Reports

Phillip Arthur Pratt · Prevention of Future Deaths report View report

30 Jul 2013 West Sussex E. Bussey-Jones

Phillip Arthur Pratt died on 2 November 2012 at St Richards Hospital after a fall-related fracture, surgery, and a sudden deterioration attributed to bronchopneumonia. The report raised concerns about incomplete medication information, delayed consideration of alcohol detoxification, delayed discontinuation of tramadol after confusion developed, delayed shoulder X-rays, and the unavailability of requested additional nursing staff for a high-risk patient.

Derek Edward Bartlett Twivey · Prevention of Future Deaths report View report

30 Jul 2013 West Sussex E. Bussey-Jones

Derek Edward Bartlett Twivey, aged 91, suffered repeated falls after being admitted to Fairlight Nursing Home and was later readmitted to hospital with subdural haematomas, where he died. The principal concerns were the need to complete a risk assessment within 24 hours regardless of staffing or time of year, and the timeliness of action when accommodation was found to be unsuitable for his needs.

Stanley Charles Dodson · Prevention of Future Deaths report View report

23 Jul 2013 Surrey M. Fleming

Stanley Charles Dodson was found dead at his home on 1 October 2012 after contacting a community alarm operative to request a doctor and the on-call doctor was unable to reach him by telephone. The concern was that the doctor’s unsuccessful attempts to contact him were not reported back to the operative, preventing consideration of further action to contact him.

Dana Louise Baker · Prevention of Future Deaths report View report

29 May 2013 Worcestershire G. Williams

Dana Louise Baker was a looked after child whose foster placement broke down, after which she stayed with an adult friend and the following day hanged herself in a public place. The principal concerns were inadequate knowledge, understanding and communication between agencies, and the confidential handling of Individual Management Reviews, which prevented agencies from understanding areas of mutual concern.

Clive William · Prevention of Future Deaths report View report

23 May 2013 North Wales (East and Central) J. Gittins

Clive William, a resident at Cae Glas Psychiatric Rehabilitation Care Home, died in bed on 21 October 2013. Concerns were raised about poor standards of care, missed medication and appointments, and a complaints process that could prevent concerns reaching senior management, potentially leaving residents at risk of harm.

Roshen Abbas Ladak-Ebrahim · Prevention of Future Deaths report View report

5 May 2013 North London A. Walker

Roshen Abbas Ladak-Ebrahim, aged 22, was found having hanged himself at home on the evening of 11 October 2012. The report raised concerns about assessing and recording immediate risk of self-harm, ensuring patients at risk were not left alone, and requiring appropriate medical consultation and follow-up when prescribing medication associated with increased self-harm risk.

Jack William PAYTON · Prevention of Future Deaths report View report

30 Apr 2013 West Somerset M. Rose

Jack William PAYTON was found down an embankment after his car left the A38 while he was driving home from dialysis on 17 October 2012. The report raised concern about the handling of the incident by Portishead control room staff, including the downgrading of the initial report and the delay in locating him; the post-mortem found ischaemic heart disease, but could not confirm whether earlier discovery would have changed the outcome.

SEBASTIAN VAUGHAN DAVIES · Prevention of Future Deaths report View report

28 Mar 2013 Norfolk D. Osborne

Sebastian Vaughan Davies was a detained patient at the Norvic Clinic who became unresponsive after returning from unescorted leave and later died in hospital. The concerns related to whether hourly night-time observations adequately identified patients who had remained immobile or provided continuity between staff carrying out observations.

Francoise Simone Annabel SNAPE · Prevention of Future Deaths report View report

13 Feb 2013 Worcestershire G. Williams

Mrs Snape was admitted to Worcestershire Royal Hospital on 2 August 2014 after an infarcted stroke and later developed a massive pulmonary embolus. Thromboembolic medication caused a catastrophic bleed resulting in her death. Concerns included the absence of a VTE assessment and failure to consider relevant NICE guidance on mechanical anti-DVT devices, which represented a lost opportunity for informed care and may have changed the outcome.

Gareth Mark Slater · Prevention of Future Deaths report View report

30 Jan 2013 Manchester South J. Kearsley

Gareth Mark Slater, who had a history of bipolar affective disorder and had been discharged from hospital into his own accommodation, was found in the River Medlock on 31 March 2013 after apparently falling from Bardsley Bridge. The Inquest concluded that he died from drowning and multiple injuries, with bipolar affective disorder recorded as a contributing condition, and found no evidence of an intention to end his life. Concerns included inadequate discharge planning, lack of a care plan and follow-up arrangements, insufficient assessment of his ability to live independently, and poor preparation of his accommodation.

Andrew John Fallon · Prevention of Future Deaths report View report

7 Jan 2013 Manchester South J. Pollard

Andrew John Fallon was admitted to Stepping Hill Hospital on 9 November 2012 after four days of vomiting and abdominal pain, suffered a cardiac arrest later that day, and died on 15 November after severe neurological damage and withdrawal of ventilator support. Concerns included Emergency Department staffing levels, delays in treatment, and the proposed use of a primary care facility for patients with minor conditions.

George Renshaw · Prevention of Future Deaths report View report

16 Sep 2012 Manchester South J. Pollard

George Renshaw, a resident at Mayfield Care Home, left through a fire door on 17 February 2013, fell down concrete steps, fractured his cervical spine and subsequently developed pneumonia, leading to his death. The report raised concern that there was no proper and efficient system for the speedy reassessment and transfer of care-home residents whose conditions were rapidly deteriorating, despite concerns about his advancing dementia being reported.

Heather Beatrice Planner · Prevention of Future Deaths report View report

13 Dec 2008 Buckinghamshire C. Butler

Heather Beatrice Planner died at Wycombe Hospital on 1 April 2019 from a gastrointestinal bleed in the context of large bowel ischaemia. The report states that she had not received her prescribed apixaban anticoagulation at home for two days before admission, and identifies concerns about medication administration, communication and record-keeping processes for carers, as well as the subsequent investigation.