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Louise Sharon Henry · Prevention of Future Deaths report View report

16 Oct 2015 Derby and Derbyshire S. Cartwright

Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.

Caroline Robey · Prevention of Future Deaths report View report

16 Oct 2015 Leicester City and South Leicestershire L. Brown

Caroline Robey was a fit 34-year-old working mother who became unwell and attended community healthcare providers on six occasions over five days. She was initially diagnosed with a viral infection and later diarrhoea and vomiting, before being admitted to hospital with suspected sepsis; despite treatment, she died the following day from Group A streptococcal infection and evolving sepsis. The principal concerns were the absence of sepsis screening by community healthcare providers, failure to adopt available sepsis toolkit resources, and inadequate consideration of her repeated attendances.

William Gordon Tolen · Prevention of Future Deaths report View report

15 Oct 2015 Manchester South J. Pollard

William Gordon Tolen was living at Shawe Lodge when he developed problems with his legs and left great toenail; a podiatrist removed the toenail, after which he developed cellulitis. The investigation concluded that the death was from natural causes, with septicaemia and cellulitis recorded as the medical cause of death. Concerns included inadequate record-keeping, delays in arranging podiatry care, insufficient staff training, and the inappropriate conditions in which the procedure was carried out.

Alan Tear · Prevention of Future Deaths report View report

14 Oct 2015 Leicester City and South Leicestershire L. Brown

Alan Tear was receiving palliative treatment for cholangiocarcinoma and died after a biliary drain insertion. He died from an intraperitoneal bleed caused by a misplaced drain and peritoneal perforation. Concerns included missed post-operative observations, failure to report a rising EWS to medical staff, and unclear communication between the interventional radiology and nursing teams.

Nathaniel Luke Phillips · Prevention of Future Deaths report View report

13 Oct 2015 Manchester South J. Kearsley

Nathaniel Luke Phillips died at Tameside General Hospital after an acute asthma attack; the inquest recorded hypoxic brain injury due to the attack. Concerns included the cost of regular asthma prescriptions, his apparent loss to adult asthma services, and delays in ambulance availability during his final emergency.

Catherine Mary Findlay · Prevention of Future Deaths report View report

13 Oct 2015 Manchester West S. Jones

Catherine Mary Findlay, aged 37, was found unresponsive and not breathing at her home on 24 May 2015 and was pronounced dead by paramedics. The post-mortem and inquest attributed her death to Methoxyphenidine (MXP) and cocaine toxicity. The report raised concerns that MXP was freely available online as a “research chemical” despite being misused and potentially life-threatening, and requested a review of its status and control.

Mrs Withers · Prevention of Future Deaths report View report

12 Oct 2015 Northamptonshire H. Shah

Mrs Withers, aged 77, suffered a fall at home causing a fracture, significant haemorrhage and cardiac arrest. She died after a 2 hour 50 minute delay before paramedics arrived. The concerns included procedures for obtaining and retaining medical history, calling back a lifeline or third party, staffing levels, and ambulance handover times at hospital.

Suzanne Samantha Greenwood · Prevention of Future Deaths report View report

9 Oct 2015 Manchester West A. Walsh

Suzanne Samantha Greenwood died at Haslam Park, Bolton, on 23 December 2014 after being found collapsed and unresponsive with a ligature around her neck; she had also taken Zopiclone and alcohol. The principal concerns were the absence of contact after she failed to attend appointments, her not being discharged or reported to her General Practitioner, and the lack of systems and timescales for managing missed appointments and notifying other healthcare professionals.

Patrick Joseph Carrick · Prevention of Future Deaths report View report

9 Oct 2015 Newcastle upon Tyne K. Dilks

Patrick Joseph Carrick underwent laparoscopic high anterior resection for colorectal cancer on 23 January 2012 and subsequently deteriorated, later dying from a rare but recognised complication of the surgery. Concerns included a significant unexplained departure from his management plan during rapid deterioration, failure to action blood analysis results, inadequate monitoring, delays in administering antibiotics, and inadequate completion of nursing and medical notes.

Maureen Chatterley · Prevention of Future Deaths report View report

8 Oct 2015 Manchester West A. Walsh

Maureen Chatterley died at Royal Bolton Hospital on 24 December 2014 after a fall causing a right hip fracture, subsequent dislocations and multiple surgical procedures. The report raised concerns that a possible excess dose of lorazepam was not investigated and that medication stock in patient drawers and ward cupboards was not recorded or controlled, although the Inquest accepted that any excess dose did not contribute to her death.

