Reports

DAVID LESLIE SELMAN · Prevention of Future Deaths report View report

1 Oct 2013 Oxfordshire N. Graham

David Leslie Selman, who had schizophrenia and epilepsy, died after consuming a large amount of legal highs that adversely reacted with his prescription drugs. When he developed unusual behaviour, shaking and spasms at a public house, ambulance attendance was delayed by a miscommunication about whether the crew should stand down or stand back, and information about his condition was not passed on for reassessment of the resources needed. He later went into cardiac arrest before arriving at hospital and could not be revived; the inquest recorded multiple drug toxicity as the medical cause of death.

Michael Joseph Hirrell · Prevention of Future Deaths report View report

1 Oct 2013 Leicester City and South Leicestershire L. Brown

Michael Joseph Hirrell died from carbon monoxide poisoning between 18 and 25 January 2013 after using a borrowed generator at his home following disconnection of the electricity supply. The principal concerns were that his vulnerability was not recognised or protected during the disconnection, staff did not feel empowered to halt it, and wider consumer-protection arrangements may not prevent similar deaths.

Dorothy Townley · Prevention of Future Deaths report View report

29 Sep 2013 Manchester South J. Kearsley

Dorothy Townley sustained burns after spilling tea at home on 28 September 2012; the burns became infected and she was admitted to hospital on 11 October. Despite active treatment, she died on 20 October 2012. Concerns included communication between District Nurses and the GP, limited knowledge and training in burn treatment, inadequate wound assessment documentation, and unclear processes for requesting urgent blood tests.

Jared William McDowall · Prevention of Future Deaths report View report

27 Sep 2013 Avon M. Voisin

Jared William McDowall was born on 15 January 2012 and died unexpectedly at the hospital on 17 January 2012, aged 48 hours. The inquest concluded that he died from natural causes and had medical conditions that had not been diagnosed. Concerns included the weight thresholds used to determine monitoring, the need for guidance based on gestation and sex, improved presentation of risk information, joint working, and education on hypoglycaemia and recognising an unwell baby.

Rose Jean COLES · Prevention of Future Deaths report View report

27 Sep 2013 Avon M. Voisin

Rose Coles was born prematurely at 34 weeks’ gestation and had congenital heart disease for which she received treatment. Evidence raised concerns about communication between the neonatal intensive care unit and cardiac unit, including whether the cardiac unit was suited to caring for premature babies and whether a protocol, checklist or improved communication would assist staff.

Joan Farran · Prevention of Future Deaths report View report

26 Sep 2013 Gateshead and South Tyneside T. Carney

Joan Farran, who had multiple co-morbidities and was cared for by her adult son, died at home from bronchopneumonia due to chronic obstructive pulmonary disease and Alzheimer’s disease. The report states that her death from a potentially treatable pneumonia was contributed to by neglect in obtaining medical support and treatment. Concerns included inadequate coordination and information-sharing between agencies, limited assessment of the home environment, withdrawal of community visits without replacement services, and the cancellation of a GP home visit without further follow-up.

Betty Grace Payne · Prevention of Future Deaths report View report

26 Sep 2013 Carmarthenshire and Pembrokeshire M. Layton

Betty Grace Payne, aged 84, lived alone and was found dead after a house fire on 16 July 2013. The report identified concerns about the sharing of information about vulnerable people with the Fire Service and the availability of fire-safety checks and related training.

Gwilym Pugh Jones · Prevention of Future Deaths report View report

25 Sep 2013 North Wales (East and Central) J. Gittins

Gwilym Pugh Jones was admitted to Wrexham Maelor Hospital after an apparent stroke and later developed symptoms suggestive of a Clostridium Difficile infection. A stool sample requested by a clinician was not obtained or tested, resulting in a missed opportunity for diagnosis and treatment; he subsequently died with sepsis, peritonitis and toxic megacolon associated with pseudomembranous colitis.

Anna Ulmer Ahmed · Prevention of Future Deaths report View report

25 Sep 2013 Inner South London A. Harris

Anna Ulmer Ahmed, aged 30, was assessed by ambulance staff and later by her GP after experiencing chest pain; she died at home a few hours later from sudden adult cardiac death syndrome. The report raised concerns about low awareness of the condition in general practice and a lack of, or limited awareness of, guidelines for urgent referral of patients vulnerable to it.

Linda Hudson · Prevention of Future Deaths report View report

24 Sep 2013 County Durham and Darlington A. Tweddle

Linda Hudson had been discharged from hospital after a previous suicide attempt and was found dead by hanging in her home two days later, although the exact time of death was unclear. Concerns included the quantity of medication supplied at discharge, failure to notify her family, and a delay in arranging follow-up contact after discharge.

