Reports

Shaun MASLIN · Prevention of Future Deaths report View report

19 Jun 2014 Surrey R. Travers

Shaun Maslin died after a pressurised gas-pipeline test failed at a worksite on 21 October 2011, when bracing broke and an end cap struck him. The report raised concerns about specific qualifications for gas-pipeline pressure testing and the absence of a national requirement for regular retraining and re-testing of gas-industry operatives.

Names not published · Prevention of Future Deaths report View report

19 Jun 2014 West Somerset M. Rose

Seven people died when 34 vehicles collided in thick fog on the M5 motorway near Taunton on 4 November 2011; 51 others were injured. The concerns related to preventing vehicles entering areas of severely reduced visibility, detecting and warning of fog, and managing risks from firework displays that may increase fog or smoke near highways.

SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report View report

17 Jun 2014 Norfolk D. Osborne

Sol Hadhasseh had a complex mental health history and was found unresponsive at her flat on 28 November 2013 after concerns were raised for her welfare. The inquest concluded that she had killed herself, with the medical cause of death recorded as tramadol toxicity; concern was raised that her transfer between mental health trusts had not been arranged through a direct Trust-to-Trust referral.

AUDREY VERA GARLAND · Prevention of Future Deaths report View report

17 Jun 2014 Manchester South J. Pollard

Audrey Vera Garland developed worsening necrotic and gangrenous ulcers on her legs and feet, and her condition deteriorated until her death. The report identified concerns about failures to recognise and appropriately treat the ulceration, missed hospital appointments because transport was not organised, and inadequate assessment during a GP home visit.

David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report View report

16 Jun 2014 Inner North London M. Hassell

David Andrew Llewellyn O’Garro suffered a sudden death in epilepsy while occupying a single cell at HMP Pentonville, with nobody present to raise the alarm during what was likely his final seizure. Concerns included the failure to complete or locate a cell sharing risk assessment and a lack of clarity and shared understanding among prison staff about ensuring prisoners with epilepsy had a cellmate.

Mrs Care · Prevention of Future Deaths report View report

16 Jun 2014 Cornwall A. Cox

Mrs Care, an 86-year-old woman with poor mobility, was transferred to Helston Hospital for rehabilitation after treatment at Treliske and died there on 12 October 2013 after rapidly deteriorating. Extensive bruising and a soft tissue haematoma were found, with the haematoma recorded as contributory to her death; the inquest found it was more likely than not that trauma caused the bruising during her stay at the Royal Cornwall Hospital, but its precise cause was not established. The report also raises concerns that an Allow Natural Death Order was not communicated to the family and that their calls about the bruising were not returned.

Alun Sheppard · Prevention of Future Deaths report View report

13 Jun 2014 North Wales (East and Central) J. Gittins

On 21 December 2013, Alun Sheppard inflicted a number of stab wounds upon himself with a kitchen knife at The Fields, Holt, Wrexham. He initially survived and was treated, but his condition deteriorated and he died at Maelor Hospital Wrexham on 10 January 2014. The principal concern was whether the Health Board could balance the patient’s right to confidentiality with facilitating familial support to optimise the prospect of recovery.

June Lilian Rose · Prevention of Future Deaths report View report

11 Jun 2014 London (West) L. Tagliavini

June Lilian Rose was bed bound and in deteriorating health when she was prescribed fentanyl patches at an excessive dose, which were applied and replaced before the error was discovered. She later died at home on 14 August 2012; the recorded cause of death included bilateral pneumonia, Alzheimer’s disease and fentanyl toxicity. The principal concern was the lack of mandatory national training or refresher training for GPs on prescribing fentanyl and similar morphine-based pain relief medications.

Bridget May CAHILL · Prevention of Future Deaths report View report

11 Jun 2014 Black Country R. Balmain

Bridget May CAHILL died in hospital from a morphine overdose after being admitted with unresponsiveness and receiving treatment including naloxone. The principal concern was how a patient prescribed and receiving less than the maximum permitted morphine dose could nevertheless suffer an overdose, including whether dosing should account for factors such as body weight, comorbidities, and possible accumulation during long-term therapy.

Miss Lucy Moffatt · Prevention of Future Deaths report View report

10 Jun 2014 South Yorkshire (Western) C. Dorries

Miss Lucy Moffatt, who was experiencing an acute phase of paranoid schizophrenia, fell or jumped from the second-floor window of her room at a Crisis House in Sheffield after being admitted on 9 July 2013. The report raised concerns that the window restraint could appear secure without being locked, could be defeated with scissors, and was not supported by sufficiently robust monitoring and key-control systems. It also identified concerns about CQC inspectors not being made properly aware of relevant Department of Health guidance and information about the restraint’s limitations.

