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George Nigel Palmer · Prevention of Future Deaths report View report

15 Sep 2015 Surrey M. Fleming

George Nigel Palmer was found dead at his home on 7 April 2014, suspended from a belt attached to his bedroom door. He had a history of depression and anxiety and had received inpatient and community mental health support before being discharged after his perceived improvement and move to Durham. Concerns were raised about discharge follow-up mechanisms for patients moving to a different area and the appropriateness of follow-up letters when contact cannot be made.

Stephen Owen O’MALLEY · Prevention of Future Deaths report View report

14 Sep 2015 Liverpool and the Wirral A. Rebello

Stephen Owen O’MALLEY, a contracted commercial diver, died after experiencing breathing difficulties while working underwater at an offshore wind farm in the North Sea. The report states that he suffered a cardiac arrest following hypoxia caused by impaired breathing associated with compression from his neck dam ring. A substantive concern was that his rescue was delayed because the standby diver could not locate the harness C-clip, and whether checking that the C-clip was free and accessible should form part of pre-dive checks.

ANTHONY STEPHEN CLEVELAND · Prevention of Future Deaths report View report

14 Sep 2015 Suffolk P. Dean

Anthony Stephen Cleveland collapsed after exercising unsupervised at a gym on 11 June 2013 and died some days later in intensive care following a cardiac arrest and hypoxic injury associated with severe coronary artery stenosis. Concerns included inadequate supervision and resuscitation, inadequate risk assessment, a lack of qualified first aiders, and the absence of formalised national guidance for risk assessment in fitness centres and gyms.

Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report View report

14 Sep 2015 Stoke-on-Trent and North Staffordshire M. Jones

Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing care.

Mr Ronald Francis Bonfield · Prevention of Future Deaths report View report

11 Sep 2015 Powys, Bridgend and Glamorgan Valleys G. Hughes

Mr Ronald Francis Bonfield sustained a head injury at home on 29 September 2014, was admitted to Prince Charles Hospital on 1 October, and died there on 2 October 2014. The inquest recorded that he was taking Warfarin, was over-anticoagulated, and that his INR levels were not being monitored as required. The substantive concerns related to inconsistent procedures for monitoring delegated INR testing and the risk of unmonitored over-anticoagulation.

Thomas Nicholls · Prevention of Future Deaths report View report

11 Sep 2015 Manchester West A. Walsh

Thomas Nicholls died in hospital on 14 April 2015 after recurrent vomiting, aspiration pneumonia and deterioration following PEG feeding, in the context of prior strokes and other illness. The substantive concerns included inadequate staff training in the mobility, handling and care of residents receiving PEG feeds, an unreported vomiting incident, inadequate recording of incidents, and malfunctioning bed equipment.

George James Ainsworth · Prevention of Future Deaths report View report

11 Sep 2015 Manchester West A. Walsh

George James Ainsworth died at Salford Royal Hospital after being struck by a bus in Bolton and suffering multiple injuries. Concerns related to the junction’s 90-degree bend, restricted bus-driver visibility, the absence of guard rails limiting pedestrians to the crossing, and potentially insufficient time for pedestrians to cross.

CRAIG CHAPPELL · Prevention of Future Deaths report View report

8 Sep 2015 East Riding and Kingston Upon-Hull R. Baxter

Craig Chappell was found hanging in his cell at HMP Humber Everthorpe Site on 8 August 2014 after experiencing depression, bereavement, pain, alcohol use and prescription drug use. The principal concerns were inadequate communication of family concerns, insufficient guidance for supporting potential abuse victims, and inappropriate reliance by non-healthcare staff on his presentation and views without further investigation.

Andrew Douglas Frere · Prevention of Future Deaths report View report

8 Sep 2015 South Yorkshire (Eastern) N. Cameron

Andrew Frere self-harmed while imprisoned at HMP Moorland and was managed under the ACCT procedure. He died on 10 February 2014 after suspending himself by a ligature formed from a bedsheet in his cell. Concerns were raised about failure to follow, or closely approximate, the requirement for regular medical review during continuous observation, and about ACCT reviewers not being specifically instructed to read recent ongoing observations.

David Efemena · Prevention of Future Deaths report View report

8 Sep 2015 London (East) N. Persaud

David Efemena became unresponsive while sleeping outdoors during an Air Training Corps fieldcraft exercise on 23 March 2014 and was pronounced deceased in hospital at 09:09 after resuscitation attempts. The report raised concerns about the absence of an AED and AED-trained first aider, inadequate communication checks, the distance between cadets and adult staff, lack of overnight supervision, and insufficient staffing.

