Reports

Luna Lesko · Prevention of Future Deaths report View report

23 Aug 2013 Inner South London A. Harris

Baby Luna Lesko died after being found collapsed with no respirations following an airway occlusion, inadequate required observations and a prolonged period of hypoxia, despite resuscitation and intensive care. The report raised concerns about delays in cardiotocograph monitoring and delivery by caesarean section, including insufficient out-of-hours theatre capacity and a potential risk to future babies.

Mr Walker · Prevention of Future Deaths report View report

21 Aug 2013 West Sussex C. Wilkinson

Mr Walker, who had depression, suicidal ideation and a history of impulsive self-harm attempts, died after leaving the hospital ward and hanging himself in nearby woodland. Concerns included insufficient risk care planning, unexplained reductions in observation levels, the time taken to declare him missing and inform police, and the scalability of the ward’s external fences.

Mohammed Mozammel Hussain CHAUDHURY · Prevention of Future Deaths report View report

20 Aug 2013 Inner South London A. Harris

Mohammed Chaudhury suffered multiple injuries in a traffic collision and later developed five severe, septic pressure sores while in hospital. The report raised concerns about inadequate turning, incomplete care planning and tissue-viability referrals, inconsistent risk scoring, shortages in nursing staff, and uncertainty about whether staffing levels for unconscious patients requiring regular turning were safe.

Derek BRIERLEY · Prevention of Future Deaths report View report

20 Aug 2013 Manchester North S. Nelson

Derek Brierley’s urethral catheter became blocked and attempts to recatheterise him were unsuccessful, including an abandoned suprapubic catheter insertion, after which he became acutely unwell with features of peritonitis. Concerns included the likely high insertion site, the absence of Trust guidelines on competence and training for the procedure, and difficulties locating a suprapubic catheter beforehand.

Nicola Matthews · Prevention of Future Deaths report View report

20 Aug 2013 South London R. Palmer

Nicola Matthews took an overdose of medication after leaving hospital on 15 October 2010 and was found unrousable at her partner’s home in the early hours of 16 October, later being pronounced dead in hospital. The principal concern was that decisions about her discharge, including follow-up arrangements and the nature and quantity of medication supplied, were unclear and inadequately documented or communicated.

Ann Margaret SPEARING · Prevention of Future Deaths report View report

20 Aug 2013 Avon T. Moore

Ann Margaret SPEARING had a history of learning difficulties, bereavement and dependency issues and lived in assisted accommodation. She was reviewed by mental health, hospital and eating-disorder services but was not considered to have a qualifying mental illness, medical condition or eating disorder. She starved herself over many months and died of pneumonia and malnutrition, with self-neglect contributing in the context of bereavement, a move to a new home, anxiety and dependence issues. The principal concern was that organisational eligibility criteria excluded her from effective care, leaving her passed between agencies without positive intervention.

KEWAR GUY DOMINIC HARDING · Prevention of Future Deaths report View report

16 Aug 2013 Dorset S. Payne

Mr Harding, who had a learning disability and lived at home with his mother, deteriorated over the Easter weekend and was found critically unwell with suspected sepsis on 2 April 2013. He was admitted to hospital, transferred to Birmingham for consideration of extra-corporeal assistance and possible heart transplantation, and died on 7 April 2013; the principal concern was that an urgent mental health assessment requested on 19 March had not taken place before 2 April, potentially delaying detection and treatment of his physical decline.

Sadie Ann Jane McGrady · Prevention of Future Deaths report View report

16 Aug 2013 North Wales (East and Central) J. Gittins

Sadie Ann Jane McGrady died after the vehicle in which she was travelling was struck on a dual carriageway, causing severe head injuries from intrusion of the vehicle’s rear quarter panel. The report raised concerns about substandard repairs to a previously written-off vehicle, the lack of independent checks before repaired vehicles returned to the road, and whether such repairs could increase injury severity in collisions.

JORDAN ANTHONY BUCKTON · Prevention of Future Deaths report View report

14 Aug 2013 Dorset S. Payne

JORDAN ANTHONY BUCKTON, aged 20, was found hanging by a ligature in his cell at HMYOI Portland on 28 January 2012. Concerns included failures to share information about his previous self-harm, to follow up after antidepressant medication was prescribed, and to continue an Emotional Wellbeing course after staff absence.

Vera Lillian STEEL · Prevention of Future Deaths report View report

13 Aug 2013 Surrey M. Burgess

Vera Lillian STEEL, a resident of Glebe Nursing Home, suffered severe burns after dropping a lit match into her lap while attempting to smoke on the garden terrace on 24 March 2012. She died later that evening despite treatment; the principal concern was the availability and use of fire-protective clothing for smokers in care homes and similar settings.

