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Joyce Mary Ravenhill · Prevention of Future Deaths report View report

24 Aug 2016 Cheshire N. Rheinberg

Joyce Mary Ravenhill became ill with abdominal pain and vomiting on Christmas Day 2015, was not given an earlier out-of-hours doctor appointment after two triage assessments, and was later found to have an incarcerated femoral hernia causing intestinal obstruction. She underwent surgery but died on 2 January 2016; the principal concern was that there was no facility or operational policy to communicate the urgency of the first triage assessment to the second triage nurse.

MICHAEL DUNDON · Prevention of Future Deaths report View report

23 Aug 2016 West Yorkshire Eastern D. Hinchliff

Michael Dundon died after ingesting safety gel liquid-absorbing crystals that had been placed in unused urine bottles in his hospital room. He was unsupervised despite needing one-to-one supervision, and the crystals caused an airway blockage and cardiorespiratory arrest. The principal concerns were that the risks of the crystals were not fully understood and that staff needed awareness, training, and risk assessments regarding their safe use.

Stephen Sean CAHILL · Prevention of Future Deaths report View report

23 Aug 2016 Bedfordshire and Luton I. Pears

Stephen Sean CAHILL died after being struck by a train while lying across the track near Sandy Railway Station on 29 March 2016. The principal concern was that the access gate and fencing provided little deterrence or hindrance to people seeking to access the railway line, and a recommended review had not been undertaken.

Nicholas Patrick SULLIVAN · Prevention of Future Deaths report View report

22 Aug 2016 Manchester City N. Meadows

Nicholas Patrick SULLIVAN, who had a chronic mental illness and was experiencing suicidal ideation and auditory hallucinations, attended an emergency department but was not triaged or referred for a timely mental health assessment. He left after waiting, later reiterated that he was suicidal, ran into a road and was struck by a car, dying from his injuries on 30 November 2014. The principal concerns included failures to record mental health risks at reception, trigger urgent triage and safeguarding, activate escalation procedures, and ensure appropriate coordination and staffing.

Amanda Coppen · Prevention of Future Deaths report View report

19 Aug 2016 Inner South London P. Barlow

Amanda Coppen suffered fatal injuries when she was struck by a bus while crossing Pilot Busway on 4 January 2016. The inquest evidence indicated that she was crossing on a signal-controlled pedestrian crossing when the signal was red to pedestrians and green to traffic. Concerns included the unusual road layout potentially misleading pedestrians and motorists, and a possible increased risk to schoolchildren following the construction of a nearby school.

John Richard William JONES · Prevention of Future Deaths report View report

19 Aug 2016 Inner North London M. Hassell

John Jones, aged 48, died instantaneously after jumping in front of a moving train at West Hampstead Railway Station on 18 April 2016. During his month-long admission to the Nightingale Hospital, he largely remained alone in his room and did not engage with the available group therapy. The principal concern was that the hospital environment appeared suboptimal for addressing his difficulty accepting help and providing effective treatment.

George Watson · Prevention of Future Deaths report View report

19 Aug 2016 Coventry R. Brittain

George Watson fell from his bed at approximately 04:30 on 3 September 2014 after being admitted following a fall, and died on 21 October 2014 from a subdural haemorrhage, skull fracture and compound fracture of his left humerus. The principal concerns included supervision and staffing arrangements, raised bed rails, discharge without necessary oral pain relief and inadequate investigatory processes, including cooperation with police inquiries.

Nathan Anthony Lowe · Prevention of Future Deaths report View report

19 Aug 2016 City of London R. Palmer

Nathan Anthony Lowe was discharged from hospital and a Section 2 Mental Health Act Order in October 2015, with community psychiatric follow-up arranged. He fell to his death in central London on 12 May 2016; the concern was whether more should have been done to contact him between 10 March and 12 May given his illness and non-compliance with follow-up.

Margaret Ann Richardson · Prevention of Future Deaths report View report

19 Aug 2016 Essex C. Beasley-Murray

Margaret Ann Richardson suffered at least five falls while a patient in Kitwood Ward at St Margaret’s Hospital Epping and died in Princess Alexandra Hospital Harlow after the last fall. The inquest identified failings in implementing the Trust’s falls policy, and the report raised concern about putting in place a robust, comprehensive action plan with timescales.

Diana Maxine RITCHIE · Prevention of Future Deaths report View report

18 Aug 2016 Brighton and Hove V. Hamilton-Deeley

Diana Maxine Ritchie was recovering from major surgery when she deteriorated overnight on 5–6 March and suffered a cardiac arrest at around 12.20 hrs on 6 March. Concerns included missed opportunities to escalate care in response to raised NEWS scores, inaccurate or potentially delayed observations, and failures in the use of NEWS across the Trust.

