Search PFD Monitor

Grazyna WALCZAK · Prevention of Future Deaths report View report

4 Mar 2021 Inner North London M. Hassell

Grazyna Walczak died after jumping three storeys from her flat on 25 or 26 September 2020 while suffering an acute depressive illness. Before her death, she was assessed as being at low to moderate risk, but was not asked whether her family could be notified. The report also raised concern that a required 72-hour investigation report was completed about five months after her death.

Paula Anne SPEIRS · Prevention of Future Deaths report View report

4 Mar 2021 Inner North London M. Hassell

Paula Anne Speirs died following the ingestion of non-prescribed benzodiazepines before a planned procedure at Weymouth Street Hospital. The procedure was cancelled because staff considered her intoxicated, but she was allowed to sleep in a room without formal observations or specific monitoring instructions. The concerns included inadequate monitoring of an intoxicated patient and a lack of instructions to nursing staff on avoiding positional asphyxia.

Averil Hart · Prevention of Future Deaths report View report

3 Mar 2021 Cambridgeshire and Peterborough S. Horstead

Averil Hart died from anorexia nervosa on 15 December 2012, after severe weight loss and deterioration following her discharge from specialist eating-disorder treatment. The report identified concerns about inadequate monitoring and coordination of care, insufficient eating-disorder training and specialist provision, failures to provide nutritional support, delays and miscommunication in hospital care, inadequate data on eating-disorder prevalence and deaths, and the impact of the COVID-19 pandemic.

Zahid Ahmed · Prevention of Future Deaths report View report

3 Mar 2021 Bedfordshire and Luton T. Stoate

Zahid Ahmed, aged 19, died after a heavy goods vehicle collided with the Kia in which he was a passenger after it stopped in a live lane of the M1 following a mechanical defect. The report raised concerns that the absence of a hard shoulder and the lack of a clear safe place to stop after leaving the Emergency Refuge Area could create a risk of future deaths.

Helen Margaret McLean · Prevention of Future Deaths report View report

3 Mar 2021 Liverpool and the Wirral A. Rebello

Helen Margaret McLean was without Edoxaban from 5 November 2020 after medication and discharge information were not correctly transferred between hospital, GP practices and her nursing home. She was admitted to hospital with an ischaemic stroke on 18 November 2020 and died on 21 November 2020; the report found it more likely than not that Edoxaban may have prevented the fatal event. A substantive concern was that the discharge summary was not received by the GP practice and contained an incorrect GP practice identifier, with medication-transfer processes also failing to identify the omission.

Steven Paul David Gary Stout · Prevention of Future Deaths report View report

3 Mar 2021 East London G. Irvine

Steven Paul David Gary Stout was detained under section 136 of the Mental Health Act after cutting both wrists while intoxicated by alcohol, and was later admitted to a mental health ward. He was discharged on 18 October 2019 without a referral to the home treatment team and was found unresponsive, suspended by his neck from a ligature, on 4 November 2019; he could not be resuscitated. The concerns included failures to accurately record and file important medical records and to ensure an effective referral to the home treatment team.

Martin Keith Sullivan · Prevention of Future Deaths report View report

2 Mar 2021 Manchester South A. Bridgman

Martin Keith Sullivan, aged 15, died on 24 November 2019 after experiencing a severe asthma attack. He was prioritised as Category 2 during two 999 calls, and his father was not asked about taking him directly to hospital; ambulance delays followed before Martin was taken to hospital, where resuscitation was unsuccessful. Concerns included whether the MPDS algorithm and call-handler script recognised the severity of his symptoms, whether Category 2 response times could be met, and whether direct transport to hospital should have been discussed.

Mr Frank Charles Medley · Prevention of Future Deaths report View report

2 Mar 2021 Lancashire and Blackburn with Darwen J. Adeley

Mr Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.

Shirley FROGGTT · Prevention of Future Deaths report View report

1 Mar 2021 Derby and Derbyshire R. Hunter

Shirley Froggtt died on 8 November 2018 after falling from a wheelchair at a nursing home, sustaining a fractured femur followed by bronchopneumonia. The report identified that her care plan required a lap-strap, but it was not applied because a buckle was missing, and raised concerns about the nursing home’s systems for ensuring compliance with care plans, policies and protocols.

Mr Joseph Agnew · Prevention of Future Deaths report View report

26 Feb 2021 Inner South London A. Harris

Mr Joseph Agnew suffered an out-of-hospital cardiac arrest after being removed from a bus and left in a bus shelter, was later found unresponsive, and died five days after admission with a devastating brain injury. The report raised concerns about police training and assessment of intoxicated people with reduced responsiveness, including recognising snoring and monitoring breathing, post-incident learning, and the lack of a safe referral facility for acutely intoxicated homeless people found on buses.

