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Sylvia Scully · Prevention of Future Deaths report View report

11 Aug 2020 Manchester South C. Morris

Sylvia Scully became unwell with sudden abdominal pain and vomiting and attended Tameside General Hospital on 9 February 2020. A radiologist initially reported another patient’s scan in error, and the correct diagnosis of hollow viscus perforation was made after her condition had deteriorated so severely that she could not withstand emergency surgery; she died in hospital on 10 February 2020. Concerns included variations in radiologists’ access to systems and equipment for out-of-hours reporting, the absence of a formal investigation into her care, and the lack of a Rapid Assessment and Treatment Model for walk-in emergency patients.

Moses Victor Boardman · Prevention of Future Deaths report View report

11 Aug 2020 Inner North London G. Irvine

Moses Victor Boardman, an elderly and frail man, was mistakenly discharged to his home instead of sheltered accommodation, where he was found without heating, light or food and subsequently readmitted to hospital after a further cerebrovascular accident. While assessed as being at risk of aspiration and requiring supervised feeding, he was later found eating a whole fruit unsupervised, suffered a choking incident, and died at 04.48. The substantive concerns included discharge and transport safeguards, failure to escalate missed care visits, monitoring of patients fed at risk, and the response to a potential reversible cause of collapse when a DNACPR order was in place.

Francis Xavier Cooney · Prevention of Future Deaths report View report

10 Aug 2020 Birmingham and Solihull E. Brown

Francis Xavier Cooney fell at home, underwent surgery for a scalp laceration, developed delirium during his hospital stay, and was discharged home after an occupational therapy assessment. Following discharge he became more confused and anxious about changes to his medication, and on 27 January 2020 he was found hanging from the bannister and declared deceased. The principal concern was that medication changes were not communicated directly to his daughter and next of kin, who held lasting power of attorney, leaving her unable to explain the changes or reassure him; the report also raised concern about the lack of a root cause analysis or similar investigation into the communication breakdown.

Peter William Howarth · Prevention of Future Deaths report View report

9 Aug 2020 Manchester South C. Morris

Peter William Howarth, who had complex underlying health problems, died in hospital after sustaining injuries in a number of falls, including a fractured neck of femur requiring surgery. The report raised concern that Borough Care had not investigated the fall at the care home that led to his final hospital admission.

Anthony John WILLIAMSON · Prevention of Future Deaths report View report

7 Aug 2020 Cornwall and Isles of Scilly A. Cox

Anthony John Williamson, an experienced kayaker, departed from Trebarwith Strand in a group and was later recovered from the sea after coming out of his kayak in heavy swells at Cambeath Point. He could not be resuscitated, and a final post-mortem cause of death was awaited. Concerns were raised about the adequacy of coastguard cover during the Coronavirus pandemic and whether reduced lifeguard services were being mitigated by additional emergency-service resources.

Jan KLEMPAR · Prevention of Future Deaths report View report

7 Aug 2020 Cornwall and Isles of Scilly A. Cox

Jan Klempar was swimming in the sea at Porthcurno in west Cornwall, where no lifeguards were on duty despite the beach ordinarily having lifeguard cover. The concerns raised relate to reduced or absent lifeguard cover on Cornish beaches, public information about coverage, and plans to mitigate shortfalls through additional emergency resources.

Theresa Robertson · Prevention of Future Deaths report View report

6 Aug 2020 East London G. Irvine

Theresa Robertson was found deceased outside 90 Greengate Street on the evening of 18 September 2019, after being captured on CCTV in the area two days earlier. The medical cause of death was recorded as Amitriptyline and Zopiclone toxicity and hypothermia. Concerns included missing records of important telephone calls and a consultation, prescriptions exceeding the surgery’s seven-day limit for high-risk patients, and the absence of assurance that other patients’ prescriptions had been audited.

Alana Molly CUTLAND · Prevention of Future Deaths report View report

5 Aug 2020 Milton Keynes T. Osborne

Alana Molly CUTLAND, a 19-year-old student, died on 25 July 2019 after opening the door of a light aircraft flying in Madagascar and falling from it. The report states that she had taken doxycycline as an antimalarial and was believed to have experienced a psychotic or delirium event. The principal concern was that the drug information leaflet did not mention this possible reaction and should be reviewed.

Richard KING · Prevention of Future Deaths report View report

5 Aug 2020 Milton Keynes T. Osborne

Richard King developed sudden acute back pain at home on 12 October 2019, and a paramedic attended after his son called the ambulance service. The paramedic did not carry out recognised observations, and Mr King was later found unresponsive and confirmed dead. The inquest recorded that he died from a ruptured dissecting thoraco-abdominal aortic aneurysm, and raised concern that the failure to conduct detailed observations resulted in a lost opportunity for further medical treatment and hospital assessment.

