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Darren Adams · Prevention of Future Deaths report View report

29 Apr 2021 South Yorkshire (Eastern) L. Harris

Darren Adams was transferred between prisons and, within 24 hours of arrival, experienced a deterioration in his mental health. He was found ligatured in his cell on 12 November 2017 and was declared dead at hospital on 13 November 2017; the inquest concluded that he died by suicide. Concerns included nursing staff misdiagnosing hypostasis and rigor mortis, insufficient training in identifying these conditions, and potentially confusing definitions in CPR guidance.

Sean Kay · Prevention of Future Deaths report View report

28 Apr 2021 Cambridgeshire and Peterborough S. Horstead

Sean Kay had longstanding mental health problems and was awaiting confirmation of ongoing support when his body was recovered from an area of water near Stonea Bridge on 26 February 2020. The report states that he had taken his own life while the balance of his mind was disturbed. The principal concern was a gap in commissioned service provision in Norfolk and Waveney, leaving him between services without appropriate care.

Mr Paul Sartori · Prevention of Future Deaths report View report

28 Apr 2021 East London N. Persaud

Paul Sartori sought emergency medical assistance for chest pain on 24 October 2019, was directed from A&E to an urgent care centre, diagnosed with costochondritis, and later died at home on 27 October 2019 after becoming unresponsive. A post-mortem examination found a ruptured dissecting aortic aneurysm. The report raised systemic concerns about awareness and diagnosis of aortic dissection in emergency departments, including the adequacy of current guidance and risk-scoring tools.

Caitlin Ann SWAN · Prevention of Future Deaths report View report

27 Apr 2021 Cornwall and Isles of Scilly S. Covell

On 28 December 2019, Caitlin Ann SWAN lost control of her bicycle while descending Tubbоn Hill, collided with a vehicle, and fell into the path of an oncoming vehicle, sustaining catastrophic head and neck injuries. The principal concern was that there were no signs warning road users of the junction with Trebost Lane, which was only visible 75 to 50 metres away and required vehicles to negotiate an acute turn at near walking pace.

Alan Massam · Prevention of Future Deaths report View report

26 Apr 2021 Manchester South A. Mutch

Alan Massam, a resident with dementia, had repeated falls after moving to a dementia residential home and was twice admitted to hospital. After a traumatic brain bleed and rib fractures were identified, he deteriorated and died in hospital on 24 October 2019. Concerns included inadequate information-sharing between agencies, discharge without effective communication or confirmation that the care home could meet his needs, and the absence of a clear escalation process when he refused medication and fluids.

Alfred Jones · Prevention of Future Deaths report View report

24 Apr 2021 Manchester South A. Mutch

Alfred Jones was admitted to hospital after an accidental fall at home and sustained further vertebral fractures in a fall on the ward. While awaiting investigation and being medically optimised for discharge, he contracted Covid-19 in hospital and died on 7 September 2020 from bronchopneumonia in combination with Covid-19, with falls and vertebral fractures among the listed contributing conditions. The report raised concerns that shortages of MRI scanner availability and radiology staff prolonged his admission, contributing to the ward fall and Covid-19 infection.

Derek Albert RUSSELL · Prevention of Future Deaths report View report

23 Apr 2021 Mid Kent and Medway S. Matthewson

Derek Albert Russell, who had a history of falls, was admitted to hospital after an unwitnessed fall and was assessed as being at high risk of further falls. Despite repeated requests, falls alarm equipment was unavailable, and he later suffered another unwitnessed fall and brain haemorrhages before developing COVID-19 and dying. The principal concern was the chronic shortage of falls alarm equipment at Medway Maritime Hospital, which increased patients’ risk of falls and serious injury and compromised clinical staff’s ability to monitor and reduce that risk.

Guy Clifton Paget · Prevention of Future Deaths report View report

23 Apr 2021 West Yorkshire Eastern K. McLoughlin

Guy Clifton Paget, a prisoner at HMP Leeds with terminal oesophageal cancer, was found confused in his cell on 16 March 2021 and died at 15:06 that day in an ambulance at the prison gate. The ambulance could not leave because of incorrect paperwork and a malfunctioning vehicle gate. The concerns related to the need for effective, urgent, and tested systems to enable emergency ambulances to enter and leave prisons with prisoners requiring hospital treatment.

Kelly Frances HEWITT · Prevention of Future Deaths report View report

22 Apr 2021 Milton Keynes T. Osborne

Kelly Frances HEWITT, a prison officer, was found hanging at her home on 18 December 2018 and was confirmed dead by paramedics. She had been suffering from depression, which was recognised by work colleagues and prison managers. Concerns were expressed about the lack of mental health support available to prison officers, and the report states that this provision should be reviewed.

