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Daniel Robert Ludlam · Prevention of Future Deaths report View report

7 Jun 2022 Central and South East Kent K. Hepburn

Daniel Robert Ludlam died at the scene on 30 December 2019 after an obstructed hiatus hernia caused gastrointestinal haemorrhage and hypovolemic shock. Concerns included that NHS Pathways triage did not specifically account for callers with learning disabilities, and that the absence of a suitable procedure could lead to incorrect triage or delays in sending paramedic support, particularly where no carer was available to assist communication.

Andrew Arden Nixon · Prevention of Future Deaths report View report

6 Jun 2022 Dorset R. Middleton

Andrew Arden Nixon’s mental health deteriorated from around October 2020, and after referral and assessment by mental health services he was found suspended by a ligature in wooded grounds in North Dorset on 3 March 2021. The principal concerns were that family members or carers were not fully involved in risk assessment and care planning, and that criteria for considering a Carer’s Assessment were not applied at the earliest appointment.

Esma GUZEL · Prevention of Future Deaths report View report

1 Jun 2022 Hull and East Riding of Yorkshire D. Bell

Esma Guzel, aged five, died on 10 May 2019 after developing vomiting and abdominal pain due to complications of a congenital diaphragmatic hernia. After a GP assessment and subsequent deterioration, the 111 service advised attendance at an out-of-hours GP service, where she arrived in cardiac arrest and could not be resuscitated. The principal concerns relate to questioning about vomitus, the 111 algorithm’s assessment and disposition, and referral to paediatric services.

Angela Maguire · Prevention of Future Deaths report View report

1 Jun 2022 West London L. Brown

Angela Maguire deteriorated after being referred for investigation of suspected malignancy and died in Kingston Hospital on 8 April 2021 following an upper gastrointestinal bleed. The report identified the lack of a shared regional system for accessing radiology images, which meant Kingston Hospital could not access previous images from Queen Mary's Hospital; this resulted in missed opportunities for diagnosis and palliative care, although it did not affect the outcome in this case.

Samuel Joseph Gomm · Prevention of Future Deaths report View report

1 Jun 2022 South Wales Central G. Hughes

Samuel Joseph Gomm, who had chronic mental ill health exacerbated by periods of alcohol abuse, died after deliberately self-inflicting lacerations to his neck at home on 3 June 2019. The principal concerns related to the WARRN risk-assessment tool: its format, accessibility and presentation could make fluctuating self-harm risks difficult for new or infrequent users to identify, potentially resulting in under-estimation of risk and sub-optimal mitigating measures.

Mark SUMNALL · Prevention of Future Deaths report View report

30 May 2022 Derby and Derbyshire P. Nieto

Mark Sumnall died in hospital on the morning of 21 December 2020 after choking and aspirating on a sandwich given by hospital staff. He had a recognised choking risk, but hospital staff were not aware of it despite his care plan being sent with him in a Red Bag. The report raised concerns about failures to identify and use the Red Bag and to transfer relevant care and risk information between the care home, ambulance service and hospital.

Albert Thomas Stafford Manley · Prevention of Future Deaths report View report

30 May 2022 Wiltshire and Swindon D. Ridley

Albert Thomas Stafford Manley, known to his family as “Jim”, died at Southampton General Hospital on 31 May 2021 from multiple traumatic injuries sustained when his Ford Mondeo collided with an oncoming Land Rover Discovery on the B3081 near Tollard Royal. The report raises concern that the road layout, junction and bends could be misread by unfamiliar drivers, potentially contributing to collisions, and considers whether further warnings or other measures could reduce this risk.

Dean Ryan CROSSMAN · Prevention of Future Deaths report View report

26 May 2022 Teesside and Hartlepool J. Wharton

On 18 June 2019, Dean Ryan Crossman was found hanging after contact with emergency and crisis mental health services following suicidal behaviour the previous evening. The report identifies ongoing concerns about out-of-hours access to second doctors for Mental Health Act assessments and delays in securing private ambulance attendance.

SAIFUR RAHMAN · Prevention of Future Deaths report View report

26 May 2022 Birmingham and Solihull J. Bennett

Saifur Rahman was found in cardiac arrest in his cell at HMP Birmingham on 20 January 2021, was taken to hospital after resuscitation, and died on 23 January 2021. The post-mortem recorded hypoxic/ischaemic encephalopathy associated with external neck compression, and the jury found that his intention was to commit suicide. The report raised concerns about delayed emergency calls, inadequate records of cell history, insufficient cell risk assessments, and the lack of a formal process for prison and mental health staff to inspect and act on cell risks.

