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Glen Jordan · Prevention of Future Deaths report View report

7 Sep 2016 Black Country Z. Siddique

Glen Jordan, who had a history of depression and suicidal thoughts, was admitted to Bushey Fields Hospital as an informal patient on 20 April 2016. He was found hanging with the strap from a holdall in his room at around 2am on 24 April 2016 and died shortly afterwards. The principal concern was the balance between removing potentially hazardous personal items and allowing patients to retain personal belongings under least restrictive policies; the inquest also identified a failure to respond to an obvious risk of self-harm.

Christopher Glyn Jones · Prevention of Future Deaths report View report

7 Sep 2016 North Wales (East and Central) J. Gittins

Christopher Glyn Jones died after placing himself into collision with a train while under the care of the Community Mental Health Team. The inquest identified delays in treatment plans and risk assessments, failures in providing intended treatments, and inadequate escalation of concerns during a significant decline in his mental health; it also identified possible service deficiencies in staffing cover.

Louise Turner · Prevention of Future Deaths report View report

7 Sep 2016 Exeter and Greater Devon L. Brown

Louise Turner died on 27 June 2014 from inhalation of helium after recently being discharged from a lengthy inpatient stay while receiving treatment for a serious mental health illness. The report raised concerns about inadequate post-discharge care and contact, ineffective duty and buddying arrangements, expectations that patients initiate contact, and the absence of female intensive psychiatric care beds in Devon.

Beverley Dorothy Upton · Prevention of Future Deaths report View report

7 Sep 2016 Rutland and North Leicestershire R. Chapman

Beverley Dorothy Upton, a heavy goods vehicle driver, died after being trapped between a loading shovel bucket and the side of her lorry while it was being loaded at work on 4 November 2015. Concerns included the method of loading, the lack of clear written and enforced rules requiring drivers to remain in their cabs and wear high-visibility clothing, and insufficient training and health and safety documentation.

Dildar Shariff · Prevention of Future Deaths report View report

7 Sep 2016 Manchester North J. Robertson

Dildar Shariff died at Fairfield General Hospital on 10 May 2016 after a cardiac arrest, following a fall, head pain and vomiting. An intracerebral haemorrhage was confirmed, and the report states that his haemodialysis placed him at increased risk of haemorrhage. The principal concern was that this risk was not widely recognised or referred to in the relevant NICE guidelines, potentially creating a risk to other patients.

Edward Angus Mallen · Prevention of Future Deaths report View report

7 Sep 2016 Cambridgeshire and Peterborough B. Cheney

Edward Angus Mallen, who was suffering from depression and had disclosed suicidal thoughts, died after lying across a railway line and being struck by a train on 9 February 2015. The concerns included unclear responsibility for his care, advice from a non-prescriber about medication, lack of information about possible worsening symptoms and increased suicidal feelings, and inadequate awareness of routes to further psychiatric advice.

David Wade · Prevention of Future Deaths report View report

6 Sep 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

David Wade, who was receiving Warfarin therapy for atrial fibrillation, developed severe headaches, vomiting and collapse on 14 June 2016. A CT scan showed a non-survivable cerebellar haemorrhage; the report identified concern that there was no system for providing anticoagulant patients with information about brain-bleed symptoms and what action to take.

Samantha Ann Hopkins · Prevention of Future Deaths report View report

6 Sep 2016 Portsmouth and South East Hampshire D. Horsley

Samantha Ann Hopkins, who was 36 weeks pregnant, collapsed at home after falling and striking her head. Paramedics initiated the PARAMEDIC 2 Trial and administered one dose of the trial drug, although pregnant women were excluded from the trial. The concern was that the exclusion warning was inside the drug packet rather than prominently displayed on its outside, and that participating ambulance services had not been given guidance on highlighting exclusions.

Dr Imad Hassan · Prevention of Future Deaths report View report

5 Sep 2016 South Wales Central G. Hughes

On 17 April 2016, Dr Imad Hassan suffered an out-of-hospital heart attack and cardiac arrest, was resuscitated, and taken to Prince Charles Hospital. He suffered a further cardiac arrest and died at 04:35 on 18 April 2016. The report raised concerns about the lack of a formal backup and transfer pathway for patients requiring PCI when capacity was unavailable at the relevant hospitals, including for unconscious STEMI patients.

John Gerard JONES · Prevention of Future Deaths report View report

5 Sep 2016 Avon R. Sowersby

John Gerard JONES had been receiving support because of a perceived risk of suicide, and admission to hospital was recommended but not undertaken. He later took his own life by drowning in the River Avon on or around 1 February 2016. The principal concern was that his GP was not notified of his discharge from the Crisis Team for approximately a week, leaving uncertainty about community support during that period.

