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Robert Cobbina · Prevention of Future Deaths report View report

25 Jun 2019 Inner South London X. Mooyaart

Robert Cobbina entered the River Thames on 2 November 2018 and was later retrieved from the river and pronounced dead at the shore. The concerns related to emergency-call handling, including whether callers were prompted to request coastguard or other waterborne assistance and to provide riverfront location references, potentially delaying the deployment of appropriate assets.

Lewis James Doyle · Prevention of Future Deaths report View report

24 Jun 2019 Liverpool and the Wirral A. Rebello

Lewis James Doyle, who had multiple medical conditions including coronary artery disease and recurrent depressive illness, died on 8 January 2019 after developing worsening respiratory illness and pulmonary oedema following traumatic injuries sustained when he fell in front of a train. The principal concern was that discharge letters, including information about suspended or stopped medication, should be sent to all current medical attendants across primary, secondary and tertiary care.

Priscilla Tropp · Prevention of Future Deaths report View report

24 Jun 2019 North London A. Walker

On 27 November 2018, Priscilla Tropp fell down steps at Mill Hill Broadway Station and was taken to hospital, where she died from injuries sustained in the fall. The principal concern was the absence of a station flow chart or plan for managing people who become ill or injured, including steps to mitigate potential injury to them and others using the station.

Marcus William George McGuire · Prevention of Future Deaths report View report

23 Jun 2019 Birmingham and Solihull E. Brown

Marcus William George McGuire died at HMP Birmingham on 24 April 2018 after being found in his cell with a ligature around his neck. The inquest concluded that his suicide was possibly contributed to by failures to carry out a mental health assessment, respond to missed anti-psychotic medication, involve mental health services in the ACCT process, assess his risk using all relevant information, and properly manage the ACCT.

Deborah Anne Hopkinson · Prevention of Future Deaths report View report

21 Jun 2019 Manchester North M. Cox

Deborah Anne Hopkinson was treated for Cushing’s disease caused by a pituitary adenoma and later developed pneumocystis pneumonia. Her condition deteriorated during intensive care, and she died at Fairfield General Hospital on 26 September 2018 after a cardiac arrest. Concerns included equipment failures, delays in specialist advice and delays in recognising and treating complications associated with Cushing’s disease.

Ryan Stephen TRIMMER · Prevention of Future Deaths report View report

21 Jun 2019 East Sussex J. Healy-Pratt

Ryan Trimmer was remanded to HMP Lewes on 4 March 2017, had a history of self-harm and suicide attempts, and was found hanging in his cell on 22 April; he died in hospital on 26 April 2017. The inquest identified inadequate ACCT reviews as a matter that caused or contributed to his death. The report also raised concerns about prison staff resourcing on the healthcare wing and the lack of first-aid training among some frontline staff.

Michael John Owen COX · Prevention of Future Deaths report View report

20 Jun 2019 Cornwall and Isles of Scilly A. Cox

Michael John Owen Cox had a long history of mental illness and was living at Ridgewood Care Home after being placed there in July 2016. He was found deceased in his room on 01/04/2017; the inquest jury recorded a conclusion of misadventure due to drug/alcohol use. The principal concern was the potential shortage of suitable placements for people with similar mental health histories, including persistent difficulties in finding appropriate facilities and limited resources.

Pte Geoff Gray · Prevention of Future Deaths report View report

20 Jun 2019 Surrey H. QC

On 17 September 2001, 17-year-old Private Geoff Gray was found shot in the grounds of the Officers’ Mess at Princess Royal Barracks, Deepcut, with two fatal head wounds and a SA80 rifle beside him. The report raises concerns that the death was initially assumed to be suicide and investigated through a routine rather than forensic post-mortem, with photographs, imaging, wound documentation and clothing retention not undertaken, creating a risk that homicides could go undetected.

Tien Dong PHUNG · Prevention of Future Deaths report View report

19 Jun 2019 Inner North London S. Bourke

Tien Dong PHUNG died in hospital on 25 December 2018 after deteriorating following a kidney transplant and developing infection, fluid overload and a cardiac arrest. Post-mortem examination identified Strongyloides stercoralis in his lungs, and the medical cause of death was recorded as pulmonary strongyloidiasis. The concerns included that Strongyloides is not routinely screened for before transplant surgery and can present with non-specific symptoms, particularly in people whose immune systems are compromised.

James William Francis · Prevention of Future Deaths report View report

19 Jun 2019 West Sussex P. Schofield

James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.

