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Caspian Thorn · Prevention of Future Deaths report View report

19 Sep 2019 Manchester South A. Mutch

Caspian Thorn was born with significant brain damage after chronic placental insufficiency and died in hospital on 29 September 2018 after developing a gram-negative hospital-acquired infection and sepsis. The concerns included failure to offer induction or follow up a missed growth scan, poor communication and support for a vulnerable family, undocumented triage calls, inadequate documentation of decision-making, delayed recognition of a pathological CTG, and delayed recognition of signs of sepsis.

Mark Jarvis · Prevention of Future Deaths report View report

19 Sep 2019 Suffolk N. Parsley

Mark Jarvis was found apparently deceased in his cell at HMP Warren Hill on 30 December 2015 and was later pronounced dead. The inquest concluded that the death resulted from a cardiac event precipitated by ingestion of a New Psychoactive Substance, with ischaemic heart disease recorded as the medical cause of death. Concerns included difficulties with the prison prescription system, including the inability to readily verify current and previous prescriptions, and the potential misuse of medications.

Peter Geoffrey Francis Harrison · Prevention of Future Deaths report View report

19 Sep 2019 Manchester South A. Mutch

On 17 December 2018, Peter Geoffrey Francis Harrison was found at the bottom of an external staircase and had multiple injuries, including head injuries. The inquest concluded that the death was suicide; concerns included that the maintenance staircase was accessible from a shopping area and had no lockable gate, despite not requiring regular public access.

Graham Martin SAFFERY · Prevention of Future Deaths report View report

18 Sep 2019 Bedfordshire and Luton E. Whitting

Graham Martin SAFFERY was found deceased at home on 19 June 2018 after taking prescribed oxycodone and amitriptyline. The inquest conclusion stated that the combination carried a risk of sudden death and that his prescription remained unchanged despite signs of over-sedation. A substantive concern was that the BNF did not appear to provide the caution and monitoring advice given by other pharmacological guidance for simultaneous prescribing of these medicines.

Tyla Katherine Joan COOK · Prevention of Future Deaths report View report

17 Sep 2019 Norfolk J. Lake

Tyla Cook had a complex mental health history and took 24 paracetamol tablets on 9 November 2017. After delayed treatment and subsequent deterioration, Tyla suffered a cardiac arrest and died at Queen Elizabeth Hospital on 15 November 2017. Concerns included delays in specialist assessment, the absence of an up-to-date written care and crisis plan, and the failure to organise a planned multi-disciplinary learning event addressing emergency response skills.

Dr Jonathan Edward Ball · Prevention of Future Deaths report View report

17 Sep 2019 West Yorkshire Eastern K. McLoughlin

On 24 November 2018, Dr Jonathan Edward Ball died after his Skoda collided with a stationary 32-ton HGV on the A647 Stanningley bypass near Pudsey, Leeds. The substantive concerns related to the absence of advance warning equipment and emergency-service notification for the stranded HGV, and the limited visibility or resilience of its rear hazard warning lights.

Tae’jelle Kaliyah Francois · Prevention of Future Deaths report View report

16 Sep 2019 West Yorkshire (West) A. Brocklehurst

Tae’jelle Kaliyah Francois suffered an acute asthma attack that continued despite prescribed medicine. While travelling to hospital and waiting for admission, her condition deteriorated, she collapsed, and she died at Huddersfield Royal Infirmary despite resuscitation. The report raised concerns that she was taken to the Accident and Emergency waiting area without visual assessment by reception or triage staff, and that an opportunity to recognise and escalate her critical condition was missed.

Blaithin Grianne Buckley · Prevention of Future Deaths report View report

16 Sep 2019 Northamptonshire J. Devonish

Blaithin Grianne Buckley died at Northampton General Hospital on 30 April 2018 after being found hanging in a phone booth at St. Andrews Healthcare while on five-minute observations. Concerns included the delay in calling an ambulance and uncertainty about whether procedures adequately explained when an ambulance should be called. The inquest also identified failures relating to locking the phone booth, transferring relevant patient history, and the process for calling the ambulance service.

Arthur William Jepson · Prevention of Future Deaths report View report

16 Sep 2019 South Yorkshire (Western) D. Urpeth

Arthur William Jepson suffered stomach pain and called 999; the ambulance arrived at 19.31 after the initial call was triaged as Category 5 and later reclassified as Category 3. The inquest identified that a required two-hour review to consider re-categorisation did not take place, raising concern that this could affect another case, although it was considered unlikely to have changed the outcome here.

Ffion Louise Jones · Prevention of Future Deaths report View report

16 Sep 2019 South Wales Central D. Regan

Ffion Jones died following an Addisonian crisis and cardiac arrest while waiting almost an hour for an ambulance at her GP’s surgery. Her urgent ambulance call was not escalated to the clinical support desk, and the report identified an ongoing lack of a dedicated means for external healthcare professionals to urgently discuss a patient’s clinical need with ambulance service staff. The report stated that there was a real risk of recurrence.

