Reports

Jeanne Elsie Summers · Prevention of Future Deaths report View report

16 Apr 2015 West Yorkshire (West) M. Burke

Jeanne Elsie Summers was admitted to hospital with an exacerbation of chronic obstructive pulmonary disease and infection, and later suffered an unwitnessed fall while mobilising to the toilet, resulting in an open right ankle fracture. She subsequently developed pneumonia and died on 24 July 2013. Concerns included the absence of a clear mobility assessment before discharge, incomplete physiotherapy records, unsuitable footwear and unsafe transfer practices, and inadequate investigation of the fall.

Robert Henry Payne · Prevention of Future Deaths report View report

16 Apr 2015 Powys, Bridgend and Glamorgan Valleys A. Barkley

Robert Henry Payne was admitted to hospital after falling at home and fracturing his left neck of femur. While in hospital, he experienced repeated falls, including one that dislocated the repaired hip and necessitated further surgery; the reported concerns included falls despite high-risk assessments and a ward transfer without an apparent transfer document, followed by a fall that was not witnessed. He later developed an infected surgical wound and died on 13 July 2014.

Stephen Paul Myers · Prevention of Future Deaths report View report

15 Apr 2015 County Durham and Darlington J. Hamilton

On Christmas Eve 2014, Stephen Paul Myers drank a bottle of isopropyl nitrite (“Poppers”) purchased from a local shop, collapsed, and died after resuscitation was attempted. The concerns included the product’s toxicity if swallowed and the adequacy of its labelling and packaging, including the need for updated hazard information, precautionary statements, pictograms, a signal word and a tactile warning.

Austen Harrison · Prevention of Future Deaths report View report

13 Apr 2015 Oxfordshire D. Salter

Austen Harrison, aged 4, died on 8 June 2013 after an unfixed three-way mirror fell on him in a Hugo Boss store. The concerns included inadequate health and safety training and understanding of responsibilities, the absence of regular professional health and safety audits, and apparent failures to ensure that existing safety systems were followed and that the mirror was securely fixed.

Hayden Meirion NORTON · Prevention of Future Deaths report View report

13 Apr 2015 Exeter and Greater Devon E. Earland

Hayden Meirion NORTON, a prisoner at HMP Dartmoor, became unwell with flank pain on 6 January 2014, suffered cardiac arrest, and died after resuscitation attempts. The report states that he died from a ruptured atherosclerotic abdominal aortic aneurysm. Concerns included a lack of recorded blood-pressure monitoring, no record that he had been informed about screening for aortic aneurysm, and a delay in calling an emergency ambulance because HMP Dartmoor did not have an emergency code protocol.

Maurice Camfield · Prevention of Future Deaths report View report

10 Apr 2015 West Yorkshire (East) D. Hinchliff

Maurice Camfield suffered a traumatic brain injury in a road traffic collision in Bangkok, was repatriated to the United Kingdom, and later died in an ambulance after becoming unresponsive during transfer to hospital. The substantive concern was that the agreed care plan requiring one-to-one nursing care at all times was not followed.

Daniel Hannen Foss · Prevention of Future Deaths report View report

8 Apr 2015 Swansea and Neath Port Talbot C. Phillips

Daniel Hannen Foss, aged 37, died following a collision at a pedestrian crossing on the Kingsway, Swansea, on 24 September 2013. The report raised concerns about numerous pedestrian-coach collisions and incidents on the Kingsway/Metro system, including two fatalities, and identified a serious road-design issue requiring attention.

Aleysha Martine Karla McLoughlin · Prevention of Future Deaths report View report

8 Apr 2015 Manchester West J. Leeming

Aleysha Martine Karla McLoughlin, aged 16, died by hanging at her foster home on 3 April 2014 after a history of self-harm, overdoses and assessed ongoing risk of impulsive self-harm. The concerns included training for professionals to recognise self-harm, systems for sharing information when young people self-harm, urgent multi-agency discussions including mental health services, and a formal support pathway for young people who resist engagement.

CHRISTOPHER WATSON · Prevention of Future Deaths report View report

1 Apr 2015 Norfolk J. Lake

Christopher Watson, who had become isolated after losing his job, was found dead in his home on 7 January 2015 after having been dead for some weeks. The concerns focused on Norfolk County Council Adult Social Care closing his file after sending a letter that Mr Watson might not receive, open or understand, and on the lack of direct contact to ensure he understood that help was available and to assess whether his capacity needed assessment. The inquest recorded that he died from exsanguination after cutting his own arm, with his intention not known.

John Lowe · Prevention of Future Deaths report View report

1 Apr 2015 Nottinghamshire S. Haskey

John Lowe was an inpatient receiving mental health assessment and care after suffering a stroke. After a series of falls, his final fall on 18 February 2014 caused a fractured left neck of femur, which materially contributed to his death from bronchopneumonia on 26 February 2014. Concerns related to nursing staff beliefs that 1:1 nursing could not be provided solely for falls risk or physical care needs.

