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Amarjit SINGH · Prevention of Future Deaths report View report

18 Sep 2023 Inner North London M. Hassell

Amarjit Singh, aged 41, was found dead in his cell at HMP Pentonville on the morning of 21 November 2021 after his cellmate reported that he had suffered a fit, but medical attention was not sought and the cell door remained locked. The inquest jury determined that he died from natural causes, contributed to by neglect. Outstanding concerns included a careless cell-sharing risk assessment and gaps in prison staff and prisoner guidance and first-aid understanding, including failures to recognise the need for CPR or distinguish unconsciousness from death.

Anthony John Friend · Prevention of Future Deaths report View report

18 Sep 2023 Worcestershire D. Reid

Anthony John Friend, who was living with the effects of a brain tumour and required regular personal care, sustained a significant head injury on 17 April 2023 after slipping through a sling while being hoisted from a chair to his bed. He was discharged home for palliative care and died there on 20 April 2023. The principal concern was that an old toileting sling had previously been judged unsuitable and unsafe, but remained at his property and continued to be used, with shortcomings identified in communication, supervision and arrangements for safer alternatives.

Kimberley Sampson and Samantha Mulcahy · Prevention of Future Deaths report View report

17 Sep 2023 Central and South East Kent C. Wood

Kimberley Sampson and Samantha Mulcahy died after developing disseminated herpes simplex infections acquired before or around delivery, with both progressing to multi-organ failure despite intensive treatment. The principal concerns were delays in recognising a viral cause and commencing antiviral therapy, alongside a lack of national guidance on antiviral treatment for women presenting with systemic infection in the postpartum or peripartum period. The investigation also found uncertainty about testing staff who had treated both women and was unable to establish whether they had a common source of infection.

Sienna Scarlett Monterio · Prevention of Future Deaths report View report

16 Sep 2023 Blackpool and the Fylde A. Wilson

Sienna Scarlett Monterio was born by emergency caesarean section on 6 April 2022 and died later that morning following a severe fetal-maternal haemorrhage. The report raises concern that blood gas analysers may not be configured to measure haemoglobin in neonatal resuscitation settings, with variation between trusts potentially limiting information available to clinicians; it states this issue did not contribute to Sienna’s death.

Riya HIRANI · Prevention of Future Deaths report View report

15 Sep 2023 Inner North London M. Hassell

Riya Hirani, aged nine, was transferred to Great Ormond Street Hospital after presenting in cardiac arrest, having previously been assessed and discharged from Northwick Park Hospital. The concerns were that the severity of her illness was not recognised, despite her mother's repeated concerns, and that she was not given intravenous antibiotics, admitted, or escalated for a second opinion. Riya died five days after the cardiac arrest; her recorded cause of death included hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest, invasive group A streptococcal infection and influenza B infection.

Eclipse Morrison · Prevention of Future Deaths report View report

15 Sep 2023 Warwickshire L. Lee

Eclipse Morrison died at Nottingham City Hospital on 21 July 2021, the day after her birth, following perinatal asphyxia and complications associated with gestational diabetes, excessive fetal growth and shoulder dystocia. The principal concerns included failures to follow up missed appointments, consider and discuss appropriate timing and mode of delivery, identify risk factors during labour, and ensure adequate fetal monitoring. Further concerns related to the implementation and quality assurance of Badgernet, escalation procedures for ultrasound concerns, counselling about shoulder dystocia, and interpretation of Montgomery guidance.

Geoffrey Robin Brooks · Prevention of Future Deaths report View report

15 Sep 2023 Exeter and Greater Devon P. Spinney

Geoffrey Robin Brooks, who had nephrogenic diabetes insipidus, was admitted to hospital in October 2020 after his health deteriorated and died on 12 November 2020 despite treatment. The discharge summary did not clearly state that his required fluid intake of 2.5 to 3 litres per day was a target, and the target was not met while he was in the nursing home; the inquest concluded that he died from complications of nephrogenic diabetes insipidus on a background of poor fluid intake.

Marcel Maksymilian WOCHNA · Prevention of Future Deaths report View report

14 Sep 2023 Hampshire, Portsmouth and Southampton J. Pegg

Marcel Maksymilian WOCHNA, aged 15, drowned in the River Itchen on 8 November 2021 after voluntarily entering the water to evade arrest. The inquest found that insufficient immediate action was taken by attending officers to attempt a rescue, and identified inadequate knowledge of the working near water policy. Principal concerns included lack of awareness of Cold Water Shock, rescue procedures, handcuffing risks near water, and the effective dissemination and awareness of the relevant procedure.

Richard Geraint Griffiths · Prevention of Future Deaths report View report

14 Sep 2023 North Wales (East and Central) K. Robertson

Richard Geraint Griffiths moved to the Conwy area in October 2022 to live with his mother, and the transfer of his care from the South Gwynedd Community Mental Health Team did not occur. He was found suspended on 26 March 2023 and was pronounced deceased at the location; the inquest concluded suicide. Concerns included deficiencies in the Health Board’s investigation, an unfinished transfer-of-care process, and delays in implementing electronic mental-health patient notes.