Benjamin Thomas Brown · Prevention of Future Deaths report View report

5 Sep 2016 North London A. Walker

Benjamin Thomas Brown was a patient detained under section 2 of the Mental Health Act who was found unresponsive at 8.45am after gaps and inaccurate entries in the required 15-minute observation records. He was recognised as having died at 10.06, and the inquest recorded natural causes, with sudden cardiac death due to cardiac arrhythmia. The substantive concerns related to auditing 15-minute observations, staff resuscitation training, and auditing the prescription and management of clozapine.

Mrs Catherine Dinnen · Prevention of Future Deaths report View report

2 Sep 2016 East London N. Persaud

Mrs Catherine Dinnen was admitted to hospital after left-sided weakness and suspected stroke, later developing vomiting, diarrhoea and breathing difficulties. She suffered a cardiorespiratory arrest on 27 August 2013 and was pronounced deceased that day. The principal outstanding concern was the timeliness of obtaining a medical review, in the context of reported difficulties securing out-of-hours medical attendance and concerns about staffing levels.

Ana Geanina SIRGHI-MARIN · Prevention of Future Deaths report View report

1 Sep 2016 Inner North London M. Hassell

Ana Geanina Sirghi-Marin died on 29 July 2016 from Escherichia coli sepsis associated with a naturally occurring uterine infection while sixteen weeks pregnant, after undergoing amniocentesis. The principal concern was that unusually dark yellow, non-blood-stained amniotic fluid was not sent for immediate microbiological analysis and promptly followed up, despite the absence of fever or another infection indicator at the time.

Robert Arnold Dearing · Prevention of Future Deaths report View report

30 Aug 2016 Central Lincolnshire P. Smith

Robert Arnold Dearing was struck from behind by a motor car while cycling on Sand Lane, Barkston, on 3 July 2015. The inquest concluded that he died as a result of the road traffic collision, with head injury recorded as the medical cause of death. Concerns related to the use of an unregulated anti-glare visor, which substantially reduced light transmission and could obscure the driver’s view of the road ahead.

Harry Stuart Gill · Prevention of Future Deaths report View report

30 Aug 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

Harry Gill became unwell with vomiting, made five calls to NHS 111, and collapsed and died shortly after an ambulance was being arranged on 2 June 2016. The inquest concluded that he died from a heart attack brought on by vomiting caused by an intermittent bowel blockage, and that his death could probably have been prevented if his condition had been appropriately assessed. The principal concern was that only one of five calls received the appropriate response, indicating that the vomiting pathway was not sufficiently robust.

Peter Lawrence · Prevention of Future Deaths report View report

30 Aug 2016 Cambridgeshire and Peterborough S. Milburn

Peter Lawrence was remanded into custody at HMP Peterborough and, on 02.02.15, was found in a prison workshop toilet cubicle having stabbed himself with a chisel; he was taken to hospital where death was confirmed. The concerns related to identifying and recording suicide or self-harm risks during the initial screening of first-time prisoners, and to the absence of meaningful interaction with a custodial officer who could help identify and manage such risks.

Maureen Patricia FLYNN · Prevention of Future Deaths report View report

26 Aug 2016 Manchester South A. Bridgman

Maureen Patricia FLYNN was admitted to hospital with a urinary tract infection and later suffered a fall from her bedside chair, fracturing her left hip. She underwent surgery, subsequently developed a chest infection that did not respond to antibiotics, and died on 7 May 2016. Concerns included the incomplete falls risk assessment, staff not being alerted to this, and the Patient Safety Investigation not identifying the omission.

Kyle William Lowes · Prevention of Future Deaths report View report

26 Aug 2016 North Northumberland T. Brown

Kyle William Lowes, aged 16, died after his motor scooter collided with a car in Berwick-upon-Tweed on 30 January 2015. Emergency response was delayed because the nearby Berwick ambulance crew was on a meal break, requiring a paramedic to travel from Wooler; the report raised concerns about delayed responses to life-threatening incidents in Berwick-upon-Tweed when only one crew is available or is outside the area.

Raymond Charles Woodward · Prevention of Future Deaths report View report

26 Aug 2016 Birmingham and Solihull E. Brown

Raymond Charles Woodward suffered a cardiac arrest and died on 19 February 2016 while undergoing a colonoscopy after Buscopan was administered. The report identified concerns that the risk of adverse reactions to Buscopan in patients with coronary artery disease was not widely known and that existing prescribing information did not specifically address ischaemic heart disease.

Pamela June Conway · Prevention of Future Deaths report View report

26 Aug 2016 North Wales (East and Central) J. Gittins

Pamela June Conway developed an infected knee and experienced cumulative delays, including around 21 hours before receiving antibiotics, during which she went into irrevocable septic shock. The concerns included the absence of a finalised care pathway for patients with an infected prosthesis and an almost two-hour delay between knee aspiration and antibiotic administration. The inquest recorded that her death was due to natural causes exacerbated by delayed medical treatment.