Bradley Geoffrey Michael Cockel · Prevention of Future Deaths report View report

9 Jun 2014 Essex E. McGann

Bradley Geoffrey Michael Cockel was found deceased on 27 April 2013 at Bramle Road, Witham. The inquest concluded drug overdose, with the medical cause recorded as 25B-NBOMe intoxication; concerns included that the drug and some related compounds were not controlled under legislation at the time.

William Leonard Beckwith · Prevention of Future Deaths report View report

9 Jun 2014 Derby and Derbyshire R. Hunter

William Leonard Beckwith sustained a cervical spine fracture after a fall at home, was discharged from hospital without the fracture being diagnosed, and died on 11 October 2013 after readmission with acute stridor and subsequent deterioration. The principal concern was that, despite his age and history of falls, he was discharged home in the early hours without formal assessment of his abilities, his home environment, or his wife’s ability to care for him, and without post-discharge planning or needs assessment.

Charles Ronald Hardiman · Prevention of Future Deaths report View report

9 Jun 2014 Teesside C. Bailey

On 26 February 2014, Charles Ronald Hardiman was pushed backwards by a back door moved suddenly by a gust of wind while he was at the top of steps at a public house. He fell down the stairs and sustained fatal head and chest injuries. The principal concern was that open front and back doors created a wind tunnel, causing the back door to move forcibly and suddenly.

Ryan Patrick BOYLE · Prevention of Future Deaths report View report

9 Jun 2014 Surrey S. Wickens

On 21 February 2013, 19-year-old Ryan Patrick Boyle died following a road traffic collision while driving during a police pursuit. The jury found that dynamic risk assessments by the Force Control Room were insufficient. The report raised concerns about staff training, notification of pursuits, and ensuring that at least two people monitor the Force desk at all times.

Thomas Allen · Prevention of Future Deaths report View report

9 Jun 2014 Suffolk P. Dean

Thomas Allen died from injuries sustained when five untethered horses entered the unlit A14 on Christmas Eve 2012, causing a series of collisions; he died the following day. The principal concerns were that fly grazing was a national problem, was not a criminal offence in England, and that a police/local authority protocol was not yet in force in Suffolk.

John Cook · Prevention of Future Deaths report View report

9 Jun 2014 Oxfordshire N. Gardiner

John Cook, a 73-year-old man receiving palliative care in a nursing home, experienced severe breathing difficulty and died on 6 October 2012. Ambulance personnel believed a Do Not Attempt Resuscitation form was in effect, but it had expired when he was discharged from hospital. The report raised concerns about unclear form wording, failure to retrieve or mark expired forms, difficulty identifying the issuing hospital, and communication failures that led to an unnecessary inquest and police investigation, although the report stated these failures did not affect the outcome.

Audrey Christine DAWS · Prevention of Future Deaths report View report

9 Jun 2014 Plymouth, Torbay and South Devon A. Cox

Audrey Christine Daws was admitted to Derriford Hospital with chest pain and other symptoms, but her chest X-ray was delayed and its result was not identified promptly. The X-ray eventually showed air under the diaphragm indicating a perforation; she underwent surgery, deteriorated and died. The principal concerns were inadequate handover of outstanding investigations and delays in ordering, performing and reviewing the X-ray.

Daniel Joseph McCallum Keane · Prevention of Future Deaths report View report

9 Jun 2014 Manchester West K. McLoughin

Daniel Keane was found dead at home after a period in which he had difficulty managing his Type 1 diabetes and was left without active support apart from his family. The cause of death was recorded as ketoacidosis. The reported concerns included a lack of leadership and coordination, no clear post-discharge care plan, ineffective multidisciplinary meetings, and uncertainty about the GP’s role, including the prescribing of citalopram and failure to respond to concerns about Daniel’s wellbeing.

James McArdle · Prevention of Future Deaths report View report

8 Jun 2014 Wirral A. Wilson

James McArdle was an elderly independent man admitted to hospital on 24 November 2013 who suffered two falls on 5 December 2013, the second resulting in a non-survivable condition. The concern was that a coloured wristband system identifying patients at risk of falls had been withdrawn without replacement, potentially removing protection for elderly patients at risk of falling.

Frances Margaret Ann Bell · Prevention of Future Deaths report View report

6 Jun 2014 Essex C. Beasley-Murray

Frances Margaret Ann Bell presented at Southend Hospital with abdominal pain on 30 March 2012, was discharged shortly after midnight, readmitted the next day, underwent abdominal surgery on 1 April, and died on 13 April 2012. The report identified very serious failings in her care, including no senior clinical input at presentation and an unacceptable delay before surgery, and noted that no Root Causes Analysis Investigation was carried out.