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Graham George Smith · Prevention of Future Deaths report View report

23 May 2019 Leicester City and South Leicestershire L. Browne

Graham George Smith died in a house fire at his home on 24 April 2018, after deteriorating during alcohol and benzodiazepine withdrawal and refusing hospital transport on three occasions. The report raised concerns that emergency call handling could not link repeat calls about the same patient and address, and that attending ambulance crews lacked information, senior review and warning of heightened concern.

Sasha Sabrina FORSTER · Prevention of Future Deaths report View report

23 May 2019 Central Hampshire D. Reid

Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.

Tyereece Johnson · Prevention of Future Deaths report View report

23 May 2019 Inner West London S. Radcliffe

Tyereece Johnson, aged 16, died following a collision with a police vehicle while driving a moped with two passengers. The report raised concern that the approximate age of the moped riders was not passed to the Police Control Centre, despite witnesses considering it relevant to risk assessment and tactical decision-making.

Jonathan Richard McCARTHY · Prevention of Future Deaths report View report

22 May 2019 North West Kent R. Hatch

Jonathan Richard McCarthy was admitted to hospital with confusion, aspiration pneumonia, sepsis, acute kidney injury and swallowing difficulties, and later deteriorated with another aspiration pneumonia and hyperglycaemia. The stated concerns were failures to correctly monitor blood sugar and ketones, administer the correct insulin dose, and provide adequate nursing care and escalation to the medical team.

Christopher George Barnes · Prevention of Future Deaths report View report

20 May 2019 Gloucestershire K. Skerrett

Christopher George Barnes, a 69-year-old lorry driver, fell approximately 2.3 metres from the load on his lorry while attempting to untangle securing straps and died from his injuries on 24 April 2018. The principal concern was whether consignors, consignees and their employees sufficiently understood the hazards of working at height on vehicles or trailers and had appropriate safety measures and controls in place.

Richard Geoffrey Phillips · Prevention of Future Deaths report View report

20 May 2019 Dorset R. Middleton

Richard Geoffrey Phillips died at the scene after a car lost control on ice while he was riding his motorcycle on the B3091 on 19 December 2017. The concerns identified included poor drainage of surface water, ice forming on the carriageway, and the maintenance and condition of the road and its verges.

Barry Marshall Fullarton · Prevention of Future Deaths report View report

17 May 2019 Liverpool and the Wirral A. Rebello

Barry Marshall Fullarton died on 17 December 2018 after intentionally falling from the balcony of his bedroom, while suffering from a reactive depressive illness following a stroke. The principal concern was that mental health assessments should account for how a disorder manifests over time, including the possibility that an afternoon assessment during improved mood may not reflect needs during morning low mood.

Jaspal Singh BAHRA and 3 others · Prevention of Future Deaths report View report

17 May 2019 Buckinghamshire C. Butler

Jaspal Singh Bahra, Saavan Singh Mundae, Michael Leonard Green and Thanh Trung Nguyen died at the scene after the aircraft they were flying collided over Wilderness Wood in Buckinghamshire on 17 November 2017. The report raised concerns about reliance on the “See and Avoid” procedure in unregulated airspace without universal electronic proximity warning or collision-avoidance devices, and about the lack of mandatory carbon monoxide monitors or warning devices in light aircraft.

Mellin Beard · Prevention of Future Deaths report View report

17 May 2019 Manchester South C. Morris

Mellin Beard, who had complex health problems including spinal cord compression and reduced mobility, developed pressure sores that later deteriorated despite care. He died on 16 October 2018 from left ventricular failure due to ischaemic and hypertensive heart disease, with infected pressure sores among the contributing health problems. Concerns included delays in referrals for community nursing after hospital discharge and significant reliance on agency nurses.

Jenson James Francis · Prevention of Future Deaths report View report

17 May 2019 South Wales Central D. Regan

Jenson James Francis was delivered by caesarean section and developed chorioamnionitis and funisitis in the context of maternal sepsis. The report records cardio-pulmonary failure following a failure to deliver him in good time and states that he was exposed to the effects of developing maternal sepsis. Principal concerns included poor CTG interpretation and training, unclear clinical leadership and communication, inadequate records, insufficient staffing and escalation, and wider systemic shortcomings in the maternity unit.

