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Mary Jane BUSH · Prevention of Future Deaths report View report

20 Oct 2021 Norfolk J. Lake

Mary Jane BUSH, who had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation, was found at her home on 6 August 2020; the inquest conclusion was suicide. The principal concerns were delays in her mental health assessment and psychological therapy, ongoing delays in providing therapy, and difficulties with recruitment and retention of suitably skilled staff.

Donna Constantine · Prevention of Future Deaths report View report

19 Oct 2021 Manchester South A. Mutch

Donna Ann Constantine, a vulnerable adult known to multiple agencies, was found severely decomposed at her home on 21 September 2019 after neighbours raised concerns. The post-mortem examination could not establish a cause of death, and the inquest conclusion was open. Concerns included the use of unmonitored police work mobile phones for contact from vulnerable people, alongside the absence of clear escalation, audit-trail, and verbatim call-recording policies.

Mohammed Abdus Salem · Prevention of Future Deaths report View report

18 Oct 2021 Manchester North J. Robertson

Mohammed Abdus Salem, who had chronic myelomonocytic leukaemia, was admitted to hospital after his condition deteriorated and died after being found unresponsive on 1 April 2021. A further intended dose of Rasburicase was not administered on 1 April despite high urate levels; it was considered more likely than not that giving it would have prolonged his life by up to 48 hours. The Root Cause Analysis did not examine the factors behind the omitted dose or its consequences, raising concerns about the rigour of the review and organisational learning from the death.

Sky Louise Rollings · Prevention of Future Deaths report View report

16 Oct 2021 Stoke-on-Trent and North Staffordshire E. Serrano

Sky Louise Rollings was transferred from a child and adolescent mental health hospital to an adult mental health unit on 4 November 2019 and died at Royal Stoke University Hospital on 9 November 2019, following an incident at Harplands Hospital. The inquest heard concerns about differences between child and adult mental health care and the lack of inpatient provision for people aged 14 to 25, which was considered to create a risk of further deaths.

Mr Harbans SINGH · Prevention of Future Deaths report View report

15 Oct 2021 Warwickshire S. McGovern

Mr Singh was admitted to Warwick Hospital with severe hypothyroidism on 23 April 2021 and died the following day. Concerns included failures in the discharge process, omission of his new diagnosis and medication from the discharge summary, and significant thyroid blood-test results not being flagged or acted upon.

Darren John Lawrence · Prevention of Future Deaths report View report

15 Oct 2021 Manchester City N. Meadows

Darren John Lawrence had a history of suicidal thoughts, plans, previous attempts, mental ill health, disengagement from services and medication noncompliance. He was found dead at his home on 29 August 2020, and the inquest conclusion was suicide. Principal concerns included inadequate communication and follow-up between mental health services and the GP practice, failure to ensure that prescribed venlafaxine was issued and collected, insufficient escalation when direct contact with him was unsuccessful, and inadequate systems for managing correspondence and medication.

Kirsty Marie Doodes · Prevention of Future Deaths report View report

14 Oct 2021 Cornwall and Isles of Scilly A. Cox

Kirsty Marie Doodes, who had a history of mental ill-health, was discharged from hospital on 18 March 2020 and later deteriorated at home. She died from her injuries on 27 March 2020 after being taken to hospital. The concerns included insufficient note-keeping, inadequate detail about the future care plan and management of acute deterioration, and insufficient involvement of her carer in the discharge process.

Paul Ashley Barton · Prevention of Future Deaths report View report

14 Oct 2021 Nottinghamshire G. Clow

Paul Ashley Barton experienced significant distress, personality changes, dysfunctional behaviour, possible paranoid or delusional thoughts, and repeated suicidal thoughts and acts. He died by hanging on 28 November 2020. Concerns included the Crisis Resolution Home Treatment Team’s focus on avoiding inpatient admission, reliance on patients’ expressed intentions or denials despite fluctuating suicidal intentions, and shortcomings in the Trust’s investigation of his death.

Alexandra Jane Tolley · Prevention of Future Deaths report View report

14 Oct 2021 West Yorkshire Eastern K. McLoughlin

Alexandra Jane Tolley, aged 20, was detained in a psychiatric hospital and absconded while being escorted in the hospital grounds on 27 October 2019. She was found in cardiac arrest and died at hospital the following day. Concerns included instructions not to restrain or follow her, the informal approval of ground leave without documented criteria, and the continued use of similar absconding instructions despite an ongoing risk of further deaths.

Mr Murray Hyslop · Prevention of Future Deaths report View report

14 Oct 2021 Nottinghamshire G. Clow

Mr Murray Hyslop developed Covid-19, reduced fluid intake and appetite, and became dehydrated, malnourished and affected by acute kidney injury. He was admitted to hospital on 24 December 2020 but did not recover and died from natural disease on 16 January 2021. Concerns included inadequate prevention of pressure damage, failure to identify when he needed medical attention, and a lack of openness about learning from adverse events.

