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Ami Louise Mitchell · Prevention of Future Deaths report View report

3 Nov 2022 Avon S. Fox

Ami Louise Mitchell was under the care of AWP Trust with suicidal ideation from March to May 2022 and died by hanging on 31 May 2022. The report raises concerns that, despite delusions, hallucinations, intrusive thoughts of killing her partner and children, and requests for admission, no formal diagnosis was made and there was no escalation in management or admission.

Raneem Oudeh and Khaola Saleem · Prevention of Future Deaths report View report

3 Nov 2022 Birmingham and Solihull L. Hunt

Raneem Oudeh and her mother, Khaola Saleem, were murdered outside Khaola’s home address just after midnight following an incident at a Birmingham shisha lounge. Both women died from multiple stab wounds. The report raises a concern that serious staff shortages in the domestic abuse team led to cases not being effectively investigated, placing repeat victims of domestic abuse and coercive control at serious risk.

Jade Hutchings · Prevention of Future Deaths report View report

28 Oct 2022 West Sussex P. Schofield

Jade Hutchings, who was 18, had been struggling with his mental health and using alcohol and drugs. After going missing while under their influence, he was found hanging at home and died in hospital on 23 May 2020. Concerns included inadequate police mental-health training and a lack of early-intervention provision for older children through the REBOOT scheme.

Sylvia GIBSON · Prevention of Future Deaths report View report

27 Oct 2022 County Durham and Darlington J. Chipperfield

Sylvia GIBSON, aged 96, sustained injuries in an unwitnessed fall at Lambton House Care Home on 17 August 2022. Staff knew about the fall but did not convey this information to the doctor who visited her later that day; the report identified a lack of systems for communicating important information, while stating that the failure did not appear to have contributed to her death.

Hazel Lillian MAYHO · Prevention of Future Deaths report View report

26 Oct 2022 Hampshire, Portsmouth and Southampton J. Pegg

Hazel Lillian MAYHO, aged 82, died on 27 May 2022 after suffering a brain injury when she fell in the garden of a nursing home. The report raised concerns about hazards in the garden, staff being unable to effectively observe vulnerable residents, and the absence of an effective exit control or alert system for residents at risk of entering the garden alone.

Vincenzo Joseph Michael LIPPOLIS · Prevention of Future Deaths report View report

26 Oct 2022 Lincolnshire P. Cooper

Vincenzo Joseph Michael LIPPOLIS, aged 21, died on 1 November 2021 after being found hanging in woodland at Sand Dunes, Mablethorpe. Concerns were raised about why he was not admitted under the Mental Health Act after a recent suicide attempt and why a recommended face-to-face assessment was replaced by a telephone call, after which the case was closed the same day.

John Henry WHITE · Prevention of Future Deaths report View report

25 Oct 2022 South Wales Central G. Hughes

John Henry White suspended himself on 20 October 2019 and was transferred to Royal Glamorgan Hospital, where he died on 23 October 2019. The inquest jury concluded that the failure to release the ligature sooner possibly contributed to his chances of survival. The principal concerns were the incomplete distribution of ligature cutters to frontline officers and the availability of bespoke training for officers responding to similar incidents.

Bradleigh Trevor Barnes · Prevention of Future Deaths report View report

24 Oct 2022 Dorset R. Griffin

Bradleigh Trevor Barnes was found suspended by a ligature in his cell at HMP YOI Portland on 28 December 2019. The inquest concluded that the death was suicide. Concerns included a lack of national NHS guidance for healthcare staff on the use of force in prison and the absence of a local operating policy between the prison and healthcare provider at HMP YOI Portland.

Terri Ann Malone · Prevention of Future Deaths report View report

24 Oct 2022 Herefordshire H. Bricknell

Terri Ann Malone was drinking excessively and probably died from ketoacidosis as a consequence of excessive alcohol consumption. The concerns included treatment planning without direct contact by an experienced practitioner, discharge after a missed appointment and unanswered voicemail despite a lengthy wait, and discharge without establishing her current circumstances or other agencies’ involvement.

Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report View report

24 Oct 2022 Birmingham and Solihull L. Hunt

Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to hospital. Both were found to have metabolic acidosis, acute kidney injury, rhabdomyolysis and sickle cell trait; the final causes of death remained under investigation, with the most likely cause of collapse described as sickle cell trait combined with military exercise. The principal concern was the risk of death or harm to non-UK selection candidates, including the need to consider screening for sickle cell trait.

Matthew James Rouch · Prevention of Future Deaths report View report

24 Oct 2022 South Wales Central R. Knight

Matthew Rouch, aged 41, was fatally injured in a motorbike collision with a roundabout on the A48 near Cowbridge on 29 September 2021. The report raised concerns that the A48 Forage roundabout junction was dangerous and that, without changes to improve awareness and reduce vehicle speeds, further deaths might occur.

