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Mrs Elsie Leaver · Prevention of Future Deaths report View report

26 Apr 2023 Inner West London F. Wilcox

Mrs Elsie Leaver died on 23 August 2020, aged 89, from multiple organ failure following a mixed drug overdose. The report raised concerns about missing psychiatric history, inadequate psychiatric assessment and risk assessment, failure to access available health information, and the lack of formal psychiatric liaison cover at QMH.

Janet SMITH · Prevention of Future Deaths report View report

26 Apr 2023 Leicester City and South Leicestershire C. Mason

Janet Smith, an 81-year-old woman with advanced dementia and ischaemic heart disease, sustained spinal fractures after an unwitnessed fall at her care home on 15 March 2022 and died on 22 March 2022 after deterioration and placement on palliative care. The principal concern was that insufficient staffing meant no carer was monitoring the lounge, allowing her to leave unattended, and that the provider had not done everything possible to mitigate the risk of harm or death from residents being left unmonitored.

Colin Robert GUMM · Prevention of Future Deaths report View report

26 Apr 2023 Lincolnshire P. Cooper

Colin Robert GUMM, a vulnerable adult receiving a care package, was found collapsed by his carers and died at Lincoln County Hospital on 27 November 2021 despite treatment. The concerns include gaps in Adult Social Care monitoring and safeguarding, the identification of apparent underweight and clinical dehydration only shortly before his death, conflicting evidence about alcohol provision, and the reported premature closure of a safeguarding enquiry before toxicology results were received.

Nancy Carolyn Price · Prevention of Future Deaths report View report

26 Apr 2023 North Wales (East and Central) K. Sutherland

Nancy Carolyn Price, aged 62, presented with sudden loss of movement and sensation in both lower limbs and was diagnosed with limb ischaemia. There were delays in assessing and transferring her for vascular surgery, after which she developed multi-organ failure and died on 1 January 2021. The principal concerns were the delayed Health Board investigation, delayed sharing of learning, and unrealistic or incomplete action plans, which limited the timely identification of learning and training needs.

JOHN ALFRED ROBERTS · Prevention of Future Deaths report View report

25 Apr 2023 Cornwall and Isles of Scilly G. Davies

John Alfred Roberts, aged 78, was admitted with vomiting and retching and was found to have an inoperable perforated sigmoid colon. He was discharged home for palliative care and died there on 26 June 2021. The substantive concerns related to an inadvertent reduction in his prednisolone dosage at Royal Cornwall Hospital and the adequacy of medication-error arrangements, as well as omissions in NICE’s BNF guidance about the risk of bowel perforation associated with corticosteroids in people with diverticular disease.

Erik Leigh Marshall · Prevention of Future Deaths report View report

25 Apr 2023 South Yorkshire West M. Whittle

Erik Leigh Marshall, aged 17, died at his home on 30 September 2023 after being found suspended by a ligature. He had ADHD, mental health issues and an autism diagnosis, with high-risk sensory behaviours. The report identified a gap in commissioning and support for sensory needs: an occupational therapy referral was not accepted because he was aged 17, while adult services would only accept him from age 18.

Christopher Evans · Prevention of Future Deaths report View report

24 Apr 2023 Avon P. Harrowing

Christopher Evans, who was vulnerable and had physical health problems, was found unresponsive and almost completely submerged in a bath of very hot water on 28 September 2020 and was pronounced dead at the scene. The report identified concerns that his supported accommodation was not subject to CQC or HSE oversight and that the regulatory framework did not require assessment or management of scalding risks or provision of engineering controls for vulnerable residents.

Samuel Thomas Howes · Prevention of Future Deaths report View report

24 Apr 2023 South London J. Taylor

Samuel Thomas Howes died from fatal injuries after jumping in front of a train on 2 September 2020. The inquest found that his ongoing mental health issues, drug use and alcohol dependency probably contributed to his death. Substantive concerns included inadequate mental health and social care responses, failures to share risk information between agencies, inadequate custody safeguarding and failures in the missing-person investigation.

Peter William Frederick Lawrence · Prevention of Future Deaths report View report

21 Apr 2023 Berkshire H. Connor

Peter William Frederick Lawrence underwent spinal surgery on 11 January 2022, developed infection and abscesses, and died at the Royal Berkshire Hospital on 3 March 2022. The report raised concerns that a clinician’s failure to maintain formal medical records, instead retaining information in personal memory, posed a risk to patient safety and to future patients, including a risk of death.

Names not published · Prevention of Future Deaths report View report

21 Apr 2023 Bedfordshire and Luton E. Whitting

Two women were found in the River Great Ouse at Kempston Mill on 16 April 2023 after renting canoes, and both were pronounced dead at the scene. The report identifies concern that, although there was a barrier at the top of the weir, there was no similar barrier at the hazardous bottom where recirculating flow was present, particularly during high water levels.

