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Kevin John Gilbert · Prevention of Future Deaths report View report

14 Dec 2015 Central and South East Kent R. Redman

Kevin John Gilbert suffered an aortic root dissection on 29 January 2015 and died after cardiac arrest during transfer from William Harvey Hospital to St Thomas’ Hospital. The concerns included confusion about transfer protocols, delay in accepting him for transfer, and refusal to escalate the decision to a consultant; the report stated that his chances of survival would have been greater had the delay been avoided.

Alan Walker · Prevention of Future Deaths report View report

14 Dec 2015 North Wales (East and Central) J. Gittins

Alan Walker died after a nasogastric feeding set was connected to an intravenous line, resulting in the infusion of liquid feed. The report raised concern that equipment connectivity issues were not recorded in nursing notes and might not be relayed during staff handovers.

Paul David Whitehead · Prevention of Future Deaths report View report

14 Dec 2015 West Yorkshire Eastern K. McLoughlin

Paul David Whitehead sustained severe crush injuries after becoming trapped between the moving conveyors of a packing machine at work and subsequently died in hospital. Concerns were raised that the workplace emergency response, including first aid provision and contacting and directing emergency services, was not sufficiently efficient or effective.

William Jeffrey MASKELL · Prevention of Future Deaths report View report

14 Dec 2015 Exeter and Greater Devon E. Earland

William Jeffrey MASKELL, who had Bipolar Disorder, was found collapsed in his university room after ingesting a fatal quantity of Venlafaxine and Lamotrigine. He was taken to hospital but was declared deceased. Concerns included the lack of a clear protocol for involving relevant agencies and the Police, delays in attending and forcing entry, and a risk of future deaths from untimely intervention.

Margaret O’Brien · Prevention of Future Deaths report View report

11 Dec 2015 West London C. Inyama

Margaret O’Brien was discovered unresponsive in her bed at the care home where she resided, after showing signs of a cold the previous evening. The substantive concern was an absence of specific, prescribed staff training on carrying out and recording observations of residents.

Elsie Marjorie Brown · Prevention of Future Deaths report View report

10 Dec 2015 Nottinghamshire S. Haskey

Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

Ololade Olaobaju · Prevention of Future Deaths report View report

10 Dec 2015 London Inner (South) P. Barlow

Ololade Olaobaju was treated for progressive respiratory failure following community-acquired pneumonia and was transferred to intensive care for mechanical ventilation. After unsuccessful attempts at intubation, needle cricothyroidotomy and “Quicktrack”, she suffered a cardiac arrest during an attempted surgical tracheostomy and could not be resuscitated. The report identified a concern that existing guidance did not cover the preferred front-of-neck access when anaesthetists and ENT surgeons were both present, particularly in a rapidly deteriorating “Can’t Intubate Can’t Oxygenate” situation.

Jake Robinson · Prevention of Future Deaths report View report

9 Dec 2015 Manchester South J. Kearsley

Jake Robinson died at home on 23 August 2015 after taking his own life; the recorded cause of death was hanging and illicit drug use. Concerns included failures to share information about prescribing diazepam, the failure to identify this issue in the review of his death, fragmented substance-misuse services, and the unexplained rearrangement of a Community Mental Health Team appointment shortly before his death.

Madhumita Mandal · Prevention of Future Deaths report View report

8 Dec 2015 South London S. Lynch

Madhumita Mandal became unwell and attended Croydon University Hospital on 7 September 2013, where the inquest recorded multiple organ failure due to sepsis associated with a ruptured endometriotic ovarian cyst. The principal concerns were delays in assessment and treatment, including initial streaming by a receptionist without medical training, and failures in clinical supervision. The report also raised concerns about differing assessment based on whether patients arrived by ambulance.

Ben Clive HISCOX · Prevention of Future Deaths report View report

8 Dec 2015 Avon T. Moore

Ben Clive HISCOX lost his footing while running close to the touchline during play and came into contact with the clubhouse. The report raised concerns that the distance between the touchline and clubhouse was less than Football Association guidelines and that no action appeared to have been taken by the referee on the day.

