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Jennifer Ruth Whinney · Prevention of Future Deaths report View report

27 Nov 2023 Inner North London M. Lee

Jennifer Ruth Whinney developed recurrent infections in her PICC lines after being admitted to the Royal London Hospital for bowel surgery, leading to septicaemia and multi-organ failure. She died following surgery to repair a bowel fistula. The report raised concern that her medical records were not sent to a specialist appointment and that there was no individual responsibility for ensuring records accompanied patients, risking important information not being passed on.

Benn Curran-Nicholls · Prevention of Future Deaths report View report

27 Nov 2023 Manchester City A. Bridgman

Benn Curran-Nicholls ate yew tree berries and leaves during a walk in Fletcher Moss Park, collapsed later that day, and died in hospital in the early hours of 19 September 2022. The report identified a risk of similar deaths and stated that informing the public about the risk could reduce it.

Mohammed Zeeshan Akram (Zee) · Prevention of Future Deaths report View report

27 Nov 2023 Inner North London M. Lee

Mohammed Zeeshan Akram, known as Zee, had a history of suicidal ideation and a psychotic disorder. He died at Whittington Hospital on 21 March 2023 after being found unresponsive at his flat. The principal concern was that GPs were not routinely informed when patients stopped taking prescribed medication, including where suicidal ideation or a risk of stockpiling might be present.

Boycie [Alexander/Chatterton] · Prevention of Future Deaths report View report

27 Nov 2023 Inner West London B. Richmond

Boycie was born at 36 weeks and 6 days with congenital oesophageal atresia and tracheo-oesophageal fistula, underwent three planned surgical procedures, and died after developing respiratory complications following the third procedure. Experts expressed concern that treatment would be better supported by a properly managed and funded national register for tracheo-oesophageal fistula cases, which they considered likely to improve outcomes and survival rates.

Luke Mervyn WHITELAW · Prevention of Future Deaths report View report

27 Nov 2023 Inner North London I. Potter

Luke Mervyn Whitelaw, who was known to mental health services, died by suicide; his body was recovered from the River Thames on 17 March 2023. Before his death, his mental health deteriorated and a referral for urgent psychiatric review following his disclosure that he would accept informal hospital admission was not acted on. Concerns included insufficient consideration of historic and current risks, inadequate documentation and exploration of deterioration, and a lack of reassurance that identified learning points would be addressed.

Margaret AUSTIN · Prevention of Future Deaths report View report

27 Nov 2023 County Durham and Darlington J. Richards

Margaret Austin died at Stanley Park Care Home on 17 September 2023, following an unwitnessed fall from her bed on 1 July 2023 that caused a pubic rami fracture and contributed to her overall decline. Concerns included incomplete and discrepant documentation about managing her high falls risk, lack of evidence that the risk management plan was reviewed as her risks changed or after falls, and outstanding falls-risk training for most care-home staff at the date of the inquest.

Gracie Elizabeth Spinks · Prevention of Future Deaths report View report

27 Nov 2023 Derby and Derbyshire M. Kewley

Gracie Elizabeth Spinks was unlawfully killed by a former work colleague on 18 June 2021, dying from a stab wound to the neck. The report describes serious police failings in investigating her stalking complaint and in dealing with a rucksack containing weapons, and raises concerns about stalking investigations, risk assessments, record keeping, dangerous items found in the community, and the availability of independent stalking advocates.

Barbara Jean Rymell · Prevention of Future Deaths report View report

27 Nov 2023 Somerset S. Marsh

Barbara Jean Rymell, a frail elderly resident with dementia and mobility limitations, was left unattended on a mechanical stairlift at her care home on 8 August 2022. She left the stairlift, attempted to climb the stairs, fell, and became entrapped with her head under the stairlift chair; she was pronounced deceased when paramedics arrived. The report raises concerns about staff leaving vulnerable residents unattended and about care workers’ English proficiency affecting their ability to communicate the nature of an emergency and obtain appropriate medical assistance.

Amirah KHALIFA · Prevention of Future Deaths report View report

27 Nov 2023 Liverpool and the Wirral A. Bhardwaj

Amirah Khalifa was admitted to hospital in December 2022 after feeling generally unwell and deteriorated despite active treatment, dying on 31 January 2023. The report states that multiple organ failure caused by sepsis and intestinal haemorrhage was more likely than not related to long-term steroid therapy. Principal concerns included failures to document, monitor and review the steroid treatment, recognise its complications, and ensure that its clinical indication and intended duration were communicated to primary care; the SCR also did not automatically flag long-term steroid use or record the clinical indication for prescribed drugs.

Zulfiqar HUSSAIN · Prevention of Future Deaths report View report

24 Nov 2023 Manchester North J. Mitchell

Zulfiqar Hussain, who was 48 years old, was found dead at home on 2 April 2023 from combined drug toxicity causing significant respiratory depression, compounded by pneumonia. The report identified concerns that incoming correspondence was not reliably brought to clinicians’ attention and that adverse medication markers were not being added to electronic medical records, creating a risk that contraindicated medicines could be prescribed.

