Search PFD Monitor

John Anthony Atkin · Prevention of Future Deaths report View report

6 Mar 2017 Surrey A. Crawford

John Atkin, a driver/technician, was bitten by a spaniel while delivering and installing healthcare equipment at a service-user’s home on 23 February 2016. He continued working but became increasingly unwell and was found deceased at home on 27 February 2016; the stated medical cause of death was staphylococcal septicaemia associated with a dog bite wound. Concerns included assumptions about healthcare professionals identifying hazardous dogs and the absence of a policy preventing drivers from entering homes before making direct contact with the homeowner.

Vadims ALEKSEJEVS · Prevention of Future Deaths report View report

3 Mar 2017 Northamptonshire H. Shah

Vadims ALEKSEJEVS, who had been living in a tent after becoming homeless, was found unresponsive outdoors on 9 November 2016 and pronounced deceased that morning. The circumstances involved synthetic cannabinoid use, alcohol intoxication and hypothermia. Concerns included whether homeless people had access to outreach from adult social care or addiction services, the presence of other vulnerable people at the campsite, and the availability of housing options or statutory housing duties.

Joan RIMMER · Prevention of Future Deaths report View report

3 Mar 2017 Liverpool and the Wirral A. Rebello

Joan Rimmer, who had dementia and lived in a residential home, suffered an unwitnessed fall on 28 November 2016 and was later diagnosed with a right hip fracture. She underwent surgery but subsequently stopped eating and drinking and died on 16 January 2017. The court was concerned that the community matron assessed her without taking physiological readings and wrongly judged that she had refused an X-ray, contributing in part to a two-week delay in diagnosing the fracture.

Alan Walsh · Prevention of Future Deaths report View report

3 Mar 2017 Inner South London A. Harris

Alan Walsh fell from a 2.5-metre ladder while inspecting a fault in a ceiling void at Eltham Leisure Centre and died the same day from injuries sustained in the fall. The report raised concern about a lack of awareness of the safety-critical role of the ladder’s spigots and the possibility that they could be inadvertently sheared off, although their absence was not found to have caused the accident.

Terence Millington · Prevention of Future Deaths report View report

2 Mar 2017 South Yorkshire (Western) C. Dorries

Terence Millington, who had severe lung disease and metastatic cancer, suffered persistent nose bleeds at Weston Park Hospital on 18 November 2015 and died after a cardiac arrest. The concerns included inadequate arrangements for the on-call senior doctor to wake when called, the consultant’s distance from the hospital, and the incorrect supply of one of two requested nasal packs.

Paul William BARBER · Prevention of Future Deaths report View report

2 Mar 2017 Brighton and Hove V. Hamilton-Deeley

Paul William BARBER had recently diagnosed aggressive lung cancer and developed pericarditis with fluid around his heart. Samples of the fluid were sent to microbiology in the wrong containers, causing a potential delay, and the identification of two organisms was not reported to clinicians until shortly after his death. The report identified these as failings, while stating that, on the balance of probabilities, they did not affect the outcome in this case.

Darran Hunt · Prevention of Future Deaths report View report

1 Mar 2017 Carmarthenshire and Pembrokeshire G. Lewis

On 8 February 2015, Darran Hunt was involved in a struggle with police after attempting to evade detention and placing a package in his mouth. He choked on the package and died despite efforts to clear his airway and provide life support. The report raises concerns about police training and guidance on using PAVA spray, forced searches of a detainee’s mouth, and control and restraint where a detainee has placed something in their mouth.

Thomas Moore Unsworth · Prevention of Future Deaths report View report

1 Mar 2017 Manchester West J. Leeming

Thomas Moore Unsworth, aged 80, was a pedestrian crossing Great Moor Street in Bolton when he was hit by a left-turning bus on 28 January 2016 and died from a head injury. Evidence at the inquest raised concerns that the junction layout, building line and street furniture limited drivers’ views of pedestrians and created blind spots.

Ceriann Richards · Prevention of Future Deaths report View report

1 Mar 2017 South Wales Central A. Barkley

Ceriann Richards was found acutely unwell and suffering seizures at home on 14 August 2016. An ambulance took approximately three hours to convey her to hospital, where she died later that morning. A post-mortem found very high, toxic levels of Venlafaxine, while the principal concern was delay in ambulance despatch linked to hospital handover delays.

Reverend Colin Hodge · Prevention of Future Deaths report View report

28 Feb 2017 Dorset S. Nicholls

On 19 January 2016, Reverend Colin Hodge stumbled on an uneven pavement at a junction in Wareham and fell against a turning vehicle, then struck his head. He was taken to hospital and died on 25 January from an inoperable head injury. Concerns included the poor state of repair and lack of a clear boundary between the pavement and roadway, with vehicles sometimes cutting the corner.