Susan Janet ADAMS · Prevention of Future Deaths report View report

21 Apr 2021 Staffordshire South A. Haigh

Susan Adams was found dead in a hotel in Sutton Coldfield on 4 November 2020 after being unable to live at her home in Tamworth. Her death resulted from the consequences of excessive alcohol consumption, with the inquest recording combined toxicity of ethanol, pregabalin and fentanyl with hepatic cirrhosis and steatosis. The report raised concerns about commissioning difficulties affecting access to regular secondary psychiatric care because her home address and GP practice were in different counties.

Vilmantas Venskutonis · Prevention of Future Deaths report View report

21 Apr 2021 Lincolnshire P. Cooper

Vilmantas Venskutonis was admitted to Pilgrim Hospital with chest pains, which intensified before he was transferred to Lincoln County Hospital, where he died. The report acknowledges 11 separate intervention opportunities that were missed at Pilgrim. The principal concern was whether a nine-point action plan intended to prevent further deaths had been fully implemented, and, if not, why each point had not been completed.

MARY NABILIA GWANYAMA · Prevention of Future Deaths report View report

21 Apr 2021 Surrey C. Topping

Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.

Ella Adoo-Kissi-Debrah · Prevention of Future Deaths report View report

20 Apr 2021 Inner South London P. Barlow

Ella Adoo-Kissi-Debrah died aged 9 after an asthmatic episode led to cardiac arrest on 15 February 2013. The report states that air pollution, including exposure to nitrogen dioxide and particulate matter from traffic emissions, significantly contributed to her asthma and death. It also identifies concerns about pollution limits, public access to pollution information, and communication of air-pollution health risks by healthcare professionals.

Stephen James Oakes · Prevention of Future Deaths report View report

19 Apr 2021 Stoke-on-Trent and North Staffordshire M. Jones

Stephen James Oakes, aged 59, died in hospital on 23 December 2017 after a carefeed 14F nasogastric tube inadequately drained stomach contents, allowing vomit to pass the tube and leading to aspiration pneumonia in the context of metastatic bronchial carcinoma and small bowel obstruction. The principal concerns included inadequate product description and staff training, insufficient hospital evaluation of the tube, failure to recognise inadequate drainage or consider alternatives, and possible wider product-labelling problems.

Peter John Hussey · Prevention of Future Deaths report View report

19 Apr 2021 Stoke-on-Trent and North Staffordshire M. Jones

Peter John Hussey died after post-surgical complications following reversal of an ileostomy. A carefeed 14F nasogastric tube inadequately drained his stomach, allowing vomiting and contributing to aspiration pneumonia. Concerns included insufficient product description and staff training, inadequate evaluation of the tube, and failure to recognise poor drainage and consider alternative treatment or escalation.

Mr Yusuf Seyit · Prevention of Future Deaths report View report

16 Apr 2021 Inner South London A. Harris

Mr Yusuf Seyit had been in hospital since January and, after developing suspected urinary and chest infections, deteriorated into septic shock. He died on 3 July 2019. The concerns were uncertainty about whether there was a plan for timely antibiotic treatment, and uncertainty about when Amikacin was administered despite evidence that it was needed within an hour in septic shock.

Roy Charles Evans · Prevention of Future Deaths report View report

16 Apr 2021 County of Ceredigion P. Brunton

Roy Charles Evans, aged 55, died from injuries sustained when a road sweeper he was operating on Cefnllan Hill, Aberystwyth, went out of control and collided with a stone wall on 13 July 2018. The principal concerns were that the vehicle had a worn tyre, a fractured trailing arm pivot and missing indicator side repeater lamps, and that these faults should have resulted in the vehicle being taken out of service before the collision.

Danielle Lea Broadhead · Prevention of Future Deaths report View report

15 Apr 2021 West Yorkshire (Western) M. Fleming

Danielle Lea Broadhead lost control of her vehicle on Barnsley Road, Flockton, after clipping a kerb where a grass verge becomes a pedestrian pavement on a bend, and collided with a tree. She sustained fatal head injuries; the substantive concerns were whether the road layout met regulations and standards and whether measures were needed to highlight the kerb to oncoming motorists.

Saima Hussain · Prevention of Future Deaths report View report

15 Apr 2021 Manchester South A. Farrow

Saima Hussain had a history of mental health difficulties and took her own life by hanging in August 2019. The report raised concerns that communication about her referral from the Community Mental Health Team to Psychological Therapies Services was not reliable, direct, or tailored to her needs, leaving her without a clear point of contact or adequate information about her care plan.

Ailsa Stewart · Prevention of Future Deaths report View report

15 Apr 2021 Manchester South C. Morris

Ailsa Stewart, who was bed-bound, lived alone and relied on domiciliary carers, was left without domiciliary care after her care package was suspended following a hospital assessment. She was found gravely ill at home on 29 April 2019 and subsequently died in hospital; the inquest recorded that her death was from natural causes, contributed to by neglect. The report identified concern that there was no cohesive national framework or guidance governing suspension of domiciliary care packages and the communication of responsibilities between agencies.