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Andrew Selwyn Roberts · Prevention of Future Deaths report View report

20 Aug 2015 North Wales (East and Central) J. Gittins

Andrew Selwyn Roberts was arrested on 24 December 2011, after being tasered and having taken an overdose, and was taken to hospital before being assessed as fit to return to custody. The transfer of care form inaccurately stated that he had been assessed by psychiatric liaison, although he had not been seen by that team. The substantive concerns were that the form was completed by a nurse rather than the examining doctor, contained inaccurate information, and was not completed and provided to police at the time of examination.

Sharon Louise Henshall · Prevention of Future Deaths report View report

20 Aug 2015 Preston and West Lancashire C. Hammond

Sharon Louise Henshall sustained a fractured ankle while skiing in Italy and died in the early hours of 18 February 2015 after collapsing from a pulmonary embolus. The report raised concerns that there was no venous thromboembolism risk-assessment tool or interim process for patients discharged with lower-limb immobilisation, and that access to prophylaxis varied between hospitals.

Elsie Clarke · Prevention of Future Deaths report View report

20 Aug 2015 Manchester South J. Pollard

Elsie Clarke was a resident at Hurst Hall care centre and developed significant pneumonia on 10 February 2015, dying later that day. The report identified concerns about missed opportunities to summon medical help, inadequate staff training and observations, failures in record-keeping and handover, and deficiencies in out-of-hours medical processes and death reporting.

Joyce Plested · Prevention of Future Deaths report View report

20 Aug 2015 Manchester South J. Pollard

Joyce Plested was riding her mobility scooter near a Sainsbury store when she was struck by a car while crossing Curzon Road, sustaining an injury that later led to her death. The report raised concerns about the crossing’s position near a busy mini roundabout and suggested that moving it and protecting the footpath with barriers would create a safer environment.

Stephen Richardson · Prevention of Future Deaths report View report

19 Aug 2015 Stoke-on-Trent and North Staffordshire I. Smith

Stephen Richardson, who had Down syndrome and lived in a care home, suffered a fractured pelvis after an unrecognised injury and later developed a chest infection before dying in hospital on 16 January 2015. Concerns were raised about hospital nursing care, including the provision of solid food and inappropriate drinking equipment despite recorded instructions, which might have caused aspiration.

David Anthony SWEENEY · Prevention of Future Deaths report View report

19 Aug 2015 Inner North London M. Hassell

David Anthony Sweeney was found unconscious and vomiting after a public call to the London Ambulance Service on 18 April 2015. The call was incorrectly categorised, an ambulance arrived 1 hour 40 minutes later, and Mr Sweeney suffered a cardiac arrest shortly before its arrival; he died a week later from hypoxic brain injury and acute alcohol toxicity. The principal concern was that the call did not receive red prioritisation and that a recurring theme might be emerging in the handling of calls about unconscious patients.

Barry Gordon Pike · Prevention of Future Deaths report View report

19 Aug 2015 Plymouth, Torbay and South Devon A. Cox

Barry Gordon Pike, aged 57, attended Derriford Hospital with chest pain and was discharged after being assessed as suffering from reflux; blood results showing a raised Troponin level had apparently not been reviewed. He died suddenly 10 days later. The report identifies concerns about care and service delivery, including the Emergency Department algorithm for acute coronary syndrome and continuing lack of clarity that could lead to confusion and mismanagement.

Ian David Morley · Prevention of Future Deaths report View report

17 Aug 2015 West London C. Inyama

Ian David Morley, a wheelchair-bound resident in supported accommodation with multiple sclerosis, died after being found alight in his wheelchair, apparently after a cigarette fell onto a towel covering the seat. Concerns included the absence of a fresh risk assessment after his condition deteriorated and inadequate fire risk management at Greenrod Place.

Eileen SMITH · Prevention of Future Deaths report View report

12 Aug 2015 Hertfordshire E. Thomas

The report concerns Eileen SMITH. The supplied text contains no details about the circumstances of death or substantive concerns.

Dean Christian JOSEPH · Prevention of Future Deaths report View report

12 Aug 2015 Inner North London M. Hassell

Dean Christian JOSEPH broke into his former girlfriend’s home, took her hostage with a knife and remained in the property during an approximately one-and-a-half-hour siege. He was shot by a firearms officer when he moved the knife to the hostage’s throat. Concerns included differing understandings of whether armed containment was overt or covert, the lack of guidance from a trained hostage negotiator for the first officer on scene, possible gaps in guidance about TASER effective range, and shortcomings in post-incident police procedures.

