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William Joseph Wilkinson · Prevention of Future Deaths report View report

6 Nov 2013 Manchester South J. Pollard

William Joseph Wilkinson slipped on the pavement while shopping on or about 9 December 2012, fractured his ankle, was admitted to hospital, and later died after complications. Concerns included the availability of ordered one-to-one nursing, difficulties logging onto the hospital computer system, an incomplete Fluid Balance Chart, and the lack of direct orthopaedic input in the Emergency Department.

Henry MCQUOID · Prevention of Future Deaths report View report

6 Nov 2013 Worcestershire G. Williams

Henry McQuoid, a resident at Moundsley Hall Home with dementia and swallowing difficulties, choked on food while eating lunch and died. The report raised concerns that there may have been insufficient staff to assist residents who needed help with feeding, with some staff reportedly feeling understaffed and too many agency staff being employed.

Ethel Cross · Prevention of Future Deaths report View report

5 Nov 2013 Blackpool and the Fylde A. Wilson

Ethel Cross, who had a history of falls, fell on ward 4 at Clifton Hospital when a wheeled chair slipped, suffering a fractured neck of femur, and died the following day. Concerns were raised about wheeled chairs being accessible to elderly patients at risk of falls and the lack of an available alarm to alert staff when a high-risk patient mobilised unsupported.

Susan Jill Hammond · Prevention of Future Deaths report View report

4 Nov 2013 Central Lincolnshire S. Fisher

Susan Jill Hammond, who had a known penicillin allergy, was admitted to hospital after becoming ill and was administered intravenous Augmentin despite allergy warnings. She suffered a cardiac arrest and died on 3 July 2009. The principal concerns were that allergy warnings were not sufficiently noticed and that the handover between departments did not communicate her penicillin allergy.

Rachael Claire Slack and 2 others · Prevention of Future Deaths report View report

1 Nov 2013 Derby and Derbyshire R. Hunter

On 2 June 2010, Andrew David Cairns entered Rachael Claire Slack’s home, stabbed their son Auden George Slack and Rachael Slack to death, and then stabbed himself to death. The principal concerns were failures in information-sharing between Police and Mental Health Services, and failures to communicate the assessed risk and safety measures to Rachael regarding the threat posed by Andrew.

Joanne Manning · Prevention of Future Deaths report View report

1 Nov 2013 East London N. Persuad

Joanne Manning had a history of poly-substance abuse and methadone treatment, developed asthma and increasing breathlessness, and died from respiratory failure. The inquest conclusion attributed the respiratory failure to the combination of her respiratory disease, methadone, mirtazapine, cocaine and morphine. Concerns included a failure to provide the methadone-prescribing psychiatrist with information about her diagnosis and treatment, and the absence of a procedure ensuring clear communication between general practice and secondary care methadone providers.

John William Wright · Prevention of Future Deaths report View report

31 Oct 2013 Inner North London G. Elliman

John William Wright, who had a history of paranoid schizophrenia and COPD, was admitted to hospital with pneumonia and suffered several falls, including a fall that caused a fractured spine and left humerus. He died on 15 April 2013 from recurrent chest infections; the inquest concluded that his death resulted from an accident. Concerns included the lack of investigation into the cause of the fall and uncertainty about whether all relevant staff were trained in falls protocols and recording requirements.

Wilhelmina Isobel Newton · Prevention of Future Deaths report View report

31 Oct 2013 North and West Cumbria D. Roberts

Wilhelmina Isobel Newton, a resident at Grisedale Croft Residential Home, fell from her bed and was found on the floor at about 04.30 hours. She was not attended by a nurse until 09.45 hours, was later admitted to Cumberland Infirmary, and died on 15 May 2013 from a subdural haematoma following the fall. The principal concern was the apparent absence of clear written guidance for staff responding to potential head injuries in elderly residents, particularly those receiving medication affecting blood clotting.

Winston Llewellyn Johns · Prevention of Future Deaths report View report

30 Oct 2013 Powys, Bridgend and Glamorgan Valleys L. Hunt

Winston Llewellyn Johns was found unrousable with a blood sugar level of 1.4 during a 999 call. He was advised to undergo CPR, sustained a sternum fracture and multiple rib fractures, and later died in hospital from pneumonia caused by those fractures. The concerns were that the low blood sugar information was not factored into the advice and that the ambulance service’s computer programme contributed to CPR being incorrectly advised.

Damion Anthony Andre Martin · Prevention of Future Deaths report View report

30 Oct 2013 Liverpool M. Fleming

Damion Anthony Andre Martin was remanded to HMP Liverpool on 6 December 2011 and was found hanging in the toilet area of his cell on 11 December 2011; attempts to resuscitate him were unsuccessful. The report raised concerns about the identification of domestic-abuse-related suicide risk during reception, basic life-support refresher training, the restricted view into the toilet area, and whether a prison officer completed a roll-check visit.

