Reports

Barrie Lewis · Prevention of Future Deaths report View report

19 Feb 2015 Powys, Bridgend and Glamorgan Valleys A. Barkley

Barrie Lewis was found by his family hanging from a rope attached to a garage rafter on 31 August 2014. The inquest concluded that his death was suicide. Concerns included the absence of a specific risk assessment for suicidal ideation, poor communication between mental health services, no reliable system assigning responsibility for assistance, and a lack of clinical records of crisis-team contact.

Elizabeth Muriel Leah · Prevention of Future Deaths report View report

19 Feb 2015 Manchester South J. Pollard

Elizabeth Muriel Leah, an 87-year-old care home resident with severe dementia, fell on 2 July 2014 and broke her femur. Although an ambulance was called, staff were advised to take her to hospital by taxi because of an anticipated ambulance delay. The principal concerns were insufficient ambulance and staffing capacity, delays transferring patients into emergency departments, and hospital bed-blocking.

Maria Silkin · Prevention of Future Deaths report View report

19 Feb 2015 Manchester South J. Pollard

Maria Silkin fell at a care home on or about 2 September 2014, broke her hip, was taken to hospital a week later, underwent surgery, and subsequently developed pneumonia. The concerns were that her falls history was inaccurately recorded as showing no previous falls and that this contributed to a delay in taking her to hospital.

John DACK · Prevention of Future Deaths report View report

19 Feb 2015 London Inner (North) M. Hassell

John Dack sustained fractures to both ankles, underwent procedures and was discharged home unable to weight bear without the planned follow-up. He later developed an infected left ankle with osteomyelitis and died on 24 September 2014 after hospital treatment. The report’s principal concern was that an incorrect address in his medical notes prevented follow-up despite notifications from his daughter; it also raised concern about early discharge home after the MDT meeting.

Keri Victoria Holdsworth · Prevention of Future Deaths report View report

18 Feb 2015 Hartlepool C. Donnelly

Keri Victoria Holdsworth died after sustaining fatal injuries in a road traffic crash at the junction of the A19 and the road from Dalton Piercy village on 13 June 2014. The report raised concern that this was the latest in several serious incidents at the junction, including three fatal incidents within the previous five years.

Henry Denis Whitwell Powell · Prevention of Future Deaths report View report

18 Feb 2015 Leicester City and South Leicestershire L. Brown

Henry Denis Whitwell Powell, who had advanced dementia and required 24-hour care, died on 11 August 2014 after a fall while climbing over bed rails, suffering a head injury and not regaining consciousness. The principal concerns were inappropriate discharge care planning, misunderstanding and insufficient training regarding bed rails, and inadequate coordination and follow-up between hospital and community services for equipment provision.

Alan Vaughan Jones · Prevention of Future Deaths report View report

18 Feb 2015 Swansea and Neath Port Talbot P. Bennett

Alan Vaughan Jones had Addison’s disease and became unable to take his steroid medication after developing gastroenteritis. His condition deteriorated, and he died at 08.50 hours on 8 April 2011; the inquest concluded that Addison’s Disease resulted from neglect. Concerns included inadequate training in the use of electronic patient-record software and failures of the software to highlight important diagnosed conditions as alerts.

George Marks · Prevention of Future Deaths report View report

17 Feb 2015 Mid Kent and Medway K. Thomas

George Marks was admitted with confusion, immobility and a chest infection, and was later diagnosed with a deep vein thrombosis and a thrombus in the pulmonary artery. After his anticoagulant medication was changed to Rivaroxaban, he was not given it from the evening of 28 February until 4 March, and he died on 6 March 2014. The principal concerns were agency staff’s failures in medication administration, record-keeping and handover procedures.

Huseyin Hasan Erdogan · Prevention of Future Deaths report View report

17 Feb 2015 North London J. Taylor

Huseyin Hasan Erdogan hanged himself on 4 June 2014 and died on 13 June 2014 from cerebral hypoxia resulting directly from the hanging. The inquest identified a failure by mental health practitioners to conduct and act upon a fully informed assessment of his mental state, contributing to no steps being taken to prevent the hanging. Concerns were also raised that action-plan steps intended to address recommendations had not been completed by the inquest and that further deaths might not be prevented without their completion.

infant Rahat Qayyum (otherwise known as Mohammed Rahat Yousaf) · Prevention of Future Deaths report View report

16 Feb 2015 Manchester North L. Hashmi

Infant Rahat Qayyum was delivered in very poor condition on 5 July 2013 after abnormalities on CTG traces were not fully recognised, and died on 19 July 2013 from hypoxic ischaemic encephalopathy due to or as a consequence of perinatal asphyxia. The concerns identified included the absence of national guidelines for interpreting antenatal CTG tracings and issues concerning the dissemination, application and applicability of the Trust’s Interpreting Policy, particularly in relation to informed consent.

