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Mary Jane Chapman · Prevention of Future Deaths report View report

8 Oct 2019 Cheshire C. Welch

Mary Jane Chapman underwent elective knee replacement surgery and was discharged with a low platelet count, but a required follow-up blood test was not arranged. She was later admitted with a dangerously low platelet count and died on 4 March 2018 from a large myocardial infarction caused by coronary artery thrombosis associated with catastrophic antiphospholipid syndrome. The principal concerns related to unclear discharge responsibilities and procedures, inadequate communication and documentation of critical follow-up investigations, and insufficient evidence that subsequent changes had improved these processes.

Alf REWIN · Prevention of Future Deaths report View report

7 Oct 2019 Buckinghamshire C. Butler

Alf Rewin died at Wexham Park Hospital on 22 November 2018 after taking an overdose of Quetiapine, Methylphenidate and Duloxetine and becoming unresponsive before arrival. The principal concern was that overdose cases could receive a Category 3 ambulance response with a target of up to 120 minutes, despite the risk of unconsciousness, cardiac arrest or other potentially fatal events requiring earlier attendance.

Master Alex Malcolm · Prevention of Future Deaths report View report

5 Oct 2019 Inner South London A. Harris

Master Alex Malcolm, aged 5, died on 22 November 2016 from a head injury and was found to have been unlawfully killed; a perpetrator was convicted of murder. The jury identified concerns including the perpetrator’s misclassification, failures to share information and safeguard the deceased’s mother, inadequate probation supervision, failure to secure approved premises, and failures to respond to licence breaches. Further concerns included shortages of approved premises, domestic-violence safeguarding arrangements, and recruitment and retention difficulties among probation officers.

Jane Diane Livingston · Prevention of Future Deaths report View report

4 Oct 2019 Swansea and Neath Port Talbot A. Gruffydd

Jane Diane Livingston was receiving treatment for anxiety and depression and died by suicide after being found hanging in a multi-storey car park on Trawler Road, Swansea. The report identified concern that gateway assessors did not have access to her earlier review and stated concerns, potentially leading to an assessment and treatment plan based on incomplete information.

Pamela Evans · Prevention of Future Deaths report View report

4 Oct 2019 Bedfordshire and Luton A. Street

Pamela Evans, aged 87, fell and hit her head at Bedford Hospital after becoming dizzy while walking to the toilet, and died on 4 November 2018 from a large right-sided acute on chronic subdural haematoma. Concerns included inconsistent understanding among nurses about when to call the critical care outreach team, limited action that team could initially take, errors in recording her NEWS, and failures to identify these issues through the Trust’s serious incident investigation.

Michael Lobban · Prevention of Future Deaths report View report

4 Oct 2019 London Inner (West) R. Caller

Michael Lobban, who had drug dependency and mental illness, was found dead at home on 23 October 2017 with a significant methadone overdose and other drugs in his body. The report raised concerns about the speed and completeness of Boots’ investigation into missing methadone, the robustness of its controlled-drug audit procedures, and the General Pharmaceutical Council’s reporting and investigative arrangements for discrepancies in controlled drugs.

Jane Diane Livingston · Prevention of Future Deaths report View report

4 Oct 2019 Swansea and Neath Port Talbot A. Gruffydd

Jane Diane Livingston was receiving treatment for anxiety and depression and died by suicide after being found hanging in a multi-storey car park on Trawler Road, Swansea. The report identified concern that gateway assessors did not have access to her earlier review and stated concerns, potentially leading to an assessment and treatment plan based on incomplete information.

Saeid Hedayat · Prevention of Future Deaths report View report

2 Oct 2019 West Sussex R. Simpson

Saeid Hedayat lost control of his vehicle on the B2112 after encountering floodwater caused by a blocked drain, and the vehicle overturned, causing multiple injuries. He suffered a hypoxic brain injury and died. Concerns included risk assessments that did not account for recurring zone 1 drain blockages, were not regularly reviewed, and did not respond to relevant flooding reports, as well as the absence of warning signs despite recurring road flooding.

Richard Lester Ridout · Prevention of Future Deaths report View report

2 Oct 2019 West Sussex R. Simpson

Richard Lester Ridout was involved in a single-vehicle road traffic collision on 20 January 2019 and was later readmitted with respiratory failure, where cervical fractures and pulmonary contusions were discovered. The inquest concluded that he died from Influenza A and streptococcal pneumonia causing sepsis and multiple organ failure. Concerns were raised that the assessment and escalation of treatment after the collision did not include a trauma call, trauma CT scan, or cervical spine imaging despite the reported collision circumstances, injuries, neck pain and medication use.

Philip Vernon Owen · Prevention of Future Deaths report View report

2 Oct 2019 Manchester South A. Owen

Philip Vernon Owen was found dead in his flat on 30 October 2016 after being killed by a stab wound to the neck. The report describes failures in mental health risk assessment, discharge planning and communication after the perpetrator’s release from custody, and concerns about how risks associated with short custodial sentences were communicated to sentencing courts and managed by relevant services.

