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Margaret Elizabeth Greenacre · Prevention of Future Deaths report View report

17 Feb 2021 North Northumberland and South Northumberland A. Hetherington

Margaret Elizabeth Greenacre, known as Betty, was a care home resident who suffered an unwitnessed fall on 30 August 2020, sustaining significant soft tissue damage to her lower right leg. She deteriorated after the injury and died in hospital on 18 September 2020. Concerns included late or missing statutory notifications of incidents and poor care-home record keeping, including care plans that were not updated and did not accurately reflect residents’ needs.

Katie Emma Corrigan · Prevention of Future Deaths report View report

17 Feb 2021 Cornwall and Isles of Scilly A. Cox

Katie Emma Corrigan had a history of chronic pain, anxiety and depression, and developed an addiction to pain-relieving medication. She obtained medication from multiple sources, and the report raised concerns that doctors, pharmacists and alert systems did not prevent her from obtaining sufficient opiate medication to cause her death.

Alan Jones · Prevention of Future Deaths report View report

16 Feb 2021 Gwent C. Saunders

Alan Jones was admitted to Neville Hall Hospital after a fall at home and, during his admission, fell seven times. On 13 November 2019 he fell while he should have been under constant supervision, suffered a fatal head injury, and died the following day. Concerns included inadequate multidisciplinary management of his falls risk, failure to provide the required supervision, and unsafe staffing levels.

Mrs Ruby Baggaley · Prevention of Future Deaths report View report

16 Feb 2021 West Yorkshire Eastern K. McLoughlin

Mrs Ruby Baggaley, aged 90, sustained a right distal femur fracture in a fall and died in hospital on the night of 24 January 2020 after complex surgery. Her blood pressure remained abnormally low after surgery, but escalation to senior clinicians was delayed until she was critically ill. Concerns included inadequate monitoring and failure to escalate her deteriorating condition, as well as uncertainty about whether clear escalation instructions and additional staff training had been implemented.

LUCY PATRICIA COLGATE · Prevention of Future Deaths report View report

12 Feb 2021 Surrey C. Topping

Lucy Patricia Colgate, who had poorly controlled generalised epilepsy, suffered an epileptic fit at home on 28 March 2019 and became wedged behind an inward-opening door in a prone position. She developed positional asphyxia and a hypoxic cardiac arrest before paramedics could free her; the evidence indicated that an outward-opening door was likely to have allowed her to survive, and that this risk was not widely appreciated.

Michele Brenda Duckworth · Prevention of Future Deaths report View report

12 Feb 2021 Stoke-on-Trent and North Staffordshire S. Murphy

Michele Brenda Duckworth, who had paraplegia, end stage renal failure and a renal transplant requiring immunosuppression, was admitted with profuse diarrhoea and low blood pressure and later deteriorated with sepsis. She died on 23 February 2020, with the post-mortem finding death due to Escherichia coli bacteraemia of unknown source. The principal concern was that Tazocin was prescribed and continued despite previous ESBL colonisation, contrary to the trust guideline.

Michael Dent-Jones · Prevention of Future Deaths report View report

12 Feb 2021 Surrey A. Crawford

Michael Dent-Jones was found deceased at St Catherine’s Priory on 14 July 2018 after an unintentional Tramadol overdose. The report identifies concerns that Approved Premises staff may not have been familiar with or applying guidance on the delivery and collection of residents’ prescribed medication and other resident-safety procedures.

Gillian McKinlay · Prevention of Future Deaths report View report

12 Feb 2021 Lancashire and Blackburn with Darwen J. Adeley

Gillian McKinlay, aged 68, was admitted to Royal Blackburn Hospital on 23 April 2018 with a provisional diagnosis of small bowel obstruction. A nasogastric tube requested by clinicians was not sited before her death four hours later, and the Coroner considered this contributed to the death. Concerns included unclear responsibility for patients in the Accident and Emergency Department, failure to undertake or escalate a clinically indicated review, and inadequacies in the Trust's investigation and subsequent measures.

Philippa Jane Louise Day · Prevention of Future Deaths report View report

12 Feb 2021 Nottinghamshire G. Clow

Philippa Jane Louise Day took an overdose of prescribed insulin on 7 or 8 August 2019, suffered hypoglycaemic encephalopathy and died of her injuries on 16 October 2019. The principal concerns related to inadequate training for call handlers dealing with people with mental ill health, brief and inaccurate call records, and an assessment and review process that failed to rectify an incorrect decision and included a misleading appointment letter.

Mrs Anne Patricia Harper · Prevention of Future Deaths report View report

12 Feb 2021 Oxfordshire G. Brannigan

Mrs Anne Patricia Harper, aged 78, fell down the stairs at home on 13 September 2020, sustained extensive fractures, developed respiratory failure and died in hospital on 14 September 2020. The report identified concerns about the absence of trauma leadership and coordination, delays in assessment and transfer, gaps in monitoring and analgesia, and the lack of an adequate alternative analgesia plan.