Pauline Russell · Prevention of Future Deaths report View report

4 Aug 2020 Norfolk Y. Blake

Pauline Russell, a poorly controlled diabetic, was discharged from hospital after her insulin dose was increased, but she and her husband could not read the written discharge instructions. She subsequently received a higher incorrect insulin dose, became unresponsive in a hypoglycaemic coma, and died from aspiration pneumonia. The principal concern was that the hospital did not check patients’ literacy or provide discharge instructions in an accessible alternative format.

Amy Hogan · Prevention of Future Deaths report View report

31 Jul 2020 Manchester South C. Morris

Amy Hogan reported feeling unwell from around September 2019 and attended an out-of-hours doctor on 20 January 2020 with light-headedness, weakness and exhaustion. She became acutely unwell and collapsed at home the following day, dying at hospital aged 23. The principal concerns were that her previous GP records had not transferred and that the out-of-hours GP could not electronically access her regular records, including information that she was prescribed the oral contraceptive pill.

Reginald Collins · Prevention of Future Deaths report View report

30 Jul 2020 Manchester South A. Mutch

Reginald Collins fell and fractured his neck of femur, underwent surgery, and remained in hospital after becoming medically optimised because a suitable placement was unavailable. He developed aspiration pneumonia and died on 22 October 2019; concerns included delays in discharge and the lack of suitable complex EMI beds locally and nationally.

Samuel Garner · Prevention of Future Deaths report View report

27 Jul 2020 Manchester South A. Mutch

Samuel Garner had an accidental fall at a nursing home on 8 October 2019 and was admitted to hospital three days later, where rib fractures and a traumatic pneumothorax were diagnosed. He died in hospital on 19 October 2019. Concerns included treatment in the Emergency Department corridor, delays in draining his chest, and a significant delay in transfer to a surgical ward because of competing demands and limited bed capacity.

Jerrelle MCKENZIE · Prevention of Future Deaths report View report

17 Jul 2020 Bedfordshire and Luton E. Whitting

Jerrelle MCKENZIE was admitted to Luton & Dunstable Hospital on 3 August 2019 after taking an overdose of Dinitrophenol (DNP), and died there later that evening. The concerns were that DNP was banned in the UK because of its harmful effects, that social media may have influenced his use of it to lose weight and improve his body image, and that he accessed it through the internet or dark web.

Kobi David WRIGHT · Prevention of Future Deaths report View report

16 Jul 2020 Norfolk J. Lake

Kobi David WRIGHT was delivered on 3 March 2019 after unsuccessful forceps and caesarean delivery attempts and was declared dead after showing no signs of life. The concerns included conflicting accounts of cervical dilatation and the clinical reasoning for proceeding to delivery, failure to allow further progression before intervention, aspects of the forceps and caesarean procedures, and a lack of recent emergency obstetric training.

Luiz Claudio Ramos Dos Anjos · Prevention of Future Deaths report View report

13 Jul 2020 Essex C. Beasley-Murray

Luiz Claudio Ramos Dos Anjos died on 7 November 2019 at the railway track at St Dominic’s footbridge, Colchester, from multiple traumatic injuries following a train collision. The report raised concern that the footbridge parapet and sides provided relatively easy access to the railway track, and stated that this issue had not been remedied.

John Cheetham · Prevention of Future Deaths report View report

13 Jul 2020 Manchester South A. Mutch

John Cheetham died at Stepping Hill Hospital on 19 January 2020 after an unwitnessed fall while awaiting a hospital bed in the Emergency Department, sustaining a subarachnoid haemorrhage and subsequently developing cerebral oedema and Clostridium difficile infection. The concerns included prolonged Emergency Department waits caused by bed-capacity pressures, shortages of appropriately trained nurses, and failure to complete a falls-risk assessment at the earliest opportunity, increasing risks for elderly patients vulnerable to falls.

Bartosz Cezary KUSIAK · Prevention of Future Deaths report View report

10 Jul 2020 County Durham and Darlington O. Longstaff

Bartosz Cezary Kusiak was struck by a motor vehicle while walking on the unlit A690 in Durham on 23 January 2020 and later died in hospital from fatal injuries. Concerns included the limited visibility of pedestrians to drivers, the emergency stopping distance being greater than the available visibility distance, and the absence of a footpath alongside the road.

Gwilym Emrys PRICE · Prevention of Future Deaths report View report

10 Jul 2020 Staffordshire South A. Haigh

Gwilym Emrys PRICE suffered deteriorating mental health after a physical injury and was found hanging at his home on 25 February 2020; he died later that day in hospital. Shortly before his death, his GP referred him to MPFT without using its approved referral form, which could result in incorrect prioritisation in other cases.

Prince Kwabena Fosu · Prevention of Future Deaths report View report

6 Jul 2020 West London C. Inyama

Mr Fosu was being held in a single cell at Harmondsworth IRC when he was found unresponsive on 30 October 2012. The inquest jury found that control points protecting vulnerable detainees were grossly ineffective and that there had been failures across agencies to recognise, monitor and respond to his deteriorating condition. The stated concerns included recognising when to refer detainees to healthcare and ensuring that concerns were reported simultaneously to healthcare managers and the Home Office contract monitor.