Reports

Graham Darby · Prevention of Future Deaths report View report

24 Jul 2014 Inner North London G. Elliman

Graham Darby, who had alcohol dependence, was found dead at his home the day after being evicted and forcibly re-entering the property; the inquest concluded that the cause of death was suspension by ligature and that his death was a suicide. A significant concern was that a reported threat to take his own life using a knife and rope if evicted was not passed on to the housing agency, and was therefore not sufficiently flagged between agencies.

Kenneth John PAUL · Prevention of Future Deaths report View report

23 Jul 2014 South Lincolnshire A. Forrest

Kenneth John Paul sustained fatal injuries after being run over by a reversing delivery vehicle on 29 November 2013. The vehicle had no automatically operating audible warning device when reverse gear was engaged, and there was no legislative requirement for such a device on light commercial vehicles of that type.

John William THORPE · Prevention of Future Deaths report View report

23 Jul 2014 South Lincolnshire P. Cooper

John William THORPE, aged 78, died by drowning after he was found in the Forty Foot Drain on 24 March 2014. Before his death, he had reported low mood, hopelessness and self-harm, was prescribed fluoxetine, and was asked to self-refer to psychological therapy. The concerns included the lack of a direct mental-health referral, the absence of a definite follow-up arrangement, and whether the risks associated with starting antidepressants and his history of suicidal behaviour were adequately considered.

Graeme Alexander Kidd · Prevention of Future Deaths report View report

23 Jul 2014 Norfolk J. Lake

Graeme Alexander Kidd was found hanging at home on 6 March 2014 and died in hospital on 7 March 2014. The report identified concerns about locum doctors’ access to records and knowledge of local mental health services, delays in GP referrals, the lack of medication advice when the prescribing doctor was unavailable, and the delayed implementation of an action plan addressing these matters.

Molly Rae Keen · Prevention of Future Deaths report View report

22 Jul 2014 Buckinghamshire R. Hulett

Molly Rae Keen was delivered by caesarean section on 10 June 2013 in a very poor condition, and resuscitation was stopped at 11.54 hours. The report raised concerns about inconsistent use and recording of fetal growth charts, the failure to refer for further opinion or a possible scan despite indications of below-normal growth, and a continuing lack of clarity in joint care arrangements.

Yahya Ahmad Khan · Prevention of Future Deaths report View report

22 Jul 2014 Hertfordshire E. Thomas

The report identifies Yahya Ahmad Khan as the deceased person. No circumstances of death or substantive concerns are provided in the supplied text.

Edward John Devlin · Prevention of Future Deaths report View report

22 Jul 2014 County Durham and Darlington C. Oliver

Edward John Devlin was found dead in his cell at HMP Durham on 17 July 2011, having died from the effects of dihydrocodeine. The report raised concerns that medication, including potentially dangerous drugs, may have been slid under locked cell doors without confirming receipt or administration, creating risks of diversion, inaccurate medication records, stockpiling and potentially lethal overdose. It also found that his physical condition on the night before his death warranted medical assessment, but no such assessment was carried out.

Marcin Jack STOGA · Prevention of Future Deaths report View report

21 Jul 2014 Oxfordshire D. Salter

Marcin Stoga had been held on remand at HMP Bullingdon since November 2012 and was found hanging in his cell on 24 April 2013, the day after attending court. Concerns included information about a previous overdose not being available during his initial assessment, and prisoners with mental health difficulties or a medium/high risk of self-harm not being routinely assessed after returning from court. The inquest jury confirmed suicide and identified missed opportunities to support him that were systemic in nature.

Kathleen Cornthwaite · Prevention of Future Deaths report View report

18 Jul 2014 Blackburn, Hyndburn and Ribble Valley M. Singleton

Kathleen Cornthwaite, aged 76, was an inpatient at Pendle Community Hospital when her tramadol prescription was increased after a fall causing a rib injury. The inquest concluded that she died of cardiorespiratory failure due to combined tramadol and fluoxetine toxicity. Concerns included the imprecise tramadol dose recorded, failure to account for her age, size and frailty, and failure to consider interactions with other prescribed medicines.

Michael Arthur Warren · Prevention of Future Deaths report View report

17 Jul 2014 Berkshire P. Bedford

Michael Arthur Warren died from serious head injuries after a large branch from an oak tree fell onto the roof of the car he was driving on 5 October 2012. The concerns included limited training and guidance for highway inspectors assessing tree hazards, insufficiently targeted tree inspections, a lack of clear national guidance for local authorities, and the absence of professional management of the landowner’s trees near the highway.

