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Rachael Chloe WALKER · Prevention of Future Deaths report View report

16 Mar 2023 Derby and Derbyshire P. Nieto

Rachael Chloe Walker died in hospital on 19 June 2021 after a placental haemorrhage and amniotic fluid embolism at 37 weeks of pregnancy. The report identified missed opportunities involving the recording and implementation of an earlier delivery plan and national guidance. The principal concern was whether the Trust had sufficiently robust processes for updating clinical guidance and ensuring essential equipment and procedures were in place.

John Anthony IBBOTSON · Prevention of Future Deaths report View report

16 Mar 2023 North Yorkshire and York S. Watson

John Anthony Ibbotson, a 57-year-old warehouse operative, was found at work with a pallet on top of his back on 21 September 2020 and was pronounced dead shortly afterwards. The inquest heard that pallets were more likely than not double stacked directly on top of one another, although it was unclear what caused the pallet to fall. Concerns included limited awareness of relevant pallet-stacking standards, insufficient information passed through the supply chain, the absence of labelling for single-deck pallets, and training that did not include the prohibition on stacking them.

Brian George Harfield · Prevention of Future Deaths report View report

16 Mar 2023 West Sussex P. Schofield

On 3 May 2022, a fire started near Brian George Harfield’s recliner chair and he was overcome by smoke. He was found unconscious and, despite medical intervention, was pronounced deceased at the scene. The principal concern was the lack of compulsory sprinklers or other fire-safety measures in extra-care and retirement-type accommodation outside care homes, particularly for people with declining health or mobility.

Jai SINGH · Prevention of Future Deaths report View report

15 Mar 2023 Birmingham and Solihull E. Brown

Jai Singh died at City Hospital on 28 January 2022 after being found in cardiac arrest in his cell at HMP Birmingham, having asphyxiated after placing a bag over his head. The report identifies repeated failures to communicate and record family and clinical concerns, use interpreters, assess risk, operate the ACCT process, and provide appropriate mental-health admission and transfer. It also identifies ongoing risks from the absence of a psychiatrist in the prison mental-health MDT and the lack of ongoing risk-assessment documentation in SystemOne.

Sara Anest JONES · Prevention of Future Deaths report View report

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

Sara Anest Jones died at Royal Stoke University Hospital on 2 April 2021 from complications of a bowel injury sustained in a road traffic collision on 30 March 2021. The concerns included delayed and unconfirmed delivery of a CT radiology report between hospitals, failure to follow up signs of possible bowel injury, and the absence of a protocol for prompt and secure delivery of radiology reports in such circumstances.

Tarik Roger Drakes · Prevention of Future Deaths report View report

15 Mar 2023 Dorset R. Griffin

Tarik Roger Drakes, who had a history of using heroin, was found collapsed and unresponsive at his supported accommodation on 12 November 2022. He was taken to hospital, where he was found to be in multi-organ failure, and died on 29 November 2022. Concerns were raised about staffing, welfare checks, monitoring, supervision, safeguarding, emergency access, and follow-up of his support needs at the accommodation.

Nicola Norman · Prevention of Future Deaths report View report

14 Mar 2023 Inner West London F. Wilcox

Nicola Norman died on 20 January 2020, aged 42, after being found dead hanging at her mother’s address. Before her death, she contacted the Single Point of Access while highly anxious, reported feeling a burden and later reported an overdose and cutting her wrists. The principal concerns were that these contacts were not routinely discussed with a supervising clinician, passed to a suitably qualified clinician for assessment, or notified to her GP and mental health services.

Jane Walker · Prevention of Future Deaths report View report

13 Mar 2023 North West Wales K. Robertson

Jane Walker was a passenger on a rigid inflatable boat involved in a collision with a jet ski on the Menai Straits. She suffered significant internal injuries, was treated by paramedics and later died in hospital. The principal concern was that paramedics could not administer faster-acting alternative analgesics, such as mucosal fentanyl, because of controlled drug legislation, potentially affecting patients requiring immediate pain relief.

Gunapathyammah Ranganathan · Prevention of Future Deaths report View report

13 Mar 2023 West London L. Brown

Gunapathyammah Ranganathan, who was elderly and frail, fell backwards while walking to the bathroom with a Zimmer frame during a care visit on 11 July 2021. She sustained a severe head injury and died in hospital on 14 July 2021. The report raised concerns that the new carer lacked adequate training and shadowing experience, and that Mrs Ranganathan was left unattended despite requiring direct supervision while mobilising.

Charlotte Comer · Prevention of Future Deaths report View report

13 Mar 2023 Worcestershire D. Reid

Charlotte Comer, who had significant mental health disorders and a history of suicide attempts and self-harm, left hospital before treatment for a self-inflicted arm wound and later took a substantial overdose of Propranolol and Amlodipine. She died on 20 July 2021 despite treatment. The principal concerns were instability and excessive workloads in the care coordinator system, including a five-month period without an appointed coordinator, and the failure to prevent a senior clinician from overriding a multidisciplinary team decision about specialist treatment.

