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Mustafa Dawood Bakht ABDELKARIM (Mustafa Dawood) · Prevention of Future Deaths report View report

19 Nov 2021 Gwent C. Saunders

On 30 June 2018, Mustafa Dawood was pursued by Immigration Officers at a car wash in Newport, climbed onto a roof, fell through plastic roofing, and died in hospital from severe head injuries. The jury identified concerns that officers remained close after the pursuit was to be abandoned, that this decision was not effectively communicated, that a baton was kept racked, and that officers lacked appropriate pursuit training; these factors could have contributed to his death.

Sarah McGarrigle · Prevention of Future Deaths report View report

19 Nov 2021 Manchester North C. McKenna

Sarah McGarrigle, aged 23, was found deceased at home on 1 March 2020. She died from catastrophic internal haemorrhage caused by spontaneous rupture of oesophageal varices associated with chronic alcohol use, in the context of trauma, mental disorder and self-neglect. The principal concerns were that relevant information about her history and community behaviours was not properly considered on Aspen Ward, and that a requested assessment of her mental disorder and capacity did not take place.

Ms Karen Redding · Prevention of Future Deaths report View report

18 Nov 2021 Black Country Z. Siddique

Ms Karen Redding died after drinking an excess of Oramorph, becoming increasingly drowsy and suffering a fatal overdose. During the inquest, concern arose that care staff handed her the medication without checking the box contents, and that she was not seen by a doctor after disclosing that she had taken too much.

Rebecca Dobson and 4 others · Prevention of Future Deaths report View report

18 Nov 2021 West Sussex P. Schofield

On 10 February 2018, a helicopter crashed over the Grand Canyon and caught fire. Rebecca Dobson, Jason Hill, Stuart Hill, Eleanor Udall and Jonathan Udall survived the crash but died from thermal injuries and smoke inhalation caused by the ensuing fire. The principal concerns were that helicopters without crash-resistant fuel systems remained in operation, that retrofit installation was not mandatory, and that the absence of a central register prevented passengers from knowing whether an aircraft had such a system.

Victoria HARRILD-JONES · Prevention of Future Deaths report View report

17 Nov 2021 Suffolk N. Parsley

Victoria Harrild-Jones died at home on 27 December 2019 after developing a pulmonary embolism following gastric bypass surgery, with peritonitis, reduced mobility and thrombosis identified in the account of her death. The principal concern was that she was not prescribed prophylactic anti-coagulation medication after discharge, unlike the treatment described as required for UK-based patients under NICE guidance, potentially resulting in care below the standard expected in the UK for military personnel and dependants treated overseas.

Trevor Alton SMITH · Prevention of Future Deaths report View report

17 Nov 2021 Birmingham and Solihull L. Hunt

Trevor Smith died after being shot by a member of a police armed response unit during an attempted arrest at his home. The principal concerns were that information about an alleged previous overdose was not recorded or cascaded to the firearms team, and that officers were confused about CPR rescue breaths and coordination during resuscitation.

Sharon Anne ROBINSON · Prevention of Future Deaths report View report

16 Nov 2021 West Yorkshire (Western) A. Howard

Sharon Robinson died at Airedale Hospital on 7 February 2019 after an antibiotic administered on 27 January induced an anaphylactic reaction. The principal concern was that a possible patient sensitivity to an antibiotic might be disregarded and the antibiotic given despite that risk.

Joseph MARTIN · Prevention of Future Deaths report View report

16 Nov 2021 Inner North London M. Hassell

Joseph Martin approached Metropolitan Police Service officers near Westminster Bridge on 3 June 2021, after concerns had been raised about his mental health and safety. The inquest found that he was suffering a psychotic relapse at the time of his death, but the exact circumstances were unclear. The report raised concerns that important information about his mental health and vulnerability was not shared between police forces and that individual errors and wider system weaknesses failed to provide a safety net.

Emma Burbury · Prevention of Future Deaths report View report

11 Nov 2021 Cornwall and Isles of Scilly A. Cox

Emma Burbury collapsed after an altercation with her partner and died in hospital on 19 September 2018; the forensic pathologist considered it possible that injuries from the altercation caused or contributed to her death, but the evidence was insufficient to establish this as probable or certain. The report identified a missed opportunity to provide treatment after her July 2017 assessment and concerns about services for people with dual diagnoses, including care coordination, communication between organisations, engagement, and discharge arrangements.

Mared Thomas Foulkes · Prevention of Future Deaths report View report

10 Nov 2021 North West Wales K. Sutherland

Mared Thomas Foulkes, aged 21, died beneath the Britannia Bridge on 8 July 2020; the inquest concluded that her death was suicide. Concerns included complex and potentially misleading examination-result communications, and the absence of a system for personal tutors to contact vulnerable students before failed results were released.

