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Peter O’Donnell · Prevention of Future Deaths report View report

20 Mar 2018 Manchester West S. Nelson

Peter O’Donnell was admitted for an elective right total hip replacement and later developed a chest infection and deteriorated. The report identifies concerns about ineffective communication, irregular observations, inadequate documentation, delayed antibiotics, missed opportunities to escalate care, unclear consultant and junior doctor arrangements, and the absence of transfer protocols for unwell patients. It also raises concerns about private hospitals’ reporting requirements and the reporting of nurses’ retrospective additions to clinical records.

Mrs Sheila Sullivan Ross (Sheila) · Prevention of Future Deaths report View report

19 Mar 2018 Sunderland D. Winter

Mrs Sheila Sullivan Ross died at Sunderland Royal Hospital on 12 November 2017 after an unwitnessed fall at a care home, sustaining bilateral pubic rami fractures and subsequently deteriorating with urinary sepsis. Concerns included an outdated falls risk assessment tool, limitations in the care home buzzer system that could prevent timely assistance, and poor communication with Sheila’s family.

Kellie Marie TAYLOR formerly known as Kellie Marie DANVILLE · Prevention of Future Deaths report View report

19 Mar 2018 East Riding and Hull P. Marks

Kellie Marie TAYLOR, formerly known as Kellie Marie DANVILLE, died after jumping from the Humber Bridge into the river below. The concern was that the existing CCTV system did not provide images of sufficient quality to enable those monitoring it to accurately see behaviour or activities at the bridge, potentially delaying intervention.

Jean Griffiths · Prevention of Future Deaths report View report

15 Mar 2018 Manchester West J. Leaming

Jean Griffiths died at Salford Royal Hospital on 15 July 2017 after displaying symptoms of Acute Interstitial Pneumonitis; her disconnected oxygen lead did not contribute to her death. The report raised concerns about poor oxygen-prescribing practice and the risk to patient safety when supplementary oxygen is given without a valid prescription and target range, although there was no evidence that this contributed to Jean Griffiths’ death.

Peter STOJILJKOVIC · Prevention of Future Deaths report View report

14 Mar 2018 Manchester South A. Mutch

Peter Stojiljkovic was discharged from hospital on 9 June 2017 after being prescribed melatonin and was later found suspended by a ligature at his home on 22 July 2017. The concerns included poor communication between the hospital, GP and Peter about community prescribing, differing prescribing policies, the complexity of prescribing guidance, and the possibility that he would need to obtain melatonin from unlicensed sources. There was also no evidence of communication with the GP before discharge to support a smooth transition into the community.

Freddie Oliver DOBINSON-EVANS · Prevention of Future Deaths report View report

14 Mar 2018 Inner North London M. Hassell

Freddie Dobinson-Evans had undiagnosed Dravet syndrome and died from causes recorded as post-cardiac arrest syndrome and Dravet syndrome. A genetic test report was communicated to his father as “absolutely normal”, although Freddie had a pathogenic SCN1A gene mutation; the report identified the potential for significant consequences for another child.

Janet Hall · Prevention of Future Deaths report View report

14 Mar 2018 Manchester South C. Morris

Janet Hall died after a series of hospital admissions and attendances, with the medical cause described as acute left ventricular failure and B Cell lymphoma on a background of ischaemic heart disease. A principal concern was that an Emergency Department discharge letter stated that blood tests were normal, although her full blood count was abnormal, and that discharge letters did not routinely include complete blood results, limiting opportunities for GPs to identify trends.

Thomas Edward Curtin · Prevention of Future Deaths report View report

14 Mar 2018 Cornwall and Isles of Scilly E. Carlyon

Thomas Edward Curtin, who was detained under the Mental Health Act on an acute mental health ward, absconded during escorted leave and later died in hospital on 20 August 2016 from heroin intoxication. The report raised concern that private locked rehabilitation providers were not subject to a national response-time framework, potentially leaving patients on wards inappropriate for their needs while awaiting placement.

Catherine Kennedy · Prevention of Future Deaths report View report

13 Mar 2018 Manchester South C. Morris

Catherine Kennedy, who had bipolar affective disorder, died after consuming more than 60 paracetamol tablets while on leave from hospital and subsequently being medically reviewed over 14 hours after staff were informed of the overdose. The report identified concerns about miscommunication and assumptions during telephone conversations between ward staff and on-call doctors, including the inconsistent use of a structured communication and documentation method.

Leigh William Wilde · Prevention of Future Deaths report View report

12 Mar 2018 Manchester South A. Mutch

Leigh William Wilde had raised concerns about issues at his workplace and was found suspended from a ligature at his home after being suspended from employment. Concerns included a lack of documentation and risk assessment relating to the suspension, no evidence of discussion of risk or referral to support services, and unclear approaches to whistleblowers and their support.

