Reports

Edna Elsie Mary Eden · Prevention of Future Deaths report View report

27 Nov 2013 Berkshire P. Bedford

Edna Elsie Mary Eden, who had been living independently, was admitted to hospital after feeling unwell and reporting recent right-sided chest pain. She remained in A&E and the AMU for approximately fourteen and a half hours before being seen by a doctor, then arrested and could not be revived. The report identified missed opportunities involving delayed medical review, failure to recognise or escalate abnormal findings, inadequate communication, incorrect observation scoring, and lack of antibiotic cover.

Alan Stanfield · Prevention of Future Deaths report View report

26 Nov 2013 Avon S. Fox

Alan Stanfield Browning was discharged from Somewhere House on 10 August 2012 after treatment for alcohol and drug abuse, and CCTV showed him jumping from Clifton Suspension Bridge on 16 August 2012. Concerns included discharge without family being informed about accommodation arrangements, discharge on a Friday leaving little time to secure accommodation, and uncertainty about routine family involvement before discharge.

Barry James LEWIS · Prevention of Future Deaths report View report

26 Nov 2013 Manchester North L. Hashmi

Barry James Lewis suffered an anaphylactic reaction of unknown origin and developed severe airway swelling and difficulty speaking. Despite emergency treatment, attempts to secure his airway were difficult, he suffered respiratory and cardiac arrest, and he died after 50 minutes of resuscitation. The substantive concerns related to the availability and suitability of emergency airway instruments, theatre access, night staffing, and out-of-hours ENT cover across multiple sites.

Garrett Joseph Franklin ELSEY · Prevention of Future Deaths report View report

22 Nov 2013 Avon T. Moore

Garrett Joseph Franklin ELSEY, aged 22, was found among waste dumped at a refuse site after collection by a refuse lorry. The concern was that an important HSE document about people in commercial waste containers might not have been read by the public, and that an alert system might be needed to raise awareness in the industry.

Peter Galea · Prevention of Future Deaths report View report

21 Nov 2013 Sunderland D. Winter

Peter Galea, a 51-year-old man, attended hospital and other agencies repeatedly over a 72-hour period and was assessed as low risk on three occasions. On 11 June, after leaving his GP surgery and threatening to jump from a bridge, his body was found under the Queen Alexandra Bridge and he was pronounced dead. Concerns included limited mechanisms for breaking referral cycles, restrictions on direct GP referral for admission to a place of safety, and whether different action might have prevented the outcome.

Jack William PARTINGTON · Prevention of Future Deaths report View report

21 Nov 2013 Manchester North L. Hashmi

Jack Partington was born by planned caesarean section on 25 November 2011 and developed breathing difficulties requiring neonatal ventilation. After developing a pneumothorax, he was treated with intubation and ventilation but deteriorated and died on 26 November 2011. Concerns included gaps in neonatal handover and care planning, treatment decisions made without multidisciplinary consultation, lack of routine use of exhaled carbon dioxide detectors, absence of national guidance on paralysing agents and neonatal ventilation, and inadequate monitoring of ventilatory pressure after intubation.

Lisa Jane CLAYTON · Prevention of Future Deaths report View report

21 Nov 2013 Manchester North L. Hashmi

Lisa Jane Clayton had severe clinical depression and a history of self-harm attempts. On 27 June 2012, she went missing from home and was found at the foot of The Spindles car park after being seen on the wall surrounding its seventh floor. The principal concerns were that the wall and rails provided insufficient prevention of access, CCTV monitoring and security-control-room staffing were inadequate, and previous concerns about suicide attempts at the location had not led to sufficient action.

Annie Ceinwen Jones · Prevention of Future Deaths report View report

20 Nov 2013 North Wales (East and Central) J. Gittins

Annie Ceinwen Jones was admitted to hospital on 1 December 2012 after feeling very poorly and sustaining extensive bruising in a fall from a stand aid. The investigation identified inadequate mobility assessment, an unsafe stand aid, and gaps in staff awareness and competence, although the report states that the incident did not contribute to her death; the inquest conclusion was natural, with bronchopneumonia, volvulus of the sigmoid colon with infarction, and intestinal obstruction recorded as the medical cause of death.

LUKE JACOB GOODWIN · Prevention of Future Deaths report View report

20 Nov 2013 West Yorkshire (Western) M. Burke

Luke Goodwin, a 21-year-old university student, was found dead at home on 18 January 2013 after inhaling helium using a plastic bag, tubing and a helium canister. The report raised concerns about the ready availability and design of helium canisters, and about clear, detailed online information and links facilitating suicide methods and purchases.

