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Gerardo Abadilla Tongobanua · Prevention of Future Deaths report View report

27 May 2014 Avon M. Voisin

On 7 February 2011, Gerardo Abadilla Tongobanua fell 29 metres during a fast rescue boat drill onboard the MV Tombarra while it was docked at Royal Portbury Dock, Bristol, after the fall wire snapped. The concerns identified were that the winch motor could overstress the fall wire and that the failed electronic switch did not stop the motor, while the relevant code and standard did not adequately specify system design or safety-device requirements.

Miss Akua Anokye-Boateng · Prevention of Future Deaths report View report

26 May 2014 Inner South London A. Harris

Miss Akua Anokye-Boateng, who had well-managed sickle cell disease, suffered a three-day illness, collapsed suddenly, and died on 16 January 2013. The inquest recorded acute peritonitis and shock due to a perforated duodenum associated with NSAID ingestion and Helicobacter-associated chronic ulceration. Concerns included uncertainty about best practice and whether guidance or additional precautions are needed when NSAIDs are used in children with sickle cell disease.

Liam Martin Coleman · Prevention of Future Deaths report View report

25 May 2014 North London A. Walker

Liam Martin Coleman collapsed at home in the early hours of 3 October 2012 and died after London Ambulance Service crews provided advanced life support. The principal concern was that insufficient ambulances were available to cover Red 1 and Red 2 calls during that period; the report states that the delay did not more than minimally or trivially contribute to his death.

Michaela Jade Christoforou · Prevention of Future Deaths report View report

25 May 2014 North London A. Walker

Michaela Jade Christoforou was a 17-year-old patient at Rhodes Farm Hospital who died at St Mary’s Hospital Paddington on 17 April 2013 after being found suspended by bunting around her neck in a hospital classroom. The substantive concern was that not all staff at the unit carried a ligature cutter.

Josephine Foday and Komba Kpakiwa · Prevention of Future Deaths report View report

23 May 2014 Essex C. Beasley-Murray

Josephine Foday and Komba Kpakiwa were found floating in the swimming pool at Down Hall Country House Hotel, and their deaths were confirmed shortly afterwards. The inquests concluded that the deaths were accidental and that the cause of death for both was consistent with drowning. Concerns included the pool’s dangerous profile, inadequate risk assessments and signage, lack of lifeguards and trained aquatic-rescue staff, and ineffective supervision arrangements, including unmonitored CCTV.

Ross Robson · Prevention of Future Deaths report View report

23 May 2014 Milton Keynes T. Osborne

Ross Robson Boyd died following a number of falls from his wheelchair while resident at the Willows Care Home in Milton Keynes. The principal concern was that he was admitted without an adequate assessment of his needs and placed in a setting that was inappropriate for those needs.

Josephine Foday and Komba Kpakiwa · Prevention of Future Deaths report View report

23 May 2014 Essex C. Beasley-Murray

Josephine Foday and Komba Kpakiwa were found floating in the swimming pool at Down Hall Country House Hotel, and their deaths were confirmed shortly afterwards. The inquests concluded that the deaths were accidental and that the cause of death for both was consistent with drowning. Concerns included the pool’s dangerous profile, inadequate risk assessments and signage, lack of lifeguards and trained aquatic-rescue staff, and ineffective supervision arrangements, including unmonitored CCTV.

Samarjit Natasha SINGH · Prevention of Future Deaths report View report

23 May 2014 The Wirral A. Rebello

Samarjit Natasha Singh developed postnatal depression after giving birth to her son and had acts of deliberate self-harm and a threat of self-harm. On 4 December 2012, she was found in cardiac arrest following hanging and sustained an irreversible hypoxic brain injury; she died the following day. The report identified concerns about the absence of a Specialist Community Perinatal Mental Health Service and a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region.

Christian Murray Cecil Devereux · Prevention of Future Deaths report View report

23 May 2014 Rutland and North Leicestershire R. Chapman

Christian Murray Cecil Devereux died at the scene after suffering head injuries in a frontal collision while driving in a race at Donington circuit on 5 May 2013. The report raised concerns that he was not wearing a HANS-type device and that wearing one might have prevented or reduced his injuries.

