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Dorothy McDermott · Prevention of Future Deaths report View report

10 Jul 2015 Manchester North S. Nelson

Dorothy McDermott, who was 80 and had been housebound for 2½ years, fell three times at home and was placed in emergency respite care. The care home provided residential but not nursing care, and staff were not trained to examine or care for pressure sores. An inquest concluded that opportunities to examine her sacrum were missed, and she died in hospital after developing a Grade 4 pressure sore and septicaemia.

Mr. Alun Walters · Prevention of Future Deaths report View report

9 Jul 2015 Powys, Bridgend and Glamorgan Valleys S. Jane-Richards

Mr. Alun Walters, who was prescribed Warfarin following receipt of a metallic heart valve, died after a gastro-intestinal haemorrhage in circumstances of suspected elevated Warfarin levels and failed INR monitoring. His prescriptions continued despite no INR tests after November 2013, and 51 prescriptions were provided without dosage assessment. Concerns included failures by the medical practice in monitoring, prescription systems and notifying the pharmacy that Warfarin had been withdrawn, while the pharmacy supplied Warfarin without a valid prescription.

Michael George · Prevention of Future Deaths report View report

9 Jul 2015 Inner South London A. Harris

Michael George died after developing a life-threatening hyperglycaemic condition while receiving long-term Olanzapine treatment. The report identified concerns about inadequate monitoring for diabetes, delays and insufficient urgency in transfer to A&E, incomplete referral information, and gaps in the subsequent oversight and care arrangements for the physical health of mental health inpatients.

Toni Piel · Prevention of Future Deaths report View report

9 Jul 2015 Manchester North M. Cox

Toni Piel suffered a head injury in a fall at home on 10 December 2014 and was treated at hospital before being discharged. He was found dead at home on 23 December 2014, with the inquest concluding that he died from a head injury caused by a fall, although it was not established whether this was linked to the earlier injury. Concerns included that his home circumstances and the absence of anyone able to observe him were apparently not considered at discharge, and that risk factors were not documented.

Meryl Parry · Prevention of Future Deaths report View report

8 Jul 2015 Cumbria R. Chapman

Meryl Parry, who had Alzheimer’s disease and tended to wander, was discharged from a residential home on 1 September 2014 after leaving it unobserved and was returned home. She was subsequently unlawfully killed by her husband; concerns included the absence of a system requiring residential homes to seek Social Services advice before discharge and risks to residents’ safety and welfare afterwards.

Amanda Jane Ellams · Prevention of Future Deaths report View report

8 Jul 2015 Manchester South J. Pollard

Amanda Jane Ellams died approximately four days after surgery to repair an incisional hernia in February 2015. The concerns included inadequate medical and nursing record-keeping, incomplete pre-operative medical information, discharge despite low oxygen saturations and inadequate oxygen monitoring, and three unanswered calls to the out-of-hours District Nursing telephone service during the night of her death.

Yvonne Davies and Andrew Francis Davies · Prevention of Future Deaths report View report

7 Jul 2015 Manchester South J. Pollard

Yvonne Davies was stabbed in the neck by her husband, Andrew Davies, who then hanged himself. The report raised concerns that an off-duty police officer entered and moved around the scene, potentially contaminating it, and was not removed by the first attending officers.

Michael Lee Thorley · Prevention of Future Deaths report View report

7 Jul 2015 Manchester South J. Pollard

Michael Lee Thorley was found at his home after a delay in gaining entry following an emergency ambulance call. The medical cause of death was combined opiate/opioid toxicity, and the pathologist said there was a chance his life might have been saved if naloxone had been administered immediately. The report raised concerns about the delay in entry, the absence of a clear policy for forced entry, shortcomings in searching and investigating the scene, and the failure of a Detective Inspector to attend.

John Paul Clarke · Prevention of Future Deaths report View report

6 Jul 2015 Inner West London K. McLoughlin

John Paul Clarke died on 5 March 2014 after his motorcycle contacted the raised kerb of a traffic island in London, causing him to fall and collide with a rigid metal Keep Left sign. The concerns included failures to identify a missing sign, defective lighting, and incomplete highway asset records, together with an inspection system that was not sufficiently effective to identify and remedy these defects.

Phyllis Broomhead · Prevention of Future Deaths report View report

6 Jul 2015 South Yorkshire (Eastern) N. Mundy

Phyllis Broomhead, who had dementia and lived at Lord Hardy Court EMI Residential Home, suffered repeated falls, including three significant falls requiring hospitalisation. On 9 June 2013 she fell from her bed while trying to reach the toilet, sustained a head injury and died later that day from a traumatic left-sided subdural haemorrhage. Concerns included incomplete implementation of measures, staff training and record keeping, safeguarding screening, and the lack of closer monitoring or alternative placement for residents at high risk of serious injury.

