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Karl James BOLAM · Prevention of Future Deaths report View report

14 Jan 2021 Surrey A. Loxton

Karl James BOLAM fell and sustained a head injury at his home in the early hours of 14 August 2018. He made several calls for an ambulance, but paramedics did not attend until 3.42am, by which time he was unconscious; he died on 17 August 2018 without regaining consciousness. The principal concern was that emergency call scripts did not positively encourage lone callers to contact someone to be with them, particularly when paramedic attendance was delayed.

Cherylan CLULOW · Prevention of Future Deaths report View report

12 Jan 2021 Dorset R. Middleton

Cherylan Clulow was found semi-conscious at home after police were initially unable to gain access beyond the communal door, and she died in hospital on 30 August 2019 following extensive and multiple strokes. The substantive concerns related to delays in accessing shared accommodation during emergencies, including the lack of formal information, training, and general distribution of fire drop keys or key fobs to police officers.

Natalie Jane Edgington · Prevention of Future Deaths report View report

11 Jan 2021 Manchester North C. McKenna

Natalie Jane Edgington, aged 28, died at her mother’s address on 24 February 2020. She died from the effects of an accumulated dose of methadone, which she was unable to properly eliminate because of impaired liver function. Concerns included prescribing methadone without sufficient information about her liver disease or an up-to-date liver function test, and the absence of evidence that a lower starting dose was considered.

Elizabeth PAMMENT · Prevention of Future Deaths report View report

8 Jan 2021 Inner North London M. Hassell

Elizabeth Pamment lived in sheltered accommodation and died from pneumonia after two falls on the same night, the second leaving her alone on the floor until she was found the following morning. The principal concerns were that Peabody had not recorded or communicated an agreed instruction to contact her nearby daughter during an emergency, and had no protocol for recording or sharing such instructions with the alarm monitoring service.

John BERROW · Prevention of Future Deaths report View report

7 Jan 2021 Gwent C. Saunders

On 11 October 2019, John Berrow attended an optician with unequal pupils and altered eyesight, was referred routinely to an eye hospital, then collapsed later that day and died in hospital. His death was attributed to a ruptured Berry aneurysm. Concerns included failure to recognise unequal pupils as a possible sign of intracranial bleeding or aneurysm, the lack of practical clinical reference tools, and the absence of a mechanism for sharing learning from clinical incidents among practitioners at Specsavers.

Arthur Edward JOHNSON · Prevention of Future Deaths report View report

5 Jan 2021 Hampshire, Portsmouth and Southampton J. Pegg

Arthur Edward JOHNSON died on 20 April 2020 after an unwitnessed fall at a residential home caused a head injury and intracerebral haemorrhage; a spontaneous intracranial haemorrhage also contributed to the death. Concerns were raised that the residential home’s post-falls process did not clearly distinguish between possible and suspected head injury or specify when 999/111 should be called, and about staff training to recognise intracranial injury.

Hariharan Harichandra · Prevention of Future Deaths report View report

5 Jan 2021 Inner North London E. Buckett

Hariharan Harichandra, a 65-year-old man, fell from an electric wheelchair in hospital on 5 December 2019, sustaining a neck fracture, and died at The Royal Free Hospital on 19 December 2019. The concerns included errors in reporting and reviewing the CT scan, incomplete falls assessment, insufficient consideration of wheelchair safety equipment and spinal condition, and failure to record a severe adverse reaction to a naso-gastric tube.

Linda Joan Gillchrest · Prevention of Future Deaths report View report

4 Jan 2021 Surrey R. Travers

Linda Joan Gillchrest was found dead at home on 19 July 2020 after not being seen for two days. The inquest heard that she had purchased online a publication containing detailed instructions for self-administering a fatal dose and had bought a quantity of a substance in excess of the recommended fatal dose without restriction. The principal concerns were the unrestricted online availability of such publications and lethal quantities of substances, and the lack of protection for vulnerable people before such purchases.

Pardeep Singh PLAHE · Prevention of Future Deaths report View report

4 Jan 2021 Birmingham and Solihull E. Brown

Pardeep Singh Plahe died at Queen Elizabeth Hospital on 12 August 2020 after inflicting a catastrophic injury to his neck with a decorative samurai sword. He had been increasingly concerned about a physical health complaint and had a scheduled GP telephone consultation that was missed because of a technical problem with the EMIS system. The report raised concerns that consultation lists could fail to update, creating a risk that urgent telephone consultations might be missed, and that the identified mitigation depended on practitioners remembering to log out and back in to the system.

Steven Clive Cooke · Prevention of Future Deaths report View report

30 Dec 2020 Stoke-on-Trent and North Staffordshire E. Serrano

Steven Clive Cooke died at his home on 9 July 2019 after hanging himself by a ligature fashioned from a grey wiring cable. The principal concern was the absence of national guidance on engaging with the families of mental health patients to obtain as full a picture as possible.

