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Norman Arthur BEARD · Prevention of Future Deaths report View report

7 Oct 2016 Stoke-on-Trent and North Staffordshire M. Jones

Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.

Andrew David Machin · Prevention of Future Deaths report View report

7 Oct 2016 Coventry E. Whitting

Andrew David Machin died by hanging from a tree in Pailton Pastures shortly after being informed of the Prison Service’s decision to dismiss him after 18 years of service. His body was discovered by police on 10 May 2016. The report raised concerns about limited support from prison management during the disciplinary investigation and the absence of an internal investigation into the dismissal process after his death.

Helen Louise MILLARD · Prevention of Future Deaths report View report

6 Oct 2016 East Riding and Hull P. Marks

Helen Louise MILLARD hanged herself using bathroom taps at the Westlands Mental Health Unit, Hull, between 18:32 and 18:59 on 12 May 2015, and died at Hull Royal Infirmary at 01:28 on 13 May 2015. The principal concern was that the ligature-point classification system treated points one metre or less above the ground as amber, despite evidence that ligature risk was independent of height and that such points could cause death rapidly.

Colin George Wellings · Prevention of Future Deaths report View report

5 Oct 2016 South Wales Central A. Barkley

Colin George Wellings was riding a domestically constructed three-wheeled motorised trike when he lost control entering a mini island, was thrown from it and died at the scene from serious head and other injuries. The concerns were that this class of vehicle was exempt from seatbelt and helmet requirements and that legislation should be considered to bring such vehicles in line with other mainstream mechanically propelled vehicles.

Haydn James Burton · Prevention of Future Deaths report View report

4 Oct 2016 Central Hampshire G. Short

Haydn James Burton, a prisoner at HMP Winchester, was found suspended from a ligature point in his cell on 15 July 2015 and died in hospital on 18 July 2015 from the delayed effects of ligature suspension. The concerns included inadequate implementation of ACCT plans and observations, uncertainty about confidentiality rules in the Prison Listener scheme, and limitations in recording and communicating information about closed ACCT plans.

Amy El-Keria · Prevention of Future Deaths report View report

3 Oct 2016 West Sussex P. Schofield

Amy El-Keria, aged 14, died on 13 November 2012 after tying a ligature around her neck and suspending herself from a radiator while receiving inpatient mental health care. The inquest identified concerns about staffing levels being insufficient to provide the one-to-one support in her care plan and the shortage of acute mental health beds for young people close to home, limiting family support.

Karnel Kane Haughton · Prevention of Future Deaths report View report

23 Sep 2016 Birmingham and Solihull E. Brown

Karnel Kane Haughton, aged 12, was found unconscious at home with a ligature around his neck and died at Birmingham Heartlands Hospital on 1 June 2016. The report considered that he had likely been engaging in the “choking game”. Concerns included the open availability of uncensored online videos, the lack of national guidance and dedicated support, and the risk that poorly handled awareness-raising could encourage children to try these activities.

DAPHNE MCCORKLE · Prevention of Future Deaths report View report

22 Sep 2016 London Inner (South) H. QC

Daphne McCorkle was discharged from hospital with a Grade 2 pressure sore, which deteriorated while she was receiving community care. She died in hospital on 20 November 2014 from sepsis caused by the infected pressure sore. Concerns included the frequency and quality of District Nurse visits and assessments, inadequate care-plan reviews and documentation, delayed referral to a Tissue Viability Nurse, lack of advice about night-time turning, and a gap in night-time care provision.

Liam Adrian John Lambert · Prevention of Future Deaths report View report

20 Sep 2016 Leicester City and South Leicestershire L. Brown

Liam Adrian John Lambert was a young offender at Glen Parva Young Offenders Institution who died after ligaturing himself in a single cell on the evening of 19 March 2015. The report identified concerns about bullying and assaults, inadequate completion and use of the ACCT self-harm documentation, its inappropriate closure, prison resourcing, and delays in the emergency response and access for paramedics.

Charles Edward Pitcher · Prevention of Future Deaths report View report

19 Sep 2016 Plymouth, Torbay and South Devon I. Arrow

On 5 July 2016, Charles Edward Pitcher jumped over the walkway barrier of the Tamar Bridge and landed in Wolseley Road, Plymouth, suffering fatal injuries. The report raised concerns that the barrier was too easy to cross, that people in Wolseley Road were at risk, and that further procedures and measures should be reviewed to reduce the likelihood of suicide from the bridge.

