Search PFD Monitor

Nisren Abdul-Karim · Prevention of Future Deaths report View report

11 Sep 2024 Manchester South A. Mutch

Nisren Abdul-Karim had underlying health conditions and developed hallucinations before being admitted to Wythenshawe Hospital, where she sustained a fractured hip in an unsupervised fall. She was transferred to Trafford General Hospital for rehabilitation, continued to deteriorate, and died there on 5 January 2024. The principal concern was that neurology notes recorded on patient pass were difficult to access and contained limited detail, resulting in disjointed neurology care and an unclear overview, particularly at sites without face-to-face neurology services.

James Astley · Prevention of Future Deaths report View report

10 Sep 2024 Manchester South A. Mutch

James Astley had dementia, was immobile, and became increasingly frail following worsening nutrition, fluid intake, and swallowing difficulties. He was admitted to hospital with urosepsis and dehydration and died there on 22 January 2024. The concerns included incorrectly completed MUST documentation, poor-quality fluid and nutrition charts, and limited, insufficiently detailed documentation at the care home.

Amanda Richardson · Prevention of Future Deaths report View report

9 Sep 2024 West Yorkshire Eastern K. McLoughlin

Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.

Ian William Deavall · Prevention of Future Deaths report View report

9 Sep 2024 Greater Manchester West B. Hartley

Ian William Deavall, who had ischaemic heart disease and hypotension, suffered a cardiac arrest in his cell at HMP Forest Bank on 24 January 2023. The emergency cell bell was deactivated by another prisoner, cancelling the alert in the wing office and removing the only indication of the exact cell, so staff became aware of the emergency more by accident than design. The report identifies an ongoing risk because emergency cell bells can still be readily deactivated by other prisoners and no fail-safe measures are currently proposed.

John Francis HOWLETT · Prevention of Future Deaths report View report

6 Sep 2024 Manchester South A. Mutch

John Francis Howlett had severe chronic obstructive pulmonary disease, was bedbound and required oxygen in a care home, where he became increasingly frail with poor nutrition and fluid intake. He developed an infection, was admitted to hospital, and died on 31 January 2024 after continuing to decline. Concerns included his spending 22 hours in an emergency department corridor and the care home’s inadequate systems for robustly monitoring his nutritional status and fluid intake.

Emilia ALLSOPP · Prevention of Future Deaths report View report

6 Sep 2024 Manchester South A. Mutch

Emilia Allsopp, who had dementia and significant cardiac conditions, suffered an accidental fall at her care home. A fracture was not initially diagnosed, but was identified after she returned to hospital the following day; she later developed a lower respiratory tract infection and died at Tameside General Hospital on 15 January 2024. The principal concern was the lack of suitable community-based support, which meant her family could no longer care for her at home and she moved to an unfamiliar care-home environment.

Brandon William Turner · Prevention of Future Deaths report View report

5 Sep 2024 Cornwall and Isles of Scilly A. Cox

Brandon William Turner, who had diagnoses of PTSD and autism, died from suicide on 21 June 2023 at age 21; the recorded cause of death was asphyxia from fatal pressure on the neck. He had been referred to a community mental health therapy pathway, but treatment had not commenced before his death. Concerns included staffing shortages, the absence in Cornwall of a therapeutic alternative to hospital detention for people with complex PTSD/EUPD in crisis, and a lengthy autism assessment waiting list.

Carol Ann Guest · Prevention of Future Deaths report View report

5 Sep 2024 South Yorkshire (Eastern) N. Mundy

Carol Ann Guest died by suicide after hanging herself at home on 24 March 2024, before a planned consultant visit could be arranged following an urgent mental health referral. The principal concerns were inadequate crisis support for patients over 65, delays in sending and responding to the urgent referral, and the provision of a crisis number that was not available to people over 65.

Charles Henry DANIELS · Prevention of Future Deaths report View report

4 Sep 2024 Cheshire J. Devonish

Charles Henry Daniels was admitted to Stepping Hill Hospital in January 2024 after a fall and was later discharged home in March despite being described as clearly unwell. He returned to hospital with an acute on chronic subdural bleed and died on 21 March 2024. Concerns included inadequate nursing record-keeping, failure to alert a doctor to his deterioration before discharge, and the distress caused by his condition and discharge arrangements at home.

Margaret Aitchison · Prevention of Future Deaths report View report

3 Sep 2024 South Yorkshire (Eastern) N. Mundy

Margaret Aitchison, a resident of Broom Lane Care home, accessed a fire door and fell down an unheated stairwell after a fire alarm activation, sustaining traumatic injuries and being found hypothermic; she died from her injuries. The report raised concerns about inadequate resident and fire-exit checks after alarm activations and whether updated procedures had been effectively communicated and implemented.

