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Jack Edward Braniff · Prevention of Future Deaths report View report

5 Jun 2017 Manchester North C. McKenna

At approximately 01:00 on 5 November 2016, Jack Braniff stepped into the path of an oncoming car on Middleton Road and died at hospital at 02:10 from injuries sustained in the collision. Concerns related to an illuminated advertising board obstructing pedestrians’ and drivers’ views, and overhanging tree canopies compounding visibility problems and potentially contributing to further fatalities.

Derrick Lawrence Brocklehurst · Prevention of Future Deaths report View report

5 Jun 2017 Manchester South A. Mutch

Derrick Lawrence Brocklehurst was admitted to hospital after being found immobile and incontinent at home, with grade 4 pressure ulcers, and died on 2 December 2016 from a pulmonary embolus. Concerns included missing records of carer visits and the absence of a discharge summary from the hospital to the GP after his A&E attendance.

David Ian Hamilton · Prevention of Future Deaths report View report

5 Jun 2017 Manchester South A. Mutch

David Ian Hamilton developed insomnia in October 2016, sought help from healthcare services, and was prescribed mirtazapine. He became increasingly anxious and reported thoughts of self-harm before being found dead at home on 7 February 2017; the investigation concluded that the death was suicide. Concerns included limited information-sharing between health professionals, unclear referral and escalation processes, lack of referral to sleep clinic services, and insufficient documentation of therapy selection.

Jessica Mary BIRKHEAD · Prevention of Future Deaths report View report

2 Jun 2017 Exeter and Greater Devon J. Tomalin

Jessica Mary Birkhead was found unconscious by her husband on 28 July 2015 and died in hospital later that day after ingesting a large quantity of paracetamol and pregabalin, which was not prescribed for her. The concerns raised were that mainstream adult support services were not equipped to meet her intellectual disabilities and that appropriate support pathways should be considered for people with similar learning difficulties and associated medical problems.

Michael John Halfpenny · Prevention of Future Deaths report View report

1 Jun 2017 Leicester City and South Leicestershire L. Brown

Michael John Halfpenny requested screening for an aortic aneurysm in March 2016 because of a strong family history, but the referral was sent to the wrong department, rejected, and not followed up. He later presented with severe abdominal pain on 9 December 2016, but diagnosis was delayed until he was peri-arrest; he died following emergency surgery for a ruptured abdominal aortic aneurysm. Concerns included inadequate referral and follow-up processes, uncertainty about the screening programme, and failures to ensure screening requests reached the correct team.

Jonathan David Palmer · Prevention of Future Deaths report View report

31 May 2017 Inner West London K. McLoughlin

Jonathan David Palmer was found suspended from a ligature in his cell at HMP Wandsworth on 19 November 2015 and was declared dead after resuscitation efforts were abandoned. The Inquest found the cause of death to be hanging. The substantive concerns included the lack of an effective system for families to provide and have health information disseminated within the prison, and apparently ineffective controls on contraband such as Spice.

Mrs Sarah Poole · Prevention of Future Deaths report View report

30 May 2017 Black Country Z. Siddique

Mrs Sarah Poole was admitted to hospital with sudden headache and back pain, but an abnormal ECG was incorrectly considered normal and she was discharged home. She was readmitted the following day, diagnosed with an aortic dissection and underwent emergency surgery, but developed complications and died on 5 November 2016. The principal concern was a failure to record and endorse the reviewing doctor’s name and to consider previous abnormal ECG results during handover.

Kenneth Evans · Prevention of Future Deaths report View report

30 May 2017 Black Country Z. Siddique

Kenneth Evans was admitted to hospital after a mechanical fall and fractured pubic ramus, and subsequently developed an extensive pulmonary embolism. He died on 11 March 2017 after cardiac arrest and continued clinical deterioration. The inquest identified that thromboprophylaxis and an effective blood-clot risk assessment had not been arranged, with missed opportunities to administer heparin.

Jamie Pashley · Prevention of Future Deaths report View report

28 May 2017 Inner South London J. Morris

Jamie Pashley died on 26 August 2015 after being found in his flat with high levels of alcohol in his body; the inquest concluded that the death was accidental and caused by alcohol intoxication. The principal concerns were whether people discharged after alcohol detoxification should receive fixed appointments, follow-up telephone contact, and improved access to an alcohol liaison nurse rather than being expected to manage their rehabilitation proactively.

Lucy Francesca Goldstone · Prevention of Future Deaths report View report

26 May 2017 Manchester City F. Borrill

Lucy Francesca Goldstone had a severe asthma attack and became unresponsive on a tram in Manchester city centre on 7 April 2016. Despite CPR by bystanders and ambulance clinicians, she died at Manchester Royal Infirmary; the recorded cause of death was bronchial asthma and aspiration of food material. The report raised concern about the availability of automated external defibrillators on trams and tram stops, and indicated that updated information and guidance would be sought.

