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Susan Beverley George · Prevention of Future Deaths report View report

29 Feb 2016 Manchester (North) L. Hashmi

Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.

Antony Edmund Briggs · Prevention of Future Deaths report View report

28 Feb 2016 Manchester South J. Pollard

Antony Edmund Briggs developed a very aggressive bladder tumour, with delays in treatment; the inquest recorded natural causes and a medical cause involving pulmonary embolism, deep venous thrombosis, immobility and pelvic obstruction due to bladder carcinoma, with ischaemic heart disease. Concerns included differences between the Buxton and Stepping Hill information systems, failure of information to be acted on, and the infiltrating adenocarcinoma not being identified as soon as it could have been.

Jakovas Fofonovas · Prevention of Future Deaths report View report

26 Feb 2016 Inner South London A. Harris

Jakovas Fofonovas died on 23 May 2015 after accessing the railway and being struck by a train near Abbey Wood railway station. Concerns were raised that unsafe bridge features enabled access to the railway and that recommendations to improve safety and restrict public access had not been implemented by the inquest.

Mr Richard Parkes · Prevention of Future Deaths report View report

26 Feb 2016 Black Country Z. Siddique

Mr Richard Parkes collapsed and died on 28 December 2015 after developing deep vein thrombosis with associated pulmonary thromboembolism. Concerns included poor record keeping, unavailable records from an August appointment, and the practice policy of not seeing patients more than ten minutes late, including on an occasion when Mr Parkes was not seen because he was late.

Mr Devindar Lal Seth · Prevention of Future Deaths report View report

26 Feb 2016 East London N. Persaud

Mr Devindar Lal Seth, aged 94, suffered a fall, fractured his hip and underwent surgery before developing opiate toxicity after postoperative pain treatment. The opiate toxicity was not identified by ward staff until family members raised concerns, and there was also a delay in ventilation after he suffered aspiration. The report identified a lack of clear guidance for ward staff about the risks and side effects of opiate medication in older orthopaedic patients.

Betty Addison · Prevention of Future Deaths report View report

25 Feb 2016 Manchester West R. Griffin

Betty Addison fell while walking for a bus, sustained a fracture to her right femur, underwent surgery, and later died after collapsing at a care home on 2 December 2015. She was given five additional Dalteparin injections beyond those prescribed, raising concerns about the control and monitoring of medication administration at Alexandra Court Care Home, although the report states that the additional medication was not causative or contributory to her death.

Amy Rose COOPER · Prevention of Future Deaths report View report

25 Feb 2016 Liverpool and the Wirral A. Rebello

Amy was born at 40 weeks’ gestation by caesarean section on 8 July 2015 and required immediate resuscitation before being confirmed dead later that evening. Intrauterine growth restriction was not evident to the community midwives or hospital maternity unit until post-mortem investigations; the report also raised concerns about incompatible record-keeping systems and the sharing of maternity information between services.

David Palmer · Prevention of Future Deaths report View report

25 Feb 2016 South Lincolnshire M. Spittal

David Palmer, aged 59, died from a massive head injury caused by an unlicensed shotgun. The report notes that unlicensed firearms are generally not stored securely and may be available for impulsive use, and states that three of four firearm deaths investigated involved unlicensed weapons.

Wilfrid Pearson · Prevention of Future Deaths report View report

24 Feb 2016 Manchester South J. Pollard

Wilfrid Pearson was admitted to Tameside Hospital on 22 April 2015 with epilepsy, developed status epilepticus, and died at a local hospice about a month later. Concerns included possible failures in updating and communicating the status epilepticus protocol, unclear and incomplete records, inadequate escalation of care, staffing pressures, and the legal basis for detaining him after he left the ward.

Mrs Marie Rollason · Prevention of Future Deaths report View report

24 Feb 2016 Black Country Z. Siddique

Mrs Marie Rollason sustained a head injury in a fall and was discharged after a CT scan showed no fractures or haemorrhages. She subsequently experienced repeated loss of consciousness and was discharged again after an ECG abnormality was recorded as “okay”. The report identifies concerns that this was a missed opportunity for further observation and basic medical care; she later collapsed and died, with the inquest recording pulmonary embolism as the cause of death, contributed to by neglect.

Edith Kirkham · Prevention of Future Deaths report View report

23 Feb 2016 Manchester South J. Pollard

Edith Kirkham fell at home on 13 August 2015, broke her hip, underwent surgery and was later moved to intermediate care, where she was not mobilised despite medical advice; she died some days later in North Manchester General Hospital. Concerns included unclear management arrangements, inadequate staffing and handover, failures to read or understand clinical instructions, lack of physiotherapy, and missing records relating to her stay.

