. The principal concerns were poor communication and confusion between services about responsibility for his psychiatric care, including the sharing of key information and provision of appropriate crisis guidance to the residential home.

Jack Basil Lynn · Prevention of Future Deaths report View report

18 Feb 2014 North Northumberland T. Brown

Jack Basil Lynn, who lived alone and received daily care visits, was found unresponsive at home on 15 October 2013 after a morning visit during which the carer did not check his wellbeing. The concerns were that there was no continuous medication communication sheet and that no safety or wellbeing check was made during the allocated visit, creating a potential risk to future residents despite the inquest finding that Mr Lynn died from natural causes.

Lisa Marie Inkin · Prevention of Future Deaths report View report

13 Feb 2014 Inner West London F. Wilcox

Lisa Marie Inkin, who had severe anorexia nervosa and was on home leave from an eating disorders unit, took her own life by diving in front of a train at Victoria Station on 9 April 2013. The report raised concerns about the lack of local specialist inpatient eating disorder services, communication between local and out-of-area providers, inadequate escalation of information about suicidal intent, possible failures to record or answer calls, and the proposed lack of overnight supervision and transport difficulties in Kent.

Professor John Elfed Davies · Prevention of Future Deaths report View report

13 Feb 2014 Inner West London F. Wilcox

Professor John Elfed Davies, aged 71, was found deceased in his hotel room on 10 June 2013 with self-inflicted incised wounds to his neck and multiple stab wounds to his chest. The inquest concluded that he took his own life, and a note indicated that GMC proceedings were playing on his mind. The principal concern was that doctors undergoing GMC investigations may experience unrecognised and unsupported adverse psychological effects, including suicidal or other self-harming behaviour.

Georgina Violet SWINDELLS · Prevention of Future Deaths report View report

12 Feb 2014 Inner North London R. Brittain

Georgina Violet Swindells underwent a right hemicolectomy for colon cancer and subsequently developed persistent hypotension and haemorrhage, dying on 18 September 2013. Concerns included delayed and failed transfer of CT images, the absence of an effective backup process, apparently erroneous reporting of the scan, and insufficient investigation data and incident reporting.

Refat Hussain · Prevention of Future Deaths report View report

12 Feb 2014 Inner West London F. Wilcox

Refat Hussain had latent TB and developed symptoms consistent with active TB in February 2013, which went unrecognised. She was later admitted to hospital, deteriorated despite treatment, and died on 11 May 2013 after pulmonary TB, pneumonia and cardiac arrest. The principal concern was that out-of-hours GPs lacked access to patients’ GP medical records, reducing their ability to make accurate diagnoses.

Adrian Anthony Cowan · Prevention of Future Deaths report View report

7 Feb 2014 North London A. Walker

Adrian Anthony Cowan, who was detained under the Mental Health Act 1983, had a seizure on 14 June 2012 and was later found unresponsive in his room after being observed breathing normally. The inquest recorded natural causes, with pulmonary thromboembolism and deep vein thrombosis as the medical cause of death, alongside epilepsy and diabetes. Concerns related to unclear emergency-response guidance, including the failure to require the duty doctor to attend, and staff difficulties in responding calmly and applying basic life-support training.

John William GROOBY · Prevention of Future Deaths report View report

7 Feb 2014 Warwickshire S. McGovern

John William Grooby, a motorcyclist, died after being struck by a deer on the A3400 between Tredington and Shipston on Stour on 24 October 2013. The substantive concern was the lack of signage warning motorists that deer use the area as a “game track”.

Ronald Sidney Ellwood · Prevention of Future Deaths report View report

6 Feb 2014 Staffordshire South A. Haigh

Mr Ellwood died from a chest infection after spending several weeks in the intensive care unit at Queen’s Hospital. Concerns were raised about bugs associated with invasive tubes and about heat, ventilation and the possible benefit of more fresh air in the intensive care unit.

Ethel Smith Leese · Prevention of Future Deaths report View report

6 Feb 2014 Staffordshire South A. Haigh

Ethel Smith Leese, aged 94, was admitted to hospital after a fall at her care home on 1 January 2013 and died on 4 January 2013. The inquest concluded that her death was accidental, involving intracerebral and subdural haemorrhage, a fall, warfarin-induced coagulopathy, and other listed conditions. The principal concern was chaotic monitoring arrangements for her warfarin levels, including uncertainty and errors concerning her address and GP practice after she moved to the care home.

Rachael Hannah DALLISON · Prevention of Future Deaths report View report

6 Feb 2014 Staffordshire South A. Haigh

Rachael Hannah DALLISON died aged 23 after sustaining fatal injuries in a road traffic collision on the B5013 at Willslock near Uttoxeter on 11 May 2013. The report raised concerns about repeated collisions at the bend and differences in warning signs for drivers approaching from the direction she travelled, including the absence of a chevron.

Keith Ronald Martin · Prevention of Future Deaths report View report

5 Feb 2014 Surrey K. Henderson

Keith Ronald Martin attended A&E with chest pain and left-arm tingling, but there were delays in triage, investigations, treatment and senior review. He later deteriorated with a myocardial infarction, was transferred for emergency treatment, and died after the infarction was described as incompatible with life. The concerns included failure to appreciate and act promptly on his symptoms and raised troponin, unclear chest-pain management protocols, and inadequate documentation.

Brian Robert Henry KENT · Prevention of Future Deaths report View report

5 Feb 2014 South London R. Palmer

Brian Robert Henry KENT’s death was investigated, with the inquest concluding on 23 January 2014. The report indicates that a lifeguard service should have been provided on the beach, but family members said no lifeguard was present on the day in question; it also identifies a concern about warning signs for people intending to bathe.

Samuel Boon · Prevention of Future Deaths report View report

4 Feb 2014 South London S. Lynch

Samuel Boon, aged 17, collapsed from suspected exertional heatstroke and/or hyponatremia while trekking in high temperatures on a school trip in Morocco and died during a 25-minute journey to a local medical centre. Concerns included inadequate preparation and risk assessment, insufficient assessment of participants’ fitness and medical information, inadequate training about heatstroke and hyponatremia, and evacuation arrangements that had not been adequately assessed or equipped.

Michael John Telford · Prevention of Future Deaths report View report

3 Feb 2014 Cumbria (North & West) D. Roberts

On 6 December 2012, Michael John Telford was driving on the B5302 when another vehicle entered his carriageway after travelling through floodwater and collided with his car. Evidence at the inquest indicated that water spilling onto the road was a regular hazard, with concern that further accidents might occur if the issue was not addressed.