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Sebastian · Prevention of Future Deaths report View report

11 Jun 2019 Plymouth, Torbay and South Devon I. Arrow

Sebastian was a six-year-old boy who became ill on 10 October 2015 and deteriorated over the following weekend. He suffered a cardiac arrest and was confirmed deceased at Derriford Hospital on 12 October 2015. The concerns included limitations in NHS Pathways questions and support arrangements that may have hindered recognition and escalation of an acutely unwell child, as well as the absence of a failsafe mechanism for repeated enquiries about the same complaint.

Glenys Button · Prevention of Future Deaths report View report

10 Jun 2019 South Wales Central R. Knight

Glenys Button, aged 78, died at Royal Glamorgan Hospital on 5 November 2018 after sustaining a head injury, including a basal skull fracture, pneumocephalus and brain bleed, following a likely accidental fall at home. The report raised concerns about delays, miscommunication, confusion and inadequate documentation in referrals to on-call neurosurgery, including uncertainty and changes over her potential transfer to Cardiff.

Beverley Shaw · Prevention of Future Deaths report View report

10 Jun 2019 Manchester North J. Kearsley

Beverley Shaw was found deceased in her bed at home in Oldham in the early hours of 11 December 2018. The inquest heard that she had multiple prescribed medicines, was receiving methadone, and was using cocaine and butane gas. Concerns included inadequate communication between the substance misuse service and GP practice about her butane gas use, lack of a full medication review, and incomplete transfer of medical records.

Richard Stanley Lee Hallett · Prevention of Future Deaths report View report

6 Jun 2019 Dorset B. Allen

Richard Stanley Lee Hallett was riding a motorcycle when it collided with a white Iveco van at a junction in Poundbury on 14 September 2018. He sustained severe head injuries and died in hospital two days later; concerns were raised about the lack of road markings and parking restrictions, which reduced sightlines and increased the risk of collisions at junctions.

Jeanette Ann Robinson · Prevention of Future Deaths report View report

3 Jun 2019 Cornwall and Isles of Scilly A. Cox

Jeanette Ann Robinson, who had morbid obesity and type II diabetes, suffered a fall, developed a sacral pressure ulcer, and was admitted to hospital in a septic condition. She died in hospital on 21 December 2016. The report raised concerns that an accidentally deflated pressure-relieving mattress had no alarm or other warning system, and that an unsuccessful attempted transfer to a community hospital contributed to the outcome.

Kathleen Smith · Prevention of Future Deaths report View report

3 Jun 2019 North Wales (East and Central) D. Pojur

Kathleen Smith, who had advanced dementia and was at risk of choking, died after being fed unsuitable food and aspirating. The report raised concerns about inadequate staff training, failure to assist during the choking emergency, poor communication, and insufficient management oversight of safe food and fluid care.

David Bird · Prevention of Future Deaths report View report

3 Jun 2019 Bedfordshire and Luton E. Whitting

David Bird was arrested and held in police custody after concerns that he might take his own life, but was released without the medical assessment requested by police. He was found hanging in his bedroom on 21 August 2018. The principal concerns were the adequacy of custody officers’ training in interpreting detainee behaviour and in identifying when a detainee should see a healthcare practitioner before release.

Mr Matthew Jones · Prevention of Future Deaths report View report

3 Jun 2019 Bedfordshire and Luton E. Whitting

Mr Matthew Jones, who had paranoid schizophrenia and polysubstance misuse, was discharged from hospital to minimally supported temporary accommodation and suffered a cardiac arrest shortly afterwards; his death was attributed to cocaine toxicity. The report identified concerns about inadequate training and poor coordinated, multi-agency working, including insufficient attention to housing in hospital discharge planning.

Joshua Oliver Maxwell Blackham · Prevention of Future Deaths report View report

31 May 2019 Berkshire H. Connor

Joshua Blackham, a 30-year-old police officer, was found hanged on 29 November 2016 after his suspension from duty and amid increasing personal pressures, including relationship breakdown, financial concerns and concerns about contact with his daughter. The report raised concerns about inadequate welfare-officer training, insufficient information sharing, lack of arrangements for welfare contact when the officer was unavailable, and shortcomings in the NHS mental-health support for which Joshua had been referred.

Christopher Williams · Prevention of Future Deaths report View report

31 May 2019 Norfolk Y. Blake

Christopher Williams underwent a procedure to remove an infected foot-surgery screw and later developed severe leg pain, bilateral paraesthesia, worsening back pain, and suspected cauda equina. There were delays in ambulance attendance and Emergency Department admission, and concerns about incorrect call triage, failure to escalate his worsening condition, and communication about an arranged admission bed. His condition deteriorated with sepsis, multi-organ failure and worsening heart failure, and he died on 26 January 2019.