Thelma Patricia JONES · Prevention of Future Deaths report View report

12 Aug 2015 Brighton and Hove V. Hamilton-Deeley

Thelma Patricia JONES was admitted to the Acute Medical Unit from 16 to 23 February 2015, became acutely unwell, and was moved to intensive therapy after being intubated on the unit. The concerns were limited evidence of coordinated care planning and incomplete National Early Warning System scoring after her acute deterioration and a medical emergency team call on 23 February 2015.

John Hills · Prevention of Future Deaths report View report

11 Aug 2015 West Sussex C. Wilkinson

John Hills, a resident of a nursing home, suffered fatal burns after his clothing and blankets caught fire while he was smoking in the conservatory. The report raised concerns about the failure to ensure he was wearing his fire-retardant apron and about insufficient awareness, communication and prevention of the fire risks associated with paraffin-based emollient creams such as Cetraben, particularly in community care settings.

Julia Ann Clarke Hayward · Prevention of Future Deaths report View report

11 Aug 2015 Surrey S. Wickens

Julia Ann Clarke Hayward died on 23 May 2014 after intentionally placing herself in the path of an oncoming train while suffering from mental illness. The inquest identified concern that care plans agreed when discharging mental health patients into the care of family members were not documented or provided to those family members, leading to uncertainty about their obligations.

LORRAINE JOYCE BIRD · Prevention of Future Deaths report View report

10 Aug 2015 Bedfordshire and Luton T. Osborne

Lorraine Joyce Bird fractured her ankle after a fall and later attended a plaster room with numbness in her foot. The report identifies concerns that a developing deep vein thrombosis was not recognised or medically reviewed, that there was no adequate assessment protocol, and that she had not received low molecular weight heparin. The inquest concluded that this resulted in a lost opportunity for further treatment and that she died on 13 September 2014.

Gordon Eric Atkinson · Prevention of Future Deaths report View report

7 Aug 2015 Plymouth, Torbay and South Devon I. Arrow

Gordon Eric Atkinson lived alone in a poor-condition caravan and had numerous falls, including an unwitnessed fall that caused burns. He was later admitted to a care home, nursing home and hospital, where he died on 6 February 2015. The concerns included unsuitable accommodation, self-neglect, and an inappropriate care package.

George Boulton · Prevention of Future Deaths report View report

7 Aug 2015 Leicester City and South Leicestershire L. Brown

George Boulton developed an intracerebral bleed at home on 12 February 2015 and died on 14 February 2015 at Leicester Royal Infirmary. The report identified delays in arranging emergency transfer and failures to communicate or recognise the need to withhold dalteparin, which materially contributed to the continuing bleed.

James Reuben Maxwell Adams · Prevention of Future Deaths report View report

7 Aug 2015 Cornwall E. Carlyon

James Adams was found dead at home on 10 August 2012 with a plastic bag and helium cylinders, and suicide notes were found nearby. He had persistent depressive disorder, alcohol dependency and a mixed type personality disorder, and was being treated by mental health services. Concerns included the police response to a welfare concern, information sharing, shortages of acute psychiatric beds, and inadequate staffing at designated mental health places of safety.

Ronald Arthur Laidlar · Prevention of Future Deaths report View report

7 Aug 2015 Manchester South J. Pollard

Ronald Arthur Laidlar was discovered deceased in the driveway of his house, naked from the waist down and with a considerable amount of blood around his head. The report raised concerns about missing personal property, inadequate searches and scene investigation, failure to test blood evidence or take fingerprints, and insufficient consideration of possible third-party involvement.

Kathleen Ludmila Neville · Prevention of Future Deaths report View report

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

Kathleen Ludmila Neville was admitted to hospital after an accidental fall that fractured her femur and later died following complications after surgery and a prolonged hospital stay. Her regular thyroid medication was omitted for five weeks because it was not recorded on the drug chart and the hospital lacked a Medication Reconciliation Policy; this contributed to lassitude and confusion but not to her death. The principal concern was that the absence of such a policy could allow medication errors to persist and potentially contribute to future deaths, particularly with medicines whose omission could be fatal.

THOMAS THEO CHARLES THURLING · Prevention of Future Deaths report View report

6 Aug 2015 Norfolk J. Lake

Thomas Theo Charles Thurling, who had increasing depression, anxiety and suicidal ideation, was found dead at home on 28 October 2014 after he did not respond to visits. The inquest concluded that he took his own life, with medical cause of death recorded as asphyxiation. Concerns included medication changes not being adequately monitored, a prolonged absence of his Care Co-ordinator without alternative cover or review, and staff shortages.