Search PFD Monitor

Macloud Nyeruke · Prevention of Future Deaths report View report

18 Sep 2020 West Yorkshire Eastern K. McLoughlin

Macloud Nyeruke was admitted to hospital on 23 November 2019 with fever, cough and confusion, and died there on 22 February 2020. He had multidrug-resistant tuberculosis and multidrug-resistant bacterial infections. The concerns included that his medical conditions were not disclosed to the Trust, uncertainty about appropriate PPE training, and risks associated with nursing agencies supplying support workers without knowledge of their health vulnerabilities or work location.

PAULINE VIOLET OAKLEY · Prevention of Future Deaths report View report

18 Sep 2020 Inner North London J. Stevens

Pauline Oakley fell onto an electric heater at her home on 3 April 2020, causing a fire. She sustained burns covering 60% of her body and died later that day in hospital. The concerns included the absence of assessments of the safety and suitability of her home and appliances, and the apparent lack of monitoring of the building’s fire alarm.

Joseph Francis Luke Nihill · Prevention of Future Deaths report View report

18 Sep 2020 West Yorkshire Eastern K. McLoughlin

On 4 April 2020, Joseph Francis Luke Nihill, aged 23, was found dead at his mother’s home after taking a substance to end his life; the inquest concluded that his death was suicide caused by toxicity. The principal concerns were that an online contact provided advice on suicide methods and that potentially lethal substances were made available and promoted for this purpose.

YUGAL LIMBU · Prevention of Future Deaths report View report

14 Sep 2020 Central and South East Kent S. Hayes

Yugal Limbu became separated from his family after drinking with friends and family, was last seen walking towards home while intoxicated, and was later found deceased in the River Stour. The inquest concluded that he accidentally fell into the river and suffered submersion. Concerns were raised about a hazardous gap and sloped surface near the footbridge at Victoria Way, including uncertainty over which local authority was responsible for the area.

Isaac Jakob NEWTON · Prevention of Future Deaths report View report

14 Sep 2020 Blackpool and the Fylde A. Wilson

Isaac Newton was a previously healthy four-month-old baby who died after being placed in a double bed and sleeping alongside his father and half-sibling. He was found unresponsive the following morning, and the inquest recorded that his airway was obstructed by the weight of an adult body overlying him, depriving him of oxygen. The principal concern was the risk to young infants from unsafe sleeping practices, including co-sleeping with adults or older children and potential impairment from drug or alcohol use.

Lee William Davies · Prevention of Future Deaths report View report

10 Sep 2020 Shropshire, Telford and Wrekin J. Lees

Lee William Davies, a detained patient, absconded from a mental health ward on 17 June 2019 and was found unconscious the following day after an out-of-hospital cardiac arrest. He died in hospital on 18 June 2019 after treatment was withdrawn; the inquest recorded a brain injury caused by illicit drug use. Concerns included the reduction of his observation levels despite his risk of absconding to obtain drugs, and ward-garden planting and monitoring arrangements that could allow drugs or other items to be concealed.

Brian Griffiths · Prevention of Future Deaths report View report

10 Sep 2020 Swansea and Neath Port Talbot C. Phillips

Brian Griffiths died in hospital on 2 October 2019 after being struck and pinned by a vehicle that unexpectedly accelerated at a Tesco Express store and petrol station on 30 September 2019. The principal concern was that an opportunity may have been missed after an earlier collision in April 2019 to obtain an independent assessment of the driver's fitness to drive, including through an elderly-driver referral scheme.

Alyn Rees · Prevention of Future Deaths report View report

9 Sep 2020 Gwent C. Saunders

Alyn Rees became acutely unwell on 3 December 2019, experienced breathing difficulties, deteriorated into cardiac arrest, and died after paramedics were unable to revive him. Concerns were raised about the approximately two-hour wait for an emergency ambulance, the lack of advice about the expected arrival time, the absence of an indicated response time for an Amber 1 call, and delays transferring patients into hospital care that prevented ambulances from being released.

Linda Ann PHILLIPSON · Prevention of Future Deaths report View report

8 Sep 2020 Brighton and Hove V. Hamilton-Deeley

Linda Ann PHILLIPSON died from a major pulmonary embolism during surgery for a complicated tibial fracture. The substantive concerns were delay in applying the external fixator and the apparent failure to mobilize her; the inquest conclusion also referred to unnecessary delay and suboptimal care leading to increased immobility before transfer.

Ellie Jessalyn Isaacs · Prevention of Future Deaths report View report

4 Sep 2020 East London N. Persaud

On 19 June 2019, 22-year-old Ellie Isaacs was struck by a motor vehicle while crossing the A12 at a Pelican crossing in Romford before the pedestrian light turned green; she sustained fatal injuries and died in hospital on 21 June 2019. The concerns included obstructed driver views, the crossing’s location and changing speed limits, and high levels of vehicles failing to stop during the amber traffic-light phase, which together raised a risk of future deaths.