Barnabas Newlyn · Prevention of Future Deaths report View report

19 Nov 2013 London Inner (North) S. Lynch

Barnabas Newlyn, a four-year-old boy being treated for Ewing’s sarcoma, suffered a large intracerebral haemorrhage after collapsing at home and died following emergency surgery. The report raised concerns that road transfer times from QEQM to specialist hospitals may not provide a realistic opportunity to save patients needing time-sensitive critical care, particularly neurosurgical emergencies.

STUART ARRON COLLINS · Prevention of Future Deaths report View report

18 Nov 2013 Teesside C. Bailey

Stuart Arron Collins was taken to hospital while intoxicated and fully conscious, but was discharged several hours later with a reduced level of consciousness. After arriving at an address, he became unconscious and suffered cardiorespiratory arrest before being returned to hospital, where he died later that day. Concerns included uncertainty about his assessment on arrival, the absence of required hourly nursing observations, incomplete nursing records, and the possible accessibility of alcohol hand sanitiser gel.

Andrew PHRYDAS · Prevention of Future Deaths report View report

15 Nov 2013 Inner North London M. Hassell

Andrew Phrydas died after being struck by a London Underground train near Finsbury Park Station after entering the tunnel and crossing between the Victoria and Piccadilly lines. The report identified concerns about London Underground’s lack of a process to shut down both lines simultaneously and its failure to alert the driver about Andrew’s presence on the track by the most direct and effective method.

David Allan Cox · Prevention of Future Deaths report View report

15 Nov 2013 Derby and Derbyshire S. Cartwright

David Allan Cox died after his vehicle left a narrow, icy bridleway at a sharp blind bend, overturned and entered the river. The principal concern was that the absence of barriers, together with the narrow track and further blind bends, created an ongoing risk of vehicles leaving the bridleway and entering the river.

Dean Griffiths · Prevention of Future Deaths report View report

14 Nov 2013 Central and South East Kent R. Redman

Dean Griffiths died during a live-firing exercise at Lydd Ranges in September 2011 after a shot passed through a target and perimeter wall and struck him. The principal concern was time pressure to complete exercises, with a need for sufficient time for the Range Conducting Officer to complete a final assurance check.

Kevin Paul SUTTON · Prevention of Future Deaths report View report

14 Nov 2013 West Somerset K. Sutton

Kevin Paul SUTTON, who had Huntington’s disease and continuing depression, was discharged to Halcon House and took his own life on 3 September 2012. During the inquest, evidence indicated that no care plan had been prepared, so Halcon House staff were not made aware of the suicidal risk; the stated concern was the Trust’s failure to provide care plans.

Anthony Brian Flynn · Prevention of Future Deaths report View report

14 Nov 2013 Manchester West J. Leeming

Anthony Brian Flynn, who had diagnosed testicular cancer, was remanded into custody at Forest Bank Prison on 24 July 2012 and died there on 28 September 2012. The report raised concerns that he was handcuffed and chained during hospital appointments and examination, that a consultant’s concerns about the lack of compassion and difficulty conducting a sensitive examination were not acknowledged or investigated, and that training and procedures concerning restraints and clinicians’ powers needed consideration.

Kathleen Rosemary Dixon · Prevention of Future Deaths report View report

11 Nov 2013 South and East Cumbria I. Smith

Kathleen Rosemary Dixon was receiving treatment for mental illness that was escalating, but its severity was not recognised by those treating her, and she drowned in a river. The concern raised was that similar circumstances had occurred in previous inquests and that the Trust should be assessed independently.

John Gwynfryn MORRIS · Prevention of Future Deaths report View report

11 Nov 2013 Hertfordshire E. Thomas

The report concerns the death of John Gwynfryn MORRIS. No circumstances of death or substantive concerns are provided in the supplied transcription.

Timothy Patrick CLAYTON · Prevention of Future Deaths report View report

11 Nov 2013 Inner North London M. Hassell

Timothy Patrick Clayton died after sustaining an unsurvivable traumatic head injury during a sustained attack in which he was kicked to the head and body. Although his family consented to organ donation and the coroner decided not to object, Kent Police contacted the family about the effect on the homicide prosecution, leading them to withdraw consent. The report’s principal concern was that this placed an improper burden on the grieving family and subverted the coroner’s decision, resulting in six organs not being donated.

Peter Patrick Adrian Barnes · Prevention of Future Deaths report View report

8 Nov 2013 West Yorkshire (West) N. Cameron

Peter Patrick Adrian Barnes died from asphyxia caused by hanging in the grounds of Cygnet Hospital, Wyke, while detained under Section 3 of the Mental Health Act 1983. Serious incidents known to nursing staff, including comments about suicide and marks on his neck, were not communicated to the Responsible Clinician, who granted unescorted leave. The report raised concerns about systems for communicating and auditing information and care decisions, involving families in care decisions, and sharing information with police when patients were absent without leave.