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Arthur Ronnie TROTT · Prevention of Future Deaths report View report

29 Nov 2022 West Sussex K. Henderson

Arthur Ronnie Trott died four days after an unexpected footling breech delivery at home, following a delay in transfer to hospital; the report states that this materially contributed to severe hypoxic ischaemic encephalopathy and his death. Concerns included insufficiently robust emergency guidance for footling breech presentations and limited consultant midwife support, guidance and training across ambulance services.

Janice HOPPER · Prevention of Future Deaths report View report

28 Nov 2022 Norfolk J. Lake

Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.

Susan Jane PERRY · Prevention of Future Deaths report View report

28 Nov 2022 South Wales Central G. Hughes

Susan Jane PERRY had a chronic complex mental ill health condition and was receiving long-term care and support at supported accommodation. She was found deceased in her room on 23 October 2020, and the inquest found that COVID-19 infection and elevated levels of prescription medication contributed to her death. The principal concern was that medication cupboard keys were kept nearby in unsecured locations, creating a risk that a service user could access medication; no evidence was received that practices and procedures across similar accommodation addressed this risk.

Miriam BOULIA · Prevention of Future Deaths report View report

28 Nov 2022 Inner North London A. Smith

Miriam Boulia was struck by a bus while crossing Great Eastern Street on a red pedestrian signal and sustained catastrophic, unsurvivable injuries; she was declared deceased at the scene. The report identified concerns that signal timings at the junction did not allow pedestrians enough time to cross safely, with a high number of similar collisions and improvements potentially taking two to four years.

Mrs Joan Robinson · Prevention of Future Deaths report View report

25 Nov 2022 Manchester South C. Morris

Mrs Joan Robinson was admitted to hospital after sustaining multiple cervical spinal fractures in a fall at home. During her admission she developed confusion, difficulty swallowing, poor oral intake, atrial fibrillation, congestive cardiac failure and acute kidney injury, and palliative care was instituted. Concerns related to incomplete and non-mandatory training in the Malnutrition Universal Screening Tool and insufficient support, holding or attendance for the Trust’s Nutrition and Hydration Committee.

Ann Daghlin · Prevention of Future Deaths report View report

25 Nov 2022 North Wales (East and Central) E. Dudley-Jones

Ann Daghlin died in hospital on 13 February 2021 from sepsis resulting from a sacral pressure sore, with metastatic breast cancer contributing. The report states that her refusal of showering and full-body washing meant the pressure sore went unnoticed until it was identified by a carer. Concerns were raised that TLC nursing and home care lacked a formal review system and mechanisms to monitor whether care plans were being met.

Philip John BATTLE · Prevention of Future Deaths report View report

25 Nov 2022 Liverpool and the Wirral A. Rebello

Philip John Battle died by suicide on 8 July 2022 after contacting the ambulance service about an overdose and an attempted hanging. The report raised concerns that the ambulance triage process focused on physical health rather than immediate mental-health and self-harm risks, and that no attempt was made to contact someone who could check on his safety. It also identified limited coordination and shared mental-health crisis resources between ambulance, police and health services.

Bonnie Rose WEBSTER · Prevention of Future Deaths report View report

25 Nov 2022 Norfolk J. Lake

Bonnie Rose Webster was born by emergency caesarean section in a poor condition on 9 February 2022, required resuscitation and neonatal treatment, and died the following day after her condition deteriorated. Concerns included communication with her parents about the seriousness of the situation, a delay in giving prescribed antibiotics, and paediatric staff being alerted on foot rather than through the emergency bleep system.

Keith Andrew WESTON · Prevention of Future Deaths report View report

24 Nov 2022 North Yorkshire and York C. Cundy

Keith Andrew WESTON was found in the garden of his home on 9 March 2022 after shooting himself with a licensed firearm. The principal concern was that prosecutions by non-police authorities did not automatically trigger checks of the Police National Computer, meaning firearms licensing authorities might not be alerted to assess a person's continuing suitability to possess firearms.

Anthony James REEDMAN · Prevention of Future Deaths report View report

22 Nov 2022 Cornwall and Isles of Scilly G. Davies

Anthony James Reedman suffered a basilar artery stroke while at home, but an ambulance delay meant thrombolysis was administered 4.5 hours after the stroke. He died following a further brain haemorrhage after the unsuccessful thrombolysis attempt. The principal concerns were the lack of a 24/7 thrombectomy service for Royal Cornwall Hospital Trust patients and the absence of a service level agreement with the nearest 24/7 service when the local service was unavailable.

