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TERENCE TALBOT · Prevention of Future Deaths report View report

3 Dec 2021 Mid Kent and Medway S. Hayes

Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.

Alexander George Theodossiadis · Prevention of Future Deaths report View report

3 Dec 2021 West Yorkshire Eastern K. McLoughlin

Alexander George Theodossiadis, aged 25, died in hospital on 28 January 2020 after treatment for bacterial meningitis, a fall from a hospital bed, and a resulting head injury. Concerns included difficulty obtaining a timely GP appointment and insufficient symptom assessment, inadequate hospital transfer handover and care planning, uncertainty about meningitis management, and failure to assess or communicate his risk of falling.

Alaynah Khadija AHMED · Prevention of Future Deaths report View report

2 Dec 2021 Inner North London M. Hassell

Khadija suffered a cardiac arrest at school on 1 July 2021 and died a week later from a hypoxic brain injury. The principal concern was that the teaching assistant had not been trained in CPR and no staff member attempted CPR when Khadija became unresponsive; frequent CPR training was identified as needing consideration.

Kaja Weronika SPIEWAK · Prevention of Future Deaths report View report

1 Dec 2021 West Sussex R. Simpson

On 7 April 2021, Kaja Weronika SPIEWAK was identified as vulnerable while travelling by train and was later declared deceased at 1.07pm after being at Southbourne Station. The report raised concerns about inadequate training, inappropriate control-room guidance, incomplete recording of actions, and failures to share welfare concerns with relevant agencies.

Connor Arthur Steven Hout · Prevention of Future Deaths report View report

30 Nov 2021 West Yorkshire Eastern J. Wolstenholme

Connor Arthur Steven Hout, aged 24, was found deceased in his prison cell on 10 June 2019 after several brief observations by prison officers during the morning. The report identified that welfare checks did not require officers to obtain a response or engage with prisoners, including those who appeared to be asleep, creating a risk that prisoners in distress or otherwise causing concern could be missed.

James Michael Lacey · Prevention of Future Deaths report View report

29 Nov 2021 Lancashire and Blackburn with Darwen J. Adeley

James Michael Lacey, otherwise known and living as Victoria Lacey, died by suicide on 13 June 2020 after taking a fatal dose of a readily available chemical together with other preparations. The report raised concerns about the ease of purchasing the substance and the less rigorous controls applied to reportable poisons compared with regulated poisons.

Jordan Shaun Mhlanga-Veira · Prevention of Future Deaths report View report

26 Nov 2021 Berkshire H. Connor

Jordan Shaun Mhlanga-Veira, aged 15, got into difficulty while playing with friends in a river at a site in Cookham, Berkshire, on 31 May 2021 and subsequently drowned. He was found dead in the early hours of the following morning. The report raised concerns about the absence of safety measures at the site, including warning signs, throw ropes and buoys, and about the lack of a statutory framework for safety measures at inland waters.

Frances Rose Thomas · Prevention of Future Deaths report View report

26 Nov 2021 Surrey K. Henderson

Frances Rose Thomas was a vulnerable teenager who, while attending Stepping Stones School, was often left without formal supervision and had unsupervised access to school electronic devices. On 25 September 2018, after accessing material at school, she went home and undertook a similar act resulting in her death. The report raised concerns about inadequate school e-security, monitoring and supervision, outdated regulatory guidance, and insufficient controls over age-inappropriate content on an online platform.

Felicity Jane Clough · Prevention of Future Deaths report View report

26 Nov 2021 Dorset R. Griffin

Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.

Gary Williams · Prevention of Future Deaths report View report

26 Nov 2021 Liverpool and the Wirral A. Rebello

Gary Williams died on 28 July 2017 after a pulmonary thromboembolism and deep venous thrombosis, with ictal automatism due to temporal lobe epilepsy also recorded as a cause. The report describes concerns about the lack of detailed information passed during handovers, omissions in medical records concerning restraint, use of force and injuries, and inconsistent communication between hospital departments. It also notes that ictal automatism was not included in College of Policing training materials on restraint.

Neil James STEWART · Prevention of Future Deaths report View report

25 Nov 2021 Newcastle upon Tyne K. Dilks

Neil James Stewart travelled to Amsterdam in November 2017 and, on 18 November 2017, entered the Noordzeekanaal after jumping from a party boat; his body was recovered on 3 December 2017. The concerns addressed written safety policies and warnings for guests, venue-specific risks, and clarity about safety responsibilities between entertainment providers and venue organisers.

