Reports

Henry Marsh · Prevention of Future Deaths report View report

2 Jul 2014 North London A. Walker

Henry Marsh had multiple diagnoses and was under the care of the Home Treatment Team when he failed to attend a psychology appointment and was found unresponsive at home. The principal concern was that the Home Treatment Team had too many patients to manage effectively, making multidisciplinary meetings difficult; the inquest recorded suicide and polydrug intoxication as the medical cause of death.

John Henry ADAMS · Prevention of Future Deaths report View report

1 Jul 2014 Brighton and Hove V. Hamilton-Deeley

John Henry Adams died following multiple complications of an appropriate cardiac intervention after being recruited to a cardiac trial just before the procedure. Concerns included whether there was sufficient time for informed consent, the suitability and preparedness of the trial operator, and the recording and communication of the trial’s possible relevance to the cardiac tamponade and subsequent death.

Sindy Louise Woodhall · Prevention of Future Deaths report View report

1 Jul 2014 Manchester North L. Hashmi

Sindy Louise Woodhall had longstanding addictions to alcohol and butane and propane, which she misused regularly. She was found collapsed in the street on 24 October 2013, was taken to hospital, and subsequently died; the concerns included the sale of large amounts of potentially fatal gases to her by retailers aware of her addiction, along with lack of regulation and limited Trading Standards powers.

Jake Reginald Hardy · Prevention of Future Deaths report View report

30 Jun 2014 Manchester West A. Hewitt

Jake Reginald Hardy, a 17-year-old detained at HM YOI Hindley, died on 20 January 2012 after being found partially suspended by a ligature in his cell. The report describes failures to identify, record and respond to his vulnerabilities, self-harm risk and reports of verbal bullying, including failures in safeguarding, ACCT care planning, supervision and overnight risk assessment. Concerns also included ligature points in cells, inadequate personal officer support, staff training and communication systems, and limited access to family telephone support.

Dayani Chauhan-Ahmed · Prevention of Future Deaths report View report

30 Jun 2014 Leicester City and South Leicestershire L. Brown

Dayani Chauhan-Ahmed was born in poor condition after a prolonged second stage of labour exceeding 5.5 hours and died after intensive care was withdrawn with parental consent. The substantive concerns included ineffective communication about the length of labour, uncertainty about staff knowledge and adherence to escalation procedures, and insufficient midwifery and medical availability during periods of extreme demand.

Jessica Hope Bond · Prevention of Future Deaths report View report

30 Jun 2014 Essex C. Beasley-Murray

Jessica Hope Bond suffered significant brain injury following a uterine rupture during her mother's labour, which necessitated an emergency caesarean section, and she died seven months later. The report raises concern that Propess should not be administered to patients with a history of previous caesarean section or uterine surgery because of the potential risk of uterine rupture and associated obstetrical complications.

William Reid · Prevention of Future Deaths report View report

30 Jun 2014 Cumbria (North & West) D. Llewelyn

William Reid was found deceased at his home on 24 July 2013, having lived alone and with a delay in the discovery of his death. Concerns included delayed recognition of his deteriorating condition, delayed hospital admission, and failure to inform his GP about his hospital admission and discharge.

Ahmad Doumani Khan · Prevention of Future Deaths report View report

28 Jun 2014 South Yorkshire (Western) D. Coutts-Wood

Ahmad Doumani Khan, aged 20, died from multiple injuries after falling from the top level of the Q Park car park in Sheffield on 3 May 2012. The report identified a concern that access to the car park perimeter wall was very easy and dangerous, allowing people to climb onto it quickly and easily.

ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report View report

27 Jun 2014 Manchester City N. Meadows

Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.

Sadik Miah · Prevention of Future Deaths report View report

26 Jun 2014 Inner South London A. Harris

Sadik Miah, who had schizophrenia and was detained in hospital, collapsed suddenly and died in Lambeth Hospital on 15 October 2011 despite resuscitation. Concerns included the monitoring of ECG abnormalities and antipsychotic-related arrhythmia risk, delays in obtaining specialist advice about hyponatraemia, and the lack of regular physician support for psychiatric in-patients with physical health problems.

Lloyd Edward Butler · Prevention of Future Deaths report View report

25 Jun 2014 Birmingham and Solihull L. Hunt

Lloyd Edward Butler was arrested for being drunk and incapable and detained at Stechford Police Station, where he was found struggling to breathe and subsequently died after suffering cardiac arrest. The report describes untimely observations and rousing, staff distraction and unprofessional behaviour, and concerns about inadequate leadership, training, and the wider culture in custody suites.

