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RYAN JAMES VOUT · Prevention of Future Deaths report View report

6 Nov 2017 Nottinghamshire A. McNamara

Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.

John NICHOLS · Prevention of Future Deaths report View report

2 Nov 2017 Norfolk J. Thompson

John Nichols died at Queen Elizabeth Hospital, King’s Lynn, on 18 June 2017 after sustaining a head injury when a fire door closed between him and his carer shortly after a fire drill at his care home. The concern was that the Fire Drills Policy did not provide sufficient safeguards to ensure residents, particularly those with dementia, were monitored before, during and after fire drills.

William Henry BERGMAN · Prevention of Future Deaths report View report

31 Oct 2017 Inner North London M. Hassell

William Henry Bergman, who had vascular dementia, was admitted to hospital with pneumonia and died after sustaining a forehead impact while being changed on 19 December 2016. He was later found to have a subdural haematoma and massive intracranial bleed. The principal concern was that the staff nurse treated the injury as minor without requesting immediate observations or medical review, and did not change the management plan when a bruise and lump were later noted.

Bernard Hender and Douglas McTavish · Prevention of Future Deaths report View report

31 Oct 2017 North Wales (East and Central) D. Lewis

Bernard Hender and Douglas McTavish died on 10 October 2014 after a fire at their shared flat, with the deaths attributed to smoke inhalation and carbon monoxide poisoning. The inquest found, on the balance of probabilities, that the fire was caused by an electrical fault in a tumble dryer. Concerns included Whirlpool’s assessment and use of information about fire risks associated with door switch assemblies, and insufficient public awareness of the risk of fires caused by spontaneous combustion.

Vilhelmas BORKERTAS · Prevention of Future Deaths report View report

31 Oct 2017 Inner North London M. Hassell

Vilhelmas Borkertas took his own life on 21 November 2016 after his cellmate found him hanging from the window bar. Resuscitation attempts were unsuccessful. The principal concern was that Mr Borkertas, who was described as bisexual, was placed in a cell with a cellmate recorded as homophobic, without evidence that the potential dangers of this were considered; the report stated there was nothing to indicate this affected the outcome but that it might be devastating in another case.

Kate Louise Pierce · Prevention of Future Deaths report View report

31 Oct 2017 North Wales (East and Central) D. Lewis

Kate Louise Pierce became unwell on 29 March 2006 and was discharged from hospital after being diagnosed with viral tonsillitis. She returned approximately 36 hours later in a deteriorated condition, was diagnosed with pneumococcal meningitis, and later died in Florida on 19 March 2013 after suffering brain damage and other health conditions. The principal concerns were uncertainty about when a sick child should receive senior paediatric assessment before discharge, and a lack of clearly defined and consistently applied processes for identifying and acting on learning opportunities after adverse events or re-presentation.

Gordon Penistan · Prevention of Future Deaths report View report

31 Oct 2017 Central Hampshire G. Short

Gordon Penistan, who had dementia and had recently moved to a residential home, became unsettled by a loud noise and sustained an unwitnessed fall on a staircase on 24 May 2017. He suffered a head injury and died from a subdural haematoma. The substantive concerns included the handling of his move to a less expensive home, including the lack of a best-interests meeting and inadequate communication and consideration of the effects of the move on him.

Bernard Hender and Douglas McTavish · Prevention of Future Deaths report View report

31 Oct 2017 North Wales (East and Central) D. Lewis

Bernard Hender and Douglas McTavish died on 10 October 2014 after a fire at their shared flat, with the deaths attributed to smoke inhalation and carbon monoxide poisoning. The inquest found, on the balance of probabilities, that the fire was caused by an electrical fault in a tumble dryer. Concerns included Whirlpool’s assessment and use of information about fire risks associated with door switch assemblies, and insufficient public awareness of the risk of fires caused by spontaneous combustion.

Jane Allison Powell · Prevention of Future Deaths report View report

30 Oct 2017 Manchester North L. Hashmi

Jane Allison Powell was found deceased at home on 6 December 2016 after last being seen alive between 25 and 28 November 2016. The probable cause of death was multiple drug toxicity, and the report raised concern about the ease of obtaining large amounts of medication, including prescription-only drugs, over the internet and the risk of future deaths.

Stuart Michael Campbell · Prevention of Future Deaths report View report

30 Oct 2017 Manchester South A. Mutch

Stuart Michael Campbell was found suspended by a ligature on 5 March 2017 after reporting escalating drug and alcohol use and emotional distress. The inquest identified concerns about the absence of escalation from the drug and alcohol service to Pennine Care, unclear guidance and lack of clinical support for workers, and uncertainty about how shared care with the GP could be facilitated and documented.

