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Olive Darbyshire · Prevention of Future Deaths report View report

22 May 2015 Blackpool and the Fylde A. Wilson

Olive Darbyshire fell while trying to get from her bed to the toilet, suffered a hip fracture, and was admitted to hospital. An urgent CT pulmonary angiogram requested after suspected pulmonary embolism was not carried out after she was incorrectly categorised as an outpatient, and she later developed a major intestinal bleed and died on 28 December 2014. Concerns included the failure to complete or follow up the urgent scan and the effects of incorrect categorisation and reduced Christmas-period staffing.

Barbara Patterson · Prevention of Future Deaths report View report

21 May 2015 Northumberland (North) C. Henley

Barbara Patterson suffered a cerebral stroke at home on 1 January 2015, fell from a stair lift, and died at Wansbeck Hospital on 2 January 2015. The substantive concerns included the failure to provide timely CPR advice, a fault in the Pathways system relating to agonal breathing, ambulance dispatch and delayed arrival, and wider ambulance service capacity issues.

Mrs Wanda Stachurska · Prevention of Future Deaths report View report

20 May 2015 West Sussex B. Dolan

Mrs Wanda Stachurska was found deceased on 18 November 2014 after being discharged from hospital the previous evening following a suicide attempt involving an overdose and attempted hanging. Concerns included the quality of the mental health risk assessment, including the use of an untrained security guard as an interpreter and the failure to communicate relevant information about the earlier attempted hanging. The report also raised concerns that neither Trust conducted a serious incident review after her death.

Irene HAMILTON-PARKER · Prevention of Future Deaths report View report

20 May 2015 Staffordshire South A. Haigh

Irene HAMILTON-PARKER died in hospital in the early hours of 10 February 2015 after being found at home with clothing on fire while attempting to light a cigarette with an inappropriate lighter. The principal concern was the flammability of man-made clothing fabrics and whether steps could reduce the flammability of clothing manufactured or imported in the country.

Viola Burke · Prevention of Future Deaths report View report

20 May 2015 Inner North London J. Devonish

Viola Burke, aged 80, died on 5 January 2015 after developing a productive cough and shortness of breath, receiving a diagnosis of chest infection, and later collapsing at home. Concerns included reliance on an asthma pump despite no recorded asthma diagnosis, the absence of a care plan that would have provided Out of Hours clinicians with fuller medical records, and questions about the implementation and accessibility of the care plan system.

Sheila Johnson · Prevention of Future Deaths report View report

19 May 2015 Derby and Derbyshire R. Hunter

Sheila Johnson died on 15 May 2013 from catastrophic haemorrhage from a femoral graft wound, less than 24 hours after discharge from hospital with an open left groin wound. The report identified failures in responding to recognised bleeding before discharge and concerns about the inadequacy of the Trust’s investigation, including the omission of key witnesses, limited review of clinical documentation, factual inaccuracies, and the lack of an urgent recall system for patients discharged with potentially life-threatening conditions.

Diana Ruth Hughes · Prevention of Future Deaths report View report

18 May 2015 Gloucestershire K. Skerrett

Diana Ruth Hughes, aged 66, underwent cholecystectomy that was converted to open surgery and later developed widespread bowel infection and infarction. She deteriorated rapidly and died in the recovery room on 9 January 2014. The substantive concern was how specific instructions for a surgical procedure are communicated to other medical personnel via the WHO/Surgical checklist.

George Richardson · Prevention of Future Deaths report View report

15 May 2015 Sunderland D. Winter

George Richardson died in Sunderland Royal Hospital on 9 February 2015 after admission for urinary retention, during which he underwent several catheterisation procedures and suffered urethral trauma. The report raised concerns about repeated catheterisation by different individuals without a consolidated catheterisation record, meaning staff were not always aware of previous difficulties or prompted to involve a urologist.

Jacques Gerard Lakeman and Torin Callan Lakeman · Prevention of Future Deaths report View report

15 May 2015 Manchester West A. Walsh

Jacques Gerard Lakeman and Torin Callan Lakeman, brothers, died at The Grapes Public House, Stoneclough, Bolton, on 1 December 2014. The medical cause of death for both was recorded as fatal MDMA toxicity, with the inquest conclusion being misuse of Ecstasy. The report raised concerns about the online supply and postal delivery of illicit drugs, including the unknown strength and contents of substances and the lack of regulation.

Sara Jane Green · Prevention of Future Deaths report View report

15 May 2015 Manchester South A. Bridgman

Sara Jane Green died at Cheadle Royal Hospital on 18 March 2014 after being found with wire spiral binding wrapped around her neck; resuscitation was unsuccessful. The inquest identified concerns about her prolonged admission and the inadequate or unavailable provision of placements and discharge arrangements. It also identified concerns about delays in medical record-keeping, which could prevent important information from being available to staff and create a risk of harm to patients.