Saif Mubeen Hussain · Prevention of Future Deaths report View report

25 Nov 2021 Berkshire H. Connor

Saif Mubeen Hussain died at John Radcliffe Hospital on 10 June 2021 after being admitted following an incident in Bracknell, Berkshire, on 3 June 2021; the recorded cause of death was polytrauma. During his transfer between units, he was administered a Heparin infusion at almost eight times the prescribed rate. The report identified concerns about unfamiliarity with anticoagulants, inadequate double-checking, the Guardrails system being switched off, differences between prescription and administration rates not being flagged, and the use of separate hospital computer systems.

Joel Robinson · Prevention of Future Deaths report View report

25 Nov 2021 Berkshire H. Connor

Joel Robinson took his own life on 25 March 2019 after experiencing difficulties and perceived bullying during his military posting in Germany. The report raised concerns about the army’s passive approach to suicide prevention, including the identification and monitoring of risk factors, and about awareness of service complaint procedures.

Marshall Metcalfe and Jane Ireland · Prevention of Future Deaths report View report

25 Nov 2021 Blackpool and the Fylde A. Wilson

Marshall Metcalfe was transferred to hospital after sustaining catastrophic injuries on 7 May 2020, where his death was verified. Jane Ireland was found deceased at home on 7 June 2020, after the death of her seventeen-year-old son; the report records toxic effects, fatty liver disease and bronchopneumonia in relation to her death, while her intent could not be established. The principal concern was the lack of Children’s Social Care involvement in Marshall’s discharge planning and the potential future risk arising when social care cases are closed during mental health admissions and require re-referral before discharge.

Dr Malcolm Dixon · Prevention of Future Deaths report View report

25 Nov 2021 Manchester South C. Morris

Dr Malcolm Dixon became unwell in autumn 2019 with what was later diagnosed as a severe depressive illness and was admitted as an informal, voluntary patient to Priory Hospital, Altrincham. He died there on 29 December 2019 following an impulsive act undertaken in the context of severe mental illness. Concerns included inaccurate observation records, electronic care-record timestamps being overwritten, and the absence of professional documentation requirements for some unregistered staff.

Darrell Lee DEVLIN · Prevention of Future Deaths report View report

23 Nov 2021 Cumbria N. Shaw

Darrell Lee Devlin died at home on 23 February 2021 after being unwell with a chest infection and while receiving methadone treatment. The inquest record reported active bronchopneumonia and an extremely high level of Flubromazolin in his bloodstream. Concerns focused on reliance on telephone contacts, the absence of in-person assessment and drug testing, and the resulting difficulty in assessing and supporting him while receiving treatment.

BERENICE NADIKA BELL · Prevention of Future Deaths report View report

22 Nov 2021 Inner North London J. Stevens

Berenice had booked into an Airbnb and was found dead there on 20 May 2021 after failing to check out, having left a note. Evidence indicated that she had sought psychotherapy in April 2021 and had been feeling anxious and depressed; she had also lost her life savings after being scammed. Concerns included the role of ████████ in deaths among people under 35 and evidence that Berenice had accessed various ████████ family and mental health professionals, alongside reports of similar post-death findings by other families.

Barrie Keith Housby · Prevention of Future Deaths report View report

22 Nov 2021 Blackpool and the Fylde A. Wilson

Barrie Keith Housby, a hospital patient at high risk of falls, left his bed while the staff member assigned to observe him had temporarily left his bay and suffered a fatal fall. The report identified staffing shortages as contributing to the incident and raised concern that ongoing shortages at Clifton Hospital were putting elderly and vulnerable patients at risk.

Michelle Jeffries · Prevention of Future Deaths report View report

22 Nov 2021 Manchester South C. Morris

Michelle Jeffries had a complex medical history involving chronic, debilitating pain and had been prescribed large quantities of analgesic medication, including opiates. The report raised concern about the absence of local guidance on safely overseeing high-dose multiple analgesic prescriptions in the community and on when referral to a pain specialist should be required.

Robert Ellery · Prevention of Future Deaths report View report

19 Nov 2021 South Wales Central D. Regan

Robert Ellery was found ████████ in his prison cell on 31 October 2016. The report identified a 19-minute delay in informing the ambulance service and no direct communication method between ambulance call-centre staff and the prison staff providing basic life support. These issues delayed information sharing and impeded the provision of resuscitation guidance, giving rise to concerns about risks to other deaths.