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Terence Ewart JAMES · Prevention of Future Deaths report View report

17 Dec 2019 Central and South East Kent S. Hayes

Terence Ewart JAMES, aged 85, was living in a residential home when he sustained an unwitnessed fall on 17 April 2019 and a further fall on 20 April, resulting in a neck of femur fracture. He underwent surgery but became delirious, did not thrive, and died in hospital on 14 May 2019. Concerns included failures to inform the GP of the first fall, hand over the fall history to care staff, and escalate pain and deterioration for further medical advice.

Mr. Mark Anthony Anderson · Prevention of Future Deaths report View report

17 Dec 2019 South Wales Central S. Richards

Mr Mark Anthony Anderson suffered fatal head injuries in a collision between motorcycles travelling in opposite directions on a narrow path in Trelai Park, Cardiff, on 28 May 2019. The report raises concern that motorcyclists were using the park for unrestricted racing and off-road activities, putting members of the public, particularly children and elderly people, at risk.

Barry Jack Gordon Liffen · Prevention of Future Deaths report View report

17 Dec 2019 Inner West London F. Wilcox

Barry Jack Gordon Liffen, who had dementia and other chronic illnesses and was taking anticoagulants, fell at his sheltered accommodation on 10 March 2019 and sustained a head injury causing subdural bleeding. His condition later deteriorated, and he died in hospital on 11 May 2019 after developing recurrent pneumonia. The concerns identified were the need for clinical assessment after falls and when staff observe deterioration in frail residents at Glebelands.

Lewis Victor Mendelson · Prevention of Future Deaths report View report

17 Dec 2019 Manchester South A. Mutch

Lewis Victor Mendelson, who had profound learning and physical disabilities, became unwell after vomiting on 8 May 2019, was taken to hospital, later received end-of-life care, and died at home on 16 May 2019. The concerns included the absence of a DoLS authorisation, statutory care review and allocated social worker, as well as hospital treatment and end-of-life decisions without a formal best interests meeting or IMCA involvement.

Eugeniusz Malek · Prevention of Future Deaths report View report

17 Dec 2019 Inner West London F. Malek

Eugeniusz Malek, a 50-year-old plasterer, fell from a ladder onto an uncapped scaffolding pole on 23 June 2018 and sustained fatal injuries. The principal concern was that ends of scaffolding poles in areas where workers may fall, trip or collide with them should be capped.

Layla Stephanie Dobson · Prevention of Future Deaths report View report

16 Dec 2019 West Yorkshire Eastern J. Hobson

Layla Stephanie Dobson, a 23-year-old student with a history of mental health issues, self-harm and suicidal ideation, was found deceased at her home on 11 March 2019. The inquest recorded that she died by hanging and reached a conclusion of suicide. Concerns included the absence of a formalised process to guide practitioners on appropriate support pathways and insufficient flagging of information about current self-harm or suicide in referral decisions.

Joyce Marchant · Prevention of Future Deaths report View report

16 Dec 2019 Manchester South A. Mutch

Joyce Marchant died at Tameside General Hospital on 1 June 2019 from complications of a liver abscess, including biliary sepsis and multi-organ failure. The report identified concerns about delays in arranging drainage because of limited interventional radiology capacity, delayed communication of abnormal results to her GP through the postal system, and the lack of a clear communication strategy between the district general hospital and tertiary centre.

Arnold Fletcher Ward · Prevention of Future Deaths report View report

16 Dec 2019 Manchester South A. Mutch

Arnold Fletcher Ward was a resident at Fernlea Nursing Home who developed a deteriorating grade 4 sacral pressure ulcer, later associated with osteomyelitis, and died in hospital on 21 January 2019 from a myocardial infarction. Concerns included inadequate monitoring and escalation of the pressure ulcer, failure to follow up a referral to the Tissue Viability Nursing Team, and the resulting lack of appropriate wound dressing.

Shirley Anne Nightingale · Prevention of Future Deaths report View report

16 Dec 2019 Manchester South A. Mutch

Shirley Anne Nightingale died at Tameside General Hospital on 20 May 2019 after a catastrophic gastrointestinal bleed. The report identified concerns about the lack of clear systems for prioritising urgent endoscopies, following up requests, and recording or authorising departures from recommended timescales.

