Reports

Kirsty Lisa Pritchard · Prevention of Future Deaths report View report

17 Oct 2014 Black Country Z. Siddique

Kirsty Lisa Pritchard had complex medical needs and a history of self-harm and suicidal ideation. After being discharged from hospital, she contacted the community team several times reporting thoughts of self-harm and suicide; she was later found deceased at home, hanging with a belt around her neck, and was pronounced deceased at 14:15 on 20 January 2013. The report raised concerns about delayed communication of worsening symptoms and risk to the responsible consultant, and deficiencies in systems for contacting and locating her after an immediate risk was reported.

William Thomas Anderson · Prevention of Future Deaths report View report

17 Oct 2014 West Yorkshire Eastern M. Williamson

William Thomas Anderson died in his cell at HMP Wealstun on 19 September 2010 after taking prescription medication belonging to others and drinking hooch, having appeared intoxicated or under the influence of alcohol or drugs the previous afternoon. The concerns included insufficient vigilance around inmate gatherings involving drugs and alcohol, incomplete staff training and recording of observations, failure to use an emergency code, and delay in summoning paramedic assistance.

Yaser Saleh · Prevention of Future Deaths report View report

17 Oct 2014 Inner South London A. Harris

Yaser Saleh, aged 15, died on 13 September 2012 after collapsing with cardio-respiratory arrest from acute asthma. The report raised concerns that electronic systems did not identify asthma patients needing review when they were no longer receiving regular prescriptions, creating a risk of preventable deaths in people with chronic diseases.

Stephen Atherton · Prevention of Future Deaths report View report

17 Oct 2014 Inner North London R. Brittain

Stephen Atherton, aged 27, died on 16 May 2013 from severe head injuries after falling from height after leaving a neurosurgical ward. The report identified concerns about delays and communication in referrals and investigations, and about the absence of safeguards to prevent him leaving the ward despite risks to himself.

Roger William Maurice De Klerk · Prevention of Future Deaths report View report

16 Oct 2014 South London S. Lynch

On 12 November 2013, Roger William Maurice De Klerk was cycling along Addiscombe Road when his bicycle wheels contacted tramlines, causing him to fall into the path of a bus. The bus collided with him and his bicycle. Concerns included the danger posed by tramlines to cyclists, confusing cycle-lane design and signage, and the intended route across tactile paving and pedestrian areas.

David Alan Thomson · Prevention of Future Deaths report View report

16 Oct 2014 Liverpool A. Rebello

David Alan Thomson, who had chronic obstructive pulmonary disease and was using home oxygen, died at home after an e-cigarette battery reportedly exploded and ignited an oxygen pipe. The report raises concern that incompatible or incorrect micro-USB chargers may cause e-cigarette batteries to explode, particularly in proximity to oxygen equipment.

Severyn Witold Glowinski · Prevention of Future Deaths report View report

15 Oct 2014 Worcestershire G. Williams

Severyn Witold Glowinski, a serving prisoner diagnosed with paranoid schizophrenia, was transferred to segregation and remained there for a little under a fortnight. He was found hanging in his cell on the evening of 3 July 2013 while subject to an open ACCT for self-harm. Concerns included poor communication about his care plan, inaccurate paperwork copied from another prisoner’s file, and a lack of awareness of requirements concerning the segregation of prisoners on an open ACCT.

Lucasz Lewandowski · Prevention of Future Deaths report View report

15 Oct 2014 Manchester (North) L. Hashmi

Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.

Alan Charles Peck · Prevention of Future Deaths report View report

14 Oct 2014 Manchester South J. Pollard

Alan Charles Peck had been an inpatient at Tameside Hospital for approximately six weeks, underwent a hemi-colectomy, and was then discharged to Willow Wood Hospice. Concerns were raised that his syringe driver was not connected while he was on the surgical ward and that he was deprived of medication during transfer to the hospice.

George Robert Vickery · Prevention of Future Deaths report View report

13 Oct 2014 Portsmouth and South East Hampshire D. Horsley

George Vickery fell after getting out of an ambulance outside Oak Park Community Clinic while attending for leg treatment, sustaining a broken hip and dying the next day in hospital. The concern was that the decision to treat him at the clinic rather than at home did not take account of his GP’s request that he be treated at home.

