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John Allen Martin HENDERSON · Prevention of Future Deaths report View report

17 Jan 2023 Mid Kent and Medway I. Brownhill

John Allen Martin Henderson was found dead in his bunk at HMP Rochester on 27 May 2021. The inquest recorded natural causes, namely ischaemic heart disease, following a fatal haemorrhage into the wall of the left circumflex artery. Concerns included delayed medical investigations, the absence of a welfare check at the start of the day, and a lack of a clear process for sharing relevant medical information with front-line prison staff.

Teegan Marie Barnard · Prevention of Future Deaths report View report

17 Jan 2023 West Sussex K. Henderson

Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning after her death.

Sean DUIGNAN · Prevention of Future Deaths report View report

16 Jan 2023 Bedfordshire and Luton S. Cummings

Sean DUIGNAN, a police sergeant, was found deceased at the Luton Airport policing unit after taking a handgun and ammunition from the armoury and shooting himself. The concerns included repeated failures of the armoury access system, inadequate monitoring, a universally known override PIN, and an incorrectly assigned single-access arrangement, which resulted in lax security and access to weapons.

Gary Dennis COOPER · Prevention of Future Deaths report View report

12 Jan 2023 Cumbria R. Cohen

Gary Cooper, aged 41, was found unresponsive at home on 3 July 2022 after having suffered from depression and psychosis; resuscitation was unsuccessful and his death was confirmed at 15:15. The inquest concluded suicide, while the report records two concerns whose substantive content is redacted.

Ashley Michel Bullard · Prevention of Future Deaths report View report

11 Jan 2023 West London M. Walsh

Ashley Michel Bullard died after a Volvo S80 fell from a vehicle lift while he was working underneath it at Wheel Art Ltd. The lift’s freeplay and the alignment of its pads contributed to the pads moving from a structural part of the car to a non-structural part, causing the car to fall and fatally injure him. Concerns included inadequate maintenance, the use of unsuitable bolts, insufficient warnings and manuals, and risks associated with outer lift points and tolerated freeplay in two-post vehicle lifts.

Carol Ann Welch · Prevention of Future Deaths report View report

11 Jan 2023 Warwickshire L. Lee

Carol Ann Welch became unwell with symptoms initially diagnosed as migraine, returned to the emergency department with changed symptoms, and was discharged without further investigation. She suffered a cardiac arrest on 30 April 2022 and died on 1 May 2022 after an undiagnosed cerebral aneurysm and subsequent spontaneous subarachnoid haemorrhage. Concerns included failure to investigate possible neurological findings, failure to follow guidance on consultant review after an unexpected return within 72 hours, and uncertainty about how relevant learning and guidance would be embedded, assessed and communicated across the medical team.

Leroy Patrick HAMILTON · Prevention of Future Deaths report View report

11 Jan 2023 Birmingham and Solihull L. Hunt

Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.

Lucy Amanda Jones · Prevention of Future Deaths report View report

11 Jan 2023 Gwent C. Saunders

Lucy Amanda Jones developed a serious mental illness in 2019 and died by hanging on 12 March 2022. She remained on a waiting list for Cognitive Behavioural Therapy and was not seen in the community after a planned follow-up in January 2022; attempts to contact her were limited to two phone calls, with no cold call made when she could not be contacted.

Floyd Everton CARRUTHERS · Prevention of Future Deaths report View report

5 Jan 2023 Birmingham and Solihull I. Dreelan

Floyd Everton Carruthers was detained at HMP Birmingham and died in hospital on 14 June 2021 after developing infective endocarditis, cardiac tamponade, and multi-organ failure. The report raises concerns about inadequate safeguarding training and escalation processes, insufficient record keeping and handover, and failures to refer him to healthcare despite missed meals and not leaving his cell. The jury concluded that his death was contributed to by neglect.

Beryl ELLISON · Prevention of Future Deaths report View report

3 Jan 2023 Sefton, St Helens and Knowsley J. Thompson

Beryl Ellison was receiving end-of-life care at Alexandra Care Home and was found deceased there on 28 June 2022. The inquest concluded that her death resulted from underlying poor health in combination with taking an excessive quantity of prescribed medication. Concerns included unsupervised access to syringe medication, prior family reports about medication being left in her room, and the absence of an explanation for the excessive oxycodone concentration found after her death.

Anthony David Blower · Prevention of Future Deaths report View report

31 Dec 2022 Hampshire, Portsmouth and Southampton R. Simpson

Anthony David Blower died at home on 25 October 2020 after sustaining multiple falls, bilateral subdural haematoma and further bleeding following hospital admission and surgery. The concerns identified included nursing care-plan risk assessments not being updated, poor documentation, and inadequate oversight of hydration, with Mr Blower becoming seriously dehydrated during his admission.

