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Doris Mary Ridgwell · Prevention of Future Deaths report View report

15 May 2018 Surrey A. Loxton

Doris Mary Ridgwell was admitted to hospital with knee swelling and pain, with an INR of 8.1 that was not successfully communicated to the ward or acted upon before her discharge. She was later admitted with a large subdural haematoma and intraventricular bleed, and the inquest determined that she died as a consequence of over-anticoagulation. Concerns included unclear procedures for communicating abnormal coagulation results, delays in making results available to healthcare professionals, and discharge summaries that did not include blood test results.

Hans-Peter Schmidt · Prevention of Future Deaths report View report

14 May 2018 Cornwall and Isles of Scilly G. Davies

Hans-Peter Schmidt died on 17 June 2017 at Lands End, Cornwall, from multiple injuries following an unwitnessed fall from a cliff while cycling along the cliff edge. The report raised concerns about the maintenance and absence of permanent barriers at identified cliff hot spots, inadequate warning signs and pictograms, and the lack of staff training uptake offered by the RNLI.

Philip David Ashton · Prevention of Future Deaths report View report

14 May 2018 Milton Keynes T. Osborne

Philip David Ashton, a resident of Mallard House, was administered warfarin in error on 13, 14 and 15 October 2017. He was found bleeding from an arteriovenous graft on 17 October, and the report raised concerns about the medication error, the lack of an emergency response and the unavailability of his medical information to ambulance staff; he later died in hospital.

Gladys Kathleen Rich · Prevention of Future Deaths report View report

14 May 2018 Northamptonshire H. Shah

Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.

CHARLES EVAN GRAINGER · Prevention of Future Deaths report View report

12 May 2018 Derby and Derbyshire R. Syed

Charles Evan Grainger was admitted to Milford House Residential Unit after a fall and later sustained injuries in a witnessed fall there on 24 November 2013. The inquest concluded that his death was accidental, with the medical cause recorded as bronchopneumonia and central cord syndrome. Concerns included failures to share his history of falls between relevant agencies and inadequate investigation of the circumstances surrounding his fall.

Ahmed Amin TABECHE · Prevention of Future Deaths report View report

11 May 2018 London (East) N. Persaud

Ahmed Amin TABECHE died at Aspray Care Home on 15 September 2016 after choking while being fed vegetable soup containing pieces of vegetables. The report identified insufficient guidance and supervision about his feeding requirements, and inadequate systems and written information for visitors feeding a person at risk of choking.

Thomas Allan Ratchford · Prevention of Future Deaths report View report

11 May 2018 Manchester North C. McKenna

Thomas Allan Ratchford had been immobile for six years and was admitted to Marland Court Residential Home for respite care on 4 October 2017. During his admission, he developed a deep tissue injury that extended from his sacrum to his inner thighs, and the report states that inappropriate use of a hoist for pressure relief more likely than not contributed to his death. The principal concern was that the home manager and carers had insufficient training in moving and handling and pressure relief, and had not obtained appropriate advice about using the hoist.

Marcus Anthony Allen · Prevention of Future Deaths report View report

11 May 2018 West Yorkshire Eastern K. McLoughlin

Marcus Anthony Allen died on 1 June 2017 after falling from a window at his home, sustaining fatal head injuries. The principal concern was that the large lounge window had no restrictor device and could create a risk of falling when a person attempted to close it; other windows in the complex may have presented the same hazard.

Edward Joyce · Prevention of Future Deaths report View report

9 May 2018 Inner South London P. Barlow

Edward Joyce suffered an accidental scalding injury on 19 November 2017 and later developed septic shock from infected burns. He became severely unwell on 22 November and died despite attempts at resuscitation. Concerns included that a temperature of 38.9°C did not trigger an urgent hospital referral and was not recorded when his mother telephoned the hospital, and that parents were not advised to bring him back to hospital.

KIRSTY ELIZABETH TOLLEY · Prevention of Future Deaths report View report

9 May 2018 Norfolk J. Lake

Kirsty Elizabeth Tolley had several health problems and was admitted to Queen Elizabeth Hospital with severe anaemia and a high temperature. She was later found unresponsive in bed on 19 November 2017 and was declared dead despite resuscitation. Concerns included blood tests not being carried out daily as required, incomplete Early Warning Score monitoring, and a lack of documented escalation or additional observations when scores reached 3; the medical cause of death was unascertained.