Doreen Helen MILLER · Prevention of Future Deaths report View report

26 May 2017 Wiltshire and Swindon D. Ridley

Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.

Bonamie Elena Miriam Armitage · Prevention of Future Deaths report View report

25 May 2017 Gloucestershire K. Skerrett

Bonamie Elena Miriam Armitage, a 9-year-old girl, died after being struck in the chest by a kick from a larger horse during a hunt on 2 April 2016. The report raised concerns about the lack of mandatory requirements for children’s protective equipment, demonstrated competence, and adult supervision ratios during hunts.

Daphne Edith Williams · Prevention of Future Deaths report View report

25 May 2017 North Wales (East and Central) J. Gittins

Daphne Edith Williams fell outside her home on 23 September 2016 and sustained a fractured hip. An ambulance response took more than six hours, during which she remained on a concrete path; the report raised concerns about ambulance delays, emergency department admission, resource availability and patient flow, while stating that the delay could not be said to have contributed to her death.

Dominic Michael WHITE · Prevention of Future Deaths report View report

24 May 2017 Inner North London M. Hassell

Dominic White, who had bipolar affective disorder and psychosis, rapidly deteriorated over several days and was assessed as requiring detention under section 2 of the Mental Health Act. Before he could be conveyed to a mental health hospital, he left the emergency unit and was found the following day at an electricity substation with injuries consistent with a fall from height. The concerns included whether mental health observation levels were communicated effectively and the clinical decision-making involved in allowing him to leave after detention had been decided.

Robert John MULLIS · Prevention of Future Deaths report View report

23 May 2017 Central and South East Kent P. Harding

Robert Mullis, who had Parkinsons, Vascular Dementia and was partially sighted, disembarked a train at Ashford railway station and walked onto the tracks, where he was struck by two trains and died from his injuries. The report raises a concern about track access from railway platforms, with Network Rail and South Eastern addressing this issue nationally.

Kevin George Morgan · Prevention of Future Deaths report View report

22 May 2017 Milton Keynes T. Osborne

Kevin George Morgan, who had poorly controlled type 1 diabetes, was found deceased in his flat after family contacted police when they had not heard from him for several weeks. His body was heavily decomposed, and there were no suspicious circumstances. The principal concerns were the lack of effective follow-up by social services and housing, inadequate responses to safeguarding and safety concerns, and the absence of a post-death serious incident or safeguarding review.

Kate Dolby · Prevention of Future Deaths report View report

19 May 2017 Nottinghamshire H. Connor

Kate Dolby was found dead at home on 9 October 2016, with the cause of death recorded as Propranolol toxicity; the inquest concluded that her death was suicide. The report identified delays and communication breakdowns in accessing Early Intervention in Psychosis services, with workload, waiting lists and insufficient medical staffing identified as substantive concerns.

Alice Amaryllis Gibson-Watt (“Alice”) · Prevention of Future Deaths report View report

18 May 2017 London (West) S. Ormond-Walshe

Alice Gibson-Watt developed postpartum psychosis and, after receiving Haloperidol during seclusion in an acute mental health ward, suffered cardiac arrest and later died from hypoxic brain damage on 20 November 2012. The report raised concerns about inadequate monitoring and documentation of vital signs, missed opportunities for medical assessment and ECG, delayed recognition of the arrest, and delays in commencing CPR and using a defibrillator.

Mr William Frederick Wilkes · Prevention of Future Deaths report View report

17 May 2017 Milton Keynes T. Osborne

Mr William Frederick Wilkes was admitted to hospital after a fall at a residential home and remained in hospital after being assessed as ready for discharge. Delays in arranging suitable continuing healthcare placement, communication failures, and inconsistent provision of one-to-one enhanced care were identified; he suffered a further fall, fractured his hip, and died on 22 September 2016. The report raised concerns that discharge procedures were cumbersome and time-consuming and that local arrangements were needed to enable discharge within days rather than weeks.

Lilly Baxandall · Prevention of Future Deaths report View report

17 May 2017 North Wales (East and Central) J. Gittins

Lilly Baxandall was found collapsed at home after an unwitnessed fall and was taken to hospital by ambulance. Her ambulance handover was delayed for almost four hours amid capacity issues, and a CT scan later showed a large acute subdural haematoma that could not be treated; she died on 5 September 2014. The report raised concerns about continuing ambulance and handover delays, bed shortages, patient flow and delayed transfers of care, placing patients’ lives at risk.