MARTIN LEE TILLEY · Prevention of Future Deaths report View report

12 Mar 2018 Gloucestershire C. Saunders

Martin Lee Tilley had a long history of substance misuse and significant mental health problems, including self-harm discussions, suicidal thoughts, and apparent visual and auditory hallucinations before his last appointment with the Homeless Healthcare Team in July 2017. He was found deceased on 17 October 2017 from the combined toxic effects of prescribed and non-prescribed medication; concerns were raised that there was no evidence of follow-up by the team after July and no answer explaining whether his presentation should have led to an emergency psychiatric assessment or referral to tertiary mental health services.

David Anthony Sketchley · Prevention of Future Deaths report View report

9 Mar 2018 Gloucestershire C. Saunders

David Anthony Sketchley, a resident of Ashley House Nursing Home, died after falling through a gap in a bariatric commode chair and sustaining a traumatic perianal injury. The report identified concerns about inadequate supervision, unclear care-plan requirements and definitions of supervision, and insufficient documented assessment of the commode’s suitability.

BERNARD LESLIE GERRARD · Prevention of Future Deaths report View report

8 Mar 2018 Derby and Derbyshire R. Syed

Bernard Leslie Gerrard sustained injuries in an unwitnessed fall at the care home, was found to have a left fractured neck of femur, and died on 2 December 2017 despite treatment. The principal concern was a prolonged ambulance response, including delays to both the initial Category 3 response and the later Category 2 response, which EMAS attributed to insufficient resources and funding.

Venkata Naga Lakshyasi KAGGA · Prevention of Future Deaths report View report

7 Mar 2018 Manchester South A. Mutch

Venkata Naga Lakshyasi KAGGA died on 9 July 2017 after a button battery lodged in her oesophagus and caused an oesophageal arterial fistula. Before her death, she was seen by doctors and ambulance staff, but the battery was not identified. Concerns included failures to examine and assess her, non-compliance with ambulance policy for children under five, inadequate information sharing, and limited understanding of the risks posed by button batteries.

Ms Ivanika Olivari · Prevention of Future Deaths report View report

7 Mar 2018 Inner West London F. Wilcox

Ms Ivanika Olivari died on 3 August 2017 at St George’s Hospital after suffering a cardiac arrest at home associated with a malfunctioning pacemaker. The principal concerns were failures to leave a message or use all available contact numbers in an urgent situation, and the need for guidance, policies and staff training to prioritise risk to life and permit appropriate messages to patients.

Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report View report

7 Mar 2018 Inner West London F. Wilcox

Mrs Elizabeth Marion Griffin, who was wheelchair bound due to advanced multiple sclerosis, was alone at home in bed when a dishwasher fire started on 14 July 2017. She activated her pendant alarm, but the responder did not recognise the smoke alarm, could not communicate effectively with her, and did not call the fire brigade; Mrs Griffin later died in hospital on 21 August 2017 from smoke inhalation injuries and bronchopneumonia. The concerns included delayed action by the dishwasher manufacturer, lack of appliance-owner registration and contact, and shortcomings in telecare arrangements, including unlinked fire alarms, responder training, communication, and escalation procedures.

William John Abrahams · Prevention of Future Deaths report View report

6 Mar 2018 Inner North London S. Bourke

William John Abrahams presented to hospital with a ruptured abdominal aortic aneurysm and died there on 28 August 2017 during attempted endovascular repair. The substantive concerns included that he was not invited for aneurysm screening because he was over 65 when the screening programme was introduced, and that the benefits of opting into screening may not be apparent because aneurysms are asymptomatic until they leak.

ELLIE MAY CLARK · Prevention of Future Deaths report View report

6 Mar 2018 Gwent W. James

Ellie May Clark was a child with severe asthma who became seriously unwell after attending her GP surgery and was later found to have died from bronchial asthma. The report identified concerns about care planning, triage delays and systems, her being turned away from an emergency appointment without clinical assessment or safeguarding advice, the recording of her severe asthma, and staff support when challenging decisions.

Georgia Polydorou · Prevention of Future Deaths report View report

6 Mar 2018 Inner North London S. Bourke

Georgia Polydorou was an in-patient being treated for congestive cardiac failure when she fell while going to the toilet on 10 July 2017. She later became unresponsive and was found to have a large acute subdural haematoma; after surgery and a prolonged period on a ventilator, she died on 18 September 2017. Concerns included the decision not to perform a CT scan within eight hours of the fall despite concurrent use of aspirin, clopidogrel and enoxaparin, the delayed presentation of head-injury signs in elderly patients, and communication difficulties relating to her limited English and the significance of headache after the fall.

Rastislav Petrisko · Prevention of Future Deaths report View report

6 Mar 2018 Inner South London A. Harris

Rastislav Petrisko, who had a history of suicide attempts, drug and alcohol misuse, and mental health admissions, took a fatal overdose after being granted unescorted leave from a mental health ward. The concerns included an apparently unsuitable low-risk assessment, inappropriate unescorted leave, delayed notification of police when he failed to return, and differing approaches to risk assessment.