Andrew BIDDLECOMBE · Prevention of Future Deaths report View report

25 Feb 2021 Hampshire, Portsmouth and Southampton J. Pegg

Andrew BIDDLECOMBE died on 10 July 2020 after the motor car he was driving collided with a sign-post and rolled over, causing fatal head and neck injuries. It could not be ascertained whether he suffered a medical episode or whether poor eyesight and mobility hindered him in avoiding the collision. The concerns included that he had not been advised about the impact of his medical conditions on safe driving or the legal requirement to notify the DVLA, and that the practice did not inform the DVLA of relevant medical conditions.

David Edwin BLINMAN · Prevention of Future Deaths report View report

24 Feb 2021 South Wales Central G. Hughes

On 28 December 2018, David Edwin BLINMAN was walking home when he was struck by, or fell into the path of, a reversing articulated lorry and was crushed by its rear wheels. His death was declared at the scene. Concerns included inadequate risk assessments and mitigating measures for pedestrians in vehicle blind spots, the inability to conduct 360-degree checks while reversing without additional measures, and insufficient regard to Rule 202 of The Highway Code.

Jaden Matthew FRANCOIS-ESPRIT · Prevention of Future Deaths report View report

22 Feb 2021 Inner North London M. Hassell

Jaden hanged himself at home on either 25 or 26 August 2020, after becoming increasingly withdrawn and feeling isolated. The principal concern was that his deteriorating mental wellbeing was not recognised by colleagues, so he was not offered psychological counselling or other support. Other concerns included difficulties related to dyslexia, workplace treatment, and the need for a fuller understanding of station culture and Jaden’s experiences.

Sarah Jane Buckingham · Prevention of Future Deaths report View report

22 Feb 2021 Hampshire, Portsmouth and Southampton S. Marsh

Sarah Jane Buckingham died by hanging at her home on 12 August 2019 after a period of depression and a recent voluntary admission to a mental health hospital. The principal concern was that hormonal treatment or hormonal changes associated with perimenopause were not considered by the mental health clinicians treating her depressive illness, despite relevant previous episodes following childbirth.

Cecilia EDWARDS · Prevention of Future Deaths report View report

22 Feb 2021 Inner North London M. Hassell

Cecilia Edwards was admitted to Whittington Hospital on 26 September 2020 with a severe right elbow infection and died there two weeks later. The report identified concerns that a category 3 pressure ulcer was not referred promptly to a tissue viability nurse, that many visiting nurses were agency staff without clear protocols, and that nursing visits were not routinely coordinated with carers, resulting in incomplete care on some occasions.

David Lewis · Prevention of Future Deaths report View report

19 Feb 2021 Oxfordshire D. Salter

David Lewis died at the scene after his vehicle overshot the Vendee Drive roundabout in Bicester at speed on 16 July 2020. The report raised concern that, despite improved signage and reduced speed limits, drivers may still fail to notice the roundabout in sufficient time, particularly because it is approached around a bend or deflection. It identified possible need for further engineering measures, such as rumble strips or bars.

Mr. Brian David BUTTON · Prevention of Future Deaths report View report

19 Feb 2021 Brighton and Hove V. Hamilton-Deeley

Mr. Brian David BUTTON contracted COVID-19 pneumonia while a patient on Catharine James Ward at The Royal Sussex County Hospital in Brighton. The report raised concern that the ward’s 13 beds were not socially distanced; the inquest concluded with a finding of medical misadventure.

Lisa CODLING · Prevention of Future Deaths report View report

19 Feb 2021 Brighton and Hove V. Hamilton-Deeley

Lisa Codling, aged 49, took an overdose of paracetamol on 5 September 2020 after an emotionally charged encounter, and her death was confirmed by paramedics that evening. The principal concern was that the ambulance took 3 hours and 10 minutes to arrive; the inquest found that earlier arrival might have allowed ICU treatment that could have changed the outcome.

Ms Lisa Grant · Prevention of Future Deaths report View report

19 Feb 2021 Black Country Z. Siddique

Ms Lisa Grant was admitted to Hallam Street Hospital in July 2019 and collapsed on the ward on 1 August 2019, later dying at Sandwell Hospital. The inquest identified bilateral pulmonary embolism due to deep vein thrombosis, and concerns included her increased DVT risk associated with obesity and inactivity, alongside a recognised rare risk associated with risperidone, despite an assessment that no further DVT treatment or assessment was required.

Mr Kevin Clarke · Prevention of Future Deaths report View report

18 Feb 2021 Inner South London A. Harris

Mr Kevin Clarke, a 35-year-old man with complex mental health problems, was found by police in a disturbed state on 9 March 2018, restrained, and later suffered a fatal cardiac arrest in an ambulance. The report identified concerns about inappropriate restraint, inadequate monitoring and dynamic risk assessment, unsuitable conveyance and positioning, insufficient clinical assessment, and weaknesses in training, leadership and supervision by police and ambulance staff.