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Jason Paul DEVOTI · Prevention of Future Deaths report View report

21 Jan 2020 Worcestershire D. Reid

Jason Devoti had a history of mental health issues and alcohol dependency and was found deceased in accommodation on 9 October 2018 after West Midlands Police failed to attend a P2 welfare-check request for more than 22 hours. The inquest heard that he died from acute ethyl alcohol poisoning, although the time of death could not be established. The principal concerns were police control-room backlogs, inadequate escalation and training, and the risk that vulnerable people subject to P2 incidents would not receive a timely response during periods of increased demand.

Aston Neil McLean · Prevention of Future Deaths report View report

20 Jan 2020 Berkshire H. Connor

In the early hours of 6 August 2014, Aston Neil McLean was pursued by Thames Valley Police and was trapped underneath an armed response vehicle after a collision. Ambulance staff declared him deceased at the scene, but subsequent evidence indicated that the vehicle could likely have been lifted within 4½ minutes and that he may have survived if it had been lifted soon after the collision. The principal concerns relate to guidance on recognising life extinct, declaring death where extraction is delayed or difficult, defining “similar massive injuries”, and ensuring ambulance crews have relevant information from local fire services.

Deborah Margaret LAMONT · Prevention of Future Deaths report View report

20 Jan 2020 South Wales Central G. Hughes

Deborah Margaret Lamont travelled to a hotel on 28 March 2019, where she suspended herself by a ligature and was found deceased by police officers shortly after 11pm. The principal concern was that police officers might incorrectly conclude that the power under section 136 of the Mental Health Act did not apply in a hotel room, potentially placing an individual at risk of death.

Samantha Savage-Greene · Prevention of Future Deaths report View report

20 Jan 2020 Manchester South A. Bridgman

On 23 May 2018, Samantha Savage-Greene jumped from a bridge over the M67 motorway and sustained fatal injuries. The principal concern was difficulty obtaining monitoring from the Home Based Treatment Team, with an apparent gap between the RAID and Home Based Treatment Team protocols for patients who were not admitted.

Matthew WILLOUGHBY · Prevention of Future Deaths report View report

19 Jan 2020 Blackpool and the Fylde A. Wilson

Matthew WILLOUGHBY, aged 27, died on 9 August 2019 after inadvertently falling from a fourth-floor window while leaning out to shout to a passer-by. The principal concern was that window safety adaptations, previously advised by a council inspector to prevent someone climbing out, had been removed and not replaced, creating a risk to current and future tenants.

Janet Shirley Jasper · Prevention of Future Deaths report View report

17 Jan 2020 Rutland and North Leicestershire T. Rawden

Janet Shirley Jasper died in hospital on 12 December 2017 after a gas explosion at a neighbouring property caused an enormous flash and bang, resulting in thoracic trauma and multi-organ failure. The principal concerns were that 254 nearby properties were at risk of similar floor failures and that gas distribution networks had inconsistent policies on inspecting adjoining properties after reports of gas smells.

Peter SUDLOW · Prevention of Future Deaths report View report

17 Jan 2020 Shropshire, Telford and Wrekin J. Lees

Peter SUDLOW developed a sacral pressure sore during a hospital admission following ischaemic myelopathy and paraplegia. The sore deteriorated, became infected, and he later died in a hospice on 8 April 2019. Concerns included failures to refer to the Tissue Viability Nurse at relevant stages and a lack of clear guidance on referrals, pressure sore prevention, and the relationship with Waterlow scores, particularly for patients with paraplegia or neurological deficits.

Shneur Zalman Kaye · Prevention of Future Deaths report View report

17 Jan 2020 Manchester North E. Morgan

Shneur Zalman Kaye died at home on 24 August 2018, aged 14, from suffocation caused by inhalation of helium. The report raises concerns that a safeguarding referral was closed without contacting Shneur or his parents and that the referral and reasons for it were not shared with relevant third parties or agencies, potentially limiting assessment and protective action.

Daniel Jeffrey Moran · Prevention of Future Deaths report View report

15 Jan 2020 Manchester West R. Syed

Daniel Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.

Marlon Roy WATSON · Prevention of Future Deaths report View report

14 Jan 2020 Staffordshire South A. Haigh

Marlon Roy Watson was a serving prisoner at HMP Dovegate who died by hanging in his cell on 29 September 2018. The concerns included whether healthcare staff fully understood the ACCT process, and the inquest findings identified issues including reliance on self-referral, administrative errors, unanswered or unacknowledged calls, and lack of access to relevant patient information between healthcare teams.

