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Darren Barry WILLIAMS · Prevention of Future Deaths report View report

6 Nov 2019 Milton Keynes T. Osborne

Darren Williams was found hanging from a bed frame in his cell at HMP Woodhill on 4 January, and the inquest jury concluded that he took his own life. The report identifies failures in ACCT procedures, action planning, information sharing and the provision of support. Concerns included ACCT reviews taking place without Healthcare attendance and relevant information from previous ACCTs not being considered when new ACCTs were opened.

Neville Lewis MCNAIR · Prevention of Future Deaths report View report

5 Nov 2019 East Sussex F. King

Neville Lewis MCNAIR was found unresponsive in his cell at HMP Lewes on 16 June 2018 and could not be revived after extensive CPR. The inquest concluded that the cause involved heroin toxicity with aspiration, and raised concerns about the availability of Naloxone in prison wings and prison officers’ training and awareness of its use.

Christopher Byron · Prevention of Future Deaths report View report

5 Nov 2019 Manchester North J. Kearsley

Christopher Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

Russell Paul BOWRY · Prevention of Future Deaths report View report

3 Nov 2019 Bedfordshire and Luton E. Whitting

Russell Paul Bowry died after falling 11 metres through exposed roof material while working at height on a stage structure at Cardington Studios. The concerns included inadequate planning and supervision of work at height, insufficiently designed fall-protection systems, and unsafe working practices affecting self-employed riggers.

Xavier Thomas and 10 others · Prevention of Future Deaths report View report

1 Nov 2019 London Inner (South) M. QC

On 3 June 2017, three attackers carried out vehicle and knife attacks at London Bridge and Borough Market, killing eight victims: Xavier Thomas, Christine Archibald, Sara Zelenak, James McMullan, Sébastien Bélanger, Alexandre Pigeard, Kirsty Boden and Ignacio Echeverría Miralles de Imperial. The report identifies substantive concerns relating to protective security, counter-terrorism investigations, emergency response, communications, locating casualties, medical equipment and training, and rental vehicles used in terrorist attacks.

Joshua Hoole · Prevention of Future Deaths report View report

1 Nov 2019 Birmingham and Solihull L. Hunt

Joshua Hoole collapsed and died during an 8-mile, 25 kg loaded march as part of an annual fitness test at Dering Lines Barracks on 19 July 2016. He showed signs of heat illness before collapsing, and was declared deceased despite emergency treatment. The principal concerns included inadequate training and understanding of heat-illness guidance, failure to check or correctly measure the Wet Bulb Globe Temperature, inadequate communication about heat-illness cases, and failure to stop the activity when students became unwell.

Liyakat Ali SIDAT and 2 others · Prevention of Future Deaths report View report

1 Nov 2019 Cheshire J. Harkin

On 4 November 2018, Liyakat Ali Sidat was driving on the A34 Melrose Way when he overtook two vehicles on a bend and collided with an oncoming vehicle. He, his wife Salma Bibi Sidat and their daughter Hajra Bibi Sidat sustained fatal injuries; concerns focused on the danger of the bend, the absence of a continuous white line to prevent overtaking, and the risk posed by overtaking on that stretch of road.

Liyakat Ali SIDAT and 2 others · Prevention of Future Deaths report View report

1 Nov 2019 Cheshire J. Harkin

On 4 November 2018, Liyakat Ali Sidat was driving on the A34 Melrose Way when he overtook two vehicles on a bend and collided with an oncoming vehicle. He, his wife Salma Bibi Sidat and their daughter Hajra Bibi Sidat sustained fatal injuries; concerns focused on the danger of the bend, the absence of a continuous white line to prevent overtaking, and the risk posed by overtaking on that stretch of road.

Liyakat Ali SIDAT and 2 others · Prevention of Future Deaths report View report

1 Nov 2019 Cheshire J. Harkin

On 4 November 2018, Liyakat Ali Sidat was driving on the A34 Melrose Way when he overtook two vehicles on a bend and collided with an oncoming vehicle. He, his wife Salma Bibi Sidat and their daughter Hajra Bibi Sidat sustained fatal injuries; concerns focused on the danger of the bend, the absence of a continuous white line to prevent overtaking, and the risk posed by overtaking on that stretch of road.

Mrs Annie Lloyd · Prevention of Future Deaths report View report

30 Oct 2019 Black Country Z. Siddique

Mrs Annie Lloyd was taking warfarin and appears to have taken a higher-than-intended dose for around two weeks. She was found unconscious on 6 April 2019 with a large subdural haematoma and raised intracranial pressure, and died the same day. Concerns identified during the inquest included inadequate checking of her warfarin dosage and reliance on family members to confirm the required dose.

