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Matthew Luke Fulleylove · Prevention of Future Deaths report View report

30 Apr 2018 West Yorkshire Eastern K. McLoughlin

Matthew Luke Fulleylove, aged 30, sustained a fatal head injury on 5 June 2014 when his head became trapped between two heavy industrial machines passing on adjacent rail tracks during the production of large concrete beams. Concerns were raised about the restricted working space, the small gap between the machines, continued machinery passes, and the incomplete implementation of recommended safety measures.

Catherine Burns · Prevention of Future Deaths report View report

28 Apr 2018 Blackpool and the Fylde A. Wilson

Catherine Burns was admitted to hospital with abdominal pain, deteriorated during a prolonged wait for medical assessment, suffered respiratory arrest, and died on 5 December 2017. The principal concerns were emergency department workload, delayed medical assessment, insufficient monitoring, and failure to recognise deterioration promptly, creating a risk of future deaths.

Sara Antonia MORAN, known as Sally · Prevention of Future Deaths report View report

28 Apr 2018 Blackpool and the Fylde A. Wilson

Sara Antonia MORAN, known as Sally, was found deceased at home on 22 April 2017 after being reported missing; the medical cause of death was morphine toxicity and the inquest conclusion was drug related. The report raised concern that excessive demands on mental health professionals and inadequate staffing could result in service users not receiving the attention they need, potentially with fatal consequences.

PAUL DAVID ANTHONY JAMES · Prevention of Future Deaths report View report

27 Apr 2018 Mid Kent and Medway C. Sutton-Mattocks

PAUL DAVID ANTHONY JAMES died in HMP Elmley on 20 December 2016 after inflicting an incised wound to his abdomen with a razor blade. The report identifies concern that he was given access to razor blades despite his history of serious self-harm and suicidal statements.

Katy Roberts · Prevention of Future Deaths report View report

27 Apr 2018 Inner South London L. Tagliavini

Katy Roberts, who was aged 16, was under the care of CAMHS at SLAM when she died; the inquest concluded that her death was suicide. The report describes concerns that changes to her care plan were not confirmed in writing, that there was no clear route to challenge or appeal them, and that written routes for seeking help in emergencies and non-emergencies were not clearly communicated.

Yazin ELHAJE · Prevention of Future Deaths report View report

26 Apr 2018 Avon M. Voisin

Yazin Elhaje became ill with suspected meningitis, was initially discharged with a diagnosis of sinusitis, deteriorated, and died from bacterial meningitis on 8 October 2017 despite treatment. The principal concern was that discharge safety-netting advice to his parents addressed headaches rather than the differential diagnosis of meningitis.

Novia Emilia Delima · Prevention of Future Deaths report View report

20 Apr 2018 Manchester South A. Mutch

Novia Emilia Delima was brought to hospital on 25 July 2016 after blood was seen in her nappies, and she was not seen by a doctor until several hours after triage. She was subsequently diagnosed with sepsis, deteriorated despite treatment, and died later that day from neonatal herpes simplex and E. coli septicaemia. The concerns included delays in emergency assessment, the need for early paediatric input for very young babies, and consultant call-out arrangements that did not require attendance solely because of long waits.

Stanley Langdon · Prevention of Future Deaths report View report

19 Apr 2018 County Durham and Darlington O. Longstaff

Stanley Langdon died at Dipton Manor Care Home on 21 May 2017 from complications arising from a periprosthetic left femoral fracture sustained while carers assisted him to climb onto a minibus. The report states that he would not have sustained the fracture if he had been transferred in a wheelchair using the available hydraulic lift. The principal concerns were that services began without an adequate care plan or needs assessment, and that care planning was not based on complete information or agreed with his family, creating a risk of similar accidents and deaths in future.

Amanda Mary Spark · Prevention of Future Deaths report View report

19 Apr 2018 Dorset R. Griffin

Amanda Mary Spark, who suffered with depression, was found collapsed and unresponsive at her home on 3 September 2017 and died from an overdose of prescribed medication. The inquest concluded that her death was suicide. The principal concern was that supervision applied to her mental health medication did not also cover prescribed physical health medication, and that there was no clear policy or communication process addressing this.

Adrian Jennings · Prevention of Future Deaths report View report

19 Apr 2018 Manchester South A. Mutch

Adrian Jennings had a history of mental health issues and self-harm attempts and died on 10 December 2016 after taking a fatal cocktail of drugs and alcohol. The principal concerns included poor communication and inadequate discharge support planning between mental health services, failures to record key information when he arrived at hospital, and a policy gap concerning the reporting of high-risk absconding before triage.

