Reports

Iana-Liza Chervonenko · Prevention of Future Deaths report View report

28 Jan 2015 London (East) N. Persaud

Iana-Liza Chervonenko was delivered by emergency caesarean section after delays associated with a pathological CTG, heavy workload, poor communication and clinical decision-making on the labour ward. She was born at 02.30 with no heart rate or spontaneous respiration and died at twenty-four hours of age from hypoxic-ischaemic encephalopathy caused by intra-partum asphyxia. Concerns included inadequate medical cover, deficient documentation and communication, and the absence of a system to notify the treating team when theatre became available.

Susanna Geraty · Prevention of Future Deaths report View report

27 Jan 2015 Surrey K. Henderson

Susanna Geraty, a previously fit and well 75-year-old woman, died after developing acute renal failure and hyperkalaemic cardiac arrest five days after surgery for a fractured tibia and fibula. The principal concerns were inadequate assessment, monitoring and recording of postoperative fluid balance, failure to respond promptly to family concerns or recognise her deteriorating condition, and an investigation report’s failure to consider dehydration as a possible cause of the acute renal failure.

MRS HILARY MOOCK and MRS JANICE TAYLOR · Prevention of Future Deaths report View report

23 Jan 2015 West Sussex P. Schofield

Mrs Hilary Moock and Mrs Janice Taylor sustained fatal injuries in a road traffic collision on 28 September 2013 while travelling as passengers near the entrance to St Mary's Farm and Benges Cottages. The report identified concerns about the unlit rural road, limited visibility, unclear entrance, uneven unmade road surface and the potential risk to vehicles slowing to turn into the entrance.

Phillip Roy Smith · Prevention of Future Deaths report View report

21 Jan 2015 West Yorkshire (Western) M. Burke

Phillip Roy Smith was diagnosed with a likely pancreatic carcinoma and underwent a percutaneous transhepatic cholangiogram with external drain insertion. He deteriorated overnight with severe pain, vomiting and a subsequent cardiac arrest, and died in intensive care on 15 March 2014 after treatment was withdrawn. The concerns included missing nursing and doctors’ records, undocumented observations, medication, blood gas results and fall details, and the junior doctor’s decision not to seek additional senior support despite concerns about Mr. Smith’s deterioration.

Sian Leigh ARMSTRONG · Prevention of Future Deaths report View report

21 Jan 2015 Avon M. Voisin

Sian Leigh ARMSTRONG had a history of depression and had previously attempted suicide by overdose. She was assessed as needing CBT after this attempt, but had not received it by her death in June 2014. The principal concern was the delay in providing CBT, with a request for reassurance that it would be made available to children requiring it in a timely manner.

Robert Alan JONES · Prevention of Future Deaths report View report

21 Jan 2015 Exeter and Greater Devon E. Earland

Robert Alan JONES suffered multiple falls following a stroke and later deteriorated, dying at South Molton Community Hospital on 1 April 2014. The inquest recorded accidental death, with acute on chronic subdural haematoma and multiple falls due to cerebrovascular accidents. Concerns included inadequate communication about the total number of falls, use of an out-of-date post-falls checklist, and incomplete or incorrectly recorded neurological observations.

Mrs Awa Jeng · Prevention of Future Deaths report View report

20 Jan 2015 London (East) N. Persaud

Mrs Awa Jeng was admitted after a fall that caused a fractured left hip and underwent surgery. She subsequently required dialysis but was not adequately monitored on the ward, and tests were delayed until her potassium was at a life-threatening level. She deteriorated, suffered cardiac arrest during intubation, and could not be resuscitated; the inquest concluded that inadequate monitoring and delayed haemofiltration contributed to her death.

Simon Robert ALLISTON · Prevention of Future Deaths report View report

19 Jan 2015 Bedfordshire and Luton T. Osborne

Simon Robert ALLISTON lived alone and was found deceased in his flat after neighbours had not seen him for approximately a week; paramedics confirmed his death. The concerns included his discharge from mental health services without a formal handover, despite the Community Team considering that he still needed support, with no recorded reason for discharge and no formal Serious Incident Investigation after his death.

Mark Robert Anstice · Prevention of Future Deaths report View report

16 Jan 2015 Norfolk J. Lake

Mark Robert Anstice, who had a history of mental health and social problems and previous self-harm, was found hanged on 27 September 2014. Concerns included that recommended support-worker or care-coordinator provision was not actioned, uncertainty about a carer’s assessment referral, gaps in team awareness of appointments, and difficulties supporting his attendance at group sessions due to lack of transport or means.

