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Dereck John CHAPMAN · Prevention of Future Deaths report View report

23 Oct 2020 Blackpool and the Fylde A. Wilson

Dereck John Chapman, known to his family as John, died on 3 February 2020 from pneumonia and heart disease while recovering in hospital after surgical repair of a fractured neck of femur sustained in a fall at his nursing home. Concerns were raised about the nursing home’s insufficient response to his falls and dementia-related inability to reliably communicate symptoms, and about inaccurate, incomplete and unreliable record keeping, which were considered to pose risks of future deaths.

Benjamin Popavach · Prevention of Future Deaths report View report

23 Oct 2020 Plymouth, Torbay and South Devon I. Arrow

Benjamin Popavach was a voluntary patient on home leave from a mental health unit, could not be contacted by medical staff, and was subsequently found in the sea off Corbyn Head, Torquay. The report identifies concerns about completing risk assessments for patients going on leave, including community risks and actions if plans break down, and sharing this learning with ward staff and community teams.

Karen Jane Winn · Prevention of Future Deaths report View report

22 Oct 2020 Suffolk N. Parsley

Karen ‘Jane’ Winn died at West Suffolk Hospital after developing bilateral pulmonary emboli and deep venous thromboses in the context of haemolytic anaemia. Although prophylactic anticoagulation was identified as necessary, it was not administered during most of her admission, and the report states that this contributed to her death. Concerns included a lack of early haematology consultant involvement, repeated manual overriding of the automated VTE assessment warnings, and inadequate electronic flagging of the anticoagulation decision.

Raymond Claude Woodhouse · Prevention of Future Deaths report View report

21 Oct 2020 Cornwall and Isles of Scilly A. Cox

Raymond Claude Woodhouse had severe Parkinson’s disease and underwent a total knee replacement, after which he developed infections in his elbow and knee and died on 11 February 2019. Concerns included difficulties obtaining staff attention, poor cleanliness, a potential delay in antibiotics, and multiple late or omitted doses of prescribed Parkinson’s medication.

Roger Wood · Prevention of Future Deaths report View report

21 Oct 2020 East London G. Irvine

Roger Wood had been monitored for an abdominal aortic aneurysm, which measured 5.5 cm in June 2017. The scan result was sent to his GP but was not acted upon, and he was not referred for specialist treatment. He later died from a fatal rupture of the aneurysm on 12 February 2019. The principal concern was that the treatment pathway relied on a GP referral link that could fail, allowing vital diagnostic information not to be acted upon.

Douglas OWENS · Prevention of Future Deaths report View report

19 Oct 2020 Blackpool and the Fylde T. Holloway

Douglas Robert Owens developed acute cardiac failure, hypotension, aspiration pneumonia and multi-organ failure after cataract surgery, treatment for raised intraocular pressure, ongoing eye pain and painful urinary retention. He died in intensive care on 7 July 2018. Concerns included arrangements for urgent ophthalmic transfer, specialist assessment, monitoring and review of deterioration, fluid documentation, and recording medication doses.

Sarah Fernyhough · Prevention of Future Deaths report View report

16 Oct 2020 Essex C. Beasley-Murray

Sarah Fernyhough died at home in the early hours of 22 May 2019 after taking an overdose of venlafaxine, amisulpride and hydroxyzine, as well as cocaine, cannabis and alcohol. The report identified a delay in ambulance attendance and concerns about the categorisation of her call, including the failure to ensure that the relevant call recording or full medical information was reviewed by the person able to upgrade its categorisation.

William Edward TURNER · Prevention of Future Deaths report View report

15 Oct 2020 County Durham and Darlington C. Oliver

William Edward TURNER, aged 74, died at the scene after a multi-vehicle collision on 8 October 2019, when a vehicle travelling in the opposite direction went out of control and caused a head-on collision. The report raised concern about whether the driving-licence surrender periods for people with epilepsy should be revisited or reviewed in light of the circumstances.

THOMAS JEFFERY KING · Prevention of Future Deaths report View report

15 Oct 2020 Essex L. Brookes

Thomas Jeffery King was found hanging at his home on 28 April 2020, and his death was confirmed at the scene. The inquest concluded that he had intentionally ended his own life while experiencing very low mood and a history of poor mental health. The principal concern was that the Health and Justice Team used software that could not be accessed by other relevant mental health teams, meaning important information about crises and risks could be unavailable when assessing and managing a person.

Avis Mary Addison · Prevention of Future Deaths report View report

14 Oct 2020 Cornwall and Isles of Scilly A. Cox

Avis Mary Addison died on 22 February 2017 after being murdered by her late husband; the recorded medical cause of death included suffocation, and the inquest conclusion was unlawful killing. The substantive concerns included possible failures or delays in recognising domestic abuse and safeguarding issues, and whether GP practices had appropriate domestic violence and safeguarding policies, training, and early-warning processes.