Daniel HALL · Prevention of Future Deaths report View report

10 Nov 2021 South Wales Central S. Richards

Daniel Hall was a 20-year-old student at the University of South Wales who expressed suicidal thoughts on two occasions while awaiting mental health support. He died at his student accommodation on 9 December 2019, and the coroner’s short-form conclusion was suicide. The principal concern was lengthy delays in accessing mental health support despite expressed suicidal ideation and known autism spectrum disorder, together with a lack of safeguarding.

Philip Anthony ELLIS · Prevention of Future Deaths report View report

10 Nov 2021 County Durham and Darlington C. Oliver

Philip Anthony Ellis died on 28 May 2021 at a drugs rehabilitation service after self-administering drugs that he had obtained while leaving the premises unsupervised. The principal concerns were that he was able to leave the service in breach of its rules to obtain drugs, and that Free the Way had not undertaken a serious incident review into the supervision failures.

Susan Merton · Prevention of Future Deaths report View report

9 Nov 2021 North Wales (East and Central) J. Gittins

Susan Merton underwent a CT scan whose report did not identify a common bile duct stone. After the stone was recognised and treatment was scheduled, her condition deteriorated acutely and she died at Glan Clwyd Hospital on 23 August 2019. The report raised concerns that the Health Board had not implemented or reviewed actions from its investigation within its own timeframe, potentially putting lives at risk.

Ethel Ann Beaumont · Prevention of Future Deaths report View report

9 Nov 2021 Cambridgeshire and Peterborough L. QC

Ethel Ann Beaumont died on 11 May 2020 after developing nitrofurantoin-induced liver injury and liver failure while being treated before planned surgery. The report found that a significantly raised ALT result should have been followed up promptly and raised concerns about unclear responsibility between hospital and primary care for monitoring antibiotics prescribed at the hospital’s request.

Mollie Daisy DIMMOCK · Prevention of Future Deaths report View report

9 Nov 2021 Buckinghamshire C. Butler

Mollie Daisy DIMMOCK died 34 minutes after delivery at Stoke Mandeville Hospital from perinatal asphyxia caused by hypoxia associated with umbilical cord compression during shoulder dystocia. The report identified uncertainty in national guidance because there is no definition of a large-for-gestational-age baby, creating variation in decisions about delivery mode and management of shoulder dystocia.

Katrina Makunova · Prevention of Future Deaths report View report

5 Nov 2021 Inner South London A. Harris

Katrina Makunova had experienced abuse, coercive and controlling behaviour, and threats before she was fatally pushed by her ex-boyfriend on 12 July 2018. The report identified concerns about knives and gang affiliation not being consistently recognised or recorded as risk factors, and about workload pressures affecting the capacity of police Child Safety Units to carry out safeguarding effectively and safely.

Robert Wright · Prevention of Future Deaths report View report

4 Nov 2021 South Wales Central D. Regan

Robert Wright, aged 80, died at Prince Charles Hospital on 26 July 2019 after his condition deteriorated; post-mortem examination identified necrotising cholecystitis caused by gallstones. The principal concern was that a hospital referral for consideration of cholecystectomy was not available to the consultant surgeon because paper referrals were routinely added to patient notes only shortly before clinic appointments, creating a risk that clinicians may not have all relevant information.

Christian Gary HINKLEY · Prevention of Future Deaths report View report

4 Nov 2021 Mid Kent and Medway S. Matthewson

Christian Gary Hinkley, a prisoner at HMP Swaleside, died from smoke inhalation after a fire developed in his barricaded cell during the night of 28–29 July 2019. The report raises concerns that prison fire detection systems could not reliably detect cell fires early enough to allow life-saving action, particularly for prisoners at increased risk, and that installing in-cell detectors across prisons could take years.

RHIAN EMMA KATE ROSE · Prevention of Future Deaths report View report

3 Nov 2021 Worcestershire N. Lane

Rhian Rose became unwell during a hospital admission for the second phase of medical termination of pregnancy following feticide for trisomy 21. Her condition deteriorated, leading to emergency caesarean section, hysterectomy and cardiac arrest; she died from multi-organ failure and sepsis on 25 November 2019. The principal concerns were insufficient consideration of informed consent and maternal choice regarding mode of delivery, and inadequate guidance on infection risks and delivery options following feticide.

Saskia Jones and 2 others · Prevention of Future Deaths report View report

3 Nov 2021 London City H. QC

On 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.