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William Nichols · Prevention of Future Deaths report View report

18 Aug 2023 Gateshead and South Tyneside L. Benyounes

William Nichols underwent a femoral endarterectomy and developed a deep patch infection, followed by a catastrophic haemorrhage from the right femoral artery. The report identifies concerns about inconsistent communication between hospital and community teams, insufficient documented discharge advice, poor communication about bleeding concerns, and inadequate community-team record keeping.

Luke Matthew Brooks · Prevention of Future Deaths report View report

17 Aug 2023 Manchester North J. Kearsley

Luke Matthew Brooks died unexpectedly at home on 25 October 2022 after approximately one week of cold/flu-like symptoms. The inquest recorded acute respiratory distress syndrome due to Aspergillus pneumonia. Concerns included the absence of a register of private landlords and an ambulance-service policy advising people with non-immediately life-threatening chest pain to attend A&E on their own.

Shirley Frances Ashelford · Prevention of Future Deaths report View report

17 Aug 2023 Inner South London C. Williams

Shirley Frances Ashelford died after the lowering mechanism of a ceiling hoist failed while she was transferring from her bed to a mobility scooter, leaving her suspended in a chest harness. The harness tightened and, in combination with respiratory weakness caused by multiple sclerosis, led to fatal asphyxia. Concerns included inadequate awareness and training about positional asphyxia and emergency lowering, failures to share information about reported hoist problems, and a possible design fault in the hoist's lowering function.

Malcolm Ralph Unwin · Prevention of Future Deaths report View report

17 Aug 2023 North Wales (East and Central) J. Gittins

Malcolm Ralph Unwin suffered an unwitnessed fall from his bed while a patient at hospital on 30 December 2022 and died at Wrexham Maelor Hospital on 6 January 2023. The report raised concern that he had not been assessed for bed rails and that the absence of bed-rail assessment from the Welsh Nursing Care Record could result in such assessments being missed in future.

Absolom Adolphus Abraham Zephaniah DUFFY · Prevention of Future Deaths report View report

16 Aug 2023 Lincolnshire M. Johnson

Absolom Duffy was travelling in his Land Rover Defender when he exited Sand Lane, Saxilby, onto Doddington Road and collided with another vehicle; he died from his injuries. The concern was whether the junction would be safer with a stop command rather than a give-way warning because of its restricted view.

Kelvin Igweani · Prevention of Future Deaths report View report

16 Aug 2023 Milton Keynes S. Cummings

Kelvin Igweani died from gunshot wounds after police forced entry into a flat where he had barricaded himself with a two-year-old boy during a severe mental health episode. The report identifies a concern that, despite repeated attempts by his mother to obtain help, unclear information and direction about accessing emergency mental health assessment and care meant Kelvin did not receive that support.

Devon Drew Turner · Prevention of Future Deaths report View report

16 Aug 2023 Berkshire K. Thorne

Devon Drew Turner, who had Mosaic Trisomy 9 and significant respiratory vulnerability, died at hospital on 10 May 2022 after being found unresponsive at home. The report raises concerns about the reliability, suitability, alarm function and data recording of SATS monitoring machines provided for use by vulnerable babies at home, including whether parents were adequately trained on the particular device supplied.

Ian Darwin · Prevention of Future Deaths report View report

15 Aug 2023 County Durham and Darlington J. Chipperfield

Ian Darwin died from multiple injuries after being found below ████████, Durham, on 6 March 2023. The report raises concern that Tees Esk and Wear Valleys NHS Foundation Trust routinely delays serious incident investigations, potentially allowing lethal hazards to persist and compromising investigations intended to prevent avoidable deaths. The inquest had not been heard and the investigation had not concluded at the time of the report.

Haik Patrick NIKOLYAN · Prevention of Future Deaths report View report

15 Aug 2023 Buckinghamshire C. Butler

Haik Patrick NIKOLYAN committed suicide and was found unresponsive in his cell at HMYOI Aylesbury in the early hours of 11 March 2019. The inquest identified concerns including failures to protect him from harm, withdrawal of depression medication without documented risk assessment or enhanced monitoring, bullying and exploitation, ineffective safeguarding and communication, and inadequate consideration of his Autism Spectrum Disorder.

Leonard Jomo Isaac KING · Prevention of Future Deaths report View report

15 Aug 2023 Milton Keynes S. Cummings

Leonard Jomo Isaac King died at Milton Keynes University Hospital on 4 May 2022 following a hypoxic cardiac arrest caused by airway obstruction from epiglottitis. The report identified concerns that adult epiglottitis may be mistaken for a sore throat or tonsillitis, and that there were missed opportunities to recognise and escalate his condition and transfer him to an emergency department.

