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Rebekah Juliet Mills · Prevention of Future Deaths report View report

15 May 2023 Manchester South A. Mutch

Rebekah Juliet Mills suffered a knee injury in an accidental skiing fall, underwent surgery, collapsed at home several days later, and died from a pulmonary embolism. The inquest identified unclear clinical guidance about reducing the risk of DVT in young, immobile patients taking oral contraception who require surgery, with differing approaches and insufficient recognition of the potential fatal risk.

Drew Howe · Prevention of Future Deaths report View report

15 May 2023 Manchester South C. Morris

Drew Howe was found dead on 19 October 2022 in a lorry on the A18 in Lincolnshire, having suspended himself by the neck with a ligature. He had experienced a deterioration in his mental health and was awaiting further assessment after being discharged without a diagnosis or treatment plan; concerns were raised that the Trust’s investigation did not fully examine his contacts with mental health services or derive all available learning.

Thomas Victor HUNTLEY · Prevention of Future Deaths report View report

14 May 2023 Hampshire, Portsmouth and Southampton R. Simpson

Thomas Victor Huntley died in HMP Winchester after he was found unresponsive in his cell on 28 May 2020, following a planned act intended to end his life. The inquest identified concerns about missing and inadequately recorded risk information, failures in ACCT documentation and risk assessment, inadequate observations, information sharing between prison and healthcare staff, and ligature risks in cells.

Angela Vanessa CRADDOCK · Prevention of Future Deaths report View report

12 May 2023 Cheshire J. Devonish

Angela Vanessa Craddock died on 11 April 2018 after an offender attended her address and inflicted survivable injuries. Concerns included failures to identify and share information about breaches of a restraining order, incomplete risk assessment and recall information, and ineffective deployment of police resources to enforce the recall notice.

Odessa Carey · Prevention of Future Deaths report View report

12 May 2023 North Northumberland and South Northumberland A. Hetherington

Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.

Barbara Mitchell · Prevention of Future Deaths report View report

12 May 2023 North London P. Straker

Barbara Mitchell died at Northwick Park Hospital on 9 July 2022 after falling at home while being assisted by a carer. The report raised concern about specialist staff training in moving and handling individuals, particularly after a fall.

Nicholas John PENNICOTT · Prevention of Future Deaths report View report

11 May 2023 West Sussex, Brighton and Hove P. Schofield

Nicholas John PENNICOTT’s health deteriorated from March 2021, and he suffered a cardiac arrest at home on 19 August 2021 while awaiting an urgent neurology appointment. The report identified persistent neurology capacity problems, including a long-term consultant vacancy and long waiting times, which led to a missed opportunity for earlier specialist assessment.

Milan Peter HAMZA (Otherwise known as Milan Peter RADOCZ) · Prevention of Future Deaths report View report

10 May 2023 Cambridgeshire and Peterborough S. Milburn

Milan Peter Hamza, also known as Milan Peter Radocz, was an 8-year-old front-seat passenger in a vehicle that left the road, entered a pond and became submerged on 3 September 2022. He was unable to escape and died from drowning. The principal concern was the lack of signage warning westbound drivers about the sharp bend, despite the water hazard beyond it.

Vivien RADÓCZ · Prevention of Future Deaths report View report

10 May 2023 Cambridgeshire and Peterborough S. Milburn

Vivien RADÓCZ died after the vehicle she was driving left the road, entered a pond, and became submerged; she was unable to escape and her death was confirmed at the scene. The report raised concern that there was no signage warning westbound drivers of the sharp bend, despite the additional hazard posed by the water beyond it, creating a risk of future incidents and deaths.

Mojeri Adeleye · Prevention of Future Deaths report View report

10 May 2023 South Yorkshire (Western) A. Combes

Mojeri Adeleye was born extremely prematurely after pre-labour premature rupture of membranes and died following premature labour. The report identified concerns that staff did not sufficiently regard his mother’s knowledge of her pregnancy and estimated due date, and that his parents were not involved in discussions about possible measures before the 22-week mark.

James Philliskirk · Prevention of Future Deaths report View report

10 May 2023 South Yorkshire (Western) A. Combes

James Philliskirk was assessed twice in A&E after becoming unwell following a recent chickenpox infection and was sent home on both occasions. He developed sepsis and died at home on 13 May 2022. Concerns included failures to escalate to senior staff, unclear guidance on chickenpox reinfection and secondary complications, confirmation bias, inadequate assessment of skin lesions, and insufficient weight given to GP referral outside the usual route.

Sandra Dianne Finch · Prevention of Future Deaths report View report

9 May 2023 Staffordshire South E. Serrano

Sandra Dianne Finch, a 44-year-old woman with Type 1 diabetes who used an insulin pump, developed rising glucose levels, sleepiness and vomiting after a recent dental procedure and antibiotic treatment. An ambulance response was delayed following categorisation of her call as category 3 and a clinical review process without a time limit; she was later found to have died from ketoacidosis. The principal concerns were rigid ambulance categorisation pathways and the absence of a time limit or prioritisation system for assessing category 3 calls.

Bency Joseph · Prevention of Future Deaths report View report

7 May 2023 Essex S. Hayes

Bency Joseph died instantly on 27 May 2022 from a traumatic head injury after falling headfirst from an upstairs window at home during a severe psychotic episode. The concerns included delays in prescribing and providing therapeutic medication, failure to act on the family’s attempts to escalate the issue, and shortcomings in the Trust’s investigation, including not involving the family or Senior Pharmacist.

Joshua Asprey · Prevention of Future Deaths report View report

5 May 2023 East Sussex M. Spencer

Joshua Asprey, aged 19, died on 14 June 2021 from multiple injuries after deliberately jumping from a cliff; the inquest recorded a conclusion of suicide. The report raised concern about inconsistencies between the sertraline patient information leaflet and the British National Formulary regarding the risk of suicidal behaviour, and the potential for prescribers to be unaware of or fail to discuss that risk.

Helen COOGAN · Prevention of Future Deaths report View report

4 May 2023 Inner North London M. Hassell

Helen Coogan died in October 2022 from a natural cause, with the medical cause recorded as sudden cardiac death and metastatic neuroendocrine carcinoma, alongside other conditions. The report raised concern that qFIT tests requested after gastrointestinal symptoms had no recorded results and identified this as a matter worthy of investigation, particularly for a possible system issue.

Sienna Daisy Barber · Prevention of Future Deaths report View report

3 May 2023 Manchester North J. Kearsley

Sienna Daisy Barber, a previously healthy child, developed a high temperature and was assessed by her GP, NHS 111 and at hospital before becoming increasingly unwell and dying at Royal Oldham Hospital on 29 January 2022. The report raised concerns about the absence of NICE guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups including children under five, and about the lack of recommended rapid antigen testing for this group.

Callum Wong · Prevention of Future Deaths report View report

3 May 2023 North London P. Straker

Callum Wong was found having hanged himself on 27 August 2022. The report raised concern about considering exceptions to patient confidentiality in cases of mental ill health where informing third parties could provide crucial non-medical support.

Winbourne Gregory Charles · Prevention of Future Deaths report View report

28 Apr 2023 East London G. Irvine

Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.

Ben Alan SHIPLEY · Prevention of Future Deaths report View report

27 Apr 2023 West Yorkshire (Western) I. Pears

Ben Alan Shipley, aged 22, died on 29 August 2019 after absconding from hospital and being struck by a train. The report raises concern about delays in securing a mental health bed, during which a section 2 detention could not be completed and Ben was reliant on the goodwill of A&E staff and his family for safety.

Caroline Victoria Forte · Prevention of Future Deaths report View report

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

Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS services.