Martha Ann Davies · Prevention of Future Deaths report View report

16 Sep 2016 Essex C. Beasley-Murray

Martha Ann Davies, a 98-year-old woman, fell at home, underwent surgery for a fractured hip, was transferred for rehabilitation, suffered a further fall, and died in hospital on 29 November 2015. The report identified concerns including communication failings, reliance on agency and junior staff, delayed response to deterioration, lack of engagement by ward staff and management, and documentation failings; the inquest concluded that she did not receive adequate care and appropriate treatment at Clacton District Hospital, which may have contributed to her death.

Denis William Patrick Cronin · Prevention of Future Deaths report View report

16 Sep 2016 Leicester City and South Leicestershire C. Mason

Denis William Patrick Cronin drowned after a dive at Stoney Cove on 26 April 2015. The report identifies concerns about inadequate risk assessment, training and supervision, dive planning, failure to follow BSAC guidance, and weight-belt configuration that created a foreseeable risk it could not be released.

David Nigel Phillips · Prevention of Future Deaths report View report

16 Sep 2016 Swansea and Neath Port Talbot C. Phillips

David Nigel Phillips, who had a history of mental illness, previous suicide attempts, alcohol-related issues and type 2 diabetes, was found drowned in a rock pool near Mumbles Pier on 4 January 2015. He had been arrested the previous day after being found intoxicated in his parked car and had told police he had been attempting to take his own life. The principal concerns were that an experienced mental health professional should have assessed him and that the healthcare professional lacked access to his medical records, including mental health records, to review his medication and risks accurately.

Marko Petrovic · Prevention of Future Deaths report View report

15 Sep 2016 West Yorkshire (Western) M. Fleming

Marko Petrovic died from multiple injuries after a cantilever scaffolding platform became unstable and fell from the roof of Calderdale Royal Hospital while it was being dismantled on 11 January 2016. Concerns included the absence of written guidelines for dismantling cantilevered scaffolds and the lack of a specific risk assessment and method statement for dismantling the scaffolding.

Philip Richard David BREATNACH · Prevention of Future Deaths report View report

15 Sep 2016 Brighton and Hove V. Hamilton-Deeley

Philip Richard David Breatnach's circumstances are referred to in the Record of Inquest. The concerns relate to online applications for medication, inadequate checking of answers and failure to contact his GP, and the prescribing of Dihydrocodeine by a prescriber who had not seen him, including concerns about the quantity, suitability for migraine, and dosing instructions. The inquest concluded with a finding of MISADVENTURE (DEPENDENCE ON DRUGS).

Roy Gordon Millar · Prevention of Future Deaths report View report

13 Sep 2016 Plymouth, Torbay and South Devon A. Cox

Roy Gordon Millar attended hospital with slurred speech and facial droop, and scans identified an abnormality requiring follow-up. The repeat scan results were not sent to the correct consultant, and a requested outpatient appointment was not arranged. A brain tumour was identified after he re-presented with a more severe facial droop, but he died on the date planned for biopsy and debulking surgery; the report also describes failures to book follow-up appointments affecting approximately 146 patients.

Keith William Rushton · Prevention of Future Deaths report View report

13 Sep 2016 West Yorkshire (Western) M. Fleming

Keith William Rushton slid from his bed at home on 15 December 2015 and was unable to get up, remaining there until he was found on 16 December. An ambulance arrived approximately two hours after it was called, and he died later that day from multi-organ failure and rhabdomyolysis associated with crush injuries to his legs. The concerns focused on ambulance response times and telephone protocols for identifying prolonged lies, particularly involving obese patients.

Arthur Thomas Adley · Prevention of Future Deaths report View report

13 Sep 2016 North London A. Walker

Arthur Thomas Adley, a resident at Candle Court Nursing Home, was pushed by another resident on 8 April 2016, fell and struck his face and head on a table, and died in hospital the same day. The substantive concern was that safeguarding systems did not prevent risks posed to other residents by residents who presented a risk when placed in care homes.

Zane Ilorie Christopher Yusuf GBANGBOLA · Prevention of Future Deaths report View report

13 Sep 2016 Surrey R. Travers

Zane Ilorie Christopher Yusuf GBANGBOLA, aged seven, died on 7 February 2014 after exposure to carbon monoxide from a petrol-driven pump used during severe flooding at his family home. The report raised concerns that HAE safety guidance for internal-combustion-engine equipment used in confined areas was inadequate and potentially misleading, and that the use of HSE branding could be interpreted as endorsement of the guidance.

Lauris Kodors · Prevention of Future Deaths report View report

13 Sep 2016 North London A. Walker

Lauris Kodors was struck by a train and suffered fatal injuries in the Harrow Tunnel on 11 April 2016; he was discovered on 12 April and confirmed to have died on 13 April 2016. The report raised concern that the RSSB Rule Book allowed trains to be stopped only where a person might damage a train, not where a person might be in danger from a train.