Jonathan Edward Michael Sellman · Prevention of Future Deaths report View report

17 Aug 2016 South Yorkshire (Western) P. Dorries

Jonathan Edward Michael Sellman sustained fatal injuries when his vehicle lost control on the A630 Sheffield Parkway on 28 March 2016, apparently after encountering standing water, and collided with a barrier and lamp post before tumbling down an embankment. The substantive concerns were water pooling on the carriageway and the condition of the verges, which might cause an out-of-control vehicle to be pushed upwards and land on or over the Armco barrier.

Christine Dryden · Prevention of Future Deaths report View report

17 Aug 2016 West Yorkshire (Western) M. Fleming

Christine Dryden was found unresponsive in a house fire on 20 April 2016 and died in hospital on 23 April 2016 after attempts to resuscitate her. The inquest heard that the working smoke and heat detectors had not been regularly checked, raising concerns about arrangements for maintaining and periodically checking detectors in the properties.

Harry Glibbery · Prevention of Future Deaths report View report

16 Aug 2016 Plymouth, Torbay and South Devon A. Cox

Harry Glibbery had a chronically infected left hip replacement and underwent a Girdlestone procedure before developing pulmonary emboli. He died on 7 April 2016 after a catastrophic intracerebral haemorrhage while receiving Clexane. The principal concerns were that the Clexane prescription exceeded the Derriford Protocol dose, the error was not identified during pharmacy reviews, and difficulties weighing him may have prevented a dose review as he lost weight.

Saleh Awadh Mohamed Al-Awlaki · Prevention of Future Deaths report View report

15 Aug 2016 Plymouth, Torbay and South Devon I. Arrow

Saleh Awadh Mohamed Al-Awlaki, a young student, was struck by a car on Great Western Road, Paignton, and died from his injuries. The report raised concern about the suitability of pedestrian railings between Paignton Railway Station and Bus Station to channel pedestrians towards the crossing and reduce vehicle-pedestrian collisions.

Michael Peter McMonigle · Prevention of Future Deaths report View report

15 Aug 2016 County Durham and Darlington C. Oliver

Michael Peter McMonigle was admitted as an informal patient to Farnham Ward at Lanchester Road Hospital and was assessed as being at significant risk of self-harm. On 11 August 2015 he left the hospital during accompanied leave, was later found suspended by a ligature, and was declared dead on 12 August. The principal concerns included failures to update and communicate risk information and leave arrangements, inadequate handover and policy implementation, and delays and omissions in responding to his absence.

Darren Mindham · Prevention of Future Deaths report View report

15 Aug 2016 South London S. Lynch

Darren Mindham, who worked as an assistant in a veterinary practice, removed pentobarbital from a former employer’s drugs cupboard, kept it at home, and later used it to take his life. The inquest concluded that he died from acute pentobarbital intoxication after self-administering the drug at home on 28 August 2015 while suffering from depression; the concern raised was the availability and control of pentobarbital, given its use in suicide and evidence that reducing access to means can reduce suicide rates.

Oliver Hamlin · Prevention of Future Deaths report View report

15 Aug 2016 Avon M. Voisin

Oliver was found dead hanging from a tree at Norton Wood, Clevedon, after expressing paranoid thoughts and being triaged by the Primary Care Liaison Service. The concerns raised were that no risk assessment was carried out during triage, risk assessments should be documented, and weekend cover for the service should be considered.

Jean Stockley · Prevention of Future Deaths report View report

12 Aug 2016 West Sussex K. Harrold

Jean Stockley was admitted after an unwitnessed fall down 13 stairs that caused spinal fractures. Her respiratory condition later deteriorated, leading to respiratory failure, intensive care treatment and her death on 20 April 2015. Concerns included failure to review her after a significant NEWS score increase, uncertainty about which doctor should be contacted, reluctance to escalate concerns to senior doctors, and possible benefits of automated NEWS monitoring.

Stephen St Clair · Prevention of Future Deaths report View report

12 Aug 2016 Isle of Wight C. Sumeray

Stephen St Clair, a prisoner at HMP Isle of Wight, was found in his cell on 4 November 2013 with a severe cut to his throat and was pronounced dead at 05.55 hours. The report describes concerns about signs of paranoia and possible psychosis not being recognised as suicide or self-harm risk, and about the absence of corresponding wording in the Prison Service suicide risk guidance, which may have contributed to an ACCT not being opened.

Michael Blow · Prevention of Future Deaths report View report

12 Aug 2016 Portsmouth and South East Hampshire K. Harrold

Michael Blow was admitted after falling downstairs and sustained chest injuries, including fractured ribs, lung contusions and a pneumothorax. His condition later deteriorated, with blood in the chest drain, an INR of 9, and he died following cardiac arrest; the recorded cause of death included haemothorax, fractured ribs and warfarin treatment. Concerns included a requested INR test not being carried out and warfarin being restarted using an outdated INR result without sufficient account of other treatments and medication.