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Dr Lee Winslow · Prevention of Future Deaths report View report

17 Aug 2022 Manchester South C. Morris

Dr Lee Winslow was found dead at home on 12 June 2021 after taking medication with the intention of ending his life; the inquest concluded that he died from toxicity and recorded suicide. The report raises concerns that, after his earlier suicide attempt and admission to taking medicines from Trust stocks, the case was not formally referred to the Police or General Medical Council, and that decisions were made without meaningful external or multidisciplinary review.

Susan Mary Regan · Prevention of Future Deaths report View report

17 Aug 2022 Manchester South C. Murray

Susan Mary Regan, aged 61, experienced deteriorating mental and physical health, including malnutrition, dehydration, disturbed behaviour and possible self-harm, before being admitted to hospital and later discharged with support. On 25 July 2020, she took her own life at home. The principal concerns were that the Home Treatment Team did not consult her sons about possible hospitalisation and did not properly record or communicate a care plan with them.

Philip Jones · Prevention of Future Deaths report View report

17 Aug 2022 Manchester South A. Mutch

Philip Jones developed difficulty swallowing in February 2021, lost significant weight, and was diagnosed with Motor Neurone Disease after hospital admission in September 2021. He developed bronchopneumonia, deteriorated, was discharged home, and died there on 9 October 2021. Concerns included backlogs for neurology appointments, incompatible IT systems affecting information sharing, and delays in communications from consultants to other clinicians and patients.

Helen Ruth BURNELL · Prevention of Future Deaths report View report

12 Aug 2022 Somerset T. Williams

Helen Ruth Burnell choked on a sandwich while eating dinner and suffered a fatal hypoxic brain injury after respiratory and cardiac arrest. The report raised concerns that staff had not adequately recognised choking risks and that improved training was needed to support adherence to meal-time recommendations.

Brandon James Pryde and David Ernest Faulkner · Prevention of Future Deaths report View report

12 Aug 2022 Manchester South A. Farrow

Brandon Pryde and David Faulkner died at the scene after a stolen BMW, driven by Brandon Pryde, travelled against the flow of traffic on the M60 and collided with David Faulkner’s vehicle at high speed. Concerns arose that the protocol for transferring command and control of police pursuits between GMP and NWMPG did not operate in practice, resulting in no effective command and control during the pursuit.

Gerald Kenneth Tuck · Prevention of Future Deaths report View report

12 Aug 2022 Dorset R. Griffin

Gerald Kenneth Tuck, who had dementia and lived in a residential home, sustained repeated falls in December 2021 and January 2022. After the final fall, he was diagnosed with two acute subdural haematomas, his condition deteriorated, and he died on 2 March 2022. The concern was that the home had no written policy or guidance requiring care plans and falls risk assessments to be reviewed after incidents.

Lily May Girton · Prevention of Future Deaths report View report

11 Aug 2022 East London N. Persaud

Lily May Girton, who had anxiety, depression and emotional dysregulation, died after taking her own life while suffering from mental illness. The inquest found that her death was contributed to by failures in the community CAMHS team concerning psychiatric assessment, risk management and titration of antidepressant medication. It also raised concerns that inadequate staffing and resources in CAMHS services pose a risk of future deaths of young people.

Ms Katie Horne · Prevention of Future Deaths report View report

11 Aug 2022 Inner South London A. Harris

Ms Katie Horne presented with jaundice, developed severe hepatitis and liver failure, tested positive for Covid-19, developed Covid pneumonitis, and died on 11 April 2020. The principal concerns were delays in identifying crucial blood test results, consulting a gastroenterologist, starting steroid therapy, and referring her for possible liver transplantation.

Neil David James McDougall · Prevention of Future Deaths report View report

10 Aug 2022 Somerset S. Marsh

Neil David James McDougall, a former serviceman with a history of mental health problems following active military service and alcohol misuse, was discovered deceased at home on 23 February 2021. The inquest concluded the death was accidental and involved toxicity. Concerns included the lack of individual post-deployment debriefing, the absence of mandatory mental health assessment during Army discharge, and the coordination of support for departing personnel.

Allan Michael WADDUP · Prevention of Future Deaths report View report

10 Aug 2022 North Northumberland A. Hetherington

Allan Michael WADDUP died in prison on 13 December 2019 after seeking mental health support. He had been referred and later self-referred, but was discharged without an assessment, was not assessed before his death, and concerns were raised about appointment notification, the Did Not Attend process, delays in triage, and the absence of weekend triage or urgent-assistance guidance on the prison kiosk.

Mathew Christopher Moore · Prevention of Future Deaths report View report

9 Aug 2022 Dorset S. Nicholls

Mathew Christopher Moore died on 7 August 2021 in Bournemouth, Dorset, having attached a rope as a ligature. The report records concerns about the combined use of prescribed medication and excess alcohol, including potentially unsafe prescribing, a lack of documented communication of concerns to Mr Moore, and the need for clearer policies, dosage review, follow-up, and information-sharing within the surgery.

