Reports

Bertha CRAY · Prevention of Future Deaths report View report

24 Jan 2014 Inner North London R. Brittain

Bertha CRAY’s oesophagus was perforated during an upper-gastrointestinal endoscopy, and she later died from bronchopneumonia resulting from the perforation and surgical treatment. The report raised concerns about the possible inadvertent alteration or replacement of ‘nil by mouth’ signage, uncertainty about how this occurred, and the lack of demonstrated action following the incident investigation.

DESGRAE REGINA TUCKER · Prevention of Future Deaths report View report

23 Jan 2014 Gwent W. James

Desgrae Regina Tucker was admitted with abdominal pain, underwent gall bladder removal surgery, was discharged home, and died at home six days later. Concerns included inadequate recording and consideration of anti-embolic stockings and no anti-coagulant medication being prescribed on discharge.

Paul Alan Rogerson · Prevention of Future Deaths report View report

22 Jan 2014 York City W. Coverdale

Paul Alan Rogerson, aged 26, fell into the River Ouse in York on 26 March 2011 after consuming several pints of beer and drowned. The report raised concerns about inadequate life-buoy and throwing-line provision and maintenance, a lack of warning signs, and shortcomings in river-rescue training, communication and procedures.

Mone Jahni Karl White · Prevention of Future Deaths report View report

21 Jan 2014 North London A. Walker

Mone Jahni Karl White, who had dilated cardiomyopathy and recurrent illness requiring hospital treatment, was admitted to Northwick Park Hospital on 5 July 2012 and became unresponsive on 7 July 2012 despite treatment attempts. The treating doctors had not seen specialist guidance about Mone’s clinical requirements, and the report raised concern about ensuring such advice is brought to the attention of all treating clinicians.

Mrs Nutbeam · Prevention of Future Deaths report View report

21 Jan 2014 Berkshire P. Bedford

Mrs Nutbeam was struck by a car and later underwent debridement surgery for an infected leg wound. She vomited and aspirated during the procedure and subsequently died; the principal concerns were failures to transfer information about her vomiting between hospitals and to record or communicate vomiting symptoms before surgery, together with whether pre-operative questioning should routinely address recent vomiting.

Frederick Douglas Pring · Prevention of Future Deaths report View report

21 Jan 2014 North Wales (East and Central) J. Gittins

Frederick Douglas Pring experienced chest pains, but no ambulance was available after his first emergency call because of delays handing over patients at hospitals and ambulance crews being on rest breaks. He died at home on 21 March 2013 before an ambulance arrived; a post-mortem identified ischaemic heart disease and severe chronic obstructive pulmonary disease. The principal concern was that delays in patient handovers at Emergency Departments left patients waiting in ambulances and made ambulance resources unavailable for other calls.

Kyle Ashley Smith · Prevention of Future Deaths report View report

21 Jan 2014 Manchester West J. Leeming

Kyle Ashley Smith was found unresponsive by his wife on 19 October 2013 and was pronounced dead by ambulance staff. A post-mortem found that his death was due to the combined toxic effects of Tramadol, Codeine and Zopiclone; concerns included a delay in an urgent mental-health referral reaching the assessment team, the reason for which had not been investigated and was not known.

William Howard DOWLING and Victoria Elaine ROSE · Prevention of Future Deaths report View report

21 Jan 2014 Wiltshire and Swindon D. Ridley

On 2 March 2013, William Howard Dowling shot Victoria Elaine Rose twice in the head before shooting himself in the head. The report raised concerns about information sharing between general practitioners and firearms licensing authorities, the wider public-safety implications of confidentiality, and the independence and transparency of firearms licensing decisions involving current or former police employees.

Gregg O’REILLY · Prevention of Future Deaths report View report

19 Jan 2014 Inner North London M. Hassell

Gregg O’Reilly was admitted as an emergency with dehydration, poor nutritional state, high stoma output, acute kidney injury and a high white cell count. He later developed multi-organ failure and repeated bleeding from his abdominal wound, but did not recover after surgery and critical care admission. The report raised concerns that he was not referred to critical care by 17.01.14 and that no observation records could be found between midnight and 3am before his second bleed and cardiac arrest call.