Margaret Russell · Prevention of Future Deaths report View report

22 Nov 2022 South Yorkshire (Western) A. Combes

Margaret Russell was admitted to hospital after a fall that caused a fractured hip and required surgery. Following surgery, she was given a meal despite a missed referral concerning her swallowing difficulties and no temporary dietary measures; she choked on the meal. CPR was not commenced because a DNA CPR was in place, which the report states was contrary to Trust and Resuscitation Council policy.

Joan Rossington · Prevention of Future Deaths report View report

22 Nov 2022 South Yorkshire (Western) A. Combes

Joan Rossington was an inpatient at the Royal Hallamshire Hospital and received daytime support from her own care staff. After those staff had left on 16 June 2022, she fell while attempting to move across the ward, sustained significant head injuries, and died from those injuries on 17 June 2022. The principal concern was that her own care staff were not included in or aware of the ward’s care plans and risk assessments, including those relating to falls, creating a potential risk of care contrary to clinical guidance.

Daniel Lee · Prevention of Future Deaths report View report

21 Nov 2022 South Yorkshire (Western) S. Eccleston

Daniel Lee, aged 22, died by hanging at a disused quarry on 16 September 2021, with the intention to end his life; the inquest concluded that his death was suicide. The report identified concerns about superficial risk assessments, the absence of a key worker, communication with the armed forces and family, and uncertainty about risk-based information sharing.

Andrew MacIntyre Brown · Prevention of Future Deaths report View report

21 Nov 2022 West London A. Van Dellen

Andrew MacIntyre Brown, aged 23, died after being struck by a police vehicle at a pedestrian crossing on 5 November 2019. The vehicle was travelling at an unsuitable speed at night and was not using lights and sirens. The report identifies concerns that police driving policies insufficiently addressed the safety of pedestrians and other road users and were unclear about the circumstances in which a silent approach could be used.

Celia Lindsey MARSH · Prevention of Future Deaths report View report

21 Nov 2022 Avon M. Voisin

Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.

Rowan Louis Thompson · Prevention of Future Deaths report View report

17 Nov 2022 Manchester North J. Kearsley

Rowan Louis Thompson was a detained patient at the Gardner Unit who was found in his room on 3 October 2020, thought to be having a seizure, and died shortly after arriving at hospital. The investigation and inquest identified severe hypokalaemia, failures to communicate blood test results, missed and falsified observation records, inadequate emergency response arrangements, and concerns about staffing and auditing.

Roy Middleton · Prevention of Future Deaths report View report

17 Nov 2022 South Yorkshire (Western) T. Rawden

Roy Middleton fell at home on 9 February 2022, sustaining a head injury while taking warfarin. Emergency medical assistance arrived more than six hours after the initial call, and he died in hospital on 10 February 2022 from a traumatic acute subdural haemorrhage. The principal concern was that the emergency dispatch algorithm did not take anticoagulant medication into account when determining the response category for a head injury.

Awaab Ishak · Prevention of Future Deaths report View report

16 Nov 2022 Manchester North J. Kearsley

Awaab Ishak died on 21 December 2020 at the Royal Oldham Hospital, aged two, following a severe respiratory condition associated with prolonged exposure to mould in his home. The report identifies concerns about inadequate guidance and risk assessment for damp and mould, limited access to up-to-date health information, delays in addressing recognised disrepair where legal claims were ongoing, and the lack of independent complaints investigation for private landlords.

Susan Elizabeth SKILLEN · Prevention of Future Deaths report View report

16 Nov 2022 Liverpool and the Wirral A. Bhardwaj

Susan Elizabeth Skillen, aged 61, was admitted to hospital on 26 May 2022 after being found at home with reduced consciousness, low blood pressure, hypoglycaemia and severe neutropenia, and died later that day. The inquest concluded that she died from neutropenic sepsis, with skin loss associated with phototoxicity considered the most likely source of infection and the combined effects of sun exposure and rheumatoid arthritis medication contributing. The substantive concern was that phototoxicity is an extremely rare side effect of methotrexate but did not appear in the literature provided to patients, and it was unclear whether the patient literature required review.

Sally-Ann Few · Prevention of Future Deaths report View report

15 Nov 2022 Mid Kent and Medway C. Wood

Sally-Ann Few was found dead at home on 12 March 2022, after being discharged from hospital the previous day with both slow-release and faster-acting morphine; a post-mortem found that she died as a consequence of morphine toxicity. Concerns included the GP prescribing system not showing that Oromorph had been stopped, a discrepancy between inpatient morphine prescriptions that was not reviewed, and poor medical record keeping that did not document decision-making, discussions, or advice.