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Ryan Louis Ouslem · Prevention of Future Deaths report View report

24 Sep 2024 West Sussex, Brighton and Hove R. Simpson

Ryan Louis Ouslem was found deceased at home on 1 August 2022 after previously posting a Facebook message that raised concerns for his welfare and indicated that his flat was unsafe to enter. The report raises concerns about police mental-health training and assessment, the sharing of relevant information between police and mental-health services, and the lack of joint training under new working arrangements.

Kelly Marie STEVENS · Prevention of Future Deaths report View report

24 Sep 2024 Worcestershire D. Reid

Kelly Stevens, who had profound learning and physical disabilities and received nutrition, hydration and medication via a PEG tube, was admitted to hospital on 28 December 2023. She suffered a seizure on 3 January 2024 caused by an excessively low, unrecognised sodium level, aspirated vomit, developed aspiration pneumonia and died in hospital later that night. Concerns included the absence of clear overall consultant responsibility, failure to monitor electrolytes and record fluid intake and output properly, and the copying of outdated care plans in her notes.

George Neville Coulthard · Prevention of Future Deaths report View report

24 Sep 2024 Manchester South A. Mutch

George Neville Coulthard sustained skin wounds after an accidental fall, experienced gastrointestinal bleeds while in hospital, and later deteriorated and died at Bramhall Manor on 27 January 2024. The principal concerns were delays in discharge due to difficulty finding a suitable care home, ineffective communication about whether he required end-of-life care or rehabilitation, failure to clarify care arrangements, and limited community access to wound-care support.

DENNIS RICHARD HARRY · Prevention of Future Deaths report View report

22 Sep 2024 Cornwall and Isles of Scilly G. Davies

Dennis Richard Harry died at Royal Cornwall Hospital on 10 January 2023 from heart disease and Covid-19 infection following an 18-hour-and-50-minute ambulance delay, including delays in response and hospital handover. The report identified systemic concerns about inadequate social care, community hospital provision and primary healthcare support contributing to delayed discharges, ambulance delays and emergency department crowding. It also identified no single organisation with responsibility for ensuring sufficient social care provision or overseeing patient safety risks from ambulance delays.

Susan Dear · Prevention of Future Deaths report View report

20 Sep 2024 Berkshire H. Godfrey

Susan Dear developed abdominal pain and, after a prolonged wait for an ambulance, was driven to hospital by her family, where she was recognised as deceased shortly after arrival on 4 January 2023. The principal concerns were severe ambulance delays caused by insufficient available resources, chronic staffing and capacity pressures, hospital handover delays, and continuing risk that emergency ambulance demand would outstrip resources.

Margaret Rose MAYCROFT · Prevention of Future Deaths report View report

20 Sep 2024 Worcestershire D. Reid

Margaret Rose Maycroft was readmitted to Worcestershire Royal Hospital after falls and was found to have suffered an ischaemic stroke. During her admission, she sustained further falls resulting in a displaced fractured neck of femur, underwent surgery, and later died at Princess of Wales Community Hospital, Bromsgrove, while receiving palliative care. The principal concern was that, although falls risk assessments were completed, no falls prevention measures were documented or put in place, and there was no evidence that this issue had since been addressed.

Suzanne Rose Eccles · Prevention of Future Deaths report View report

19 Sep 2024 Manchester South C. Morris

Suzanne Rose Eccles died on 3 March 2024 at Tameside General Hospital after developing pneumonia and empyema following recent surgery for lung cancer; her death was also contributed to by ischaemic heart disease. The report identified concern that Emergency Department clinicians could not easily access records made by colleagues on the Virtual Ward.

Gordon Long · Prevention of Future Deaths report View report

19 Sep 2024 East London G. Irvine

Gordon Long was admitted to hospital on 1 July 2023 with suspected dry gangrene of the left foot, was assessed by a vascular specialist on 6 July, underwent amputation on 7 July, and died on 8 July 2023. The concerns were the unexplained delay in referral to the vascular team, shortcomings in the patient safety investigation, and the lack of clear evidence that an action plan had resulted in changed practice.

Peter Ivor Jeffery · Prevention of Future Deaths report View report

19 Sep 2024 Somerset S. Marsh

Peter Ivor Jeffery, aged 68, entered the water at Burnham-on-Sea on 29 October 2023 to assist a stranger and her dog in distress and was overcome by a rip tide. He was unable to be rescued and his body was discovered near Stert Island on 12 November 2023. The report raises concerns that the risks of entering the water, including undercurrents and rip tides, were not prominently and clearly displayed to people without local knowledge, particularly outside the season when additional signage or flags were absent.

Evelyn Grace March · Prevention of Future Deaths report View report

19 Sep 2024 West Yorkshire Eastern K. McLoughlin

Evelyn Grace March was born after a prolonged labour and was discharged home with her parents four hours later. The following night, while being breastfed in her mother’s bed, she was found unresponsive and could not be revived. The report raises concerns about maternal exhaustion, the early discharge after prolonged labour, and the risk of accidental suffocation while a sleeping adult was in bed with the baby.

