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Mrs Tripta Bhanote · Prevention of Future Deaths report View report

16 Sep 2021 Black Country Z. Siddique

Mrs Tripta Bhanote, who was 86 and living in a residential care home, was found on the floor on several occasions in May 2020 and her condition then declined rapidly before she died. Concerns included unclear procedures for escalating acute illness to emergency services, uncertainty about referral to the enhanced care and quality team, and poor procedures for identifying residents’ DNAR status.

Chloe Alice ENGLISH · Prevention of Future Deaths report View report

15 Sep 2021 West Yorkshire (Western) I. Pears

On 14 May 2021, Chloe Alice English died from a traumatic head injury after deliberately climbing over fencing at a known location for suicide attempts and jumping. The concern was that the existing suicide prevention measures were not effective, as CCTV showed she reached the point of jumping in just under 2 minutes 30 seconds.

Diana Iris Joan Reay · Prevention of Future Deaths report View report

15 Sep 2021 Stoke-on-Trent and North Staffordshire E. Serrano

Diana Iris Joan Reay was transferred to hospital on 17 February 2021, where she was diagnosed with community acquired pneumonia, which led to sepsis and an acute kidney injury. A concern was raised that scans were repeatedly misinterpreted, causing a fluid-filled cyst to be mistaken for a full bladder and resulting in unnecessary re-catheterisations.

Siwan Llio SMITH · Prevention of Future Deaths report View report

14 Sep 2021 Gwent C. Saunders

Siwan Smith had a long-standing history of anxiety and depression, which worsened during the Covid-19 pandemic, and she died by hanging at home on 23 November 2020. The report raised concern that, when she sought an earlier appointment and was distressed, reception staff did not identify whether she required urgent mental health support or arrange a call from a clinically trained person.

Barry Martin · Prevention of Future Deaths report View report

10 Sep 2021 Manchester South C. Murray

Barry Martin had a history of self-neglect, depression and heavy alcohol consumption, and was found deceased on 24 December 2020 after police had boarded up the front door of his property. His death was attributed to acute heart failure associated with acute pneumonia, bronchitis, coronary artery disease and physical frailty, with self-neglect contributing. The principal concern was that occupied houses boarded up by police should be checked to ensure residents have other safe exit routes.

Billy Martyn WARWICK-JONES · Prevention of Future Deaths report View report

10 Sep 2021 West London L. Brown

Billy was killed while riding his motorbike when he was struck head-on by a car travelling on the wrong side of the A3. The driver was elderly, unwell with a urinary tract infection, delirious and had driven for 16 hours. The concerns included insufficient advice about delirium-related unfitness to drive and inadequate testing and guidance on road safety for older drivers.

Lee Ryan Thrumble · Prevention of Future Deaths report View report

10 Sep 2021 Mid Kent and Medway S. Matthewson

Lee Ryan Thrumble was a serving prisoner who suspended himself by the neck in a cell at HMP Rochester on 17 April 2018 and died the following day. The inquest found that failures to meet his mental health needs and to respond adequately to deteriorating behaviour contributed to his death. The principal concern was that incomplete access by clinical staff to NOMIS information, linked to non-compulsory training, could prevent prisoners’ mental health needs and risks from being identified and managed appropriately.

Joshua SAHOTA · Prevention of Future Deaths report View report

9 Sep 2021 Suffolk N. Parsley

Joshua Sahota, a 25-year-old man, died on 9 September 2019 after being found with a plastic carrier bag over his head and a bed sheet around his neck while an inpatient on a mental health ward. The report raised concerns about ineffective communication to families and friends regarding items classified as restricted, including plastic carrier bags, and the inquest identified concerns including insufficient staffing, insufficient observations and one-to-one support, inadequate documentation, no psychologist availability, and an unclear restricted-items policy.

Kenneth Audsley · Prevention of Future Deaths report View report

9 Sep 2021 West Yorkshire Eastern K. McLoughlin

Kenneth Audsley, an experienced high-voltage electrical engineer aged 56, was overcome by carbon monoxide while investigating a fault inside an industrial transformer at work. The transformer contained substantially less oil than it should have, allowing carbon monoxide to accumulate. Concerns included insufficient awareness of the risk, a lack of warning signs and manufacturer warnings, no recommended periodic maintenance regime, and the possibility that other transformers could pose comparable risks.

Roger Phelps · Prevention of Future Deaths report View report

7 Sep 2021 Manchester South A. Mutch

Roger Phelps was admitted to Tameside General Hospital with deteriorating cardiac function and remained on a general medical ward because a Heart Unit bed was unavailable. He contracted Covid-19 as an inpatient, developed sepsis and deteriorated before dying on 4 November 2020; post-mortem examination also identified endocarditis. The principal concern was delays of more than 48 hours in Covid-19 swab results, which could leave infectious patients on non-Covid wards and expose other patients.

