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Keith Gallimore · Prevention of Future Deaths report View report

11 May 2015 Inner North London R. Brittain

Keith Gallimore, who had discussed plans to commit suicide with a clinical psychologist, was found deceased at home on 4 December 2014. The medical cause of death was the combined toxic effects of heroin and cocaine, and suicidal or accidental intent could not be established to the required standard. Concern was raised that potentially important iCope information was not accessible to other services within the same Trust without a proactive request, including in out-of-hours settings.

Miss Chandni Nigam · Prevention of Future Deaths report View report

11 May 2015 Berkshire P. Bedford

Miss Chandni Nigam, a 19-year-old woman with a history of depression and suicidal ideation, died after being struck by a train at Twyford Railway Station on 4 February 2014. The report raised concern that the NHS Mental Health Team did not obtain relevant history or input from her previous private clinicians when care transferred to the NHS.

John Lobo · Prevention of Future Deaths report View report

11 May 2015 South London S. Lynch

John Lobo suffered multiple falls on a cruise ship, including a fall causing a C7 fracture, and was later repatriated to the UK by road without continuous neck immobilisation. The report identified concerns about relying on non-medical assessments of fitness to travel and transport arrangements, particularly where independent medical assessment was not obtained for direct repatriation.

Thaker Jamal Hafid · Prevention of Future Deaths report View report

8 May 2015 Cardiff & the Vale of Glamorgan A. Barkley

Thaker Jamal Hafid was found unresponsive by his wife at home on 9 February 2015 and was confirmed deceased at the scene. Post-mortem testing found Acetylfentanyl, an unlicensed and highly potent opioid that he had apparently ordered online to help wean himself off heroin; the report raised concern that its availability could lead to further deaths.

Michael Lawrence HACKER · Prevention of Future Deaths report View report

8 May 2015 Avon M. Voisin

Michael Lawrence HACKER, aged 66, refused hospital admission for treatment of gangrene and was assessed as lacking capacity to refuse admission on 19 December 2014. He died at home on 28 December 2014 from gangrene of the foot, with type 2 diabetes mellitus. The report raised concerns about ambulance service training and policy concerning the Mental Capacity Act, including whether restraint or force could be used when a person lacking capacity refused hospital transfer.

Baby Olsberg · Prevention of Future Deaths report View report

7 May 2015 Manchester North L. Hashmi

Baby Olsberg was born on 23 December 2013 and developed worsening symptoms in the hours after birth. Despite medical treatment and transfer to tertiary care, he suffered three cardiac arrests and died on 24 December 2013; blood cultures confirmed GBS infection. The concerns identified were the lack of routine antenatal GBS screening and routine prophylactic intrapartum antibiotics, and the resulting potential risk of serious harm or death to babies.

Mrs. Evelyn KENNEDY · Prevention of Future Deaths report View report

7 May 2015 Brighton and Hove V. Hamilton-Deeley

Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

Jayne Jowett · Prevention of Future Deaths report View report

1 May 2015 Nottinghamshire E. Didcock

Jayne Jowett, who was resident in a low secure and locked rehabilitation mental health facility, became unwell with intermittent respiratory difficulties, low oxygen saturations, dizziness, breathlessness and episodes of collapse before she died of a pulmonary embolus on 23 September 2014. The report identified concerns about staff training and response to National Early Warning Scores, understanding of significant clinical signs, and the lack of clear arrangements for sharing physical-health information between the facility and the GP surgery.

Julius CATACHANAS · Prevention of Future Deaths report View report

1 May 2015 Warwickshire S. McGovern

Julius Catachanas, aged 25, died following a road traffic collision while driving at night on Campden Road, where his car collided with a lorry at the junction with the Fosseway. Concerns were raised about the absence of street lighting and whether the junction should be staggered to prevent vehicles crossing the Fosseway straight through.

William THOMPSON · Prevention of Future Deaths report View report

30 Apr 2015 Inner North London M. Hassell

William Thompson died in a fire at his supported-housing home after discarded cigarette ignited his bedding, and he was killed by smoke inhalation. Although smoke and heat detectors were installed in the hall and kitchen, there was no smoke detection system in his bedroom. The report raised concern that his social workers had not considered bedroom smoke detection despite his significantly raised fire risk from smoking, drinking and immobility.

