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Michael Leslie PEGG · Prevention of Future Deaths report View report

26 Jan 2024 Worcestershire D. Reid

Michael Leslie Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after two significant seizures and died there on 15 January 2023 following deterioration and pneumonia. The report raised concerns that steroid treatment fell far short of relevant NICE guidelines, that staff awareness and application of the guidelines were insufficient, and that crowded treatment areas created difficulties in providing appropriate care.

Christopher Kapessa · Prevention of Future Deaths report View report

24 Jan 2024 South Wales Central D. Regan

Christopher Kapessa, aged 13, was intentionally pushed into the River Cynon at the Red Bridge on 1 July 2019, became submerged and could not be saved after resuscitation attempts. The report identified concerns about inadequate water-safety policies, unclear inspections and guidance, a lack of warning signage and rescue equipment, and remedial works that were not completed.

Brian CHAPMAN · Prevention of Future Deaths report View report

24 Jan 2024 Cambridgeshire and Peterborough S. Milburn

Brian Chapman was an upper-deck passenger on a bus that collided with an articulated lorry on the A47 at Wisbech St Mary on 26 June 2018. He suffered significant and unsurvivable traumatic injuries and died at the scene. The principal concern was that buses travelling predominantly rural routes at high speeds were not required to have passenger seatbelts, creating an obvious risk of death in collisions.

Thomas Roy LANGLEY · Prevention of Future Deaths report View report

23 Jan 2024 Derby and Derbyshire S. Kaushal

Thomas Roy Langley was found collapsed in a hotel room and died at the hotel on 22 May 2019 after taking toxic levels of MDMA. The report raised concerns about the absence of a fully trained first-aid employee on site overnight and the lack of basic first-aid training and refresher courses for all staff.

Thomas Grenville Hammersley Ithell · Prevention of Future Deaths report View report

22 Jan 2024 North Wales (East and Central) K. Robertson

Thomas Ithell, aged 77, died in hospital on 20 November 2022 after prostate cancer progressed and caused his death. He had become lost to follow-up, with PSA monitoring and clinical review not occurring for about 10 months after November 2021. Concerns included the absence of a Datix report and Health Board investigation, lack of assurance about learning or changes, and staff time constraints affecting incident reporting.

Kate Elizabeth O’Donnell · Prevention of Future Deaths report View report

22 Jan 2024 Teesside and Hartlepool C. Bailey

Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.

Donna Georgina Smith · Prevention of Future Deaths report View report

22 Jan 2024 Teesside and Hartlepool C. Bailey

Donna Georgina Smith suffered chest pain at home on 17 July 2021, deteriorated into cardiac arrest, and died shortly after arriving at hospital. The report identifies concerns that her worsening condition was not recognised or escalated from Category 2 to Category 1, that the methods for detecting deterioration were not sufficiently robust, and that the ambulance response took one hour and six minutes.

Rachel Louise MORTIMER · Prevention of Future Deaths report View report

20 Jan 2024 South Yorkshire (Western) M. Whittle

Rachel Louise Mortimer took her own life on 25 June 2023 by hanging, following previous overdoses and a recent episode involving overdose and an attempt to hang herself. The report identified concerns that family and paramedics were not given advice about available support or emergency options, and that no alternative service was arranged after a planned risk-mitigation referral was unavailable.

Matthew George WICKES · Prevention of Future Deaths report View report

19 Jan 2024 Hampshire, Portsmouth and Southampton C. Wilkinson

Matthew George WICKES died in hospital on 30 June 2022 after jumping from a road bridge in Southampton during an acute anxiety crisis. Concerns included university staff awareness and training on student mental health and neurodiversity, gaps between academic assessment and pastoral support, difficulties in effectively reaching struggling students, and inadequate recording of academic meetings and agreed support.

John Thomas GRAY · Prevention of Future Deaths report View report

19 Jan 2024 Suffolk N. Parsley

John Thomas Gray died at Ipswich Hospital on 13 July 2022 after falling from the promenade at Felixstowe beach while asleep on his mobility scooter. He suffered multiple rib fractures leading to respiratory failure, and the inquest concluded that his death was accidental. The principal concern was that, where there was no barrier, existing signage and markings would not warn a person asleep on a mobility scooter about the risk of falling, potentially leading to future loss of life, particularly where the drop was unusually high.

DAVID CHARLES MITCHENER · Prevention of Future Deaths report View report

19 Jan 2024 Surrey J. Stevens

David Mitchener was admitted to East Surrey Hospital with hypercalcaemia on 10 May 2023 and died there on 20 May 2023. The substantive concerns were the potentially serious risks of excessive vitamin supplement use, the absence of appropriate dosage guidance and warnings, and food labelling requirements that did not require these risks to be stated on the packaging.