Thomas Beaty · Prevention of Future Deaths report View report

31 Mar 2015 Manchester North L. Hashmi

Thomas Beaty was born by emergency caesarean section after an abandoned instrumental delivery on 11 April 2014. At 26 hours of age, he suffered a catastrophic head injury, hypovolaemic shock and hypoxic brain ischaemia, and died. The report raised concerns that guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, including unclear terminology and misleading guidance about traction.

Sharon Louise Suki Butcher · Prevention of Future Deaths report View report

31 Mar 2015 County Durham and Darlington A. Tweddle

Sharon Louise Suki Butcher died of natural causes, with the inquest recording ischaemic heart disease, coronary artery atheroma, diabetes mellitus and cirrhosis of the liver. The report raised concerns about a 10-minute delay in calling an ambulance after an emergency medical code was broadcast, failure to follow the prison’s local protocol, and recurring lack of clarity in responding to medical emergencies.

Olive Nugent · Prevention of Future Deaths report View report

31 Mar 2015 Newcastle Upon Tyne K. Dilks

Olive Nugent fell down the stairs at home on 16 December 2014 and her falls detector activated, but no warden attended for 2 hours and 27 minutes. She sustained an unsurvivable brain injury and died. The principal concerns were delayed and subjective prioritisation of responses, insufficient staffing, and the risk to people who were unable to respond verbally through the device.

Jason Houghton · Prevention of Future Deaths report View report

30 Mar 2015 Manchester West A. Walsh

Jason Houghton died on 30 June 2014 in a hotel room with a cannula connected to a homemade drip, alongside syringes, Valium vials and other drug-related items. The inquest recorded that his death involved the combined toxic effects of ketamine, heroin, diazepam and dextromethorphan and concluded misadventure. Concerns were raised about the unregulated internet supply and international importation of illicit drugs, including heroin in the form of diacetyl morphine.

Kenneth John WILLIAMS · Prevention of Future Deaths report View report

30 Mar 2015 Surrey S. Wickens

Kenneth John Williams was admitted with shortness of breath and was diagnosed with tension pneumothorax, leading to insertion of a chest drain. The report states that the diagnosis was incorrect, the drain ruptured a pulmonary bulla and caused bleeding, and concerns included reviewing previous imaging and medical history and involving the respiratory team before and after chest-drain insertion.

Kelly Patrick WILLIS · Prevention of Future Deaths report View report

30 Mar 2015 Central and South East Kent R. Redman

Kelly Patrick Willis underwent atrial ablation at St Thomas’ Hospital on 8 October 2012 and was subsequently admitted to William Harvey Hospital several times with symptoms of general unwellness. He died from cerebral infarction, multiple septic emboli and an atrio-oesophageal fistula complicating the ablation. The principal concerns were delays in contacting the tertiary centre and failure to act on an email advising that complications should be considered and investigated.

Andrea Jane Thirkell · Prevention of Future Deaths report View report

30 Mar 2015 County Durham and Darlington A. Tweddle

Andrea Jane Thirkell had an unwitnessed fall at a nursing home and was taken to hospital, where she was deemed fit for discharge but remained in the department for several hours without structured monitoring or observation. She returned to the nursing home, was found unresponsive, and was later diagnosed at hospital with a serious head injury before dying later that day. Concerns related to the lack of formal monitoring during delayed discharge and the absence of formal guidance for late-night discharges, which could result in inconsistent or potentially erroneous decisions.

Sabrina Stevenson · Prevention of Future Deaths report View report

30 Mar 2015 Inner North London R. Brittain

Sabrina Stevenson, aged 28, died on 16 December 2012 from a ruptured ectopic pregnancy after delays in ambulance response and assessment. The report identified concerns about ambulance response times, staffing vacancies, outstanding training issues, the absence of certain call-handling and clinical systems, pre-hospital assessment, extraction techniques, and governance processes.

Rafal Delezuch · Prevention of Future Deaths report View report

27 Mar 2015 Leicester City and South Leicestershire M. Gotheridge

Rafal Delezuch was seen behaving bizarrely and showing paranoia in Leicester before being restrained by police under section 136 of the Mental Health Act and taken to hospital. The inquest concluded that he died from amphetamine-induced delirium in association with prolonged struggle. Concerns included staff awareness and training on restraint, lack of familiarity with the dangers of prolonged prone restraint, difficulties obtaining and selecting medication for rapid tranquillisation, and an overlooked warning about diazepam in NICE guidance.

Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report View report

25 Mar 2015 Essex E. McGann

Mr Harold Ambrose shot his wife, Mrs Wendy Ambrose, and then himself; police found both bodies. Mr Ambrose had a shotgun licence and developed worsening mixed dementia, but neither his GP nor the mental health trust referred the matter to the police firearms department. The report identified that there was no requirement for them to notify police about mental health concerns when aware that a patient held a firearms licence.