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Christiana Betty Dawson · Prevention of Future Deaths report View report

16 Oct 2024 South Yorkshire (Western) T. Rawden

Christiana Betty Dawson, known as Betty, was a resident at Darnell Grange who experienced at least ten falls and died in hospital on 19 March 2024 after surgery for a fractured neck of femur and with frailty. The concerns included the management of her falls risk, her return to residential care despite acknowledged difficulties managing that risk, and agency staff not being provided with home-specific training, policies or procedures about moving residents after a fall.

Paul Anthony CHASE · Prevention of Future Deaths report View report

15 Oct 2024 Liverpool and the Wirral A. Bhardwaj

Paul Anthony Chase, also known as Paul Anthony Malone, was found deceased hanging in Woolton Woods, Liverpool, on 13 March 2024; the post-mortem examination found the cause of death to be hanging. He had a history of post-traumatic stress disorder and cocaine use, and the inquest concluded that he died by suicide. The report raised concerns about limited mental health, alcoholism and addiction support for veterans, including waits of up to 18 months for some services.

Stephen Charles Stringer · Prevention of Future Deaths report View report

15 Oct 2024 Manchester South A. Mutch

Stephen Charles Stringer developed a hoarse voice from January 2023, but its persistence and deterioration were not recognised as a potential cancer warning sign until October 2023. He was diagnosed in January 2024 with stage 4 squamous cell carcinoma of the glottis and treated palliatively. The report identified concerns about delayed referral, gaps in electronic patient enquiry systems, fragmented oversight of his care, and limited awareness of persistent hoarseness as a possible cancer symptom.

Tamara DAVIS · Prevention of Future Deaths report View report

15 Oct 2024 West Sussex, Brighton and Hove J. Andrews

Tamara Davis attended hospital after being unwell for five days and was treated for suspected chest infection before deteriorating and dying on 13 December 2022 from multi-organ failure associated with bronchopneumonia caused by Influenza A infection. A substantive concern was the use of an overcrowded Emergency Department corridor for patient care, where patients lacked privacy, toilet facilities and confidentiality, and where the area was not designated as a clinical area or included in the nursing staffing template.

Stephen Anthony SLEAFORD · Prevention of Future Deaths report View report

14 Oct 2024 Leicester City and South Leicestershire I. Cartwright

Stephen Anthony Sleaford, a prisoner at Gartree Prison, was found with a ligature around his neck in his cell on 27 October 2022 and was pronounced dead at 08:01. The concerns included inadequate first-aid and CPR training for prison officers, gaps in the earliest emergency response, obscured cell observation panels, and unclear guidance about entering cells during emergencies.

Janet Kathleen SEDDON · Prevention of Future Deaths report View report

14 Oct 2024 North Yorkshire and York C. Cundy

Janet Kathleen Seddon underwent surgery after a CT scan was re-reviewed and found to show abdominal pathology that had not been identified in the initial report. She deteriorated with signs of sepsis and died in hospital on 9 February 2023. Concerns included the delay in identifying the pathology, the absence of a proper assessment of harm, and delays in disclosing the reporting error to her family and the Coroner.

Stephen Frederick DULLING · Prevention of Future Deaths report View report

14 Oct 2024 North Yorkshire and York C. Cundy

Stephen Frederick Dulling, who had Parkinson’s disease, symptoms of dementia and swallowing problems, was admitted to York District Hospital and choked while eating toast, subsequently dying from aspiration pneumonia. Concerns included the response to reported risks before admission and multiple nursing-care lapses during his hospital admission, including the appropriateness of his diet, nutritional monitoring, response to choking and incident investigation.

Caroline Ann STAITE · Prevention of Future Deaths report View report

14 Oct 2024 Herefordshire H. Bricknell

Caroline Ann STAITE was recovered from the River Wye near the Canary Bridge, Hereford, after being reported in the river on 8 March 2024, and was pronounced deceased at 0241 hours on 9 March 2024. The concerns related to the robustness of procedures for considering patients for Mind, and to transparent arrangements for returning patients from Mind to the care of the Neighbourhood Mental Health Team.

Locket Ure Williams · Prevention of Future Deaths report View report

14 Oct 2024 Surrey R. Travers

Locket Williams, aged 15, died from injuries after leaving home and jumping to the road below on the night of 27 September 2021; their death was recognised at 00:01 on 28 September 2021. The report identified concerns about insufficient child psychiatric inpatient capacity, the recording and communication of suicide risk, and CAMHS engagement with multi-agency safeguarding meetings. The inquest found that the death was more than minimally contributed to by delays in assessment, underestimation of suicide risk, and delayed therapeutic treatment.

John Austin FOLLON · Prevention of Future Deaths report View report

14 Oct 2024 South Wales Central G. Kynaston

John Follon was admitted to hospital after an inferior myocardial infarction and underwent coronary stenting. While being monitored after the procedure, a telemetry lead became disconnected; the alarm was silenced without a patient check, and he was later found in cardiac arrest and died despite resuscitation. The report identifies an ongoing risk that patients may remain unmonitored for a significant period, particularly during night shifts, because alarms can be silenced without checking the patient and monitoring is not continuous.