Malcolm James BASTEN · Prevention of Future Deaths report View report

30 Dec 2022 Surrey C. Topping

Malcolm James Basten died after sustaining head and chest injuries in a fall while working at height on a construction site. The report identified inadequate safeguards, including no edge protection, incomplete boarding, no safe internal access, and an unsecured scaffold ladder. Concerns also included the absence of required notification and inspection for this project and no mandatory accredited health and safety training requirements for principal contractors.

Gavin Peter Pedleham · Prevention of Future Deaths report View report

30 Dec 2022 Surrey C. Topping

Gavin Peter Pedleham inadvertently drank a dose of Oramorph left in a glass at a family Christmas party after consuming a significant quantity of alcohol. He was found dead the following morning, and the inquest recorded morphine and ethanol toxicity, concluding that his death was accidental. The substantive concern was that community use of Oramorph is not subject to similar safe-storage requirements as its use in institutional settings, allowing access by others.

Jordan Kevin Pry · Prevention of Future Deaths report View report

30 Dec 2022 Surrey R. Travers

Jordan Kevin Pry died after his car aquaplaned on surface water while travelling on the M25 on 2 April 2018, left the carriageway and collided with a tree. The principal concern was an ongoing risk of further deaths at the location, where aquaplaning incidents had continued and a flat spot remained while investigations and decisions about risk management were ongoing.

Emma Louise Powell · Prevention of Future Deaths report View report

28 Dec 2022 North Wales (East and Central) J. Gittins

Emma Louise Powell got into difficulties while paddleboarding at Conwy Morfa on 14 July 2022 and was recovered after being submerged for more than ten minutes. The inquest evidence raised concerns that she was not wearing life-saving equipment, used an inappropriate ankle leash in fast-flowing water, and had received no safety advice at the point of sale about safety vests or leash positioning.

Name not published · Prevention of Future Deaths report View report

22 Dec 2022 Manchester City N. Meadows

The deceased suffered serious traumatic injuries in an accidental fall in Pakistan, including flail chest and a subdural haemorrhage that were not initially diagnosed, and later deteriorated during her flight to the United Kingdom. She was admitted to hospital in Manchester, but despite medical management her condition deteriorated and she died on 26 July 2019. The substantive concerns included inconsistent oxygen prescribing and documentation, wider risks from over- or under-oxygenation, and the absence of guidance addressing fitness to fly after trauma with respiratory implications.

Glenys Lillian Phipps · Prevention of Future Deaths report View report

22 Dec 2022 Gwent C. Saunders

Glenys Lillian Phipps was admitted to hospital for investigations of abdominal pain and, while confused and living with dementia, fell twice after an inadequate assessment of her risk of falling and no personalised care plan. Her second fall caused a cerebral bleed, and she died from the head injury on 21 September 2020. The substantive concern was that newly qualified nurses may assume responsibility for patients before being trained in the multifactorial risk assessment process for falls.

Donald Frederick HOOKER · Prevention of Future Deaths report View report

21 Dec 2022 East Riding and Hull L. Harris

Donald Frederick HOOKER died on 28 August 2021 after his motorcycle’s drive chain broke while he was travelling on the Humber Bridge, causing a collision and fall. His crash helmet came off during the incident, and he sustained severe head and facial injuries. The principal concerns were the lack of understanding of why motorcycle helmets come off or rotate during collisions and the absence of clear checks or education concerning helmet sizing and fitting.

Angeline Marie Phillips · Prevention of Future Deaths report View report

21 Dec 2022 Manchester West A. Walsh

Angeline Marie Phillips died at her home on 30 January 2021 after police and ambulance services were contacted following concerns about her welfare and previous suicide attempts. The principal concern was that police did not attend within the required response time and responsibility was passed to a third party, with concerns that the policy could allow similar delays and risks to future deaths.

Alexander Michael BRAUND · Prevention of Future Deaths report View report

20 Dec 2022 Nottinghamshire L. Bower

Alexander Michael Braund was a 25-year-old remand prisoner at HMP Nottingham who became acutely unwell with an undetected atypical pneumonia and died on 10 March 2020 after cardiac arrest and withdrawal of life support. The principal concerns included failures in NEWS2 assessment and monitoring, the absence of a joint healthcare and prison-staff care plan, delays in entering his cell and calling a medical emergency code, and potential weaknesses in the integrity of amended electronic medical records.