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Alice Jean FOX · Prevention of Future Deaths report View report

9 Jun 2023 Derby and Derbyshire P. Nieto

Alice Jean FOX, known as Jean, died in hospital on 1 July 2021 from severe infection resulting from bacterial infection of the surgical site following partial hip replacement after a fall. Concerns included her lengthy wait in the discharge lounge and late arrival at rehabilitation, which meant usual admission assessments were not completed, and delays in reviewing blood results and referring her back to hospital despite signs of infection.

Eifion Wyn Huws · Prevention of Future Deaths report View report

8 Jun 2023 North West Wales K. Sutherland

Eifion Wyn Huws, aged 63, died by suicide at his daughter’s home on 10 June 2022 after being found suspended by a ligature. Concerns included the Emergency Department not having access to a very urgent mental-health referral held in hard-copy notes, and delays in completing and sharing the Health Board’s investigation and implementing resulting actions.

Ivan Rumenov Ignatov · Prevention of Future Deaths report View report

8 Jun 2023 Dorset R. Griffin

Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.

Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report View report

8 Jun 2023 Inner North London E. Buckett

Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.

David Barnet WILSON · Prevention of Future Deaths report View report

8 Jun 2023 West Yorkshire (Eastern) K. McLoughlin

David Barnet Wilson was admitted to hospital with suspected colitis and underwent a flexible sigmoidoscopy, during which a recognised colonic perforation occurred. He died at Pinderfields Hospital on 31 December 2022; concerns included inadequate explanation and tailoring of procedural risks, failure to mention the risk of death, and obtaining consent while he was under morphine sedation.

Anthony George Smith · Prevention of Future Deaths report View report

7 Jun 2023 Lancashire and Blackburn with Darwen N. Rheinberg

Anthony George Smith was found hanging in his cell at HMP Preston on 4 May 2022 while suffering an acute relapse of schizophrenia, and officers commenced resuscitation. The report raised concerns that mouth-to-mouth resuscitation was performed without available mouth protection, creating risks of blood-borne virus transmission and potentially discouraging rescue breaths, and noted the need for readily accessible protection masks.

Brenda SHIELDS · Prevention of Future Deaths report View report

7 Jun 2023 Cumbria N. Shaw

Brenda Shields died at home in Carlisle on 8 December 2022 after taking her life by ligature suspension while under the influence of a very high blood alcohol level. The principal concerns were that she was discharged without planned follow-up, her family was not involved as expected, relevant notifications and referrals were delayed or not made, and insufficient weight was given to her alcohol problems and recent history when assessing risk.

David WOOD · Prevention of Future Deaths report View report

7 Jun 2023 Milton Keynes T. Osborne

David Wood had recently undergone open heart surgery and was suffering from depression and difficulty sleeping after discharge from hospital. On 22 June 2022, he was found suspended by the neck at his home. A review identified concerns about communication of possible delirium to his GP and wife, discharge planning, and the protocols for discharge following heart surgery.

Alexander Shone BLEWITT · Prevention of Future Deaths report View report

6 Jun 2023 Milton Keynes S. Cummings

Alexander Shone Blewitt died at Milton Keynes University Hospital on 11 July 2022 after returning to the emergency department with faecal incontinence and abdominal pain, following an earlier visit where he had been referred from an urgent care centre. A possible acute abdomen was confirmed by CT, and he suffered a cardiac arrest before surgery. Concerns included inaccurate communication of important symptoms and treatment information, inadequate clinical recording, and the absence of reliable records of intravenous fluids administered in the emergency department.

Jennifer Evelyn RACKLEY · Prevention of Future Deaths report View report

6 Jun 2023 Berkshire H. Connor

Jennifer Evelyn Rackley died at Wexham Park Hospital on 15 January 2022 after a fall at her nursing home on 17 December 2021. Concerns included that her bed may have been in the centre of the room with only one sensor mat despite her high falls risk, and that the care home's reported investigation had no written record and could not identify the carers involved.

Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report View report

5 Jun 2023 Derby and Derbyshire S. Cartwright

Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s investigation.

