Search PFD Monitor

Mark Bentley Hudson · Prevention of Future Deaths report View report

4 Nov 2014 Blackpool and the Fylde A. Wilson

Mark Bentley Hudson was admitted to hospital for chest pain, underwent urgent coronary artery bypass surgery, and later suffered cardiac arrests. During the second arrest, specialist assistance was delayed or may not have been contacted, and an oesophageal intubation went unrecognised; the concern was that procedures for urgent CICU requests via the switchboard were not sufficiently robust.

SANDRA HAZEL ELIZABETH HIGHAM · Prevention of Future Deaths report View report

3 Nov 2014 London (Inner South) H. Hill

Sandra Hazel Elizabeth Higham died at St Thomas's Hospital, London, on 7 December 2013 after developing an atrial-oesophageal fistula following an ablation procedure for atrial fibrillation. The principal concerns were that this rare but known complication can be difficult to diagnose because of non-specific symptoms and limited awareness, and that early diagnosis, prompt surgery and prolonged antibiotic therapy may be important for survival.

CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report View report

31 Oct 2014 Inner South London S. Ormond-Walshe

Christopher Toke Ajayi, who had schizo-affective disorder and insulin-dependent type II diabetes, was discharged into unsupported accommodation and was found decomposed there on 17 September 2012 after apparently receiving no professional or carer visits for about a month. The report identified concerns about discharge planning, lack of supported accommodation and GP care, failures to communicate his medical needs, and failure to follow up missed appointments, medication and insulin treatment. The inquest found the cause of death to be hyperosmolar non-ketotic coma associated with diabetes mellitus, with neglect contributing.

Maureen Annette ELLETT · Prevention of Future Deaths report View report

31 Oct 2014 Brighton and Hove V. Hamilton-Deeley

The report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.

Alan Derek Evans · Prevention of Future Deaths report View report

29 Oct 2014 Powys, Bridgend and Glamorgan Valleys A. Barkley

Alan Derek Evans died at the scene after losing control of his motorcycle while overtaking on the A489, colliding with an oncoming vehicle and being run over by another vehicle. Concerns included the road’s single broken white line and whether a protruding old-style cat’s eye may have contributed to the loss of control.

Polly Elisabeth Jane CARPENTER · Prevention of Future Deaths report View report

28 Oct 2014 Exeter & Great Devon E. Earland

Polly Elisabeth Jane Carpenter, who had a history of psychotic depression and repeated suicide attempts, left an inpatient psychiatric unit on 5 May 2011 and deliberately sat on a railway track, where she was struck by a train and died. The concerns included weaknesses in recording risk assessments, observations and nurse allocation, limited staff awareness of current risk, and inadequate security of unit windows, which contributed to her absconding.

Chrylin Angela Maria Norrell-Goldsmith · Prevention of Future Deaths report View report

27 Oct 2014 Surrey R. Travers

Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.

Betty SMITH · Prevention of Future Deaths report View report

27 Oct 2014 Central and South East Kent R. Redman

Betty SMITH underwent surgery for a large intrathoracic hiatus hernia on 22 October 2012, deteriorated the following day, was admitted to intensive care on 24 October, and died on 25 October from intraabdominal and intrathoracic haemorrhage following repair of the hiatus hernia. Concerns included the lack of a secured High Dependency Unit bed before surgery, inadequate anaesthetic pre-assessment and the failure to refer her to a tertiary centre. The report also identified reduced intensive care capacity due to closed beds and nursing shortages as compromising care.

JACKSON TERRY SELLERS MITCHELL · Prevention of Future Deaths report View report

27 Oct 2014 Norfolk J. Lake

Jackson Terry Sellers Mitchell was born prematurely at 31 weeks and received parenteral nutrition through an umbilical venous catheter. He developed abdominal distension, deteriorated despite treatment and transfer to another hospital, and died on 10 May 2014. The post-mortem attributed his death to intraperitoneal extravasation of parenteral nutrition solution associated with umbilical vein catheterisation; concerns included the catheter's lower position and the need for further investigation into catheter positioning and fluid extravasation.

Agnes Mary Hannan · Prevention of Future Deaths report View report

27 Oct 2014 Manchester South J. Pollard

Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life care.

Philip Allen · Prevention of Future Deaths report View report

27 Oct 2014 Inner South London P. Barlow

Philip Allen, who had vascular dementia, was transferred from The Oaks Care Centre to QEH in September 2012 following a deterioration in his condition and died there. The concern was that Quetiapine continued to be prescribed as a repeat prescription after specialist advice to discontinue it, because the surgery’s system did not prevent this; the inquest evidence was that the further prescriptions did not contribute to his death.

