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Steven Easdale · Prevention of Future Deaths report View report

13 Feb 2023 Hertfordshire G. Sullivan

Steven Easdale was struck by a car while crossing the B197 Digswell Hill on 5 November 2021 and died at Addenbrookes Hospital on 12 December 2021 from injuries sustained in the collision. The principal concern was that an unlit pedestrian refuge and nearby streetlamp posed a danger to road users and pedestrians; the coroner considered that illumination may have helped the driver see Mr Easdale earlier and avoid the collision.

Minaal Salam · Prevention of Future Deaths report View report

13 Feb 2023 Stoke-on-Trent and North Staffordshire E. Serrano

Minaal Salam, aged 5, was struck by a Volkswagen Touran outside her primary school on Waterside Drive on 1 April 2022 and died at the scene. The concern was that traffic management around the school should be investigated, as inadequate traffic measures could pose a risk of future deaths.

Michael ROBERTS · Prevention of Future Deaths report View report

13 Feb 2023 Inner North London M. Hassell

Michael Roberts died by suicide on the evening of 20 August 2022 after shooting himself with a gun taken from his workplace, where he had access to firearms. A DBS certificate recorded no convictions despite his past conviction for a violent offence, which had led to his dismissal as a police officer; the report states that he would not have been employed at Proof House if the conviction had been correctly recorded. It was unclear whether the inaccurate DBS certificate resulted from an error by the DBS or the MPS.

Michael POULTON · Prevention of Future Deaths report View report

13 Feb 2023 Wiltshire and Swindon I. Singleton

Michael POULTON was released from police custody on 22 June 2019, with arrangements for police transport to a family member’s home, but there was a delay and he left the custody suite. He was found suspended by a ligature in a field the following day; concerns related to people in police custody lacking money, communication with family, or ready access to transport home, and to arrangements for facilitating their return.

Celia Sanderson · Prevention of Future Deaths report View report

10 Feb 2023 Manchester South A. Mutch

Celia Sanderson was involved in a road traffic collision and died at Wythenshawe Hospital after developing severe injuries, neurological damage and an acute myocardial infarction while awaiting transfer to a major trauma centre. The concerns included delays in triage and clinician review, shortages of senior emergency department and radiology staff, delays in CT scanning and reporting, and insufficient recognition of potential “silver trauma” cases in district general hospitals.

Sandra Adina Lomax · Prevention of Future Deaths report View report

10 Feb 2023 Manchester South A. Mutch

Sandra Adina Lomax died at Stepping Hill Hospital on 25 June 2022 after complications developed from an oesophageal stent that was not removed within the required six-week period. The concerns included inadequate communication and case ownership, delayed escalation, lack of detailed national guidance, absence of a commissioned specialist service, staffing gaps in the regional MDT, and ineffective communication of MDT recommendations.

Bridget GORMLEY · Prevention of Future Deaths report View report

9 Feb 2023 Worcestershire D. Reid

Bridget Gormley fell at her care home in Worcester on 20 July 2022 and was found to have significant traumatic intracranial bleeding. She was transferred to Worcestershire Royal Hospital, where she died on 31 July 2022. The principal concerns were that her falls risk assessment and care plan were not updated after repeated falls, and that staff may not have understood their duties to update residents’ documentation.

George Frederick Kearsey · Prevention of Future Deaths report View report

9 Feb 2023 East London G. Irvine

George Frederick Kearsey sustained injuries in a fall at home, was admitted to hospital, developed aspiration pneumonia, and died on the evening of 8 June 2022. Concerns included inconsistent administration of IV fluids, missing fluid balance charts, poorly maintained clinical records, and inadequate review of fluid monitoring during consultant-led ward rounds.

Stephen Robert Wood · Prevention of Future Deaths report View report

8 Feb 2023 Dorset R. Griffin

On 30 May 2021, Stephen Robert Wood was riding his motorcycle when it entered a 60-metre stretch of grass covering the carriageway, causing him to fall into the path of an oncoming car. He sustained numerous significant and unsurvivable injuries and died. The principal concern was a lack of knowledge about when road obstructions should be reported, meaning hazards may not be removed or warnings provided to other road users.

Richard Nigel KEW · Prevention of Future Deaths report View report

7 Feb 2023 Leicester City and South Leicestershire D. Hocking

Richard Nigel KEW underwent surgery for a small bowel neuroendocrine tumour and multiple liver metastases. During mobilisation after surgery, a central venous catheter line was not secured with a bung, allowing air to enter his circulation; he deteriorated, never regained consciousness, and died on 5 September 2022. The concern was that other NHS Trusts might not have policies and procedures to prevent this type of error.