Katie Julia WILKINS · Prevention of Future Deaths report View report

26 May 2022 Liverpool and the Wirral K. Ainge

Katie Julia WILKINS was a 14-year-old girl with acute promyelocytic leukaemia and associated coagulopathy who suffered a catastrophic intracerebral haemorrhage after fibrinogen concentrate was not administered in accordance with her treatment plan. She underwent decompressive surgery but did not recover and died on 31 July 2020. The principal concern was that management of coagulopathy in APML patients at Alder Hey Trust would continue to be led by Oncology Consultants rather than Haematologists, despite the serious bleeding risk.

Elizabeth Margaret Mills · Prevention of Future Deaths report View report

25 May 2022 East London G. Irvine

Elizabeth Margaret Mills was admitted to hospital with abdominal pain on 25 March 2021, underwent surgery for a perforated pyloric ulcer, and later developed pneumonia requiring increasing oxygen therapy. She died after removing an oxygen mask while unattended in a side ward, when nasal cannulae were replaced but were no longer connected to an oxygen supply. Concerns included poor medical record-keeping about the do-not-attempt-CPR process, reliance on her husband to keep the mask in place, and the Trust’s failure to investigate unexpected events through a Serious Incident Investigation.

Raymond Gillespie · Prevention of Future Deaths report View report

25 May 2022 North Wales (East and Central) K. Sutherland

Raymond Gillespie, a care home resident with multiple comorbidities, suffered an unwitnessed fall on 8 October 2021 and waited almost 15 hours for a paramedic response after calls to the Welsh Ambulance Service Trust. The report identified delays caused by resource availability and ambulance handover delays, with a continuing risk of future deaths or harm while patients await transfer or community paramedic assistance.

Ian Michael Cockfield · Prevention of Future Deaths report View report

25 May 2022 East London G. Irvine

Ian Michael Cockfield died in hospital on 12 July 2021 after collapsing and sustaining a cardiac arrest despite resuscitative efforts. The report raised concern that, after transfer to a mental health ward, his falls risk assessment was not reviewed and he subsequently fell while mobilising unsupervised, sustaining a serious head laceration.

Michael Nestor WYSOCKYJY · Prevention of Future Deaths report View report

24 May 2022 Norfolk J. Lake

Michael Nestor WYSOCKYJY became unwell on 20 September 2021 and was taken to Queen Elizabeth Hospital, where delays occurred before a chest x-ray was performed. A large right-sided pneumothorax was identified shortly before he suffered cardiac arrest and was pronounced dead. Concerns related to delays in ambulance offloading and the lack of clear escalation arrangements to ensure requested x-rays were completed in a busy emergency department.

Robert Arthur Brown · Prevention of Future Deaths report View report

20 May 2022 North East Kent J. Andrews

Robert Arthur Brown, who had a history of suicide attempts and suicidal ideation, was discharged from hospital after four days without his wife being contacted. On 9 September 2020, he was found fatally injured at cliffs close to his home address. The principal concerns were that “carer breakdown” might not be identified before discharge and that, without a process requiring contact with a carer where no CPA was in place, anticipated care might not be available.

Sangeerth GIRIRATHAN · Prevention of Future Deaths report View report

19 May 2022 Milton Keynes T. Osborne

Sangeerth GIRIRATHAN, aged 23, was involved in a road traffic collision on the M1 motorway and suffered a traumatic brain injury. While receiving intensive care, he suffered a cardiorespiratory arrest after a tracheostomy blockage was not recognised because the monitor alarm was switched off, and he died on 12 December 2021. The concerns included disengaged monitoring alarms and the absence of regulations governing the hours worked by van drivers.

Hassan Zubair · Prevention of Future Deaths report View report

19 May 2022 East London G. Irvine

Hassan Zubair was identified on Platform 3 of Goodmayes station after a welfare concern was reported, and was struck and killed instantly by a train at 13:45 on 2 December 2021. The principal concern was the failure of the signals controller to advise trains travelling through the relevant section to proceed with caution.

Spencer George BARR · Prevention of Future Deaths report View report

19 May 2022 Birmingham and Solihull A. Hodson

Spencer George BARR was found unresponsive at home on 9 December 2021 and was declared deceased by paramedics after an overdose involving opioids, cocaine and pregabalin. He had a long history of substance misuse and labile mental health and was under the care of probation, addiction and mental health services. The principal concerns were inadequate sharing of information and cooperation between agencies, the lack of central points of contact, and limitations on inter-agency referrals.

Matthew John Evans · Prevention of Future Deaths report View report

18 May 2022 Surrey K. Henderson

Matthew John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.

Marjorie Grayson · Prevention of Future Deaths report View report

16 May 2022 South Yorkshire (Western) A. Combes

Marjorie Grayson died by suicide on 3 September 2020 after falling from a first-floor bedroom window at her home. The report identified concerns about the use of a hospital order without additional restrictions, inadequate consideration of the seriousness of her previous offence and impulse-control risks, limited face-to-face contact after discharge during the Covid-19 pandemic, and insufficient support and communication for her family.