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Barbara Ann WOODMAN · Prevention of Future Deaths report View report

22 Dec 2023 Surrey D. Stewart

Barbara Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.

Wyndham Richard Thomas · Prevention of Future Deaths report View report

21 Dec 2023 Nottinghamshire L. Bower

Wyndham Richard Thomas was a serving prisoner who was found unconscious in his cell after ligating on 4 November 2018 and died in hospital on 6 November 2018. The substantive concerns were the absence of in-cell ligature-point risk assessments and maps, and the lack of designated safer cells at HMP Nottingham, which reduced opportunities to mitigate the risk of self-harm and death by ligature asphyxiation.

Denise Jane PORTER · Prevention of Future Deaths report View report

21 Dec 2023 West London H. Hinton

Denise Jane PORTER died after jumping onto the tracks at Turnham Green Underground Station in front of an oncoming train on 19 February 2023. A prior similar incident had been referred to Oxleas NHS Trust, but the Trust relied on a partial summary and did not make further inquiries into the available police information. The report raised concern that this resulted in missed opportunities to recognise the level of risk and make an appropriate referral or care plan.

Carrianne Franks · Prevention of Future Deaths report View report

21 Dec 2023 Nottinghamshire L. Bower

Carrianne Franks, a Royal Air Force nurse working on placement at an NHS hospital, was exposed to smear-positive tuberculosis in November 2020 and died from tuberculosis on 27 August 2021. She was not classed as a close contact and was not informed of the exposure, which delayed diagnosis and treatment. The principal concerns were that healthcare professionals may not be recognised as a heightened-risk group, contact-tracing thresholds may be too restrictive, and staff education and notification arrangements may be insufficient, particularly for agency and seconded workers.

KIMBERLY ANNA LIU · Prevention of Future Deaths report View report

21 Dec 2023 Inner North London I. Potter

Kimberly Anna Liu, who had become addicted to sedative and other medications, was found unresponsive at home on 7 February 2023 and was pronounced dead. The inquest concluded that this was a drug-related death caused by mixed drug toxicity. The principal concern was that unregulated websites supplied prescription-only sedative medications without prescriptions or adequate checks, potentially exploiting vulnerable people with medication addictions and providing means for suicide or self-harm.

NICHOLAS JAMES GLAVIND DYMOND · Prevention of Future Deaths report View report

21 Dec 2023 Exeter and Greater Devon A. Longhorn

Nicholas Dymond, who had a history of intermittent drug use, developed paranoia and expressed suicidal thoughts about jumping in front of a train. After a Mental Health Act Assessment following his arrest, he was discharged and ran away when the arranged taxi arrived; less than three hours later, he stepped in front of a train and was pronounced deceased at the scene. The concerns identified included independent doctors potentially conducting assessments without access to patient records and witnesses’ lack of understanding of voluntary admission and the least restrictive option.

Shaun PARKS · Prevention of Future Deaths report View report

20 Dec 2023 South Yorkshire (Western) K. Dickinson

Shaun PARKS attended Doncaster Royal Infirmary with a heart attack and waited for an ambulance transfer to the Northern General Hospital. He deteriorated and died during a procedure on 13 December 2022. Concerns included a 3-hour 18-minute ambulance response delay, insufficient emergency dispatch staffing, and hospital delays in offloading patients that reduced ambulance availability.

James CAMPION · Prevention of Future Deaths report View report

20 Dec 2023 Liverpool and the Wirral A. Bhardwaj

James Campion, aged 57, died after consuming mirtazapine and alcohol following contact with the Psychiatric Crisis Team about taking an overdose. An ambulance was not allocated until six hours after the initial call, and he was found deceased at home when the crew arrived. The principal concerns were delays in mental health assessment, call triage and ambulance dispatch, alongside inadequate family contact information and limited family involvement.

Joanne Constable · Prevention of Future Deaths report View report

20 Dec 2023 Cambridgeshire and Peterborough C. Jones

Joanne Constable was a passenger on a motorbike that collided with a tractor-trailer on the A141 Isle of Ely Way on 2 August 2020. Vegetation on the highway verge obstructed the tractor driver's view, and Mrs Constable sustained multiple injuries and was pronounced deceased. The report raised concerns about inadequate systems for recording, tracking and addressing highway hazards and defects, creating a risk of further fatal collisions.

Gregor Patrick Edward Lynn · Prevention of Future Deaths report View report

20 Dec 2023 Cambridgeshire and Peterborough C. Jones

Gregor Patrick Edward Lynn developed a neck lesion in March 2019, which was excised privately without histological analysis because of the additional cost. When the lesion recurred in May 2020, it was diagnosed as melanoma that had metastasised, and he died on 8 July 2022 after the disease spread to his brain. The principal concern was that patients paying privately for procedures may decline histological analysis because it is an additional cost, unlike within NHS treatment.