Jack FARRINGTON · Prevention of Future Deaths report View report

14 Sep 2023 Hampshire, Portsmouth and Southampton R. Simpson

Jack Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.

Geoffrey Douglas HOAD · Prevention of Future Deaths report View report

13 Sep 2023 Norfolk J. Lake

Geoffrey Douglas Hoad underwent a total hip replacement on 3 August 2022 and subsequently developed a paralytic ileus, respiratory compromise and deteriorating renal function. He was transferred to Norfolk and Norwich University Hospital after an ambulance response that took more than 14 hours, and he died on 7 August 2022 after developing cardiac ischaemia and a myocardial infarction. The principal concern was the continuing considerable delays in attending ambulance calls amid very high demand and pressure on the healthcare system.

Melissa Hannah Kerr · Prevention of Future Deaths report View report

13 Sep 2023 Norfolk J. Lake

Melissa Kerr underwent liposuction and a Brazilian Buttock Lift in Istanbul on 19 November 2019 and became unwell during surgery before being declared dead. The concerns included limited assessment and information about the risks, limited documentary evidence, and surgical techniques that increased the risk of fat embolism. The report also raised concerns about patients travelling abroad for the procedure without being aware of its risks and where there are limited controls over the surgery.

Rashdah Waseem Begum Bhatti · Prevention of Future Deaths report View report

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

Rashdah Waseem Begum Bhatti died at home after haemorrhaging from varicose veins while taking anticoagulants. Ambulance assistance was delayed for several hours, and concern was raised that call handlers failed to provide clinically beneficial advice available within the Medical Priority Dispatch System and that reminders to staff might not reduce such errors.

Amanda Jane Kramer · Prevention of Future Deaths report View report

11 Sep 2023 East London G. Irvine

Amanda Jane Kramer, aged 56, was found unresponsive at home on 31 December 2022 and died from an overdose of prescribed zopiclone. The report raised concerns that zopiclone had been prescribed for approximately 18 years without clear evidence that its ongoing need, associated risks, or adherence to dosage instructions had been reviewed, including after previous deliberate overdoses of prescribed medication.

Ms Cherry Lynne GARLAND · Prevention of Future Deaths report View report

8 Sep 2023 Avon R. Sowersby

Ms Cherry Lynne GARLAND died on 11 October 2022 in the Bristol Royal Infirmary from sepsis and right-sided heart failure after cardiac treatment, vascular injury, Covid and pneumonia. During her transfer from the Cardiac High Dependency Unit to the Cardiac Ward, a transcription error omitted antibiotics from her medication list, although the evidence accepted was that discontinuing them would have been reasonable at that time. The report raises concern that incompatible medication systems, manual transcription and insufficient pharmacist capacity create a known risk of future medication errors and deaths.

KRISTOPHER COREY JAMIE LEE TILBURY · Prevention of Future Deaths report View report

8 Sep 2023 Hertfordshire J. Stevens

Kristopher Corey Jamie Lee Tilbury died in his prison cell at HMP The Mount after smoking a synthetic cannabinoid and consuming alcohol, causing respiratory depression. The report raised concerns that illicit drugs and alcohol remained widely available at the prison, including on a wing for prisoners with substance misuse issues, creating a significant risk of future deaths.

Lynsey Sarah Smalley · Prevention of Future Deaths report View report

8 Sep 2023 North West Wales K. Robertson

Lynsey Sarah Smalley, aged 42, set fire to her bed at home during an acute psychotic episode on 8 April 2021. She suffered inhalation injuries, was admitted to intensive care, and died at Ysbyty Gwynedd, Bangor on 16 May 2021. The substantive concerns were conflicting investigation reports, disjointed patient-safety and governance processes, delays in completing actions, and risks arising from paper-based medical records that may impede continuity of care.

Graham Thomas John SMITH · Prevention of Future Deaths report View report

7 Sep 2023 Birmingham and Solihull S. Brenchley

Graham Smith, who had Myasthenia Gravis, was admitted with suspected biliary sepsis and a chest infection. He received Gentamicin, which was contraindicated for Myasthenia Gravis, and was not prescribed his usual Pyridostigmine; he subsequently developed a myasthenic crisis, respiratory failure and multi-organ dysfunction, and died after further deterioration. The principal concern was that insufficient awareness of Myasthenia Gravis and the interaction between Gentamicin and the condition could persist among clinicians more widely.

Lamont Ashley Roper · Prevention of Future Deaths report View report

7 Sep 2023 North London A. Walker

Lamont Ashley Roper was found dead at the bottom of Lock 17 after entering the canal following a cycling pursuit, a stop-and-search request, and a struggle with a police officer near the canal railings. The concerns included the availability of water-rescue equipment and resources, access to specialised divers, and the risks and training associated with police cycle patrols and pursuits near bodies of water.

Sultana Choudhury · Prevention of Future Deaths report View report

7 Sep 2023 East London G. Irvine

Sultana Choudhury died in hospital on 17 December 2022 after suffering a renal haemorrhage following a renal biopsy, leading to hypovolaemia and cardiac arrest. The concerns included failure to diagnose the ongoing haemorrhage, administration of VTE prophylaxis despite haematuria, and inadequate monitoring during her admission.