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Marion May Luckraft · Prevention of Future Deaths report View report

29 Sep 2023 East London G. Irvine

Marion May Luckraft was admitted to hospital with jaundice and died on 17 April 2023 after developing a duodenal perforation following ERCP and pancreatic stent placement, biliary sepsis and shock. The principal concerns were cumulative delays in diagnostic and treatment processes, delayed escalation to high dependency care, fragmented treatment across two hospital sites, and the absence of a clear treatment pathway for biliary sepsis.

John Frederick WRIGLEY · Prevention of Future Deaths report View report

29 Sep 2023 Derby and Derbyshire S. Kaushal

John Wrigley died after his kart left the track during a qualifying session on 3 May 2021, crossed wet grass and struck a lorry tyre wall at high speed. The report raised concerns that additional energy-absorbing protection was available but not used, and that insufficient regard was given to wet grass and wet-weather risks when deciding whether racing should proceed.

Steven Sanders · Prevention of Future Deaths report View report

29 Sep 2023 Birmingham and Solihull E. Brown

Steven Sanders was a detained patient at St Andrew's Healthcare who was found unresponsive and not breathing on 20 November 2022 after returning from authorised leave, and was pronounced deceased at 23:04. A pathologist initially attributed his death to coronary artery disease, but later information raised suspicion that he may have taken an illicit substance. The principal concern was that illicit substances were entering and being distributed within the hospital, creating a risk to life among vulnerable detained patients.

Frederick William LE GRICE · Prevention of Future Deaths report View report

29 Sep 2023 Essex S. Simblet

Frederick William LE GRICE had prostate problems and recurrent urinary tract infections treated with nitrofurantoin. After taking the drug for several years, he developed coughing, breathlessness and interstitial lung disease; he later died from pneumonia, with interstitial lung disease and nitrofurantoin toxicity contributing. The concerns relate to limited awareness and unclear guidance for clinicians and patients about nitrofurantoin-associated lung damage and the need to recognise and monitor respiratory symptoms.

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 on 14 October 2020, after police encountered him undressed by the roadside while his partner was trying to take him to hospital. The report raised concerns that police did not detain him under section 136 of the Mental Health Act for assessment and that officers had limited access to qualified, clinically informed mental health advice and records when responding to community mental health crises.

Scott James DONOGHUE · Prevention of Future Deaths report View report

28 Sep 2023 East Riding and Hull L. Harris

Scott James DONOGHUE had a history of anxiety and depression, previous suicide attempts, and was receiving support from the Home Based Treatment Team after attending the Humber Bridge intending to end his life. He died by hanging himself at home on 24 May 2022. The principal concerns were the lack of continuity among staff overseeing his care and the adequacy of the Home Based Treatment Team as an alternative to hospital admission.

Benjamin Henry Hazelden · Prevention of Future Deaths report View report

26 Sep 2023 North East Kent C. Wood

Benjamin Henry Hazelden died at the scene on 11 February 2022 after he assaulted two staff members, ran to a nearby train station and was hit by a train. The report identified limited availability of suitable specialist placements for young adults with autism and risks of self-harm or harm to others; he was discharged home with increased support because no suitable specialist bed was available.

Carol Leeming · Prevention of Future Deaths report View report

25 Sep 2023 Newcastle and North Tyneside G. Nolan

Carol Leeming had several medical conditions and had repeatedly sought advice from her GP. On the afternoon before her death, she called an ambulance requesting help and hospital admission, but the out-of-hours GP believed an ambulance had been requested through an electronic system when no such facility existed, so no ambulance was requested. The principal concerns were the lack of required induction before the GP started work, the absence of online induction for those unable to attend in person, staff confusion about call-centre systems, and regular turnover of short-term GPs.

Brian David MORETON · Prevention of Future Deaths report View report

25 Sep 2023 Newcastle and North Tyneside J. Thompson

Brian Moreton was admitted with diarrhoea, recurring fever and a distended abdomen; a toxic megacolon present on CT was not reported to those treating him. He was treated for severe colitis, later found to have a perforated bowel, and died from infections following surgery and immunosuppression. The principal concern was poor and misleading communication between clinicians, departments and hospital trusts, including deficiencies in the information provided to radiologists and assumptions about his clinical improvement and surgical referral.

Shaun Daniel Houghton · Prevention of Future Deaths report View report

25 Sep 2023 Manchester West A. Walsh

Shaun Daniel Houghton was found dead in a rural area on 1 December 2022 after self-discharging from Atherleigh Park Hospital against medical advice the previous day. During the inquest, concerns were raised about self-discharge procedures, including the absence of routine referral to a Consultant or Senior Doctor, the lack of a checklist for junior doctors, and medication not being prescribed or dispensed at discharge.

