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Maria Katarina HRYNIW · Prevention of Future Deaths report View report

20 Dec 2018 Manchester South A. Mutch

Maria Katarina HRYNIW, who was PEG fed following a stroke and had very limited mobility, developed bronchopneumonia and died at The Lakes Care centre on 14 April 2018. Concerns included the lack of assessment of the suitability and volume of continued PEG feeding near the end of life, continued administration despite reported difficulty coping with the prescribed volume, and unclear responsibilities between the SALT team and care home regarding assessment and decision-making.

Michal Piotr Netyks · Prevention of Future Deaths report View report

19 Dec 2018 Liverpool and the Wirral A. Rebello

Michal Piotr Netyks, a Polish national serving a custodial sentence at HMP Altcourse, died after jumping head first from first-floor railings on 7 December 2017, the day he was due to be released but was instead detained under immigration powers. The report identifies concerns about the timing and explanation of the immigration detention paperwork, access to legal advice and support, the prison railings, and aspects of the Home Office’s handling of the case.

Henry Curtis-Williams · Prevention of Future Deaths report View report

19 Dec 2018 West London S. Cummings

Henry Curtis-Williams died from hanging at Acton Cemetery on 17 May 2018; the inquest conclusion was hanging and suicide. Concerns included inadequate contemporaneous recording, discharge by junior doctors without prior senior review, and informal communication without records of important messages.

Kurt Cochran and 5 others · Prevention of Future Deaths report View report

19 Dec 2018 London Inner (West) H. QC

On 22 March 2017, Khalid Masood drove a vehicle across Westminster Bridge, fatally injuring Kurt Cochran, Leslie Rhodes, Aysha Frade and Andreea Cristea, before fatally stabbing PC Keith Palmer at the Palace of Westminster. The report raised concerns about the protection of public entrances, officers’ access to and understanding of Post Instructions, use of the ADAM System, supervision and training, and wider protective security measures.

Miss Kirsty Walker · Prevention of Future Deaths report View report

19 Dec 2018 Surrey A. Crawford

Miss Kirsty Walker died in hospital on 27 September 2015 after being found unresponsive in prison with a ligature tied around her neck. She had a history of self-harm and had engaged in 235 acts of self-harm during her imprisonment, including 215 involving ligatures. The report raised concern that prisoners were taking well over 14 days to transfer to secure hospitals under section 47 of the Mental Health Act 1983, presenting a risk of further deaths.

John Duckenfield · Prevention of Future Deaths report View report

18 Dec 2018 South Yorkshire (Western) D. Urpeth

John Duckenfield was receiving intermediate care following a fall and was later admitted to Northern General Hospital, where he died on 21 January 2018. The inquest identified concerns about falsely asserted and unrecorded observations, failure to call a GP when requested, and inaccurate or misleading care-home records.

Jacqueline Françoise VALVONA · Prevention of Future Deaths report View report

18 Dec 2018 Isle of Wight C. Sumeray

Jacqueline Françoise VALVONA, aged 90, died in hospital on 20 August 2018 after being struck by a vehicle when she stepped into the A3054 in Wootton. The principal concern was the lack of a safe pedestrian crossing at that location, which was used by many elderly people, including residents with mobility difficulties, to reach a nearby bus stop and the Sloop Inn.

Mrs Ruth Ellen Edwards · Prevention of Future Deaths report View report

18 Dec 2018 South Wales Central R. Knight

Mrs Ruth Ellen Edwards died at home on 31 August 2018 after hanging herself from an attic ladder, following a long history of mental health problems and previous suicide attempts. Concerns included her discharge after a drug overdose without psychiatric liaison assessment, inadequate risk assessment and inaccurate communication about the overdose, and potentially insufficient medication reviews despite access to many medications at home.

Mrs. Susan Longden · Prevention of Future Deaths report View report

18 Dec 2018 Avon P. Harrowing

Mrs. Susan Longden underwent a routine surveillance colonoscopy on 31 January 2018 and later developed severe abdominal pain. After NHS 111 triage arranged a doctor call rather than a Category 3 ambulance, she became unresponsive, suffered cardiac arrests and was pronounced deceased after arrival at hospital. The concerns included the NHS Pathways algorithm not asking about recent procedures, insufficient emphasis on speaking directly with the patient when the caller is someone else, and previous concerns raised with the organisation.