Ryan John EVANS · Prevention of Future Deaths report View report

20 Dec 2023 Hampshire, Portsmouth and Southampton D. Stewart

Ryan John EVANS died after being found hanging in the communal area of his accommodation on 3 April 2018. The concerns included that, despite evidence of self-harm and suicidal ideation, no mental health assessment was carried out at hospital, and that mental health information and referrals were not effectively documented or communicated during his time in police custody.

Martin Samuel WILLIS · Prevention of Future Deaths report View report

19 Dec 2023 Shropshire, Telford and Wrekin J. Ellery

Martin Samuel Willis was a serving prisoner at HMP Stoke Heath when he was found hanging in his cell on 15 September 2022. He was on the suicide and self-harm prevention scheme, but concerns included failures in observation recording and supervision, uncertainty about the appropriate observation level and possible transfer for mental health treatment, and the need for a collective review of the care provided.

Richard HEDGES · Prevention of Future Deaths report View report

19 Dec 2023 North West Kent A. Blunsdon

Richard Hedges was admitted to critical care after an unwitnessed fall down a short external staircase, resulting in cardiac arrest, traumatic cervical spine fractures and extensive hypoxic brain injury. He was later moved to comfort care and died on 26 September 2023. Concerns related to the staircase included worn concrete steps without a non-slip surface or edge highlighting, a handrail that was too short, and poor lighting.

Linda Louise Banks · Prevention of Future Deaths report View report

19 Dec 2023 County Durham and Darlington J. Richards

Linda Louise Banks died at the University Hospital of North Durham on 10 April 2022 after taking a paracetamol overdose, against a background of alcohol misuse and deteriorating mental health. The report identified concerns about the quality of mental health assessments, triage, safety planning and record keeping, the underestimation of risk, failure to identify possible learning difficulties and provide reasonable adjustments, and delays in investigating the care provided. It also identified concerns that similar issues found in an earlier thematic review had not been effectively addressed.

Amanda Hitch · Prevention of Future Deaths report View report

19 Dec 2023 Essex S. Simblet

Amanda Hitch died on 12 February 2022 after deliberately jumping in front of a train intending to die. She was receiving community mental health treatment. Concerns included important clinical information not being visible to the care team, structured risk-management tools not being specifically considered, and railway-station attendances not being reliably passed to her care coordinator under a multi-agency support plan.

Chloe Elizabeth MACDERMOTT · Prevention of Future Deaths report View report

19 Dec 2023 Inner West London P. Rogers

Chloe Elizabeth MACDERMOTT died at home in the early hours of 23 May 2021 after ingesting a substance purchased through Amazon US. The report identifies concerns about online forums encouraging, assisting and counselling suicide, inadequate age restrictions and signposting to help, harmful content not being effectively removed, and the availability and delivery of the product to UK users without effective border or customs controls.

Margaret Ann Waylett · Prevention of Future Deaths report View report

19 Dec 2023 East London N. Persaud

Margaret Ann Waylett underwent surgery for a humerus fracture and developed ongoing low blood pressure and intermittent oxygen requirements. She later suffered a cardiac arrest and died in hospital after, according to the report, necessary medical intervention was not provided. Concerns included failures to provide medical reviews, lack of access to NEWS charts and confusion about responsibility for her care.

MORGAN-ROSE HART · Prevention of Future Deaths report View report

19 Dec 2023 Essex S. Hayes

Morgan-Rose Hart, who was detained on a female mental health ward, died on 12 July 2022 after being found unresponsive with a ligature around her neck. The report identified concerns about missed and falsified observations, failures to complete physical welfare checks after bathroom alerts, inadequate escalation of risk, shortcomings in investigation and record keeping, and insufficient suitable placements for people with autism and mental health and self-harm risks in Essex.

Carl Anthony OWSTON · Prevention of Future Deaths report View report

18 Dec 2023 West Sussex, Brighton and Hove G. Jones

Carl Owston died at home on 10 January 2023 from sudden unexplained death in alcohol misuse with steatosis and steatohepatitis. A care package commissioned for him could not be provided because no care provider was available, raising concern that shortages of carers and care providers may result in people not receiving needed care, with potentially fatal results.

Nuel-Junior DZERNJO · Prevention of Future Deaths report View report

18 Dec 2023 Suffolk C. Wood

Nuel-Junior Dzernjo, who was receiving high-dose steroids and was immunosuppressed, developed chicken pox and deteriorated after being assessed at hospital on 21 February 2023. He was discharged despite ongoing abnormal observations, inability to mobilise and confusion, then deteriorated at home and died after collapsing the following day. The investigation identified unclear guidance on treatment, including whether intravenous rather than oral Acyclovir was indicated.