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Marcie Joan TADMAN · Prevention of Future Deaths report View report

13 Mar 2019 Avon M. Voisin

Marcie Joan Tadman died on 5 December 2017 at Royal United Hospital after admission with pneumonia and parapneumonic effusion. The report describes failures to recognise and manage sepsis, follow hospital procedures and protocols, communicate effectively, conduct proactive reviews, and make appropriate decisions. It also identifies the absence of a paediatric high dependency unit at the hospital as a concern.

Mr Frederick Raymond BROOKER · Prevention of Future Deaths report View report

12 Mar 2019 East London N. Persaud

Mr Frederick Raymond Brooker, who used a wheelchair in a residential care home, sustained multiple falls, including a fall on 10 July 2018 that caused a catastrophic traumatic bleed and from which he died on 14 July 2018. The principal concerns were that, despite his recognised high risk of falling, the care home did not put adequate care plans or other measures in place, review the wheelchair or involve relevant services, investigate subsequent falls, or provide evidence of encouragement to use the wheelchair seatbelt.

Marjorie GARTSIDE · Prevention of Future Deaths report View report

12 Mar 2019 Manchester North C. McKenna

Marjorie Gartside, aged 100, fractured her hip in an unwitnessed fall at a residential home and underwent surgery. She was discharged from hospital on two occasions, with concerns about inaccurate information regarding her mobility, unsafe discharge processes, lack of care handover and unclear palliative-care arrangements, and anticipatory medication not being sent with her. She died at the Home on 19 October 2018.

Terence Bradfield · Prevention of Future Deaths report View report

11 Mar 2019 Plymouth, Torbay and South Devon D. Archer

Terence Bradfield entered Derriford Hospital on 1 December 2013 with gastric bleeding and died on 17 December 2013, primarily from the consequences of his gastrointestinal bleed. The report raised concerns that his long-term steroid medication was not given or adequately managed, including when he was vomiting, and about staff training and the absence of policies for steroid management and “Nil by Mouth” patients with co-morbidities.

David Alexander MOBS​​BY · Prevention of Future Deaths report View report

11 Mar 2019 Brighton and Hove V. Hamilton-Deeley

David Alexander MOBS​​BY fell while working at Blatchington Mill School on 3 August 2018 and was found unconscious after working alone. The report raises concerns about inadequate health and safety arrangements for work at height, lack of training, supervision and risk assessment, and delays in providing CPR, including the absence of a first aider or designated person on site.

Margaret Bernadette WILSON · Prevention of Future Deaths report View report

11 Mar 2019 Manchester City J. Harkin

Margaret Bernadette Wilson was admitted with swelling, pain and bruising, and was provisionally diagnosed with cellulitis and treated with antibiotics without prior blood tests. She later developed chest pain, was diagnosed with endocarditis, did not respond to treatment and died. The report identified concern that the absence of a blood test and the prescribing of antibiotics masked the endocarditis, and stated that earlier diagnosis and treatment would more likely than not have resulted in a different outcome.

Ms Jennifer McKoy · Prevention of Future Deaths report View report

11 Mar 2019 Black Country Z. Siddique

Ms Jennifer McKoy underwent laparoscopic cholecystectomy in August 2018 and later developed disseminated gallbladder adenocarcinoma, with a retrospective review finding that carcinoma had been present in the original histology but was not identified. She died on 17 May 2019 after developing pulmonary venous thrombo-embolism, deep phlebo-thrombosis and disseminated gallbladder adenocarcinoma. Concerns included inadequate audit of non-suspicious samples and limited evidence of a protocol for managing anticoagulation or prophylaxis for community patients with identifiable risk factors for complications.

Peter CARROLL · Prevention of Future Deaths report View report

11 Mar 2019 Manchester City J. Harkin

Peter CARROLL had a chronic ulcer that developed into malignancy, and died following peritonitis, a perforated caecal volvulus, and perianal squamous cell carcinoma, with coronary artery atheroma, pulmonary embolism and obesity also recorded. The report raised concerns about a six-month delay in biopsy reporting, the absence of leading physician sign-off, and failures in recording and labelling the biopsy, which may have prevented curable treatment from being offered.

John Peter RICHARDSON · Prevention of Future Deaths report View report

8 Mar 2019 West Sussex P. Schofield

John Peter Richardson was admitted as a voluntary patient to Meadowfields Hospital with suicidal thoughts and went missing after leaving the hospital grounds on 3 February 2018. His body was found in woodlands on 4 February 2018, and death was confirmed at the scene. The report identified concerns including the absence of a further risk assessment and care plan, poor communication and record keeping, and confusion about his leave arrangements.

Simon Robinson · Prevention of Future Deaths report View report

7 Mar 2019 Oxfordshire D. Salter

Simon Robinson died at home on 2 February 2018 after stabbing himself in the neck with a kitchen knife during a psychotic episode. His wife’s 999 call requesting police attendance was incorrectly graded, resulting in a delayed response. The principal concern was that the partnership agreement between police and mental health services did not adequately cover mental health crises in private places, including the expected initial police response when there is a fear for welfare or safety.

