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Howard Simon Sankey · Prevention of Future Deaths report View report

27 Dec 2013 Manchester West A. Walsh

Howard Simon Sankey died on 4 July 2013 after being found suspended by a ligature in a garage, having left a note indicating his intention to end his life. The report raised concerns about the handling of his mental-health referral, including inappropriate categorisation, inadequate prioritisation and follow-up after failed contact, ineffective handovers and review systems, staffing levels, team management, and staff training.

Roy Frank Fletcher · Prevention of Future Deaths report View report

20 Dec 2013 Blackpool and the Fylde A. Wilson

Roy Frank Fletcher, who had a long history of depression, left Parkwood Hospital on 6 July 2010 after exiting through a partially open ward door and following another service user out of the building. He was found deceased at approximately 7.30 pm at a local holiday park, having taken his own life by hanging. The report raised concerns that the Trust’s post-incident review was not sufficiently thorough, including that it had not explored how he exited or whether similar incidents had occurred.

Kate Louise PIERCE · Prevention of Future Deaths report View report

20 Dec 2013 North Wales (East and Central) J. Gittins

Kate Louise PIERCE died on 14 March 2013, aged 7, following complications associated with meningitis, including acquired cerebral palsy, epilepsy and chronic lung disease. The report raised concerns about the handling of her diagnosis at Wrexham Maelor Hospital and whether a doctor misled her parents about obtaining a second opinion. It also raised concerns about that doctor's fitness to practise and continued work as a GP, identifying a risk of future deaths.

Keith Samuel Peters · Prevention of Future Deaths report View report

20 Dec 2013 Manchester West J. Leeming

Keith Samuel Peters lived alone with Type II diabetes, chronic pancreatitis and alcohol dependence, and was admitted to hospital after his sister became concerned about his condition; he died on 12 September 2013. Concerns included delays and lack of prioritisation in assessing his social care needs, and the absence of a system to reallocate cases when an assessment could not be completed within the required period.

Adrian Johnson · Prevention of Future Deaths report View report

20 Dec 2013 Inner South London A. Harris

Adrian Johnson died by an act of accidental hanging between 12.50 and 13.55 on 13 May 2010 in the Segregation Unit of HMP Belmarsh. The report identified failures in initial screening and ACCT review processes, including inadequate attention to mental health assessment, medication needs, nicotine dependency, clinical information and protection measures. Concerns remained about prison screening for tobacco withdrawal and the consistency and adequacy of ACCT case management and observation decisions for vulnerable prisoners.

Michael Longley · Prevention of Future Deaths report View report

19 Dec 2013 Central and South East Kent R. Redman

Michael Longley had an adverse reaction to Rivaroxaban administered after hip surgery. He was admitted to hospital with an unrecordable platelet count and died the same day; the report also identified difficulties in communication between Integrated Care 24 and the District Nursing Service.

Kenneth Smalley · Prevention of Future Deaths report View report

19 Dec 2013 Manchester West A. Walsh

Kenneth Smalley died after surgery to remove an infected aortic graft and repair an aortoduodenal fistula. During the surgery, an operating table moved uncontrollably and its emergency stop button did not work; later, bleeding from splenic lacerations required a splenectomy, and he deteriorated and died. Concerns included the safety, inspection, maintenance, positioning and checking of operating-table handsets, staff training and auditing, and the sharing of investigation findings between relevant organisations.

Christine Ann WILLIAMSON · Prevention of Future Deaths report View report

18 Dec 2013 Shropshire, Telford and Wrekin J. Ellery

Christine Ann Williamson, aged 62, died following a physical assault by her husband, who had advanced Alzheimer’s dementia and was unaware of his actions or their consequences. The concerns included the absence of an earlier referral and assessment of her as a vulnerable adult at risk, and inadequate information sharing that might have enabled preventative measures.

Sandra Wordingham · Prevention of Future Deaths report View report

17 Dec 2013 Cardiff & the Vale of Glamorgan J. Woolley

Sandra Wordingham, a resident of Springbank nursing home, was found unconscious after a suspected epileptic fit on 22 July 2013 and remained unconscious overnight before being taken to hospital. She died in hospital on 26 July 2013; the medical cause of death was recorded as intracerebral haemorrhage. The principal concern was that no medical opinion was sought despite her remaining unconscious for longer than expected after an epileptic fit, creating a risk to similarly treated residents.