Geoffrey Duke · Prevention of Future Deaths report View report

30 May 2019 Stoke-on-Trent and North Staffordshire M. Jones

Geoffrey Duke became unwell repeatedly after a pacemaker box change in June 2016 and was later found to have infection involving the pacemaker wires. The principal concerns were that the pacemaker was not considered as a possible source of infection, no cardiology referral was made, and there was no evidence of a referral process for patients who became unwell after pacemaker surgery. He died in hospital on 20 December 2017 after deterioration during treatment and surgery.

Susan Barbara HENDERSON and Margaret Louise SHAW · Prevention of Future Deaths report View report

30 May 2019 Milton Keynes T. Osborne

Susan Barbara Henderson and Margaret Louise Shaw died at the scene from injuries after one car aquaplaned across the A5, Milton Keynes, into the path of an oncoming vehicle. Evidence indicated that standing water had accumulated because blocked roadside gullies had not been identified during routine inspections, prompting concern that the inspection process should be reviewed.

Emily Katherine Inglis · Prevention of Future Deaths report View report

30 May 2019 Carmarthenshire and Pembrokeshire M. Layton

Emily Katherine Inglis was found deceased in her bedroom at Prince Philip Hospital on 22 April 2016, with a plastic bag over her head; the cause of death was given as plastic bag asphyxia. The inquest identified concerns about the absence of an overarching risk management plan and deficiencies in record-keeping, including risk management strategies and handover records.

Peter Moran · Prevention of Future Deaths report View report

30 May 2019 Stoke-on-Trent and North Staffordshire M. Jones

Peter Moran, who lived alone with a care plan and had dementia and limited mobility, died in hospital after a cooker grill was left alight and a subsequent fire-related incident caused smoke inhalation. The concerns were that carers had been instructed to switch off appliances and remove cooker knobs, but the cooker had not been properly turned off and removing the knobs did not appear to be an appropriate way to make the appliance safe.

Gloria Elizabeth MEKINS · Prevention of Future Deaths report View report

28 May 2019 Teesside and Hartlepool C. Bailey

Gloria Elizabeth Mekins was a resident at Rossmere Park Care Home when she choked while eating a snack on 2 October 2018 and died at the care home. Concerns included the absence of first aid by the staff member who found her, confusion about the existence of a DNA CPR leading to a delay in first aid, and the care home's failure to investigate or address these issues.

Maia Hazel Ann Strachan · Prevention of Future Deaths report View report

28 May 2019 Newcastle upon Tyne K. Dilks

Maia Hazel Ann Strachan was born on 6 July 2017 and died in hospital on 7 July 2017 after a complicated delivery involving shoulder dystocia, hypoxic ischaemic encephalopathy and severe macrosomia. The report identified concerns about inaccurate and suboptimal ultrasound assessment, inaccessible obstetric and diabetic records, missed opportunities for Caesarean delivery and joint decision-making, fetal scalp electrode use, documentation, and dissemination of expert findings.

Ahmed Hassam Motala · Prevention of Future Deaths report View report

24 May 2019 Gloucestershire C. Saunders

Ahmed Motala was cycling to work on the A38 in Gloucester on 29 November 2018 when he collided with a lorry; the injuries he sustained resulted in his death. The report raised concern that the cycle lane was in very poor condition, requiring cyclists to swerve or cycle close to the traffic lane, and that cyclists’ lives could be put at risk if it remained unrepaired.

Ray Ronald Westlake and Barry Malcolm Clow · Prevention of Future Deaths report View report

24 May 2019 Gloucestershire C. Saunders

On 9 December 2018, Barry Malcolm Clow lost control of his car on the A424 near Upper Rissington and collided with another vehicle; Ray Ronald Westlake, a passenger in the other vehicle, and Mr Clow died at the scene from their injuries. The concern was that standing and running water regularly overwhelmed roadside drainage on this stretch of road, with no warning signs for the potential for flooding, putting future motorists' lives at risk.

Ray Ronald Westlake and Barry Malcolm Clow · Prevention of Future Deaths report View report

24 May 2019 Gloucestershire C. Saunders

On 9 December 2018, Barry Malcolm Clow lost control of his car on the A424 near Upper Rissington and collided with another vehicle; Ray Ronald Westlake, a passenger in the other vehicle, and Mr Clow died at the scene from their injuries. The concern was that standing and running water regularly overwhelmed roadside drainage on this stretch of road, with no warning signs for the potential for flooding, putting future motorists' lives at risk.

Noah Lomax · Prevention of Future Deaths report View report

24 May 2019 South Yorkshire (Western) A. Davies

Noah Lomax, aged 15, died on 1 August 2018 after jumping from Conisbrough Viaduct, having previously expressed suicidal intentions and made plans to take his own life. His GP referral to CAMHS was closed because it contained insufficient information for a risk assessment, and his family were not notified. The principal concern was that the referral form and process could result in inadequate information being provided and delays in care.