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Demet AKCICEK · Prevention of Future Deaths report View report

7 Sep 2022 Inner North London M. Hassell

Demet Akcicek was found dead in bed beside her sleeping seven-year-old son on the morning of 27 May 2022. The inquest determined that she died after taking an excess of prescribed and online-obtained medication, and that she did not intend to take her life. Concerns included a failure by a mental health service worker to arrange follow-up after a welfare call, and an insufficiently clear record of that call.

Michael James Robert ROLFE · Prevention of Future Deaths report View report

7 Sep 2022 Lincolnshire P. Cooper

Michael James Robert ROLFE, a 72-year-old man, was admitted on 23 August 2019 with decreasing consciousness and a cerebellar haemorrhage with intraventricular extension, and died the following day after treatment was considered not possible. The report raises concern that prescribing Rivaroxaban in the context of liver impairment, low platelets and impaired renal function may have increased bleeding risk and may have contributed to the rectal bleeding and cerebral haemorrhage.

Name not published · Prevention of Future Deaths report View report

6 Sep 2022 Plymouth, Torbay and South Devon I. Arrow

The deceased suffered from debilitating conditions and lived in insanitary conditions. After a long lie and a subsequent visit where she was found in extremis with sepsis, she died at Torbay Hospital on 25 February 2022; the report identified a probable missed opportunity to provide timely care and treatment before she was found in extremis.

James Alan Tice · Prevention of Future Deaths report View report

5 Sep 2022 Manchester North C. McKenna

James Alan Tice, who had recurrent depressive disorder with anxiety features, took his own life at home on 28 April 2022 while awaiting an informal admission to an older adult mental health ward. The report identifies concerns about the availability of beds for such admissions and psychotherapy services for older adults whose needs exceed community provision.

Stephen WELLS · Prevention of Future Deaths report View report

5 Sep 2022 West Sussex K. Harrold

Stephen Wells was treated for colon cancer with liver metastases, but after liver surgery he received no further contact or oncology follow-up for one year because communication and referral processes between two NHS trusts failed. He later developed widespread liver and lung metastases and died at home on 4 October 2021. The report raises concerns about inter-provider referrals, tracking systems, communication between trusts, use of the Datix system, and clarity over patients’ key contacts.

Jennifer Wong · Prevention of Future Deaths report View report

2 Sep 2022 Oxfordshire D. Slater

Jennifer Wong died at the scene of a road traffic accident on Headington Road, Oxford, on 26 September 2021, after a mobile crane turning left knocked her from her cycle and ran over her. The report identifies concerns about the crane driver's significant nearside blind spots and the lack of close-proximity mirrors or other visibility measures. It also raises concerns about the layout and width of the cycle lane, which may bring cyclists into conflict with vehicles turning left.

Violet Elizabeth Howard · Prevention of Future Deaths report View report

2 Sep 2022 Manchester North C. McKenna

Violet Elizabeth Howard was admitted to hospital with sepsis caused by a hepatic abscess and later developed extensive eczematised psoriasis. The psoriasis affected her fluid balance, renal function and general reserves and was a contributory factor in her death; earlier dermatology input was considered likely to have reduced her distress, discomfort and pain, although the evidence did not establish that it would have prevented her death. The principal concern was a gap in dermatology commissioning arrangements for in-patients at Royal Oldham Hospital who lived outside the Oldham area.

Name not published · Prevention of Future Deaths report View report

31 Aug 2022 Manchester City N. Meadows

A 78-year-old woman developed severe sepsis and necrotising fasciitis following dental treatment. She was not triaged or assessed promptly at hospital, suffered a cardiac arrest, underwent emergency surgery, and died on 6 July 2019. The concerns included the currency and implementation of sepsis protocols, staff training and awareness, and timely recognition and treatment of sepsis.

Dainton Harley Hill Cressell GITTOS · Prevention of Future Deaths report View report

31 Aug 2022 Lincolnshire P. Cooper

Dainton Harley Hill, an 11-year-old vulnerable child with cerebral palsy who could not speak, bear his own weight, or call for help, was left unsupervised in a bath on 22 January 2021 and was later found unresponsive. The inquest concluded that parental neglect in failing to supervise him contributed directly to his death, which was consistent with drowning. Concerns were raised about the lack of supervision, failure to use a non-slip bath mattress, prior social services records concerning neglect and emotional harm, and the decision not to bring charges.