Ania Sohail · Prevention of Future Deaths report View report

7 Feb 2023 Manchester North C. McKenna

Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.

Patricia Grace Eileen Green · Prevention of Future Deaths report View report

4 Feb 2023 Manchester South A. Mutch

Patricia Grace Eileen Green had an accidental fall at home and remained prone on the floor for nine hours while waiting for an ambulance. She deteriorated, including in her breathing, and later died in hospital from COVID-19 pneumonia, with the investigation noting the fall and prolonged time on the floor as contributing factors. Concerns included delays in ambulance response and emergency department assessment, linked to shortages, high demand and delays transferring patients from emergency departments.

Kirsty Margaret McKie · Prevention of Future Deaths report View report

4 Feb 2023 Manchester South A. Mutch

Kirsty Margaret McKie lived and worked in Bali and died in hospital on 24 July 2022 after unknowingly consuming methanol that had been sold as alcohol fit for human consumption. The report identifies concerns about low awareness of methanol poisoning risks among expatriates and tourists and limited UK Government publicity about those risks.

Benjamin Paul Stanley · Prevention of Future Deaths report View report

4 Feb 2023 Manchester South A. Mutch

Benjamin Paul Stanley developed chronic pancreatitis, became severely malnourished, and was admitted to Stepping Hill Hospital on 11 May 2022. He deteriorated, developing liver cirrhosis, sepsis and a Clostridium difficile infection, and died in hospital on 19 May 2022. The concerns identified included prolonged waits in A&E linked to demand and a lack of beds; in his case, direct entry to a ward was considered to have been in his best interests, but he had to wait in A&E for a bed.

Jason Anthony Williams · Prevention of Future Deaths report View report

2 Feb 2023 Dorset R. Griffin

Jason Anthony Williams was found unresponsive in his cell at HMP Guys Marsh on 31 July 2020, and his death was confirmed by paramedics. The report states that synthetic cannabinoid intoxication was the medical cause of death and that he had deliberately taken drugs without intending fatal consequences. Concerns included inadequate guidance on vulnerable prisoners, shortcomings in the keyworker programme and NOMIS record keeping, and the absence of a Governor notice about increased psychoactive-substance risks.

Daniel Graeme Futers · Prevention of Future Deaths report View report

2 Feb 2023 Sunderland D. Winter

Daniel Graeme Futers died after falling from Wearmouth Bridge, Sunderland, on 5 April 2022. The report identified concerns about incomplete recording of information, inadequate planning for home leave and discharge, and insufficient situational awareness, including reconciliation of conflicting accounts about him.

Mary Doreen White · Prevention of Future Deaths report View report

1 Feb 2023 Gwent N. Rees

Mary Doreen White was admitted to hospital in April 2021 and suffered three falls while an inpatient, including fractures requiring surgery. Her condition deteriorated while recovering from surgery, and she died from a chest infection, with frailty of old age also recorded. Concerns included staffing shortages, difficulties providing required enhanced observation on the ward, and the absence of a documented and communicated plan for managing patients requiring Level 4 enhanced care in that setting.

Hugo Carlos · Prevention of Future Deaths report View report

1 Feb 2023 Berkshire A. McCormick

Hugo Carlos died in November 2021 after developing obstructive jaundice caused by a liver lesion and undergoing procedures including biliary drain insertion and hepatic artery embolization. The principal concern was that the EMIS system did not reliably alert general practitioners when follow-up investigations were due, placing responsibility on patients and creating a continuing risk that patients could be lost to necessary follow-up.

Samantha Jane BOAZMAN · Prevention of Future Deaths report View report

31 Jan 2023 Leicester City and South Leicestershire F. Butler

Samantha Jane Boazman, who was detained under section 3 of the Mental Health Act and living in a locked rehabilitation ward, was found unresponsive in her bathroom on 22 October 2021 and was pronounced dead later that evening. The report identified concerns about delayed access to emergency equipment and CPR, and about predictable and inadequate recording of patient observations. The inquest jury found gross neglect involving shortcomings including inadequate training, failure to remove ligature risks from bedrooms, and inadequate induction and training of temporary staff.

David John Nash · Prevention of Future Deaths report View report

31 Jan 2023 South Yorkshire (Western) A. Combes

David John Nash developed a fatal cerebellar abscess caused by mastoiditis and died at Leeds General Infirmary on 4 November 2020. The inquest identified a missed opportunity during his GP appointment on 2 November 2020 to direct him to face-to-face or urgent care. A further concern was how clinical complaint reviews were informed by, and communicated to, the GP practice and wider primary care network.