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Zakariyya Thomas Clark · Prevention of Future Deaths report View report

7 Oct 2014 South Yorkshire (Eastern) N. Mundy

Zakariyya Clark was injured after being dropped, sustaining skull fractures and minor brain bleeds, but was discharged from hospital without a CT scan. He was later found unresponsive after sleeping and was declared dead; the inquest concluded that the death was due to Sudden Infant Death Syndrome and natural causes. The principal concern was that full assessments and observations were not carried out or documented when babies and children attended the emergency department, potentially putting future patients at risk.

Elouise Winship · Prevention of Future Deaths report View report

7 Oct 2014 North Wales (East and Central) J. Gittins

Elouise Winship was delivered unresponsive on 11 March 2011, was resuscitated, and died 13 hours later. Concerns included the absence of a documented standard regime for fetal heart auscultation after maternal opiates and the need for further maternal examination and fresh observations following a recognisable change in condition during labour.

Ella Rose Block · Prevention of Future Deaths report View report

7 Oct 2014 Plymouth, Torbay and South Devon I. Arrow

Ella Rose Block was admitted to Derriford Hospital on 1 March 2013, unwell and feverish, deteriorated overnight, and died on 2 March 2013. The concerns identified were that an opportunity may have been missed to provide suitable treatment and that newly qualified clinicians may not readily identify deaths of children resulting from sepsis.

Kai Lambe · Prevention of Future Deaths report View report

6 Oct 2014 Staffordshire South A. Haigh

Kai Lambe, aged 9, drowned in the River Dove after going down a salmon chute and sinking under the water. The report raises concern about a five-minute delay between Derbyshire receiving the emergency call and Staffordshire’s log commencing, and whether control room operators should dispatch officers immediately in urgent incidents on or near the county border.

Matthew Alexander Flatman · Prevention of Future Deaths report View report

6 Oct 2014 Portsmouth and South East Hampshire D. Horsley

Matthew Alexander Flatman died at Queen Alexandra Hospital, Portsmouth, on 5 July 2013 after experiencing chest, jaw and arm pain, followed by a cardiac arrest. The inquest recorded that he had taken MDAI, a so-called legal high, the previous evening, and concluded that its consumption precipitated a myocardial infarction and subsequent cardiac arrest in the context of severe coronary artery disease. The report raised concerns about the fatal risk posed by MDAI and the slow process of proscribing it as an illegal drug.

John Andrews · Prevention of Future Deaths report View report

3 Oct 2014 Milton Keynes E. Gray

John Andrews, who had a history of stroke and recurrent falls, was admitted after falls at home and later developed pneumonia and died on 1 June 2014. The principal concern was that he was discharged home without his family being advised, with no groceries or heating and without formal care arrangements in place; he fell while home alone before care was arranged.

Darren William Thorpe and 2 others · Prevention of Future Deaths report View report

2 Oct 2014 Northumberland (South) E. Armstrong

On 11 May 2014, Darren William Thorpe, Gavin Thomas Bradley and Mark Thorpe entered the River Tyne in a kayak and failed to return; their bodies were later located downstream of Riding Mill weir. The inquest concluded that all three died by drowning in accidental deaths. The substantive concerns related to the weir’s design, the availability of a suitable upstream landing area with warnings, and other steps to prevent similar deaths.

Lexi Branson · Prevention of Future Deaths report View report

2 Oct 2014 Rutland and North Leicestershire T. Kirkland

Lexi Branson, aged 4¾ years, died after a dog attacked her in the living room of her home, causing extensive neck and facial injuries and preventing breathing. The report identified concerns about the absence of national or local standards for re-homing stray dogs, assessing dogs and applicants, and independently verifying kennel policies and their implementation.

Mr Pether · Prevention of Future Deaths report View report

2 Oct 2014 London (East) N. Persaud

Mr Pether was admitted after a fall that caused a right femur peri-prosthetic fracture, with a pre-existing infection and an open fracture increasing the risk of infection. Transfer for complex surgery was delayed, and records identified no focused medical or nursing checks of limb viability between 11 and 20 December 2012. The wound was found to be infected and necrotic on 20 December; despite surgery, amputation and intensive care, Mr Pether deteriorated and died from left ventricular failure after developing multi-organ failure.

Derek Hawkins · Prevention of Future Deaths report View report

30 Sep 2014 Manchester (North) C. McKenna

Derek Hawkins, who had bipolar disorder and was admitted for reassessment and treatment after increased suicidal thoughts, disclosed on 22 November 2013 that he intended to hang himself. He left the ward unescorted on 24 November and was found hanging in a derelict building near the hospital grounds that evening. The concerns included failures in communication, unclear leave arrangements, inadequate risk assessment after his disclosure of suicidal intent, and a risk-assessment tool that relied on subjective practitioner assessments.

