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Name not published · Prevention of Future Deaths report View report

5 Jul 2023 Inner North London M. Hassell

On 18 March 2021, the deceased took cocaine, developed features of acute behavioural disturbance, arrested before an ambulance arrived, and died in hospital the following day after resuscitation. The substantive concerns were the delay in moving him to the floor and commencing CPR, and insufficient proactive support from officers not directly monitoring his vital signs during the resuscitation.

Stella Ann JAMES · Prevention of Future Deaths report View report

4 Jul 2023 South Wales Central R. Knight

Stella Ann James, aged 40, died at the Royal Glamorgan Hospital on 20 January 2021 after being admitted with severe pneumonia and sepsis following severe food restriction, malnutrition and very low body weight. The principal concerns were that she appeared to meet the criteria for an adult at risk of neglect, without an apparent mechanism for Social Services to be aware of her status, and whether a register or anonymous referral mechanism could support unannounced social-work visits.

Arezou Tirgari · Prevention of Future Deaths report View report

3 Jul 2023 City of London A. Hewitt

Arezou Tirgari died on 1 June 2023 after jumping from the roof terrace of a building operated by Landsec. The report raises concern that insufficient action had been taken to prevent people from jumping from the roof terrace, creating an ongoing risk of further deaths.

Andre Felipe Mendes Moura · Prevention of Future Deaths report View report

3 Jul 2023 Manchester South A. Mutch

Andre Moura died on 7 July 2018 after suffering cardiac arrest in a police vehicle while under arrest and being transported following a significant struggle. The report identified concerns about officers’ recognition and training in acute behavioural disturbance, use of objective responsiveness checks, the safety officer role, and the absence of body-worn camera recording during escort.

Liam Ryan Wayne Bentley · Prevention of Future Deaths report View report

3 Jul 2023 Mid Kent and Medway P. Harding

Liam Ryan Wayne Bentley was a serving prisoner at HMP Swaleside who had a history of self-harm and expressed fears about other prisoners and suicidal thoughts. He later took his own life, although his intention was unclear. The report identified concerns about inadequate psychological support, failures in self-harm monitoring and care planning, ineffective communication, and staff shortages and training gaps.

Kaye McCoy · Prevention of Future Deaths report View report

30 Jun 2023 Gwent C. Saunders

Kaye McCoy, who had depression, anxiety and Unstable Affective Disorder, died by hanging on 11 September 2022 after a severe downturn in her mental health. The report identified concerns about inadequate family involvement in her care and the lack of weekend or out-of-hours crisis support for Older Adults.

SAM MALCOLM TAYLOR · Prevention of Future Deaths report View report

30 Jun 2023 Herefordshire H. Bricknell

Sam Malcolm Taylor had mental health issues and previous suicide attempts, and was found alone in a tent next to the River Wye. The report raised concerns that a council communication process failure meant no contact was made with him or approved contacts before his death, that a housing vulnerability assessment was not progressed, and that systems for identifying process failures should be effective.

Sinon MASHA · Prevention of Future Deaths report View report

30 Jun 2023 Birmingham and Solihull E. Brown

Sinon Masha was born at home on 17 December 2021 following a breech presentation that was not identified until labour. After a 27-minute delay before delivery of his head, he suffered a catastrophic hypoxic brain injury and died on 21 December 2021. The principal concern was that the Trust’s process for managing home births against medical advice was not operating as set out in its guidance, was fragmented, and might result in insufficiently informed birth choices that put lives at risk.

Victoria STOREY · Prevention of Future Deaths report View report

30 Jun 2023 Surrey A. Loxton

Victoria Storey was found deceased in her bedroom on 3 September 2022 after taking an accidental overdose of a potent synthetic opioid that was not licensed for medicinal use. The report raised concerns that the substance was illicitly traded and marketed as common pharmaceutical opiates, that its contents were unknown to users, and that it was not then controlled under the relevant drug legislation despite its high risk of fatal overdose.

Mr. Clinton Peter Fear · Prevention of Future Deaths report View report

29 Jun 2023 Avon S. Fox

Mr Clinton Peter Fear underwent cardiac valve replacement surgery in November 2012, contracted Mycobacterium Chimaera infection from a Liva Nova heater cooler unit, suffered a disabling illness and died from the infection in July 2022. The report raises concerns that guidance limiting patient notification to surgeries from January 2013 was inconsistent with evidence of infections occurring earlier, potentially contributing to delayed diagnosis and harm.

Mr Matthew John Phipps · Prevention of Future Deaths report View report

29 Jun 2023 East London N. Persaud

Matthew Phipps was admitted to hospital with severe acute kidney injury and symptoms associated with likely sepsis, and was recognised as critically unwell. There were delays in transferring him to intensive care, administering antibiotics, monitoring him, carrying out blood tests and commencing renal replacement therapy; the inquest found that these failings did not contribute to his death. A concern arose about the lack of a contingency plan for providing intensive care when the intensive care unit is full.

