Reports

Margaret Walker · Prevention of Future Deaths report View report

25 Mar 2014 Manchester West J. Leeming

Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.

Sean Andrew Morley · Prevention of Future Deaths report View report

24 Mar 2014 Warwickshire D. Clark

Sean Andrew Morley was struck and killed by a motor vehicle while crossing the A444 Bedworth By-pass on foot between 3am and 4am on 2 September 2012. The report raised concerns that the road was regularly used by pedestrians and cyclists despite having no warning signs, street lighting, barriers, or other protective features, and that these conditions created a risk of further fatal collisions.

Phyllis Barnes · Prevention of Future Deaths report View report

24 Mar 2014 Surrey K. Henderson

Phyllis Barnes underwent elective laparoscopic anterior resection and was discharged home, but developed persistent vomiting and became increasingly unwell. She was later readmitted with an anastomotic leak and died from complications. Concerns included delayed recognition of the seriousness of her symptoms, a superficial nurse-led telephone consultation with uncertain follow-up, and a lack of formal communication with her daughter.

DERRICK ARTHUR PLATER · Prevention of Future Deaths report View report

21 Mar 2014 Norfolk D. Osborne

Derrick Arthur Plater was a resident of Goodwins Hall nursing home who developed a pressure sore after hospital admission on 1 May 2011, was readmitted on 25 May 2011, and died on 7 June 2011. Concerns were raised that the local authority placed him in the care home without visiting it, relying on assurances despite his complex needs, and that it was unclear whether guidance or protocols existed for when such visits should be undertaken.

MRS KERRY JACOBS · Prevention of Future Deaths report View report

21 Mar 2014 West Sussex B. Dolan

Mrs Kerry Jacobs died on 8 July 2013 from a pulmonary embolism arising from a deep vein thrombosis in her right calf. Concerns included the prescription of a steroid dose outside usual ENT practice and BNF guidelines without adequate documentation or confirmation with the consultant, and the lack of a protocol requiring discussion between pharmacists and clinicians when prescriptions are queried.

Robert Erryl Jones · Prevention of Future Deaths report View report

20 Mar 2014 Carmarthenshire and Pembrokeshire J. Layton

Robert Erryl Jones was admitted for bowel surgery and remained in hospital as his health declined. Delays in reporting and acting on the results of an emergency CT scan led to a significant delay in further surgery. The principal concern was that CT scan results should be made available promptly to the relevant departments and acted upon without delay where appropriate.

Jackson J Chadd · Prevention of Future Deaths report View report

20 Mar 2014 Surrey K. Henderson

Jackson became unwell at home with fever, poor feeding, diarrhoea, a rash and abnormal observations, and was discharged from A&E with a diagnosis of gastroenteritis. He returned in septic shock and died despite resuscitation; the medical cause of death was fulminant meningococcal infection. Concerns included inadequate supervision and assessment, failure to apply fever guidelines, and failure to act on a parent’s concerns.

CHRISTOPHER RICARDO WILLIAMS · Prevention of Future Deaths report View report

19 Mar 2014 Cheshire A. Moore

Christopher Ricardo Williams was detained under the Mental Health Act and resident in a medium secure unit when he became unresponsive and was pronounced dead at the scene on 6 November 2013. The inquest concluded that the death was from natural causes, with the medical cause recorded as massive pulmonary embolism. Concerns included a defibrillator not working, failure to check it daily, absence of a cross-check system, and no hospital policy for managing sudden or unexpected deaths.

Matthew David James Simmonds · Prevention of Future Deaths report View report

18 Mar 2014 Central Hampshire G. Short

Matthew Simmonds, who was dependent on invasive ventilation, died after assisted ventilation ceased during a change of ventilators because the replacement ventilator was not switched to a functioning mode. The principal concern was that a locally developed care-planning system for complex community discharges, particularly ventilated patients, had not been shared with Clinical Commissioning Groups outside the county.

David Gary Chatburn · Prevention of Future Deaths report View report

18 Mar 2014 Manchester North L. Hashmi

David Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health services.

