Search PFD Monitor

Chloe HUNT · Prevention of Future Deaths report View report

19 Jun 2024 Essex S. Hayes

Chloe Hunt died in hospital on 15 March 2022 after swallowing pens that caused gastrointestinal obstruction and a fatal cardiac arrhythmia secondary to metabolic derangement. The concerns included insufficient consideration of her trauma-related difficulties in hospital, delays and inadequate planning for removal of the pens, and failure to recognise and respond to her deteriorating clinical condition.

Maureen Alison Woollen · Prevention of Future Deaths report View report

19 Jun 2024 South Yorkshire (Western) T. Rawden

Maureen Alison Woollen was discharged to Deerlands Residential Home after being identified as at high risk of falls. She was later found on the floor, developed facial bruising and reduced food and drink intake, and was admitted to hospital with an intracerebral haemorrhage, from which she died; concerns included missed opportunities to seek medical attention, inadequate care-note use, and failure to conduct a falls risk assessment on admission.

Jacob Lee Shorter · Prevention of Future Deaths report View report

18 Jun 2024 South Yorkshire (Western) M. Whittle

Jacob Lee Shorter, who was receiving support after leaving long-term foster care, died after entering the train tracks at Heeley Loop in Sheffield on 1 January 2024 and being struck by a train. The report raised concern that an independent visitor’s knowledge of Jacob’s previous suicidal ideation was not shared with his foster carer or other relevant people, and that the training and escalation arrangements for such disclosures were unclear.

William Richard STOCKIL · Prevention of Future Deaths report View report

18 Jun 2024 West Sussex, Brighton and Hove J. Andrews

William Richard Stockil was admitted to hospital after being found on the floor at home following a long lie, with rhabdomyolysis and dehydration. An electronic prescription error and ineffective alerts resulted in his antibiotics stopping before further antibiotics were prescribed when signs of infection developed; he died from pneumonia. The report identified a risk that medications may cease when they should be continued if no prescribing clinician accesses the patient’s records.

STEFAN WALKER · Prevention of Future Deaths report View report

17 Jun 2024 Swansea and Neath Port Talbot E. Ramsay

STEFAN WALKER was a detained patient receiving inpatient psychiatric treatment when he became unresponsive in his room on 29 June 2020 after concerns that he had consumed illicit substances and was physically unwell. The inquest concluded that his death was drug related, with the medical cause given as buprenorphine and flualprazolam intoxication and cardiac enlargement. The principal concern was that paramedics did not carry flumazenil, which might be needed in acute circumstances involving certain benzodiazepines.

Amina Ahmed Ismail · Prevention of Future Deaths report View report

14 Jun 2024 Manchester South A. Bridgman

Amina Ahmed Ismail, aged 19, died on 15 September 2023 at Pankhurst Ward, Priory Hospital Cheadle, after self-ligaturing; the medical cause of death was ligature strangulation. The report describes her prolonged stay in a PICU, deterioration in her mental health, shortages of appropriate specialist care beds, and delays in arranging and funding a suitable placement as concerns contributing to the circumstances of her death.

Eric Thompson · Prevention of Future Deaths report View report

14 Jun 2024 North Wales (East and Central) K. Robertson

Eric Thompson presented with confusion and poor mobility and was found to have high potassium levels. The results were not initially documented or escalated, he did not receive treatment for hyperkalaemia, and he subsequently suffered cardiac arrest and died; the report identified concerns about reliance on person-to-person communication without an electronic alert system for abnormal laboratory results.

Michael HARRISON · Prevention of Future Deaths report View report

14 Jun 2024 Cheshire J. Devonish

Michael Harrison, a scaffolding-firm driver, died after a HIAB crane arm came down on him while he was unloading scaffolding on 26 February 2021. The concerns included the remote control not being isolated, the potential for inadvertent crane operation, and the absence of an obvious audible sound when the crane arm was operated.

Christopher Henrik LARSEN · Prevention of Future Deaths report View report

13 Jun 2024 Rutland and North Leicestershire I. Thistlethwaite

Christopher Henrik Larsen, a 52-year-old man, was found hanging at his home in Leicestershire on 6 January 2023 and died before a planned mental health triage call. Concerns included inadequate documentation and decision-making in multidisciplinary team meetings, inaccurate interpretation of risk information, insufficient risk assessment and discharge planning, and weaknesses in the serious incident investigation and learning process.

Linda MCLAUGHLIN · Prevention of Future Deaths report View report

13 Jun 2024 Manchester South A. Mutch

Linda McLaughlin was treated for chronic myeloid leukaemia with nilotinib and later developed interstitial lung disease, probably as a consequence of the treatment. She was admitted with bronchopneumonia and died at Tameside General Hospital on 27 October 2023. Concerns included limited awareness of this rare complication, consent processes that may not mention it, and a lack of clear guidance on stopping treatment when patients are in remission.

