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Vivienne Greener · Prevention of Future Deaths report View report

18 Dec 2023 North Wales (East and Central) D. Pojur

Vivienne Greener was taken by ambulance to Glan Clwyd Hospital after vomiting blood and died there on 20 March 2018 following a massive upper gastrointestinal haemorrhage. The report identified concerns including delayed admission and triage, delayed provision of blood products, failures to escalate and trigger haemorrhage pathways, insufficient staffing and the lack of out-of-hours emergency endoscopy.

David Hemmings · Prevention of Future Deaths report View report

18 Dec 2023 Inner West London F. Wilcox

David Hemmings fell in his flat, sustaining severe pelvic fractures and a displaced right femur fracture. He later developed a wound infection and died of peritonitis following surgical treatment. The principal concern was that staff training on moving and handling after a fall was insufficient or unmemorable, leading staff to move him unsafely and delay seeking clinical care.

John Michael Thomas · Prevention of Future Deaths report View report

15 Dec 2023 North Wales (East and Central) J. Gittins

John Michael Thomas died on 2 December 2023 after losing control of the motorcycle he was riding and colliding with an oncoming vehicle, sustaining fatal injuries. Witness evidence indicated that the motorcycle may have slipped on the road, and concerns were raised about flooding and the general condition of parts of the A539, including issues previously brought to the Local Authority’s attention.

Terence Edward Hines · Prevention of Future Deaths report View report

15 Dec 2023 Worcestershire D. Reid

Terence Edward Hines developed an MRSA infection after surgery for a fractured right neck of femur and died in hospital on 15 July 2023. The report identified failures to carry out the required Red clean of a hospital room and routine MRSA screening, and raised concerns about staff awareness of relevant policies and procedures.

John Robert Taylor · Prevention of Future Deaths report View report

15 Dec 2023 Teesside and Hartlepool C. Bailey

John Robert Taylor took a deliberate insulin overdose and contacted emergency services for help. The ambulance arrived more than 13 hours later, and he died in hospital on 27 July 2022; the inquest concluded that the delay contributed to his death. Concerns included inadequate checking of the property’s unlocked door, the failure to include this issue in the internal investigation, and the lack of consideration of using a taxi to transport him to hospital sooner.

Peter Alfred Kelly · Prevention of Future Deaths report View report

15 Dec 2023 South Yorkshire (Eastern) N. Mundy

Peter Alfred Kelly was released from police custody on the morning of 26 April 2023 and was found hanged at 07:45 the following day, believed to have been dead for some time. The concerns included failures to complete the pre-release risk assessment properly, understand processes for involving the Liaison and Diversion team, and recognise potential mental health vulnerabilities at release.

Olivia Amy RUSSELL · Prevention of Future Deaths report View report

14 Dec 2023 Cheshire V. Davies

Olivia Russell had a history of anxiety, started citalopram in November 2020, stopped taking it without consulting a GP around June 2021, and restarted it in August 2021 after a relapse. She took her own life on 19 September 2021. Concerns included a lack of recorded evidence that risks associated with stopping medication or initially feeling worse had been discussed, uncertainty about consistent adherence to relevant guidance, and delay in carrying out a significant event review after her death.

Reece William NELSON · Prevention of Future Deaths report View report

12 Dec 2023 North Lincolnshire and Grimsby M. Johnson

Reece Nelson was found hanging at his home address in Grimsby on 28 February 2022 and was pronounced dead by paramedics. His family had tried to contact his Care Coordinator because of concerns about his mental state, but they were not informed that the coordinator was on sick leave and no return call was made.

Ruth Carla Perry · Prevention of Future Deaths report View report

12 Dec 2023 Berkshire H. Connor

Ruth Carla Perry’s mental health deteriorated significantly during and after an Ofsted inspection of Caversham Primary School in November 2022. She displayed suicidal ideation and planning a few days later, and took her own life on 8 January 2023; the inquest concluded that her suicide was contributed to by the inspection. The principal concerns included the conduct and fairness of the inspection, limited Ofsted training and policy for managing school leader distress, confidentiality requirements, report publication timescales, and aspects of the inspection system affecting school leader welfare.

Catherine Lisa Jones · Prevention of Future Deaths report View report

12 Dec 2023 North Wales (East and Central) J. Gittins

Catherine Lisa Jones died at Wrexham Maelor Hospital on 10 November 2016 from widespread metastatic ovarian cancer contributed to by pseudomembranous colitis. The report describes concerns that a biopsy had been wrongly classified as benign, that a lesion was not identified during subsequent surgery or on a scan, and that surgery conducted through pooled lists was not supported by a documented, approved system of work, potentially resulting in a lack of cohesive care and treatment.