Philip Richard Hayes · Prevention of Future Deaths report View report

30 Oct 2019 Newcastle upon Tyne K. Dilks

Philip Richard Hayes suffered an aortic dissection on 14 April 2019 and died on 18 April 2019 after delays in ambulance response and diagnosis. The principal concerns included failure to reassess the emergency response despite five subsequent calls reporting additional symptoms and deterioration, inconsistent triage and referral for clinical input, and the appropriateness of algorithm-based triage.

David John KIRSCH · Prevention of Future Deaths report View report

30 Oct 2019 Worcestershire D. Reid

David John Kirsch was found deceased in his cell on 19 March 2018 after inflicting a large wound to his neck with the lid of a tin. The principal concerns were the lack of allocated case-manager oversight for his ACCT document, deficiencies in recording and addressing risks, failure to escalate the case, and inadequate staff knowledge and assessment of his suicide risk.

Robert Thomas GINN · Prevention of Future Deaths report View report

30 Oct 2019 Inner North London M. Hassell

Robert Thomas Ginn hanged himself in his cell at HM Prison Pentonville and was discovered at around 1.05am on 29 November 2018. Concerns were raised about the quality of the nurse-led resuscitation attempt, including failure to check breathing, inadequate oxygenation, variable chest compressions, lack of coaching, and incorrectly applied defibrillator pads.

Mrs Elizabeth Glen Self · Prevention of Future Deaths report View report

29 Oct 2019 South Yorkshire (Western) C. Dorries

Mrs Elizabeth Glen Self was admitted to hospital following a heart attack and later suffered a serious fall after becoming entangled in a line attached to her left leg. Injuries were not immediately recognised, and there were delays of more than thirteen hours in dealing with requested x-rays and a CT scan. The concerns included inadequate training in making x-ray requests, a possible breakdown in communications, and systems that allowed imaging requests to remain unresolved for hours.

Charlotte Grace · Prevention of Future Deaths report View report

29 Oct 2019 Cumbria N. Shaw

Charlotte Grace was discharged from hospital on 20 September 2018 and was found hanging the following evening; the inquest recorded that she took her life by hanging on 21 September 2018. The principal concern was that the Home Treatment Team and her nominated next of kin were not invited to the discharge meeting, despite her being at chronic high risk of suicide and being referred for follow-up care.

Julius Jake Little · Prevention of Future Deaths report View report

28 Oct 2019 Inner North London G. Irvine

Julius Jake Little, a 20-year-old undergraduate living in university halls, was found unresponsive on 7 June 2019 with a ligature around his neck and was pronounced dead despite resuscitation efforts. The report raised concerns about how universities use disclosed mental-health information, including limited student responses to support offers and the lack of communication of disclosure information to tutors and halls staff.

Thomas Henry SMYTH · Prevention of Future Deaths report View report

28 Oct 2019 Milton Keynes T. Osborne

Thomas Henry Smyth, aged 86, was admitted after a fall and died from a subdural haematoma on 3 August 2019 after anticoagulation medication was inappropriately restarted. The report raised concerns that staff could not access vital information recorded in the electronic notes and records, and about the use, training and effectiveness of the notes system.

Jean Evelyn WAGHORN · Prevention of Future Deaths report View report

25 Oct 2019 Brighton and Hove V. Hamilton-Deeley

Jean Evelyn WAGHORN fell at home and sustained fractures to her neck, after which she was transferred between hospitals three times in just over 48 hours. She developed pneumonia while receiving conservative care in hospital and died on 29 June 2019. The substantive concerns were that two transfers were inappropriate, the relevant transfer policy was effectively ignored, and previous recommendations concerning the policy had not been implemented for Mrs Waghorn.

Catherine Gardiner and 2 others · Prevention of Future Deaths report View report

24 Oct 2019 Berkshire H. Connor

Catherine Gardiner, Jason Aleixo and Lorraine McLellan died after a minibus carrying staff and students from Prior's Court came to a sudden stop on the M4 and collided with another vehicle on 11 October 2018. The reason for the abrupt stop remained unclear, although the investigation considered a vehicle problem more likely than driver input. The principal concern was that the DMF protection system could shut down the engine without recording a fault code, together with the need for further forensic examination of the vehicle by Ford.

Julie MORREY · Prevention of Future Deaths report View report

24 Oct 2019 Stoke-on-Trent and North Staffordshire A. Barkley

Julie MORREY died in Royal Stoke University Hospital on 10 January 2019 after presenting with renal failure and bronchopneumonia. The report raised concerns about inadequate communication between hospital departments, a lack of proactive nursing management, insufficient fluids for over 24 hours, and no senior clinician review during that period.