Search PFD Monitor

Alex Dews · Prevention of Future Deaths report View report

10 Oct 2023 South Yorkshire (Western) A. Combes

Alex Dews went to a bridge at Dearne Valley Country Park on 14 July 2022, fell into shallow water, and died at Sheffield Children’s Hospital on 18 July 2022. The report raises concerns about school documentation and assessment processes, barriers to referral to NHS mental health services, unclear allocation of school-procured psychology support, and inadequate communication with the support provider.

Mark Anthony McKessy · Prevention of Future Deaths report View report

9 Oct 2023 Manchester South A. Mutch

Mark Anthony McKessy had learning disabilities and care needs and developed alcoholic liver disease following regular and prolonged alcohol use. He deteriorated after admission to Stepping Hill Hospital and died there on 18 February 2023. The principal concerns were poor communication and information sharing between agencies, lack of coordinated care, and insufficient recognition of how his health, social care and learning disability needs interacted, including the extent of his capacity.

Kirandip Bharaj · Prevention of Future Deaths report View report

9 Oct 2023 Blackpool and the Fylde A. Anthony

Kirandip Bharaj died aged 45 on 14 September 2019 after sustaining burns and inhaling fumes in an accidental fire at her flat. She had a known eating disorder, declining weight and increasing confusion before her death. The principal concern was that adult social care staff may not recognise deterioration in eating disorders without appropriate tools, training and access to relevant guidance, potentially leaving people without urgent medical assessment and treatment.

Margaret Gertrude Kelly · Prevention of Future Deaths report View report

9 Oct 2023 North Wales (East and Central) J. Gittins

Margaret Gertrude Kelly underwent elective hernia repair on 28 March 2022, after which her bowel was probably damaged. She attended the Emergency Department the following day but was not seen by a surgical doctor for several hours; emergency surgery was undertaken on 30 March, and she died at Glan Clwyd Hospital on 31 March 2022. The report raises concerns about unsustainable pressure on staff, delays in treatment, and insufficient or ineffective strategic planning and support to reduce pressures within the department.

Sandra Curran · Prevention of Future Deaths report View report

9 Oct 2023 Manchester South A. Mutch

Sandra Curran died after becoming unresponsive while snorkelling in the sea off Bugibba Saint Paul's, Malta, on 4 July 2022; an investigation found that she died from asphyxia as a consequence of drowning. The principal concern was that UK tour operator welcome information did not warn about the risks and challenges of sea swimming or snorkelling in Malta, particularly for weak swimmers.

Adam Connolly Stuyvesant · Prevention of Future Deaths report View report

6 Oct 2023 Wiltshire and Swindon I. Singleton

Adam Connolly Stuyvesant was involved in a minor road traffic collision on 17 August 2022 and sustained an ankle injury that was immobilised with a plastic boot. He collapsed on 22 August 2022 and died despite resuscitation efforts; the post-mortem confirmed pulmonary embolus arising from deep vein thrombosis associated with lower-limb immobilisation. The report raised concerns that the hospital’s DVT risk assessment did not account for immobilisation when considering anti-clotting medication.

John George CONDRON · Prevention of Future Deaths report View report

6 Oct 2023 Cheshire C. Keighley

John George Condron was found dead at his home on 2 November 2017, suspended from loft roof beams by a rope ligature. He was under police investigation and had not been informed that no further action had been decided in relation to the most serious allegation, which the report states exacerbated the extreme anxiety and stress he was experiencing. The principal concern was the absence of an agreed timescale or protocol for informing suspects of such decisions, with concern that further self-inflicted deaths could occur as a result.

Jessica Evie BAKER · Prevention of Future Deaths report View report

5 Oct 2023 Liverpool and the Wirral A. Rebello

Jessica Evie Baker, a 15-year-old pupil, died after being partially ejected and trapped beneath a school coach during a motorway collision. The report raises concerns that seatbelts fitted to the coach did not appear to be used and asks about government advice and public information on seatbelt use for school commuter coaches.

Iris Elaine Fordham · Prevention of Future Deaths report View report

5 Oct 2023 East London G. Irvine

Iris Elaine Fordham was admitted to hospital after an unwitnessed fall and concerns about her ability to keep herself safe due to Alzheimer’s disease. Failures to complete a falls risk assessment, falls care plan and enhanced care assessment led to the removal of 1:1 care, after which she sustained a fractured neck of femur in a further unwitnessed fall. She underwent surgical repair and died in a step-down care centre; concerns included poor clinical record-keeping, failures in falls-risk management and the absence of action through disciplinary or regulatory channels.

Lilian Margaret BOARD · Prevention of Future Deaths report View report

5 Oct 2023 Lincolnshire P. Cooper

Lilian Margaret BOARD, aged 91, died at Lincoln County Hospital on 1 February 2023 after intentionally ingesting tablets the previous day; a note of intent was left. The principal concern was that both her GP and the hospital had prescribed the same medication, raising a question about checks to prevent duplicate prescriptions.