Sophie Louise Lyons · Prevention of Future Deaths report View report

19 Jun 2019 Manchester South A. Mutch

Sophie Louise Lyons was struck by a car during a dangerous manoeuvre at an illegal car cruising event in Trafford Park on 31 May 2018. She died in Salford Royal Hospital on 1 June 2018 from a catastrophic traumatic brain injury. The report identified ineffective measures, poor communication, limited resources and an inadequate multi-agency response to the known risks of car cruising.

Aram Ali Mustafa · Prevention of Future Deaths report View report

19 Jun 2019 Birmingham and Solihull L. Hunt

Aram Ali Mustafa, an asylum seeker living in initial accommodation, was found hanging by a scarf in his room on 4 February 2019 and was declared deceased at 23.10. The report identified concerns that earlier suicide and safeguarding information was not sufficiently detailed or logged across the organisations involved.

Mason Logue · Prevention of Future Deaths report View report

19 Jun 2019 Manchester South A. Mutch

Mason Logue, who had been born prematurely and had a complex medical history, was found unresponsive in his mother’s bed at home on 28 October 2017. The post-mortem examination did not identify a clear cause of death, and the medical cause was recorded as unascertained. Concerns included limited integration and information sharing between services, the absence of an overarching supportive care plan and a single professional coordinating his care, and difficulties arising from differing protocols and the lack of a single IT system across NHS trusts.

Alfred Sykes · Prevention of Future Deaths report View report

18 Jun 2019 Manchester South A. Bridgman

Alfred Sykes became lost while travelling home by bus on 7 February 2018 and was found dead beneath undergrowth at St Georgian's Cricket Club on 11 February 2018. The principal concern was that information about his last sighting and direction of travel was not given adequate consideration, and that the subsequent police search of the sports fields was inadequate. The report states that a larger search on the morning of 8 February might have found him earlier, although he would not have been found alive in the circumstances described.

Mr John Gogarty · Prevention of Future Deaths report View report

17 Jun 2019 South Yorkshire (Western) C. Dorries

Mr John Gogarty was unlawfully killed at his home on 13 July 2015 by two people who planned to steal money to pay a drug debt; he was stabbed 69 times. The report identified missed opportunities and inadequate monitoring by the Probation Service, including failures relating to licence breaches, drug testing and recall. It also identified a missed opportunity for information about an offender’s relationship with a female patient to be shared with the Probation Service.

Oliver Hall · Prevention of Future Deaths report View report

17 Jun 2019 Suffolk N. Parsley

Oliver Hall, a six-year-old boy, became acutely unwell on 23 October 2017 and died in the early hours of 24 October 2017 after developing meningococcal septicaemia. The report identified concerns about NHS 111 disposition information not being transferred to ambulance and treating clinicians, delays in ambulance availability information, and conflicting guidance about the significance of his heart rate.

Shahida Begum · Prevention of Future Deaths report View report

16 Jun 2019 East London N. Persaud

Shahida Begum became unwell on 3 July 2018, attended an out-of-hours GP and then A&E, and was later directed back to a GP despite observations that should have triggered further assessment. She collapsed on 10 July 2018, was found to have sepsis, and died in hospital from an invasive group A streptococcal infection. The principal concern was that clinical streaming at Newham University Hospital took place before clinical observations were available, contributing to decisions about directing patients away from A&E.

Sebastian Clark · Prevention of Future Deaths report View report

13 Jun 2019 West London S. Cummings

Sebastian Clark died on 12 March 2017, four days after his birth, from multiorgan failure and hypoxic ischaemic encephalopathy following acute chorioamnionitis. Concerns included the absence of screening for streptococcal infection in women in labour and the need to consider guidance to reduce similar local deaths.

Richard Wayne Barraclough · Prevention of Future Deaths report View report

12 Jun 2019 South Yorkshire (Western) T. Rawden

Richard Wayne Barraclough died at Northern General Hospital on 18 January 2019 from advanced carcinomatosis and urothelial tract carcinoma. Evidence indicated that he had worked without protective equipment and was regularly and extensively exposed to polycyclic aromatic hydrocarbons. The report raised concern that employees continued to work in the same environment without protective equipment, creating a risk of future deaths.

Miss Nguyen Ngoc Quyen · Prevention of Future Deaths report View report

12 Jun 2019 Sunderland D. Winter

Miss Nguyen Ngoc Quyen died on 15 August 2017 at Success Road, Shiney Row, Houghton Le Spring; her death was consistent with the effects of fire. The report identified concerns about failures to act sufficiently, promptly and in a coordinated manner on known breaches of life licence conditions, including failures in information sharing between the Police and Probation Service, alongside wider organisational and supervision failings.