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Craig Steadman · Prevention of Future Deaths report View report

12 Aug 2024 Hampshire, Portsmouth and Southampton R. Rhodes-Kemp

Craig Steadman was in custody at HMP Winchester and had diabetes, a mental health history, and previous self-harming incidents. He was found suspended by a ligature in his cell after a further self-harm incident, and CPR was unsuccessful. The principal concern was that findings and recommendations from investigations into his death were not shared with staff directly involved in his care, limiting the dissemination and implementation of learning.

Geoffrey Stewart Toase and Michael William Midgley · Prevention of Future Deaths report View report

12 Aug 2024 Kingston Upon Hull and the East Riding of Yorkshire J. Swift

On 3 August 2019, Geoffrey Stewart Toase and Michael William Midgley died at the scene of a head-on motorcycle collision on the A166 Garrowby Hill. The collision involved a car travelling wholly on the wrong side of the carriageway, and the driver was considered likely to have been experiencing a hypoglycaemic episode. Concerns were raised about DVLA medical review practices, including limited requests for medical information, insufficient GP forms, inadequate consideration of interacting conditions, lack of verification of self-declarations, and absence of audit of licensing decisions.

Mr Parminder Singh Sanghera · Prevention of Future Deaths report View report

12 Aug 2024 Black Country Z. Siddique

Mr Parminder Singh Sanghera was arrested after displaying erratic behaviour, including running naked, and was taken to hospital before being held in police custody. He was released without charge on 13 February 2023 and was later found deceased in a canal near the custody suite. The principal concern was that, despite his behaviour and vulnerability, no full mental health assessment was undertaken before his release and risk assessments did not identify a risk of suicide or self-harm.

Douglas ARMSTRONG · Prevention of Future Deaths report View report

12 Aug 2024 Liverpool and the Wirral D. Lewis

Douglas ARMSTRONG had an unwitnessed fall at home on 16 December 2023 and sustained a fractured neck of femur that was not identified by care agency responders or a district nurse. His hospital arrival and likely surgery were delayed by around 18 hours, and he died in hospital on 5 January from aspiration pneumonia resulting from the injury. The principal concern was that responders may lack the skills, knowledge, training, or communication needed to identify such injuries or recognise when further assessment is required.

Nimo OSMAN · Prevention of Future Deaths report View report

12 Aug 2024 Inner North London I. Potter

Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

Mr David Thompson · Prevention of Future Deaths report View report

12 Aug 2024 Manchester North J. Kearsley

Mr David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.

Miles Ethan Hurley · Prevention of Future Deaths report View report

9 Aug 2024 West Sussex, Brighton and Hove K. Henderson

Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.

Mary Margaret Horgan · Prevention of Future Deaths report View report

8 Aug 2024 Manchester South A. Farrow

Mary Margaret Horgan fell at home and sustained a traumatic cervical spinal injury with fracture dislocation and severe spinal cord compression. After delays and communication difficulties surrounding MRI interpretation and the Patient Pass referral system, she was transferred to hospital and placed on end-of-life care, dying on 5 June 2023. The principal concern was uncertainty and confusion between medical teams about how Patient Pass operated, which could put patients’ lives at risk.

Emma Pattison and 2 others · Prevention of Future Deaths report View report

8 Aug 2024 Surrey R. Travers

Between 22:49 on 4 February 2023 and 00:40 on 5 February 2023, George Pattison shot and killed his wife, Emma Pattison, and daughter, Ellette Pattison, before shooting himself. The report raises concerns about online medical consultations potentially bypassing disclosure safeguards for shotgun licensing and about obtaining full information concerning coercive controlling behaviour.

Sean Martin DAVIES · Prevention of Future Deaths report View report

8 Aug 2024 Mid Kent and Medway P. Harding

Sean Martin Davies, who was serving an indeterminate sentence for public protection at HMP Swaleside, died by suspension in his cell on 25 February 2023. He had expressed hopelessness and left a note linking his death to the IPP sentence. Concerns included risk assessment and management for prisoners subject to IPP sentences, welfare checks not being conducted in line with guidance or policy, and shortcomings in staff training and handovers.

Mrs Gillian Patricia Stokes · Prevention of Future Deaths report View report

8 Aug 2024 Surrey K. Hayes

Mrs Gillian Patricia Stokes died from sarcoma of the right chest wall after previously receiving radiotherapy for breast cancer and having breast reconstructive surgery with an implant. The report raises concerns about insufficient guidance for identifying radiation-induced sarcoma and imaging the chest wall in patients with implants, the five-year surveillance period after breast cancer, and the failure to arrange a recommended two-week follow-up after aspiration.

