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Kerri Louise Mothersole · Prevention of Future Deaths report View report

5 Mar 2024 Mid Kent and Medway C. Wood

Kerri Louise Mothersole, a 44-year-old woman, died on 20 August 2022 after developing endometrial cancer with brain metastases. Her diagnosis was delayed, including because an earlier ultrasound report and associated images were not provided to treating clinicians or uploaded to hospital clinical notes, and community imaging was not available on the central imaging system.

Isabella Shere · Prevention of Future Deaths report View report

5 Mar 2024 Inner South London F. Hallett

Isabella Shere died at home in Lewisham, London, on 2 February 2023, aged 14. The inquest concluded that her death was suicide, with the medical cause recorded as asphyxia caused by hanging. The concerns included the availability and accessibility of information relating to methods of ending life on Quora, related content and user-engagement features encouraging further consumption, and insufficient monitoring or moderation.

Sarah Rhiannon Keen · Prevention of Future Deaths report View report

4 Mar 2024 Mid Kent and Medway P. Harding

Sarah Keen, who had a history of mental health difficulties and required support with daily activities, died after being discharged from hospital to supported accommodation. A post-mortem examination determined the medical cause of death to be multi-drug toxicity involving fluoxetine and dihydrocodeine in the presence of cocaine. The principal concerns were inadequate communication to carers about her risks and medication, insufficient guidance about discharge medication, and use of an abbreviation that was not universally understood.

Sandra Elizabeth SENIOR · Prevention of Future Deaths report View report

4 Mar 2024 Inner North London I. Potter

Sandra Senior travelled to central London on 24 September 2023 and gained access to Tavistock Chambers, where she completed suicide. The report raised concerns that the building’s access-control and safety systems were not operating or being used effectively, allowing unauthorised access, and noted that this was the second similar death there within approximately 18 months.

Vanessa FORD · Prevention of Future Deaths report View report

4 Mar 2024 Inner North London I. Potter

On 23 September 2023, Vanessa Ford consumed a significant amount of alcohol during an acute mental health crisis, accessed the railway network and was struck by a train after dropping onto the tracks. The report raised concerns about frequent public access to the railway in the area, the effectiveness of safety measures on the wall, and street furniture making access easier and potentially undermining safety efforts.

Mr Lee Martin Hughes, also known as Martin Lee Hughes · Prevention of Future Deaths report View report

4 Mar 2024 Inner West London F. Wilcox

Lee Martin Hughes was found deceased in his cell at HMP Wandsworth on 25 December 2021 while remanded in custody. The medical cause of death was methadone and benzodiazepine intoxication, and the jury concluded that drug-related misadventure was contributed to by neglect. Concerns included the assessment and prescribing of methadone, failure to respond appropriately to signs of sedation and impaired consciousness, and inadequate communication and escalation between healthcare disciplines.

Jean Thomas · Prevention of Future Deaths report View report

4 Mar 2024 Swansea and Neath Port Talbot A. Gruffydd

Jean Thomas fell at home and remained on the floor for approximately 14 hours while waiting for an ambulance, during which a sacral pressure sore began to develop. The sore was exacerbated by a further delay in offloading her from the ambulance and by delays in obtaining an appropriate anti-pressure sore mattress; it later became infected, and she died at Morriston Hospital. The report raises concerns about pressure sores developing or worsening when vulnerable patients experience delays in ambulance response and hospital offloading.

Tina NEVERLAND · Prevention of Future Deaths report View report

1 Mar 2024 Mid Kent and Medway B. Patel

Tina Neverland was a pedestrian crossing Maidstone Road, Chatham, when she was struck by a motorcycle on 26 July 2023. She suffered a traumatic brain injury and died at Kings College Hospital on 30 July 2023; the inquest concluded that her death resulted from a road traffic collision.

Jennifer Ann Trigger · Prevention of Future Deaths report View report

1 Mar 2024 North Wales (East and Central) J. Gittins

Jennifer Ann Trigger was admitted to Wrexham Maelor Hospital on 29 January 2020 after suffering an acute stroke and was prescribed beriplex, a time-critical treatment, which was not administered until the following morning. The report identified miscommunication and limitations in the bleep system as contributing to delays in prioritising and administering the treatment, followed by deterioration in her condition and her death on 31 January 2020.

Christopher Paul Vickers · Prevention of Future Deaths report View report

29 Feb 2024 Gateshead and South Tyneside L. Benyounes

Christopher Paul Vickers had worsening mental health and ADHD symptoms, with escalating risks of self-harm and harm to others. He was found with a ligature around his neck on 18 July 2021 and death was certified that day. The report identified repeated missed opportunities to coordinate his care through multi-disciplinary or multi-agency meetings and to make safeguarding referrals despite the escalating risks.