Janet Irene SPENCER · Prevention of Future Deaths report View report

4 Oct 2023 Nottinghamshire M. Wall

Janet Irene Spencer suffered an unwitnessed fall in her assisted living accommodation on 30 August 2022, sustaining a traumatic acute subdural haematoma. She was treated in hospital and placed on end-of-life care, but did not recover and died some 13 days later; underlying ischaemic heart disease contributed to, but did not directly cause, her death. The report identified concerns about inadequate and outdated risk assessments and care plans during discharge or transfer, and insufficient information-sharing to support smooth transfers between care facilities.

Ronald Leslie HARRIS · Prevention of Future Deaths report View report

4 Oct 2023 Herefordshire H. Bricknell

Ronald Leslie Harris’s family contacted the practice in April 2023 about worsening mental health difficulties and requested further help, but a routine appointment was offered with a stated 4–6 week wait and no follow-up call was made. He died by suicide on 5 June 2023. Concerns included incomplete triage documentation, failure to make the requested call, and the triage doctor’s lack of awareness of the waiting time and the telephone-call transcript; a review of mental-health triage protocols was noted, but no revised protocol had been advised by the inquest.

Michelle Louise WHITEHEAD · Prevention of Future Deaths report View report

4 Oct 2023 Nottinghamshire L. Bower

Michelle Louise Whitehead died on 7 May 2021 while an inpatient, after acute hyponatraemia caused by psychogenic polydipsia. The report identified failures to follow the Rapid Tranquilisation policy, including inadequate monitoring of consciousness and delays in responding to her deterioration, and raised concerns about staff training, policy clarity, monitoring guidance, and the detection and management of psychogenic polydipsia.

Kellie Jean POOLE · Prevention of Future Deaths report View report

4 Oct 2023 Derby and Derbyshire P. Nieto

Kellie Jean POOLE died on 25 April 2022 after collapsing during a led cold water immersion session in the River Goyt. The report states that cold water likely triggered a heart rhythm disturbance and that she had an abnormal heart. The principal concerns were the limited oversight and regulation of cold water immersion providers, including health warnings, safety measures, leader training, first aid provision, insurance, risk assessments and guidance from relevant authorities.

Manoel Messias Santos · Prevention of Future Deaths report View report

3 Oct 2023 Inner South London J. Goldring

Manoel Messias Santos, a Brazilian national detained in prison and facing immigration detention and possible deportation, was found hanging in his cell in the early hours of 2 November 2020 and was declared dead at 3.30am. The jury found that his understanding of his immigration position made a material contribution to his death and identified failures in notifying him about the IS91 notice and communicating his immigration position. The report also raised concerns about delays in notification and case handling, access to legal advice, communication between agencies, dissemination of learning, and staff understanding of the policy on opening cell doors at night.

Jack Peter Zarrop · Prevention of Future Deaths report View report

2 Oct 2023 West London A. van Dellen

Jack Peter Zarrop, who had a history of mental-health difficulties, alcohol abuse and previous suicide attempts, died by suicide while in custody. The jury identified failures relating to referral to Liaison and Diversion services, opening an ACCT, access to relevant history, and removal of a bedsheet and closure of a hatch as main contributing factors. The report raised concerns about the use and training of Custodial Nurse Practitioners in police custody and the training of agency prison healthcare staff in the ACCT process.

Paula LENIHAN · Prevention of Future Deaths report View report

2 Oct 2023 Birmingham and Solihull S. Rickard

Paula Lenihan was found deceased at her home on 6 March 2023. The medical cause of death was ischaemic and hypertensive heart disease, with combined toxicity from drugs in her system. The principal concern was that risk assessments within the Birmingham & Solihull Mental Health NHS Foundation Trust were not being completed or updated satisfactorily, creating a risk from insufficient recording of risk information.

Leighton Alan Dickens · Prevention of Future Deaths report View report

29 Sep 2023 South Wales Central D. Regan

Leighton Alan Dickens died by incomplete atypical hanging alone at his home address on 14 October 2020. The inquest heard that police did not detain him at hospital for mental health assessment, and identified limited access to qualified, clinically informed mental health advice and records for officers responding to community mental health crises.

Douglas Nickols · Prevention of Future Deaths report View report

29 Sep 2023 Surrey A. Crawford

Douglas Nickols suffered an unwitnessed fall at his care home on 28 February 2023, sustaining a fractured left neck of femur. He was admitted to East Surrey Hospital, but surgery did not take place until 5 March 2023; he later developed bronchopneumonia and died at the hospital on 11 March 2023. The principal concern was that limited trauma capacity meant hip-fracture surgery could be delayed beyond the NICE-recommended timeframe, potentially placing patients at risk of early death.

John Trevor WINSWORTH · Prevention of Future Deaths report View report

29 Sep 2023 Norfolk J. Lake

John Trevor Winsworth, aged 92, was found on the floor at his home on 14 February 2023 and later died in hospital on 21 February 2023 after a traumatic intracranial bleed following a fall. The report raises concerns about delays in ambulance attendance, delays in admission to the Accident and Emergency Department, and continuing delays by the ambulance service in responding to calls.