Eliza Bashir · Prevention of Future Deaths report View report

24 Oct 2014 Manchester North S. Nelson

Eliza Bashir swallowed a button battery from a torch on 22 March 2013. Although the battery was removed and she remained well for almost a week, she collapsed on 30 March 2013 and died after resuscitation failed. Concerns included the lack of a lockable battery compartment because the torch was not classified as a toy, uncertainty among clinicians about managing such incidents, and the accessibility and sale of button batteries to young children.

Hilda May Cole · Prevention of Future Deaths report View report

24 Oct 2014 Staffordshire South A. Haigh

Hilda May Cole, aged 86, was found dead at home on 7 July 2014 after dying from burns, probably caused by a lit cigarette dropped onto a sofa or material on it. The concern was that her pendant alarm system could have been linked to a fire alarm, but her family were unaware of this facility and had not subscribed to it; the report questioned whether existing and new customers were adequately informed.

Isa Riaz Mushtaq · Prevention of Future Deaths report View report

24 Oct 2014 Manchester (City) S. Lewis

Isa Riaz Mushtaq was delivered by emergency caesarean section after reduced fetal movement, a suspicious antenatal CTG and fetal bradycardia. He did not recover from the bradycardia/asystole episode, developed severe hypoxic ischaemic encephalopathy and died on the third neonatal day. The principal concern was the absence of detailed national guidance for interpreting and managing abnormal antenatal CTGs, including when urgent delivery is required.

Sonielia Laura Caya HOLMES · Prevention of Future Deaths report View report

23 Oct 2014 Bedfordshire and Luton T. Osborne

Sonielia Laura Caya HOLMES was admitted to Bedford Hospital on 17 April 2013 with confusion and seizures, later suffering a fall that caused a brain bleed. She died from multi-organ failure at 17:06 on 4 May 2013. The principal concerns were repeated failures to contact Haematology doctors and failures to respond to requests for advice and review, despite the use of known contact details.

Maria Christina Stubbings · Prevention of Future Deaths report View report

23 Oct 2014 Essex C. Beasley-Murray

Maria Christina Stubbings was murdered in December 2008 by a man who had previously served a life sentence in Germany for murder and had been arrested for assaulting her. The principal concerns relate to gaps in the identification, notification, monitoring and control of people with serious foreign convictions entering or residing in the UK.

Phyllis Kerry · Prevention of Future Deaths report View report

23 Oct 2014 Nottinghamshire H. Connor

Phyllis Kerry, who was taking long-term Warfarin, was admitted with symptoms suggestive of stroke and found to have a haemorrhagic stroke. She deteriorated and died after the intracerebral bleed increased. The principal concerns were uncertainty about which specialty was responsible for deciding on immediate Warfarin reversal, the absence of clear guidelines, and inadequate communication of relevant guidelines to staff.

Mary Elizabeth Grace Stroman · Prevention of Future Deaths report View report

21 Oct 2014 Wiltshire and Swindon D. Ridley

Mary Elizabeth Grace Stroman, aged 16, died on 15 January 2014 after lying on a railway line and being struck by a train. The inquest concluded that she took her own life while suffering from Complex Post Traumatic Stress Disorder. The principal concerns were delays in funding her long-term therapeutic placement and the temporary termination of a later placement without consultation with the other funding authority, including potential effects on vulnerable individuals’ mental health and safety.

Elsie Sue PLUMB · Prevention of Future Deaths report View report

21 Oct 2014 Avon M. Voisin

Elsie Plumb was born full term and died within an hour of delivery from early-onset neonatal sepsis due to Group B streptococcal infection. Her mother had been identified as positive for Group B streptococcus and was recorded as needing antibiotic cover in labour, but this did not happen. The report raised concern that hospital guidance on administering antibiotics and the relevant professional guideline should be clarified.

Samuel Duckworth · Prevention of Future Deaths report View report

20 Oct 2014 Inner South London A. Harris

Samuel Duckworth was found dead in his flat after taking an overdose of Diazepam, Codeine and alcohol; the inquest recorded the medical cause of death as Diazepam, Codeine and Alcohol intoxication. The principal concern was that he could readily purchase prescription-only drugs on the internet, with the report identifying this as an ongoing risk to other vulnerable people whose medication should be medically supervised.