SIMON TONY HAINES · Prevention of Future Deaths report View report

22 May 2014 Norfolk D. Osborne

Simon Haines was found unresponsive in his parked vehicle on 21 November 2013 and was declared deceased at the scene. The inquest concluded that he killed himself, with the medical cause of death recorded as diphenhydramine toxicity. The report raised concern that there was unclear guidance and insufficient consideration of re-signposting people experiencing difficulty after a significant decision or outcome, creating a continuing risk that others might not receive appropriate support.

Mark Darren Bartholomew · Prevention of Future Deaths report View report

21 May 2014 Manchester North S. Nelson

Mark Darren Bartholomew, who had a longstanding diagnosis of paranoid schizophrenia and was detained in hospital after transfer from prison, died by hanging on 25 July 2013 during a routine observation check. Concerns included an inadequate response to emergency services, the absence of the ligature cutter needed to release him promptly, and insufficient detail in observation records.

Rainer Wickens · Prevention of Future Deaths report View report

20 May 2014 Surrey R. Travers

Rainer Wickens fell through the roof of a single-storey rear extension while assisting with its demolition, sustaining a thoracic spine fracture. After surgery, concerns arose about low oxygen saturations and possible pulmonary embolism; he suffered a cardiac arrest and died before testing could be completed. The report identifies concerns about delayed treatment for clot formation, gaps in medical notes, poor handover communication, and delays in obtaining a CTPA scan.

Peter Franklin · Prevention of Future Deaths report View report

19 May 2014 Mid Kent and Medway P. Harding

Peter Franklin, who had longstanding mental health difficulties and increasingly frequent hospital attendances, died after jumping from a motorway bridge following an attempted jump earlier that day. The concerns included unclear communication about whether a referral, advice or assessment was required, relevant information not being passed on, and delays in sharing information with his GP.

Stephen John Owens · Prevention of Future Deaths report View report

19 May 2014 Powys, Bridgend and Glamorgan Valleys G. Hughes

Stephen John Owens was fatally injured in a running-down accident on the Ely Valley Road on 29 August 2013. Concerns related to an unilluminated street lamp, another lamp obscured by foliage, and the resulting level of illumination possibly affecting the driver's ability to see him.

Denise Sharon Parramore · Prevention of Future Deaths report View report

19 May 2014 South Yorkshire (Western) D. Coutts-Wood

Denise Sharon Parramore, who had a lengthy history of mental ill health and previous self-harm, died from respiratory depression after taking Tramadol in excess of the prescribed level in combination with other medication. The concerns were that psychiatric services were unaware of the Tramadol prescription and that primary and secondary care should have open two-way communication and access to each other's documentation.

William PIERCY · Prevention of Future Deaths report View report

16 May 2014 Kingston upon Hull & the East Riding of Yorkshire P. Marks

William PIERCY died at Hull Royal Infirmary on 25 July 2013 from pneumonia resulting from an injury sustained in a road traffic collision four days earlier. The principal concern was that his seat belt had become disengaged, leaving him unrestrained and allowing him to be thrown forward and fracture his neck; a seat belt alarm might have alerted carers to the disengagement.

Harold Gordon Henshall · Prevention of Future Deaths report View report

16 May 2014 Stoke-on-Trent and North Staffordshire D. James

Harold Gordon Henshall, an elderly man with limited mobility, was struck by a vehicle while crossing Church Street, Leek, on 17 February 2013. He suffered multiple injuries, was admitted to hospital, and died on 27 March 2013. Concerns were raised that street lighting and crossing facilities near St Edwards Church were inadequate, particularly for predominantly elderly church users.

Gary Bradshaw · Prevention of Future Deaths report View report

15 May 2014 Manchester South J. Pollard

Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical records.

Arthur Clifford Shaw · Prevention of Future Deaths report View report

14 May 2014 Portsmouth and South East Hampshire D. Horsley

Arthur Clifford Shaw was struck by a car while crossing Privett Road, Gosport, on 31 December 2012 and died in hospital on 1 January 2013 from injuries sustained. The report raised concern that assessment of older drivers' fitness to drive did not specifically consider mental fitness, including dementia, beyond sight and hearing tests.

Mitchell Harvey Clifton · Prevention of Future Deaths report View report

13 May 2014 Staffordshire South A. Haigh

Mitchell Clifton died at the scene of a road traffic collision after being struck by a van while travelling on a footpath on a scooter. The report raised concern about the layout of the access way to the car park, which was regularly used by pedestrians and vehicles, and suggested that it might be improved.