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Ellen Mercer · Prevention of Future Deaths report View report

26 Apr 2024 Berkshire H. Connor

Ellen Mercer attended Wexham Park Hospital by ambulance in the early hours of 9 February 2023 after deterioration associated with her mental health, nitrous oxide use, leg injuries and reduced mobility. She died in the emergency department approximately 24 hours after arriving; a post-mortem examination identified bilateral pulmonary artery thromboembolus and deep vein thrombosis. The substantive concerns relate to the absence of a formal VTE risk assessment and uncertainty in hospital policies about when the 24-hour period for such an assessment begins, particularly for patients waiting in emergency departments.

Charlie Millers · Prevention of Future Deaths report View report

26 Apr 2024 Manchester North J. Kearsley

Charlie Millers was detained under the Mental Health Act and was found in his room with a ligature after returning from home leave; he died five days later in hospital. The report raises concerns about whether required observations were carried out and documented, and about the effectiveness and independence of investigations into such deaths. It also identifies a lack of oversight across previous concerns and investigations.

Orlando NOVA DAVIS · Prevention of Future Deaths report View report

26 Apr 2024 West Sussex, Brighton and Hove P. Schofield

Orlando Nova DAVIS suffered an irreversible brain injury after his mother developed unrecognised hyponatremia and seizures during labour, restricting oxygen before his birth. He died aged 14 days on 24 September 2021; the principal concerns were a lack of recognition and understanding of hyponatremia among midwives and clinicians, and inaccurate recording of fluid input and output despite additional fluids being given.

Dr Jonathan Harvey Shaw · Prevention of Future Deaths report View report

25 Apr 2024 Manchester North C. McKenna

Dr Jonathan Harvey Shaw took his own life by intentionally ingesting the contents of a package purchased online from a Malaysian company. The package had been stopped by UK Border Force but was released without consultation with Greater Manchester Police, after which Dr Shaw used its contents to end his life. The report identifies concerns about the 30-day limit on holding the consignment and the absence of national guidance or training for police and UK Border Force on managing such consignments and coordinating welfare checks or safe destruction.

Mr David WELLINGTON · Prevention of Future Deaths report View report

25 Apr 2024 Black Country J. Lees

Mr David Wellington died at the scene after being struck by a reversing Renault box van while he was a pedestrian on a service road in Walsall on 12 December 2023. The concerns included the absence of a designated pedestrian route, road markings, pedestrian separation, warning signs and a speed limit, as well as obstructions affecting pedestrian visibility and emergency-service access.

Richard Carpenter · Prevention of Future Deaths report View report

25 Apr 2024 Wiltshire and Swindon D. Ridley

Richard Carpenter underwent major cardiac surgery on 19 November 2021 and was discharged home on 28 November. After developing increasing left-sided pain late on 30 November, he became unresponsive and died at home at 05:00 on 1 December 2021, following a postoperative bleed. The principal concern was that delays in Category 2 ambulance responses, linked in part to hospital bed shortages and delayed discharges, could increase the risk of otherwise preventable deaths, although no causal link was found between the delay and Richard’s death.

Ash BANNISTER · Prevention of Future Deaths report View report

25 Apr 2024 Leicester City and South Leicestershire I. Thistlewaite

Ash Bannister, a 16-year-old who was gender neutral, died in a residential care home on 7 August 2021 after being found hanging. Principal concerns included the removal of Ash’s personal Ligature Risk Assessment without documented reasons, inadequate documentation and communication, inconsistent waking-night cover, failure to follow the support plan, staff training gaps, and an investigation process described as not fit for purpose.

Derek HAND · Prevention of Future Deaths report View report

24 Apr 2024 Derby and Derbyshire A. Davies

Derek HAND experienced continued bleeding after a tooth extraction while taking Clopidogrel, lost consciousness, and was admitted to hospital. Although his condition initially improved, he later developed swallowing difficulties and aspiration pneumonia, deteriorated, and died on end-of-life care. The principal concern was whether current guidance should require blood testing before dental procedures for patients taking Clopidogrel to identify a risk of excess bleeding.

Nicholas Kim Harrison · Prevention of Future Deaths report View report

24 Apr 2024 Swansea and Neath Port Talbot K. Heaven

Nicholas Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.

Shahida KHAN · Prevention of Future Deaths report View report

24 Apr 2024 Hampshire, Portsmouth and Southampton J. Pegg

Shahida KHAN died on 17 December 2022 at Cloverdale Care Home after being given substantial quantities of prescribed medication, causing toxicity and respiratory depression. She had epilepsy and suffered three seizures immediately before her death. It could not be ascertained how she came to be given toxic and fatal quantities of medication, raising a concern about the risk of recurrence for other people in the care home.