Finnulla Catherine MARTIN · Prevention of Future Deaths report View report

29 Apr 2015 Inner North London M. Hassell

Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.

Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report View report

29 Apr 2015 Manchester West A. Walsh

Jorge Emanuel Mousinho Assabay E Castro died at home on 16 October 2014 after being found collapsed and unresponsive. He had post-traumatic epilepsy but had not received sodium valproate after 3 July 2014, despite attending his GP practice three times without the medication issue being reviewed. The principal concerns were the lack of systems to identify uncollected prescriptions and to alert GPs to medication-adherence concerns, particularly for vulnerable patients.

Rasharn Kirk WILLIAMS · Prevention of Future Deaths report View report

29 Apr 2015 Inner North London M. Hassell

Rasharn became distressed and breathless at a school disco on 23 October 2014, later deteriorated, suffered a cardiac arrest in an ambulance, and died in hospital that evening. The report identified potential ambiguity in his care plan about when breathlessness constituted an emergency and noted that a medical-information notice was not displayed at the time of his death.

Barry Wilson · Prevention of Future Deaths report View report

29 Apr 2015 North West Wales P. Jones

Barry Wilson underwent a right hemicolectomy and was discharged from hospital on 24 December 2014. He collapsed at home after discharge and died at Ysbyty Gwynedd, Bangor, on 25 December 2014; the recorded cause of death was peritonitis following anastomotic breakdown. The concern was that the defective anastomosis should have been detected before or at discharge, and that earlier detection might have prevented his death.

Doreen Wood · Prevention of Future Deaths report View report

29 Apr 2015 Nottinghamshire H. Connor

Doreen Wood, who had atrial fibrillation and was taking Warfarin, died on 25 September 2014 from an intracerebral haemorrhage after repeated raised INR results. The report raised concerns that her INR was not checked soon enough and that the surgery’s monitoring system relied on healthcare assistants to volunteer relevant clinical information without routinely using standardised questionnaires.

Colour Sergeant Martyn HORTON and 3 others · Prevention of Future Deaths report View report

28 Apr 2015 Wiltshire and Swindon D. Ridley

On 23 June 2010, four service personnel died by drowning after their Ridgeback vehicle collided with a parked Afghan National Police vehicle, left the road and overturned in a canal in Afghanistan. The report raised concerns about the Ridgeback and related vehicle fleet, including suspension fitness, driver and gunner height restrictions, lighting effectiveness, tyre-pressure equipment, maintenance documentation, emergency lighting and recognition of recurring component failures.

Rita Paton · Prevention of Future Deaths report View report

28 Apr 2015 Inner North London R. Brittain

Rita Paton, who had type 2 diabetes, hypertension, chronic kidney disease and dementia, died on 8 December 2014 from ischaemic and hypertensive heart disease, contributed to by chronic kidney disease and diabetes mellitus. Concerns included the lack of a system to ensure requested blood tests were completed and reported, the absence of a clear process for involving family when a patient lacks capacity to make decisions about appointments, and limited access to patients’ medical and medication information for attending medical crews.

Greg Revell · Prevention of Future Deaths report View report

28 Apr 2015 Leicester City and South Leicestershire L. Brown

Greg Revell was found hanging in his cell at HM YOI Glen Parva, and resuscitation was unsuccessful. The concerns included that a previous ligature self-harm attempt did not lead to an ACCT, uncertainty among prison officers about when to open an ACCT, insufficient consideration of recorded risk factors, and weaknesses in capturing healthcare information and obtaining a GP summary.

Julie McCabe · Prevention of Future Deaths report View report

28 Apr 2015 North Yorkshire and York G. Fell

Julie McCabe died after an adverse reaction to para-phenylenediamine (PPD) in hair dye caused anaphylactic shock and irreversible brain damage. The report’s concerns included inadequate information about the scale and severity of allergic reactions to PPD, risks from black henna tattoos causing sensitisation, and the practical limitations of the required pre-use allergy test.

Tamara HOLBOLL · Prevention of Future Deaths report View report

27 Apr 2015 Inner North London M. Hassell

Tamara Holboll died from stab wounds to the neck and chest after she and her son had sought hospital admission because they feared he would harm her, but the admission was not effected. The principal concern was a recurring lack of precision in communication within Camden & Islington NHS Trust, including insufficient clarity about what information should be delivered, by whom, when, and how.