Marion Joanne Turner · Prevention of Future Deaths report View report

25 Jun 2014 Essex C. Beasley-Murray

Marion Joanne Turner, aged 40, was found hanging at her home on 18 January 2013. A concern was raised that a solicitor’s message about concerns for her mental health was left unread in a pigeon hole until the following day.

Ralph Stephen Goslin · Prevention of Future Deaths report View report

25 Jun 2014 Inner North London M. Hassell

Ralph Stephen Goslin, an inpatient detained under Section 3 of the Mental Health Act, was found unresponsive in a bath on 21 June 2014 and died later that day in hospital. A concern was raised that a junior doctor did not recognise his sodium valproate level as subtherapeutic because of the reference range shown, delaying recognition of his failure to take anti-epilepsy medication.

Wilfred Roy Aspinwall · Prevention of Future Deaths report View report

25 Jun 2014 Liverpool A. Rebello

Wilfred Roy Aspinwall was a frail prisoner with several co-morbidities who sustained falls, including a hip fracture, and later died after a gradual deterioration in health on 21 April 2013. The inquest concluded that he died from natural causes. A substantive concern was that the PPO report and Clinical Review had not been shared with the healthcare provider at HMP Liverpool.

Peter John Hinchliffe · Prevention of Future Deaths report View report

25 Jun 2014 South Yorkshire (Eastern) R. Curtis

Peter John Hinchliffe, a fit 33-year-old man, died after collapsing while cycling on 11 September 2010; the inquest concluded that the cause of death was arrhythmogenic right ventricular cardiomyopathy, which was undiagnosed and untreated. The principal concerns were delays and differing approaches in investigating syncope, including delays in transferring investigations to the NHS, and inconsistent advice about exercise for young athletes in a recognised red-flag situation.

JOAN DOROTHY RICHARDSON · Prevention of Future Deaths report View report

23 Jun 2014 West Yorkshire Eastern D. Hinchliff

Joan Dorothy Richardson became seriously unwell with rapid swelling, bruising and discolouration of her arm. After her GP surgery was closed for staff training on 21 November 2013, she was seen the following day, suffered a cardiac arrest in hospital, and died; the cause of death was streptococcal toxic shock syndrome. The concerns were that emergency medical cover and clear arrangements for patients should be available when GP surgeries close for training, and that the delay of almost 24 hours contributed to the outcome.

Else Merete-Harvey Samuel · Prevention of Future Deaths report View report

20 Jun 2014 Suffolk P. Dean

Else Merete-Harvey Samuel was admitted to hospital after a fall, with continuing groin pain and a possible hip or pelvic fracture. Although initial radiographs did not show a fracture, some repeat views, including the pelvis, were not taken; a pelvic fracture was found at post mortem, alongside significant natural disease. The principal concerns were incomplete clinical information on imaging requests, insufficient senior discussion when investigations were challenged, and weaknesses in the subsequent incident investigation.

Samuel James Openshaw · Prevention of Future Deaths report View report

20 Jun 2014 Suffolk P. Dean

Samuel James Openshaw, who had serious and complex congenital heart problems, deteriorated at West Suffolk Hospital and died hours after being admitted to the Evelina Hospital’s paediatric intensive care unit following a delay in specialist retrieval. The report raised concerns about delays in specialist paediatric retrieval and slow, insecurely difficult electronic transfer of echocardiograph images, which could affect other sick children.

Peter James FAREBROTHER · Prevention of Future Deaths report View report

20 Jun 2014 Shropshire, Telford and Wrekin J. Ellery

Peter James Farebrother was found deceased on 24 August 2013, hanging from a belt ligature attached to the en-suite shower door in his room at Pine Ward. Concerns included the delayed transfer to Pine Ward, failures in handover and observation assessment, the return of his belt, and the suitability of the shower door as a ligature attachment point. The inquest jury concluded that the risk of returning his belt and placing him on general observation was not fully recognised and that these factors combined contributed to his death.

Redmond Johnson · Prevention of Future Deaths report View report

20 Jun 2014 Suffolk P. Dean

Redmond Johnson, aged 67, suffered a cardio-respiratory arrest while being transferred to Ipswich Crown Court on 25 November 2011 and died after transfer to Ipswich Hospital. The report identified concerns about the assessment of his fitness for transfer, including a record stating that he had no known medical risks despite the healthcare professional not having seen him. It also identified concerns about the management and documentation of his complex healthcare needs in custody, including liaison with community providers, specialist appointments, investigations, medication and care monitoring.