Search PFD Monitor

Frederick Robert Peter King · Prevention of Future Deaths report View report

15 Nov 2022 Berkshire J. Goldring

Frederick Robert Peter King was a resident at Birchwood Care Home and died in hospital on 9 September 2021 from an acute kidney injury caused by dehydration, with frailty and vascular dementia contributing to his death. The concerns included inadequate fluid provision, incomplete care records, and the absence of a care-home manager on the ground in the three days before his death.

Ronald Alfred KELLY · Prevention of Future Deaths report View report

15 Nov 2022 Milton Keynes T. Osborne

Ronald Alfred KELLY, aged 91, was found hanging on 19 September 2022 after recently being discharged from hospital and struggling to cope. The concerns included his discharge following surgery without a care package or follow-up, a rejected district nurse referral that was not actioned, and the apparent absence of a system for automatically following up patients discharged home who may need support and care. The inquest concluded that Mr Kelly died from suicide.

Karen Lesley Starling and Anne Edith Martinez · Prevention of Future Deaths report View report

14 Nov 2022 Cambridgeshire and Peterborough K. Morton

Karen Lesley Starling and Anne Edith Martinez underwent lung transplant procedures at the new Royal Papworth Hospital and subsequently contracted hospital-acquired M abscessus infections, in consequence of which they died. The report identifies concerns that existing hospital water-system guidance provided no relevant guidance on mycobacteria or M abscessus, did not require routine testing or specify acceptable levels, and did not address additional measures for immunosuppressed patients or the risks associated with new hospitals.

Ghulam Mohammad · Prevention of Future Deaths report View report

14 Nov 2022 East London G. Irvine

Ghulam Mohammad, an 89-year-old man, was admitted to hospital after an unwitnessed fall and later sustained a head injury in a further hospital fall. His CT head was delayed for four days, and enoxaparin was prescribed and administered before the extent of any intracranial injury was known. The report also identifies inadequate record keeping and omissions in the initial investigation and consultant statement concerning the use of enoxaparin.

Lee Bradley Brown · Prevention of Future Deaths report View report

13 Nov 2022 East London N. Persaud

Lee Bradley Brown was detained at Bur Dubai Police Station in Dubai after his arrest on 7 April 2011 and was found unresponsive in his solitary cell on 12 April 2011. The inquest identified concerns including beatings, inadequate food and water, unh abitable living conditions, lack of necessary medical care, and lack of access to consular services. It also heard concerns about emergency access protocols, travel advice about detention in Dubai, and procedures for providing consular access to detained British nationals experiencing a mental health crisis.

Derek Shaw · Prevention of Future Deaths report View report

11 Nov 2022 Suffolk C. Wood

Derek Shaw fell at home and became unwell the following morning, but an ambulance was delayed and he suffered a cardiac arrest before the crew arrived. The inquest heard that earlier ambulance attendance was likely to have meant he would not have died, and that ambulance availability was affected by a complex capacity problem involving local NHS trusts.

David John Morganti and 3 others · Prevention of Future Deaths report View report

10 Nov 2022 Cornwall and Isles of Scilly A. Cox

The report concerns several deaths involving delays in ambulance attendance and/or admission to Royal Cornwall Hospital, including deaths after falls, head injuries and a stroke. The principal concerns are the ongoing delays caused by ambulances being held at the hospital, limited intermediate and social care capacity, and the risk that unsafe or inadequately staffed discharge arrangements may worsen patients’ health and lead to readmission.

Samuel Robert Pearson · Prevention of Future Deaths report View report

10 Nov 2022 South London J. Landau

Samuel Robert Pearson had complex mental and physical needs and was moved to temporary accommodation after a van crashed into his home. The inquest narrative stated that the accident and accommodation increased his anxiety, and that he accidentally died after taking an overdose and alcohol on 6 July 2021. Concerns included inadequate multi-agency working and information sharing during the emergency move, and a referral-screening backlog that was not communicated to his GP.

Michael Raymond SMITH · Prevention of Future Deaths report View report

10 Nov 2022 County Durham and Darlington C. Oliver

Michael Raymond SMITH entered HMP Durham on 10 July 2020, was transferred to SACU after being found to have packages concealed internally, and was discovered self-suspended on 11 July; he died in hospital on 13 July 2020. The principal concerns included the absence of medical and mental health assessments, inadequate staffing while he was subject to three-man unlock, delays in responding to the suspension, and weaknesses in SACU record keeping and multidisciplinary oversight.

Maria Immocalata Whale · Prevention of Future Deaths report View report

9 Nov 2022 South Wales Central S. Richards

Maria Immocalata Whale, aged 67, suffered a fatal pelvic haemorrhage and abdominal wall haematoma at home on 29 June 2021 after experiencing increasing abdominal pain. The report identifies concerns about the inability of the Out of Hours GP service to provide assistance, the delayed ambulance response, and emergency triage that did not adequately assess the gravity of her condition.