Charles Gavin BRADLEY · Prevention of Future Deaths report View report

17 Mar 2014 Liverpool A. Rebello

Charles Gavin Bradley fell unwitnessed in the Assessment Unit at Arrowe Park Hospital on 21 February 2013 and sustained head injuries that proved fatal. The investigation and inquest identified inadequate record-keeping and communications, including failures concerning his transfer and unclear recording of the fall.

Daniel Philip Taylor · Prevention of Future Deaths report View report

17 Mar 2014 Staffordshire South A. Haigh

Daniel Taylor died at the scene of a road traffic collision on Colliery Road, Brereton, on 6 September 2013 after losing control of the car he was driving and crashing into a tree. The report raised concern about whether the road location and bend required additional warning signs or markings.

Peter Desmond Vickers · Prevention of Future Deaths report View report

17 Mar 2014 Staffordshire South A. Haigh

Peter Desmond Vickers Banks died in hospital on 16 May 2013 from injuries sustained when he was hit by a car while crossing a road in Stafford on 5 May 2013. The report raised concern that the tactile-paved crossing point in Westhead Avenue was probably too close to the main Weston Road, with a suggestion that protective railings be extended and the crossing moved further into Westhead Avenue.

Gavin Anthony ROBERTS · Prevention of Future Deaths report View report

14 Mar 2014 Rotherham N. Mundy

Gavin Anthony Roberts died in a fatal collision while riding his motorcycle on Hollings Lane on 24 October 2013. He lost control after overtaking on a bend and collided with an oncoming vehicle; significantly underinflated tyres were a major factor. The concerns related to the 60 mph speed restriction being higher than the safe speed for the bend, its increase from 40 mph on the approach, and the apparent inadequacy of warning signs given the number of incidents at the location.

David Robert Oldfield · Prevention of Future Deaths report View report

14 Mar 2014 West Yorkshire Eastern M. Williamson

David Robert Oldfield sustained fatal stab wounds to the jugular vessels in his neck during an incident at his home on 5 October 2012. He was tasered by firearms officers after emergency services attended and died shortly afterwards. Concerns included whether the tasering was appropriate and justifiable, and uncertainty about the circumstances immediately preceding it.

Teresa Lonergan · Prevention of Future Deaths report View report

14 Mar 2014 Inner South London A. Harris

Teresa Lonergan, aged 73, was found dead at home on 4 September 2012 after taking an overdose of morphine that she had hoarded. The concerns included large quantities of prescribed morphine being available, repeat prescriptions and no reported monitoring of her consumption of controlled drugs.

Norma Doris Sheppard · Prevention of Future Deaths report View report

14 Mar 2014 Staffordshire South A. Haigh

Norma Doris Sheppard fell in her care home, broke her right hip, underwent surgical repair, later suffered a stroke affecting her swallowing, and died on 10 April 2013 from the effects of the fall. There was considerable confusion about whether she was to receive subcutaneous fluids after discharge from hospital to a care home, contrary to the written discharge document.

Michael Anthony Tarratt · Prevention of Future Deaths report View report

14 Mar 2014 Leicester City and South Leicestershire L. Brown

Michael Anthony Tarratt, who had a history of poly-drug and alcohol abuse and was receiving methadone treatment, was found deceased at home from multiple drug toxicity. The concerns included a lack of contact between drug and alcohol services and his GP for 18 months, and the prescription of tramadol to an opioid-dependent patient without routine information-sharing between services.

JANETTE SUTHERLAND · Prevention of Future Deaths report View report

13 Mar 2014 Gwent W. James

On 24 October 2013, Janette Sutherland lost control of her vehicle near Risca, left the carriageway and collided with a concrete headwall, sustaining fatal injuries. The report identified the drainage channel and concrete headwall as hazards and raised concern that no safety barrier was present to prevent vehicles leaving the carriageway and striking the headwall.

Mrs Jean James · Prevention of Future Deaths report View report

13 Mar 2014 Sunderland D. Winters

Mrs Jean James was admitted to the Acute Medical Unit on 24 December 2013, where prophylactic Dalteparin was intended but not prescribed. A pharmacy query was not effectively communicated, and the omission was not subject to effective review. Mrs James died on 8 January 2014; the post-mortem identified bilateral pulmonary thromboembolism due to deep venous thrombosis, and the inquest concluded: “Natural Causes Contributed to by Neglect”.