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Jennifer Sarah Myfanwy SPENCER · Prevention of Future Deaths report View report

18 Dec 2020 East Sussex J. Healy-Pratt

Jennifer Sarah Myfanwy Spencer's mental health deteriorated after she ingested Shamanic hallucinogenic drugs and practised Kundalini Yoga, before she deliberately fell from Beachy Head on 16 November 2019 intending to end her life. The report identifies a lack of awareness among mental health professionals about Shamanic hallucinogens and their potential to cause or exacerbate psychosis, resulting in sub-optimal assessment, treatment and care.

Philip Taylor · Prevention of Future Deaths report View report

17 Dec 2020 Manchester South A. Mutch

Philip Taylor, who had Lewy Body Dementia and lived in a residential care home, became severely dehydrated during a chest infection and died in hospital on 6 January 2020 after developing an acute kidney injury. Concerns included failure to recognise and respond to dehydration, delayed ambulance transfer and hospital assessment, inadequate monitoring, and limited national guidance for care home staff and paramedics.

Andrew Gibbins · Prevention of Future Deaths report View report

17 Dec 2020 Suffolk J. Devonish

Andrew Gibbins, who had a long history of mental health admissions, ran into the path of a lorry on the A14 on 15 January 2020 and died from his injuries. Before this, he had reportedly expressed suicidal feelings to a security guard while unescorted, but this information and concerns about his presentation were not passed to clinical staff. The inquest concluded that he had taken his own life.

Patricia Ann Douglas · Prevention of Future Deaths report View report

16 Dec 2020 Cumbria N. Shaw

Patricia Ann Douglas contacted NHS 111 with severe breathlessness and a history of anaemia requiring a blood transfusion. Her referral to a Covid assessment service contained an incomplete telephone number, so the doctor could not contact her and the call was closed; she later deteriorated, collapsed at A&E and could not be resuscitated. Concerns included the initial triage pathway, the failure to follow up the referral, and a potentially missed opportunity to investigate and treat her.

Eddie Coffey · Prevention of Future Deaths report View report

15 Dec 2020 Hertfordshire J. Stevens

Eddie Coffey was born at Lister Hospital in a poor state, with a low heart rate and symptoms of hypoxia, and required resuscitation before transfer to neonatal intensive care. He died at Luton & Dunstable Hospital from perinatal asphyxia. Inquest evidence identified gross failures in monitoring and managing the foetal heart rate during labour, and raised concerns about whether the same situation could recur and whether other maternity units were following incorrect guidelines.

Don Maximus Del Rocco Fernandes · Prevention of Future Deaths report View report

15 Dec 2020 Oxfordshire D. Salter

Don Maximus Del Rocco Fernandes, a three-month-old infant with VACTERL Association, died after a nasogastric tube was dislodged, replaced, and flushed; the tube had been inserted into the left main bronchus. The principal concerns were the failure to correctly confirm tube placement, uncertainty arising from a change in x-ray policy, and whether further measures were needed to prevent similar incidents involving misplaced tubes.

Robert James GOODMAN · Prevention of Future Deaths report View report

15 Dec 2020 Hampshire, Portsmouth and Southampton J. Pegg

Robert James GOODMAN died at Southampton General Hospital on 30 March 2020 after an unwitnessed fall the previous day caused a head injury and subdural haematoma. The principal concern was that his CT scan occurred 30 hours after the injury because the Trust policy did not reflect revised guidance for patients receiving any anticoagulant treatment.

Christopher Swain · Prevention of Future Deaths report View report

14 Dec 2020 West Sussex P. Schofield

Christopher Swain, who was detained under Section 3 of the Mental Health Act 1983, was found unresponsive in his room at Langley Green Hospital on 22 September 2019 with a ligature around his neck and was confirmed deceased by paramedics. Concerns included inconsistent staff practices when conducting observations, uncertainty about when he was last seen alive, the absence of a formal mental health review, care plan and adequate risk assessment, inadequate record-keeping, no recorded therapeutic engagement, and failure to provide staff to accompany a sectioned patient to another hospital.

Elsie Yvonne Taylor · Prevention of Future Deaths report View report

14 Dec 2020 Black Country J. Lees

Elsie Yvonne Taylor, aged 68, fell at home on 15 September 2020, sustained rib fractures and a pneumothorax, and died later the same day after deteriorating in hospital. Concerns included incomplete recording of her reported decision to decline hospital admission and the advice given, lack of information about the consultation and deterioration symptoms, and no attempt to contact her GP or family despite her living alone.