Lucia Jayne Stear · Prevention of Future Deaths report View report

13 Sep 2019 Liverpool and the Wirral A. Rebello

Lucia Jayne Stear was born after a large tree bough fell onto her pregnant mother's car on Arrowe Park Road, causing abdominal trauma. Lucia was delivered by emergency caesarean section, developed multi-organ failure, and died at 15 hours old. The inquest identified inadequate tree management, inspection, training, risk assessment, accountability and communication by Wirral Borough Council, and raised concerns about whether other public authorities faced similar risks.

William Oliver · Prevention of Future Deaths report View report

12 Sep 2019 Manchester North J. Kearsley

William Oliver died at home on 1 November 2018 after becoming acutely unwell and contacting emergency services. The report describes concerns about inappropriate handling and re-triage of subsequent calls, ambulance resource availability affected by meal-break rostering and prolonged hospital turnaround times.

Carl Anthony Schmidt · Prevention of Future Deaths report View report

11 Sep 2019 West Yorkshire Eastern K. McLoughlin

Carl Anthony Schmidt, a 51-year-old HGV driver, developed neurological symptoms after accelerated radiotherapy and chemotherapy for tonsillar cancer and died on 20 November 2018. The concerns were that the treatment could expose patients to neurological damage and that the mechanism of the injury required further investigation.

Maureen Margaret Jarvis · Prevention of Future Deaths report View report

11 Sep 2019 Staffordshire South A. Haigh

Maureen Margaret Jarvis was detained at the George Bryan Centre and taken to hospital on 15 August 2018, where she died on 17 August 2018 from the effects of a burst ulcer. The report raised concerns that she did not receive a full physical examination during her admission, and also identified issues with record-keeping and the level of personal care.

Gurdeep Singh Dundhal · Prevention of Future Deaths report View report

10 Sep 2019 Birmingham and Solihull L. Hunt

Gurdeep Singh Dundhal, who had paranoid schizophrenia and used illicit substances, died after jumping from the fifth storey of a car park on 27 April 2019; he passed away in hospital on 28 April 2019. The concerns included delays and resource problems in arranging a mental health assessment, missing information during the assessment, the decision to use section 2 rather than the recommended section 3, and failure to investigate and learn lessons across agencies.

Reece Tristan Lapina-Amarelle · Prevention of Future Deaths report View report

8 Sep 2019 East Sussex A. Craze

Reece Tristan Lapina-Amarelle, aged 20, died by suicide after being discharged from hospital with the expectation that he would immediately attempt to take his life. The report identifies concerns about insufficient resources and treatment for people with serious mental illness and substance misuse, inadequate information-sharing between services, limitations of voluntary support, and the Mental Health Act's failure to provide an appropriate plan of action focused on safety.

Millie Creasy · Prevention of Future Deaths report View report

6 Sep 2019 Bedfordshire and Luton E. Whitting

Millie Creasy suffered a prolonged seizure at home on 31 July 2018, was discharged from hospital after limited neurological observations, and was readmitted after deteriorating. She subsequently suffered respiratory arrest caused by brain herniation from raised intracranial pressure, and brain stem death was confirmed on 5 August 2018. Concerns included the lack of continued neurological observations, the absence of consideration of neuroprotective strategies after a prolonged seizure, and whether earlier identification and treatment of raised intracranial pressure might have improved her chances of survival.

Ms Shannon Quinn · Prevention of Future Deaths report View report

6 Sep 2019 Black Country Z. Siddique

Ms Shannon Quinn, a 24-year-old woman with a complex mental health history and repeated self-harm, was found hanging in her room at Oak House on 9 January 2019 and was pronounced deceased shortly afterwards. The report identified concerns including inadequate information sharing and joint care planning, insufficient staff training, escalating ligature risk without sufficient environmental measures, and failure to adhere to five-minute observations.

Tillie SPENCER-ADAMS · Prevention of Future Deaths report View report

5 Sep 2019 Hertfordshire G. Sullivan

Tillie Spencer-Adams was found unresponsive in her mother's bed on 18 June 2018 and could not be resuscitated. The medical cause of death was unascertained, with the inquest concluding Sudden Unexpected Death in Infancy. The report identified concern that injuries potentially sustained in a road traffic collision, including fractures and head injuries, may have been overlooked when she attended hospital on 4 May 2018.

Imran Mahmood · Prevention of Future Deaths report View report

4 Sep 2019 Staffordshire South A. Haigh

Imran Mahmood, a serving prisoner, was found dead in his cell at HMP Dovegate on 16 July 2018 after taking more heroin than his body could cope with; the inquest recorded morphine/heroin poisoning. The report raised concerns that e-cigarette heating coils could be used to cook heroin and could also present a fire risk in prisons.