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Joanna Sarah Louise Orpin · Prevention of Future Deaths report View report

31 Dec 2019 Isle of Wight C. Sumeray

Joanna Sarah Louise Orpin experienced severe, treatment-resistant agitated depression before leaving home on 13 February 2018 and disappearing near Culver Cliff. Her body was found on mudflats at Bosham Quay on 18 February 2018, and the inquest concluded that she killed herself. The substantive concerns included recurring incidents involving people in mental distress at Culver Cliff and the apparent absence of suicide-prevention signs there.

Maureen Waterfall · Prevention of Future Deaths report View report

30 Dec 2019 Manchester South A. Farrow

Maureen Waterfall fell at home on 12 July 2019 while taking the anticoagulant Edoxaban and sustained a head injury that led to a subdural haematoma. She died at Willow Wood Hospice on 26 July 2019. Concerns included the lack of a licensed specific antidote for Edoxaban, uncertainty about treatment effectiveness and timing, the absence of national guidance, and the storage of antidote supplies away from the resuscitation unit.

Enid Baber · Prevention of Future Deaths report View report

27 Dec 2019 Nottinghamshire G. Clow

Enid Baber, who was cognitively impaired, died suddenly after getting into or falling backwards into a bath late at night or in the early hours of the morning. The report raised concerns that people living in their own homes with significant restrictions on their liberty might be unlawfully deprived of liberty without adequate safeguards, partly because relevant social workers were not required or prompted to assess this and had not received specific training.

Julie Helen Taylor · Prevention of Future Deaths report View report

24 Dec 2019 Manchester South A. Mutch

Julie Helen Taylor, who had Down syndrome and significant learning disabilities, died at Stepping Hill Hospital on 23 September 2018 from pneumonitis following a chicken pox virus infection contracted while awaiting discharge. The concerns included inadequate reasonable-adjustment planning, lack of best-interests meetings and documented decision-making, poor communication between agencies, limited access to suitable learning-disability beds and support, information-sharing difficulties, and delayed recognition of chicken pox.

Ifeoma Onwuka · Prevention of Future Deaths report View report

24 Dec 2019 Norfolk Y. Blake

Mrs Onwuka was admitted for induction of labour and developed severe bleeding and disseminated intravascular coagulopathy after delivering her baby. She underwent a hysterectomy after a delay, and an expert concluded that the delay in surgery to control the bleeding contributed to her death. The principal concerns were apparent lack of confidence in performing emergency hysterectomy, inadequate investigation of the cause of the coagulopathy, and lack of leadership and overview of her care.

Keith Graham WHETTON · Prevention of Future Deaths report View report

24 Dec 2019 Staffordshire South A. Haigh

Keith Graham WHETTON had an unwitnessed fall in his care home on 7 September 2019, was later found to have a fractured right hip, underwent surgery, and died at the care home on 5 October 2019. Concerns included the delay in seeking medical attention after the fall and the possibility that family members were not informed promptly.

Adam Wilcox · Prevention of Future Deaths report View report

23 Dec 2019 Hampshire (Central) C. Wilkinson

Adam Wilcox was struck by a motorcycle while crossing the A27 Mansbridge Road on 7 March 2019 and died in hospital from his injuries. The report raised concerns that this stretch of road had no safe pedestrian or cycle crossing, no warnings to motorists, and that pedestrians and cyclists were likely to cross where the footpath ended and barriers began. It also identified the road as busy and noted previous collisions, including incidents involving pedestrians.

Kieran Luke Hubbard · Prevention of Future Deaths report View report

23 Dec 2019 Manchester City N. Meadows

Kieran Luke Hubbard, who had a history of depressive disorder and recurrent suicidal thoughts, was found dead on 8 February 2019 after hanging himself at a building site. The principal concerns were failures to expedite and properly coordinate an inpatient bed, failures to communicate and escalate the decision to abandon the bed search, inadequate guidance about driving during a mental health crisis, and shortcomings in the post-death investigation.

Keith HILL · Prevention of Future Deaths report View report

20 Dec 2019 Inner North London M. Hassell

Keith Hill was admitted with biliary sepsis and underwent a liver biopsy, after which he developed bleeding requiring surgery and later suffered bowel haemorrhage. The report identified concerns about communication between specialists, inadequate medical records, and insufficient support and scrutiny around the prescription and dispensing of micafungin.

David Richard Fowler · Prevention of Future Deaths report View report

20 Dec 2019 Manchester (West) R. Galloway

David Richard Fowler, who had a significant history of mental illness, substance misuse and a brain injury, died after falling from a motorway bridge on 26 December 2018 with the intention of ending his life. Eight days earlier, his detention under section 3 of the Mental Health Act 1983 was removed without a community plan or legal framework. The report identified concerns that his family was not invited to the relevant meeting or consulted, and that there was confusion about responsibility for informing family members.

