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Daniel LYLE · Prevention of Future Deaths report View report

23 May 2023 Inner West London P. Rogers

Daniel LYLE, who suffered from paranoid psychosis, experienced a psychotic episode on 20 March 2020 and climbed approximately 30 feet into a tree while displaying paranoid and delusional beliefs. He fell from the tree, sustained fatal head and chest injuries, and died despite resuscitation efforts. The principal concern was that police training was not sufficiently focused on understanding mental health symptoms and presentation, or on practical strategies to support decision-making during mental health crises.

Karl Mitchell · Prevention of Future Deaths report View report

22 May 2023 Avon P. Harrowing

Karl Mitchell, a lorry driver, was crushed by a rotating stabilising leg while retracting a stabiliser beam during the delivery of a container on 23 September 2021. He was taken to hospital and died from his injuries on 25 September 2021. The report raises concerns that many unmodified lorry-mounted cranes remain in use and that operators may be unaware of available safety modifications and the risk of crushing.

Michael James Francis Bray · Prevention of Future Deaths report View report

22 May 2023 Suffolk P. Taheri

Michael James Francis Bray was at home on 9 and 10 October 2021 after drinking alcohol and contacting a crisis helpline while considering hanging himself; he died by hanging between about 1:50 am and 5:53 am on 10 October 2021. The report identified concerns about prolonged delays in responding to Category 2 ambulance calls, including persistently above-target response times, alongside issues concerning inter-agency communication, police and ambulance responses, and welfare checks.

KAIUS JOHN PAUL TUTT · Prevention of Future Deaths report View report

22 May 2023 Cornwall and Isles of Scilly G. Davies

Kaius John Paul Tutt died from multiple injuries after the motorcycle he was riding collided with a car on the A391 near St Austell on 14 October 2022. The principal concerns were faded or missing road-marking deflection arrows, visibility issues at the collision location, and the limited benefit of the downhill overtaking opportunity. The report also records a recommendation to amend the road layout, with no funding then available to facilitate it.

Emilia Watson · Prevention of Future Deaths report View report

19 May 2023 Warwickshire R. Brittain

Emilia Watson was delivered by Caesarean section on 5 April 2021 after concerns about fetal wellbeing and fetal heart rate; she died shortly after birth despite resuscitation attempts. The report raised concerns about the limited home-birth experience of the two attending midwives and the lack of specific regulatory requirements for training or ongoing exposure to home-birth practice.

Elsie Mary MURPHY · Prevention of Future Deaths report View report

19 May 2023 Cumbria N. Shaw

Elsie Mary MURPHY slipped in a puddle on a footpath in Maryport on 27 September 2022, fell, and died in Cumberland Infirmary the following day from a fatal injury. The concern was that a puddle regularly formed at the location because water appeared to discharge onto the path, creating a risk of further accidents.

Norma Winifred BRUTON · Prevention of Future Deaths report View report

19 May 2023 Birmingham and Solihull V. McKinlay

Norma Winifred BRUTON was admitted to hospital with a pneumothorax and other lung conditions, suffered an unwitnessed fall while walking to the bathroom, and sustained a fractured neck of femur. Her condition deteriorated after surgery and she died in hospital; concerns related to falls-risk assessments not prompting staff to consider or document attachments such as chest drains and intravenous infusions, or their relevance to falls risk.

Amelia Barbosa · Prevention of Future Deaths report View report

19 May 2023 Cambridgeshire and Peterborough S. Goward

Amelia Barbosa suffered an acute hypoxic injury immediately before delivery that continued during resuscitation, and she died in hospital on 13 December 2020 at 7 days old. Concerns included unreliable cord blood sampling, delays in obtaining vascular access and administering treatment, inadequate consideration of blood transfusion before resuscitation stopped, and delayed effective cooling. The report also raised concerns that learning and training on these issues had not been fully implemented.

Samuel Alexander Morgan · Prevention of Future Deaths report View report

18 May 2023 Swansea and Neath Port Talbot K. Heaven

Samuel Alexander Morgan, who was suffering from alcohol addiction and had diagnoses of ADHD and social anxiety, was found deceased at his parents’ house on 9 May 2019 after tying a ligature around his neck. The principal concern was that addiction and mental health services could not electronically access each other’s records, meaning important information about suicide risk and patient safety might be lost or insufficiently understood between treating teams.

Akash Dinesh Bhudia · Prevention of Future Deaths report View report

18 May 2023 East London N. Persaud

Akash Bhudia had a persistent cough and was treated for presumed pneumonia before a follow-up chest X-ray showed worsening and new lung consolidation. He later coughed and vomited blood, could not be resuscitated, and a post-mortem examination found a pulmonary abscess most likely caused by tuberculosis. The principal concern was that significant X-ray findings suggestive of tuberculosis were not highlighted to the referring clinician, and that no alert process appeared to be in place to ensure timely action.