Gareth WILLIAMS · Prevention of Future Deaths report View report

31 Aug 2022 Gwent C. Saunders

Gareth Williams, who had worsening tinnitus and declining mental health with suicidal thoughts, was discovered hanging on 23 August 2021 and could not be revived. The concern was that he was left without sufficient support because mental health and ENT services transferred him between teams without directly communicating.

David Honnor · Prevention of Future Deaths report View report

30 Aug 2022 Dorset S. Nicholls

David Honnor had oesophageal cancer and underwent radiotherapy and stent placement before his condition worsened in 2022. He obtained a gas canister and died from asphyxia; the inquest recorded suicide. Concerns included public access to these products, whether they should be licensed, the lack of colour coding to help emergency services identify gas cylinders, and whether safety information was clear and sufficient.

Jennifer Lilian Davies · Prevention of Future Deaths report View report

30 Aug 2022 Brighton and Hove P. Schofield

Jennifer Lilian Davies was struck by a parcel delivery vehicle while crossing the road in Brighton on 21 May 2020, sustaining a serious head injury. She died in hospital on 23 May 2020; the report raised concerns that delivery van drivers may work long hours without a legal requirement to take a break, potentially placing pedestrians at risk.

Glenn Barton · Prevention of Future Deaths report View report

30 Aug 2022 Somerset S. Marsh

Glenn Barton fell and struck his head on 19 August 2020, later developing a major subdural haemorrhage and dying on 22 August 2020. The concern was that clinical guidance was ambiguous about whether patients with conditions such as leukaemia, which can affect blood clotting, should receive a CT scan after a head injury, creating a risk of missed opportunities to scan such patients.

Christopher Michael Lloyd · Prevention of Future Deaths report View report

26 Aug 2022 Manchester South C. Morris

Christopher Michael Lloyd died at home after suspending himself by the neck with a ligature. The principal concern was that, despite interactions with mental health services and support for alcohol and drug addiction, he did not have ready local access to a dual-diagnosis service for co-existing mental-health and substance-misuse issues.

Christina Avis RUSE · Prevention of Future Deaths report View report

26 Aug 2022 Norfolk J. Lake

Christina Avis RUSE underwent a total left hip replacement on 14 December 2021, deteriorated, and died on 15 December 2021 after transfer to hospital was required. The report raises concern about delays in ambulance availability and response during high demand, noting that future deaths may occur while measures to address the issue are assessed.

Yuksel Bedri ISMAIL · Prevention of Future Deaths report View report

25 Aug 2022 Bedfordshire and Luton E. Whitting

Yuksel Bedri ISMAIL, aged 23, absconded from hospital while awaiting a mental health assessment and was struck by an HGV on the M1 motorway on 28 November 2021, suffering fatal injuries. The concerns included hospital transfer arrangements for patients at risk of absconding and insufficient staff training and understanding regarding the Mental Capacity Act and preventing high-risk patients from leaving the emergency department.

Charles Evans · Prevention of Future Deaths report View report

25 Aug 2022 Black Country J. Lees

Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.

Eliot HARRIS · Prevention of Future Deaths report View report

22 Aug 2022 Norfolk J. Lake

Eliot Harris, who had schizophrenia and diabetes, was admitted to Northgate under the Mental Health Act after his condition deteriorated. His food and fluid intake remained minimal, he was last seen conscious on 9 April, and he was found unresponsive and declared dead in the early hours of 10 April 2020; the inquest recorded the medical cause of death as unascertained and an open conclusion. Concerns included inadequate observations and staff training, unclear allocation of night-duty responsibilities, incomplete records and care planning, reluctance to enter his room when concerned for his welfare, and uncertainty about ensuring requested physical health checks were completed.

Chelsea Blue Louise Mooney · Prevention of Future Deaths report View report

18 Aug 2022 South Yorkshire (Western) A. Combes

Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency response.

John Francis Heffron · Prevention of Future Deaths report View report

18 Aug 2022 West Yorkshire Eastern K. McLoughlin

John Francis Heffron, a 50-year-old wheelchair user, was found confused in his flat and later suffered a cardiac arrest while alone in an A&E cubicle. There was a delay in initiating CPR, including delays in making a crash call and ascertaining his DNAR status; he was resuscitated but sustained a hypoxic brain injury and died in hospital. The concerns included bank and agency nursing staff’s familiarity with emergency procedures, training and induction, and the adequacy and independence of the Trust’s investigation.