Amarnih Lewis-Daniel · Prevention of Future Deaths report View report

11 Dec 2023 East London N. Persaud

Amarnih Lewis-Daniel, who had experienced mental health difficulties and gender dysphoria, died after sustaining fatal injuries in a fall on 17 March 2021 while awaiting care from a Gender Identity Clinic. The report raised concerns about lengthy waiting lists, limited local support during the wait, unclear responsibility for patients’ wellbeing, limited specialist knowledge in local mental health services, and unclear guidance on prescribing bridging hormones.

Jessica Zoe EASTLAND-SEARES · Prevention of Future Deaths report View report

10 Dec 2023 West Sussex, Brighton and Hove P. Schofield

Jessie was pronounced deceased in hospital on 17 May 2022 after being found with a ligature around their neck, having been detained under the Mental Health Act and hospitalised since 4 March 2022. The report raises concerns about inadequate community provision for autistic people, including difficulties finding suitable support and the breakdown of temporary care arrangements before Jessie’s inpatient admission.

Claire Nicole Briggs · Prevention of Future Deaths report View report

8 Dec 2023 Manchester South A. Farrow

Claire Nicole Briggs died at Stepping Hill Hospital on 28 November 2022 after a propranolol overdose. The report identified delays in ambulance response and failures to conduct timely clinical reviews, alongside the absence of a consistent and reliable process for police officers to escalate concerns about suspected drug overdoses to the ambulance service.

Charlene Roberts · Prevention of Future Deaths report View report

8 Dec 2023 Manchester North J. Kearsley

Charlene Roberts died at Fairfield General Hospital on 12 January 2023 after suffering cardiac arrest during an inpatient admission; her cause of death was confirmed as cyclizine toxicity, with aspiration pneumonia, anorexia and factitious disorder also recorded. The principal concerns included the availability and prescribing of cyclizine, limited professional understanding of cyclizine dependence and the use of local intelligence systems for non-controlled drugs, and the lack of a commissioned community pathway for obtaining blood samples from compromised patients.

WILLIAM BRIAN KIN GRAY · Prevention of Future Deaths report View report

8 Dec 2023 Essex S. Hayes

William had poorly controlled asthma and experienced a life-threatening asthma attack on 29 May 2021, followed by respiratory and cardiac arrest and a brain injury not compatible with life. The report identified multiple concerns, including failures to assess, review, escalate and treat his asthma, ambulance treatment and airway-management issues, gaps in investigation and training, and limitations in asthma and emergency-care services.

Lindy Lyanne ASTON · Prevention of Future Deaths report View report

8 Dec 2023 Leicester City and South Leicestershire I. Thistlethwaite

Lindy Lyanne Aston underwent a total gastrectomy for stomach cancer and later suffered a ruptured spleen, requiring emergency surgery. She was transferred from Kettering General Hospital to Leicester Royal Infirmary, where she underwent a splenectomy, remained very unwell and died on 18 October 2021. The principal concerns were the decision not to provide immediate surgery at Kettering and inadequacies in the Trust’s investigation and incident-reporting processes, which delayed learning about potential care failures.

Jasbir Pahal · Prevention of Future Deaths report View report

8 Dec 2023 West Yorkshire Eastern O. Longstaff

Jasbir Pahal suffered an acute left middle cerebral artery stroke on 13 November 2022 and was transferred between hospitals while arrangements for thrombectomy were being considered. Imaging later showed extensive infarction, active treatment was withdrawn on 27 November, and she died on 30 November 2022. The principal concern was that thrombectomy access for patients at Calderdale Royal Hospital was available only during limited weekday hours, leaving patients without reliable access to potentially life-saving treatment outside those hours and subjecting access to local arrangements.

KATHARINE ANNE FOX · Prevention of Future Deaths report View report

7 Dec 2023 Essex S. Simblet

Katharine Fox died by hanging in October 2022 after being discharged from hospital, having been unable to access community psychology services during the following months. Concerns related to the lack of handover and continuity between hospital and community psychology services, substantial waiting times, and possible inability of clinicians to access notes held on different computer systems.

Ian Jacka · Prevention of Future Deaths report View report

7 Dec 2023 Cornwall and Isles of Scilly G. Davies

Ian Jacka suffered serious injuries after a fall from height on 3 June 2022 and later developed hypoxic brain injury following airway complications during spinal surgery. He died in intensive care on 15 June 2022. The principal concerns were omissions in record keeping and handover about a serious medical episode before surgery, and the absence of a formal written handover process for significant events involving complex patients.

Sarah CHAPPELL · Prevention of Future Deaths report View report

7 Dec 2023 Inner North London S. Simblet

Sarah Chappell was transferred to University College London Hospital on 31 May 2023 and died there on 23 June 2023. The report identified concerns about delays in transfer, failure of the appropriate clinical team to take charge, inadequate pain relief and poor communication. It also identified inappropriate management of her nasogastric tube; the inquest concluded that her care was suboptimal and that, if the tube had been managed appropriately, she would have survived this episode.