CHAND ALI · Prevention of Future Deaths report View report

7 Mar 2019 City of London A. Hewitt

Chand Ali, a 78-year-old man with severe end-stage heart failure and diabetes, was admitted to hospital with fluid overload and decompensated heart failure and died later that day. Cyclizine was administered intravenously despite cautions concerning its use in severe heart failure. Concerns included its routine use without individual risk-benefit assessment, the lack of monitoring of deaths following recent cyclizine use, and the absence of a comprehensive review of alternative antiemetics.

Matthew Bilby · Prevention of Future Deaths report View report

7 Mar 2019 Lincolnshire T. Brennard

Matthew Bilby died after his motorcycle collided with a DAF Tipper Heavy Goods Vehicle at the A16/B1166 junction in Spalding, Lincolnshire, on 6 September 2018. He sustained extensive internal injuries and was pronounced dead at the scene. Concerns included evidence that the junction was dangerous and confusing, was an accident blackspot, had been the site of four fatalities, and posed an ongoing risk to road users.

Kristopher John McDowell · Prevention of Future Deaths report View report

7 Mar 2019 North Wales (East and Central) J. Gittins

On 31 May 2016, Kristopher John McDowell fell to his death from the Pontcysyllte aqueduct after an upright rail he was holding became detached while he was on the non-pedestrian side. The concerns identified were that the parapet uprights were spaced widely enough for people to pass through, and that signage did not adequately mitigate this risk. Concerns were also raised that inspection and testing processes were inadequate to ensure the uprights remained properly engaged.

Michael Andrew HENDERSON and Stephen Brian CHAMBERS · Prevention of Future Deaths report View report

6 Mar 2019 Cumbria K. Gomersal

Michael Andrew HENDERSON and Stephen Brian CHAMBERS died at the scene after their car collided with a concrete lamp-post on the A5094 New Road on 1 May 2018. The collision involved alcohol, excessive speed and poorly maintained rear tyres. The principal concern was the risk of further serious collisions or deaths on New Road because its features may enable drivers to attain high speeds and may not sufficiently reinforce compliance with the 40 mph speed limit.

Jack Liam May · Prevention of Future Deaths report View report

1 Mar 2019 South Wales Central R. Knight

Jack May, a 20-year-old nursing student with a longstanding history of mental health problems, died in the River Taff on 25 October 2018; the inquest concluded that his death was suicide. The report raised concerns about the adequacy and accessibility of Cardiff University’s emergency, counselling, wellbeing and pastoral support services for students experiencing mental health or other personal difficulties.

Yong Keng Hong · Prevention of Future Deaths report View report

28 Feb 2019 South London S. Hayes

Yong Keng Hong, an asylum seeker with very little English, was transferred from hospital to a care home after displaying self-harm and suicidal behaviour. Despite advice for constant observations and an immediate mental health referral, the observation regime was not implemented, no interpreter or risk assessment was arranged, and his call bell was returned; he used it to hang himself from a curtain rail on 12 July. Concerns included failures in observation, communication, risk assessment, clinical follow-up and staff training.

Janie McFadyen · Prevention of Future Deaths report View report

27 Feb 2019 Manchester City N. Meadows

Janie McFadyen left a drug rehabilitation facility in Manchester on 23 November 2017 and was found unconscious on derelict land on 25 November 2017. She died after suffering cardiac arrests; the inquest recorded hypothermia and the use of Diazepam, Zopiclone, Cocaine and Heroin, with a drug-related conclusion. The principal concerns included the lack of appropriate protocols and staff training, unclear arrangements for accessing health and police guidance, and the failure to clearly determine when a person leaving the facility should be reported missing.

Kelvin Sean Speakman · Prevention of Future Deaths report View report

27 Feb 2019 Worcestershire G. Williams

Kelvin Sean Speakman was a serving prisoner at HMP Hewell with a long history of mental ill-health and extensive self-harm, including multiple attempts to hang himself. Following an incident of self-ligaturing, he suffered a hypoxic brain injury and died in hospital on 9 May 2016. The report identified shortcomings in the operation and documentation of the ACCT process, including inadequate healthcare input and inconsistent communication between staff.

SHANE GRAY · Prevention of Future Deaths report View report

27 Feb 2019 West Sussex P. Schofield

On 25 July 2018, Shane Gray entered Lythorne Lake for a swim after work, got into difficulties, and drowned. The concerns included inadequate warning signage, no physical barrier near an area intended for families with young children, text-only signage, and contractors not being directly informed of lake rules.

Theresa Margaret Feehan · Prevention of Future Deaths report View report

27 Feb 2019 Inner West London F. Wilcox

Theresa Margaret Feehan, who had severe oxygen- and steroid-dependent allergic asthma, was found deceased at home on 12 March 2018. The court recorded aspiration pneumonia and ingestion of amitriptyline and dihydrocodeine as the medical cause of death, with natural causes combined with side effects of prescribed medication. Concerns included inadequate medication review, incomplete medical-history recording, poor correlation between medication and problem lists, insufficient systems for identifying harmful medication interactions, and inadequate supervision of administrative work.