Michael David Daft · Prevention of Future Deaths report View report

24 Nov 2023 Nottinghamshire S. Wood

Michael David Daft was diagnosed with rectal cancer and a left renal mass, later confirmed as renal cell carcinoma. He died at City Hospital, Nottingham, on 10 November 2022 from a perforated bowel secondary to tumour progression; the report raised concerns about ineffective communication between multidisciplinary teams when patients are on more than one treatment pathway.

Katie Anne WILLIAMS · Prevention of Future Deaths report View report

24 Nov 2023 Plymouth, Torbay and South Devon L. Wiltshire

Katie Anne WILLIAMS took an intentional overdose of prescribed medication and was admitted to intensive care with severe complications, including aspiration pneumonia and paralytic ileus. She died at Derriford Hospital on 24 May 2021 after developing fatal serotonin toxicity associated with delayed absorption of the overdose and the subsequent administration of a sedative drug. The principal concern was that similar risks may not be fully appreciated by other NHS organisations in comparable cases.

Teresa Chmielek · Prevention of Future Deaths report View report

24 Nov 2023 Manchester North C. McKenna

Teresa Chmielek took her own life at home on 17 June 2023, after a referral to mental health services concerning her suicide risk was rejected without contact or a face-to-face review. The concerns included failure to identify or recognise the reported recent suicide attempt, lack of meaningful multidisciplinary discussion and direct contact, inadequate referral arrangements and documentation, and the absence of procedures and auditing for referral decisions.

Hazel Pearson · Prevention of Future Deaths report View report

23 Nov 2023 North Wales (East and Central) K. Robertson

Hazel Pearson, who had known coeliac disease, consumed Weetabix in hospital on 26 November 2021, then vomited, aspirated and developed respiratory deterioration before dying from aspiration pneumonia on 30 November 2021. The report raised concerns about inadequate management of food intolerances and allergies, the lack of investigation into the incident, and failures to complete incident reports for other instances of gluten ingestion.

John Charles Seagrove and 2 others · Prevention of Future Deaths report View report

23 Nov 2023 Cornwall and Isles of Scilly A. Cox

The report concerns the deaths of John Charles Seagrove, Pauline Mary Humphris and Patricia Joan Steggles, following delays in emergency ambulance response and in handing patients over to hospital staff. The report raises concerns about worsening emergency department pressures, with ambulances waiting outside, and reported burnout and recruitment difficulties among healthcare staff. In Mrs Humphris’s case, the coroner found that ambulance and hospital admission delays may have contributed to the outcome; in Mrs Steggles’s case, the inquest heard that earlier hospital arrival would probably have led to survival.

Charlotte Burton · Prevention of Future Deaths report View report

23 Nov 2023 Cambridgeshire and Peterborough S. Goward

Charlotte Burton, who was 40 and recently postpartum, returned to hospital on 27 November 2020 with shortness of breath and coughing up blood. She later deteriorated, suffered a cardiac arrest and died from acute left ventricular failure associated with cardiomyopathy, morbid obesity and pre-eclampsia. The report identified delayed recognition and treatment of likely diastolic heart failure, delayed escalation, and limited out-of-hours access to cardiology assessment as concerns.

KENNETH HEARD · Prevention of Future Deaths report View report

23 Nov 2023 Cornwall and Isles of Scilly G. Davies

Kenneth Heard suffered a major heart attack on 10 July 2022, but the ambulance responding to his 999 call arrived about eight hours later. He suffered a cardiac arrest at Royal Cornwall Hospital on 11 July 2022 and resuscitation was unsuccessful; the court found it more likely than not that he would have survived without the ambulance delay. The principal concerns were ambulance response and hospital handover delays, linked to pressure on services and insufficient social care provision, with continuing risks to life from these delays, particularly during winter demand.

Kevin Stephen O’Hara · Prevention of Future Deaths report View report

23 Nov 2023 Surrey S. Ridge

Kevin Stephen O’Hara, who was bedbound and lived alone with carers visiting four times a day, died in a fire at his home on 7 February 2023 after a lit cigarette ignited debris on a mattress used as a crash mat. The fire produced significant smoke and was detected only after smoke seeped through a closed living-room door to a hallway alarm. Concerns included inadequate review and oversight of Safe and Well Visits by Surrey Fire and Rescue Service, and insufficient oversight by Surrey Adult Social Care to ensure that required risk assessments followed visits.

Philip Laurence Justin MALONE · Prevention of Future Deaths report View report

23 Nov 2023 Birmingham and Solihull J. Bennett

Philip Laurence Justin Malone, who had treatment-resistant schizophrenia and had deteriorated significantly in late June 2023, was found deceased in his supported accommodation on 3 July 2023. The inquest concluded that his death was the consequence of suicide. The principal concern was inadequate psychiatric bed capacity in Birmingham and Solihull, after clinicians sought to admit him but no inpatient bed was available, creating an ongoing risk of future deaths.

David John Lewsey · Prevention of Future Deaths report View report

22 Nov 2023 Cornwall and Isles of Scilly A. Cox

David John Lewsey, aged 68, developed a pulmonary embolus following a left knee replacement and died after collapsing at home on 15 December 2022. Concerns included that severe side pain reported to reception staff was not passed to the advanced nurse practitioner, and that the pain’s location was not explored further. The report also raised whether staff training should better address chest or abdominal pain in recently immobilised post-operative patients.