Nigel Harper · Prevention of Future Deaths report View report

2 Jun 2023 Worcestershire D. Reid

Nigel Harper, who had been experiencing severe depression and anxiety and thoughts of self-harm, took an intentional overdose of prescribed sedative and hypnotic medications on 8 July 2022 and died in hospital on 23 July 2022. The report identified a lack of understanding between two NHS Trusts about urgent mental health referrals, resulting in an urgent assessment not being arranged as intended and a continuing risk of similar deaths.

Andrew DEAN · Prevention of Future Deaths report View report

2 Jun 2023 East Sussex M. Spencer

On 26 March 2021, Andrew Dean was found with a ligature around his neck in a cell at HMP Lewes and was declared dead later that morning. The concerns related to the lack of clearly defined processes for ensuring that new prisoners could successfully make first contact with family members and for logging and responding to incoming calls from family members concerned about a prisoner’s safety or requesting a welfare check.

Andrew John Shambrook · Prevention of Future Deaths report View report

31 May 2023 North Wales (East and Central) J. Gittins

Andrew John Shambrook took his own life by hanging on 27 March 2022. The health board acknowledged that there was no documented or robust policy for decision-making, meeting criteria, and future treatment and care pathways when a patient was referred to the Home Treatment Team; evidence indicated that Mr Shambrook had been referred but did not meet the team’s treatment criteria.

Carol Ann CLEMENTS · Prevention of Future Deaths report View report

30 May 2023 Birmingham and Solihull R. Ollivere

Carol Ann CLEMENTS was a resident at Perry Trees Centre following surgery for a hip fracture. She was incorrectly assessed as being at medium rather than high risk of falls, fell unwitnessed, and sustained a further hip fracture. She later developed pneumonia and sepsis and died in hospital on 23 October 2022. The concerns included gaps in enhanced supervision training, induction and falls-risk assessment training for staff including agency staff, and audits that checked compliance but not correctness.

Conrad Richard James Colson · Prevention of Future Deaths report View report

26 May 2023 East London N. Persaud

Conrad Colson, who had severe body dysmorphic disorder and a previous serious suicide attempt, was found deceased at home on 2 March 2022 after friends became concerned for his welfare. The inquest concluded that he took his own life while accessing aesthetic dermatology treatment, without therapeutic medication or professional mental health support, and after discharge without a robust risk assessment or relapse risk-management plan. Concerns included insufficient liaison and information sharing between mental health services, inadequate consideration of risks associated with aesthetic dermatology treatment, and training and resource gaps relating to body dysmorphic disorder.

Jessica Hodgkinson · Prevention of Future Deaths report View report

26 May 2023 Derby and Derbyshire M. Kewley

Jessica Hodgkinson died on 14 May 2021 at Chesterfield Royal Hospital shortly after giving birth, following a pulmonary embolism arising from a deep vein thrombosis and acute anaphylaxis of unknown cause. The inquest identified failures to communicate and follow up the plan for prophylactic tinzaparin until birth, and concerns about consideration and documentation of her Klippel-Trenaunay Syndrome during pregnancy.

Paige Jeannette ALLEN · Prevention of Future Deaths report View report

26 May 2023 South Wales Central G. Hughes

Paige Jeannette Allen died after falling from Southerndown Cliffs in the early hours of 21 April 2021, following an emergency services rescue attempt. The concern was that mental health practitioners assessing patients in crisis across different Cwm Taf Morgannwg University Health Board localities might not have immediate access to relevant medical records, potentially increasing the risk of incomplete or insufficient assessments.

Jean HARDY · Prevention of Future Deaths report View report

25 May 2023 Newcastle and North Tyneside K. Dilks

Jean Hardy, aged 71, crossed the B1286 Doxford Parkway at night at a point without a designated pedestrian crossing and was struck by a motor vehicle. She sustained multiple injuries and died in hospital on 8 February 2020. Concerns included common local crossing at non-designated points, lack of fencing and warning signage, and a risk of further deaths requiring a comprehensive review of pedestrian crossing provision.

Peter John CAMP · Prevention of Future Deaths report View report

24 May 2023 Hampshire, Portsmouth and Southampton J. Pegg

Peter John CAMP was found deceased in his bedroom after police attended his address following a concern for his welfare. Post-mortem examination found elevated carboxyhaemoglobin levels indicative of carbon monoxide toxicity; the source had not yet been ascertained, with faulty heating or cooking apparatus or inadequate ventilation identified as likely possibilities, and a continuing risk to life was noted at the property.