Name not published · Prevention of Future Deaths report View report

14 May 2015 Stoke-on-Trent and North Staffordshire I. Smith

The deceased was arrested on 2 October 2011 and held in custody, where he received prescribed methadone and medication for alcohol withdrawal. He was found unresponsive in his cell shortly before 9.00pm on 3 October 2011; the recorded medical cause of death was methadone intoxication, with alcohol withdrawal in a chronic alcoholic also identified. Concerns included communication between medical practitioners and custody staff, inconsistent observation levels, joint training, and training on drug and alcohol-related risks.

Steven Bottomley · Prevention of Future Deaths report View report

14 May 2015 West Yorkshire (Western) M. Fleming

Steven Bottomley was found collapsed and unresponsive after an unwitnessed fall from the open window of his flat while under the influence of drugs and alcohol, and was pronounced dead by paramedics. The window was approximately two feet above the flat floor and had no safety measures fitted. The principal concern was the safety of this window and similar windows in the properties.

Paul Littlewood · Prevention of Future Deaths report View report

13 May 2015 South Yorkshire (Western) J. Fox

Paul Littlewood fell from the gantry of a walking floor trailer while unsheeting it and died the following day from head injuries. Concerns included inadequate barriers and fall protection, the absence of a toe-plate, and the lack of safer or self-closing access protection and a ground-level fall-arrest system.

Fred Hudson · Prevention of Future Deaths report View report

13 May 2015 West Yorkshire Eastern M. Williamson

Fred Hudson died after falling approximately 25 metres from disused railway bridge AB08 in Leeds during the early hours of 28 January 2014. The bridge was accessible by several routes, had no measures to prevent access, and was next to a main road and frequently visited by members of the public, including children.

Paul Alexander Murray · Prevention of Future Deaths report View report

13 May 2015 North London A. Walker

Paul Alexander Murray died on 8 February 2015 after developing myocarditis, suffering a cardiac arrest, and later dying in hospital despite treatment. The report identified insufficient ambulance resources following a second call as a concern, with delayed attendance and hospital arrival described in the circumstances.

Hana Aisha Abd Elhamid · Prevention of Future Deaths report View report

13 May 2015 North London A. Walker

Hana Aisha Abd Elhamid was being treated with Clozapine for a mental health condition and developed diabetes, which was likely not identified because routine fasting blood tests were not carried out. She later required intubation for a diabetic coma, self-extubated and sustained airway injury, and died after subsequent breathing difficulties and treatment for a narrowed airway. The principal concerns were the failure to perform routine blood sugar testing and the resulting airway injury during treatment.

Derick James Stanmore · Prevention of Future Deaths report View report

12 May 2015 Leicester City and South Leicestershire L. Brown

Derick James Stanmore, who was serving a life sentence in HMP Gartree and had recognised medical conditions including heart disease and type II diabetes, complained of chest pains on 7 July 2014. He collapsed in his cell on 10 July 2014 and was pronounced deceased shortly after arriving at hospital; the inquest recorded acute myocardial infarction due to coronary artery atheroma. Concerns included abnormal observations not being recognised or acted upon and the attending nurse not accessing available healthcare records before taking observations.

Paul Mc Guigan · Prevention of Future Deaths report View report

12 May 2015 Manchester South J. Kearsley

Paul Mc Guigan was shot and unlawfully killed by a close protection work colleague on 9 August 2009 while both were working as armed private security contractors in Baghdad. The report identified missed opportunities and failings in managing the offender’s escalating offending behaviour and risk, and stated that G4S had not adequately vetted him before deployment. Concerns also included failures in information sharing, recording bail conditions, police disclosure processes, and the supervision and risk assessment of offenders.

Lydia Corah · Prevention of Future Deaths report View report

11 May 2015 Nottinghamshire S. Haskey

Lydia Corah died at the Trust hospital from multi-organ failure caused by Group A beta streptococcal sepsis. The report raised concerns about errors that led to her undergoing an X-ray intended for a different patient, causing delay in assessment and treatment and unnecessary radiation, and about the potential adverse effect on the intended patient.

Margaret Elaine Wright · Prevention of Future Deaths report View report

11 May 2015 Manchester West J. Leeming

Margaret Elaine Wright developed hepatitis C, liver cirrhosis and hepatocellular carcinoma following contaminated blood transfusions, and died in hospital on 23 December 2014 after her condition deteriorated following surgery. The principal concern was that the doctors’ practice did not telephone the patient or her family to obtain further information when a home visit was requested, and the doctor was unaware of her recent surgery because the practice had not received a discharge summary, resulting in a delayed visit.