Reports

Elsie Gibson · Prevention of Future Deaths report View report

21 Oct 2013 South London R. Palmer

Elsie Gibson, aged 94, slipped from a narrowed pavement while passing an unlicensed scaffold tower in High Street, Bromley, on 4 January 2013. She sustained a fractured hip and died in hospital on 9 January 2013. The concerns included the erection of the scaffold without required formalities and the apparent lack of prompt investigation or enforcement action by the Council after the incident.

ELIZABETH AURORA KERR · Prevention of Future Deaths report View report

18 Oct 2013 Manchester City N. Meadows

Elizabeth Aurora Kerr died after carbon monoxide from a malfunctioning basement boiler entered the residential flat where she lived, and she was found unconscious several hours after the Fire Service had attended the building. The report identified concerns about the movement and detection of carbon monoxide in buildings, the absence and use of carbon monoxide alarms and gas safety controls, and Fire and Rescue Service equipment, guidance and responses.

Jennifer Elsie RUSHWORTH · Prevention of Future Deaths report View report

18 Oct 2013 Manchester South J. Pollard

The circumstances of Jennifer Elsie Rushworth's death are not included in the supplied text. Concerns raised at the inquest included delays in cardiology review and surgery, insufficient surgical staffing, and questions about surgical clips used to clip blood vessels.

Brian Robert DORLING and Philippine Marthe Anne Marie de GERIN-RICARD · Prevention of Future Deaths report View report

17 Oct 2013 Inner North London M. Hassell

Brian Robert Dorling and Philippine Marthe Anne Marie de Gerin-Ricard died in separate collisions involving the pedal cycles they were riding and heavy goods vehicles on Cycle Super Highway 2 in London. The concerns included confusion caused by unbordered blue strips, the need for better education about safer cycling and driving techniques, and the difficulty of negotiating the junction where Ms de Gerin-Ricard sustained her fatal injuries.

Rosa ANDERSON · Prevention of Future Deaths report View report

17 Oct 2013 Liverpool A. Rebello

Rosa Anderson underwent laparoscopic repair of a diaphragmatic hernia, during which her oesophagus was inadvertently damaged. The resulting mediastinitis compromised her breathing and led to cardiac arrest and hypoxic brain injury; concerns included that she was discharged without a discharge summary, written information about the operation, advice contact numbers, or warnings about when to seek urgent medical assistance.

JOHN JAMES JACKSON · Prevention of Future Deaths report View report

16 Oct 2013 Black Country R. Balmain

JOHN JAMES JACKSON was found dead at his home, and life was pronounced extinct at 12 noon on 2 May 2013. Evidence indicated that he was a compulsive user of Hero Energy Mints and had more than twice the blood caffeine level reported as capable of producing a fatality. The concerns included limited information about the product’s caffeine content and the dangers of consuming large quantities, and its position between medication and sweets.

Janet Richardson · Prevention of Future Deaths report View report

16 Oct 2013 North and West Cumbria D. Roberts

Janet Richardson became seriously unwell while on holiday aboard a cruise ship and was being transferred by stretcher from the cruise ship to a rescue boat for hospital treatment. The rescue boat moved away during the transfer, causing the stretcher and Janet Richardson to fall into the sea; she was not wearing a life jacket or buoyancy aid, and the vessels were not tied together. She was later treated in Norway and England, and died on 21 April 2011; the report identifies the immersion in cold seawater and the accidental plunge as significant factors in her death.

Lucy KILVERT · Prevention of Future Deaths report View report

15 Oct 2013 Black Country R. Balmain

Lucy KILVERT was taken to hospital on 14 June 2013 after falling at home on 10 June and subsequently deteriorating; she had hit her head and was taking blood-thinning medication. The principal concern was that she did not initially receive a head CT scan, which was performed about eight hours after hospital presentation and revealed an intracranial bleed; the report also noted possible shortcomings in how the significance of blood-thinning medication was emphasised in the relevant guidelines.

Frederick Davidson · Prevention of Future Deaths report View report

14 Oct 2013 Surrey M. Flemimg

Frederick Davidson was admitted to Epsom General Hospital with aspiration pneumonia after recurrent seizures and later died following a pneumothorax caused by an unnoticed and incorrectly placed nasogastric tube. Concerns included inadequate documentation and communication, the use and checking of the tube, delayed recognition and treatment of the pneumothorax, and delays in radiology reporting.

Yousef SHOKRI-GHARAB · Prevention of Future Deaths report View report

14 Oct 2013 Liverpool A. Rebello

Yousef SHOKRI-GHARAB, an asylum seeker receiving inpatient treatment for mental illness, was found collapsed in a disused car park on 20 June 2013 and died at the Royal Liverpool University Hospital after attempts at resuscitation. The inquest concluded that he died from morphine (heroin) toxicity. Concerns included an outdated Mersey Care policy on leave for informal patients, which did not reflect practice, and leave permissions being authorised without regard to the Responsible Medical Officer's opinion.

