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Mrs Margaret Melia · Prevention of Future Deaths report View report

18 Apr 2019 Black Country Z. Siddique

Mrs Margaret Melia was admitted to Dovetail Court Care Home in October 2018, later developed declining food and fluid intake, was admitted to hospital with dehydration and a lower respiratory tract infection, and died on 7 November 2018 while receiving end-of-life palliative care. The inquest identified an inadequate discharge and pre-assessment process between Lakeview Care Home and Dovetail Care Home concerning the requirement for subcutaneous fluids.

Megan Nicole JONES · Prevention of Future Deaths report View report

17 Apr 2019 Isle of Wight C. Sumeray

Megan Nicole JONES, aged 28, was found dead at home after a history of mental health issues and treatment with combined antipsychotic medications. The report states that she was believed to have suffered a fatal cardiac arrhythmia associated with a higher-than-optimal recommended dose of the medications. The principal concern was the absence of a formal policy for regular monitoring, including QTc recording, of patients prescribed Clozapine, particularly when antipsychotic prescribing exceeded 100% of the BNF limit.

Patrick Kelly · Prevention of Future Deaths report View report

17 Apr 2019 South Yorkshire (Western) A. Combes

Patrick Kelly died from sepsis, part of which was attributed to a dental abscess. The report raised concerns that Roseberry Care Centres did not place adequate importance on dental hygiene and dental services, and lacked adequate policies for missed dental appointments and identifying when appointments were needed.

Nathan John COOKE · Prevention of Future Deaths report View report

17 Apr 2019 Isle of Wight C. Sumeray

Nathan John COOKE was found dead at home after being prescribed Methadone and Clomipramine and supplementing these with illicit medication. The inquest concluded that the death was drug related, with the medical cause recorded as cardio-respiratory failure, severe central nervous system depression, and Methadone and Clomipramine overdose. A principal concern was that the known risk associated with QTc prolongation was not adequately addressed through clinical monitoring and medication management.

Brian Goodman · Prevention of Future Deaths report View report

17 Apr 2019 Inner North London S. Bourke

Brian Goodman, who had a history of suicide attempts by hanging, was found hanging from the door-closing mechanism of his room on 9 November 2018. The concerns included that this mechanism was not changed after another ligature point had been removed and that the same type of mechanism continued to be used in One Support properties.

June Russell · Prevention of Future Deaths report View report

17 Apr 2019 Berkshire H. Connor

June Russell died following a road traffic collision on 2 May 2018 at the junction of the B470 High Street, Langley, and the A4 London Road. The report identified concerns about recurring collisions at the junction and the adequacy of its signs, traffic lights, layout and line of sight.

Jonathan Brett Yates · Prevention of Future Deaths report View report

16 Apr 2019 Gloucestershire K. Skerrett

Jonathan Brett Yates, aged 68, was admitted to hospital after a fall and had a PEG feeding tube. Although he was nil by mouth, an evening meal was delivered to him; he attempted to eat it, choked, suffered cardiac arrest, and died on 20 March 2018. The substantive concern was how a patient's nil-by-mouth status and nutritional needs are communicated effectively to staff during a hospital admission.

Nyall Cye BROWN · Prevention of Future Deaths report View report

15 Apr 2019 Norfolk J. Lake

Nyall Cye Brown was found hanging in woodland on 17 May 2018 and died in hospital on 22 May 2018. Concerns included that his care records were not reviewed before he was assessed, meaning his full history and risks could not be taken into account, and that this issue had been raised previously but was not always addressed. The issue was also not considered in the Trust’s investigation.

Jennifer Lewis · Prevention of Future Deaths report View report

15 Apr 2019 North West Kent R. Hatch

Jennifer Lewis was admitted to hospital from the Bracton Centre on 21 July 2017 with poor intake, diarrhoea, confusion, dehydration, hypotension and malnutrition, and subsequently deteriorated. The inquest concluded that she died at Darent Valley Hospital on 31 July 2017 as a result of malnutrition due to inadequate provision and intake of sufficient nourishment and nutrition, furthered by an inability to provide the necessary medical intervention at the Bracton Centre. The principal concerns were failures to arrange consultation between mental health and physical health doctors, provide suitable or adequate care for her needs, and provide appropriate care at the Centre.

Mr Thomas Smith Collings · Prevention of Future Deaths report View report

15 Apr 2019 Sunderland D. Winter

Mr Thomas Smith Collings suffered unexpected ventricular fibrillation at Sunderland Royal Hospital on 2 August 2018 and was found several minutes later without effective cardiac output. The report identified failures to detect the ventricular fibrillation, including ECG monitoring not detecting the rhythm, the crisis alarm not sounding, artefact obscuring the trace, and delays in attendance. The substantive concern was whether improvements to monitoring algorithms could enable earlier alerts and better distinguish artefact from a life-threatening event.