Codrut IEDERAN · Prevention of Future Deaths report View report

3 Dec 2015 Inner North London M. Hassell

Codrut Iederan died after pushing an unstable wall at a construction site, which collapsed on him. The report raised concerns that the site’s first aider was absent, the remaining workers were not first-aid trained, and some workers did not know how to summon an ambulance.

Laura Beth Newlands · Prevention of Future Deaths report View report

2 Dec 2015 North Wales (East and Central) J. Gittins

Laura Beth Newlands was known to Denbighshire Social Services because of concerns about self-harm related to difficult home circumstances. After her case was closed, a delay in arranging a professionals’ meeting meant that further support was not provided before she took her own life by overdose four days before the scheduled meeting. The report identified concerns about incomplete safety-plan input, delays in responding to risk, and the decision to close and not reopen the case.

Bryan Arnold CATANACH · Prevention of Future Deaths report View report

1 Dec 2015 Worcestershire A. Cox

Bryan Arnold Catanach sustained a fractured odontoid peg and cervical injury after a fall, and died in hospital on 8 February 2015 after his condition deteriorated. The report identified concerns about communication and delays in transfer and senior review, inpatient falls prevention, and the availability and use of appropriate traction equipment.

Ricky Craig HUDSON · Prevention of Future Deaths report View report

1 Dec 2015 Birmingham and Solihull E. Brown

Ricky Craig HUDSON died at Queen Elizabeth Hospital Birmingham on 13 August 2015 from injuries sustained when he fell from a quad bike on 11 August 2015. The principal concerns were that quad bike riders are not required to wear crash helmets on public roads and that no additional driving qualifications are required to drive a quad bike.

Barbara Rawlinson · Prevention of Future Deaths report View report

1 Dec 2015 Inner North London R. Brittain

Barbara Rawlinson was diagnosed with uterine sarcoma after a hysterectomy undertaken following investigation of post-menopausal bleeding, and later died from complications after further treatment. The principal concern was that no CT scan was performed before hysterectomy, with reliance on ultrasonography potentially allowing uterine sarcoma to be missed.

Stephen Martin ADAMS · Prevention of Future Deaths report View report

30 Nov 2015 Worcestershire G. Williams

Stephen Martin ADAMS was being cared for by the Home Treatment Team of Worcestershire Health and Care NHS Trust when he died by suicide by hanging at his home. The inquest identified that the suicide-risk assessment section of a Mental Health Liaison Team risk assessment document had not been completed, and that risk assessment was instead inferred from the worker’s actions.

Thelma Doris Clarkson · Prevention of Future Deaths report View report

27 Nov 2015 Portsmouth and South East Hampshire D. Horsley

Thelma Doris Clarkson fell at home on 10 February 2015, sustained head injuries, and died in hospital the following day after her condition deteriorated and an inoperable head injury was identified. The concern was that the NICE Head Injury Pathway did not treat Clopidogrel use as a trigger for a CT scan in the same way as Warfarin, despite the risk of increased bleeding from head trauma.

Darren Jones · Prevention of Future Deaths report View report

27 Nov 2015 Nottinghamshire H. Connor

Darren Jones had chronic kidney disease and a renal transplant, and later died from massive left-sided pleural and mediastinal haemorrhage associated with thoracic aortic perforation and invasive aspergillosis. The report raised concerns about protocols for seeking renal advice for transplant patients and the availability of immunosuppressant medication at short notice.

Robert Alan Mansfield · Prevention of Future Deaths report View report

26 Nov 2015 Carmarthenshire and Pembrokeshire J. Layton

Robert Alan Mansfield entered the Millpond while celebrating his 18th birthday, and his body was subsequently recovered after emergency services were unable to locate him. The report raised concerns about three deaths at the location within months, including the safety of the Millpond, fencing, lighting, warning notices and flotation equipment.

Dean Ronald Edmund BOLAND · Prevention of Future Deaths report View report

25 Nov 2015 Birmingham and Solihull L. Hunt

Dean Ronald Edmund Boland was found unresponsive in his cell at HMP Birmingham on 17 April 2015 and was pronounced dead shortly afterwards. Post-mortem examination confirmed multiple drugs in his system, and the inquest concluded that he died from mixed drug toxicity. The principal concerns included inadequate awareness, communication, monitoring, searching and security measures relating to drug use within the prison.