Ms Katy Ann SAMUELS · Prevention of Future Deaths report View report

11 Dec 2020 Coventry D. Henry

Katy Ann Samuels, a detained patient at The Caludon Centre, returned from escorted leave intoxicated after consuming alcohol and cocaine. She was later found with a dressing-gown cord around her neck in her room and died on 25 April 2019 despite resuscitation and hospital treatment. The principal concerns were unclear arrangements for escorted leave, including failure to verify or record the escort and departure time, and insufficient handover and communication procedures.

Shyama Vadwatee RAMPADARUTH · Prevention of Future Deaths report View report

11 Dec 2020 Inner North London M. Hassell

Shyama Vadwatee Rampadaruth, who had multiple co-morbidities, became unwell during a routine renal dialysis appointment on 13 April 2020, was later admitted as an emergency, diagnosed with COVID-19 and died three days later. The principal concern was that, after being separated from other patients, she waited for approximately six hours on a hard chair rather than being allowed to return home with family support while awaiting dialysis.

CLAIRE LILLEY · Prevention of Future Deaths report View report

11 Dec 2020 Inner South London J. Morris

Claire Lilley was detained under the Mental Health Act and admitted to Avery Ward following a significant overdose. While on Section 17 overnight leave at home, she hung herself on 12 February and did not survive. The report identified diffuse risk information, no central risk formulation, and insufficient management cover to review risk as substantive concerns.

Rory Attwood · Prevention of Future Deaths report View report

10 Dec 2020 Gwent C. Saunders

Rory Attwood died at home on 9 October 2018 after an acute cardiac event attributed by the pathologist to excessive MDMA consumption. The report raised concerns that he had fallen between gaps in health and social care services and that his GP was not involved in the internal investigation after his death.

Edward Mallaby · Prevention of Future Deaths report View report

10 Dec 2020 Sunderland D. Winter

Edward Mallaby died after a boxed television fell onto him in his room at Alexandra View Care Home, causing injuries, bedbound status and pneumonia. Concerns included the handling and secure storage of potentially hazardous personal property, failure or absence of alerts when he was out of bed, unclear observation arrangements, and the lack of a rapid learning exercise or deadline for policy and training review.

Samuel David Morgan · Prevention of Future Deaths report View report

9 Dec 2020 Swansea and Neath Port Talbot C. Phillips

Samuel David Morgan died at home on 16 January 2020 as a consequence of self-suspension. His risk of taking his own life had not been identified, and a review assessment was not set when citalopram was prescribed. Concerns included a change in mood after starting the medication and whether clearer warnings about the risk of suicidal thinking in young adults would better capture patients’ attention.

Thomas Rawnsley · Prevention of Future Deaths report View report

9 Dec 2020 South Yorkshire (Western) A. Combes

Thomas Rawnsley, a residential nursing home resident, developed a chest infection, later collapsed at the home and died in hospital on 4 February 2015. Concerns included the quality of safety-netting advice, the risks of telephone consultations and incomplete information during clinical triage, and inaccuracies or omissions when paramedic advice was transferred to patient information leaflets.

Kimberley Smith · Prevention of Future Deaths report View report

9 Dec 2020 Surrey A. Crawford

Kimberley Smith, who had a history of mental health conditions, alcohol dependency and self-harm, died by suicide after leaving an inpatient psychiatric unit while on unescorted leave and being found with a plastic bag over her head. The concerns included inadequate risk assessment and management of alcohol use and leave, failures in observation and missing-person procedures, and the absence of clear written policies for informal and detained patients leaving the unit.

Leslie Harris · Prevention of Future Deaths report View report

9 Dec 2020 Manchester South A. Mutch

Leslie Harris was admitted to Stepping Hill Hospital after an accidental fall, underwent surgery for a fractured hip, and later died after testing positive for Covid-19. The principal concern was that interpretation of Public Health England guidance led to his movement to a ward where patients were isolating from Covid-19, potentially exposing vulnerable inpatients to infection; the trust subsequently changed its policy.

Ann Doris Stillwell · Prevention of Future Deaths report View report

8 Dec 2020 East London G. Irvine

Ann Doris Stillwell, who was at high risk of falls, sustained a left-sided neck of femur fracture after a fall in her care home on 3 July 2020 and died from complications of her injuries on 5 July 2020. The principal concern was that 1:1 care was not authorised despite the identified risk, and the report states that this would have been the only way to mitigate the particular risk she presented to herself.

Kevin David John BRANTON and 4 others · Prevention of Future Deaths report View report

7 Dec 2020 Cornwall and Isles of Scilly G. Williams

Five people died in two separate incidents involving defective gas cookers that produced fatal levels of carbon monoxide when the grill was used with the door closed. The concerns were the absence of a central database and mandatory recording system for gas appliances, making it difficult and time-consuming to identify and trace potentially dangerous appliances and hindering communication across the supply and fitting chain.