Reports

Mr. Marcus Szigetvari · Prevention of Future Deaths report View report

14 Nov 2014 Powys, Bridgend and Glamorgan Valleys S. Richards

Mr. Marcus Szigetvari was fatally injured when his motorcycle collided with a Vauxhall Vectra at a junction on the A4233 Ynysrhy bypass in darkness and poor, rainy weather. Concerns included the difficulty for drivers exiting Llanwanno Road to cross oncoming traffic, possible misjudgement of the motorcycle’s single headlight, and nineteen other reported collisions on the road since 2001, including two fatalities.

Kirk William Williams · Prevention of Future Deaths report View report

14 Nov 2014 Teesside S. Faulks

Kirk William Williams ingested several drugs and displayed highly agitated and aberrant behaviour before being restrained by police. Although one officer considered that he should be taken to hospital, he was taken to a police station and later suffered cardiac arrest and died in hospital. The concerns included differing understandings between police and A&E staff about treating aggressive detainees, and the absence of clear dialogue or guidance for managing such medical emergencies.

Dolores Mary Hubbert · Prevention of Future Deaths report View report

14 Nov 2014 Sunderland D. Winter

Dolores Mary Hubbert suffered fatal injuries in a vehicle collision at a crossroads on the A690 at East Rainton and was pronounced dead at hospital on 29 August 2014. Her family raised concerns about the safety of the junction, including speed restrictions and the frequency of grass cutting, which might obscure drivers’ views.

John Robert Wright · Prevention of Future Deaths report View report

13 Nov 2014 Nottinghamshire A. McNamara

John Robert Wright, a Network Rail track maintenance worker, was struck by an oncoming train while working at Newark Northgate station on 22 January 2014 and died from his injuries on 31 January 2014. The concerns identified were the need for frequent reminders and training about vigilance, clearer briefings on train routes and safe working methods, and a balance between hearing protection and the ability to hear approaching trains.

Lorraine Sheridan · Prevention of Future Deaths report View report

12 Nov 2014 Black Country Z. Siddique

Lorraine Sheridan died following injuries sustained when she was struck by an articulated lorry while attempting to cross a pedestrian crossing on High Bullen Road, Wednesbury, on 30 May 2013. The report identified two documented collisions at the location and raised concern that the crossing lacked an audible indication to reinforce the pedestrian signal phase.

David Anthony Ince · Prevention of Future Deaths report View report

12 Nov 2014 Preston and West Lancashire S. Jones

David Anthony Ince was admitted to Royal Preston Hospital after collapsing at home and was discharged in the early hours. Shortly after returning home, he suffered a cardiac arrest and died despite readmission to hospital. Concerns were raised that an ECG recorded by ambulance staff was not documented in the A&E handover and that ECG traces were not routinely handed over to A&E staff.

Patricia Ann Mellor · Prevention of Future Deaths report View report

12 Nov 2014 Nottinghamshire J. Gillespie

Patricia Ann Mellor suffered a cardiac arrest during general anaesthesia in 2004, resulting in a hypoxic brain injury and severe disability. She died from aspiration pneumonia on 24 January 2014. The investigation identified acquired Long QT Syndrome associated with a combination of citalopram, nortriptyline and ranitidine, and concerns were raised about the need to identify and manage this risk before anaesthesia.

Neophytos Constantinou · Prevention of Future Deaths report View report

12 Nov 2014 Inner North London R. Brittain

Neophytos Constantinou died aged 73 at the Royal Free Hospital on 22 March 2013 from the consequences of biliary stone disease. He missed a scheduled ERCP after planned transport did not arrive, and the principal concern was a lack of clarity about responsibility and procedures for arranging transport, potentially leading to missed necessary procedures.

Mary Hallworth · Prevention of Future Deaths report View report

11 Nov 2014 Manchester South J. Kearsley

Mary Hallworth was a frail, elderly woman living at home who fell from her bed on 18 March 2014 and was found in pain. The principal concern was that no medical attention was sought or considered for 24 hours after the fall and pain; the recorded medical cause of death included a fractured left hip and bronchopneumonia.

Amar MAJID · Prevention of Future Deaths report View report

11 Nov 2014 Coventry S. McGovern

Amar Majid was found dead in a disabled toilet at the Public Library, Coventry, with a syringe in his hand and material believed to be heroin. The principal concern was that no one checked on his well-being for over five hours despite evidence that the toilets were cleaned hourly; the report also noted possible confusion about procedures for checking a toilet occupied for a considerable period.