Ian Paul Emsley · Prevention of Future Deaths report View report

8 Sep 2015 Exeter and Greater Devon E. Earland

Ian Paul Emsley, who had terminal metastatic renal cancer, died on 1 February 2015 in the palliative care wing at HMP Exeter after becoming unconscious and stopping breathing. The report identified that care at HMP YOI Portland was subject to resource constraints, meaning transfer to HMP Exeter could have occurred sooner, and found a potential for delays in transfer or compassionate release because of a lack of formal guidance or training on restraints and risk assessment.

Warren Martin Sampson · Prevention of Future Deaths report View report

6 Sep 2015 Essex C. Beasley-Murray

Warren Martin Sampson had been remanded to HM Prison Chelmsford and was subject to an ACCT when he was found hanging in his cell. Concerns included inconsistent attendance and recording at ACCT reviews, no process for following up non-attendance at first-night healthcare screening, and no system ensuring officers were familiar with local directives and instructions.

Mrs. Mary Patricia James · Prevention of Future Deaths report View report

4 Sep 2015 Powys, Bridgend and Glamorgan Valleys S. Richards

Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.

Ms. Kala Michelle Skinner · Prevention of Future Deaths report View report

3 Sep 2015 Avon P. Harrowing

On 17 December 2014, Ms. Kala Michelle Skinner experienced breathing difficulties and, after delays and two ambulance dispatches being recalled, was found in cardiac arrest and died at the scene. The report identified missed clinical red flags, inappropriate advice, insufficient and untimely welfare calls, and concerns about training, mentoring, auditing, and resources for Clinical Advisors.

May Hall · Prevention of Future Deaths report View report

3 Sep 2015 Manchester South J. Pollard

May Hall fell twice during the night of 11/12 April 2015, banging her head on both occasions, and later died from a subdural haematoma. Staff at Bourne House indicated that they were not aware of a policy for reporting falls or calling an ambulance or emergency doctor, and the report identified a need for clear, regularly reviewed staff training on responding to falls.

Rosalind Jane Anne Bernadette Baird · Prevention of Future Deaths report View report

2 Sep 2015 Portsmouth and South East Hampshire D. Horsley

Rosalind Baird underwent a left nephrectomy during which a blood vessel supplying her bowel was cut. Her condition deteriorated, and she died in hospital on 5 November 2014; the principal concern was the lack of a formal scheme to monitor inexperienced surgeons carrying out surgical procedures.

John Henry Robinson · Prevention of Future Deaths report View report

1 Sep 2015 South Yorkshire (Western) D. Urpeth

John Henry Robinson entered a nursing home for respite care, was subsequently recognised as requiring a psychiatric bed, and no suitable bed was available. His condition deteriorated after admission to hospital, where he died; the substantive concern was whether sufficient psychiatric resources were available in the area.

ISABEL ANN RICHARDSON · Prevention of Future Deaths report View report

28 Aug 2015 Norfolk J. Lake

Isabel Richardson, aged 12, took her own life by hanging after a period of self-harm and indications on social media that she might kill herself. Concerns were raised about the purpose, operation and training of the school’s Pastoral Team and whether its pastoral system was sufficiently robust and structured to address Isabel’s difficulties.

Frederick Sutton · Prevention of Future Deaths report View report

27 Aug 2015 Manchester South J. Pollard

Frederick Sutton fell and broke his hip at home on 3 February 2015, may have suffered a myocardial infarction, and died approximately 12 hours after admission to hospital. The concerns included hospital staffing levels, escalation procedures, failures to read nursing notes, incompatible computerised record systems, inadequate staff training, response to cardiac arrest, medication administration, and inaccurate next-of-kin information.

Eliza Simpson · Prevention of Future Deaths report View report

27 Aug 2015 Birmingham and Solihull E. Brown

Eliza Simpson left Roseneath Care Home unobserved on 2 April 2015 and was found recently deceased at a local allotment on 6 April 2015. The inquest recorded the medical cause of death as ischaemic heart disease due to coronary artery disease and concluded that the death was accidental. Concerns included the lack of a system to reassess and renew expired deprivation of liberty safeguarding orders and the absence of CCTV, which hampered the police investigation.