Michael Edward Giles · Prevention of Future Deaths report View report

30 Oct 2017 Worcestershire G. Williams

Michael Edward Giles became unwell, was admitted to hospital, underwent a diagnostic surgical procedure, then deteriorated and died. The report identified concerns about inconsistent shift handovers, lack of senior review at weekends, inadequate clinical and nursing leadership during a crisis, and inadequate case notes and medical records.

Stephen George Coulson · Prevention of Future Deaths report View report

27 Oct 2017 Manchester City R. Sohail

Stephen George Coulson was discharged from Manchester Royal Infirmary after an increased Fentanyl patch was applied, with no record that the previous patch had been removed and despite confusion and agitation requiring further observation under hospital policy. He was found in cardiac arrest at home in the early hours of 1 January 2016 and died in intensive care later that day. The principal concerns were controlled-drug administration and documentation, failure to escalate the need for observation and review before discharge, and the Trust’s investigation failing to identify lessons.

David Edward Jackson · Prevention of Future Deaths report View report

24 Oct 2017 West Sussex K. Harrold

David Edward Jackson, a 76-year-old man, fell at home and remained on the floor for about two weeks before he died on 17 July 2017. His death was recorded as accidental, with severe pressure sores associated with sepsis, toxaemia and rhabdomyolysis following prolonged immobility. Concerns included long-term repeat prescribing of Co-dydramol and Soneryl without regular face-to-face medical review, and unclear arrangements for prescription collection or delivery.

Siân Louise WITHERIDGE · Prevention of Future Deaths report View report

23 Oct 2017 Inner North London M. Hassell

Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis team.

Lesley Hanson · Prevention of Future Deaths report View report

22 Oct 2017 South Wales Central P. Spinney

Lesley Hanson, who had severe learning disabilities and poor stability, gained access to stairs at her supported accommodation on 11 March 2017 and fell, sustaining injuries that led to her death. The concerns were that care and risk assessments did not address the gate being left open, the type of stair-gate or locking mechanism, and that responsibility for environmental safety controls was unclear. The inquest jury found the arrangements inadequate, including failure to follow the service plan and repeated occasions when the stair-gate had been left open.

Liam Oldsworth · Prevention of Future Deaths report View report

20 Oct 2017 Lincolnshire P. Cooper

Liam Oldsworth, a child aged 22 months, was admitted with a high temperature and difficulty breathing and was treated for septicaemia and meningitis, but his condition deteriorated despite medical support. The report raises concern that a Serious Incident Analysis report dated 18/3/2015 was received by the office only within the last week, with recommendations and shared learning attached.

Scott RAYNER · Prevention of Future Deaths report View report

20 Oct 2017 Hertfordshire E. Solomons

On 16 April 2017, Scott Rayner trespassed onto the railway track near Watford Junction Station and was struck and killed by a train. The investigation identified inadequate fencing beside the track, particularly near a scrap metal dealer, creating a risk of adults and children trespassing onto a line where the speed limit was 100mph.

June Evelyn Evans · Prevention of Future Deaths report View report

19 Oct 2017 Surrey C. Topping

June Evelyn Evans was admitted to St Peter’s Hospital with diarrhoea and was assessed as being at high risk of pressure sores. She developed a severe hospital-acquired pressure sore that became infected, and she died of sepsis on 1 July 2016. The principal concerns were failures to prevent and promptly refer and treat the pressure sore, inadequate nutrition, clinicians’ delayed awareness of the sore, and understaffing across the wards.

Ronald Maurice Brewer · Prevention of Future Deaths report View report

19 Oct 2017 Gloucestershire K. Skerrett

Ronald Maurice Brewer was an 87-year-old man with significant medical conditions who was admitted to hospital, discharged to a care home for end-of-life care, and died shortly after receiving prescribed palliative and anticipatory medication. The substantive concern related to the administration, documentation, and dispensing of palliative medications.

Sean Patrick Plumstead · Prevention of Future Deaths report View report

19 Oct 2017 Central Hampshire G. Short

Sean Plumstead, a convicted prisoner at HM Prison Winchester, died on 18 September 2016 after being found hanging by a ligature in his cell and later having treatment withdrawn following severe brain injury. The report raised concerns about inadequate suicide and self-harm awareness training for prison and prisoner-facing staff, unclear responsibility for training Carillion staff, and delayed responses to emergency cell bells.