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Joanna Kowalczyk · Prevention of Future Deaths report View report

22 Jan 2025 Gateshead and South Tyneside L. Benyounes

Joanna Kowalczyk developed neurological symptoms after chiropractic neck manipulation following an earlier neck injury and hospital attendance, and was later diagnosed with vertebral artery dissection and extensive posterior fossa infarction. She died at Queen Elizabeth Hospital on 19 October 2021. Concerns included a paramedic’s lack of awareness that stroke symptoms can resolve temporarily, and the chiropractor’s failure to obtain medical or hospital records before treatment despite the recent hospital attendance and recommended investigations.

Nathan Harry SHEPHERD · Prevention of Future Deaths report View report

22 Jan 2025 Manchester South A. Mutch

Nathan Harry Shepherd died in hospital on 16 January 2024 after being found suspended from a ligature in his room at approved premises, following an unsuccessful attempt to gain immediate entry because the room had been barricaded. The inquest concluded that the death was suicide, with medical cause of death recorded as hypoxic brain injury and hanging. Concerns included the lack of policies and training for barricaded-room incidents, movable furniture that enabled barricading, ligature points, inadequate assurance of agency staff first-aid and CPR capability, and ineffective sharing of risk information.

Fahmida Khanam · Prevention of Future Deaths report View report

22 Jan 2025 West Yorkshire Eastern K. McLoughlin

Fahmida Khanam died on 12 November 2024, and a post-mortem attributed her death to natural causes. The report states that her husband had been treating her, and raises the concern that a doctor should not treat a close relative; it does not suggest suspicious conduct.

Reginald Victor Smith · Prevention of Future Deaths report View report

21 Jan 2025 Dorset R. Middleton

Reginald Victor Smith suffered a witnessed fall at his care home and underwent surgery for a fractured neck of femur. After failure of the metalwork, he underwent revision surgery, received palliative care, and died in hospital on 7 December 2023. Concerns included the possible loosening or deformation of a repeatedly used surgical jig, its loss while sent for manufacturer analysis, and the absence of quality control or auditing of jig integrity before surgery.

Carl Anthony Butler and Sean Brett · Prevention of Future Deaths report View report

21 Jan 2025 North Wales (East and Central) J. Gittins

On 26 February 2022, Carl Anthony Butler drove the wrong way along the A55 while intoxicated and collided with Sean Brett’s vehicle, resulting in both men’s deaths. Concerns were raised about the handling and acknowledgement of reports by Cheshire Constabulary, processes for adding vehicles to the ANPR/Vehicle Finder System, and delays in providing relevant training.

Paul Williams · Prevention of Future Deaths report View report

21 Jan 2025 Manchester South A. Mutch

On 9 July 2024, Paul Williams was found suspended from a ligature outside Screwfix, with police finding no suspicious circumstances. The inquest concluded that his death was suicide, with hanging recorded as the medical cause of death. The report identified eviction, homelessness, separation from his family while awaiting accommodation, and the resulting impact on his mental health as substantive concerns.

Student A · Prevention of Future Deaths report View report

20 Jan 2025 Inner North London I. Potter

Student A was found unresponsive in his student accommodation on 28 July 2024 and paramedics verified his death shortly thereafter; the medical cause was asphyxiation and the inquest conclusion was suicide. The principal concerns were delays in carrying out the welfare check and calling emergency services, limited assessment of Student A’s condition, failure to provide basic assistance or first aid, and possible inadequacy or ineffectiveness of staff training and procedures.

Donald John Drummond MITCHELL · Prevention of Future Deaths report View report

17 Jan 2025 South Wales Central P. Morgan

Donald John Drummond Mitchell was cycling home from work on 17 December 2020 when he was struck by a vehicle on the A48 and suffered catastrophic head injuries. The concern was that the road between Ewenny and Pyle had a history of fatal and serious collisions, including collisions involving cyclists, and lacked an active travel route or modifications specifically supporting cyclist safety, creating a risk of future deaths unless action was taken.

Vauna LEEMING · Prevention of Future Deaths report View report

17 Jan 2025 Worcestershire D. Reid

Vauna Leeming was admitted to hospital after an accidental fall at home that caused a fractured right neck of femur. After surgery, her condition deteriorated, she tested positive for Covid-19, suffered a pulmonary embolism and died in hospital. Concerns included incomplete documentation of anticoagulation and compression-stocking measures, failures to report omissions, and insufficient awareness among employed and agency nurses of these duties.

Jackson Yeow · Prevention of Future Deaths report View report

17 Jan 2025 South Wales Central D. Regan

Jackson Yeow, aged 16, became seriously unwell with abdominal pain and vomiting and later developed diabetic ketoacidosis and other complications. He waited approximately 9½ hours for an ambulance after his family called 999, and died on 9 April 2022. Concerns included delays in ambulance handovers associated with emergency department overcrowding, corridor care, and delayed discharge of medically fit patients.