Robin van Caliskan · Prevention of Future Deaths report View report

18 Sep 2024 Cornwall and Isles of Scilly A. Cox

Robin van Caliskan, aged five, drowned in the main pool at Atlantic Reach holiday park on 31 July 2023 after being briefly unsupervised; resuscitation was unsuccessful. The principal concern was that the pool operated without lifeguards, despite being busy and close to maximum capacity, and an enforcement officer considered the company’s approach borderline and said more should be done.

David Paul Power · Prevention of Future Deaths report View report

18 Sep 2024 Manchester South A. KC

David Paul Power, aged 28, intentionally took his own life by hanging on 7 August 2023 after a decline in his mental health. The report found that his deterioration was exacerbated by a letter incorrectly discharging him from a neighbourhood mental health team. Concerns included differing definitions of “stability” between services, which prevented access to talking therapies, and a lack of evidence that subsequent team actions had been embedded or audited.

Ali Mohammed Nazemi · Prevention of Future Deaths report View report

18 Sep 2024 West Yorkshire Eastern O. Longstaff

Ali Mohammed Nazemi died from natural causes at Pinderfields Hospital on 18 January 2024 after an acute stroke and aspiration. His transfer from home was delayed when he and paramedics became trapped in a lift, raising concern that the lift’s uncontrolled movement device could be unintentionally activated without a way to reset it, leaving people dependent on Fire & Rescue Service rescue.

Helen Jane Kerr · Prevention of Future Deaths report View report

18 Sep 2024 Surrey C. Topping

Helen Jane Kerr had a history of drug and alcohol abuse, developed psychosis, and died by hanging after being found dead at a refuge on 3 April 2023. The report identified concerns about failures to respond appropriately and promptly to information about her deteriorating mental health, inadequate assessment and treatment, limited out-of-hours information sharing, and failure to inform the refuge about risks associated with her presentation.

Sara GRINNELL · Prevention of Future Deaths report View report

17 Sep 2024 South Wales Central P. Morgan

Sara Grinnell experienced excessive vaginal bleeding and menorrhagia, with repeated referrals to gynaecology before being diagnosed with endometrial cancer in June 2021. A planned hysterectomy was postponed, her treatment options became palliative, and she died on 11 April 2022. The principal concerns were delays exceeding 22 weeks in contacting her after an urgent referral, reliance on written correspondence without further contact methods, insufficient regard to earlier referrals, and a 24-month delay between urgent referral and diagnosis.

Philip Gordon Ross · Prevention of Future Deaths report View report

16 Sep 2024 Surrey S. Ridge

Philip Gordon Ross suffered a fall at home on 3 December 2023 and was unable to move while awaiting an ambulance. His ambulance call was not clinically validated or re-triaged promptly, and the ambulance arrived at around 02:30 hours after his condition had deteriorated. He later died in hospital on 19 December 2023 from multiple organ failure caused by rhabdomyolysis and bronchopneumonia precipitated by the fall. The principal concern was that late re-triage or clinical validation of Category 3 and 4 ambulance calls may place patients at risk of early death.

Samuel Finlay Parkin · Prevention of Future Deaths report View report

16 Sep 2024 Inner West London E. Oakley

Samuel Finlay Parkin died on 16 September 2022 from hypoxic brain injury following a cardiac arrest caused by midgut volvulus. The volvulus resulted from undiagnosed intestinal malrotation, which had been present since birth and was not identified despite repeated symptoms and hospital attendances. The principal concerns included failure to undertake appropriate diagnostic testing, false reassurance from ultrasound reporting, inadequate safety-netting advice, and communication and learning issues between clinical teams.

Laura Lesley FARMER · Prevention of Future Deaths report View report

16 Sep 2024 Inner North London M. Hassell

Laura Farmer was admitted to hospital after a diarrhoeal illness and was diagnosed with HUS caused by Shiga toxin-producing E. coli. She suffered an unexpected stroke while thought to be recovering and died as a consequence. The report raises concerns about public-health investigation and communication, including limited information-gathering, lack of feedback to clinicians and family, and insufficient advice on infection-control and safety.

Paul Rodney Batchelor · Prevention of Future Deaths report View report

13 Sep 2024 Surrey S. Ridge

Paul Rodney Batchelor, a frail elderly man in a care home for respite care, became wedged after a mattress extension fell through the frame of his extended nursing bed and died of positional asphyxia and bronchopneumonia. His cries for help went unattended for over an hour. The concerns were inadequate support for mattress extensions on extended beds and the lack of formalised procedures for staff responding to distressed residents at night, including when staff are frightened or concerned about entering a room alone.

Emma Victoria HARPER · Prevention of Future Deaths report View report

11 Sep 2024 Manchester West M. Pemberton

Emma Victoria HARPER died on 4 May 2024 after falling from a footbridge onto a crash barrier beside the M602 motorway; the inquest concluded that her death was suicide. Concerns were raised that the bridge had not been included in works to increase barrier heights or otherwise prevent people at risk from falling onto the motorway, and that the basis for its exclusion was unclear.