Robert Leigh · Prevention of Future Deaths report View report

25 Sep 2023 Manchester West A. Walsh

Robert Leigh was found dead at home on 7 February 2022, having suspended himself by a ligature attached to a loft beam. The report identifies missed mental-health appointments, a lack of interim cover and a lack of resilience arrangements during the absence of his Care Coordinator as substantive concerns.

Sebastian Harry DANIELS · Prevention of Future Deaths report View report

22 Sep 2023 Hampshire, Portsmouth and Southampton R. Simpson

Sebastian Harry Daniels, who had paranoid schizophrenia and was treated with clozapine, developed severe hypertriglyceridemia and necrotising pancreatitis before dying from multiple organ failure on 4 July 2021. Concerns included the failure to escalate abnormal triglyceride results, unclear communication of required GP actions in hospital discharge summaries, delays in addressing identified deficiencies, and the requirement for patients taking clozapine to attend separate appointments for some blood tests.

Chantelle Reed · Prevention of Future Deaths report View report

21 Sep 2023 Cambridgeshire and Peterborough S. Goward

Chantelle Reed, who was 33 and had no significant medical history, attended hospital with back, neck and chest symptoms before returning with worsening breathlessness, chest pain, vomiting and fever. She was managed for suspected pulmonary embolism but died after becoming unconscious in the emergency department; the inquest recorded an undiagnosed Type A aortic dissection. Concerns included limited recognition of aortic dissection symptoms in emergency guidance and delays in radiological review that can leave abnormal findings unidentified until after death.

Melvyn Lee BLOUNT · Prevention of Future Deaths report View report

21 Sep 2023 Derby and Derbyshire S. Evans

Melvyn Blount experienced a rapid deterioration in his mental health, including confusion and delusional thoughts, and died from asphyxiation on 14 January 2023 after tying a ligature. Concerns included the lack of a clear policy for ensuring that drug alerts are communicated when a non-prescriber requests a prescription from a GP who does not see the patient, and uncertainty about responsibility for informing the patient.

Alison Mary ROSS · Prevention of Future Deaths report View report

21 Sep 2023 West Sussex, Brighton and Hove J. Andrews

Alison Mary Ross died on 11 November 2022 from an intraabdominal haemorrhage following an ascitic drain procedure performed on 10 November 2022. The report raises concern that there was no guidance for monitoring medicines self-administered by patients who did not take them when dispensed, relevant to the administration of apixaban before the procedure.

Lauren Elizabeth Bridges · Prevention of Future Deaths report View report

19 Sep 2023 Manchester South A. Bridgman

Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent providers.

Mark Bennett · Prevention of Future Deaths report View report

19 Sep 2023 South Yorkshire (Western) S. Eccleston

Mark Bennett died at Meadowhall Shopping Centre Sheffield on 14 April 2022 from a pulmonary embolism following a leg injury and immobility after a trip in the London Underground. During the inquest, concerns were raised that ambulance guidance was unclear about how long resuscitation should continue and when patients should be taken to hospital for possible thrombolysis, and that this might place future patients at risk.

Stewart Stanley · Prevention of Future Deaths report View report

19 Sep 2023 Exeter and Greater Devon P. Spinney

Stewart Stanley was remanded in custody at HMP Exeter and was found hanging in his cell on 12 July 2020 after the level of his observation had been reduced. He was taken to hospital and died on 14 July 2020. The concerns included inconsistent approaches to conducting and recording ACCT observations, differing interpretations of observation requirements, inaccurate recording of observation times, and evidence of excessive staff working hours. The inquest jury concluded that his death was probably caused or contributed to by failures to follow processes, including excluding the staff best qualified to assess his risk from the decision to remove him from constant watch.

Stephen William Cassidy · Prevention of Future Deaths report View report

19 Sep 2023 Avon S. Fox

Stephen William Cassidy fractured his hip and was admitted to Southmead Hospital, where he was given intravenous Ceftriaxone during anaesthetic induction despite a recorded Ceftriaxone allergy. He suffered a severe anaphylactic reaction and died shortly afterwards. The principal concern was that hospital staff could not routinely or easily access or automatically receive Summary Care Record information, including allergies, creating a risk of avoidable patient harm and death.

Lauren Elizabeth Bridges · Prevention of Future Deaths report View report

19 Sep 2023 Manchester South A. Bridgman

Lauren Elizabeth Bridges was detained under the Mental Health Act and remained in an out-of-area psychiatric intensive care placement for about five months after she was ready for step-down. She died on 26 February 2022 following a ligaturing incident. Concerns included inadequate record keeping and communication, missed opportunities to move her closer to home despite beds being available, and the effects of the prolonged out-of-area placement on her deterioration and death.