Valeria Munoz Biggs · Prevention of Future Deaths report View report

11 Feb 2021 Inner West London F. Wilcox

Valeria Munoz Biggs died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station while suffering agitated depression, possibly on the bipolar spectrum. The report identified concerns including underestimation of her suicide risk, inadequate engagement with and support for her family, missed planned visits, delayed psychiatric assessment, insufficient consideration of hospital admission, and treatment not in line with guidance.

Michael Richie DOBSON (‘Mike’). · Prevention of Future Deaths report View report

11 Feb 2021 Staffordshire South A. Haigh

Michael Richie Dobson (‘Mike’) died by hanging in prison on 24 November 2019 after applying a ligature to himself. The report identifies concerns about the availability of basic cell maintenance during lockdown, noting that delays in repairing electrical faults could create opportunities for prisoners to harm themselves. It also refers to poor mental health, illicit drug use, fractured family relationships, and difficulties engaging with relationships and support.

Jack Goodwin · Prevention of Future Deaths report View report

11 Feb 2021 Manchester South A. Mutch

Jack Goodwin experienced chest pains on 15 December 2017 and suffered a cardiac arrest after a delay in receiving emergency medical assistance, resulting in a hypoxic brain injury. He later developed significant cognitive impairment and died at home on 15 January 2020 from complications arising from the cardiac arrest and prolonged downtime. Concerns related to ambulance call-handling scripts, including the lack of guidance about self-transport, the need for an acute hospital, and reassessment if the patient deteriorated.

Robert Hardy · Prevention of Future Deaths report View report

11 Feb 2021 Manchester South A. Mutch

Robert Stephen Hardy was found at home on 6 August 2020 suspended from a ligature; the inquest concluded that his death was suicide. The principal concern was that an assault involving a weapon was not recorded as a crime promptly, affecting the provision of and signposting to appropriate victim support despite his recognised vulnerabilities.

Ruth Jones · Prevention of Future Deaths report View report

11 Feb 2021 Manchester South A. Mutch

Ruth Jones, a resident of The Beeches Care Home who was at risk of falls, fell while unobserved after being isolated because Covid-19 was suspected. She was admitted to hospital with a fractured neck of femur and bronchopneumonia and later died there. Concerns included the lack of guidance and staffing arrangements for safely observing residents at risk of falls during required isolation, and the difficulties caused when frail patients attended hospital without family support.

Carole Mitchell · Prevention of Future Deaths report View report

11 Feb 2021 Manchester South A. Mutch

Carole Mitchell died at home on 22 November 2019 after taking a fatal amount of her prescribed medication; the inquest conclusion was suicide. The report identifies concerns about delays in accessing psychological assessment and support-worker services, limited mental health bed capacity, and difficulties gathering information from her family because of concerns about confidentiality.

Eric Harold Bird · Prevention of Future Deaths report View report

10 Feb 2021 Black Country J. Lees

Eric Harold Bird, a 91-year-old man with dementia and assessed as being at high risk of falls, suffered seven falls during a four-week period in a specialist care centre. After a fall on 21/11/20, he sustained a subdural haematoma and died in hospital on 30/11/20. The principal concerns included failures to follow procedures after head injuries, delays in contacting emergency services and gaining ambulance access, and inadequate updating and review of his falls risk documentation and care plan.

Jason O’Rourke · Prevention of Future Deaths report View report

10 Feb 2021 Inner South London H. QC

Jason O’Rourke died by suicide in his cell at HMP Belmarsh after hanging himself with a bedsheet ligature between 7.28 pm on 1 April 2019 and 9.33 am on 2 April 2019. The jury identified possible contributing factors including inadequate follow-up of his mental health, insufficient sharing and understanding of information about his mental health and self-harm history, and inadequate safety intervention meetings. The report also raised concerns about unclear self-harm and suicide risk assessments on arrival and the lack of robust auditing of nightly roll checks.

LISA MARIE THOMPSON · Prevention of Future Deaths report View report

10 Feb 2021 Oxfordshire S. Hayes

Lisa was found unresponsive at home on 14 March 2020 after tying a ligature around her neck, was resuscitated and taken to hospital, where she died from hypoxic brain injury following cardiorespiratory arrest caused by asphyxiation. The inquest concluded that the death was suicide. Concerns included the absence of a clear care plan after an emergency review and failures to update mental-health care plans and risk assessments with material information about her overdoses and subsequent disclosures.

Lily-Mai HURRELL SAINT GEORGE · Prevention of Future Deaths report View report

10 Feb 2021 Inner North London M. Hassell

Lily-Mai Hurrell Saint George, aged 10 weeks, suffered fatal injuries after being hurt by an adult while in the exclusive care of her parents on 31 January 2018. The principal concern was that Haringey Children’s Services discharged her into her parents’ unsupervised care despite professionals expressing the view that she should not be discharged in those circumstances.