Louie Neil Johnston · Prevention of Future Deaths report View report

14 Oct 2021 East London G. Irvine

Louie Neil Johnston died in hospital on 28 April 2020 from diffuse hypoxic ischaemic encephalopathy caused by inadequate oxygen supply to his brain during delivery. The report identified avoidable delivery delays, limitations in CTG monitoring equipment, and gaps in mandatory CTG training for staff.

Mrs Vivien Brunning · Prevention of Future Deaths report View report

12 Oct 2021 East London G. Irvine

Mrs Vivien Brunning was admitted to hospital with sepsis and treated for a kidney stone, during which prescribed Clexane was temporarily held and then omitted on 13 and 14 July 2020. She developed a right brachial artery thrombosis, suffered a stroke during emergency thrombolysis, and died on 25 July 2020. Concerns included missed venous thromboembolism reviews, omitted anticoagulant doses, and failure to report the initial omission through the Trust’s incident reporting system.

Mrs Helena Opoku · Prevention of Future Deaths report View report

12 Oct 2021 East London G. Irvine

Mrs Helena Opoku was pronounced deceased at home on 4 April 2021 after dying from carbon monoxide toxicity associated with using charcoal braziers for cooking and heating after her gas and electricity had been disconnected. The report raised concerns about social services’ failure to investigate safeguarding referrals, appoint social workers within a reasonable timeframe, and assess vulnerable residents’ homes during January to March 2021.

Michael Anthony JAGGS · Prevention of Future Deaths report View report

6 Oct 2021 Inner North London M. Hassell

Michael Jaggs was admitted to hospital on 15 January 2021 and developed hypoglycaemia as a complication of treatment for hyperkalaemia. The agency nurse did not escalate his deteriorating condition for medical attention, and he died from hypoglycaemia. The principal concern was that the agency had not provided additional training or required a reflective statement, raising concern that similar learning was not taking place within the agency.

Charlotte Duffield · Prevention of Future Deaths report View report

5 Oct 2021 Cumbria N. Shaw

Charlotte Duffield, aged 40, was found deceased at home on 4 February 2021 after concerns that she had not been seen for several weeks; the exact cause of death could not be determined because of advanced decomposition. Concerns were raised that, after a referral to Adult Social Care and unsuccessful telephone contact, no physical visit or further safeguarding action appeared to have been taken despite concerns for her safety.

Aaron Darie James Fretwell · Prevention of Future Deaths report View report

5 Oct 2021 West Yorkshire Eastern K. McLoughlin

Aaron Darie James Fretwell died after an agricultural trailer body descended while he was working beneath it, causing crush injuries. Concerns included the absence of a propping device and warning signs on the trailer, and evidence that other agricultural trailers may also have lacked these safety features, creating concern about comparable future accidents.

Hannah Elizabeth ROYLE · Prevention of Future Deaths report View report

4 Oct 2021 West Sussex K. Henderson

Hannah Elizabeth ROYLE, a 16-year-old girl with severe learning disability, developed diarrhoea and vomiting before suffering a cardiorespiratory arrest on the way to hospital. She was diagnosed with a massive gastric volvulus and later sustained an irreversible hypoxic brain injury; she was declared brainstem dead on 1 July 2020. The report raised concerns about inadequate 111 triage, insufficient accommodation of disabilities, the clinical advisor’s assessment, public understanding of the service, misleading terminology, and the abdominal pain pathway.

LEON BRIGGS · Prevention of Future Deaths report View report

4 Oct 2021 Bedfordshire and Luton E. Whitting

Leon Briggs was experiencing a psychotic disorder associated with exceptionally high amphetamine use when he was detained under section 136 of the Mental Health Act. Following restraint and conveyance to Luton Police station, he suffered cardiac arrest in the custody suite and later died in hospital. The principal concerns included poor communication, inappropriate restraint and use of force, inadequate medical assessment, unsatisfactory conveyance and supervision, and failures in risk assessment and monitoring that delayed recognition of his need for urgent medical attention.

Jude Daryl Lloyd · Prevention of Future Deaths report View report

4 Oct 2021 Manchester City N. Meadows

Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

Caden Stewart · Prevention of Future Deaths report View report

4 Oct 2021 Mid Kent and Medway P. Harding

Caden Stewart, aged 16, became unwell after weightlifting in custody and was later found collapsed and unresponsive in his cell. He was diagnosed with a brain haemorrhage, underwent surgery, and died at King’s College Hospital. The principal concerns were inadequate reporting and recording procedures and insufficient communication between prison officers and healthcare staff, resulting in healthcare failing to attend his requests to be seen.