Harry Roland Ian Vass · Prevention of Future Deaths report View report

13 Jun 2024 Avon M. Voisin

Harry Roland Ian Vass attended Southmead Hospital on 26 December 2022 with agitation, paranoid thoughts and recent cocaine use, and was later admitted to the Mason Unit. He became unresponsive after vomiting, low oxygen saturations, a high temperature and discolouration of his extremities, and died after transfer back to the emergency department. Concerns included inadequate physical and non-contact observations, and a lack of awareness among mental health nursing staff that acute behavioural disturbance is a medical emergency.

Joseph Lawrence Parker · Prevention of Future Deaths report View report

13 Jun 2024 Avon M. Voisin

Joseph Lawrence Parker took an overdose of medication on 17 February 2022, collapsed, and was taken to Southmead Hospital for intubation. The breathing tube was accidentally positioned in the oesophagus and the misplacement was not identified promptly, contributing to cardiac arrest, hypoxic encephalopathy, and his death on 16 April 2022. The principal concerns relate to recognising incorrect tube placement, the use and interpretation of capnography, and the dissemination of relevant airway-management guidance.

Graham FAULKNER · Prevention of Future Deaths report View report

13 Jun 2024 Cheshire E. Wheeler

Graham Faulkner was exposed to caustic soda at work in October 2015, later developed paraplegia, and died in 2019 from sequelae of the injury. The principal concern was that the HSE did not promptly investigate the incident, resulting in evidence being unavailable or delayed and making it harder to establish the facts and learn from the death. The inquest conclusion also referred to failures in the administration and management of the Permit to Work process and a lack of challenge around PPE.

Beryl Dandridge · Prevention of Future Deaths report View report

12 Jun 2024 Oxfordshire N. Graham

Beryl Dandridge fell at her nursing home on 23 January 2024 and sustained a periprosthetic hip fracture. Her ambulance attendance and surgery were delayed, including a delay while an echocardiogram was considered necessary; she underwent surgery on 27 January and died on 28 January 2024. Concerns related to conflicting clinical views about the need for echocardiography, responsibility for expediting it, and the subject expertise involved in the structured mortality review.

Louise Helen Jones · Prevention of Future Deaths report View report

12 Jun 2024 Cornwall and Isles of Scilly G. Davies

Louise Helen Jones was found deceased at home on 1 October 2023. The inquest recorded respiratory depression and opiate drug use, following an unintentional overdose involving morphine and bromazalam alongside other central nervous system depressant drugs. Concerns included the absence of an agreed opioid treatment and end-of-treatment plan, practice policies for long-term opioid prescribing and opioid–benzodiazepine co-prescribing, and warning flags after three months of morphine prescription.

Yuri Hatton · Prevention of Future Deaths report View report

11 Jun 2024 Inner West London P. Malhotra

Yuri Hatton, who was detained at HMP Wandsworth, died in hospital on 9 November 2018 after being found unresponsive following a suspected opiate overdose and later showing features of brain stem death. The jury identified four failures that cumulatively possibly contributed to his death, including failures involving emergency response, clinical observations and communications. The report also raised concerns about limited OSG training, the frequency and monitoring of first aid training, and the lack of prison-specific training on recognising unconsciousness.

Juan David Martin · Prevention of Future Deaths report View report

11 Jun 2024 Inner West London P. Malhotra

Juan David Martin, who had been detained under the Mental Health Act and was awaiting an appropriate mental health bed, was evacuated from a hospital assessment suite during a fire alarm and ran away. He was later witnessed allowing himself to fall from height and was confirmed deceased on 13 April 2022. The principal concern was that inadequate mental health bed capacity in London created a genuine risk of future deaths.

Daniel Beckford · Prevention of Future Deaths report View report

11 Jun 2024 Inner West London P. Malhotra

Daniel Beckford was detained at HMP Wandsworth and was found hanging in his cell after taking an overdose of prescribed antibiotic medication. He was transferred to St George’s Hospital, where he was declared deceased. The report identified concerns about the provision and content of first aid training, including a lack of clarity about the use of rescue breaths during resuscitation attempts.

Margaret Ann PILGRIM · Prevention of Future Deaths report View report

10 Jun 2024 Essex S. Hayes

Margaret Ann Pilgrim died at Princess Alexandra Hospital on 29 June 2023 from congestive cardiac failure and bronchopneumonia, against a background of frailty, after an unwitnessed fall at home caused a fractured clavicle. The fracture was reported on an X-ray during her hospital admission but was not noted on her discharge summary. Concerns included the absence of treatment, pain relief, care-package consideration and fracture-clinic follow-up, and the failure to inform the patient, her family or GP about the fracture.

Sailor (previously known as Sara) COURT · Prevention of Future Deaths report View report

10 Jun 2024 South London S. Naughton

Sailor (previously known as Sara) COURT, aged 14, died by suicide on 17 September 2021 after taking an overdose at home while on the CAMHS waiting list for treatment. The principal concerns were unacceptably long waits for assessment and treatment, which had not improved and were attributed to insufficient resources relative to demand.