Reports

Muriel Dawson · Prevention of Future Deaths report View report

17 Apr 2014 West Yorkshire (Western) T. Ratcliffe

Muriel Dawson, aged 90, died shortly after being thrown forward from her unrestrained aisle seat when a public service bus braked suddenly. She suffered a complete fracture of the lumbar vertebrae and associated trauma. The principal concern was that the vehicle’s design and type-approval gave insufficient weight to the risk of death or serious injury to passengers, particularly because seats lacked restraints and a possible restraining feature was absent.

Sari Marlene KEEN · Prevention of Future Deaths report View report

16 Apr 2014 Bedfordshire and Luton T. Osborne

Sari Marlene KEEN underwent surgery to remove colon tumours on 23 October 2013, developed a faecal anastomotic leak causing peritonitis and shock, and died following cardiac arrest on 24 October 2013. The substantive concerns were insufficient staffing and failures to recognise deterioration, escalate care, and call the Hospital Crash Team when her blood pressure became unrecordable.

KATHRYN LOUISE SAWYER · Prevention of Future Deaths report View report

16 Apr 2014 Norfolk J. Lake

Kathryn Louise Sawyer, who had a significant history of mental health issues and was prescribed multiple medications including Methadone, was found collapsed and unresponsive at home on 14 August 2013 and died shortly after arriving at hospital. The medical cause of death was respiratory failure due to an overdose of Methadone in combination with therapeutic levels of other drugs. A principal concern was that, although her medication was reviewed in June 2013, there was no or no detailed record of the discussion and no plan for future medication, particularly any plan to decrease it.

Kevin Scarlett · Prevention of Future Deaths report View report

15 Apr 2014 Milton Keynes T. Osborne

Kevin Scarlett was found hanging from a bunk using a sheet as a ligature in a cell at HMP Woodhill on 22 May 2013 and died. The report raised concerns that his risk of self-harm or suicide was not properly assessed and that prison and healthcare staff lacked access to a risk assessment tool or protocol. The inquest also identified concerns about his accommodation, regime, and case management.

Mr Philip Anthony Dean · Prevention of Future Deaths report View report

15 Apr 2014 Inner West London F. Wilcox

Mr Philip Anthony Dean, who had chronic depressive illness and had become suicidal, jumped from Battersea Bridge into the River Thames on 13 August 2013 and died after being recovered and resuscitated. The principal concerns included inadequate continuity of care, discharge from the Home Treatment Team before psychology referral could be made, failure to record and communicate the GP’s concerns, insufficient assessment by medically qualified personnel, apparent under-resourcing, and an inadequate serious untoward incident investigation.

Desiree Harmony Falvo · Prevention of Future Deaths report View report

15 Apr 2014 Inner West London F. Wilcox

Desiree Harmony Falvo developed severe breathing difficulties after a procedure and was transferred to hospital in extremis. Difficulties securing her airway led to cardiac arrest and hypoxic brain injury, and she subsequently died in intensive care. The concerns were insufficient on-site emergency surgical tracheotomy expertise in some A&E departments and the adequacy of training and confidence of clinicians expected to secure airways.

Nicos Andreas MICHAEL · Prevention of Future Deaths report View report

14 Apr 2014 North East Kent R. Cobb

Nicos Andreas MICHAEL died in hospital on 1 November 2013 after suffering a cardiac arrest and significant brain injury following an acute anaphylactic reaction to intravenously administered Augmentin. The principal concerns were that allergy information was conflicting or incompletely recorded, a historic hospital record of an Augmentin reaction was not carried forward or passed to the GP, and systems did not reliably make previous allergy information available to treating staff.

Winifred Olive DENNIS · Prevention of Future Deaths report View report

14 Apr 2014 North East Kent R. Cobb

Winifred Olive DENNIS died at home on 27 December 2012 after a deterioration in health leading to reduced and ultimately no mobility. She had developed a deep sacral pressure sore, and the inquest recorded bronchopneumonia and the pressure sore as the clinical causes of death. The report identified a concern that information about her previous airflow mattress was not formally handed over when she moved between care settings, potentially reducing the provision of optimum care.

Paul Michael Ashton · Prevention of Future Deaths report View report

14 Apr 2014 Manchester West A. Walsh

Paul Michael Ashton died during a right knee arthroscopy under general anaesthesia after suffering a cardiac arrest. The concerns included the absence of hospital protocols for the perioperative management of heart-transplanted patients undergoing non-cardiac surgery, and issues concerning the availability and use of Isoprenaline during resuscitation.

Francis Nelson GOLDING · Prevention of Future Deaths report View report

14 Apr 2014 Inner North London M. Hassell

Francis Nelson Golding, aged 59, died after the pedal cycle he was riding collided with a left-turning coach at the junction of Vernon Place and Southampton Row in London. The inquest heard that three cyclists had died at the junction in the previous ten years in collisions with left-turning vehicles, and raised concerns that the junction left cyclists particularly vulnerable, including because of the oncoming bus lane. Early consideration of improvements to the junction was requested.