Roger Southwick · Prevention of Future Deaths report View report

16 May 2023 Manchester South C. Briggs

Roger Southwick was admitted to hospital on 5 November 2022 with breathlessness, a chest infection and low sodium levels following heart failure. He fell on 7 November after an inaccurate falls risk assessment and concerns about his mobility were not acted on; he sustained a significant subdural haemorrhage and died on 9 November 2022. The substantive concerns were failures to accurately assess and reassess his falls risk, and the failure of the investigation report to identify these issues.

Tamsin Ann Dolamore · Prevention of Future Deaths report View report

16 May 2023 Cornwall and Isles of Scilly A. Cox

Tamsin Ann Dolamore died aged 24 after falling from a railway bridge onto railway lines on 8 January 2018; the inquest recorded an Open Conclusion and the medical cause of death as effects of multiple injuries. The substantive concerns included delays in appointing a Sexual Offence Liaison Officer, delays and gaps in mental-health and support services, and insufficient police resources causing delays in progressing rape and serious sexual assault complaints.

Stuart Michael ROBINSON · Prevention of Future Deaths report View report

16 May 2023 Liverpool and the Wirral K. Ainge

Stuart Michael Robinson, aged 20, died by suicide in prison on 25 April 2021 after a history of attempted suicide and self-harm. The inquest highlighted the need for a registered mental health nurse or other mental health expert to attend reviews for prisoners subject to ACCT procedures, particularly where there had been repeated self-harm.

Mark Ravensdale · Prevention of Future Deaths report View report

16 May 2023 South Yorkshire (Western) A. Combes

Mark Ravensdale had longstanding mental health difficulties and was found hanged, with the inquest concluding that he died by suicide. Mental health services discharged him without speaking to him directly or adequately assessing his mental health.

Benedict Peters · Prevention of Future Deaths report View report

16 May 2023 Manchester South C. Morris

Benedict Peters was found dead at his parents’ home on 12 November 2022, after being discharged from the Manchester Royal Infirmary Ambulatory Care Unit the previous day following assessment for chest pain, shortness of breath, sore throat and an aching arm. The inquest found that he died from haemopericardium and acute aortic dissection, with a narrative conclusion referring to complications from an undiagnosed underlying heart defect. Concerns included his discharge without an in-person doctor’s review despite his symptoms, age and family history, and the absence of a Trust policy or protocol governing such discharges.

Carl Garry Thompson · Prevention of Future Deaths report View report

16 May 2023 Manchester South A. Morris

Carl Garry Thompson died from a drug overdose while on leave from Arden Ward, Stepping Hill Hospital, and was likely to have died on the night of 9 March 2022. Concerns included inadequate risk assessments and planning for his leave, insufficient response and escalation after family concerns about increased risk, and failure to provide a face-to-face Community Mental Health Team assessment or allocate a care coordinator before leave.

Raymond Lee · Prevention of Future Deaths report View report

15 May 2023 Manchester South A. Mutch

Raymond Douglas Lee had oesophageal cancer treated with radiotherapy, developed an oesophageal stricture, and later had a stent inserted. He was admitted with bleeding and died at Stepping Hill Hospital on 14 September 2021 from complications including an aorta-oesophageal fistula. The report raised concerns about limited national guidance and evidence on treating oesophageal strictures, including uncertainty about when to stop dilatation and consider stenting, and the risks of perforation associated with both procedures.

Roy WALKLET · Prevention of Future Deaths report View report

15 May 2023 Stoke-on-Trent and North Staffordshire D. Ritchie

Roy Walklet died at Royal Stoke University Hospital on 9 April 2022 from multiorgan failure caused by a massive gastroduodenal haemorrhage, contributed to by ibuprofen, after multiple large bleeds from a duodenal ulcer. Concerns included delays in performing a gastroscopy because a hospital bed had not been allocated, and a failure to ensure that the consultant gastroenterologist reviewed him during the morning ward round after he was allocated to the consultant’s patient list.

Julie Louise Hancock · Prevention of Future Deaths report View report

15 May 2023 Cornwall and Isles of Scilly A. Cox

Julie Louise Hancock underwent a right total knee replacement on 2 March 2022, was discharged on 5 March 2022, and died at home on 28 March 2022. Her post-mortem cause of death was pulmonary embolus due to deep vein thrombosis, with immobility following the knee replacement. The concerns included apparent prescription of low-risk thrombosis prophylaxis despite her being assessed as high risk, an unidentified doctor’s prescription of dalteparin that was stopped after one dose, and possible discrepancies between summary and full thrombosis-prevention guidance.

Rebecca Alice Fisher · Prevention of Future Deaths report View report

15 May 2023 Manchester South A. Mutch

Rebecca Alice Fisher was found deceased by her family on 15 April 2022 after being reported missing from a mental health ward following unescorted leave. A post-mortem found a fatal dose of drugs, including pregabalin. The principal concern was that Greater Manchester Police did not assess her as a high-risk missing person, resulting in delays to mobile telephone enquiries and specialised input; concerns also included gaps in staff understanding, documentation, information sharing, and the implementation of training and guidance.