Natalie Zara HUNTER · Prevention of Future Deaths report View report

18 Dec 2018 Isle of Wight C. Sumeray

Natalie Zara HUNTER, who had a history of mental health and alcohol-related problems and 18 previous serious suicide attempts, was found deceased in her apartment on 16 March 2018 after suspending herself by a ligature. The report raised concerns about delayed or missing discharge summaries from the Isle of Wight NHS Trust, affecting continuity of GP and mental health care, and about insufficient out-of-hours mental health and crisis staffing on the Isle of Wight.

John Anthony Delahaye · Prevention of Future Deaths report View report

18 Dec 2018 Birmingham and Solihull E. Brown

John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.

Agnes Stephanie LAMBERT · Prevention of Future Deaths report View report

17 Dec 2018 Inner North London M. Hassell

Agnes Stephanie Lambert was a mental health nurse who died after an investigation into allegations concerning her contact with a patient who was fixated on her. The inquest determined that her death was suicide, with the medical cause recorded as suspension by ligature. Concerns included the failure to move her to another ward despite recognising the patient’s fixation, and an allegedly unacceptable delay in progressing the disciplinary investigation.

BARNABY LUKE AYLWARD · Prevention of Future Deaths report View report

14 Dec 2018 West Yorkshire (West) J. Broadbridge

Barnaby Luke Aylward died in the early hours of 4 September 2017 after being overcome by smoke from an accidental house fire caused more likely than not by a lit cigarette. The report identified concerns about known fire risks associated with his heavy smoking, clutter and serious mental illness, including insufficient multi-agency risk assessment, information sharing, property inspection, care planning and preventative support.

Maurice Leslie Wrightson · Prevention of Future Deaths report View report

13 Dec 2018 North Northumberland T. Brown

Maurice Leslie Wrightson, a coach driver, died in France on 16 April 2013 after the brakes on his coach stopped responding during a mountain descent; the coach crashed into rocks and burst into flames. The principal concern was that Volvo vehicle manuals did not adequately explain the risks of using automatic gearbox mode during long downhill descents, creating uncertainty and a potential risk of future deaths.

Bertram Montague Henry Crawford · Prevention of Future Deaths report View report

13 Dec 2018 Avon M. Voisin

Bertram Montague Henry Crawford was seen walking alone onto Clifton Suspension Bridge, where he climbed over the wire fence and jumped to his death. The report raises concern about a cluster of student deaths from the bridge, including three in that year and four in two years.

Edward James Farmer · Prevention of Future Deaths report View report

12 Dec 2018 Newcastle upon Tyne K. Dilks

Edward James Farmer, a first-year student, attended an initiation event where he consumed large quantities of alcohol and was later found unresponsive without signs of breathing or a pulse. He died despite medical intervention, due to a hypoxic brain injury following a prolonged cardiorespiratory arrest. The report raised concerns about the risks of excessive alcohol consumption, recognising people at risk, timely medical intervention, and initiation events.

Benjamin Colin Williamson · Prevention of Future Deaths report View report

12 Dec 2018 Cornwall and Isles of Scilly A. Cox

Benjamin Colin Williamson had a long history of alcohol-related issues and was receiving treatment, with regular GP contact. He died on 4 April 2018, and the inquest recorded a conclusion of suicide, with asphyxia by hanging and alcohol intoxication. Concerns included fragmented mental health services for people with both mental health and alcohol problems, and inadequate liaison and feedback between Addaction and the GP.

Neil Stephen David SWAISLAND · Prevention of Future Deaths report View report

12 Dec 2018 Milton Keynes T. Osborne

Neil Stephen David SWAISLAND died after jumping from the top floor of a multi-storey car park in Milton Keynes on 14 July 2018. Evidence was heard that funding for MIND counselling services had been withdrawn by the Council and the CCG, raising concern that vulnerable people would be at increased risk of self-harm and suicide and that this could result in further suicide deaths.

John Mayhew · Prevention of Future Deaths report View report

11 Dec 2018 County Durham and Darlington C. Oliver

John Mayhew died at HMP Durham on 15 January 2017 from self-inflicted hanging. He had a recent history of suicide attempts and made comments concerning potential self-harm or suicide after returning to custody, but the ACCT was closed at the initial case review without a care plan. The report raised concerns about the lack of involvement of the person who initiated the ACCT and the ambiguity of the relevant PSI 64/2011 attendance requirements.

Padiben Dullahb · Prevention of Future Deaths report View report

11 Dec 2018 Inner North London S. Bourke

Mrs Dullahb presented to hospital with increasing abdominal pain and was later found to have bowel perforation, hypovolaemic shock and caecal volvulus. She deteriorated and died on 12 October 2017. The substantive concern was that, although out-of-hours reporting arrangements existed for CT and MRI scans, there was no similar arrangement for x-rays.