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Henry George HONOUR · Prevention of Future Deaths report View report

20 Nov 2017 Central and South East Kent P. Harding

Henry George Honour suffered an unwitnessed fall in hospital on 4 February 2017, sustaining a left hip fracture that was discovered four days later. He underwent surgery but died on 21 February 2017 from bronchopneumonia associated with immobility and the fracture. Concerns included inadequate falls-risk assessments, inappropriate use of bedrails, and failure to update the assessment or implement protective measures after the fall.

Paul Geoffrey Mullen · Prevention of Future Deaths report View report

17 Nov 2017 Manchester West A. Walsh

Paul Geoffrey Mullen died at his home in Wigan on 22 June 2017. He had been receiving daily methadone but did not collect it for three consecutive days before his death. The report raised concerns that the pharmacy’s failure to report the missed collections promptly to his designated Key Worker, and the three-day reporting threshold, may have delayed checks on his welfare.

Kathryn Verina Richmond · Prevention of Future Deaths report View report

17 Nov 2017 Dorset R. Griffin

Kathryn Verina Richmond collapsed at home on 21 April 2015, was taken to hospital after delays in ambulance attendance, and died that morning despite lifesaving treatment for a ruptured spleen. The principal concern was that non-staggered ambulance crew shifts led to simultaneous meal breaks, reducing available resources and potentially delaying responses to emergency calls.

Peter Saint · Prevention of Future Deaths report View report

17 Nov 2017 Cambridgeshire and Peterborough S. Horstead

Peter Saint was admitted for routine elective knee replacement surgery and died after an endotracheal tube was placed in his oesophagus, resulting in approximately 38 minutes without effective lung ventilation and subsequent hypoxic brain damage. The principal concerns were inadequate understanding and interpretation of capnography, failure to follow the required confirmation procedure after intubation, and insufficient ongoing training for anaesthetists in crisis situations.

Mildred Joan Griffiths · Prevention of Future Deaths report View report

17 Nov 2017 Birmingham and Solihull L. Hunt

Mildred Joan Griffiths fell at home in May 2017, sustained a femur fracture, developed a deteriorating sacral pressure sore, and died after collapsing in the early hours of 03/08/17. The report raised concerns that differing pressure-sore risk assessment tools could cause confusion and that the Braden Score might underestimate risk because it did not account for existing lesions.

Timothy John Smedley · Prevention of Future Deaths report View report

16 Nov 2017 Manchester North L. Hashmi

Timothy John Smedley was found in a shallow waterway at the foot of Rakewood Viaduct on 7 June 2017, and his death was concluded to be suicide. The concerns identified were a lack of joint access to NHS records for out-of-hours services, fragmentation of care, and difficulties for people with alcohol addiction in accessing timely and appropriate mental health services.

John Haines · Prevention of Future Deaths report View report

16 Nov 2017 Manchester North L. Hashmi

John Haines was admitted to a mental health ward in March 2017 after his anxiety and depression deteriorated, and was discharged on 14 June 2017 with planned follow-up. He was found deceased at home on 17 June 2017 after failing to respond to contact. The report raised concerns about in-patients and Home Treatment Team patients being unable to access qualified psychological therapy, including delays in accessing Healthy Minds.

Doreen Wilkins · Prevention of Future Deaths report View report

16 Nov 2017 Manchester South C. Morris

Doreen Wilkins died in hospital at age 78 after a choking incident at home following a routine care visit that did not last for its full duration. The inquest raised concerns that care-visit rotas did not allow travel time, potentially causing carers to arrive late, shorten visits, and provide less care than assessed or commissioned.

Anthony Cleon GRANT · Prevention of Future Deaths report View report

16 Nov 2017 Inner North London M. Hassell

Anthony Cleon Grant suffered a cardiac event while swimming in a public pool, drifted to the bottom, and died on poolside after lifeguards attempted resuscitation. The principal concern was that he remained submerged for five minutes and 41 seconds before being noticed, raising issues about lifeguard positioning, the number of lifeguards, and the possible use of motion early warning systems and training footage.

Kathleen Smith · Prevention of Future Deaths report View report

14 Nov 2017 Manchester South C. Morris

Kathleen Smith, who had Alzheimer’s dementia, sustained a hip fracture at her care home on 12 April 2017 after being pushed to the floor by another resident. She underwent surgery, was discharged back to the care home for palliation, and subsequently died. Concerns raised at the inquest included failures to notify her family and the organisation’s corporate risk function, and the lack of audit or review of incidents after the departure of a manager responsible for reporting and escalation.