Tom Sweeting · Prevention of Future Deaths report View report

19 Jan 2024 West London L. Brown

Tom Sweeting experienced a sudden deterioration in his mental health in August 2021 and was assessed by liaison psychiatry after reporting suicidal thoughts. On 20 August 2021, he was found suspended by a ligature at home after locking himself in the garage, and resuscitation attempts were unsuccessful. Concerns included incomplete clinical assessment documentation, failures in discharge communication and treatment-plan communication, delegation of family collateral information gathering to a junior trainee, and a lack of evidence that new training and procedures had been effectively audited.

William Steven Helstrip · Prevention of Future Deaths report View report

19 Jan 2024 East Riding and Hull P. Marks

William Steven Helstrip, aged 18, was found deceased on 26 May 2022 after taking various drugs sourced from the internet, which led to cardiorespiratory depression and death. His parents reported that the drugs had been bought on the Dark Web and sent by recorded delivery, but the initial police investigation concluded that there were no suspicious circumstances or third-party involvement. A later investigation was compromised because time-sensitive CCTV footage had been irretrievably lost, affecting the identification of the suspect.

Name not published · Prevention of Future Deaths report View report

18 Jan 2024 Inner North London M. Hassell

████████ jumped from the roof of his block of flats at 5.33pm on 26 July 2023, following a delay in the attendance of the London Fire Brigade and the provision of an extended height ladder appliance. The principal concern was that the appliance may not have been requested from the outset, despite the call relating to a person on the roof of a block of flats.

Dorota Marta KUKLINSKA · Prevention of Future Deaths report View report

18 Jan 2024 Birmingham and Solihull L. Hunt

Dorota Marta Kuklinska attended hospital with a severe headache and other symptoms suggestive of a brain bleed, but her CT scan was misreported as normal. She later collapsed, was found to have an unsurvivable brain bleed caused by a right middle cerebral aneurysm, and died in hospital. The principal concern was that, despite strong clinical signs and her refusal of a lumbar puncture, she was not referred for specialist neurosurgical advice through NORSE.

Kane Christopher Boyce · Prevention of Future Deaths report View report

17 Jan 2024 Nottinghamshire L. Bower

Kane Christopher Boyce, a serving prisoner at HMP Lowdham Grange, was found with a ligature around his neck on 3 October 2021 and could not be resuscitated. The jury found that alcohol intoxication and the failure of staff to share information, open an under-the-influence log, adequately monitor him, and consider risk when isolating cell power and ignoring cell bells contributed to his death. The report raised concerns about these practices, staff understanding of relevant policies, learning from deaths in custody, and organisational candour.

Charles Harper · Prevention of Future Deaths report View report

16 Jan 2024 Birmingham and Solihull J. Bennett

Charles Harper was struck by the unsecured tail end of coiled polyethylene pipe during dispensing operations on 27 April 2023 and died the following day. The principal concerns were that companies continue to dispense coiled pipe without securing its tail end, and that exclusion zones alone may not adequately protect workers from the unpredictable release of stored energy.

Trevor Alan MONERVILLE · Prevention of Future Deaths report View report

16 Jan 2024 East Sussex R. Redman

Trevor Alan Monerville, who had been detained at HMP Lewes, was found unresponsive in his cell on 18 April 2021 and died after suffering from epilepsy and non-epileptic attack disorder. The principal concerns were inadequate monitoring and management of his epilepsy after the ACCT closed, poor communication and information-sharing between healthcare, prison staff and family, and insufficient staff training in managing epilepsy and seizures.

Rhys Lennon Hill · Prevention of Future Deaths report View report

15 Jan 2024 Manchester South A. Mutch

Rhys Lennon Hill underwent spinal surgery and was discharged from Royal Preston Hospital on 30 January 2023. He collapsed at home on 9 February 2023 and attempts to resuscitate him were unsuccessful; a post-mortem examination found that he died from a pulmonary embolus due to a deep vein thrombosis. The principal concerns included failure to escalate his refusal of Dalteparin or assess the associated risk, failure to provide required VTE information at discharge, and wider problems with communication, documentation, medication reconciliation, and discharge processes.

Dennis John William KING · Prevention of Future Deaths report View report

15 Jan 2024 Suffolk D. Stewart

Dennis John William KING suffered a myocardial infarction after experiencing chest pain on 9 December 2022 and died on 13 December 2022 following recognised complications of emergency treatment. The report raised concerns about delays in ambulance responses and inter-hospital transfers, confusion over transfer categorisation, and the adequacy of arrangements for urgent care at regional specialist centres.