Freda Weston · Prevention of Future Deaths report View report

23 Feb 2016 Manchester South J. Pollard

Freda Weston was treated for septic arthritis in a replacement knee and died in hospital on 29 April 2015. The report states that Septrin led to disseminated intravascular coagulation and identifies concerns including delays in antibiotics, insufficient time to assess whether the new drug suited her, inadequate staffing, and failures in communication and escalation procedures.

Lisa Margaret DAY · Prevention of Future Deaths report View report

23 Feb 2016 Inner North London M. Hassell

Lisa Margaret Day died from cardiac arrhythmia from hyperkalemia, associated with diabetic ketoacidosis and poorly controlled type I diabetes. An ambulance arrived approximately four and a half hours after first being called, and concerns were raised that the 111 service did not discuss alternative transport with the friend who made the call or explain the grave consequences of vomiting illness in a person with diabetes.

Clifford Irwin Crofts · Prevention of Future Deaths report View report

22 Feb 2016 Surrey C. Topping

Clifford Irwin Crofts, who had Parkinson’s disease and aspiration difficulties, was admitted to hospital and underwent insertion of a radiologically inserted gastrostomy tube on 19 September 2014. He experienced acute pain after feeding began, but there were delays in escalating his care, obtaining a CT scan and carrying out surgery; he subsequently developed respiratory difficulties and died on 10 October 2014. The substantive concerns included failure to follow the RIG care plan, difficulties escalating care, delays in obtaining urgent CT imaging, and weekend staffing levels.

Patricia Mary Medland · Prevention of Future Deaths report View report

22 Feb 2016 Exeter and Greater Devon L. Brown

Patricia Mary Medland died from exposure to heat and fire smoke after starting a fire using petrol as an accelerant; there was no evidence of third-party involvement. She was suffering from severe mental illness, and a concern was that her daughter was identified in a care plan as a protective factor without being told about the care plan, diagnosis, or her role, potentially limiting her ability to recognise relapse.

Brenda Elizabeth MORRIS · Prevention of Future Deaths report View report

19 Feb 2016 Inner North London M. Hassell

Brenda Elizabeth Morris, aged 66, died by drowning herself in the bath at home after being admitted to Larch Lodge as an informal patient and granted weekend leave. Concerns included inadequate communication with her partner about the basis for leave, limited routine feedback from family after leave, confusion about authorisation of unplanned leave, and substandard nursing documentation affecting the recording of risk assessments.

Geoffrey John MOYSE · Prevention of Future Deaths report View report

19 Feb 2016 Brighton and Hove V. Hamilton-Deeley

Geoffrey John MOYSE’s death was the subject of an inquest that concluded with a finding of Medical Misadventure. The report raised concerns about an eight-month delay in referral, poor communication between providers, and failures to transfer investigation results into the NHS system, leaving him unwell, undiagnosed and untreated for too long.

Euphemia Lumsden Aldred · Prevention of Future Deaths report View report

18 Feb 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

Euphemia Aldred fell at home, sustained fractures to her left leg and ankle, and was treated in hospital with a plaster cast. After discharge, she was no longer prescribed low molecular weight heparin, developed a deep vein thrombosis and pulmonary embolism, and died; the report identified that the relevant Trust policy did not comply with NICE guidance on venous thrombo-embolism prevention.

Matthew Crowley · Prevention of Future Deaths report View report

17 Feb 2016 Mid Kent and Medway P. Harding

Matthew Crowley, aged 39, presented to Maidstone Hospital acutely unwell with sepsis and multiple organ failure, and died at Pembury Hospital at 06.47 on 10 June 2015 after transfer. The report identified concerns including delays in triage, senior medical review, treatment escalation, decision-making and transfer, as well as inadequate communication with the receiving ITU.

Vanessa Christine DADSWELL · Prevention of Future Deaths report View report

17 Feb 2016 Surrey S. Wickens

Vanessa Dadswell died from injuries after placing herself in the path of an oncoming train at Whitley Railway Station on 2 April 2015. She had been urgently referred to Mental Health Services by her GP, requesting that she be seen within 24 hours, but she was not seen before her death. The principal concern was the lack of an intermediate referral option between four hours and within five days, and the absence of contact within the requested 24-hour period.