Daniel Davey · Prevention of Future Deaths report View report

16 May 2019 Oxfordshire D. Salter

Daniel Davey, aged 21, died at John Radcliffe Hospital on 12 January 2018 after deliberately overdosing on propranolol in his cell at HMP Bullingdon Prison. The report raises concerns about healthcare attendance at ACCT reviews, risk assessments and management of in-possession medication, cell searches, and failures to share and act on information relevant to his safety.

Kevin John McDonald · Prevention of Future Deaths report View report

16 May 2019 Worcestershire G. Williams

Kevin John McDonald was admitted to hospital after a spinal injury, was assessed and discharged with analgesia, apparently without follow-up. He later died by suicide, leaving a note indicating that he could no longer tolerate the pain. Concerns included unclear discharge advice and follow-up arrangements, with the family stating that he was left unsure what to do about his increasing pain and that no relevant hospital documentation had been found.

Natasha Elizabeth Victoria Abrahart · Prevention of Future Deaths report View report

16 May 2019 Avon M. Voisin

Natasha Elizabeth Victoria Abrahart died on 30 April 2018 after placing a ligature around her neck. She was under the care of a mental health team that had not provided a timely and detailed management plan following several assessments. The report also identifies concerns that follow-up after starting sertraline, including review of suicide risk, did not comply with the cited NICE guideline; the inquest concluded that the death was suicide contributed to by neglect.

Mildred CLARK · Prevention of Future Deaths report View report

15 May 2019 North East Kent S. Hayes

Mildred CLARK died in hospital on 17 December 2017 following infection and failure of a bypass graft, haemorrhage, and inadequate blood supply to the leg. The inquest found that delay in diagnosing the infection and haematoma limited the available medical intervention. A separate concern was raised about a paramedic being instructed by telephone to attempt hernia reduction despite not being trained to do so, and about possible pressure on staff to avoid hospital admission during winter pressure.

Shaun David Neal · Prevention of Future Deaths report View report

15 May 2019 County Durham and Darlington J. Thompson

Shaun David Neal was killed in a road traffic collision while riding his motorcycle on the A68 near Tow Law, County Durham, on 2 September 2017. An oncoming vehicle struck him after overtaking in the opposing lane, causing fatal injuries. Concerns related to the use of broken hazard white lines at the collision location and expert evidence that double solid white lines might have prevented the overtaking manoeuvre.

Marion Hilda Prance · Prevention of Future Deaths report View report

15 May 2019 South Wales Central R. Knight

Marion Hilda Prance, aged 82, suffered a head injury after an unwitnessed fall at her care home and was given her usual morning dose of Rivaroxaban on the advice of paramedics. She was later diagnosed with a subdural haematoma, developed a catastrophic brain bleed and died the next day. The principal concerns were paramedic awareness and training regarding Rivaroxaban and the need for caution after head injuries caused by falls.

Anthony Charles WALKER · Prevention of Future Deaths report View report

14 May 2019 Portsmouth and South East Hampshire D. Clark

On 16 November 2017, Anthony Charles WALKER was found hanging in his room at The Grange Probation Hostel after being released on licence from prison to the hostel. He was pronounced deceased by attending paramedics. The inquest concluded that the death was suicide due to hanging.

Karanbir Singh CHEEMA · Prevention of Future Deaths report View report

10 May 2019 Inner North London M. Hassell

Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.

John Charles Alliston · Prevention of Future Deaths report View report

9 May 2019 Gloucestershire K. Skerrett

John Charles Alliston was found deceased in the garden of his private rental property on 8 June 2017 after sustaining a fatal electric shock from a live capillary wire associated with the oil heating system. The report raised concerns that private rental electrical installations were not mandatorily inspected to BS7671, leaving a risk of further deaths while the timing of new legislation remained unclear.

Bernard Pius O’Flynn · Prevention of Future Deaths report View report

8 May 2019 Inner South London C. Williams

Bernard Pius O’Flynn was imprisoned at HMP Thameside and developed back and abdominal pain before being diagnosed with an acute abdomen. His transfer to hospital was delayed for three days; he was later diagnosed with metastatic adenocarcinoma and died in hospital on 26 August 2018. The report identified concerns about urgent hospital transfers from prison, including the absence of expert emergency-medicine input into policies for emergencies outside Code Red and Code Blue situations.