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Simon Anthony Graham · Prevention of Future Deaths report View report

3 Oct 2018 Birmingham and Solihull E. Brown

Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.

Brian Alban Frost · Prevention of Future Deaths report View report

3 Oct 2018 Suffolk N. Parsley

Brian Alban Frost died after an unwitnessed fall at home in which he sustained severe head injuries. The report identifies loose kitchen floor tiles as a serious trip hazard and raises concerns that welfare checks for retired priests living in diocesan properties did not include independent health and safety or risk assessments, allowing hazards to remain unidentified and unrepaired.

Mrs Tipper · Prevention of Future Deaths report View report

3 Oct 2018 Black Country Z. Siddique

Mrs Tipper was struck by a bus while crossing near the junction of Poplar Road and Bearwood Road in Birmingham on 22 January 2018. She sustained severe crush injuries to her legs and later died in hospital; evidence at the inquest raised concern that the driver had developed a practice of focussing directly ahead with minimal eye contact when emerging from junctions.

Joshua Lee Edwards · Prevention of Future Deaths report View report

2 Oct 2018 West Yorkshire Eastern K. McLoughlin

Joshua Lee Edwards, aged 19, became unwell in Leeds after taking ecstasy and cocaine and died in hospital on 15 May 2017 despite treatment. The ambulance was delayed by road closures for the Leeds 10K run, and concerns were raised that repeated calls from police did not lead to escalation and that ambulance crews were unclear about crossing road-closure signs in an emergency.

Andrew Collins · Prevention of Future Deaths report View report

2 Oct 2018 South Wales Central A. Barkley

Andrew Collins became acutely unwell at home on 6 June 2018 with a severe headache, was found to have a subdural haematoma, underwent emergency neurosurgery, and died on 16 June 2018. The report raised concern about a delay of approximately three hours in sending an ambulance despite his rapidly deteriorating condition, attributed to a lack of available resources.

Hayley Emma GASCOIGNE · Prevention of Future Deaths report View report

1 Oct 2018 East Riding and Hull P. Marks

Hayley Emma GASCOIGNE became unwell at Hull Crown Court after feeling dizzy and sick, then collapsed and was taken to Hull Royal Infirmary, where she was pronounced dead. The concern was that the court complex did not appear to have a defibrillator, despite evidence that prompt defibrillation can improve survival in certain cardiac dysrhythmias.

Mrs. Joan Catherine BLABER · Prevention of Future Deaths report View report

1 Oct 2018 Brighton and Hove V. Hamilton-Deeley

The report concerns the death of Mrs. Joan Catherine BLABER, with the circumstances referred to in the Record of Inquest. The principal concerns included failures to comply with COSHH requirements, inadequate training and supervision, confusion over staff roles, poor communication of practices, and failures to report and learn from dangerous or near-miss events.

Michael Christopher Hopkins · Prevention of Future Deaths report View report

1 Oct 2018 West Yorkshire (Western) M. Fleming

Michael Christopher Hopkins sustained a right patella fracture requiring surgery and was discharged from hospital. He later collapsed at home and died from a pulmonary thromboembolism, and the report raised a concern about information given at discharge to patients at risk of thromboembolism after surgery for trauma.

Donald Berry · Prevention of Future Deaths report View report

28 Sep 2018 Manchester South A. Mutch

Donald Berry suffered severe injuries after being electrocuted while working at the Kendal Calling Festival on 22 July 2010, and died from ongoing health complications on 23 August 2016. The inquest heard concerns that a clearly visible high-voltage power line over the site had not been identified or addressed, despite an Event Safety Plan and the licensing process. It also heard that the issue had not been noted by any of the authorities involved and that site-visit arrangements were not replicated nationally.

Sheila Ann Hadfield · Prevention of Future Deaths report View report

27 Sep 2018 Manchester South A. Mutch

Sheila Ann Hadfield, who had paranoid schizophrenia and lived in a residential care home, was found on the floor of her room and transferred to hospital, where the report states that she died from sepsis. The principal concern was that the care home struggled to meet her complex mental health needs and that there was a national shortage of suitable alternative placements.

Mary Barbara Ryder · Prevention of Future Deaths report View report

27 Sep 2018 Manchester South A. Mutch

Mary Barbara Ryder underwent surgery for bladder cancer and was discharged after receiving Clexane, with reduced mobility and no further clinical review regarding Clexane. She later deteriorated, was diagnosed with a pulmonary embolism and died on 21 August 2017. The inquest raised concerns that guidance did not address whether some patients with ongoing reduced mobility might require longer treatment or emphasise review after discharge.