Mr Colin Johns · Prevention of Future Deaths report View report

18 Apr 2018 Black Country Z. Siddique

Mr Colin Johns, a 71-year-old man with a history of low mood, alcohol dependency and previous self-harm, was discharged home after presenting with suicidal thoughts and requesting psychiatric admission. He subsequently took an overdose of co-codamol and died after being found collapsed at home. Concerns included inadequate communication and history-taking about self-harm attempts and insufficient efforts to find a suitable inpatient bed.

Harry James Jellicoe · Prevention of Future Deaths report View report

18 Apr 2018 Lincolnshire P. Smith

Harry James Jellicoe was driving on the A151 in wet conditions when he lost control of his car, which left the carriageway and struck a tree. He suffered severe injuries and died in hospital some days later. The principal concerns included the road’s restricted visibility through a bridge, the absence of a specific speed restriction or priority signage, and the potential hazard posed to unfamiliar drivers; the vehicle also had extensively worn front tyres associated with longstanding misalignment.

Matthew James WILMOT · Prevention of Future Deaths report View report

17 Apr 2018 Bedfordshire and Luton I. Pears

Matthew James WILMOT went out with friends to watch the FA Cup Final and was dropped off near his home at 00.45 hours on 28 May 2017. At 07:14, he was found upside down in an excavated hole on a closed path. The principal concern was that the risk assessment did not give enough consideration to the different risks of a unique route, where pedestrians may be more likely to use the shortest path despite barriers and closure signs.

Karen Jane Edgar · Prevention of Future Deaths report View report

16 Apr 2018 Cumbria D. Roberts

Karen Jane Edgar had emotional and behavioural difficulties and was referred to CAMHS in October 2015, aged 15. She received delayed and limited mental health support, including gaps in family therapy, individual therapy, risk reassessment and care planning, before she died after hanging herself on 8 April 2017. The report raised concerns about underfunded child and adolescent mental health services, delays in treatment and inadequate resources and care.

William John Callis · Prevention of Future Deaths report View report

12 Apr 2018 Northamptonshire A. Pember

William John Callis, who was suffering from depression and had sought help from his GP surgery, died by hanging himself at his home on 28 March 2017. The inquest identified that there was no specific instruction on the correct procedure for a GP practice to follow when referring a patient to the Urgent Care and Assessment team.

Patricia Ann Heslop · Prevention of Future Deaths report View report

12 Apr 2018 Sunderland D. Winter

Patricia Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.

James Sheffield · Prevention of Future Deaths report View report

12 Apr 2018 Manchester West T. Brennand

James Sheffield suffered a cardio-respiratory arrest on 12 July 2016 after surgery following an accidental fall and died on 17 July 2016. The report identified concerns about the absence of an established system to ensure that patient-owned CPAP equipment remained with patients during internal hospital transfers and was immediately available and ready for use. The report stated that the missing CPAP machine did not have a bearing on the outcome.

George Goldby · Prevention of Future Deaths report View report

11 Apr 2018 Nottinghamshire J. Gillespie

George Goldby choked on a sandwich on 20 March 2017, was taken to hospital, and died on 24 March 2017. The principal concerns were that staff did not follow his speech and language therapy recommendations, including one-to-one supervision and dietary requirements; choking risk assessments and care plans were inadequately managed; and choking incidents were not properly reported or followed by appropriate referrals and reviews.

Andrew Reid · Prevention of Future Deaths report View report

10 Apr 2018 Manchester South A. Mutch

Andrew Reid was found suspended from a ligature at Longford Park on 17 October 2017. The inquest concluded that his death was suicide and recorded the medical cause of death as hanging. Concerns related to differences in mental-health service provision and referral routes for residents of Manchester and Trafford, including the lack of out-of-hours emergency GP referrals in Trafford and the requirement for patients to attend A&E.

Miss Lea Louise Hunsley · Prevention of Future Deaths report View report

10 Apr 2018 Manchester North L. Hashmi

Lea Hunsley, who had profound cerebral palsy and complex healthcare needs, became increasingly unwell while in respite care on 9 July 2016 and died after cardio-respiratory arrest at Wythenshawe Hospital Emergency Department shortly after midnight on 10 July 2016. The report identified missed opportunities to assess, escalate and intervene, and raised concerns about the facility’s lack of protocols, staff’s ability to recognise deterioration, inadequate observations and monitoring, failure to use care records appropriately, and insufficient action following a CQC inspection.