Mr Madhavbhai Khushalbhai Patel · Prevention of Future Deaths report View report

14 Jan 2020 Black Country J. Lees

Mr Madhavbhai Khushalbhai Patel, a 95-year-old man living at home, choked on food during a meal on 13 May 2019 and died despite emergency treatment. Concerns included that the family had not been given the IDDSI definition of “bite sized”, and that there had been no specific assessment or advice concerning bread products or eating with his hands. The inquest did not find these matters causative or contributory to his death.

John David Long · Prevention of Future Deaths report View report

14 Jan 2020 London Inner (West) R. Caller

John David Long suffered an unwitnessed fall from his bed in Benjamin Weir Ward at St. George’s Hospital on 4 May 2019, sustaining a head injury that led to his death. The concerns identified relate to the design and suitability of bed rails, the definition and administration of one-to-one care, provision of breaks without leaving the patient alone, and training for one-to-one care.

Annette Jane Lewis · Prevention of Future Deaths report View report

13 Jan 2020 Isle of Wight C. Sumeray

Annette Jane Lewis died after throwing herself from a cliff at Tennyson Down while in acute distress and behaving unusually. The concerns identified were the absence of fencing at the cliff edge and the lack of signs directing people in mental distress to support such as the Samaritans.

Miles Glynn Naylor · Prevention of Future Deaths report View report

10 Jan 2020 West Yorkshire (West) O. Longstaff

Miles Glynn Naylor, a patient detained under section 2 of the Mental Health Act 1983, died in his room on the Oakdale Ward after suspending himself from a ligature made from his trouser belt and wedged in the door hinge side. The inquest jury raised concerns about the management of ligature risks from personal items and the design of the ward doors, including access to the hinge pin side.

Muhammed Wajid · Prevention of Future Deaths report View report

10 Jan 2020 West Yorkshire (West) O. Longstaff

Muhammed Wajid was removed from Scammonden Bridge by police on 12 September 2018 and admitted voluntarily to Lynfield Mount Hospital. The following morning, he was permitted unaccompanied leave, travelled by taxi to the bridge and jumped to his death; concerns included the bridge’s history of suicides and uncertainty about whether previously proposed preventive measures had been fully implemented.

Colin Alan North · Prevention of Future Deaths report View report

9 Jan 2020 Birmingham and Solihull L. Hunt

Colin North attended a Stock Car racing event at Birmingham Wheels on 16 November 2019 to present trophies. He was struck from behind by a large tractor while walking on the track and died at the scene; the medical cause of death was multiple injuries from a road traffic collision. The concerns included a lack of pedestrian control, protected walkways and safe areas, and inadequate consideration of the risks to pedestrians and staff on the track.

Anthony Carroll · Prevention of Future Deaths report View report

8 Jan 2020 Liverpool and the Wirral A. Rebello

Anthony Carroll, aged 70, was struck by a police vehicle while crossing Scotland Road A59 in Liverpool on 25 December 2018 and was pronounced dead after being taken to hospital. The report raised concerns about public understanding of police emergency vehicle speed limits and the absence of a visual indicator showing whether the siren was activated.

Agnes Gwenllian SANSOM · Prevention of Future Deaths report View report

7 Jan 2020 County Durham and Darlington J. Chipperfield

Agnes Gwenllian Sansom was admitted to hospital on 15 July 2019 and, despite being at risk of falling and requiring supervision when mobilising, was not prevented from mobilising unaided. She fell on 20 July after nursing staff did not have access to important physiotherapy observations, sustaining the injury that led to her death; concerns included failures in patient information systems and the sharing of walking aids by vulnerable patients.

James Thomas Wheeler · Prevention of Future Deaths report View report

3 Jan 2020 Manchester South C. Morris

James Thomas Wheeler, who had refractory epilepsy alongside cerebral palsy and severe learning disability, was found unresponsive at Cheddle Lodge on 22 January 2018 and died shortly afterwards. The inquest concluded that he died following a nocturnal epileptic seizure while unobserved and not actively monitored. Concerns included the lack of authoritative UK guidance on monitoring people with refractory epilepsy and assistive technology, failures to provide required annual Care Act Reviews, and insufficient resources for local authorities to fulfil those duties.

Jacob Andrew Bates · Prevention of Future Deaths report View report

31 Dec 2019 Derby and Derbyshire P. Nieto

Jacob Andrew Bates, who had autism, mental health problems and a history of serious self-harm, died by suicide on 15 July 2017 after placing plastic ties around his neck as ligatures. The report raised serious concerns that vulnerable young people, including those with complex needs and significant risks, were being placed in unregulated settings without statutory oversight of staff competency, policies or procedures.