Reports

William David McCourt · Prevention of Future Deaths report View report

14 Jan 2014 North Yorkshire (West) R. Turnbull

William David McCourt died at the scene after losing control of his motorcycle on running water across the A6108 road. The warning sign had fallen over, and the water hazard had reportedly remained unresolved for several months. Concerns included missing records of residents’ reports, inadequate investigation of land ownership, lack of written escalation, failure to address the hazard, and inspections not recording the water as a potential hazard.

Barbara White · Prevention of Future Deaths report View report

13 Jan 2014 Manchester South J. Kearsley

Barbara White presented to Tameside Hospital with symptoms consistent with biliary colic, deteriorated after 9 December 2012, and died on 2 January 2013 despite intensive care intervention. Concerns included a 12-hour lack of clinical and nursing observations, an incorrectly recorded PARS score, staff shortages and inadequate escalation, and insufficient handover information about outstanding investigations.

Zeeyad Hamadi · Prevention of Future Deaths report View report

13 Jan 2014 County Durham and Darlington A. Tweddle

Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.

Mustafa Cicek · Prevention of Future Deaths report View report

13 Jan 2014 East Sussex A. Craze

Mustafa Cicek died following a road traffic collision on the A21 when his Ford Fiesta left the carriageway on a bend and struck a fixed structure. The concerns identified included the bend being a collision black spot, inadequate chevron-sign visibility, a potentially hazardous sapling, and the need for a “SLOW” road marking.

Michael Brendan O’SULLIVAN · Prevention of Future Deaths report View report

13 Jan 2014 Inner North London M. Hassell

Michael O’Sullivan took his own life by hanging while suffering anxiety and depression, following a recent assessment by a DWP doctor that he was fit for work. The assessing doctor and the ultimate decision maker did not obtain or consider reports from his treating doctors, including his general practitioner, psychiatrist and clinical psychologist.

JASON NOCK · Prevention of Future Deaths report View report

13 Jan 2014 Black Country R. Balmain

JASON NOCK acquired the synthetic designer drug AH-7921 on the internet and died from its toxic effects. Concerns included that the product was unregulated, consumers might not know what they were taking, and it was readily available with little or no information about safe dosage or potential consequences.

Dr Edward James Slaney · Prevention of Future Deaths report View report

10 Jan 2014 West Yorkshire Eastern M. Williamson

Dr Edward James Slaney was crossing a road in Leeds when a medium-sized goods vehicle was blown over by high wind gusts near Bridgewater Place, trapping him underneath and causing fatal chest injuries. The principal concerns were the lack of criteria for assessing the safety effects of tall-building wind conditions on all highway users and the lack of planning guidance on those effects.

Pauline Meredith · Prevention of Future Deaths report View report

10 Jan 2014 Staffordshire South M. Jones

Pauline Meredith, aged 42, was found dead in her flat on 30 August 2013. Her death was attributed to mixed drug toxicity, including a fatal level of morphine, excessive levels of tramadol and propranolol, and alcohol. Concerns included the amount and review of prescribed medication, the addition of morphine alongside existing medication and alcohol dependence, the response to family concerns, the absence of team meetings, and delays in involving community mental health services.

Mary WALDRON · Prevention of Future Deaths report View report

10 Jan 2014 Coventry R. Brittain

Mary Waldron became unwell at St Mary's Nursing Home on 24 August 2013 and was transferred to University Hospital, Coventry, where she died after suffering a cardiac arrest during the transfer. Concerns included failures to recognise and appropriately respond to her acute illness and low blood pressure, inadequate ongoing staff training, shortcomings in the nursing home's investigation and reporting, uncertainty about the CQC investigation, and potential confusion between ambulance drivers and paramedics about transfer times.

Albert James HAND · Prevention of Future Deaths report View report

9 Jan 2014 Bedfordshire and Luton T. Osborne

Albert James Hand suffered a fall at the Arndale Shopping Centre in Luton on 1 November 2013 and experienced a delay of almost one and a half hours before arriving at hospital, during which his Glasgow Coma Scale fell from 11 to 7. The concerns identified were delays in conveying patients with head injuries, insufficient ambulance crews in the Luton and Bedfordshire area, and emergency-call protocols that may put patients at risk and result in future deaths.

