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Ahmedreza Fathi · Prevention of Future Deaths report View report

5 May 2016 Leicester City and South Leicestershire L. Brown

Ahmedreza Fathi was a serving prisoner at HMP Gartree who died by suicide in May 2015 through a combination of plastic bag asphyxia and multi-drug toxicity. The report identified concerns about inadequate case planning, fragmented communication and information-sharing, inappropriate observation levels, and insufficient response to an earlier overdose.

Tony Elliott Jopson and Michael Ian Jopson · Prevention of Future Deaths report View report

4 May 2016 Cumbria D. Roberts

Tony Elliott Jopson, aged 18 months, died instantly after being ejected from a baby seat during a head-on collision on the A66 at Crackenthorpe. Michael Ian Jopson, aged 25, also died in the collision after the car he was driving crossed into the path of an oncoming goods vehicle. The substantive concern was the safety of the A66, particularly that its single-carriageway sections carry substantial goods-vehicle traffic and may contribute to avoidable deaths.

Tony Elliott Jopson and Michael Ian Jopson · Prevention of Future Deaths report View report

4 May 2016 Cumbria D. Roberts

Tony Elliott Jopson, aged 18 months, died instantly after being ejected from a baby seat during a head-on collision on the A66 at Crackenthorpe. Michael Ian Jopson, aged 25, also died in the collision after the car he was driving crossed into the path of an oncoming goods vehicle. The substantive concern was the safety of the A66, particularly that its single-carriageway sections carry substantial goods-vehicle traffic and may contribute to avoidable deaths.

Shalan Blackwood · Prevention of Future Deaths report View report

3 May 2016 Nottinghamshire S. Haskey

Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.

Darren Mindham · Prevention of Future Deaths report View report

3 May 2016 South London S. Lynch

Darren Mindham, who worked as an assistant in a veterinary practice, died by suicide after self-administering pentobarbital at home on 28 August 2015. The principal concern was that pentobarbital was subject to less strict controls, and that access to it may facilitate suicide.

Mihangel ap Dafydd · Prevention of Future Deaths report View report

3 May 2016 Carmarthenshire and Pembrokeshire J. Layton

Mihangel ap Dafydd was detained under the Mental Health Act and placed under 15-minute observations after being assessed as at risk of self-harm. On 16 February 2014 he was found hanging from a window using a bag strap; concerns included the incorrect removal of potentially harmful property and windows that had not been adapted to prevent their use as ligature points, which the jury found contributed to his death.

Jack MOLYNEUX · Prevention of Future Deaths report View report

29 Apr 2016 Brighton and Hove V. Hamilton-Deeley

Jack MOLYNEUX was awaiting discharge to a nursing home after admission to a ward for elderly male patients, where he had dementia but no acute physical illness. The report describes concerns about inadequate care, including failures relating to mobility, hydration, nutrition, mouth care, personal hygiene, psychological wellbeing, stimulation and medication, and states that these omissions and failings contributed to his death. His death was unexpected after transfer to the nursing home, where his condition and engagement reportedly improved.

Jan Bodnar · Prevention of Future Deaths report View report

29 Apr 2016 Hertfordshire G. Danbury

Jan Bodnar died after his motorcycle collided with a car crossing the A505 near Ashwell on 12 July 2015. The report raised concerns that plant growth in the central reservation severely restricted visibility for drivers and that similar risks might exist at other junctions on the road.

Patrick McGagh · Prevention of Future Deaths report View report

28 Apr 2016 Manchester South J. Pollard

Patrick McGagh died at his care home from natural causes; the medical cause of death was recorded as pneumonia, coronary artery atheroma and hypertensive heart disease. After discharge from hospital, no discharge information or prescribed antibiotics were provided to his GP or care staff, who were therefore unaware that he should have been taking them.

T E Harris · Prevention of Future Deaths report View report

28 Apr 2016 Central and South East Kent R. Redman

T E Harris, described as a 22-year-old man, was found deceased at his home by family on 1 February 2016. The inquest concluded that he had taken his own life, with the stated cause of death being asphyxiation. The substantive concern was that helium is toxic and readily available to buy on the high street or online.

Laxmi Himatlall THAKKER · Prevention of Future Deaths report View report

28 Apr 2016 Inner West London F. Wilcox

Laxmi Himatlall Thakker fell at home and was admitted to Croydon University Hospital, where her deterioration after surgery was not recognised promptly. She collapsed and was not diagnosed or treated for bleeding and vascular injury until several hours later, was transferred to St George’s Hospital in critical condition, and died in intensive care on 29 September 2014. The principal concerns included the lack of bedside observation charts, failures to escalate concerns, communication and training problems, delays in administering blood, and inadequate escalation to senior staff.