Joshua Lewis BROWN · Prevention of Future Deaths report View report

17 Jul 2014 North East Kent R. Cobb

Joshua Lewis BROWN died on 13 June 2011 after climbing over railings at the edge of cliffs at Louisa Bay and dropping forward from the cliff. The report identified concerns about limited information-sharing and engagement between the Community Health Team and Mr Brown’s family, including the absence of a process for family members to check the accuracy of information recorded about them. It also noted that the family was not made aware of available support and information about how best to support Mr Brown and themselves.

Silvia Eileen Taylor · Prevention of Future Deaths report View report

16 Jul 2014 Surrey M. Fleming

Silvia Eileen Taylor activated her emergency pendant at home after experiencing stomach pains and requested a doctor. Several attempts to contact her by telephone were unsuccessful, and she was found dead at home after entry was forced. The concerns were that the unsuccessful contact attempts were not acted on for several hours and that the difficulties establishing telephone contact were not conveyed to her family.

Julie Ann Robertson · Prevention of Future Deaths report View report

16 Jul 2014 Essex E. McGann

Julie Ann Robertson died on 11 May 2013 from complications following an operation for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. The inquest narrative described delays in escalation, obtaining blood and starting surgery, as well as poor record keeping and unclear timings. The report raised concerns that matched blood was not immediately available on the ward and that there was insufficient formal training in record keeping.

Stephen Peter Church · Prevention of Future Deaths report View report

15 Jul 2014 Berkshire R. Sidhu

Stephen Church was found dead at the entrance to the multi-storey car park at Royal Berkshire Hospital on 13 May 2011 after absconding while detained under section 136 of the Mental Health Act 1983. The concerns included a broken chain of command resulting in only one police officer being responsible for his detention, insufficient understanding of an interagency working protocol, inadequate joint working to keep him safe, and delay in contacting an approved mental health professional to arrange a Mental Health Act assessment.

Ming Tsung CHEUNG · Prevention of Future Deaths report View report

15 Jul 2014 Coventry S. McGovern

Ming Tsung CHEUNG, a student at Warwick University, was struck and killed by a lorry while crossing Lynchgate Road, Coventry. The crossing point was reportedly used by many pedestrians, with evidence of near-misses, and a large Tesco sign obscured the views of the pedestrian and lorry driver.

Adam Amos Williams · Prevention of Future Deaths report View report

14 Jul 2014 Staffordshire South A. Haigh

Adam Amos Williams, a serving prisoner aged 29, collapsed at HMP Featherstone on 5 March 2013 and died at New Cross Hospital on 6 March 2013 from a sub-arachnoid haemorrhage. The concerns raised related to communication between prison healthcare staff during emergencies, whether dynamic assessments considered the need for restraint, and the possible benefit of additional CCTV in prison common areas.

Shayla Anne Walmsley · Prevention of Future Deaths report View report

14 Jul 2014 Inner North London R. Brittain

Shayla Anne Walmsley was found deceased at her home on 9 May 2013; she had diabetes and used a Medtronic insulin pump. The cause of death remained unascertained, and the report raised concerns about delays in providing safety data, inconsistent distribution of Field Safety Notices, and failure to analyse the medical device during the post-mortem investigation.

Elaine JOBE · Prevention of Future Deaths report View report

14 Jul 2014 Exeter & Great Devon E. Earland

Elaine JOBE, an informal voluntary psychiatric patient aged 53, was found hanging in a bathroom at Ocean View on 2 February 2011 after being placed on general hourly observation. Resuscitation and transfer to hospital did not avert her death. Concerns included inadequate records of risk assessments and observations, staff training, and communication of patient status and monitoring responsibilities between shifts.

STUART MILES LONG, otherwise known as, CAMERON TURNER · Prevention of Future Deaths report View report

11 Jul 2014 Cornwall E. Carlyon

Stuart Long was struck by a van and subsequently hit or run over by at least three other vehicles after stepping or running into the A30 carriageway on 22 December 2013. He had mental health issues and alcohol misuse, and the principal concern was confusion about how to respond when anti-social behaviour involved a person who was intoxicated or mentally unwell; the report stated that taking him to a place of safety would have prevented him from jumping in front of cars.

Maria De Oliveria Alva LOPES · Prevention of Future Deaths report View report

11 Jul 2014 Surrey K. Henderson

Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.