Roy Elton TRAVERS · Prevention of Future Deaths report View report

8 Nov 2022 Inner North London M. Hassell

Roy Travers died on 6 June 2022 from a spontaneous cerebral bleed after admission to Whittington Hospital on 2 June, where he was not initially scanned and the bleed was not diagnosed. Concerns included delayed review after melaena was noted, failure to withhold apixaban, uncertainty about whether identified learning actions took place, and concerns about the treatment of Mr Travers and the late disclosure of the hospital’s review to the coroner and family.

Liridon Salikuка · Prevention of Future Deaths report View report

8 Nov 2022 Inner South London P. Barlow

Liridon Saliuka was a remand prisoner at HMP Belmarsh who, after being moved from a medical cell to an ordinary cell without a special bed or mattress, hung himself in his cell on 2 January 2020. The report identified failures to recognise and accommodate his disability, inadequate care coordination and record keeping, and discriminatory and dismissive treatment. It also raised concerns about the lack of clear documentation of required adjustments and insufficient disability awareness among prison staff.

Philip Geoffrey Day · Prevention of Future Deaths report View report

4 Nov 2022 Manchester South A. Mutch

Philip Geoffrey Day was treated with methotrexate for psoriatic arthritis and developed neutropenic sepsis after blood tests showed neutropenia and a raised CRP. He died in hospital on 15 April 2022 after developing ileitis and colitis, followed by cardiac arrest and multi-organ failure. Concerns included delays in triage, medical review and treatment; inadequate communication of information from community clinicians to hospital staff; and insufficient recognition of neutropenic sepsis risk factors and red flags.

Levi Louis Alleyne · Prevention of Future Deaths report View report

4 Nov 2022 Berkshire K. Thorne

Levi Louis Alleyne, a grab lorry delivery driver, died by electrocution at a building site after raising his lorry’s crane arm beneath overhead power lines. CPR was delayed because it was unclear whether the electricity remained live, and the ambulance control operator had no procedure or readily accessible emergency contact information for the relevant electricity network operator. The report identifies risks of delayed life-saving treatment or people approaching live electrical hazards and notes that similar mitigating procedures may not be adopted across England and Wales.

HARRY JOSEPH PENGELLY ARMSTRONG EVANS · Prevention of Future Deaths report View report

4 Nov 2022 Cornwall and Isles of Scilly G. Davies

Harry Joseph Pengelly Armstrong Evans died by hanging on 24 June 2021 during an acute mental health crisis, following academic pressures and concerns about his wellbeing. The report identified concerns about the university’s lack of proactive personal engagement, failures in safeguarding alert follow-up, insufficient staff awareness of information-sharing policies, and reliance on email and online forms to access welfare support.

Ellen Lillian MacFarlane · Prevention of Future Deaths report View report

4 Nov 2022 Manchester South A. Mutch

Ellen Lillian MacFarlane had an accidental fall at her care home and waited over five hours for an ambulance before being taken to hospital, where she was found to have a fractured neck of femur. She underwent surgery, subsequently deteriorated, and died at Tameside General Hospital. The concerns included delays in ambulance provision and difficulties obtaining cardiac tests at weekends, contributing to delays in deciding when to operate on fractured neck of femur patients.

Peter Mantador Ross · Prevention of Future Deaths report View report

4 Nov 2022 East London G. Irvine

Peter Mantador Ross sustained a subdural haemorrhage and cervical spine fracture after falling down stairs at home on 8 July 2020. The spinal fracture was misinterpreted and remained undiagnosed; later failures to maintain immobilisation and delays in MRI contributed to cardiac arrest and severe neurological injury. He subsequently developed pneumonia following an aspiration episode, and the inquest found that neglect contributed to his death. Concerns also included failures to review and communicate CT findings and poor clinical record-keeping.

John Fallon · Prevention of Future Deaths report View report

4 Nov 2022 Manchester South A. Mutch

John Fallon, who had dementia and was resident at Downshaw Lodge Care Home, choked on partially chewed meat while eating lunch without his dentures on 13 March 2022. The concerns included the lack of routine SALT assessments and diet changes when residents eat without dentures, delays in replacing or updating dentures due to limited dental services, and the absence of routinely available suction machines in care homes.

Lynn Moss · Prevention of Future Deaths report View report

4 Nov 2022 Manchester South C. Morris

Mrs Moss was found seriously unwell on the floor at her home after apparently falling or collapsing and died the following day at Tameside General Hospital. At the hospital, she waited over five hours for a full medical assessment and around 19 hours for a bed, with missed opportunities to recognise deterioration. The principal concern was that sustained demand on Emergency Departments, linked to wider health and social care pressures, makes timely monitoring and urgent treatment increasingly difficult, creating an ongoing risk of future deaths.

Graham Flindle · Prevention of Future Deaths report View report

4 Nov 2022 Manchester South A. Mutch

Graham Flindle had rectal bleeding and low haemoglobin, was initially treated for haemorrhoids, and was later found to have a malignant tumour. He underwent surgery and subsequently developed breathing complications before dying at Tameside General Hospital on 6 May 2022. Concerns included promoting FIT testing for relevant symptoms and ensuring abnormal, persistently low haemoglobin results prompted timely referral back to secondary care.