William Alfred Andrews · Prevention of Future Deaths report View report

17 Dec 2013 South Yorkshire (West) C. Dorries

William Alfred Andrews, a 77-year-old man, underwent cardiac surgery and subsequently suffered repeated circulatory arrests after a bulb syringe cap entered and remained in his left ventricle. The cap was later removed during a second operation, but his condition deteriorated and he died. Concerns included the cap's lack of visibility, inadequate awareness of its presence, and the absence of a standard procedure to check and count syringe caps at the end of surgery.

Sean Christopher Seabourne · Prevention of Future Deaths report View report

17 Dec 2013 Worcestershire G. Williams

Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

John Elvet Morgan · Prevention of Future Deaths report View report

17 Dec 2013 Cardiff & the Vale of Glamorgan J. Woolley

John Elvet Morgan, who had Alzheimer’s dementia, was admitted for respite care and collapsed on 30 August 2013. Staff did not resuscitate him because they relied on an erroneous red DNR star left on the ward whiteboard, although no DNR agreement or form existed; the post-mortem report showed pulmonary embolism. The concerns identified included reliance on whiteboard information instead of patient notes, human error in recording information, and the possible use of similar DNR systems elsewhere in Wales.

Elsie May Treece · Prevention of Future Deaths report View report

16 Dec 2013 Staffordshire South A. Haigh

Elsie May Treece died in hospital on 2 August 2013 after falls at her care home, including a fall that caused a broken arm and an inoperable brain bleed. Concerns included an alleged incident during her hospital care that may not have been reported and the absence of a CT scan after her earlier hospital attendance.

Joseph Drew Whiteside · Prevention of Future Deaths report View report

16 Dec 2013 Staffordshire South A. Haigh

Joseph Drew Whiteside, aged 20, was likely intoxicated when he fell into the River Trent at Burton late on 2 May 2013 and drowned; his body was found on 10 May 2013. The report raised concerns about repeated drownings of intoxicated young men in the river and whether additional safety measures, such as fencing or warning signs, were needed at access points.

Cynthia Fretwell · Prevention of Future Deaths report View report

16 Dec 2013 Nottinghamshire J. Gillespie

Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.

Clive GOULD · Prevention of Future Deaths report View report

16 Dec 2013 Oxfordshire N. Graham

Clive Gould, who had a complex medical history and was receiving chemotherapy for lung cancer, became unwell with sickness and shortness of breath on 18 July 2013. An ambulance was called at 4:18am but arrived at 5:47am, by which time he was in cardiac arrest and could not be revived. The concerns included the prioritisation of the ambulance call, limited system resilience, and information given to callers about possible delays.

Sarah Anne Shepherd · Prevention of Future Deaths report View report

16 Dec 2013 Surrey A. Hewitt

Sarah Anne Shepherd, a patient detained under the Mental Health Act, was found in her room with a plastic bin liner over her head on 12 September 2011 and died in hospital the following day. The report identified concerns about unclear referral processes to the Psychiatric Intensive Care Unit, failures to attempt resuscitation in accordance with guidance, and uncertainty and misleading materials concerning resuscitation training.

STEPHANIE DANIELS · Prevention of Future Deaths report View report

13 Dec 2013 Manchester City N. Meadows

Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.

Jane Dyson Gabbitas · Prevention of Future Deaths report View report

12 Dec 2013 West Yorkshire (Western) T. Ratcliffe

Jane Dyson Gabbitas was found unconscious in an abandoned car on 2 March 2013 and died at the scene despite resuscitation attempts. The inquest concluded that she died after ingesting sufficient quantities of alcohol and gabapentin to cause her death. The report raised concerns about the failure to record and monitor her absence from the SHARE accommodation unit and to respond appropriately to lengthy or inappropriate absences.

ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report View report

12 Dec 2013 South Yorkshire (Eastern) G. Saul

ROSEMARY BRONWYN FERGUSON, who had a long-standing history of epilepsy, was admitted after a head injury from a fall and was assessed as unfit for discharge because of risks associated with further falls. Despite recommendations that she remain in hospital, she was discharged to the care of a friend and was found deceased alone at home on 11 March 2013; the medical cause of death was recorded as sudden unexpected death in epilepsy. The principal concerns were that Social Services were not notified of the discharge, the friend’s expected role was unclear, and hospital records did not adequately document key communications and the date of discharge.