Peter Clive HIGSON · Prevention of Future Deaths report View report

24 Oct 2013 Surrey M. Burgess

Peter Clive Higson had treated Hodgkin’s lymphoma and underwent an autologous stem cell transplant before being admitted to hospital with severe illness. After platelet transfusions, his breathing and overall condition deteriorated; the principal concern was whether the transfusions, possibly interacting with the stem cell transplant, contributed to the chain of events leading to his death.

Mr Harold Elvidge · Prevention of Future Deaths report View report

24 Oct 2013 Nottinghamshire H. Connor

Mr Harold Elvidge died on 2 November 2012 after the wrong fluid was used to keep an arterial line open, leading to misinterpreted blood sugar levels, drug administration and brain damage. The principal concern was that other parts of the trust might not have equally robust safeguards to prevent different types of fluids being mixed up, creating a risk of future deaths.

Jacqueline Allwood · Prevention of Future Deaths report View report

23 Oct 2013 Inner South London A. Harris

Jacqueline Allwood attended a GP with several days of calf pain and concern about a family history of thrombosis. She was not referred to hospital to exclude DVT and later died from pulmonary thromboembolism secondary to DVT. Concerns included whether registration, assessment and referral processes supported early diagnosis and referral, and whether the consulting GP understood and followed appropriate standards for history-taking and examination.

John Frank Henry LANSDOWNE · Prevention of Future Deaths report View report

23 Oct 2013 Inner North London M. Hassell

John Frank Henry Lansdowne, who had schizophrenia and a history of serious suicide attempts, was admitted to St Pancras Hospital under section 3 of the Mental Health Act after talking about taking his life. He was found submerged in a bath on 18 May 2012 and died shortly afterwards. Concerns included unclear observation timings, an unrecovered observation sheet, inconsistent staff understanding of observations while a patient was bathing, and the use of baths rather than walk-in showers.

Isabella Hope HILL · Prevention of Future Deaths report View report

23 Oct 2013 Liverpool A. Wilson

Isabella Hope HILL was born prematurely at 26 weeks and died on 17 July 2013, aged 7 days, after complications associated with an umbilical venous catheter. Total Parenteral Nutrition fluid entered her abdomen after the catheter migrated, contributing to circulatory collapse, cardiac injury and subsequent cardiac arrest. The principal concern was that the Trust’s guidelines were not followed because an x-ray to confirm the catheter’s position was not performed when it should have been, raising concern about future deaths.

Christopher James MORGAN · Prevention of Future Deaths report View report

22 Oct 2013 North and East Cambridgeshire W. Morris

Christopher Morgan, a voluntary patient at Fulbourn Hospital, died from multiple injuries after diving in front of a train at or near Ely Railway Station after leaving the hospital earlier that day. The report identified concerns about communication with family and carers before changes in risk or leave arrangements, and about staffing ratios for escorted leave from psychiatric wards.

Robert Wilkinson · Prevention of Future Deaths report View report

21 Oct 2013 County Durham and Darlington A. Tweddle

Robert Wilkinson, a firearms and shotgun certificate holder with a terminal illness, intentionally took his own life using one of his firearms the day after being discharged from hospital. The report raised concerns that there had been no face-to-face meeting with him before the decision to revoke his certificates and that the revocation letter had not been personally served, meaning he retained access to the firearm used.

Mark Stephen Smith · Prevention of Future Deaths report View report

21 Oct 2013 North London A. Walker

Mark Stephen Smith died after intentionally taking an overdose of medication, complicated by ethanol use and underlying health conditions. An ambulance response was delayed, and the report states that this delay was likely to have contributed to his death. The substantive concern was whether clearer guidance and possible supervisor consultation were needed when deciding not to remain on the line with a person who had taken an intentional overdose and was alone.

Brian Belfield · Prevention of Future Deaths report View report

21 Oct 2013 North and West Cumbria R. Chapman

Brian Belfield, aged 63, died from exposure and hypothermia after leaving the Buttermere Sailbeck Fell Race route in poor weather, falling on the fell-side and coming to rest in a pool of water. The race organisers had miscalculated the number of runners and retirees and did not realise he was missing until his wife raised the alarm. Concerns included inadequate recording and checking of participants, unclear responsibility for reconciling race numbers, and unreliable communication between race control and marshals.

Daniel Maurice McMahon · Prevention of Future Deaths report View report

21 Oct 2013 North London A. Walker

Daniel Maurice McMahon suffered severe head injuries after being hit by a train at Willesden Junction Station on 11 January 2012, following reports that he had fallen from a bridge and moved onto the railway track. The report raised concerns about the accuracy and completeness of information recorded by police about the location of a person trespassing on the railway, procedures for stopping trains when an unwell person is on the line, support during mental-health leave, and the use of lung-decompression needles without a valve.