Peter John WALKER · Prevention of Future Deaths report View report

29 Jun 2023 Suffolk N. Parsley

Peter Walker died after the microlight aircraft he was flying alone crashed in a field adjacent to the runway at Beccles Aerodrome on 24 March 2022. The concerns included shortcomings in the Civil Aviation Authority’s guidance and systems for medical self-declarations, licence revalidation, and managing licence revocation or surrender for older pilots and certain microlight licence holders.

Carol Ann Hatch · Prevention of Future Deaths report View report

28 Jun 2023 West Yorkshire Eastern K. McLoughlin

Carol Ann Hatch underwent repeat hiatus hernia surgery at a private hospital on 31 August 2022 and became unwell overnight. She was transferred to an NHS hospital, treated for septic shock and organ failure for six weeks, and died on 18 October 2022. The report identifies concerns about overnight monitoring, escalation, staffing competence, record-keeping, and delays in investigations and treatment; evidence at the Inquest indicated that the failings contributed to her death.

Hilary THOMAS · Prevention of Future Deaths report View report

28 Jun 2023 Birmingham and Solihull L. Hunt

Hilary THOMAS attended hospital with abdominal pain on 28 and 29 October 2022, then reattended on 30 October in a shocked and profoundly unwell state. She underwent emergency surgery for ischaemic bowel caused by adhesions but died on 31 October 2022. The principal concerns were delayed review of blood test results, failure to escalate her case for consultant review, and delay in arranging a CT scan.

George Edward GRIFFITHS · Prevention of Future Deaths report View report

28 Jun 2023 Herefordshire H. Bricknell

George Edward GRIFFITHS was admitted to hospital with acute kidney injury, gastritis, poorly controlled diabetes and infected toes, and later developed sepsis, COVID, delirium and a significant pressure sore during his prolonged admission. The report states that doctors believed the hospital-acquired pressure sore contributed to his death. Concerns included prolonged time in the emergency department without footwear removal, inadequate pressure-area prevention and delayed reassessment and pressure-relieving measures.

Rachel Kathleen Garrett · Prevention of Future Deaths report View report

27 Jun 2023 West Sussex, Brighton and Hove P. Schofield

Rachel Kathleen Garrett had been experiencing deteriorating mental health and was found near the cliffs on several occasions. On 29 July 2020, after leaving the Royal Sussex County Hospital for a second time, she returned to the cliffs and ended her life by falling from the cliff top. The report’s principal concern was that mental health liaison staff employed by a separate mental health trust could not themselves use holding powers to prevent a patient leaving an acute hospital, creating a risk when patients with deteriorating mental health attended A&E.

Richard Stephen LITTLEWOOD · Prevention of Future Deaths report View report

27 Jun 2023 East Riding and Hull L. Harris

Richard Stephen Littlewood was involved in a motorcycle collision on the A1033 on 8 July 2022 after his motorcycle crossed the white line and struck an oncoming vehicle. He sustained multiple traumatic injuries, spent three weeks in intensive care, and died on 29 July 2022. Concerns were raised about multiple incidents on the same bend and the lack of a timescale for assessing additional road markings and signage.

Mark Steven Wright · Prevention of Future Deaths report View report

26 Jun 2023 Surrey A. Crawford

Mark Steven Wright deliberately overdosed on prescribed quetiapine at home during the night of 14 June or early hours of 15 June 2022, and was pronounced deceased after an ambulance arrived. The report identifies delays in the ambulance response, including SECAMBS operating under Stage 4 of its Surge Management Plan, as a significant concern because demand exceeded available resources and calls could not be answered within target timeframes.

Anthony William Rockall · Prevention of Future Deaths report View report

26 Jun 2023 Buckinghamshire C. Butler

Anthony William Rockall died at John Radcliffe Hospital on 26 April 2022 from a head injury sustained when he fell from the tailgate of a truck during unloading at a reclamation yard. The pallet truck was longer than the tailgate, and concerns were raised about the unloading method, the weight on the tailgate, and the absence of subsequent reviews or changes to working practices, leaving risks of loads, equipment or individuals falling from the tailgate.

Matthew William Thomas Power · Prevention of Future Deaths report View report

26 Jun 2023 Surrey S. Ridge

Matthew William Thomas Power, a 33-year-old man living in supported accommodation, died at a house in Redhill after taking illicit and prescribed drugs over the previous 36 hours; the medical cause of death was recorded as mixed drug toxicity. The concerns identified related to the EMIS prescribing system, including cancelled prescriptions remaining pending, prescriptions being grouped in a way that obscured prescribing history, and difficulty determining what had been prescribed and issued.