Leo Deady · Prevention of Future Deaths report View report

14 Oct 2013 Inner South London P. Barlow

Leo Deady died at Queen Elizabeth Hospital at one hour of age following an undiagnosed breech presentation, which was first noticed when the mother was fully dilated. The report raised concerns about missed breech presentations, the risks of vaginal breech delivery, and the absence of national guidance on routine late-pregnancy scanning to detect breech presentation.

Carol Ann Gibson · Prevention of Future Deaths report View report

12 Oct 2013 Cheshire N. Rheinberg

Carol Ann Gibson, aged 65, died at home on 8 August 2012 following an adverse reaction to nitrofurantoin, which had been prescribed despite an alert in her medical records about a previous adverse reaction. The concerns included failure to heed and appropriately investigate the alert, and possible weaknesses in the practice’s systems and staff understanding for managing patient safety alerts.

James Edward Mansfield · Prevention of Future Deaths report View report

10 Oct 2013 Cambridgeshire (South and West) Cheney

James Edward Mansfield had multiple rib fractures after a fall and was later admitted with a large right haemothorax; he died on 9 March 2013. Concerns included delayed review of the hospital discharge summary and failure to assess him after stronger painkillers were requested despite his injuries, lung and chest history, and warfarin treatment.

Kuldeep Singh Dhillon · Prevention of Future Deaths report View report

8 Oct 2013 East London C. Inyama

Kuldeep Singh Dhillon was driving a lorry on the M25 on 25 May 2012 when it collided with a stationary vehicle during a rolling road block. He was trapped when the vehicle exploded and died at the scene from extensive full-thickness burns. The report raised concerns that palletised loads were commonly carried without restraint, putting drivers at risk, and that enforcement and auditing of relevant guidance and codes of practice were insufficient.

Anthony Bernard McCormick · Prevention of Future Deaths report View report

8 Oct 2013 Manchester City N. Meadows

Anthony Bernard McCormick was admitted to hospital with gastrointestinal symptoms, vomiting, lethargy, fever and rigors, and was later found to have liver abscesses and gallstones. He underwent surgery but developed pneumonia and sepsis and died on 31 May 2011; the post-mortem found extensive empyema and sepsis. Concerns included delays in urgent admission, diagnosis, specialist referral and surgery, failures in communication and clinical review, and gaps in appropriate antibiotic treatment.

George Leonard Parkes · Prevention of Future Deaths report View report

7 Oct 2013 Birmingham and Solihull S. Ormond-Walshe

George Leonard Parkes, aged 84, died during surgery for a ruptured abdominal aortic aneurysm. The report describes him as having been lost to follow-up, allowing the aneurysm to become very large before rupture, and identifies concerns about monitoring and follow-up arrangements for patients with abdominal aortic aneurysms.

Walter Gordon Powley · Prevention of Future Deaths report View report

4 Oct 2013 Leicester City and South Leicestershire D. Coutts-Wood

Walter Gordon Powley died after falling against uncovered radiator pipes and valves at a care and nursing home, sustaining burns to his legs. The report raised concerns about the high temperature of uncovered pipework, the absence of risk assessment of the room’s physical circumstances, and inspection bodies not identifying these issues. The inquest also identified inadequate ongoing risk assessments and failures to adhere to procedures for giving and recording medication as contributing factors.

Jean James · Prevention of Future Deaths report View report

4 Oct 2013 Cornwall A. Cox

Jean James was an 85-year-old woman who developed stomach pain on 5 November 2012, was admitted to hospital with suspected appendicitis at approximately 11:00 on 6 November, and was not seen by a doctor until 17:00. She was later diagnosed with a perforated appendix, underwent surgery, and died in hospital on 19 November 2012. The principal concern was that patients admitted via their GP had no defined timeframe for medical review, unlike patients admitted through the Emergency Department, and that records of review times were not kept.

Douglas Grey · Prevention of Future Deaths report View report

3 Oct 2013 East London C. Inyama

Douglas Grey, a resident of a residential home, suffered two falls after an inflatable mattress was placed on top of his original mattress and later became unconscious. He died in hospital in the early hours of 5 May 2012; the medical cause of death was recorded as right-sided pneumonia due to an acute subdural haematoma. Concerns included the absence of a clear procedure for notifying district nurses, correctly installing equipment and reviewing its performance, and staff not recognising or reporting faults with the mattress in line with the home's policy.

Ishmail KUBILAY · Prevention of Future Deaths report View report

3 Oct 2013 Hertfordshire E. Thomas

The report identifies Ishmail KUBILAY as the deceased person. The supplied text does not include the circumstances of the death or any substantive concerns.