SOLOMON JAMES BEALEY · Prevention of Future Deaths report View report

8 Oct 2015 Norfolk J. Lake

Solomon James Bealey, aged 15, was found in his bedroom on 5 February 2015 with a bag over his head and a cord around his neck, having left a note to his family. Concerns included that no action or follow-up was taken after a nurse and doctor became aware of signs of stress and a previous suicide attempt, and that the doctor did not know letters sent to Solomon’s mother had been received.

Rebecca Emily JONES · Prevention of Future Deaths report View report

8 Oct 2015 Hertfordshire E. Thomas

The supplied report identifies Rebecca Emily JONES, but provides no information about the circumstances of her death or any substantive concerns.

Dilys Jenkins · Prevention of Future Deaths report View report

7 Oct 2015 Cardiff and the Vale of Glamorgan C. Woolley

Dilys Jenkins, who had undergone cardiac surgery and subsequently required a tracheostomy, died after the tracheostomy became dislodged, leading to respiratory and cardiac arrest. The Coroner was concerned that the tube’s length may have contributed to the dislodgement and that tracheostomy design and sizing had not kept pace with increasing population size.

Naiya Diarra · Prevention of Future Deaths report View report

7 Oct 2015 Inner North London R. Brittain

Naiya Diarra died aged 9 months on 25 June 2015 from dilated cardiomyopathy arising from severe Vitamin D deficiency. Vitamin supplementation was provided but was ultimately insufficient, and the significance of her sibling’s Vitamin D deficiency was not recognised, resulting in missed opportunities to address this. The report also raised concerns about relevant information being held in disparate record silos and not being accessible to clinicians, particularly the reviewing psychiatric team.

Edward Gascoigne · Prevention of Future Deaths report View report

7 Oct 2015 Inner North London R. Brittain

Edward Gascoigne, who had worsening confusion and low mood and a history of depressive episodes, was admitted to hospital but discharged without an inpatient psychiatric review. He was subsequently found deceased at an underground station after being hit by a train. The principal concern was that relevant information was held in disparate medical-record systems and was not available to the reviewing psychiatric team.

Geoffrey Parry · Prevention of Future Deaths report View report

7 Oct 2015 Cardiff and the Vale of Glamorgan A. Barkley

Geoffrey Parry underwent major surgery for aggressive bladder cancer on 1 May 2015, developed infection and pneumonia, and died on 29 June 2015. Concerns included an ECG result being unavailable to anaesthetists before surgery and an unlabelled intravenous noradrenaline line becoming disconnected in intensive care, causing a significant drop in blood pressure and the need for cardiopulmonary resuscitation.

Peter Scott · Prevention of Future Deaths report View report

5 Oct 2015 North Wales (East and Central) J. Gittins

Peter Scott, who had frontal lobe dementia and lived in a nursing home, died after choking on a latex glove; two further gloves were found in his stomach. The care home acknowledged that its systems did not document a process for escalating incidents or concerns to a multidisciplinary meeting to review risk assessments and care plans.

Rosina Drury · Prevention of Future Deaths report View report

2 Oct 2015 Inner South London A. Harris

Rosina Drury, who had several co-morbidities but was described as fit and independent, fell and fractured her hip before undergoing a right hemiarthroplasty. She died from a fat embolism associated with bone cement implantation, described as an unintended consequence of necessary medical treatment. The report raised concern that the absence of pre-operative orthogeriatric review could result in high-risk patients receiving cemented rather than uncemented hemiarthroplasty.

Charles Ernest Rayner · Prevention of Future Deaths report View report

1 Oct 2015 County Durham and Darlington C. Oliver

Charles Ernest Rayner died after his motorcycle collided with a vehicle and trailer turning right on the A66 near the Otter Trust turnoff on 6 April 2015. The concerns identified were that the westbound crossover had no slip road or deceleration lane, requiring vehicles turning right to slow to a virtual standstill in the outside lane, and that there was no signage prohibiting the right turn.

Kenneth (“Ken”) McCurdy and Mary (“Maida”) Brunton Cunningham McCurdy · Prevention of Future Deaths report View report

1 Oct 2015 County Durham and Darlington C. Oliver

Kenneth and Mary McCurdy died in a road traffic collision near the A66 on 1 April 2015 after their car crossed through a central reservation gap and collided with a westbound vehicle. The concerns identified were the absence of signage indicating that the gap was no entry for eastbound vehicles and the absence of signage prohibiting U-turns or right turns for eastbound vehicles.