Barry Anthony LALL · Prevention of Future Deaths report View report

15 Aug 2023 Central and South East Kent K. Hepburn

Barry Anthony LALL was a dentist whose fitness to practise was being investigated by the General Dental Council after concerns about his dental work. He was dismissed from his employment and later reported anxiety, depression and fleeting suicidal thoughts. The principal concern was the level of detail about undetermined allegations published on the GDC website during interim proceedings, and the potential detrimental effect on the mental health of those undergoing similar processes.

Marie ZARINS · Prevention of Future Deaths report View report

14 Aug 2023 Leicester City and South Leicestershire I. Thistlethwaite

Marie Zarins, aged 42, was reported missing by her family and found suspended in Leicestershire; her death was confirmed at the scene on 24 November 2021. The report raised concerns about flawed multidisciplinary team discussions, inaccurate understanding and documentation of her medication status, failures to prescribe antidepressants and sleeping tablets, and inadequacies in the subsequent serious incident investigation.

Linda Oldland · Prevention of Future Deaths report View report

14 Aug 2023 Surrey A. Crawford

Linda Oldland died at Hydon Hill Nursing Home on 3 January 2022 from a urinary tract infection that infected both kidneys and resulted in sepsis. Concerns included failures to share information about positive urine tests and the GP’s treatment plan, delayed antibiotics, failure to recognise cardiac arrest, and incorrectly informing ambulance staff that a valid DNAR form was in place.

Jeffrey MARSHALL · Prevention of Future Deaths report View report

13 Aug 2023 Surrey A. Loxton

Jeffrey Marshall died at St Peter’s Hospital in Chertsey on 13 December 2023 after suffering an ischaemic stroke caused by thrombosis of the basilar artery, following a fall and subdural haematoma. His anticoagulation had been withheld for 47 days. The principal concern was the lack of national guidance on when to recommence anticoagulation after a head injury and the lack of guidance on discussing the risks and benefits of withholding it with patients.

Baby Isabela Suciu · Prevention of Future Deaths report View report

12 Aug 2023 Inner South London A. Harris

Baby Isabela Suciu was born in hospital and later suffered a cardiac arrest at home after feeding; she did not regain consciousness and died in hospital. Concerns included the failure to escalate low temperatures for paediatric review or start antibiotics, amid conflicting Kaiser Permanente and NICE guidance. The report identified a continuing risk of confusion and avoidable delay in other neonatal units, although the omission was not shown to have caused Isabela’s death.

Doris Irene URCH · Prevention of Future Deaths report View report

11 Aug 2023 Inner North London H. Lambert

Doris Irene Urch, aged 90, fell at a care home on 6 February 2023 after support was not offered while she was ambulating. She sustained an acute left frontal intracranial haemorrhage and died on 28 February 2023. Concerns included inadequate fall-risk assessment and care planning, staff unfamiliarity with the care plan, failure to update it after an earlier fall, and inadequate preservation of historical care plans.

Rohan GODHANIA · Prevention of Future Deaths report View report

9 Aug 2023 Milton Keynes T. Osborne

Rohan GODHANIA became unwell after consuming a high-protein drink on 15 August 2020, was admitted to hospital, and died on 18 August 2020 from Ornithine Transcarbamylase Deficiency. The report identifies concerns about inconsistent NHS classification of teenagers aged 16–18 and a lack of emergency-department guidance on ammonia testing for patients presenting in extremis with an unknown cause.

Reginald Edwin Bourn · Prevention of Future Deaths report View report

8 Aug 2023 Surrey C. Topping

Reginald Edwin Bourn was admitted to hospital with an intestinal blockage and required a nasogastric decompression tube. The replacement tube was misplaced into his left lung, after which he aspirated gastrointestinal contents and died. The report raised concerns about the absence of national guidance, protocols and training for inserting and confirming the placement of nasogastric decompression tubes.

Harry Arthur STOBIE · Prevention of Future Deaths report View report

4 Aug 2023 Milton Keynes T. Osborne

Harry Arthur STOBIE suffered a stroke, underwent thrombectomy and later had a PEG tube inserted, which caused a large haemoperitoneum that was not recognised at the time. The concerns were that his deteriorating condition and abdominal pain were not monitored or escalated promptly after the procedure, and that PEG insertion procedures and protocols should be reviewed.

Gerard Murray · Prevention of Future Deaths report View report

4 Aug 2023 Nottinghamshire E. Didcock

Gerard Murray died on 16 July 2022 after leaving the mental health ward at Bassetlaw Hospital on unescorted leave and being found deceased later that day. The report identifies concerns about limited risk assessment and management, inadequate monitoring of patients returning from leave, limited family and carer involvement, and staff awareness of the ligature risk reduction pathway.