Marian Elizabeth CLODE · Prevention of Future Deaths report View report

29 Dec 2020 Newcastle and North Tyneside K. Dilks

Marian Elizabeth Clode was attacked three times by a cow while walking with her family on a public bridleway near Swinhoe Farm on 3 April 2016, and died from the resulting injuries on 5 April 2016. The concerns included cattle movements without formal or contingency plans, inadequate measures to prevent cattle breaking out, and no warning to the public about the cattle movement and associated risks.

Clive OXLEY · Prevention of Future Deaths report View report

23 Dec 2020 County Durham and Darlington O. Longstaff

Clive OXLEY entered the track at Durham railway station, climbed the viaduct parapet, and jumped onto North Road below. Concerns included whether the pedestrian barrier adequately prevented access to the track and whether gaps and limited coverage in the wire fence enabled access to the parapet; two similar incidents were also noted.

Daniel Mark HUGHES · Prevention of Future Deaths report View report

22 Dec 2020 Shropshire, Telford and Wrekin J. Ellery

Daniel Mark HUGHES died at the scene after his motorcycle collided with a motorcar on the A483 at Sweeney near Oswestry on 4 June 2017. The report raised concerns about visibility from a driveway near a blind bend, the appropriateness of the speed limit, and whether a warning of the concealed driveway should be displayed.

Tina Murray · Prevention of Future Deaths report View report

22 Dec 2020 Blackpool and the Fylde A. Wilson

Tina Murray, who lived in a care home, died on 8 January 2020 after being found unresponsive with a plastic bag secured over her head. The principal concerns were that plastic bags were accessible within the home despite a known risk of self-harm involving plastic bags, and that the care home’s risk assessments and safety measures should be robust for residents with mental health conditions, dementia and learning disabilities.

Evadney Dawkins · Prevention of Future Deaths report View report

21 Dec 2020 East London G. Irvine

Evadney Dawkins, aged 77, fell at home and was admitted to hospital on 22 July 2018. Renal monitoring planned after assessment was not undertaken for four days, when she was found to have a Grade 3 acute kidney injury; she later suffered a cardiac arrest and was pronounced deceased on 23 August 2018. Concerns also included that the Trust’s governance systems did not identify the case as a Serious Incident requiring investigation for two years.

Joseph Brindley · Prevention of Future Deaths report View report

21 Dec 2020 Manchester South A. Mutch

Joseph Brindley was admitted to hospital after a fall and was later found unresponsive at home on 16 May 2020. He died in hospital from the consequences of an intracranial bleed exacerbated by anticoagulation. The report raised concerns that rib fractures were not identified on CT and X-rays despite being visible, and that it was unclear what specific steps had been taken to prevent similar failures in recognising such injuries.

Brian JAMES EASEY · Prevention of Future Deaths report View report

21 Dec 2020 West Sussex B. Dolan

Brian James Easey was diagnosed with biphasic mesothelioma in September 2020 and died from the condition on 13 December 2020. The report raises concerns that asbestos fibres may remain on council records and could expose people who come into contact with them, with an associated risk of fatal mesothelioma.

James Alexander David Taylor · Prevention of Future Deaths report View report

21 Dec 2020 East London N. Persaud

James Alexander David Taylor died as a result of suicide after sustaining life-changing injuries in a road traffic collision, which led to refractory pain, sensory disturbances, psychological distress and suicidal ideation. The inquest heard that required long-term psychological therapy was not provided and that his participation in a functional neurological disorder programme ended after four days because of pain. Concerns were also raised about repeated changes of GP surgery, lack of continuity of care, and the absence of a clear transfer summary for his complex medical needs.

Master Ruben Bousquet · Prevention of Future Deaths report View report

18 Dec 2020 Inner South London A. Harris

Master Ruben Bousquet died after consuming popcorn that had become cross-contaminated with milk protein, causing acute anaphylaxis. The report raised concerns about timely sharing and registration of fatal food-allergy incidents, and about whether food businesses should have access to adrenaline auto-injectors.

Kalila Elizabeth Griffiths · Prevention of Future Deaths report View report

18 Dec 2020 East London N. Persaud

Kalila Elizabeth Griffiths, who had complex medical conditions including asthma, developed worsening breathing problems in January 2019 and died on 1 February 2019 from a pulmonary embolism, with asthma contributing to her death. The report states that she was discharged from hospital on 19 January despite severe respiratory deterioration and required observation and respiratory physician assessment. Concerns included the management of asthma patients nationally, inconsistent clinical guidelines, uncertainty over which guidelines should be used for acute asthma attacks, and insufficient training.