Henry Huw Duncan Campbell · Prevention of Future Deaths report View report

16 Dec 2019 Inner West London F. Wilcox

Henry Huw Duncan Campbell drowned after failing to resurface while free-diving in deep seawater off Zakynthos, Greece, on 6 August 2017. The report raised concerns about the availability of deep-water rescue equipment, watchtower manning records, and monitoring of swimmers as well as sea-craft.

Alice Marie Sloman · Prevention of Future Deaths report View report

16 Dec 2019 Avon S. QC

Alice Marie Sloman died after a routine general anaesthetic for an MRI scan precipitated cardiac decompensation associated with an undiagnosed cardiomyopathy. The principal concern was that, despite multiple conditions and her parents’ requests, she was not referred for investigation of an underlying disorder, including a clinical geneticist’s opinion, and her serious cardiomyopathy therefore went undiagnosed.

Clive Miles · Prevention of Future Deaths report View report

16 Dec 2019 Manchester South A. Mutch

Clive Miles was found dead at his home on 31 May 2019. Toxicology found toxic amounts of morphine, codeine and sertraline, and the pathologist concluded that the combination caused his death. The principal concern was that his prescriptions had been changed from weekly to monthly despite limited evidence of assessment of the risk, leaving him with a significantly increased quantity of medication.

Sammi Higgins · Prevention of Future Deaths report View report

13 Dec 2019 East London N. Persaud

Sammi Higgins had mental health conditions and a deteriorating mental state, including voices telling her to harm herself. On 3 February 2018, after presenting to mental health services following an overdose and self-harm and being discharged without weekend mental health support, she ingested a fatal combination of alcohol and tablets. Concerns included the absence of an overarching care plan or key-worker, failures in communicating and implementing a medication change, and lengthy delays in accessing psychotherapy.

Catherine Mary McNamara · Prevention of Future Deaths report View report

13 Dec 2019 Manchester South A. Mutch

Catherine Mary McNamara was found dead at home on 11 May 2019, having probably died in the early hours of 9 May 2019. She had been prescribed high levels of opiates over a number of years, and the inquest heard that prescribed opiate toxicity, in combination with over-the-counter medication, contributed to her death; efforts to reduce the dosage had been challenging.

Steven Keith Marsland · Prevention of Future Deaths report View report

13 Dec 2019 Manchester South A. Mutch

Steven Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.

Raees Osman Rauf · Prevention of Future Deaths report View report

12 Dec 2019 Derby and Derbyshire E. Serrano

Raees Osman Rauf was a mathematics student at the University of Bristol who took his own life with a shotgun to the head on 12 September 2018. The report raised concerns that non-mandatory attendance and homework, limited monitoring and face-to-face contact, and the ability to require withdrawal without such contact made it difficult to identify and support struggling students.

Peter Frosdick · Prevention of Future Deaths report View report

12 Dec 2019 Norfolk Y. Blake

Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s concerns.

Mrs Frances Jean Gibb · Prevention of Future Deaths report View report

10 Dec 2019 Brighton and Hove V. Hamilton-Deeley

Mrs Frances Jean Gibb died in circumstances considered at an inquest, which concluded with a narrative conclusion. The concerns identified were serious failings in the use of NEWS and a failure to identify a mesenteric thrombus, apparently while a junior radiologist was working overnight under pressure.

Brenda Anne Drew · Prevention of Future Deaths report View report

10 Dec 2019 Dorset R. Griffin

Brenda Anne Drew, who was partially sighted, fell at home in November 2018 and was prescribed Oramorph after sustaining a wrist fracture. She was found collapsed and unresponsive at home on 6 April 2019, and toxicology found a fatal level of morphine in her blood. The principal concerns were that repeat Oramorph prescriptions were issued without a formal review or confirmation of her wishes, including requests made by a pharmacy without consultation with the patient.

Bethany Tengquist · Prevention of Future Deaths report View report

10 Dec 2019 Brighton and Hove V. Hamilton-Deeley

Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.