Laura Hill · Prevention of Future Deaths report View report

17 Jan 2014 Manchester South J. Kearsley

Laura Hill was admitted to Stepping Hill Hospital with acute abdominal pain and sepsis due to cholangitis, fell from her bed and sustained a left hip fracture, and died on 8 October 2013. The principal concern was that Falls Risk Assessments were not carried out on admission or after transfers between wards, despite relevant training being in place.

Selina Isabella Broadhurst · Prevention of Future Deaths report View report

17 Jan 2014 Manchester South J. Pollard

Selina Isabella Broadhurst fell at the E.P.H. where she lived and suffered a head injury. She was not given a CT scan until a second hospital admission several hours later, when a major brain bleed was identified. The concern was that reliance on NICE guidelines may have contributed to missed or delayed diagnoses of severe brain injuries, particularly in very frail elderly patients.

JULIA SHEEREN DELL · Prevention of Future Deaths report View report

17 Jan 2014 Cornwall A. Cox

Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.

Wayne Spencer Malcolm Broad · Prevention of Future Deaths report View report

17 Jan 2014 North London A. Walker

Wayne Spencer Malcolm Broad was arrested while under the influence of alcohol and became unwell during transfer between police custody, court and hospital. He later developed delirium tremens, collapsed despite resuscitation and died after suffering a hypoxic injury. Concerns included the lack of a dedicated substance misuse team in police custody, the need for alignment of handcuffing procedures with guidance for seriously ill detainees, and the availability of specially trained nursing staff for patients with substance misuse.

Julie Ann Camm · Prevention of Future Deaths report View report

17 Jan 2014 West Yorkshire Eastern D. Hincliff

Julie Ann Camm, aged 49, was found dead at her home after deliberately starting a fire and sustaining multiple deep incised wounds. The principal concern was that the property had no smoke detectors, despite her vulnerability as a tenant; the report stated that a detector might have alerted others in time for her to be rescued.

Jackie Scott · Prevention of Future Deaths report View report

16 Jan 2014 North Northumberland T. Brown

Jackie Scott became ill and lost consciousness after eating a takeaway curry while staying at a campsite in Seahouses on 20 June 2013. He died at Wansbeck General Hospital from acute anaphylaxis; the principal concern was that the meal may have contained peanuts or peanut oil without his knowledge.

May Stokoe and James Henderson Stokoe · Prevention of Future Deaths report View report

16 Jan 2014 Sunderland D. Winter

On 1 May 2013, May Stokoe was fatally attacked with a knife and James Henderson Stokoe inflicted fatal knife injuries on himself. The report raised concerns about the assessment and involvement of carers or partners in mental health services, including whether their information could better inform risk assessments and whether domestic abuse involving older people might be missed.

Stephen Ellis · Prevention of Future Deaths report View report

14 Jan 2014 Manchester South J. Pollard

Stephen Ellis was admitted for heart surgery and subsequently received warfarin. After discharge, INR checks were reduced to weekly and his rising INR was apparently not properly noted; the principal concern was that high-risk patients undergoing heart surgery and subsequent warfarin treatment should be supplied with home monitoring kits.

Russell James Felstead · Prevention of Future Deaths report View report

14 Jan 2014 Manchester South J. Kearlsey

Russell James Felstead, who had severe learning disabilities, epilepsy and a history of falls, was found unresponsive on the floor of his room on 7 January 2013 and died on 28 January 2013 after a subdural haematoma was identified and operated on. Relevant information about his falls and helmet was available in the hospital records from 7 January but was not noted by doctors until 11 January, when an urgent CT scan was requested.

Craig Adam White · Prevention of Future Deaths report View report

14 Jan 2014 South Lincolnshire A. Forrest

Craig Adam White was a 21-year-old student who developed disseminated tuberculosis, including tuberculosis leptomeningitis, while receiving immunosuppressive treatment for Crohn’s disease. He had recurrent chest infections and later deteriorated with neurological illness before tuberculosis was confirmed. The principal concerns were tuberculosis screening before Infliximab treatment, healthcare professionals’ awareness of the associated risk, continuing patient education, and prompt treatment when tuberculous meningitis is suspected.

John Joseph Malone · Prevention of Future Deaths report View report

14 Jan 2014 Manchester South J. Pollard

John Joseph Malone suffered two falls at home, the second on 24 October 2013, which led to a subdural haematoma; the inquest concluded that he died an accidental death. Concern was raised that the hospital discharge letter was woefully short on detail and omitted vital information for his GPs, and that he fell within three days of discharge.