Ernest Higgs · Prevention of Future Deaths report View report

27 Apr 2016 Surrey C. Topping

Ernest Higgs, a resident of a nursing home, was admitted to hospital after his health deteriorated and died there on 20 January 2015 from aspiration pneumonia. Concerns included unclear and poorly recorded telephone advice from a GP, uncertainty over responsibility for recording clinical advice, and conflicting information about out-of-hours pathology services that contributed to a delay in blood testing.

Michael Holyoake · Prevention of Future Deaths report View report

27 Apr 2016 Leicester City and South Leicestershire C. Swann

Michael Holyoake, who was bed bound with a terminal and inoperable brain tumour, died after a fire at his home while he was being cared for there. The fire was thought most likely to have involved his lighter and E45 emollient residue on his bedding and clothing, which acted as an accelerant. The principal concerns were a lack of awareness of E45’s flammability and the absence of fire hazard warnings on its prescription or packaging.

Steven Robert MURPHY · Prevention of Future Deaths report View report

27 Apr 2016 Portsmouth and South East Hampshire D. Horsley

On 6 June 2015, Steven Robert Murphy jumped from a footbridge at Liss railway station into the path of an oncoming train and died instantaneously. The principal concern was that South West Trains had not positively responded to a British Transport Police report recommending measures to reduce the risk of people climbing over the footbridge parapet.

Caragh Melling · Prevention of Future Deaths report View report

27 Apr 2016 Inner North London R. Brittain

Caragh Melling collapsed at home after an episode of dizziness and died shortly after arriving at hospital following unsuccessful resuscitation attempts. The ambulance call triage failed to recognise her agonal breathing, and the report raised concerns that the NHS Pathways system lacked a tool to identify inadequate breathing and that it was unclear whether action was being taken to address this.

KATHRYN BULL · Prevention of Future Deaths report View report

27 Apr 2016 London Greater Inner South H. Hill

Kathryn Bull underwent gastric bypass surgery in January 2014 and subsequently experienced difficulty tolerating food, dizziness, lethargy, vomiting and blackouts. She was admitted to hospital after a fall, deteriorated with hyperammonaemia syndrome and multi-organ failure, and died following a cardiac arrest on 4 December 2014. The principal concern was that hyperammonaemia syndrome is an extremely rare adverse consequence of gastric bypass surgery, with symptoms that were not well understood and did not initially trigger concerns during follow-up.

Norma Edwina Holden · Prevention of Future Deaths report View report

25 Apr 2016 Manchester City J. Harkin

Norma Edwina Holden presented to the Accident and Emergency Department with abdominal pain, facial and mouth swelling, a swollen tongue and muffled speech, and was later found to have died from septic shock. Concerns included incomplete history-taking and communication to treating doctors, failure to recognise and act on apparent symptoms such as possible anaphylactic shock, lack of appropriate tests, and failure to obtain basic blood tests for infection or sepsis.

Marjorie Wood · Prevention of Future Deaths report View report

25 Apr 2016 Manchester South J. Kearsley

Marjorie Wood, who had dementia and was residing at Timperley Care Home, was found deceased there on 2 December 2015. The principal concern was that the care home did not know whether she was subject to a Deprivation of Liberty Safeguarding application or whether this affected her care and treatment, although no evidence showed that this lack of clarity affected her in this case.

Marina Fagan · Prevention of Future Deaths report View report

22 Apr 2016 Inner North London R. Brittain

Marina Fagan was admitted to hospital with headaches, later developed confusion, visual loss and eye movement palsy, and was diagnosed with PRES before dying on 6 October 2015. The report raised concerns about the availability of specialist neurological care, including delays in neurology input and limited out-of-hours neurologist provision, and noted that future deaths could occur in similar circumstances.

Margaret Rogerson · Prevention of Future Deaths report View report

21 Apr 2016 Manchester West M. Leeming

Margaret Rogerson, known as Peggy, died at Victoria House, Mill View Care Home, Bolton, from asphyxia due to aspiration of pureed food while being fed. The report raised concerns about a care assistant’s inability to recall training on feeding techniques and risks, the absence of refresher training, and the lack of training available to family members and others close to patients.