Ronald Sherlock · Prevention of Future Deaths report View report

9 Aug 2013 Norfolk W. Armstrong

Ronald Sherlock, a 92-year-old prisoner at HM Prison Norwich, was found unresponsive in his cell on 24 April 2012 and could not be revived. The report raised concern that prisoners in the Older Prisoners Unit did not have appropriate access to speech and language therapists for assessment and management of swallowing difficulties.

Dimitar SHTYANOV · Prevention of Future Deaths report View report

8 Aug 2013 South Lincolnshire A. Forrest

Dimitar SHTYANOV, a Bulgarian seasonal agricultural worker with a history of asthma, became ill in August 2012 and attended hospital twice before arriving in cardiac arrest on 11 August; resuscitation was unsuccessful. The inquest recorded the medical cause of death as bilateral pneumothoraces due to acute asthma. Concerns included seasonal workers’ limited awareness of GP, 999 and 111 services, and uncertainty about whether Dimitar’s medicines from Bulgaria were shown to hospital staff.

Jean Miller · Prevention of Future Deaths report View report

7 Aug 2013 Manchester (West) A. Mutch

Jean Miller was admitted for incisional hernia repair, discharged home under district nursing care, and later readmitted with a purulent wound discharge before dying in hospital on 24 January 2013. The report identified concerns about the district nursing team’s lack of baseline wound assessments, failure to involve tissue viability specialists, absence of thermometers, poor record keeping, and poor communication with the GP.

Matthew Thomas Hamilton · Prevention of Future Deaths report View report

7 Aug 2013 North and West Cumbria D. Roberts

Matthew Thomas Hamilton was fatally injured when he was thrown from his pedal cycle after braking sharply as a car approached while he emerged from a footpath in Carlisle. Concerns were raised about the lack of a barrier or restriction, the narrow pavement, and restricted visibility from fencing and shrubbery, creating hazards for footpath and road users.

Lucy Hannah Rose Bailey · Prevention of Future Deaths report View report

6 Aug 2013 Rutland and North Leicestershire R. Chapman

Lucy was born at home following a difficult labour in which her head was delivered but her body did not initially follow. She was not breathing at birth, suffered irreparable brain damage from oxygen starvation, and died the following day. The principal concern was whether paramedic training manuals and guidelines should permit gentle traction to the baby’s head and/or gentle internal manipulation during birth.

ALAN SMITH · Prevention of Future Deaths report View report

5 Aug 2013 North Wales (East and Central) J. Gittins

ALAN SMITH died after falling from a ladder that moved while he was repairing a factory door, sustaining a severe head injury. A witness reported that he had not received specific training for working at height and that generic risk assessments and method statements were not routinely used by employees.

Joseph Burrell · Prevention of Future Deaths report View report

5 Aug 2013 North London J. Taylor

Joseph Burrell was struck by a car while attempting to cross The Broadway in Stanmore and died from multiple injuries sustained in the collision. The report identifies concerns that pedestrians on the central reservation may be unable to see or determine the signals clearly, with no pedestrian lights, warning sound, or control buttons, creating a risk of pedestrians being struck by traffic proceeding through a green filter light.

David George White · Prevention of Future Deaths report View report

1 Aug 2013 South Yorkshire (Eastern) M. Beresford

The report identifies David George White as the deceased. The supplied text does not provide the circumstances of death or any substantive concerns.

Annie Rose GIBSON · Prevention of Future Deaths report View report

1 Aug 2013 West Yorkshire (East) D. Hinchcliff

Annie Rose Gibson, an 84-year-old woman living alone, was found unresponsive at home after a fall the previous day and was pronounced dead on 13 October 2012. The post-mortem cause of death was recorded as hypothermia, immobility, and fractured pelvis with haemorrhage. The principal concern was that emergency medical assistance was not obtained despite the fall and injury, and that hospital treatment might have prevented the development of hypothermia and the death.

Michael James THORNTON · Prevention of Future Deaths report View report

1 Aug 2013 West Somerset M. Rose

Michael James THORNTON was a front-seat passenger in a Land Rover that left the carriageway after swerving to avoid a deer and entered an adjoining rhyne. He was later pulled from the vehicle, and the inquest recorded drowning, reduced consciousness, traumatic head injury and ethanol ingestion; the concern was that vehicles leaving carriageways and landing in rhynes regularly resulted in occupants drowning.