Lugh Baker · Prevention of Future Deaths report View report

13 Mar 2023 Cornwall and Isles of Scilly A. Cox

Lugh Baker, a 24-year-old man with Angelman’s syndrome, epilepsy and difficulty swallowing, was found unresponsive at Rosewood House on 21 April 2021 after receiving medication in a chocolate milkshake. CPR was unsuccessful, and the cause of death was recorded as unascertained with an Open Conclusion. Concerns included gaps in monitoring, delays in reviewing new residents’ care plans, and insufficient arrangements for staff unfamiliar with a resident’s unusual presentation.

Kelly Nadine DUNNE · Prevention of Future Deaths report View report

13 Mar 2023 County Durham and Darlington J. Richards

Kelly Nadine DUNNE died at the Royal Victoria Infirmary in Newcastle on 4 July 2022 from fatal head injuries sustained in a road traffic collision on 2 July 2022. Concerns were raised about the adequacy and layout of the junction and other junctions on the A690, including traffic volume, traffic complexity, speed limits, and the timing and sufficiency of proposed safety improvements in light of planned development.

Mr Tomas Ceida · Prevention of Future Deaths report View report

9 Mar 2023 Inner South London A. Harris

Mr Tomas Ceida died in hospital after a fire at a site being used as a nightclub, where construction work was underway and staff and operatives sometimes slept overnight. The jury identified concerns including the unsuitable acoustic wall, unsafe and inadequately supervised hot works, and failures to agree and communicate fire-safety responsibilities, provide adequate fire alerts, conduct an orderly evacuation, and complete adequate fire-risk assessments. The coroner also raised concerns about regulatory follow-up, communication between authorities, documentation of contractor roles, and public and contractor awareness of fire-safety duties.

Maxine Betty Davison and 4 others · Prevention of Future Deaths report View report

8 Mar 2023 Plymouth, Torbay and South Devon I. Arrow

On 12 August 2021, Jake Davison used a lawfully held shotgun to kill his mother, Maxine Davison, and four other people in Keyham, Plymouth. The inquest identified serious failures in firearms licensing, including inadequate training, governance, supervision, scrutiny, information gathering and decisions to grant and return the shotgun certificate. The report expressed particular concern about the continuing lack of nationally accredited and mandatory training for firearms licensing staff and the risk of incorrect licensing decisions and future deaths.

Evelina Vilkiene · Prevention of Future Deaths report View report

6 Mar 2023 East London N. Persaud

Evelina Vilkiene, who was receiving mental health services, was found hanging at her home on 7 June 2022 and was pronounced dead at the scene. The report identified concerns about the absence of detailed risk assessments and jointly agreed risk-management plans during care transitions and when clonazepam was reduced, as well as the lack of subsequent care-coordinator reviews.

Maureen Edna Dick · Prevention of Future Deaths report View report

6 Mar 2023 East London N. Persaud

Maureen Edna Dick was admitted to hospital with likely sepsis and was at high risk of developing a pressure ulcer. A pressure ulcer developed and deteriorated, with concerns including inadequate risk assessment, repositioning, assessment and investigation, and failure to diagnose osteomyelitis before transfer. She died at Broomfield Hospital from her infected hospital-acquired pressure ulcer; the inquest concluded that her death was contributed to by neglect.

Kathleen Grace Fancourt · Prevention of Future Deaths report View report

2 Mar 2023 West Sussex P. Schofield

Kathleen Fancourt was killed when a Peugeot car struck her mobility scooter as she crossed Broyle Road at a pedestrian crossing on 16 September 2021. The report raises concern that drivers over 70 must renew their licences every three years but are not required to undergo medical checks, leaving potential medical conditions to self-declaration and potentially posing risks to other road users.

Annabel Jean Findlay · Prevention of Future Deaths report View report

1 Mar 2023 Inner West London J. Taylor

Annabel Jean Findlay had a history of psychiatric illness and depression and discharged herself from Priory Hospital, Roehampton on 27 August 2021 after a change in antidepressant medication. The concerns identified were that next of kin or emergency contacts were not contacted, no follow-up appointment was booked before discharge, and no attempt was made to contact her until 6 September 2021; the inquest recorded a short-form conclusion of suicide and fatal pressure to the neck as the medical cause of death.

Stephen Roy Chapple and Jennifer Chapple · Prevention of Future Deaths report View report

28 Feb 2023 Somerset S. Marsh

Stephen and Jennifer Chapple suffered significant stab wounds during a neighbour dispute and were pronounced deceased at the scene on 21 November 2021. The principal concern was that a fully functional ceremonial dagger had been presented to the assailant on leaving the British Army, placing a potentially deadly weapon in the community; the report questioned the appropriateness of such presentations, including where recipients may have mental health issues.

Peter Gary SEABY · Prevention of Future Deaths report View report

27 Feb 2023 Norfolk J. Lake

Peter Gary Seaby was a resident of The Oaks and Woodcroft Care Home who died in hospital on 22 May 2018 after choking-related symptoms and subsequent aspiration pneumonia. His lunchtime food was not prepared in accordance with his SALT Care Plan, and he did not receive the required one-to-one supervision; the inquest found these possibly contributed to his death. The report also identified concerns about informal care arrangements, staffing levels, and the absence of an internal review after his death.