Maria Christine Shafighian · Prevention of Future Deaths report View report

21 Apr 2023 Gwent C. Saunders

Maria Christine Shafighian died from the effects of metastatic oesophageal cancer on 24 November 2020. During the inquest, missed opportunities to identify and treat the tumour earlier were identified, although it could not be determined that earlier treatment would have altered the outcome. A concern was raised that urgent information from the Speech and Language Therapists was sent through an internal postal system without a process for immediate notification or timely handling, and was apparently delayed by a month before being noticed by the ENT team.

Amy Henderson · Prevention of Future Deaths report View report

21 Apr 2023 Surrey C. Topping

Amy Henderson, who had been diagnosed with post-partum depression and admitted to Priory Hospital, Woking after expressing suicidal thoughts and plans, died there on 21 March 2022 after taking her own life by suspension in a disabled toilet. Concerns included risk assessments and observations not being completed in line with policy, therapy notes indicating deterioration not being acted upon, incomplete information about her suicide risk, and ineffective management of the disabled toilet as a high-risk area.

Joseph Willy Maunick · Prevention of Future Deaths report View report

20 Apr 2023 Suffolk P. Taheri

Joseph Willy Maunick died on 15 March 2022 from a severe head injury sustained in a fall in the Emergency Department of West Suffolk Hospital, where he had been admitted as a social admission while his wife underwent emergency surgery. The report identified concerns about a national shortage of suitable care, and severe hospital pressures including insufficient staffing and resources, which prevented the constant supervision he needed and delayed transfer to a more appropriate environment.

CHESTER ALAN STANLEY MOSSOP · Prevention of Future Deaths report View report

20 Apr 2023 Cumbria K. Gomersal

Chester was a nine-month-old baby who drowned after being left alone in a bath seat that became unfixed. He sustained a severe brain injury and died on 3 June 2022. The principal concern was that bath seats may create a false sense of security, despite not being safety devices, and that national advice about their risks and safe use may not be consistently provided.

Jodie Catherine McCann · Prevention of Future Deaths report View report

20 Apr 2023 Nottinghamshire E. Didcock

Jodie Catherine McCann, a 22-year-old woman, developed gallstone pancreatitis, suffered a cardiac arrest, and required critical care and ventilation. After her tracheostomy tube became displaced and could not be replaced, she suffered a prolonged cardiac arrest caused by lack of oxygen and died. Concerns included inadequate planning and preparation for difficult airway management and tracheostomy displacement, equipment and staffing availability, and delays in the serious incident review.

Elizabeth Mavis HUTCHINS · Prevention of Future Deaths report View report

19 Apr 2023 Avon M. Voisin

Elizabeth Mavis HUTCHINS died at Royal United Hospital, Bath, on 23 January 2022 after being admitted following a fall and broken arm. She suffered myocardial ischaemia and injury that was not treated or managed, and outstanding concerns included the absence of a hospital at night team and an acute cardiac syndrome specialist nurse practitioner role.

DAVID ERNEST MASON · Prevention of Future Deaths report View report

19 Apr 2023 Worcestershire N. Lane

David Ernest Mason, aged 82, fell at home on 5 March 2022, fractured his hip and was taken to hospital after an ambulance delay. He had Addison’s disease and died in the early hours of 7 March 2022 after developing an acute adrenal crisis. The principal concerns were that clinicians and ambulance staff did not recognise the need for additional steroid replacement after trauma and physiological stress, and that relevant clinical guidance, call-handler pathways and documentation prompts did not sufficiently address this risk.

Keith Hodson · Prevention of Future Deaths report View report

18 Apr 2023 Herefordshire H. Bricknell

Keith Hodson had a complex medical history, with delays before an ambulance was called, in ambulance attendance, on hospital admission and in receiving appropriate treatment. Concerns included failure to consistently use an appropriate triage system in Accident and Emergency, inadequate escalation and monitoring, insufficient senior oversight, delays in signing off serious incident reports, and untimely communication with the next of kin.

Patrick Soames · Prevention of Future Deaths report View report

18 Apr 2023 South London E. Gritt

Patrick Soames died by suicide on 21 June 2021 after a final month involving repeated serious self-harm, including cutting, medication overdose and excessive alcohol misuse, with multiple hospital attendances. The principal concerns were that information about his risk was fragmented across NHS Trusts, police forces, local authorities and geographical areas, with no effective system to consolidate or flag his recent self-harm history nationally.

David Levett · Prevention of Future Deaths report View report

18 Apr 2023 Northamptonshire A. Pember

David Levett was a rear-seat passenger in a vehicle struck by a lorry on an all-lane-running smart motorway on 28 January 2018. He sustained severe head and chest injuries, was taken to hospital, and was confirmed deceased on 24 February 2018; evidence at the inquest raised concern that there was nowhere for the driver of the first vehicle to park safely, such as on a hard shoulder.