Oliver Sharp · Prevention of Future Deaths report View report

1 Oct 2019 Manchester South A. Mutch

Oliver Sharp died after taking a fatal dose of heroin; his death was confirmed at Wythenshawe Hospital on 18 October 2018. The inquest identified concerns about failures by mental health services to recognise and respond to his increasing level of risk during his transition from child and adolescent mental health services to reduced post-16 provision, as well as concerns about delays in autism assessment and variation in post-16 services.

Ceara Marie Thacker · Prevention of Future Deaths report View report

30 Sep 2019 Liverpool and Wirral A. Bhardwaj

Ceara Marie Thacker, a 19-year-old University of Liverpool student with a history of self-harm and contact with mental health services, was found deceased hanging on 11 May 2018. Concerns included the lack of discussion about involving her family in care planning and the absence of attempts to cut her down after she was found hanging; the first-aid training received by the person who found her did not cover hangings.

Mary Jones · Prevention of Future Deaths report View report

30 Sep 2019 Manchester South A. Mutch

Mary Jones had an accidental unwitnessed fall, was treated surgically and transferred for rehabilitation, and died on 3 March 2019 after developing acute pneumonia alongside congestive heart failure and acute kidney injury. Concerns included an out-of-hours transfer and admission, delayed falls-risk assessment, poor fluid-chart documentation, loss of records during an IT merger, absent or untraceable nutrition-related referrals, and no clear clinical review of fluid-chart outcomes.

Charles Williamson · Prevention of Future Deaths report View report

30 Sep 2019 Manchester South A. Mutch

Charles Williamson sustained a traumatic brain injury after falling in Portugal and underwent treatment and rehabilitation in several hospitals. He later developed infections and deteriorated; the report raised concern that a shortage of appropriate neuro-rehabilitation beds in Greater Manchester could delay effective rehabilitation and increase the risk of complications leading to death.

Julie Ann Barrow · Prevention of Future Deaths report View report

30 Sep 2019 Manchester South A. Mutch

Julie Ann Barrow, who had significant learning disabilities, was admitted to hospital on several occasions for perianal pain, rectal bleeding and haemorrhoids. Following treatment for adjustment disorder and significant sedation, she fell at her family home on 1 April 2019, sustained an unsurvivable brain injury and died in hospital the next day. The principal concerns included the absence of a best interests meeting and reasonable adjustment care plan, ineffective communication and understanding of her needs, inadequate support for her parents, and the loss of the learning disability liaison role.

Owen Carey · Prevention of Future Deaths report View report

30 Sep 2019 Inner South London B. Ballard

On 22 April 2017, Owen Carey ate food at Byron restaurant at the O2 centre despite making serving staff aware of his dairy allergy. The chicken contained buttermilk, causing a severe food-induced anaphylactic reaction from which he died. Concerns included the adequacy of allergen training, the prominence and effectiveness of allergen notices and information on menus, and the absence of a national register for severe food anaphylactic reactions.

Kaiya Sonja Campbell · Prevention of Future Deaths report View report

30 Sep 2019 Manchester South A. Mutch

Kaiya Sonja Campbell was born at Tameside General Hospital on 28 September 2019 following her mother’s extensive bleeding and early rupture of the membranes. She lived briefly and died soon after birth, with the medical cause recorded as extreme prematurity at 19 weeks and 6 days’ gestation. Concerns included gaps in records of her mother’s anticonvulsant prescriptions, failure to seek urgent neurology guidance, and the offering of a routine rather than appropriately identified high-risk consultant appointment.

Graham Earl · Prevention of Future Deaths report View report

30 Sep 2019 Manchester South A. Mutch

Graham Earl had pulmonary fibrosis diagnosed while receiving Amiodarone therapy and was not referred back to the cardiologist. He later developed influenza, deteriorated, and died at Stepping Hill Hospital on 16 February 2019. The principal concerns were that the link between Amiodarone and pulmonary fibrosis was not recognised promptly, the medication was amended without reference to secondary care, and there was insufficient awareness of escalation procedures for side effects.

Amy Allan · Prevention of Future Deaths report View report

30 Sep 2019 London Inner (North) E. Buckett

Amy Allan underwent elective corrective spinal surgery on 4 September 2018 and subsequently suffered severe deterioration, requiring ECMO support before dying on 28 September 2018. Concerns included inadequate pre-operative planning for ECMO, poor communication and handover between departments, extubation while her condition was deteriorating, delayed ECMO support, and a lack of clear co-ordination of her post-operative care.

Anthony Joseph McCormack · Prevention of Future Deaths report View report

27 Sep 2019 Birmingham and Solihull E. Brown

Anthony Joseph McCormack was found dead at home on 7 May 2019 after concerns about his wellbeing. He had been identified as in crisis and assessed as fit for detention, but no inpatient bed was available; concerns included inadequate assessment and monitoring by overstretched community mental health services. The inquest concluded that the death was suicide due to the unavailability of an inpatient mental health bed.