Paul Michael BRIGGS · Prevention of Future Deaths report View report

28 Feb 2017 Liverpool and the Wirral A. Rebello

On 3 July 2015, Paul Michael Briggs was riding his motorcycle to work when an oncoming Nissan Micra crossed onto his side of the road and collided with him. He suffered multiple fractures and a traumatic brain injury, remained in a minimally conscious state, and died on 21 January 2017 after artificial nutrition and hydration was withdrawn. The report raised concern that adding rumble strips to the double white lines might reduce the risk of vehicles straying into the oncoming lane, and noted that risk assessments and remedial action were still outstanding some 20 months after the incident.

Doreen Elma STAPLETON · Prevention of Future Deaths report View report

24 Feb 2017 Inner North London M. Hassell

Doreen Stapleton died at Whittington Hospital on 15 September 2016 from a pulmonary thromboembolism, after previously being diagnosed with pulmonary emboli. Following discharge, district nurses were intended to administer daily tinzaparin injections, but the referral was not received because an obsolete email address was used. The principal concern was that Doreen and her sons were not given sufficiently explicit advice about the potentially fatal consequences of missed medication and were not given the district nursing team’s telephone number or told to call if nurses did not attend.

Grant David Burns · Prevention of Future Deaths report View report

23 Feb 2017 Southampton and New Forest G. Short

Grant David Burns took an excess quantity of methadone, heroin and Alprazolam while alone at The Booth Centre between 20.05 on 22 July and 15.15 on 23 July 2016, and died from Morphine, Methadone and Alprazolam Toxicity. Concerns included a lack of co-operative working and communication between mental health, substance misuse and partner agencies, and an incomplete Root Cause Analysis report due to missing input from a key worker.

Luke Mumford · Prevention of Future Deaths report View report

23 Feb 2017 Mid Kent and Medway K. Thomas

Luke Mumford died at the scene after his car left Pilgrim's Way, struck a tree and came to rest in a field on 23 November 2016. The report raised concern that the road was unsafe to drive on at the 70 mph speed limit because it was narrow, unlit and bordered by hedgerows and trees.

Mrs. Margaret Joyce Jones · Prevention of Future Deaths report View report

22 Feb 2017 Avon P. Harrowing

Mrs. Margaret Joyce Jones died at the scene after her car collided with a northbound articulated lorry while she was turning onto the A36 from Branch Road on 5 September 2016. The report identified repeated collisions at the junction and raised concerns about the speed limit, road signs, carriageway markings, and the condition of the high-friction surface.

Mr Christopher Brookes · Prevention of Future Deaths report View report

22 Feb 2017 Black Country Z. Siddique

Mr Christopher Brookes, aged 22, fell around 40 feet from a gate at Wolverhampton bus station after leaving through a fire exit and died from his injuries on 29 October 2017. The inquest heard that there had been a similar previous incident at the same location and that security guards failed to attend when an alarm indicated unauthorised use of the fire exit.

Ashley Daniel Talbot · Prevention of Future Deaths report View report

22 Feb 2017 South Wales Central A. Barkley

Ashley Daniel Talbot, a 15-year-old pupil, was struck by a school minibus shortly after 3pm on 10 December 2014 while running to catch his bus and died at the scene. The concerns identified deficiencies in the school service road and bus bay, inadequate staff supervision, unreported near misses, and a lack of accountability among stakeholders involved in the school’s design and construction.

Maxim Karpovich · Prevention of Future Deaths report View report

22 Feb 2017 West Yorkshire Eastern D. Hinchliff

Baby Maxim Karpovich was delivered by emergency caesarean section on 16 March 2015 with no signs of life, was resuscitated and treated in the Neonatal Intensive Care Unit, and died later that day. The concerns included failures to recognise and correctly interpret abnormal cardiotocograph traces, together with wider concerns about the adequacy of CTG interpretation training and competency assessment for midwives and obstetricians.

JACK OLIVER PORTLAND · Prevention of Future Deaths report View report

21 Feb 2017 Buckinghamshire C. Butler

Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

Esther HartSilver · Prevention of Future Deaths report View report

20 Feb 2017 Inner South London S. Ormond-Walshe

Esther HartSilver died after being seriously injured when an HGV lorry turning left at the junction of Denmark Hill and Orpheus Street collided with her bicycle as she cycled to work. The report raises concerns about the junction’s design, including the risk created by traffic turning across the bus lane, inadequate warning of potential conflicts, and a history of reported collisions and near misses involving vulnerable road users.