Judith Anne SAVILLE · Prevention of Future Deaths report View report

15 Jan 2015 Exeter and Greater Devon A. Cox

Judith Anne Saville, who had a long history of agitated depression and previous psychiatric admissions and ECT treatment, was found deceased at home on 28 January 2014. The inquest concluded that she died from a Zopiclone and Paracetamol overdose and that she had taken her own life. Concerns included the quantity of medication prescribed, the need for warnings about a history of overdose in the practice’s computer system, and implementation and auditing of an action plan.

Max Carlton-Smith · Prevention of Future Deaths report View report

14 Jan 2015 Inner South London A. Harris

Max Carlton-Smith died after taking MDMA at an illegal rave and collapsing when emergency medical assistance was not summoned immediately. The rave had no on-site medical assistance, inadequate ventilation, and unregulated fire exits and procedures; the report also raised concerns about delays in calling an ambulance and the authorities’ ability to intervene at the squatted commercial premises.

Annette Charlton · Prevention of Future Deaths report View report

9 Jan 2015 Birmingham and Solihull L. Hunt

Annette Charlton, who had emphysema and lung fibrosis requiring continuous oxygen therapy, was dispensed Naproxen instead of prescribed antibiotics and died on 28 September 2014. The principal concern was that medication manufacturers used almost identical packaging, which was considered likely to contribute to dispensing errors and potentially patient deaths.

Jason Edward Lawson · Prevention of Future Deaths report View report

9 Jan 2015 Rutland and North Leicestershire R. Chapman

Jason Edward Lawson, who had epilepsy and schizophrenia, was found dead in his prison cell at HMP Stocken on 17 March 2013; the time of death was uncertain but likely late on 16 March or early on 17 March. Concerns included welfare checks that did not establish that he had died, systems that did not reliably identify medication non-attendance or lapsed prescriptions, access delays to healthcare, and the absence of a specific policy for 24-hour medical observation where constant medical supervision was unavailable.

Mark Burdett · Prevention of Future Deaths report View report

9 Jan 2015 Warwickshire S. McGovern

Mark Burdett was riding his motorcycle along Blythe Road, Coleshill, on 10 July 2014 when he collided with a car exiting from Blythe Hall. The concern was the lack of a warning sign for the concealed entrance, particularly for traffic travelling from the Coleshill direction.

Thomas Ian Hunt · Prevention of Future Deaths report View report

9 Jan 2015 South Lincolnshire A. Forrest

Thomas Ian Hunt died shortly after a road collision on 10 August 2014, after losing control of his vehicle on a wet road in Brothertoft. Concerns included the sub-optimal road surface, previous non-injury collisions not recorded on the local authority database, and whether the 60 mph speed limit was appropriate for the road through the village.

Pauline Taylor · Prevention of Future Deaths report View report

9 Jan 2015 West Yorkshire Eastern K. McLoughin

Pauline Taylor underwent surgery in November 2010 intended to remove her right kidney and ureter, but only approximately 5 cm of the ureter was removed. Persistent pain led to the discovery of an inoperable tumour in the remaining ureter, followed by metastases in the liver and lungs; she died at home on 12 May 2012. Concerns included ambiguity in the term “nephroureterectomy” and the absence of a designated person to coordinate care in this complex case.

Eve Cullen · Prevention of Future Deaths report View report

8 Jan 2015 Worcestershire G. Williams

Eve Cullen, who had epileptic seizures and a fluctuating peri-ictal confusional state, went missing from her family home on 17 July 2014 and was later found dead in an alleyway on 9 August 2014. The concerns were that a hospital referral was not actioned, two urgent referrals were not treated as urgent, and there was no uniform definition or timeframe for urgent referrals.

George Hulme · Prevention of Future Deaths report View report

8 Jan 2015 Manchester South C. Murray

On 25 June 2014, George Hulme was assaulted by another resident at Bamford Grange Nursing Home, collapsed and required CPR. The wrong resident file, which recorded a DNR, was retrieved after he was incorrectly identified, and CPR ceased; concerns included inadequate resident identification systems, induction and room labelling for agency staff and emergency responders.

Dean Emrode Elie · Prevention of Future Deaths report View report

6 Jan 2015 North London A. Walker

Dean Emrode Elie was found dead at home on 27 February 2013, having died in his sleep. He had missed several GP appointments for medication review, diabetic review and blood tests, and concerns were raised about the lack of a way to ensure his attendance; the report identified consideration of further legislation on this issue.

Dale Owen Ricardo Scott Proverbs · Prevention of Future Deaths report View report

6 Jan 2015 North London A. Walker

Dale Owen Ricardo Scott Proverbs, a patient detained under the Mental Health Act and placed in seclusion at North London Clinic, collapsed after continuous observation was not maintained and died. The report identified concerns that Partnerships In Care’s observation policies were not followed and that the applicable level of observation could be insufficient to prevent another fatality in similar circumstances.