Rowena Kathryn Golton · Prevention of Future Deaths report View report

11 Nov 2014 Manchester South J. Kearsley

Rowena Kathryn Golton had a history of recurring depression, suicidal thinking and deteriorating mental illness. On 6 April 2014, after being assessed as low risk of suicide and discharged from A&E with a plan for later crisis-team review, she jumped from a fire escape and died from multiple traumatic injuries. Concerns included limited access to psychologists within crisis teams and significant waiting times for psychological therapy.

Beryl WALTERS · Prevention of Future Deaths report View report

11 Nov 2014 Black Country A. Thompson

Beryl Walters presented to A&E with atypical chest pain and a posterior myocardial infarction. After receiving Cyclizine for nausea, she became hypotensive and tachycardic and suffered a cardiac arrest from which she could not be resuscitated; the substantive concern was the use of Cyclizine in acute coronary events despite an available alternative antiemetic and evidence advising against its use in these circumstances.

Myra Goldman · Prevention of Future Deaths report View report

10 Nov 2014 Manchester North S. Nelson

Myra Goldman died after a palisade gate fell on her. The Jury concluded that the gate fell because of fatigue of the lower right-hand hinged eye bolt and the configuration of the lugs and hinge pins; concerns were raised that this configuration placed most of the gate’s load on one hinge and that the relevant standard should be reviewed.

Roseanne Cooke · Prevention of Future Deaths report View report

10 Nov 2014 Manchester South J. Kearsley

Roseanne Cooke experienced a marked deterioration in her mental health, including suicidal thoughts, and was found having taken her own life at her mother’s home on 1 May 2014. The report identified concerns about unavailable inpatient psychological input, confusion and delays regarding psychological-service referrals, the absence of the Recovery Team from a discharge-planning meeting, and inadequate communication of the family’s concerns about her safety.

Geraldine Liege Kilborn · Prevention of Future Deaths report View report

10 Nov 2014 County Durham and Darlington A. Tweddle

Geraldine Liege Kilborn died in HMP Low Newton after repeatedly self-harming over the 22 days following her reception into the prison; the Jury could not determine her intention when she hung herself. The principal concerns were inadequate sharing and weighting of mental-health information during ACCT reviews, limited review of ACCT records by some panel members, and questions about review-panel membership and her location at the time of death.

Colin John Ireland · Prevention of Future Deaths report View report

7 Nov 2014 West Yorkshire Eastern D. Hinchliff

Colin John Ireland, a diabetic prisoner at HMP Wakefield, fell and fractured his left hip during exercise in icy weather on 11 February 2012. After surgery and discharge to the prison healthcare centre, he collapsed and died on 21 February 2012; the inquest recorded pulmonary thromboembolism and deep venous thrombosis. Concerns included delay in transferring him to hospital, difficulties with the high-security prison approval system, and the absence of an agreed protocol and training for Governors responding to medical emergencies.

Barry Horrocks · Prevention of Future Deaths report View report

7 Nov 2014 West Yorkshire Eastern D. Hinchliff

Barry Horrocks, who had vascular dementia and other physical and mental health problems, was serving a prison sentence at HMP Wakefield when he suffered a cerebral event and died in hospital on 5 April 2013. The principal concern was the lack of coordinated care and suitable support for his deteriorating ability to manage daily living and intimate personal care, including personal hygiene, toileting and medication.

Santosh Benjamin Muthiah · Prevention of Future Deaths report View report

5 Nov 2014 North London A. Walker

Santosh Benjamin Muthiah died after a fire spread through his home while he and his family were sleeping, with the medical cause recorded as cerebral anoxia due to inhalation of fire fumes. The report raised concerns about the identification and communication of appliance-fire information, risks from recalled and second-hand refrigeration appliances, product safety risk assessments, guidance and notification practices, and the construction and components of refrigeration appliances, including capacitors.

William DAVIES · Prevention of Future Deaths report View report

5 Nov 2014 Inner North London M. Hassell

William Davies was found unresponsive in his cell at HMP Pentonville and died from natural causes, identified as coronary artery atherosclerosis. Concerns were raised about unclear procedures and delays in requesting an ambulance after a life-threatening call, as well as uncertainty among prison healthcare staff about responsibilities and verification of death.

Rebecca Jodie CURTIS-SMALL · Prevention of Future Deaths report View report

4 Nov 2014 Exeter & Greater Devon J. Tomalin

Rebecca Jodie CURTIS-SMALL was caught by a rip tide while swimming with her family at Croyde Bay on 31 December 2013. She was found after a search, taken to hospital, and died from drowning and hypothermia; concerns related to the visibility and specificity of beach signage warning about rip-tide hazards.