Victoria Elizabeth Rhodes · Prevention of Future Deaths report View report

30 Sep 2014 Milton Keynes T. Osborne

Victoria Elizabeth Rhodes died after being struck by a Peugeot while attempting to cross the V11 Tongwell Street dual carriageway in Milton Keynes, despite an available footbridge. The concerns raised were the 70 mph speed limit on Milton Keynes grid roads and pedestrian access to fast roads, including a call to review the speed limit.

Christopher Paul Davies · Prevention of Future Deaths report View report

29 Sep 2014 North Wales (East and Central) J. Gittins

Christopher Paul Davies was found unresponsive at home on 5 February 2014 and was verified dead that day; the inquest recorded accidental death, with the cause stated as clozapine poisoning. Concerns were raised that information about possible interactions between clozapine, caffeine and changes in smoking, and about warning signs of toxicity, had not been communicated to the deceased or Community Mental Health Team staff.

Tiya Chetan Chauhan · Prevention of Future Deaths report View report

29 Sep 2014 Inner West London F. Wilcox

Tiya Chetan Chauhan died on 24 August 2012 at St George’s Hospital after inhaling a cube of raw jelly that obstructed her airway during a sensory tray activity at a nursery. The report identified concerns about the choking risk of raw jelly cubes, inadequate supervision, insufficient risk assessment, and the absence of warnings on packets of raw jelly.

Dorothy Mavis Clarkson · Prevention of Future Deaths report View report

26 Sep 2014 Preston and West Lancashire S. Jones

Dorothy Mavis Clarkson choked on a large piece of meat while eating at Longton Nursing and Residential Home on 25 July 2013, became unresponsive, and died in hospital on 27 July 2013. The substantive concerns related to how food was provided and presented to residents requiring modified food or assistance, and to appropriate ongoing professional training for nursing staff.

Emmanuel Tobiloba Akinmuyiwa · Prevention of Future Deaths report View report

26 Sep 2014 Birmingham and Solihull L. Hunt

Emmanuel Tobiloba Akinmuyiwa was a 7-year-old boy with sickle cell disease who died after developing severe anaemia during a sickle cell crisis. The report identified failures to check his haemoglobin and provide an earlier blood transfusion, and raised concerns about the lack of clear regional protocols and staff knowledge for managing sickle cell disease.

Jake Anthony JOHNSON · Prevention of Future Deaths report View report

24 Sep 2014 Cheshire A. MOORE

Jake Anthony JOHNSON, aged 22, died after being struck by a lorry while crossing the Manchester-bound carriageway of the M56 on 6 January 2014. The report identifies open access steps to the motorway, damaged boundary fencing, a lack of warning signs, and a nearby children’s play area as substantive concerns.

Caroling Carter Crowther · Prevention of Future Deaths report View report

24 Sep 2014 Worcestershire G. Williams

Mrs Crowther, a patient detained under Section 3 of the Mental Health Act, became physically unwell and died after paramedics declined to take her to hospital despite differing views about her capacity and need for treatment. The concerns included conflicting accounts of whether Trust policy prevented paramedics from compelling a psychiatric patient to attend hospital, including without police presence.

Leonard Henry Hudson · Prevention of Future Deaths report View report

24 Sep 2014 Sunderland D. Winter

Leonard Henry Hudson fell at home, was admitted for surgery to repair a fractured right femur, later underwent a below-knee amputation, and died from bronchopneumonia on 19 March 2014. Concerns included failures in pressure-ulcer reporting and management, delayed referral to the foot protection team, incomplete nursing documentation, variable classification of heel injuries, and other deficiencies or confusion in records, mobilisation, fluid restrictions, physiotherapy, hygiene arrangements and diabetes information.

Jerome Antoine Marie GONNET · Prevention of Future Deaths report View report

22 Sep 2014 Teesside C. Bailey

On 2 May 2012, Jerome Antoine Marie GONNET was a passenger in a car involved in a head-on collision after a female driver travelled the wrong way along the A66 eastbound carriageway. Concerns included unclear advance signage for the no-entry slip road and temporary no-entry signs that could be knocked over and become unnoticeable; two further drivers reportedly later used the exit slip road in the same way.

Martin Leslie Dean · Prevention of Future Deaths report View report

22 Sep 2014 Manchester West M. Leeming

On 13 December 2013, Martin Leslie Dean suffered an intracerebral haemorrhage at home and was transferred to Salford Royal Hospital, where a shunt and feeding tube were inserted. The inquest concluded that he died as a consequence of a naturally occurring intracerebral haemorrhage together with a complication of necessary treatment. Evidence raised concerns that visitors to the Critical Care Ward were not washing their hands on entry, despite hand washing being identified as the most effective single precaution against infection.