Arsema Dawit · Prevention of Future Deaths report View report

13 Oct 2014 Inner South London A. Harris

Arsema Dawit, aged 15, died on 2 June 2008 after being stabbed by a former friend who had been stalking her; the inquest jury concluded that the death was unlawful killing. Concerns included the recording and classification of the initial police report, inadequate and untimely investigation, insufficient supervision and communication with the family, gaps in investigative procedures, and reluctance to use interpreting services.

Mary Fenton · Prevention of Future Deaths report View report

13 Oct 2014 Manchester South J. Pollard

Mary Fenton was admitted to Tameside Hospital on 26 April 2014 needing an urgent heart pacemaker and died on 30 April 2014 after delays and missed opportunities. Concerns included limited cardiology cover and facilities, shortages of Isoprenaline, failures relating to capacity and consent, delays in inserting pacing wires, inadequate facilities to manage complications, and poor communication.

Mark Hancock · Prevention of Future Deaths report View report

11 Oct 2014 Manchester South J. Kearsley

Mark Hancock had a history of severe clinical depression and was receiving treatment at the Priory Hospital. On 12 February 2014, he was found at his parents’ house with serious self-inflicted wounds after concerns about his deteriorating presentation had been escalated but hospital admission did not occur because no bed was available. The report identified concerns about poor or absent records, the lack of a documented risk assessment, insufficient reassessment after concerns were escalated, and the absence of a procedure for admission when no bed was available.

Tracy Michelle ROOKE · Prevention of Future Deaths report View report

9 Oct 2014 Wiltshire and Swindon D. Ridley

Tracy Michelle Rooke died after losing control of her vehicle on the A3102 at Mile Elm, crossing the centre of the road and colliding with an oncoming van. The report identified thick fog and her unfamiliarity with the road as factors that more likely than not contributed to the incident and her death. A concern was raised about mud on the highway and the quality of nearby signage as potential hazards, although the report states that the mud played no part in Ms Rooke’s death.

Sapper Dylan Reece Gibson · Prevention of Future Deaths report View report

9 Oct 2014 Wiltshire and Swindon D. Ridley

Sapper Dylan Reece Gibson was found dead in his room on 25 February 2014, and the inquest concluded that he had taken his own life by hanging. A substantive concern was whether master keys should be held at guard rooms to allow prompt access to buildings during emergencies, although the coroner was not satisfied that their availability would have made a difference in this case.

Wade Dayabhai Patel · Prevention of Future Deaths report View report

9 Oct 2014 Leicester City and South Leicestershire D. Coutts-Wood

Wade Dayabhai Patel was found in the hallway of his home after falling through an inner glass door, sustaining leg injuries that led to his death. The report raised concerns that the property’s original glass did not comply with current safety requirements and that there was no legal requirement for landlords or letting agents to specifically assess glass safety.

Stephen Peter Simpson · Prevention of Future Deaths report View report

9 Oct 2014 North Northumberland T. Brown

Stephen Peter Simpson appears to have fallen down communal concrete stairs on 13 March 2014 and struck his head on an external door, later dying in hospital from a skull fracture and brain haemorrhage. The concerns were that the building had no lobby or passageway to arrest a fall and that the smooth concrete stairs lacked a non-slip surface, leaving a risk of serious injury or death from impact with the door.

Vincent Oliver · Prevention of Future Deaths report View report

9 Oct 2014 North Northumberland T. Brown

Vincent Oliver was serving a prison sentence at HMP Northumberland when his lifeless body was discovered in his cell on 4 July 2013, shortly after the cells were unlocked. The principal concern was that the prison officer unlocking his cell did not obtain a response or check his physical well-being before moving on, and that cell-unlocking procedures had not been followed on other occasions. The inquest concluded that he died from natural causes, namely ischaemic heart disease and coronary artery atheroma.

Chloe Siokos · Prevention of Future Deaths report View report

8 Oct 2014 North London A. Walker

Chloe Siokos was found dead at her home on 22 January 2013 after her husband set a fire in the house and then hanged himself; the inquest concluded unlawful killing. The report identifies concerns about the absence of a framework for deciding when primary care interpreters are required, limited interpreter availability, and the lack of a system flagging when one patient's circumstances may affect care provided to another patient.

Timothy Peter Cowen · Prevention of Future Deaths report View report

7 Oct 2014 North Wales (East and Central) J. Gittins

Timothy Peter Cowen underwent surgery on 23 April 2013 and subsequently developed bilateral extensive pneumonia with features of aspiration. He died on 2 May 2013 after deterioration and readmission to hospital. Concerns included non-mandatory training on new procedures and insufficient cover for Acute Liaison Nurses during absence.