RICHARD MARK WESTGATE · Prevention of Future Deaths report View report

16 Feb 2015 Dorset S. Payne

Richard Mark Westgate was found deceased in his room at the Bastion Hotel in Bussum, Netherlands, on 12 December 2012. The report raised concerns about exposure to organophosphate compounds in aircraft cabin air, possible consequential health damage, risks posed by impaired aircraft controllers, lack of real-time monitoring, and genetic variation in susceptibility.

Robert Paul Yarnell · Prevention of Future Deaths report View report

13 Feb 2015 Manchester West R. Griffin

Robert Paul Yarnell died after jumping from Barton Bridge on the M60 Motorway on 8 October 2014, causing multiple injuries. He had been receiving mental health care following a hospital admission, but moving out of the area led to a significant delay in continuing care. Concerns were raised that unclear procedures for transferring care between areas could leave service users without needed support and create risky situations.

Christopher David TAYLOR · Prevention of Future Deaths report View report

13 Feb 2015 Avon M. Voisin

Christopher David TAYLOR fell into the River Avon in Bath after being out drinking with friends and was unable to get out. He went under the water despite efforts by emergency services to rescue him. Concerns included a delay in dispatching the emergency response, inadequate visibility of immediate incidents, and the absence of life buoy rings and suitable fencing along a high-risk stretch of riverbank.

X Rokeby · Prevention of Future Deaths report View report

12 Feb 2015 Northamptonshire A. Pember

X Rokeby, aged 46, died on 22 December 2013 after haemorrhage from a dialysis fistula while being transported to routine dialysis. The report records concern that, despite an action plan to provide transport services with advice about spontaneous haemorrhage, the volunteer driver who attempted to assist had received no such training.

Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report View report

12 Feb 2015 Northamptonshire B. Cheney

Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.

Andrew Elliot FROST · Prevention of Future Deaths report View report

12 Feb 2015 Inner North London M. Hassell

Andrew Elliot Frost, aged 34, took his own life after jumping in front of an underground train on 25 September 2014. The report identified concerns about a lack of shared understanding between the crisis team and general practitioner, incomplete recording of information, and an inadequate pager messaging service.

Anne Horner · Prevention of Future Deaths report View report

11 Feb 2015 Manchester North S. Nelson

Anne Horner was a resident at Oak Lodge Nursing Home when she sustained head injuries in two incidents involving a toilet cubicle door. Following the second incident on 25 March 2014, she was found unresponsive and died at Salford Royal Hospital from a traumatic head injury. The principal concern was that the toilet cubicle door and available clearance may not have adequately accommodated a resident who had fallen or was slumped forward.

Rufjan BIBI · Prevention of Future Deaths report View report

11 Feb 2015 Inner North London M. Hassell

Rufjan Bibi, who had Parkinson’s disease and a previous subdural haematoma, fell at Mile End Hospital on 1 July 2014 and hit her head. The report raised concerns about inadequate nursing assistance and personal care, a suggestion that the family privately engage a nurse, and a five-hour delay before consultant review after the fall.

Jane Helen Robinson · Prevention of Future Deaths report View report

10 Feb 2015 Leicester City and South Leicestershire C. Mason

Jane Helen Robinson, who had alcoholic liver disease with ascites, was admitted to hospital with shortness of breath and underwent a TIPS procedure. Her condition deteriorated and she died on 4 May 2014; the inquest recorded natural causes. Concerns included basic observations reportedly not being recorded, lack of senior review and written rationale for observation frequency, and no evidence of a reporting and support system for staff not meeting accepted standards.

Margaret Elsie Clarke · Prevention of Future Deaths report View report

9 Feb 2015 South Yorkshire (Eastern) N. Mundy

Margaret Elsie Clarke attended the Elements Spa in Rotherham on 14 March 2013 and later became ill, was admitted to Doncaster Royal Infirmary, and died on 27 March 2013. The inquest recorded myocardial infarction due to Legionella pneumonia, and the principal concern was the lack of guidance for effectively cleaning fixed shower heads used in leisure facilities.