Zoe Amanda Knight · Prevention of Future Deaths report View report

4 Sep 2020 Manchester South A. Farrow

Zoe Amanda Knight developed chest pain and other symptoms, was taken to hospital, and deteriorated after a brief seizure while being investigated for ischaemic heart disease and pulmonary embolism. A post-mortem examination concluded that she died from a dissecting aneurysm of the thoracic aorta. The report raised concerns about the overlap of symptoms with other cardiac conditions, delayed recognition of aortic dissection, and the apparent non-implementation of a recommendation to add “aortic pain” as a chest-pain triage discriminator.

Laura Eve PARSONS · Prevention of Future Deaths report View report

3 Sep 2020 County Durham and Darlington J. Thompson

Laura Eve Parsons was found dead at home on 5 November 2019, after consuming a fatal amount of liquid morphine prescribed for breakthrough cancer pain. She had previously been admitted to hospital following an accidental morphine overdose, but a repeat prescription was later issued without the electronic prescribing system directing the prescriber to review the prominent medical-record information about that overdose.

Carlington Maurice Spencer · Prevention of Future Deaths report View report

28 Aug 2020 Lincolnshire T. Brennand

Carlington Maurice Spencer, a detainee at Morton Hall IRC, suffered a right middle cerebral artery infarction after being found unwell and was later confirmed deceased on 3 October 2017. The report identifies concerns about confirmation bias relating to presumed drug use, inadequate monitoring and record keeping, poor communication and escalation between discipline and healthcare staff, failures to recognise stroke symptoms, and delays in emergency treatment.

Toby Peter Edward Nieland · Prevention of Future Deaths report View report

26 Aug 2020 Lincolnshire T. Brennand

Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.

Daniel Richard COLEMAN · Prevention of Future Deaths report View report

25 Aug 2020 Inner North London M. Hassell

Daniel Richard Coleman, a construction site manager living at a demolition site, died in an accidental fire associated with his production of crystal meth. The report raised concerns that his occupation of the site and frequent illicit drug use went unnoticed, that site security was ineffective, that records of his presence were incomplete, and that the drug and alcohol policy had not led to any drug testing.

Siân Frances HEWITT · Prevention of Future Deaths report View report

21 Aug 2020 Milton Keynes T. Osborne

Siân Frances HEWITT died on 6 April 2019 at Milton Keynes University Hospital after collapsing at the Campbell Centre. The report describes failures to recognise and treat her deteriorating condition, including risks associated with pulmonary embolism, and concerns that the Campbell Centre was not an appropriate placement for people with autism and additional mental health problems.

Malyun Habib KARAMA · Prevention of Future Deaths report View report

21 Aug 2020 Inner North London M. Hassell

Malyun Karama died at the Royal Free Hospital from a uterine rupture after misoprostol was administered in doses exceeding national guidelines to induce labour following an intrauterine death. Abnormal observations were relayed to a senior registrar, but the doctor did not attend immediately. Concerns included the need for national learning about the increased risk of rupture in multigravida mothers and the lack of a computer in the delivery suite for contemporaneous recording of observations.

Viktor John Anthony Scott-Brown · Prevention of Future Deaths report View report

20 Aug 2020 County Durham and Darlington O. Longstaff

Viktor John Anthony Scott-Brown, aged 23, was found hanging at his home overnight on 14/15 December 2018 and pronounced dead at the scene; the inquest concluded that his death was suicide. He had been prescribed Lamotrigine without being warned about its potential association with thoughts of self-harm or suicide, and concerns were raised that reputable prescribing resources were inconsistent or silent about this potential side effect.

Ian Allen · Prevention of Future Deaths report View report

17 Aug 2020 Birmingham and Solihull L. Hunt

Ian Allen collapsed suddenly at the nursing home where he resided on 31 December 2019 and died soon after arriving at hospital. The medical cause of death was clozapine toxicity. Concerns included a high clozapine blood level not being acted upon, inadequate monitoring and dose adjustment after smoking cessation, and the absence of a system to escalate blood test results to the consultant.

Brenda Elmer · Prevention of Future Deaths report View report

14 Aug 2020 West Sussex P. Schofield

Brenda Elmer acquired a Listeria infection after consuming a contaminated sandwich while attending St Richard’s Hospital and died on 17 July 2019 after becoming seriously ill. Concerns included inadequate communication with patients who had left the area during the outbreak, which delayed recognition and appropriate treatment, and the absence of requirements for laboratories and hospital trusts to retain or share Listeria isolates, hindering the identification of connected outbreaks.