Steven Jones · Prevention of Future Deaths report View report

14 Nov 2017 South Yorkshire (Eastern) R. Curtis

Steven Jones, aged 27, was a non-verbal resident of a care home who became ill with sickness, diarrhoea, loss of appetite and sleep disturbance before dying on 10 December 2013. He was diagnosed with a perforated colon, leading to multi-organ failure and hypoxic brain injury. Concerns included failures to escalate carers’ concerns, insufficient incident reporting, delayed medical referral, and delays in calling emergency services and transferring him to hospital.

Rose Ball · Prevention of Future Deaths report View report

14 Nov 2017 Nottinghamshire H. Connor

Rose Ball, aged 82, was admitted to hospital in the early hours of 8 December 2016 and died later that day following acute peritonitis from a perforated duodenum. The report raised concerns that GP consultations on 6 and 7 December were conducted by telephone but were not recorded as such, that an abdominal examination was recorded although it did not take place, and that there was a wider pattern of diagnosing conditions by telephone without safety-netting or plans for examination.

BRIAN STANNARD · Prevention of Future Deaths report View report

14 Nov 2017 Norfolk J. Lake

Brian Stannard was a resident at Eversley Nursing Home and was found drowned on a beach at Great Yarmouth on 14 November 2016 after being seen asleep in his room earlier that morning. The report raised concerns about the nursing home’s capacity to manage his mental ill health and threats of self-harm or suicide, as well as incomplete staff records and limited use of the Lorenzo computer system.

John James Leo Scallan · Prevention of Future Deaths report View report

13 Nov 2017 Coventry B. Patel

John James Leo Scallan was admitted to hospital after sustaining injuries in an alleged assault and was subsequently transferred to a mental health ward as an informal patient. He was found unresponsive following a cardiac arrest, and the levels of sedative drugs in his blood after death exceeded those prescribed. Concerns were raised about the adequacy and reliability of intermittent observations, including staff understanding of the observation policy and reluctance to enter a patient's room to conduct checks.

Jeff David ANTWIS · Prevention of Future Deaths report View report

13 Nov 2017 Shropshire, Telford and Wrekin J. Ellery

Jeff David ANTWIS, a 14-year-old teenager with Asperger’s syndrome and a history of self-harm and suicide attempts, was struck by a train at Harlescott level crossing on 30 January 2017 and died later that day. The principal concern was that, despite indicating that he wished to die, he was given a routine medical review appointment for 17 March rather than an urgent review, alongside concerns about risk assessment, referral mechanisms and recognition of how his conditions may have affected the presentation of suicidal ideation.

Graeme Stafford Flatman · Prevention of Future Deaths report View report

10 Nov 2017 Newcastle upon Tyne K. Dilks

Graeme Stafford Flatman, an experienced pedal cyclist, suffered fatal injuries when he collided with a Nissan Qashqai while riding on the A593 at Oxen Fell, Skelwith, Ambleside. The concerns identified were the absence of warning signs about the severe gradient and limited visibility, and whether the 60-mile-per-hour speed limit was appropriate for the road.

Darren James Powney · Prevention of Future Deaths report View report

10 Nov 2017 Sunderland D. Winters

Darren James Powney, aged 37, died at home on 28 December 2016 after suffering a pulmonary embolus. He had called 999 reporting chest pains and breathlessness, but remained unattended for over an hour while ambulance and police services resolved how to respond to risk information. The report raised concerns about confusion over the relevant protocol, inadequate risk assessment and the need for faster escalation, training and implementation of procedures.

Timothy Kevin ATKINS · Prevention of Future Deaths report View report

9 Nov 2017 Portsmouth and South East Hampshire D. Horsley

Timothy Kevin ATKINS died on 2 June 2017 after a collision with another cyclist caused him to fall into the carriageway and sustain severe, unsurvivable head injuries. The collision occurred at a narrow, poorly visible pinch-point on a shared cycle/pedestrian pavement, and concern was raised about the lack of a safety barrier and the need to consider improving cyclist and pedestrian safety.

Daisy French · Prevention of Future Deaths report View report

9 Nov 2017 South Yorkshire (Western) L. Slater

Daisy French, who had a history of serious mental health difficulties and was transitioning from child to adult mental health services, died after deliberately placing herself in front of a high-speed train at Meadowhall Railway Station on 19 April 2017. The concerns included communication and information sharing between services, transition of care, differing out-of-hours arrangements for 16- to 18-year-olds, placement of an under-18-year-old in an adult crisis house, and returning her to accommodation without staff on duty after a mental health assessment.

Harminder DHILLON · Prevention of Future Deaths report View report

6 Nov 2017 Bedfordshire and Luton I. Pears

Harminder DHILLON drove around a lowered half barrier at Lidlington Level Crossing and collided with a train; the crossing was functioning appropriately. Concerns included the lack of CCTV monitoring, the limited deterrent effect of half barriers, and whether full-length barriers could prevent misuse and potential future deaths.