Emma Felicity BUTLER · Prevention of Future Deaths report View report

12 Apr 2019 Buckinghamshire C. Butler

Emma Butler was an inpatient at Ruby Ward who died at Stoke Mandeville Hospital from blood loss after incised wounds inflicted outside the Whiteleaf Centre while she was on unescorted leave. The report raised concerns about access to means of self-harm on and outside the ward, hourly observations, urgent access to ward support, and planning for discharge.

Duncan Tomlin · Prevention of Future Deaths report View report

12 Apr 2019 West Sussex E. Bussey-Jones

Duncan Tomlin died on 29 July 2014 after cardiac arrest following the use of drugs and police prone restraint, including handcuffs, leg restraints and incapacitant spray. The report identified concerns about insufficient emphasis on the heightened breathing risks of multiple factors, delayed opportunities to assess and reposition him, inadequate guidance on monitoring, the timing of CPR, and understanding atypical or post-seizure behaviour.

ARCHIE RAY GRIEVES · Prevention of Future Deaths report View report

12 Apr 2019 Gateshead and South Tyneside T. Carney

Archie Ray Grieves was born on 24 May 2017 following a complicated delivery involving shoulder dystocia. He initially showed no signs of life, later showed signs of life, and died a short time after being taken to the special care baby unit. The report identified an avoidable neonatal death, with an eight-minute delay in delivering his body after his head and missed opportunities during antenatal care and delivery to identify risks and plan a safe birth.

Christopher Thomas INNES · Prevention of Future Deaths report View report

10 Apr 2019 Central and South East Kent B. Patel

Christopher Innes died on 25 May 2018 after being struck by a van while crossing the A28 Ashford Road in Chartham, having alighted from a bus. The concerns included the unmarked bus stop, the lack of a footway or nearby pedestrian crossing on a 50 mph road, and vegetation restricting the space available for pedestrians. There was also no clear responsibility for managing the vegetation or land adjoining the bus stop.

David DOOLEY · Prevention of Future Deaths report View report

10 Apr 2019 Brighton and Hove G. Tisshaw

David DOOLEY died in an incident in the sea at Brighton seafront. The report identified that police officers did not know the location of nearby life lines, causing a delay in attempts to throw one, although it considered that adverse weather and sea conditions would have prevented an earlier successful rescue attempt. It also raised concerns about public awareness of the dangers of entering the sea after consuming alcohol or taking drugs, and the inquest concluded that the death was accidental.

Aidan David Ridley · Prevention of Future Deaths report View report

9 Apr 2019 Wiltshire and Swindon I. Singleton

Aidan David Ridley was struck by a car while crossing a road on 12 February 2016 and died three days later from hypoxic brain injury caused by how he landed, which obstructed his airway. Concerns included police call-handler advice not to turn him over, insufficient direction to seek ambulance advice or defer to medically trained bystanders, and inadequate call-handler training, guidance and supervision.

Freda Odette Mason · Prevention of Future Deaths report View report

9 Apr 2019 Lancashire and Blackburn with Darwen S. Jones

Freda Odette Mason, who had underlying conditions including chronic obstructive pulmonary disease, osteoporosis and frailty fractures, fell through a bus shelter panel that was missing and sustained multiple rib fractures. She died in hospital three days later; the substantive concern was that the local authority used a reactive system for identifying bus shelter defects, without routine inspections or a requirement for users to report problems.

Anthony Hayward BUCKINGHAM · Prevention of Future Deaths report View report

9 Apr 2019 Suffolk D. Sharpstone

Anthony Hayward BUCKINGHAM died at home on 13 March 2018 with a metal cable around his neck, after a previous suicide attempt and ongoing suicidal thoughts. The inquest highlighted concerns about the frequency of mental health visits, involvement of his father and practice nurse, a formal mental health assessment, and use of a care facility.

Tina Tait · Prevention of Future Deaths report View report

8 Apr 2019 Blackpool and the Fylde A. Wilson

Tina Tait underwent elective ovarian cystectomy surgery on 8 May 2018 and subsequently experienced complications, including a colon perforation and later deterioration. She became unresponsive and died on 16 June 2018. The principal concern was the quality, legibility, accessibility and retention of clinical records, which delayed and compromised internal death reviews and could affect continuity of care and the learning of lessons.

Ronald CLARK · Prevention of Future Deaths report View report

8 Apr 2019 Portsmouth and South East Hampshire D. Clark

Ronald CLARK underwent insertion of a stent in his common hepatic duct, but an incorrectly sized stent was inserted and significantly contributed to his death at Queen Alexandra Hospital on 2 April 2018. The report raised concern that identical packaging for different stent sizes made them difficult to identify and could lead to use of the wrong-sized stent.