Lalitab en Jayantibhai Patel · Prevention of Future Deaths report View report

13 Apr 2014 Leicester City and South Leicestershire C. Mason

Mrs Patel underwent elective laparoscopic cholecystectomy on 4 May 2012, during which inappropriate dissection damaged a vessel near the common bile duct. The vessel ruptured, causing a massive secondary haemorrhage, subsequent complications and hypoxic brain injury, followed by her death on 20 December 2012; the principal concern was inadequate systems for assessing and supervising locum consultant surgeons, creating a risk of similar events elsewhere.

Terence Norbert Dooley · Prevention of Future Deaths report View report

10 Apr 2014 Manchester City J. Harkin

Terence Norbert Dooley took a fatal overdose of medication and contacted the ambulance service, reporting his location and symptoms. Attendance was delayed by 2 hours and 38 minutes, and he was later found deceased by the canal. Concerns included the emergency call being coded green, the delay in response, poor communication, and misleading computer-generated codes.

Russell Edward Long · Prevention of Future Deaths report View report

9 Apr 2014 Cumbria (North & West) D. Roberts

Russell Edward Long was driving at night in foggy conditions when his vehicle left the road, struck a bridge parapet, overturned and fell into a river. The report raised concern that the damaged, overgrown parapet formed a ramp that could cause a similar accident, and identified the need to consider repairing it and erecting a barrier.

Sally Perrons · Prevention of Future Deaths report View report

9 Apr 2014 Nottinghamshire H. Connor

Sally Perrons collapsed at work on 22 January 2013 and was found to be in cardiac arrest. During resuscitation, an endotracheal tube was placed in her oesophagus, but this was not recognised until she reached hospital; she died the following day. The principal concerns were inadequate paramedic intubation training and refresher training, failure to use waveform end-tidal carbon dioxide monitoring, and poor dissemination of relevant guidance to frontline staff.

Ozan Cem ATASOY · Prevention of Future Deaths report View report

9 Apr 2014 Hertfordshire E. Thomas

The report identifies Ozan Cem ATASOY as the deceased person. The supplied text does not provide details about the circumstances of the death or substantive concerns.

Doris Taylor · Prevention of Future Deaths report View report

9 Apr 2014 Manchester South J. Pollard

Doris Taylor was admitted to a care home after reduced mobility and back pain, having been assessed as at high risk of falling. She suffered three falls, with the second apparently caused by a defective door-closer that knocked her over; the inquest concluded that her death was accidental and recorded pneumonia and multi-organ failure, with a fractured neck of femur among the underlying conditions. The principal concerns were inadequate staff understanding of reportable incidents and unsafe or excessively strong door-closers.

Michael Samuel Ian Anthony · Prevention of Future Deaths report View report

9 Apr 2014 Inner South London A. Harris

Michael Samuel Ian Anthony was found dead in his flat on 8 May 2013 and died from diabetic ketoacidotic coma. He had a very high Gabapentin level, and concern was raised about whether Gabapentin was contraindicated for someone with severe Type 1 diabetes and whether prescribing doctors knew of its rare potential to precipitate diabetic coma.

STEPHEN ANTHONY BEDFORD · Prevention of Future Deaths report View report

9 Apr 2014 South and West Cambridgeshire D. Morris

Stephen Anthony Bedford, aged 33, experienced chest pain at a gym on 31 July 2012, collapsed at a health centre, and was diagnosed with an ST elevation myocardial infarction before being transferred to Papworth Hospital, where his death was confirmed. The inquest recorded acute myocardial ischaemia and coronary artery thrombosis, and stated that the outcome might have been different with a more timely transfer to the specialist coronary intervention centre. Concerns included ambulance staff assessment and training, the attendance of appropriately trained paramedics on transfers, adherence to the PPCI protocol, ECG training, and communication with relatives.

Audrey Lily Kelly · Prevention of Future Deaths report View report

8 Apr 2014 Manchester South J. Pollard

Audrey Lily Kelly complained of abdominal pain on 17 November 2013, was prescribed Trimethoprim by an out-of-hours doctor who could not access her GP medical notes, and was found deceased at home two days later. The investigation concluded that she died from natural causes. The principal concern was that out-of-hours services and hospital emergency departments could not access patients’ GP notes, including allergy information, which was considered a serious procedural lapse that could put lives at risk.

Andrew Michael Horgan · Prevention of Future Deaths report View report

8 Apr 2014 Wiltshire and Swindon D. Ridley

Andrew Michael Horgan died on 16 September 2013 from acute cardiac failure following a Colchicine overdose, with coronary artery atherosclerosis, myocardial fibrosis and focal incomplete hepatic cirrhosis also identified. The principal concern was that hospital staff lacked a clear understanding of referral procedures for mental health assessment following discharge, creating a risk that similar communication failures could contribute to a future death.