Lewis Daryl COLGAN · Prevention of Future Deaths report View report

9 May 2018 Buckinghamshire C. Butler

Lewis Colgan died immediately at Princes Risborough Station on 15 September 2017 after jumping onto the track in front of a northbound passenger train. Concerns included the robustness of supervision of care coordinators and care teams, continuity of mental health care during staff changes and sickness, the process for overdue Care Programme Approach meetings, and the robustness of the investigation and resulting actions.

Joan Hanratty · Prevention of Future Deaths report View report

9 May 2018 Manchester South C. Morris

Joan Hanratty, who had a complex medical history including heart failure, ischaemic heart disease and moderate to severe Chronic Obstructive Pulmonary Disease, developed a chest infection and was prescribed antibiotics and steroids. She collapsed and suffered a cardiac arrest on 28 January 2018 and died in hospital later that day. The principal concern was that the prescribing system did not explicitly advise patients to seek medical advice if their condition did not significantly improve within a specified period after starting treatment.

Jonathan Earp · Prevention of Future Deaths report View report

8 May 2018 Gloucestershire C. Saunders

Jonathan Earp died at Gloucester Royal Hospital on 10 July 2017 from the effects of prescribed and non-prescribed drugs. Concerns included the management and disposal of Fentanyl patches and the possibility that additional Fentanyl was taken alongside illicit drugs without staff considering the combined effects.

Darren Richard Trewin · Prevention of Future Deaths report View report

8 May 2018 Exeter and Greater Devon J. Tomalin

On 31 January 2017, Darren Richard Trewin was fatally injured when the car he was driving left the A30 after encountering water flowing across the carriageway from a partially blocked drain and collided with a roadside barrier. Concerns related to the drain’s ability to capture heavy rainfall and the possible need to extend the nearside barrier to reduce the risk of vehicles leaving the carriageway.

Stephen Ian William Tidey · Prevention of Future Deaths report View report

8 May 2018 Surrey A. Loxton

Stephen Ian William Tidey was found deceased on 22 December 2016, having been found hanging from a tree outside the cabin where he was residing, with self-inflicted wounds to both wrists. The report raised concerns that a high-risk MASH referral, made after he lost his job, was not followed up and that there were no safeguards to ensure referrals were acted upon, including outside normal office hours.

WILLIAM DICKENS · Prevention of Future Deaths report View report

8 May 2018 London Inner (South) H. QC

WILLIAM DICKENS, who was assessed as at high risk of repeat self-harm, died on 10 May 2017 after being discovered hanging by a belt from the bed in his room at a mental health unit. The report raises concerns that required intermittent observations were not carried out, that observation-log entries were made after the event, and that defects in the logging process could create a risk of future deaths.

Joanne Elizabeth Richardson · Prevention of Future Deaths report View report

8 May 2018 Dorset R. Griffith

Joanne Elizabeth Richardson was found suspended by a ligature at her home on 26 September 2017 and the inquest concluded that her death was suicide. Concerns were raised about inadequate communication and lack of joined-up working between mental health teams, which meant important risk information was not shared and could lead to inaccurate risk assessments and a future death.

Kenneth William Horne · Prevention of Future Deaths report View report

3 May 2018 Stoke-on-Trent and North Staffordshire M. Jones

Kenneth William Horne suffered two falls at Royal Stoke University Hospital, including one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter, there was no nurse-to-nurse discharge call, and the Transfer of Care form was not up to date. He fell approximately six hours after admission to Leek Moorlands Hospital, sustaining a serious chest wall injury, and later died from sepsis, bronchopneumonia and chest wall injury.

Martin Glyn Baker · Prevention of Future Deaths report View report

3 May 2018 Plymouth, Torbay and South Devon A. Cox

Martin Glyn Baker, who had longstanding mental health difficulties and a history of suicide attempts, died following a prescription drug-related death. The inquest identified concerns about inadequate communication with his family, a shortage of care coordinators, and a risk assessment that did not address his periodic impulsivity.

Mrs Christine Withers · Prevention of Future Deaths report View report

1 May 2018 Black Country Z. Siddique

Mrs Christine Withers, a 72-year-old woman with small cell carcinoma of the lung, was admitted with low potassium levels and died on 17 November 2017 after her condition deteriorated rapidly. Concerns identified during the inquest included that repeat blood tests were not performed to measure potassium levels despite a recommendation to do so, and inadequate communication by nursing staff with her family about her decline.