Search PFD Monitor

Nadia Wyatt · Prevention of Future Deaths report View report

15 Jan 2024 Essex R. Mundy

Nadia Wyatt, a 53-year-old woman experiencing severe anxiety, separation anxiety and depression, died by hanging on 26 July 2023 after taking sleeping tablets and apparently drinking wine. The principal concerns included failures in record-keeping, care planning, risk assessment and risk management, including inappropriate copying from another patient’s care plan and potential over-reliance on her husband as a carer.

Iona Grace Buckingham · Prevention of Future Deaths report View report

12 Jan 2024 Northamptonshire J. Dixey

Iona Grace Buckingham was admitted to Northampton General Hospital with bronchiolitis and later developed pneumonia, pleural effusion and worsening respiratory distress. She died on 4 December 2022 during an accidental extubation and cardiac arrest, despite attempts at resuscitation. The principal concern was that a very unwell child requiring a chest ultrasound may face a substantial delay because paediatric radiology services were not routinely available outside limited hours, potentially for up to 48 hours over a weekend.

Nicholas CORK · Prevention of Future Deaths report View report

11 Jan 2024 Inner North London I. Potter

Nicholas Cork lived in supported accommodation and was found unresponsive in his room in the early morning of 22 May 2023; paramedics verified his death at 06:28. The report raised concerns that required welfare checks were not completed for at least 36–48 hours before his death, including a missed opportunity when staff opened his door but did not enter or properly assess him. It also identified concerns about inconsistent recording practices, the adequacy of the spreadsheet system, and staff training and follow-up.

Karena WICKINGS · Prevention of Future Deaths report View report

9 Jan 2024 Cumbria N. Shaw

Karena Wickings, aged 58, died at home in Brampton, Cumbria on 5 February 2023 from pulmonary embolism following a prolonged hospital admission for surgery and postoperative complications. Her mobility remained significantly restricted at discharge, when anticoagulant prophylaxis stopped. The report raises concern that discharge planning did not consider whether ongoing anticoagulant prophylaxis was indicated for patients who had not regained full mobility.

Andrew James Rees · Prevention of Future Deaths report View report

9 Jan 2024 Avon M. Buckeridge

Andrew James Rees consumed very high levels of alcohol before walking home severely intoxicated alongside Portishead Marina, where his body was later retrieved. He died due to immersion in water; concerns included a broken rescue chain that visual inspections had not identified and the absence of an apparent formal assessment of changes in use relevant to the marina risk assessment.

Walter FAULDER · Prevention of Future Deaths report View report

8 Jan 2024 Cumbria N. Shaw

Walter Faulder, aged 88, was struck by a vehicle while crossing the A595 at Orton Grange on 13 December 2022 and was pronounced deceased at the scene. Concerns included his apparent misunderstanding of the crossing arrangements and the safety of the busy crossing point, particularly for schoolchildren and older people, with a concern that further accidents and fatalities could occur without safety alterations.

Sarah Julie MITCHELL · Prevention of Future Deaths report View report

8 Jan 2024 Suffolk D. Stewart

Sarah Julie MITCHELL, who had a history of chronic back pain, medication dependence, and previous overdoses, was found deceased at her residence on 22 September 2022. The post-mortem found multiple drug toxicity from prescribed medication. The principal concerns were that she received 28 days’ worth of medication in less than 48 hours despite known overdose and hoarding risks, and that emergency department staff had no process for accessing relevant medication records and dispensing information.

David Bryan Moore · Prevention of Future Deaths report View report

8 Jan 2024 West Sussex, Brighton and Hove K. Henderson

David Bryan Moore sustained burns to 32% of his body in an industrial electrical accident and later underwent tracheostomy surgery during treatment. His tracheostomy became dislodged while he was being turned, causing hypoxic cardiac arrest and a non-survivable hypoxic brain injury; he died after care was withdrawn. The substantive concern identified was the absence of guidelines for the anaesthetic and/or Intensive Care management of a flanged tracheostomy tube.

Tammy Mary Louise WATKINS · Prevention of Future Deaths report View report

5 Jan 2024 Nottinghamshire L. Bower

Tammy Mary Louise Watkins died on 6 June 2021 after swallowing a plastic twistable crayon that perforated her bowel while she was detained at Rampton Hospital. The principal concerns were failures to risk-assess and manage foreign-body ingestion, recognise and escalate her deteriorating condition, follow NEWS2 requirements, and coordinate an emergency transfer to hospital. The report also identifies poor-quality acute physical healthcare and confusion about emergency medical calls.

Bernadette Grace FAULKNER · Prevention of Future Deaths report View report

4 Jan 2024 Inner North London I. Potter

Bernadette Grace Faulkner fell from a stepladder while accessing an electricity pre-payment meter located 7–8 feet above the ground. She was discovered several hours later and died in hospital on 8 December 2022 from injuries sustained in the fall. The principal concern was that the meter’s height and location required ladder access and created risks, including poor visibility to people entering through the communal door; there also appeared to be no industry standard requiring meters to be readily accessible by all customers.

