Reports

DANIEL WARWICK JONES · Prevention of Future Deaths report View report

3 Feb 2014 Dorset S. Nicholls

Daniel Warwick Jones died from multiple injuries in a road traffic collision while riding a motorcycle on the A356, where his motorcycle collided with a motorcar turning right into a side-road junction. The inquest heard concerns that road users were unaware of the junction warning signage and road markings, and that signage, overtaking restrictions and speed limits at or near junctions may require consideration.

Ryan Patrick John Clark · Prevention of Future Deaths report View report

3 Feb 2014 West Yorkshire (East) M. Williamson

Ryan Patrick John Clark, aged 17, died on 18 April 2011 after being discovered in his cell at HMYOI Wetherby with a ligature around his neck; his death was certified at Harrogate District Hospital. The concerns included ineffective implementation of the Personal Officer Scheme, failures in ACCT checks and trainee roll counts, and insufficient first-aid and CPR training for prison officers.

Amy Friar · Prevention of Future Deaths report View report

3 Feb 2014 Surrey R. Travers

Amy Friar was found partially suspended by a ligature in her cell at HMP Downview on 30 March 2011 and was already dead when found. The inquest concluded that she took her own life, with hanging recorded as the cause of death. The report raised concern that differing emergency codes across prisons could cause confusion and delay assistance in other circumstances, although this did not contribute to Ms Friar’s death.

Scarlett Lucie SINCLAIR · Prevention of Future Deaths report View report

3 Feb 2014 Avon M. Voisin

Scarlett Lucie SINCLAIR was born at 28 weeks gestation and transferred to Southmead Hospital’s neonatal unit at 23 days old. Within hours she became unwell, developed a distended abdomen and acute deterioration, and died a few hours after transfer for surgical management of extensive necrosis. The substantive concern was whether the assessment of a baby’s wellness, stability and suitability was sufficient before transfer between neonatal units.

Amanda Jane Vickers · Prevention of Future Deaths report View report

3 Feb 2014 North and West Cumbria D. Roberts

Amanda Jane Vickers had a long history of depression and suicidal ideation and was found hanging at her home on 22 August 2013. She was awaiting admission to 81 Lowther Street Crisis Home, but no place was immediately available; the report raised concern that this six-bedded unit was the only facility of its type in the county and suggested reviewing the availability of beds.

Daniel COLLINS · Prevention of Future Deaths report View report

3 Feb 2014 Plymouth, Torbay & South Devon I. Arrow

Daniel COLLINS occupied a flat in a property in Devonport, Plymouth, and died within one week of another occupant in the same property. The inquest concluded that his death was drug-related, and concern was raised about a history of drug abuse at the property and the risk of future drug-related deaths among its inhabitants.

Ryan Chapman · Prevention of Future Deaths report View report

31 Jan 2014 West Sussex P. Schofield

Ryan Chapman was admitted to a mental health ward and, while being accompanied to an activity, left the hospital and ran into the path of an articulated lorry. He died from his injuries on 22 May 2013. Concerns included staff misunderstanding and inconsistent application of the Trust’s leave policy, uncertainty about the role of peer support workers as escorts, delays in completing his risk assessment and care plan, limited information for his family, and inconsistent ward visitor security.

Shaun Elliott · Prevention of Future Deaths report View report

31 Jan 2014 Buckinghamshire R. Hulett

Shaun Elliott, a vulnerable adult living in supported accommodation, went missing after an education outing and was later found in cardiac arrest. He died in hospital on 11 July 2011 after sustaining irreversible hypoxic brain damage; the recorded medical cause of death was acute bronchopneumonia due to multidrug use. Concerns included the availability of missing-person coordinators at weekends, family liaison, and the assessment of missing-person risk as high risk.

William George KENT · Prevention of Future Deaths report View report

31 Jan 2014 Surrey K. Henderson

William George KENT was admitted to hospital after a fall and later developed acute respiratory distress after Haz-Tab granules were used on urine near his bed. He was transferred for further treatment but died after chlorine inhalation was identified as a significant contributing trigger. Concerns included insufficient awareness and training about the hazards and appropriate use of Haz-Tab granules, including the release of noxious gases when they contact urine.

Lee Jay Bonsall · Prevention of Future Deaths report View report

31 Jan 2014 Carmarthenshire and Pembrokeshire J. Layton

Lee Jay Bonsall was found hanging from a bannister rail at his home on 3 March 2012, and the inquest recorded the medical cause of death as asphyxia by hanging, with intent unclear. Concerns related to citalopram being prescribed on repeat and the ten-month waiting time for psychotherapy.