Mr Edward Cowey · Prevention of Future Deaths report View report

14 Oct 2020 Derby and Derbyshire E. Serrano

Mr Edward Cowey was admitted to Royal Derby Hospital on 22 January 2020, suffered a fall with a head injury on 23 January, and died on 28 January 2020 from a subdural haematoma, with anticoagulation recorded as a contributing factor. Concerns included fragmented patient information across electronic and paper systems, inconsistent local and national guidance on head injuries, gaps in anticoagulation guidance, and a falls form that did not direct doctors to relevant head-injury guidance.

Piotr Kierzkowski · Prevention of Future Deaths report View report

12 Oct 2020 Suffolk N. Parsley

Piotr Kierzkowski was found deceased at home on 17 December 2019 after experiencing a mental health crisis and being assessed for admission to a psychiatric unit. No bed was available, so he was sent home with a friend and took his own life before he could return to hospital. The principal concerns were overall bed capacity for people seeking informal admission and arrangements for temporarily housing a patient when a bed is unavailable.

Marion Glover · Prevention of Future Deaths report View report

12 Oct 2020 Manchester South A. Bridgman

Marion Glover suffered an unwitnessed fall at Melbourne Court on 24 February 2020, sustaining facial and rib fractures, and later died in hospital on 15 April 2020. The report identified a serious risk that residents with cognitive illnesses or confusion could leave the building unknowingly where there were no restrictions on leaving and no observation of the foyer, and questioned whether the accommodation was suitable for such residents.

WYNTER SOPHIA ANDREWS · Prevention of Future Deaths report View report

9 Oct 2020 Nottinghamshire L. Bower

Wynter Sophia Andrews died after being delivered by caesarean section on 15 September 2019, following missed opportunities to monitor her wellbeing and concerns that she should have been delivered earlier. The report identified concerns about the lack of robust initial critical analysis of deaths and an unsafe culture within Midwifery Services, including failures to respond to staff safety concerns, facilitate professional challenge, and make decisions based on individualised patient risk.

Noah Richard Poole · Prevention of Future Deaths report View report

9 Oct 2020 Nottinghamshire L. Bower

Noah Richard Poole died aged 8 days from complications of a head injury sustained during difficult extraction at his caesarean delivery. The report identified failures to counsel his mother properly about delivery options and to agree a birth plan, as well as a lack of professional guidance and training concerning vaginal pushes and fetal pillows during difficult fetal extraction.

May Adalaid Miller · Prevention of Future Deaths report View report

8 Oct 2020 Suffolk J. Devonish

May Adalaid Miller, aged 95, was attacked by another resident while asleep at Beech House Residential Care Home on 9 February 2020 and died from natural causes precipitated by the assault. The report raised concerns about the lack of safeguarding information sharing between agencies and care facilities, including the absence of a system to share information about the other resident’s risk factors.

Alison Jean Shirley Jeanes · Prevention of Future Deaths report View report

7 Oct 2020 Manchester South A. Mutch

Alison Jean Shirley Jeanes was admitted to hospital after an accidental fall at a care home while taking anticoagulation, with a head injury and high INR. She later developed a progressing bleed, was placed on palliative care, and died in hospital. The report raised concerns about delays in neurosurgical input, CT scanning, and further haematology advice, and about unclear responsibility for follow-up.

Emily Greene · Prevention of Future Deaths report View report

6 Oct 2020 South Yorkshire (Western) D. Urpeth

Emily Greene was found hanging from a tree in fields at the rear of Doghill, Shafton, Barnsley, on 16 November 2018, and the evidence was that she took her own life. The inquest identified concerns including inadequate specialist training, deficiencies in the sexual-assault investigation, unclear referral handling, failure to sensitively explain the decision not to pursue the allegation, unsuitable facilities for recording victim video, and mishandling of the missing-person report.

Frazer GOLDEN · Prevention of Future Deaths report View report

5 Oct 2020 County Durham and Darlington J. Thompson

Frazer Golden, aged 30, died on 9 April 2017 after his motorcycle collided with another motorcycle on the A689 road near Whit’s Hill, County Durham. Concerns included potentially confusing “SLOW” road markings alongside a change from a 30 mph to a 60 mph limit, and the absence of warning signs or double white hazard lines at a bend where forward visibility was reduced.

Joan Margaret Sanderson · Prevention of Future Deaths report View report

5 Oct 2020 Manchester South A. Mutch

Joan Margaret Sanderson died at Tameside General Hospital on 15 June 2020 after an accidental fall, surgery for a left hip fracture, and a subsequent MRSA infection. The principal concern was that an MRSA swab was not routinely collected on admission for orthopaedic patients from care homes or with a previous positive MRSA result, which could have enabled earlier identification of infection.