Kevin John McDonnell · Prevention of Future Deaths report View report

7 Aug 2024 Nottinghamshire L. Bower

Kevin John McDonnell was discovered deceased in his prison cell on 29 September 2022, having died by ligature asphyxiation; the inquest concluded that he had died by suicide. The principal concerns included failures to conduct planned ACCT reviews and checks, share identified suicide-risk information, provide necessary mental-health support, and preserve accurate documentary evidence after his death.

Malika HIBU · Prevention of Future Deaths report View report

7 Aug 2024 Inner North London M. Hassell

Malika Hibu, a five-year-old girl with autism spectrum disorder, left her home, fell into Regent’s Canal on 17 February 2024, and died after efforts to resuscitate her. The report raised concerns that the canal-side railing did not protect small children, that the housing association had not adequately assessed or acted on safety concerns, and that the development’s planning process had not considered the barrier’s safety.

Mavis DEWEY · Prevention of Future Deaths report View report

7 Aug 2024 South Yorkshire (Western) S. Eccleston

Mavis Dewey, who was 89 and living in residential care, fell at Heeley Bank Care Home after staff used a Zimmer frame instead of the equipment specified in her care plan. She sustained an open fracture to her right tibia and fibula, was diagnosed with Covid-19, and died in hospital on 29 March 2024. The principal concern was that agency staff sometimes failed to read care plans, potentially placing residents at risk.

Martyn Harvey Stringer · Prevention of Future Deaths report View report

7 Aug 2024 Oxfordshire N. Graham

Martyn Harvey Stringer was detained by police after being found at a location where he had ostensibly gone to take his own life, and was assessed as liable for detention under Section 2 of the Mental Health Act. No suitable mental health placement was found, and he later left home and stepped in front of a lorry; he died on 29 March 2023 from multi-organ failure and polytrauma resulting from a road traffic collision. The principal concern was the lack of suitable beds and placements for people requiring compulsory mental health treatment, including the decision not to offer an available Health Based Place of Safety bed to Martyn.

Alfred SPARROW · Prevention of Future Deaths report View report

6 Aug 2024 Worcestershire D. Reid

Alfred Sparrow, who lived with vascular dementia, became a resident at The Meadows Nursing Home on 11 September 2023 and died there on 1 December 2023 after fluctuating food and fluid intake, increasing frailty and a significant deterioration. Concerns included staff not always assisting him with food and fluid intake as required by his care plan, a care-note entry recording that he drank tea about two hours after his death, and the failure of the nursing home manager’s investigation to identify that false entry and the related deficiencies.

Janet Karen HARRISON · Prevention of Future Deaths report View report

5 Aug 2024 Hampshire, Southampton and Portsmouth S. Sharma

Janet Karen HARRISON was found beneath her neighbour’s collapsed wall during Storm Eunice on 18 February 2022 and suffered catastrophic injuries. After hospital admissions and treatment for multiple complications, she died in hospital on 31 August 2022 from hospital-acquired pneumonia. The concern was that other nearby walls had similarly unsafe dimensions and could collapse in future storms of similar force, placing others at risk of death.

Thomas Joseph McAuley · Prevention of Future Deaths report View report

2 Aug 2024 Dorset B. Allen

Thomas Joseph McAuley died after being struck and catastrophically injured by a grab lorry while positioned between its axles during road resurfacing work. The report raises concerns that roadwork crews may continue using the space between LGV axles to urinate, creating a risk of fatal injury from vehicle movement, and that the risk may not have been communicated more widely.

Sophie Jayne Wilson · Prevention of Future Deaths report View report

2 Aug 2024 County Durham and Darlington J. Richards

Sophie Jayne Wilson was found deceased at home on 2 July 2023 following an overdose, after she had disclosed the overdose to the Crisis team and declined assistance from ambulance responders. The principal concerns were that responders were unaware of her multi-agency familiar face plan and that crucial information about capacity, risk and how to support her was not readily accessible to them.

Peter GREGORY · Prevention of Future Deaths report View report

2 Aug 2024 Worcestershire D. Reid

On 25 June 2023, Peter Gregory was fatally injured when the home-built hot air balloon he was piloting suffered a parachute stall during a rapid ascent in a competition race and descended rapidly to the ground. Concerns related to the possible contribution of the balloon’s design to the stall, the absence of CAA guidance on amateur-built balloons, and the lack of CAA regulation or guidance for the safe oversight of competition balloon flying in the UK.