Leslie Alfred Pates · Prevention of Future Deaths report View report

30 Jan 2014 Manchester South J. Pollard

Leslie Alfred Pates was admitted to hospital, discharged home against his family’s wishes, and later transferred to a nursing home before being readmitted to hospital in a deteriorated condition. The principal concerns were failures in communication and discharge planning, including the absence of a family meeting, insufficient consideration of the family’s views, and discharge with severe pressure sores without a pressure-relieving mattress.

Tallulah Mary Scarlett WILSON · Prevention of Future Deaths report View report

30 Jan 2014 Inner North London M. Hassell

Tallulah Wilson, a fifteen-year-old schoolgirl, died after jumping in front of a train and taking her own life. The report highlighted concerns about healthcare professionals’ limited understanding of young people’s online lives and the need for research, improved clinical practice, risk-assessment refinement and relevant training.

Umul Kelsum Anna AUDU · Prevention of Future Deaths report View report

27 Jan 2014 Inner North London R. Brittain

Umul Kelsum Anna Audu developed Toxic Epidermal Necrolysis after admission to hospital with headache and back pain, and died from its effects on 20 October 2013. A concern was raised that the lack of an available transport heater could cause future patients to become hypothermic during transfers, potentially resulting in death.

Pamela Margaret Bailey · Prevention of Future Deaths report View report

27 Jan 2014 South Yorkshire (Western) D. Coutts-Wood

Pamela Margaret Bailey left Hawthorn Ward, Northern General Hospital, on 23 March 2013 and was later found deceased at a secluded location near Ladybower, Derbyshire, on 29 March 2013. The medical cause of death was hypothermia. The substantive concerns included ward door security, staffing levels, and the absence of a photograph available to police when she disappeared.

Judith Lesley Marshall · Prevention of Future Deaths report View report

27 Jan 2014 York City W. Coverdale

Judith Lesley Marshall was prescribed morphine sulphate 10mg twice daily, but a pharmacy dispensed 60mg capsules. She took the capsules as prescribed and was found dead on 30 September 2009; the inquest recorded bronchopneumonia and the effects of morphine, with a conclusion of accidental death. The principal concerns were pharmacy dispensing errors, the adequacy of checking and monitoring systems, and the absence of central monitoring of prescription errors.

Maureen Leaver · Prevention of Future Deaths report View report

27 Jan 2014 West Sussex K. Henderson

Maureen Leaver, who had dementia and severe delusions, was admitted for assessment in July 2010 and later transferred to hospital with profound hypothermia. She died on 6 October 2010; the report identified concerns about inadequate medical supervision and systems for investigating and managing acutely ill elderly patients, as well as understanding of legal duties when changing her patient status.

Lillian Rose Robinson · Prevention of Future Deaths report View report

26 Jan 2014 Surrey M. Flemimg

Lillian Rose Robinson was admitted to Brockhurst Care Home, transferred to Upper Halliford nursing home after deteriorating, and died from bronchopneumonia on 28 December 2012. The substantive concerns were communication about mental-capacity assessments, unqualified carers evaluating capacity in patients with mild or moderate dementia, and poor note-taking and continuity of care.

Alfred Leonard Hodges · Prevention of Future Deaths report View report

24 Jan 2014 North Central & North East Wales N. Jones

Alfred Leonard Hodges, who had severe mobility, frailty and hearing difficulties, died aged 97 after a fire at his home on 26 June 2013. The report raised concerns that his smoke alarm was not interlinked with his Telecare system, that interim protections were unclear, and that he had not received a free Fire Home Safety Check. The inquest concluded that the medical cause of death was carbon monoxide poisoning and severe ischaemic heart disease.

Lucy Maria GOULDING · Prevention of Future Deaths report View report

24 Jan 2014 West Sussex K. Henderson

Lucy Goulding was admitted to hospital on 26 June 2013 with worsening headaches, later collapsed and suffered a cardiorespiratory arrest, and was confirmed dead on 27 June 2013 after emergency treatment for a brain tumour. The principal concerns were inadequate consultant supervision and independent assessment of paediatric admissions, and the lack of national guidelines for assessing and investigating headaches in children.

Elizabeth Joy Turnbull · Prevention of Future Deaths report View report

24 Jan 2014 South Yorkshire (Eastern) N. Mundy

Elizabeth Joy Turnbull died on 15 June 2013 after being crushed by a bucket that dislodged from a telehandler while she was helping repair a stock fence. The concerns related to the layout of the thumbwheel controls, the absence of dual controls, and the ease with which the locking pins could be inadvertently released.