Samsam Haji Ali Ateye · Prevention of Future Deaths report View report

3 Sep 2024 West London A. Van Dellen

Samsam Haji Ali Ateye died at Harefield Hospital on 12 May 2023 after developing sepsis and multi-organ failure following aortic valve replacement surgery. She had tested positive for Covid-19 on the morning of surgery, with subsequent hospital tests also positive. The substantive concern was the policy for Covid-19 testing before cardiac, specifically valve replacement, surgery.

Terence Harry Clark · Prevention of Future Deaths report View report

30 Aug 2024 East London G. lrvine

Terence Harry Clark, who had an impaired swallow and aspiration pneumonia, was admitted to hospital on 26 October 2023 and died there on 1 November 2023 after sustaining a cardiac arrest while waiting unescorted in an X-ray waiting area. Concerns included the discovery of liquid food in his airway, the unexplained removal and loss of his naso-gastric tube, and the failure to identify the tube’s removal as a significant factor during the patient safety investigation, which impeded investigation of the death.

Wendy Ann AFFORD · Prevention of Future Deaths report View report

30 Aug 2024 Berkshire R. Simpson

Wendy Ann Afford was bedbound and living alone with a package of care before developing worsening pressure damage and an infected pressure ulcer. After hospital treatment and discharge to a care home, her health declined and she died on 15 November 2023. Concerns included inadequate skin-integrity risk assessment and monitoring, incomplete repositioning records, unclear compliance with care plans, insufficient management oversight, and possible inadequate staff training.

Rachel Gibson · Prevention of Future Deaths report View report

30 Aug 2024 Cambridgeshire and Peterborough P. Barlow

Rachel Gibson underwent hip replacement surgery in April 2022 and received an excessive dose of Ropivacaine, after which she suffered an unwitnessed cardiac arrest and irreversible brain damage. She died in hospital on 14 July 2022. The principal concerns were unclear responsibilities for prescribing, checking and administering the local anaesthetic, inconsistent prescription units, and wide variation in similar practices nationally.

Felix Burton HARTLEY · Prevention of Future Deaths report View report

30 Aug 2024 West Sussex, Brighton and Hove J. Andrews

Felix Burton Hartley was born without a heartbeat on 19 February 2023, was resuscitated after around 20 minutes without a heartbeat, and later could not recover from hypoxia and chorioamnionitis. The concern was that variable attendance times for the on-call Neonatology Consultant, covering two geographically separated hospitals, could create a risk of future deaths, although the report did not find the consultant’s attendance time causative or contributory to Felix’s death.

Kasey Beech · Prevention of Future Deaths report View report

29 Aug 2024 Inner South London X. Mooyaart

Kasey Beech attended Medway Maritime Hospital with difficulty breathing and chest pain, was directed to a service with a reported three-hour wait, and later suffered a cardiac arrest after her breathing suddenly worsened. She died at St Thomas’ Hospital on 13 October 2021 following treatment. The report raises concerns that the STREAMing model’s focus on current cardiac-sounding chest pain may delay consideration of other immediately life-threatening causes of deterioration, including infective exacerbation of asthma.

Moira FARNELL · Prevention of Future Deaths report View report

28 Aug 2024 Milton Keynes T. Osborne

Moira FARNELL fell on a broken pavement outside her home on 18 April 2024, hit her head, and was diagnosed with a traumatic subdural haematoma. Her condition deteriorated and she died in hospital on 6 May 2024; her family had contacted the council about the pavement hazard before her death, but it was not repaired.

Mrs Elizabeth Margaret Bury · Prevention of Future Deaths report View report

28 Aug 2024 Staffordshire E. Serrano

Mrs Elizabeth Margaret Bury fell on a speed bump while walking back to her care in Tape Street Carpark, Cheadle, on 15 February 2024 and died at the car park. The report identified concern that the car park had been the source of many falls because of its speed bumps.

Mason John Portman · Prevention of Future Deaths report View report

27 Aug 2024 West Yorkshire (Western) M. Fleming

Mason John Portman was the sole occupant and driver of a vehicle that lost control on 17 December 2023, collided with several objects and vehicles, and came to rest after tumbling across the A672, causing fatal injuries. The principal concern was the absence of road markings and signs advising on appropriate speed or road curvature at the location, with a request to review the road conditions and consider appropriate signage and markings.

Dave Yola Onawelo · Prevention of Future Deaths report View report

27 Aug 2024 East London G. lrvine

Dave Yola Onawelo, who had sickle cell anaemia, became unwell on 30 December 2023 and was later transferred to hospital after developing difficulty breathing. While waiting in the emergency department, he deteriorated, suffered seizures and a cardiac arrest, and resuscitation was discontinued at 19.48. The principal concerns were that he was not adequately identified as critically ill and that earlier fluid resuscitation, blood transfusion and intravenous antibiotics may have resulted in a non-fatal outcome; patient congestion, over-reliance on the NEWS algorithm, and a lack of compassion and clinical curiosity were also identified as contributing factors.