Matthew James Rogers · Prevention of Future Deaths report View report

20 Dec 2019 Blackpool and the Fylde A. Cousins

Matthew James Rogers, aged 31, was admitted to hospital with worsening pain, weakness and lethargy and subsequently developed multiple organ injury before dying on 11 July 2019. His observations were not recorded for two and a half hours despite a NEWS score above 5, amid staffing levels below the planned establishment. The investigation report did not explain how the Trust intended to address omissions of care arising from understaffing.

Samantha Brousas · Prevention of Future Deaths report View report

20 Dec 2019 North Wales (East and Central) J. Lees

Samantha Brousas became critically ill with suspected sepsis and was taken to hospital, where she was diagnosed with septic shock secondary to pneumonia and died from a naturally occurring infection. The report identified concerns about the absence of a pre-alert to the emergency department, the inability of paramedics to administer intravenous antibiotics, and the lack of a clear process for escalating concerns about delayed admission.

Tomasz Nowosad · Prevention of Future Deaths report View report

20 Dec 2019 Manchester City N. Meadows

Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

Doris Daisy Laura Clark · Prevention of Future Deaths report View report

19 Dec 2019 East London N. Persaud

Doris Daisy Laura Clark fell at home on 3 November 2018 and remained on the floor for around six hours before being taken to hospital with a suspected fractured neck of femur. She received multiple doses of morphine, including an intravenous dose that was not titrated, and was not monitored in accordance with Trust policy; concerns included inconsistent use of millilitres and milligrams between pre-hospital and hospital services when recording opiate medication.

Colin Beaumont · Prevention of Future Deaths report View report

19 Dec 2019 Warwickshire S. McGovern

Colin Beaumont was the subject of an investigation into his death, which concluded at an inquest resulting in a Narrative Verdict. The report raised concern that a nasogastric tube was misplaced twice, leading to a pneumothorax that directly contributed to his death.

Katharine Eva Stamp · Prevention of Future Deaths report View report

18 Dec 2019 West Sussex J. Healy-Pratt

Katharine Eva Stamp died while detained under the Mental Health Act from sudden cardiac arrhythmia due to hypoxia, with the hypoxia described as involving aspiration pneumonia, probable sleep apnoea, obesity, smoking and clozapine effects. The report raised concerns that clozapine side effects, particularly in relation to smoking and pneumonia, were under-appreciated and that the BNF did not provide sufficient clarity to prescribers; it also stated that the lack of an effective national weight-gain monitoring programme for mental health inpatients was causally linked to her obesity and probable sleep apnoea.

Suzanne Roberts · Prevention of Future Deaths report View report

18 Dec 2019 West Sussex J. Healy-Pratt

Suzanne Roberts died at The Dene on 18 October 2015 following a sudden cardiac arrest arising from acute kidney injury, pyelonephritis, chronic dehydration and an underlying high-output stoma. The inquest jury found neglect and identified fragmented information sharing, ineffective use of clinical records and poor communication between departments at the Royal Sussex County Hospital as concerns. The report states that multiple record systems, paper records and a portal were in use without mandatory rules or quality assurance, creating a continuing risk of future deaths.

Iris Irene SKINNER · Prevention of Future Deaths report View report

17 Dec 2019 Surrey A. Crawford

Iris Irene Skinner, a resident at Windmill Manor Care Home, fell on 18 October 2018 and died in hospital on 23 October 2018 after sustaining a fatal head injury. The inquest identified insufficient neurological observations, incomplete recording of observations, and a delay in calling an ambulance after she became unresponsive. A principal concern was that agency staff at the care home, and potentially elsewhere in the Barchester Healthcare group, may not have been familiar with the Head Injury Policy.

Jamie Finlay · Prevention of Future Deaths report View report

17 Dec 2019 Suffolk J. Devonish

Jamie Finlay was a passenger in a car involved in a collision on the A1088 near Thetford Road after another vehicle turned right before a filter lane bollard and both drivers swerved. He was taken to Addenbrooke’s Hospital, where his life support was switched off on 11 May 2017; the concern identified was that the junction design did not prevent drivers turning right ahead of the bollards onto the wrong side of them.

Constance Josephine Robinson · Prevention of Future Deaths report View report

17 Dec 2019 Manchester West A. Walsh

Constance Josephine Robinson died at Stepping Hill Hospital on 27 April 2019 after an intracerebral haemorrhage while receiving warfarin for atrial fibrillation, followed by aspiration pneumonia and decompensated heart failure. The report raised concerns that Fairfield Hospital and Stepping Hill Hospital were not open 24 hours a day, causing delays and additional travel for patients requiring overnight hyper acute stroke care, and highlighted the potential benefits of round-the-clock admission and medical availability.