Bridget Marie Connell-Graham · Prevention of Future Deaths report View report

26 Sep 2018 Manchester South A. Mutch

Bridget Marie Connell-Graham was born prematurely at 20 weeks’ gestation on 1 February 2018 and died at Tameside General Hospital from extreme prematurity. The inquest heard concerns about the lack of a clear definition of cervical trauma in NICE guidance, resulting in inconsistent national approaches to investigating such histories and planning clinical treatment during pregnancy.

Angela Mary Jackson · Prevention of Future Deaths report View report

26 Sep 2018 Manchester West A. Walsh

Angela Mary Jackson died at the Royal Albert Edward Infirmary, Wigan, after being admitted with chest and abdominal pain and found to have an extensive thoracic aortic aneurysm. She suffered a cardiac arrest and died while discussions about referral to an appropriate specialist centre were ongoing. The report identified concerns about incorrect and delayed referrals and the absence of clear, documented pathways for managing and referring patients with aortic aneurysms.

John Waite · Prevention of Future Deaths report View report

26 Sep 2018 Manchester West A. Walsh

John Waite died in hospital after suffering a haemorrhage following removal of a femoral dialysis line, alongside pneumonia and acute kidney injury after a fall and prolonged time on the floor. The principal concerns were that patients may require constant visual observation for up to one hour after catheter removal because of the potential for rapid blood loss, and that electronic systems allowed author times of clinical notes to be changed.

Caitlin Lydia Huddleston and Skye Olivia Mitchell · Prevention of Future Deaths report View report

25 Sep 2018 Cumbria R. Chapman

On 14 July 2017, Caitlin Lydia Huddleston and Skye Olivia Mitchell died at the scene after the car in which they were travelling lost control on a wet bend and collided with an oncoming van. The principal concerns were Skye’s limited driving experience, the presence of two passengers of a similar age, possible distraction, and the increased risk associated with carrying passengers.

Annette HILL · Prevention of Future Deaths report View report

21 Sep 2018 Avon T. Moore

Annette HILL was transported to the emergency department with increasing breathlessness and was assessed under the sepsis protocol before receiving intravenous antibiotics. She suffered an unexpected reaction and died despite advanced CPR; the concern was an unresolved tension between the Sepsis 6 guidelines and the BTS COPD care bundle, as antibiotics were given although she did not appear to require them based on the available information.

Hubert Kelly · Prevention of Future Deaths report View report

19 Sep 2018 Black Country L. Nash

Hubert Kelly was taken to hospital on the evening of 13 November 2017 after his health deteriorated and waited for four hours in a wheelchair in the emergency department with his family. Nursing staff later found that he had died, and concerns included patients waiting in corridors without meaningful interaction or permanent medically qualified staff, with waits of up to seven hours for clinical assessment.

Sufia Begum · Prevention of Future Deaths report View report

19 Sep 2018 Birmingham and Solihull L. Hunt

Sufia Begum was admitted to Queen Elizabeth Hospital with vomiting, confusion and generalised weakness after being prescribed clarithromycin while taking verapamil. She died on 24 April 2018 from multiorgan failure and calcium channel blocker toxicity, with the inquest concluding that she died from an unrecognised adverse drug interaction. The principal concern was that not all doctors were aware of the BNF mobile device app, identified as a useful tool for detecting potential drug interactions.

Fatemeh Afrasiabi and 70 others · Prevention of Future Deaths report View report

19 Sep 2018 Inner West London F. Wilcox

The report concerns people who died in the Grenfell Tower fire, where it was considered likely that almost all deaths resulted from smoke inhalation, although this evidence had not yet been tested in court. Concerns included the absence of a structured health-screening programme for survivors, first responders and site workers exposed to smoke, dust and potentially asbestos, together with the risk of later physical and mental health problems going unnoticed.

Paul Price · Prevention of Future Deaths report View report

18 Sep 2018 Birmingham and Solihull L. Hunt

Paul Price had a history of depression and anxiety, and was found outside his room on 04/06/18 after falling from a window; he was pronounced deceased at hospital, with the medical cause of death recorded as multiple injuries. Concerns included delays in communicating mental-health assessment information to his GP, incompatible IT systems, and a failure to return a call about concerns for his wellbeing.