Jude Augustus Gordon · Prevention of Future Deaths report View report

24 Sep 2013 South Yorkshire (Western) D. Coutts-Wood

Jude Augustus Gordon underwent surgery and anaesthesia on 23 November 2011, deteriorated with signs of respiratory failure on 27 November, and died shortly after suffering a cardiac arrest. The concerns included failure to escalate his treatment or refer him to critical care, miscalculation of the Early Warning Score, variation in how scores were calculated between Trusts, and the absence of an automatic alert system for senior clinicians.

Yvonne Sydney Annie Perry · Prevention of Future Deaths report View report

23 Sep 2013 Milton Keynes T. Osborne

Yvonne Sydney Annie Perry fractured her left hip after a fall at home, and the possibility of the fracture identified on 19 December 2012 was not acted upon until early January 2013. She later developed a severe urinary tract infection and died of sepsis on 2 February 2013; concerns included the lack of a robust process for tracking radiology reports and the absence of GP access to electronic hospital notes and records.

Sally King · Prevention of Future Deaths report View report

23 Sep 2013 Milton Keynes T. Osborne

Sally King was admitted to Milton Keynes Hospital after falling from her chairlift on 22 December 2012 and sustaining a fractured femur and ribs; the inquest concluded that she died as a result of an accident. Concerns included the failure of the Pain Team to see her during an admission of over three weeks and delays in transferring her to the Respiratory Team because of a lack of beds, with the transfer occurring on the day she died.

Michael James SWEENEY · Prevention of Future Deaths report View report

23 Sep 2013 London North (Inner) M. Hassell

Michael James Sweeney died after taking cocaine and becoming extremely agitated; he was transported to hospital by police after an ambulance was not sent within the target time. He was restrained prone until sedation was effective, then arrested and died less than two hours later. The principal concerns were the inconsistent use and understanding of the term “excited delirium”, the risk of missing other medical causes of extreme agitation, and ambulance-service prioritisation of such emergencies.

Joan Mary Jones · Prevention of Future Deaths report View report

20 Sep 2013 Leicester City and South Leicestershire C. Mason

Joan Mary Jones, a resident of a care home with Alzheimer's dementia, became unwell on 23 September 2012 and later deteriorated following an aspiration episode. She died on 1 October 2012; the inquest recorded bilateral bronchopneumonia due to locally advanced adenocarcinoma of the large bowel and Alzheimer's dementia. Concerns included failure to escalate her care and failure to communicate relevant information to attending healthcare professionals, resulting in a missed opportunity to treat and an inappropriate care package.

Caitlynn Bethany Jane Bennet and 2 others · Prevention of Future Deaths report View report

19 Sep 2013 Birmingham and Solihull S. Ormond-Walshe

The report concerns the deaths of Caitlynn Bethany Jane Bennet, Mohammed Gulam Mohinudeen and Alfie-Scott Harris. It raises concerns about cardiac tamponade as a complication of central lines used for parenteral nutrition, including whether neonatal staff recognise the risk and whether best practice is shared between units. In Alfie-Scott Harris’s case, the report identified failures in the placement of the long-line end, although these were not considered gross.

Tripta Rani KUMAR · Prevention of Future Deaths report View report

19 Sep 2013 London Eastern C. Inyama

Tripta Rani KUMAR underwent planned hysterectomy and was discharged, but was readmitted the following day with abdominal pain and a perforated bowel. She developed sepsis, suffered a cardiac arrest on 25 August 2012, and died despite CPR. A principal concern was that penicillin-containing Tazocin was prescribed despite records and a wristband indicating a penicillin allergy, after an unsigned handwritten alteration changed the record to “nil allergies”.

Daniel Onley · Prevention of Future Deaths report View report

19 Sep 2013 Gloucestershire T. Osborne

Daniel Onley, a resident at Orchard House, was found face down in his bath on 22 June 2012 and was concluded to have died from sudden unexplained death in epilepsy. Concerns included insufficient support for taking anti-convulsant medication, inadequate management of medication-related risks, and insufficient evening supervision.

Margaret Theresa CORRIGAN · Prevention of Future Deaths report View report

17 Sep 2013 Manchester South J. Pollard

Margaret Theresa Corrigan fell at home on 18 January 2013 and fractured her odontoid peg; the inquest concluded that her death was accidental and recorded medical causes including infarction, vertebral artery dissection, peg fracture and Clostridium Difficile infection. Concerns included ineffective communication, failure to diagnose the fracture promptly, failure to transfer her to a medical team when appropriate, and issuing an outpatient orthopaedic appointment while she was an inpatient.

Alva JULLIEN · Prevention of Future Deaths report View report

17 Sep 2013 Manchester South J. Pollard

Alva Jullien was admitted to hospital after a fall at home but remained there without a home assessment despite being considered medically fit for discharge. During her hospital stay she became recumbent and developed pneumonia; the inquest conclusion stated that missed opportunities during her care might have optimised her chances of survival. The principal concerns were communication and decision-making failures affecting discharge, and the decision to make her nil by mouth and place her on the Liverpool Care Pathway with, in the coroner’s view, insufficient evidence.