Jennifer Sharren Chalkley · Prevention of Future Deaths report View report

14 Oct 2024 Surrey R. Travers

Jennifer Sharren Chalkley, aged 17, died by suicide on 12 October 2021 after being found hanging in her bedroom. The report identifies concerns about delays and misconceptions affecting Education, Health and Care Plan assessments, failures to transfer safeguarding information promptly when she changed college, and shortcomings in multi-agency assessment, information sharing and support for her mental health needs and suicide risk.

Mia Louise Gauci-Lamport · Prevention of Future Deaths report View report

14 Oct 2024 Surrey K. Henderson

Mia Louise Gauci-Lamport, who had treatment-resistant epilepsy and required full-time residential care, was found cyanotic and unresponsive at around 06.32 hours on 11 September 2023 after not being visually checked when a carer entered her room. Resuscitation was unsuccessful. The report raised concerns about inadequate night-time monitoring, incomplete medical records and insufficient clinical oversight and governance.

Sally Mills · Prevention of Future Deaths report View report

14 Oct 2024 Berkshire P. Malhotra

Sally Mills choked on prescribed medication at home on 23 July 2023 after experiencing difficulty swallowing during its administration, and died later that day in hospital. The principal concerns were gaps in first-aid understanding for an unresponsive person and failures to appropriately escalate difficulties encountered during medication administration.

Oliver Davies · Prevention of Future Deaths report View report

11 Oct 2024 Worcestershire D. Reid

Oliver Davies died by suicide by hanging in his cell at HMP Hewell on 31 December 2022. The concerns included delayed and incomplete mental health assessment, failures to share relevant information about his self-harm and suicide risk, inadequate prioritisation and follow-up by the mental health care coordinator, and failures to keep him informed about healthcare and appointments.

Kingsley Efosa Imafidon · Prevention of Future Deaths report View report

11 Oct 2024 North London L. Bradford

Kingsley Efosa Imafidon, who had homozygous sickle cell disease and suspected liver cirrhosis, underwent a liver biopsy on 29 November 2023. He was found unresponsive at home on 2 December 2023, and the post-mortem examination found extensive fresh haemorrhage into the peritoneal cavity following the biopsy. The concerns included lack of apparent liaison about the relevance of his sickle cell disease, insufficient consideration of additional monitoring, and gaps in the biopsy guidance and procedure for patients with conditions such as HbSS.

Sunnah Summayah Khan and Joseph Ian Abbess · Prevention of Future Deaths report View report

10 Oct 2024 Dorset R. Griffin

On 31 May 2023, 12-year-old Sunnah Summayah Khan and 17-year-old Joseph Ian Abbess entered the waters at Bournemouth East Beach and were later found unresponsive after an intense flash rip current occurred. Both died later that day despite resuscitation attempts. The report raises concerns about public awareness of water risks and the lack of consistent water-safety education for children through the national classroom curriculum.

Florence Elizabeth Catherine STEWART · Prevention of Future Deaths report View report

10 Oct 2024 Milton Keynes T. Osborne

Florence Elizabeth Catherine Stewart, who had been admitted to the Campbell Centre as a voluntary patient following detention under section 136 of the Mental Health Act, suffered a hypoxic brain injury after hanging herself and died at Milton Keynes University Hospital on 23 January 2024. The concerns identified were the failure of high-level intermittent observations to prevent her suicide and an oxygen bottle running out during resuscitation.

Nigel Hutton HAMMOND · Prevention of Future Deaths report View report

9 Oct 2024 Suffolk N. Parsley

Nigel Hammond died at Addenbrooke’s Hospital on 14 March 2024, three days after falling from a window at home and sustaining serious injuries. The inquest concluded that the death was suicide while the balance of his mind was disturbed. The principal concern was that the AMHP could not directly refer Nigel to the Crisis Resolution and Home Treatment Team, and that this may have delayed support before his fatal fall.

Chamali BIBI · Prevention of Future Deaths report View report

9 Oct 2024 Inner North London M. Hassell

Chamali Bibi underwent a right periacetabular osteotomy on 1 March 2023 and suffered haemorrhagic shock during the procedure, followed by a stroke that evening. The principal concern was whether PAOs are being performed by sufficiently experienced surgeons, given limited procedure frequency, gaps in mentor feedback and a voluntary specialist register that may not flag outliers.

David Charles Martin · Prevention of Future Deaths report View report

8 Oct 2024 Cornwall and Isles of Scilly A. Cox

David Charles Martin, an 83-year-old man with progressive heart failure, was admitted to hospital, underwent PCI, collapsed later that day, and died in hospital on 17 September 2022. The principal concerns were inadequate induction for a locum doctor unfamiliar with the Trust’s DAPT policy and multiple missed opportunities to identify and act on the fact that he had been prescribed Aspirin only.