Jonathan Alan Thorpe · Prevention of Future Deaths report View report

7 Jan 2014 Manchester South J. Pollard

Jonathan Alan Thorpe took his own life by hanging from a tree branch in a local cemetery while using illicit drugs and experiencing deteriorating family issues. The report raises concerns that, despite his known history of self-harm and previous involvement with mental health services, his GP consultations did not refer to or seek input from Mental Health Services.

James Hadfield Withers · Prevention of Future Deaths report View report

7 Jan 2014 Manchester South J. Pollard

James Hadfield Withers died on 27 January 2013 after surgery for invasive colonic adenocarcinoma, with the inquest recording congestive cardiac failure associated with diseased heart and the stress of the operation. Concerns included a five-day delay in cardiology review, missing medical and nursing notes, incorrect recording of DNAR status, and poor communication among staff and with the family.

Grace Mary Bates · Prevention of Future Deaths report View report

7 Jan 2014 North London A. Walker

Grace Mary Bates died in hospital on 21 April 2013 from complications associated with poorly managed diabetic episodes. The report raised concern that no specialist diabetic nurse was available at the hospital over the weekend, during which her blood sugar management was poor.

Martin Geoffrey McGlasson · Prevention of Future Deaths report View report

6 Jan 2014 North and West Cumbria R. Chapman

Martin Geoffrey McGlasson, a plant operative, died at the scene on 2 September 2011 after a nearly three-tonne concrete staircase he was slurrying fell onto and crushed him. The principal concerns were the unsupported method of working, debris and incorrect batten placement potentially causing instability, and a mismatch between the method used on the shop floor and the arrangements described in risk assessments. The report also identified that similar methods were widespread and that inexpensive safer alternatives were available.

Chloe Grace FLAVELL · Prevention of Future Deaths report View report

6 Jan 2014 Avon M. Voisin

Chloe Grace Flavell became unwell and was taken to Weston General Hospital on 3 April 2013, where she died at 14:30. She was aged 3 days, and the inquest recorded congenital heart disease as the cause of death, with death from natural causes contributed to by neglect. The principal concern was that management of the reception area before triage could cause significant delays in providing immediate care and treatment, particularly for children.

Billy Paul Thomas Salton · Prevention of Future Deaths report View report

6 Jan 2014 Manchester South J. Kearsley

Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

DANIEL WILLIAMS · Prevention of Future Deaths report View report

6 Jan 2014 South Yorkshire (Eastern) N. Mundy

Daniel Williams, who had psychiatric problems following a diagnosis of diabetes and was admitted to hospital after an insulin overdose, died by hanging in his hospital room on 15 June 2013. The concerns included inadequate staff training, record keeping and communication; insufficient exploration of suicidal thoughts and intent; unclear guidance on checking rooms and patients for potential self-harm items; and the absence of a single summary of key risks and incidents in the notes.

Keith Fleming · Prevention of Future Deaths report View report

3 Jan 2014 Gateshead and South Tyneside T. Carney

Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after discharge.

ADRIAN JOHN PICKARD · Prevention of Future Deaths report View report

31 Dec 2013 West Yorkshire (East) M. Williamson

Adrian John Pickard died at St James’s University Hospital on 26 February 2012 from traumatic injuries sustained when a company vehicle overturned while negotiating a bend. The vehicle was described as un-roadworthy and travelling at an inappropriate speed. The substantive concern was that not all company vehicles carrying aggregates were weighed before departing the premises, creating a risk that they exceeded their gross legal weight.

Lynne Dring · Prevention of Future Deaths report View report

30 Dec 2013 North Lincolnshire and Grimsby P. Kelly

Lynne Dring was crossing A1098 Taylors Avenue at Hewitts Circus, Cleethorpes, when she was struck by a car exiting the roundabout. Concerns included a central illuminated bollard potentially obstructing motorists’ views and non-prescribed white lines at an Elephant crossing potentially leading pedestrians to believe they had priority.