Daniel Mark Edward TUCKER · Prevention of Future Deaths report View report

29 Feb 2024 Nottinghamshire M. Wall

Daniel Mark Edward Tucker was detained under the Mental Health Act and admitted to hospital following self-harm and suicidal thoughts, but was discharged on 22 April 2022 despite ongoing concerns about his mental state and risk. He ingested a lethal quantity of a substance later that evening and died. The report identifies concerns about risk assessment and care planning, named-nurse allocation, staff skills in engaging patients, emergency response to confirmed ingestion, and the accessibility of online suicide forums.

Kenneth Stanley Baylis · Prevention of Future Deaths report View report

29 Feb 2024 Nottinghamshire E. Didcock

Kenneth Stanley Baylis took his own life on 23 January 2023 while on unescorted leave as an informal inpatient on Kingsley Ward. The report identified concerns including inadequate suicide risk assessment and mitigation, insufficient family involvement, failure to follow planned-leave procedures, and inadequate review and investigation after serious suicide attempts or a death.

Chloe Anne Tapp · Prevention of Future Deaths report View report

28 Feb 2024 Essex R. Mundy

Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.

Nesta Jones · Prevention of Future Deaths report View report

28 Feb 2024 North West Wales K. Robertson

Nesta Jones died in hospital on 8 May 2017 after being admitted with suspected septic arthritis of a prosthetic left knee. The report describes concerns about delayed consideration and treatment of septic arthritis, junior doctors not being encouraged to challenge consultant opinions, inadequate handling of the family’s urgent complaint, and the lack of a full investigation into the death.

Sylvia Dawn CROWTHER · Prevention of Future Deaths report View report

28 Feb 2024 Bedfordshire and Luton E. Whitting

Sylvia Dawn CROWTHER, who had physical disabilities, mental health issues and alcoholism, was found unresponsive at home on 6 January 2023 after expressing distress and requesting help while living alone following her husband's arrest and bail conditions. She had left notes indicating an intention to end her life and died despite resuscitation efforts. The Court identified concerns about police handling of the arrest and conditional pre-charge bail, including failure to seek and communicate her views about bail conditions and failure to identify her dependence on her husband and consider more supportive alternatives.

Adrian Stuart Green · Prevention of Future Deaths report View report

28 Feb 2024 Plymouth, Torbay and South Devon D. Archer

Adrian Stuart Green, aged 55, died at Torbay Hospital on 1 November 2021 from alcoholic liver disease after living at Whiteley Court, where he was supposed to receive assistance with medication, support and care, meals, and shopping. The inquest heard that he did not receive appropriate care or visits for several weeks and was found in squalid and unhygienic conditions in an almost unresponsive state. Concerns included whether the local authority had adequate policies for overseeing independent providers, the CQC’s role and jurisdiction, and the lack of acknowledgement or response to a Disclosure and Barring Service referral.

Gillian Baumgardt · Prevention of Future Deaths report View report

28 Feb 2024 Avon S. Fox

Gillian Baumgardt, an elderly woman with dementia, fractured her right hip but errors in performing and reporting the x-ray led to wrong-site surgery on her healthy left hip. She underwent surgery on the right fractured hip two days later and died six weeks later, having never regained her mobility; the report found that the wrong-site surgery contributed to her death. Concerns included the absence of systems requiring pre-exposure markers and the investigation of inconsistencies between images and the injury site before radiology reports were finalised.

Deborah Jane Cooper · Prevention of Future Deaths report View report

26 Feb 2024 Wiltshire and Swindon D. Ridley

Deborah Jane Cooper, aged 61, died in circumstances suspected to involve carbon monoxide poisoning after apparatus was found and notes indicated an intention to end her life. The concern was that publications giving instructions on methods of ending one’s life were freely available through Amazon UK, with potentially inadequate regulation of their supply.

Alissa Claire NORTON · Prevention of Future Deaths report View report

26 Feb 2024 West Sussex, Brighton and Hove J. Andrews

Alissa Claire Norton died on 22 April 2022 at Royal Sussex County Hospital from hypoxic ischaemic encephalopathy caused by chorioamnionitis to which she was exposed before birth. The report raises concerns that most notes about her events and treatment were completed retrospectively, with limited contemporaneous documentation and some entries based on assumption rather than first-hand knowledge.

Jamie Peter Norman PILKINGTON · Prevention of Future Deaths report View report

22 Feb 2024 Staffordshire and Stoke-on-Trent A. Barkley

Jamie Peter Norman PILKINGTON died after his vehicle left the road, struck a tree and caught fire in the early hours of 12 March 2023. At the time, he was under the care of Mental Health Services and had been expressing suicidal thoughts. Concerns included failures to complete suicide risk assessments and insufficient exploration and management of issues relevant to his suicide risk during mental health assessments.