Maureen Johnson · Prevention of Future Deaths report View report

7 Sep 2021 Manchester South C. Morris

Maureen Johnson became unwell with diarrhoea, vomiting and abdominal pain in late February 2021, later deteriorated with shortness of breath and was found to be seriously ill before dying at Stepping Hill Hospital on 13 March 2021. The report raises concern that authoritative guidance did not exist for assessing diarrhoea and vomiting suspected to be gastroenteritis in people over 70, including guidance on recognising dehydration and when face-to-face assessment is recommended.

Joseph William DENT · Prevention of Future Deaths report View report

6 Sep 2021 County Durham and Darlington J. Chipperfield

Joseph William DENT was seen parking a car near Newton Cap Viaduct in the early hours of 20 June 2021, and his body was found near the base of the bridge shortly after 08:00. The investigation found that he died from multiple injuries after falling from the bridge, with an open conclusion because it was unclear how he came to fall. Concerns included pedestrian access to the bridge parapet and the area below, the lack of effective climbing prevention, the absence of monitored CCTV and lighting or other detection measures, and the bridge’s reported association with suicide by jumping.

Glenda May Logsdail · Prevention of Future Deaths report View report

6 Sep 2021 Milton Keynes S. Cummings

Glenda May Logsdail was admitted with acute appendicitis and underwent emergency surgery. During induction of anaesthesia, an endotracheal tube was misplaced in the oesophagus and this was not recognised for a prolonged period, resulting in hypoxia, cardiac arrest, irreversible brain damage and her death. Concerns included failures to confirm tube placement, fixation on an incorrect diagnosis, inadequate team leadership and communication during the emergency, and inconsistent ventilator display configurations.

Bituin Pizzaro Pimlott · Prevention of Future Deaths report View report

6 Sep 2021 Manchester South A. Mutch

Bituin Pizzaro Pimlott was found suspended from a ligature at the garage of her home on 22 February 2021. The inquest heard that she had been struggling with her mental health and that telephone consultations were used instead of face-to-face appointments during the pandemic. Concerns included the lack of referral by her GP practice to the crisis team and uncertainty about the guidance for making such referrals.

Mark Holden · Prevention of Future Deaths report View report

6 Sep 2021 Manchester South A. Mutch

Mark Thomas Holden was diagnosed with Covid-19 and subsequently developed a deep vein thrombosis in his left calf, which led to a pulmonary embolus. He collapsed at home on 26 February 2021 and attempts to resuscitate him were unsuccessful. Concerns included the lack of a face-to-face GP examination, failure of the electronic system to alert staff to a markedly raised D-Dimer, and NICE guidance not addressing Covid-19-related clotting risks.

Harold Blackshaw · Prevention of Future Deaths report View report

2 Sep 2021 Stoke-on-Trent and North Staffordshire E. Serrano

Harold Blackshaw died from COVID-19 on 1 March 2021 after falls, a fractured neck of femur, hip dislocations, surgery and subsequent admissions to hospital and care homes. The report raised concern that Grange Ward lacked an admission process to assess patients’ individual needs and put appropriate falls-prevention measures in place.

John Willis Humphries · Prevention of Future Deaths report View report

1 Sep 2021 South London J. Landau

John Willis Humphries was admitted to hospital with abdominal pain and developed pressure sores, which deteriorated during his stay. He was later readmitted, developed recurrent urinary tract infections associated with catheterisation, and died from pulmonary oedema and pneumonia. Concerns included the absence of reported skin integrity assessments or measures in the Emergency Department and the failure to seek advice on managing his resistance to repositioning.

Hazel Fleur Wiltshire · Prevention of Future Deaths report View report

1 Sep 2021 South London J. Landau

Hazel Fleur Wiltshire was admitted to hospital after a fall at home and died there on 19 February 2021 from pneumonia caused by the fall and Covid-19 acquired in hospital. Concerns included lengthy delays in responding to call bells, inadequate staffing and the absence of falls risk assessments across three wards.

William Buchanan · Prevention of Future Deaths report View report

1 Sep 2021 Dorset D. Rookes

William Buchanan sustained multiple rib fractures in an unwitnessed incident involving his mobility scooter at home after it was delivered. He developed pneumonia and died in hospital; the principal concern was that people can purchase mobility scooters without an assessment of their suitability or competence to use them, potentially giving rise to future deaths.

Fadhia SEGULEH · Prevention of Future Deaths report View report

27 Aug 2021 Manchester South A. Mutch

Fadhia Seguleh was receiving treatment for anxiety and depression when she was found unresponsive, attached to a ligature at her home on 24 February 2021. The concerns included fragmented care and inadequate information sharing between NHS mental health services, her GP and private therapy provider, telephone-only mental health assessments during Covid, and her attending A&E alone during a previous mental health crisis without family input.