Ian Paul HARRIS · Prevention of Future Deaths report View report

16 Jan 2025 Shropshire, Telford and Wrekin J. Ellery

Ian Paul Harris was driving on the A483 at Sweeney, Oswestry, on 23 August 2024 when his car collided with an oncoming heavy goods vehicle after he lost control, most likely due to a medical condition. The report raises concerns that he provided inaccurate information about his medical condition when renewing his HGV licence, and that an independent GP completed the medical examination without access to his medical records. It questions whether drivers should be required to obtain the report from their own GP or whether independent GPs should have access to relevant medical records.

Alexander Charles Edward Thomas · Prevention of Future Deaths report View report

16 Jan 2025 Manchester South A. Farrow

Alexander Charles Edward Thomas died on 14 August 2024 after entering the eastbound carriageway of the M56 motorway and being struck by a heavy goods vehicle. Concerns included accessible routes from a pedestrian walkway and track to the motorway's crash barrier, and a lack of fencing to prevent access onto the motorway along that stretch.

Robert John McGowan · Prevention of Future Deaths report View report

15 Jan 2025 Manchester South C. Morris

Robert John McGowan died at Stepping Hill Hospital, Stockport, on 13 August 2024 from complications arising from partially treated spontaneous bacterial endocarditis, against a background of autism and complex mental health needs. The concern was that cultural, structural and systemic barriers to accessing physical healthcare contributed to the bacterial endocarditis being only partially treated, despite advocacy, individual adjustments and a Health Passport.

Sheila Josephine WEXLER · Prevention of Future Deaths report View report

15 Jan 2025 Inner North London I. Potter

Sheila Wexler lived with dementia and other significant comorbidities and died at home on 17 February 2024 from bilateral pulmonary embolism. Delays in supplying equipment and the provision of defective turning equipment significantly increased her immobility, contributing to her death. The report identified ongoing concerns about delays and defective equipment supplied by NRS Healthcare, including wider risks affecting other patients.

Tammy Denise Milward · Prevention of Future Deaths report View report

15 Jan 2025 Surrey S. Ridge

Tammy Denise Milward, who had severe obsessive compulsive disorder and dependence on prescribed medication, was found unresponsive at home on 1 January 2024 after concerns were raised about her wellbeing. The medical cause of death was mixed drug toxicity, with toxicology showing prescribed medication in excess of prescribed levels and cocaine use shortly before her death. The principal concern was limited coordination and communication between primary and secondary care providers, including poor connectivity between their electronic record systems.

Anugrah Abraham (“Anu”) · Prevention of Future Deaths report View report

14 Jan 2025 Manchester North J. Kearsley

Anugrah Abraham (“Anu”), a serving West Yorkshire police officer, died by hanging on 4 March 2023 after leaving home the previous afternoon; the inquest recorded a conclusion of suicide. The report identified concerns about the management of his mental health, including delayed and inadequate Occupational Health responses, unclear action when he disclosed suicidal thoughts, poor information sharing, and aspects of the PCDA and Regulation 13 processes.

Angela Stacey Carney · Prevention of Future Deaths report View report

13 Jan 2025 West Yorkshire (Western) M. Fleming

On 26 September 2023, Angela Stacey Carney suffered fatal injuries after her mobility scooter travelled at speed down Westcliffe Road and into the path of a pickup at a junction. The scooter was in freewheel mode, which prevented braking, and the report raised concerns about the absence of an independent fail-safe braking mechanism and the safety of older second-hand mobility scooters.

Joseph Samuel Walsh and Tobias Crowther Barraclough · Prevention of Future Deaths report View report

13 Jan 2025 West Yorkshire (Western) M. Fleming

Joseph Samuel Walsh was driving a car carrying four passengers after alcohol and cocaine had been consumed when the vehicle collided with a wall on 20 October 2023. Joseph died at the scene, and Tobias Crowther Barraclough later died from his injuries on 12 November 2023; the surviving passengers were injured. The report raises concerns about the absence of legal restrictions on young or newly qualified drivers and the carrying of young passengers in circumstances such as these.

Diane POOLE · Prevention of Future Deaths report View report

13 Jan 2025 Liverpool and the Wirral A. Rebello

On 31 August 2024, Diane Poole left Victoria House Care Home through a faulty emergency escape door whose alarm did not sound, and staff were unaware she was missing for three hours. She was found after an unwitnessed fall, sustained head and facial fractures, and died on 23 September 2024; the fall and injuries contributed more than minimally to her death. The principal concerns were the defective emergency exit door and staff’s lack of awareness that she was missing.

June LIDDELL · Prevention of Future Deaths report View report

13 Jan 2025 West Sussex, Brighton and Hove J. Andrews

June Liddell underwent cardiac surgery involving a heart-lung bypass machine on 21 March 2023. The machine’s automated electronic remote clamp malfunctioned and unexpectedly stopped the circulation of oxygenated blood, causing a hypoxic brain injury; she died on 1 April 2023. Concerns included an error message and loss of clamp-control icons not being adequately explained in the instructions, and maintenance not identifying wear and tear in the clamp.