Mr Gerwyn John REES · Prevention of Future Deaths report View report

8 Aug 2022 Avon R. Sowersby

Mr Gerwyn John REES, who was elderly and frail, was admitted to hospital after experiencing falls and was assessed as requiring low-risk enhanced care observations. He fell twice on 29 November 2020, fracturing his hip, and later died in January 2021 following surgery, as a result of general frailty and the hip injury. The principal concerns were the initial low-risk falls assessment, inadequate steps to prevent the fall, and an apparent lack of learning and investigative rigour following his death.

Robyn Lily Audrey SKILTON · Prevention of Future Deaths report View report

7 Aug 2022 West Sussex P. Schofield

On 7 May 2021, 14-year-old Robyn Lily Audrey Skilton was found in Southwater Park with a ligature around her neck, and her death was confirmed by emergency services. The inquest concluded that Robyn took her own life while struggling with her mental health, and that mental health services failed to recognise the deterioration in her mental health or provide the care and treatment she required. The report raised concerns about delayed assessment and treatment, including a lack of timely access to Child Psychiatrist and CAMHS services and insufficient resourcing.

Ernest Bacon · Prevention of Future Deaths report View report

6 Aug 2022 Manchester South A. Mutch

Ernest Thomas Bacon suffered an accidental fall at home, sustained a fractured neck of femur, and was admitted to Tameside General Hospital, where he subsequently had an ischaemic stroke. After triggering for sepsis on 16 January 2022, he was not reviewed face to face, the sepsis pathway was not followed, intravenous antibiotics were delayed, and the failure to escalate was not recognised. He died from sepsis at the hospital on 17 January 2022.

John Edward Kay · Prevention of Future Deaths report View report

4 Aug 2022 Manchester South A. Mutch

John Edward Kay had previously undergone larynx removal for stage 4 cancer and had a speech valve, alongside significantly reduced respiratory lung function. He was admitted to Stepping Hill Hospital after a series of aspiration pneumonias and died there on 26 November 2021. Concerns included the failure to share information about caring for his valve with his care home, lack of regular monitoring and replacement, and limited understanding in the community of the specialist nurse service’s role and support.

Margaret Ena Warwick · Prevention of Future Deaths report View report

4 Aug 2022 Manchester South A. Mutch

Margaret Ena Warwick, who had significant ischaemic heart disease and left ventricular dysfunction, suffered an accidental fall at home on 23 February 2022 and was taken to hospital with a fractured neck of femur requiring surgery. Her pre-operative cardiac review, surgery and access to a high-dependency unit bed were delayed by shortages of cardiology cover, theatre capacity and HDU beds. She initially recovered after surgery but deteriorated and died in hospital on 7 March 2022.

Roy DRAPER · Prevention of Future Deaths report View report

4 Aug 2022 Derby and Derbyshire S. Lomas

Roy Draper, who had mesothelioma linked to occupational asbestos exposure, became unwell after chemotherapy in a clinical trial, later developed bronchopneumonia and suffered a massive stroke, and died in hospital on 13 February 2020. Concerns were raised about the lack of a clear process and responsibility for requesting unblinding when a clinical-trial patient became acutely unwell at another hospital, and about the absence of a formal referral system for reporting adverse events to the trials team.

Malcolm John Garrett · Prevention of Future Deaths report View report

4 Aug 2022 Manchester South A. Mutch

Malcolm John Garrett, who was immunosuppressed following a bilateral lung transplant, was admitted with severe back pain and subsequently developed pneumonia and Covid-19 while an inpatient. He deteriorated and died at Stepping Hill Hospital on 23 September 2021; post-mortem examination identified Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia as the direct causes of death. Concerns included the absence of specific guidance for managing high-risk immunosuppressed patients, expediting their discharge or using alternative treatment methods, and monitoring kidney function to reduce opiate toxicity.

Stanislav Mucha · Prevention of Future Deaths report View report

4 Aug 2022 Manchester North J. Kearsley

Stanislav Mucha, aged 17, died after jumping from a height at the Rock centre in Bury, sustaining catastrophic injuries. The report raised concerns about the lack of notes from an independent psychiatrist and the absence of documented agreement between professionals about the outcome of a mental health assessment and the actions required.

James Robert Curry · Prevention of Future Deaths report View report

4 Aug 2022 Manchester South A. Mutch

James Robert Curry died at Tameside General Hospital on 18 November 2021 from bronchopneumonia after an accidental fall caused a fractured neck of femur. The report identified prolonged waiting in the emergency department, shortages of beds and theatre capacity, lack of orthogeriatric care, and surgery taking place outside the recommended timescale as substantive concerns.