Glenys Roberts · Prevention of Future Deaths report View report

24 Oct 2022 North West Wales K. Sutherland

Glenys Roberts was found on the floor by her front door on 23 August 2021 with leg pain and loss of sensation, and was diagnosed with a complete occlusion of the distal aorta. An ambulance transfer for vascular surgery did not take place in a timely manner or at all before she became too frail to be conveyed; she was certified deceased at 07.39 on 24 August 2021. Concerns included slow progress on intra-hospital transfers, the vascular emergency transfer pathway, and an ambulance handover plan intended to improve ambulance availability.

Ruwaida Abdi Adan · Prevention of Future Deaths report View report

22 Oct 2022 East London L. Woods

Ruwaida Abdi Adan, aged 15, died after her headscarf became entangled in the moving parts of a go-kart, pulling tightly around her neck and causing asphyxia. The report identified concerns about the adequacy of checks for headscarves, loose clothing and hair, the condition and mechanical checks of karts, and the training and monitoring of track marshals.

KEITH RUPERT DIMOND · Prevention of Future Deaths report View report

22 Oct 2022 North East Kent S. Hayes

Keith Dimond died on 24 November 2021 at Queen Elizabeth Queen Mother Hospital following a catastrophic bleed from a ruptured iliac artery aneurysm, with anticoagulation contributing to the excessive bleeding. Concerns included communication failures about the known iliac artery aneurysm, lack of information about bleeding risks when anticoagulation was prescribed, delayed escalation when he deteriorated, and haematology advice on anticoagulation not being followed on two occasions.

Carl Shaun Langdell · Prevention of Future Deaths report View report

21 Oct 2022 West Yorkshire Eastern K. McLoughlin

Carl Shaun Langdell was discovered in his locked, single-occupancy prison cell with a significant neck wound and died after suffering cardiac arrest despite emergency treatment. The concerns included his identified chronic risk of suicide or self-harm, recent bizarre and agitated behaviour after refusing medication, and his being permitted to possess an unspecified item while alone in his cell overnight. The inquest recorded a finding of suicide and attributed the death to haemorrhage from a neck incision.

Daniel John O’Sullivan · Prevention of Future Deaths report View report

21 Oct 2022 Inner South London C. Williams

Daniel John O’Sullivan was found deceased on 27 March 2019 while a voluntary psychiatric patient at St Charles Hospital, after leaving the hospital unescorted and failing to return. The principal concerns were failures to update his self-harm risk assessment, formulate a care and treatment plan, document unescorted leave, and promptly notify police when he did not return. The report also raised concerns that the hospital’s serious incident investigation did not identify or investigate these issues adequately.

Robert Lee Evans · Prevention of Future Deaths report View report

20 Oct 2022 Swansea and Neath Port Talbot K. Heaven

Robert Lee Evans, a prisoner at HMP Swansea, was found deceased in his cell in the early hours of 14 January 2018 after tying a ligature around his neck, shortly after arriving at the prison and while undergoing alcohol detoxification. The concerns included inadequate assessment and monitoring of his suicide and self-harm risk, failures relating to prescribed antidepressant and detoxification medication, and failures to promptly capture evidence from prison staff witnesses after his death.

Clifford William ROSE · Prevention of Future Deaths report View report

20 Oct 2022 Milton Keynes T. Osborne

Clifford William Rose died on 10 August 2022 after a serious infection developed from a burn caused by an electric blanket, followed by amputation of his leg. The inquest identified failures in assessing his care needs and escalating concerns about his deteriorating health and self-neglect. It also found that telephone assessments had incorrectly indicated he could dress himself and was eating and drinking regularly.

Charley Ann Patterson · Prevention of Future Deaths report View report

19 Oct 2022 North and South Northumberland A. Hetherington

Charley Ann Patterson had experienced low mood, anxiety, bullying and previous self-harm. She attended hospital for support in May 2020, but the planned referral to the Northumberland (Early Help) Hub was not made and there was an absence of communication with other services and professionals. She later died by suicide on 1 October 2020. The concerns included increased demand for children’s mental health support following the Coronavirus pandemic and delays in receiving treatment and early support.

Max TURBUTT · Prevention of Future Deaths report View report

18 Oct 2022 Inner North London M. Hessel

Max Turbutt had experienced mental ill health for several years and had been supported by Kent County Council services as a care leaver. The report states that he died by suicide, with the medical cause of death recorded as hanging. Concerns were raised that attempts by Max and his father to contact his personal adviser were unsuccessful, with no phone redirect or email out-of-office message, and that a crisis number led only to an answerphone.