Olayemi Oluwarotimi Kodjo Kehinde · Prevention of Future Deaths report View report

24 Apr 2024 East London G. Irvine

Olayemi Oluwarotimi Kodjo Kehinde, a 34-year-old man with a history of schizophrenia illness, walked into fast-moving traffic on 26 October 2023, was struck by a van, and later died from his injuries. Concerns related to staff supervision of escorted leave and the Trust’s ability to identify incidents requiring meaningful intervention or a full governance investigation.

Nuliyati BUSINJE · Prevention of Future Deaths report View report

23 Apr 2024 Cheshire V. Davies

Nuliyati Businje was an inpatient on a psychiatric unit when, after abnormal observations and worsening hyperglycaemia during her admission, she suffered a cardiac arrest. Post-mortem examination found a massive pulmonary embolus due to deep venous thrombosis. The concerns included limitations in VTE risk assessment for patients with risk factors other than reduced mobility, insufficient recognition of increased DVT risk among psychiatric inpatients, and inadequate awareness of how clot-related observations may normalise.

Emanuel Kolade LADAPO · Prevention of Future Deaths report View report

23 Apr 2024 Inner North London M. Hassell

Emanuel Kolade Ladapo had paranoid schizophrenia and depression and was receiving treatment from Camden & Islington services. He died by suicide, with the medical cause recorded as asphyxiation via a plastic bag and inhalation of nitrogen gas. Concerns included a lack of engagement with his sister, and failures to ask about suicidal feelings when he had deteriorated and remained depressed, including a failure of the initial management review to identify the omission.

Ronald Henry SPENCER · Prevention of Future Deaths report View report

23 Apr 2024 Birmingham and Solihull A. Hodson

Ronald Henry Spencer had an oesophageal stent placed on 13 November 2023, which migrated into the small bowel and caused a suspected bowel perforation. He underwent surgery to remove the stent and repair the bowel, initially recovered, then deteriorated and died on 2 December 2023. The report raised concerns about significant staffing issues and resulting delays in treatment, as well as inadequate cohesive planning for short- and long-term staffing pressures; it stated there was no direct evidence that the delays caused or contributed to his death.

Ashley Crews · Prevention of Future Deaths report View report

23 Apr 2024 Manchester City Z. Golombeck

Ashley Crews died on 20 February 2024 from injuries sustained in a fall from height after police officers attended his ninth-floor flat to execute an arrest warrant. The principal concern was that there was no local policy governing the use of handcuffs when executing an arrest warrant.

Angela Marietta Carpos · Prevention of Future Deaths report View report

22 Apr 2024 Inner North London M. Lee

Angela Marietta Carpos collapsed while eating dinner on 25 December 2022 and later died in hospital after respiratory arrest, aspiration-related hypoxia and cardiac arrest. The report raised concerns that carers were unable to recognise aspiration pneumonia and were unclear about their training, including its content and frequency. A witness was also unable to say what qualifications the company’s trainers had or what the company’s policies contained.

Mr David John CARPENTER · Prevention of Future Deaths report View report

22 Apr 2024 Coventry D. Henry

Mr David John Carpenter, a refuse collector, was lifted into the rear hopper of a bin lorry after activating a proximity start sensor, and his coat became caught on the lifting chair comb tooth. The automatic compaction cycle caused fatal injuries. The report raises concerns about risks from automatic bin-lift machinery, including inadvertent whole-body lifting, inaccessible emergency stops, inadequate warnings and the continued use of many machines with suboptimal safety.

Chenyang Li · Prevention of Future Deaths report View report

22 Apr 2024 Inner North London M. Lee

Chenyang Li, a 23-year-old third-year undergraduate student, entered a friend’s sixth-floor apartment on 30 September 2023 and climbed out of a window, falling onto concrete and dying shortly afterwards from multiple severe injuries. The report raised concern that the window did not appear to have any, or sufficient, restrictors to prevent over-opening, despite the relevant student-accommodation standard requiring such stops.

Dr Richard George Hardman · Prevention of Future Deaths report View report

19 Apr 2024 Manchester South A. Farrow

Dr Richard George Hardman had complex swallowing and respiratory problems associated with prior radiotherapy and Parkinson’s disease. He was admitted to hospital on 7 August 2023 with aspiration pneumonia, and the inquest concluded that he died from aspiration pneumonia arising from natural disease and recognised effects of necessary medical treatment. The principal concern was the absence of a mechanism for coordinating care across different medical disciplines and hospital sites under the leadership of a single practitioner.

ALEXANDER LEE REID · Prevention of Future Deaths report View report

18 Apr 2024 West Yorkshire Eastern O. Longstaff

Alexander Lee Reid received the Oxford AstraZeneca Covid-19 vaccine after being invited early because an erroneous BMI in his GP records led him to be identified as vulnerable. He died on 29 June 2021, and the inquest concluded that his death was linked to the vaccination, with the medical cause recorded as cerebral venous sinus thrombosis and Covid-19 vaccine-induced immune thrombotic thrombocytopenia. The principal concern was whether general practice IT systems should validate or challenge potentially erroneous data at the point of entry to improve data reliability and patient safety.