Reports

Mikey James Hornby · Prevention of Future Deaths report View report

16 Dec 2014 Manchester South J. Pollard

Mikey James Hornby was born on 31 March 2014 and died after being found lifeless at home on the morning after he attended an out-of-hours service with strange breathing. The report records neonatal E. coli sepsis and meningitis, with the conclusion of natural causes contributed to by neglect. Concerns included failures to refer him to hospital when he had an infected umbilical cord or possible serious illness, and the lack of access to immediate blood testing and antibiotics.

John Charles Leyin · Prevention of Future Deaths report View report

16 Dec 2014 Essex C. Beasley-Murray

John Charles Leyin was admitted to Basildon Hospital after suffering a stroke and later died after difficulties with feeding arrangements, including a nasogastric tube being placed into his lung. The concerns included failures to disseminate relevant policy and guidance, weaknesses in training systems, inadequate checks of staff training, and uncertainty about the number of trained staff available for such procedures.

Janette Insley · Prevention of Future Deaths report View report

16 Dec 2014 Manchester North L. Hashmi

Janette Insley had a longstanding history of depressive illness and was admitted to a mental health unit after her mental and psychological health deteriorated. After failing to return from home leave on 3 August 2014, she was found deceased at home having self-ligatured; concerns included a lack of inpatient psychological therapy provision and delays in accessing community-based therapy after discharge.

Andrew James AITKEN · Prevention of Future Deaths report View report

15 Dec 2014 Inner North London M. Hassell

Andrew Aitken was admitted to hospital on 10 June 2014 after taking a drug overdose, was treated and discharged on 16 June. Two months later he was found dead at home from amitriptyline toxicity, without having accessed mental health care in the meantime. Concerns included the handling of the remaining tablets, failure to seek records of a previous psychiatric admission, lack of direct referral to community mental health services despite him having no GP, and his discharge without clothes or shoes.

RHYS TUDOR WILLIAMS · Prevention of Future Deaths report View report

15 Dec 2014 Manchester South J. Pollard

On 3 March 2014, RHYS TUDOR WILLIAMS was put to bed at Sunrise Senior Living and was found deceased between his bed and the wall at 1.40 am. The report raised concerns about inadequate staff training, incorrect bed positioning, failure to apply bed brakes, insufficient staffing and communication, pre-completed care notes, and possible delays in calling an ambulance.

Simon Peter SATCHWELL · Prevention of Future Deaths report View report

12 Dec 2014 Hertfordshire E. Thomas

The report identifies Simon Peter SATCHWELL as the deceased person. No circumstances of the death or substantive concerns are included in the supplied text.

Jason Geoffrey PALMER · Prevention of Future Deaths report View report

12 Dec 2014 Exeter and Greater Devon J. Tomlin

Jason Geoffrey PALMER died from a shotgun injury to the head after consuming a large quantity of alcohol; he and his wife had separated, and the inquest concluded that he had taken his own life. The report raised concerns that information about domestic incidents held in restricted police logs was not available to the Firearms Unit when his shotgun certificate was renewed, limiting the robustness of suitability enquiries.

Patricia Edge · Prevention of Future Deaths report View report

10 Dec 2014 Manchester West S. Allen

Patricia Edge died at Royal Bolton Hospital on 20 July 2014 after bowel cancer, bowel obstruction and ischaemic bowel, with paracetamol liver toxicity also identified in the inquest conclusion. An excessive dose of paracetamol was prescribed and dispensed between 14 and 19 July 2014, and the report raised concerns about prescribing and dispensing procedures, review of the dose, and the absence of blood tests.

GARRY GILBEY · Prevention of Future Deaths report View report

10 Dec 2014 Portsmouth and South East Hampshire K. Harrold

Garry Gilbey developed worsening arm, chest and breathing symptoms while imprisoned and was later diagnosed with inoperable lung cancer after being admitted to hospital on 25 June 2012. He died on 3 July 2012. The substantive concerns included unclear ambulance-call procedures and emergency thresholds for prison officers, inadequate communication of healthcare events to night staff, and failures to ensure that specialist investigations were arranged, completed and properly checked.

Paul Leslie HYDE · Prevention of Future Deaths report View report

5 Dec 2014 Brighton and Hove V. Hamilton-Deeley

Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.