Stephen COSTER · Prevention of Future Deaths report View report

4 Jan 2024 East Sussex R. Redman

Stephen Coster died from meningoencephalitis owing to Streptococcus pneumoniae after becoming seriously unwell while detained at HMP Lewes. The inquest found delays in providing treatment and transferring him to hospital, with concerns including inadequate observations and assessment, poor record keeping, failures to escalate, and breakdowns in communication and leadership between prison and healthcare staff.

Elizabeth Roberts · Prevention of Future Deaths report View report

4 Jan 2024 Manchester South L. Costello

Elizabeth Roberts was severely frail and bedbound and developed a large sacral sore with sepsis, followed by congestive cardiac failure. She died at Tameside General Hospital on 19 May 2023; the principal concern was residual staffing shortages in the District Nursing Service, which the Trust was unable to resolve without a national change of approach.

Bobby LEE otherwise known as Kim Sing Lee · Prevention of Future Deaths report View report

4 Jan 2024 Inner North London I. Potter

Bobby Lee died at home on 6 July 2023 from smoke inhalation and severe burn injuries after a house fire caused by the over-charging of a lithium-ion e-bike battery with an unsuitable charger. The report identifies concerns about the safety and quality of e-bike conversion kits, battery chargers and online marketplace sales, including the absence of sufficient standards and controls and the risk of incompatible chargers causing battery fires and further deaths.

James Arthur HOLGATE · Prevention of Future Deaths report View report

3 Jan 2024 East Riding and Hull L. Harris

James Arthur HOLGATE, aged 89, was admitted after recurrent falls and progressive decline, sustained a traumatic head injury after a fall in the Emergency Department, deteriorated, and died on 1 November 2023. The report raises concern that medical research and training establishments may be unable to accept body donations where an inquest is pending, potentially because of an anomaly or uncertainty in the interpretation of the Human Tissue Act 2004.

Sylvia May NASH · Prevention of Future Deaths report View report

2 Jan 2024 Birmingham and Solihull R. Ollivere

Sylvia May NASH fell at The Orchards Nursing Home on 11 March 2023 and sustained a fractured neck of femur, which was surgically fixed at Birmingham Heartlands Hospital. She developed septic shock and died in hospital on 14 April 2023. Concerns were raised that agencies did not adequately understand or follow the process for decisions such as removing 1:1 observations, and that communication about responsibilities was insufficient.

Meghan Irene CHRISMAS · Prevention of Future Deaths report View report

29 Dec 2023 Surrey D. Stewart

Meghan Irene CHRISMAS attempted suicide by hanging on 18 October 2021 and, after resuscitation, died two days later on 20 October 2021 from a hypoxic brain injury. The report raised concerns about the delayed handling and supervision of communications in the Hampshire Police Force Control Room and the absence of an adequate structure for sharing important clinical information between NHS and private healthcare providers.

Andrew Douglas Guillaume · Prevention of Future Deaths report View report

29 Dec 2023 Coventry and Warwickshire D. Lakin

Andrew Douglas Guillaume was admitted to Warwick Hospital on 5 June 2023 with shortness of breath and a cough, and was later assessed as likely having severe aortic stenosis requiring urgent referral. He deteriorated, was admitted to the Cardiothoracic Critical Care unit at UHCW on 19 June 2023, and died on 20 June 2023; concerns included difficulties contacting the UHCW switchboard, lack of awareness of an emergency contact number, and the absence of a completed referral preventing discussion at a multi-disciplinary meeting.

Karmchand Gulzar · Prevention of Future Deaths report View report

29 Dec 2023 Black Country M. Pemberton

Karmchand Gulzar was taken to Sandwell Hospital on 23 September 2022 with abdominal distension and pain and was diagnosed with acute intestinal obstruction. A CT scan and immediate surgical review were delayed; his condition deteriorated, urgent surgery took place during the evening and early morning, and he died during the operation in the early hours of 24 September 2022. Concerns included failure to follow the surgical registrar referral pathway, failure to undertake an urgent CT scan, and insufficient recognition of deterioration and concerns raised by carers and family about his condition.

Adrian Brendan GALLAGHER · Prevention of Future Deaths report View report

28 Dec 2023 Cheshire V. Davies

Adrian Gallagher was found deceased in bed on 10 November 2017 after being admitted to Hollins Park Hospital and receiving periods of unsupervised leave. His death was due to an intentional overdose and the inquest concluded that it was suicide. Concerns included the online availability of materials and drugs that could assist suicide, limited age and identity checks, and access by vulnerable mental health patients.

Larry Stephen SPRIGGS · Prevention of Future Deaths report View report

22 Dec 2023 Surrey D. Stewart

Larry Stephen Spriggs died after falling from the window of his room at Farnham Road Hospital on 27 May 2021. The inquest identified concerns about the assessment and management of inpatient risk, the use of anti-anxiety medication, communication between staff, and the implementation and management of intermittent observations. The death was recorded as contributed to by neglect and caused or more than minimally contributed to by failures in implementing intermittent observations.