Mr Tommy Faegh Faisali · Prevention of Future Deaths report View report

6 Jul 2015 Inner West London F. Wilcox

Mr Tommy Faegh Faisali, who had hepatitis C causing cirrhosis and was methadone dependent, was found deceased in his accommodation on 30 September 2014. The inquest concluded that the medical causes of death included acute pulmonary oedema, methadone toxicity and liver failure due to cirrhosis, with the jury recording drug-related misadventure. Concerns included the lack of specialist psychiatric assessment despite GP referrals, inadequate risk assessment and documentation, and poor communication and continuity of care within mental health teams.

Davina Tavener · Prevention of Future Deaths report View report

3 Jul 2015 Manchester West A. Walsh

Davina Tavener died on 1 November 2014 after collapsing during a Ryanair flight from Manchester to Lanzarote. Cardiopulmonary resuscitation continued until the aircraft landed, but the aircraft did not carry airway adjuncts, suction equipment, a bag-valve-mask or a defibrillator. The report raised concerns that the absence of this equipment could contribute to future deaths and called for review of the requirements for medical equipment on aircraft.

Patricia Anne HOLMES · Prevention of Future Deaths report View report

2 Jul 2015 Central and South East Kent R. Redman

Patricia Anne Holmes was diagnosed with fractured ribs at William Harvey Hospital on 1 February 2015 and, despite information that she was receiving anticoagulation therapy with an INR of 6, no action was taken to reverse its effect. She returned in a state of collapse on 2 February and died two days later; the principal concern was that the treating A&E doctor did not consider the risk of internal bleeding associated with her trauma, rib fractures and anticoagulation therapy.

Mrs. Gail Prentice · Prevention of Future Deaths report View report

2 Jul 2015 Powys, Bridgend and Glamorgan Valleys S. Richards

Mrs. Gail Prentice, aged 46, died after severe bleeding during an attempted percutaneous tracheostomy, caused by transection of the brachiocephalic artery. The report describes concerns about tracheostomy in altered neck anatomy following previous surgery, including the need for appropriate imaging and site selection, and about surgeons acknowledging relevant hospital and other guidelines.

David James Hallet · Prevention of Future Deaths report View report

2 Jul 2015 Powys, Bridgend and Glamorgan Valleys A. Barkley

David James Hallet was serving a prison sentence when he was transferred to HMP Rye Hill, admitted to hospital and diagnosed with metastatic pancreatic cancer. He later died at HMP Parc after being transferred to its palliative care suite; concerns included inadequate healthcare at HMP Rye Hill, linked in the report to insufficient preparation and resources for a national prison re-roll.

Mary Winifred HYDEN · Prevention of Future Deaths report View report

1 Jul 2015 Staffordshire South A. Haigh

Mary Winifred Hyden had a suprasellar meningioma and died at home on 16 February 2015; the inquest recorded pulmonary thrombo-embolism and an intracranial tumour that was not successfully treated. Concerns included failures in communication about the tumour in 2013 and 2014, and the excessive working hours of a consultant neurologist, described as increasing the potential for fatal errors.

Blaise Francis Farry · Prevention of Future Deaths report View report

30 Jun 2015 West London S. Cummings

Blaise Francis Farry died by suicide after hanging himself from a ligature made from a bed sheet suspended from a prison window on 19 January 2013. The jury identified inadequate exchange of information between healthcare and prison staff in the weeks before his death, and evidence indicated insufficient staffing to institute a nominated Officer scheme despite previous reports identifying the need for one.

Colette Hughes · Prevention of Future Deaths report View report

30 Jun 2015 South London S. Lynch

Colette Hughes died on 7 July 2014 after jumping from the top storey of a multi-storey car park at Centrale Shopping Centre in Croydon. Concerns were raised that the accessible perimeter wall had been involved in at least two previous deaths, posed a danger to people using it as seating, and that notices about Samaritans services might not be sufficient without physical modifications.

Michael Anthony Bovell · Prevention of Future Deaths report View report

29 Jun 2015 North London A. Walker

On 12 April 2014, Michael Anthony Bovell entered a railway line at Brimsdown Rail Station after reporting a suicide and was struck and run over by a train. The principal concern was that railway rules did not allow the signaller to stop the train when a person was in danger from it, and that the train, although cautioned and slowed, still struck him.

DAVIN PAUL SHORT · Prevention of Future Deaths report View report

29 Jun 2015 Norfolk D. Osborne

Davin Paul Short was discovered unresponsive in his prison cell on 4 October 2011 and was pronounced deceased shortly afterwards. The inquest concluded that he died from natural causes, with acute lobar pneumonia recorded as the medical cause of death. Concerns were raised about the lack of guidance for recording medically significant cell-bell calls and ensuring that a lone healthcare worker had a radio to respond to emergencies.