Elaine Marilyn GILES · Prevention of Future Deaths report View report

5 Dec 2014 South Lincolnshire A. Forrest

Elaine Marilyn GILES, a 66-year-old woman, died from fat embolism after falling while descending the stairs at home five days after discharge following hip replacement surgery. The principal concern was that she had been assessed as safe on stairs before discharge but could not safely negotiate the stairs at home, highlighting the need for detailed assessment of likely function in the home and adequate support after discharge.

Jade Sarah Louise Lomas Anderson · Prevention of Future Deaths report View report

5 Dec 2014 Manchester West A. Walsh

Jade Sarah Louise Lomas Anderson died on 26 March 2013 after being attacked by more than one dog while alone in a house. The report raised concerns about inadequate control of dogs, limitations and fragmentation of dog-control legislation, insufficient owner responsibility and education, and the need for earlier intervention to prevent future incidents.

Peter Harry Mackie · Prevention of Future Deaths report View report

5 Dec 2014 Buckinghamshire R. Hulett

Peter Harry Mackie, a prisoner at HMP Springhill, was found hanging in the prison chapel on 28 December 2013 and was declared deceased. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the availability and deployment of first aiders and healthcare staff across the prison sites, and a lack of clarity about when CPR should be commenced and what action untrained staff should take.

James Duncan STEWART · Prevention of Future Deaths report View report

4 Dec 2014 Bedfordshire and Luton T. Osborne

James Duncan STEWART, a resident of Manton Heights Nursing Home, was admitted to hospital with decreased mobility and responsiveness after his Parkinson’s medication had apparently not been provided. He was discharged to Airedale Nursing Home for end-of-life care and died on 21 April 2014. The principal concerns were the absence of a system to check medication details with a previous GP practice and uncertainty about responsibility for confirming the correct medication prescription.

JO ANNE CAROL NOBBS · Prevention of Future Deaths report View report

4 Dec 2014 Norfolk J. Lake

Jo Anne Carol Nobbs had longstanding physical and mental health problems and was found dead at home on 2 June 2014 after disengaging from professionals and stopping collection of her medications. Concerns included failure to investigate or act on the relationship between her deteriorating physical and mental health, and the lack of a revised care plan when she stopped engaging with mental health services.

Sandra Danks · Prevention of Future Deaths report View report

3 Dec 2014 Teesside C. Bailey

Sandra Danks required continuous home oxygen supplied by an electrically powered apparatus. An electricity interruption stopped the apparatus, and she was unable to use the nearby spare oxygen bottle before she died. The principal concern was that the main oxygen apparatus had no backup to maintain oxygen provision during a power interruption.

Moses Andrew Arthur McDonald · Prevention of Future Deaths report View report

2 Dec 2014 Inner South London L. Tagliavini

Moses Andrew Arthur McDonald, who had paranoid schizophrenia and was taking Clozapine, was found deceased at home on 2 April 2013 after experiencing frequent urination and extreme thirst. He had not undergone glucose testing since May 2012. The principal concern was the lack of mandatory and regular glucose testing by the Clozapine clinic while he was receiving antipsychotic medication; the inquest concluded that diabetic ketoacidosis contributed to his death.

Anthony Gwyn Williams · Prevention of Future Deaths report View report

2 Dec 2014 North Wales (East and Central) J. Gittins

On 9 February 2014, Anthony Gwyn Williams, whose mental health was declining, went to Pentwmpath Woods and took his own life with a ligature while his balance of mind was disturbed. Concerns included insufficient guidance on when staff could deviate from the recognised psychiatric assessment pathway, lack of continuous access to patients’ medical records, and the need for greater engagement with families and carers about care and treatment plans.

Freda Virginia Owens · Prevention of Future Deaths report View report

27 Nov 2014 Blackpool and the Fylde A. Wilson

Freda Virginia Owens, aged 93, died after developing bronchopneumonia associated with an infected necrotic pressure ulcer of the left hip, alongside burns and scalds sustained on 2 November 2012. The report identified concerns about the gathering and exchange of information between care and medical professionals, delays in recognising the pressure ulcer, and the resulting delay in treatment.

David Peter Greenfield · Prevention of Future Deaths report View report

27 Nov 2014 County Durham and Darlington A. Tweddle

David Peter Greenfield, aged 29, was admitted to hospital for alcohol detoxification and was found unresponsive in his bedroom less than 24 hours later. The report states that his death involved pre-existing heart disease, respiratory depression linked to obesity and the effects of drugs. Concerns included staff experience and understanding of risks associated with methadone and respiratory depression, and the absence of drug screening for patients admitted for alcohol detoxification, which impeded meaningful risk assessment.