Search PFD Monitor

Mr Thomas Antony Smith · Prevention of Future Deaths report View report

16 May 2022 Bedfordshire and Luton T. Stoate

Mr Thomas Antony Smith died in a drugs-related death after serious failings in his care on Coral Ward during the night of 29–30 December 2020. The principal concerns were inadequate staff knowledge about the dangers and presentation of drugs, insufficient observation and escalation after a positive drugs test and signs of deterioration, and weaknesses in the system for assessing risks associated with Section 17 leave.

Connor Samuel Timothy Wellsted · Prevention of Future Deaths report View report

15 May 2022 Surrey K. Henderson

Connor Samuel Timothy Wellsted, a five-year-old boy with significant neuro-disabilities, was found deceased in his cot on 17 May 2017 during a residential neuro-rehabilitation stay. The investigation determined that he died following entrapment by a loose cot bumper causing airway obstruction. Concerns included inadequate cot maintenance and securing, lack of regular direct visual night-time supervision, and failures to preserve the scene, inform relevant bodies, and investigate the circumstances openly and transparently.

Michael John Draper and Rafal Wojdyl · Prevention of Future Deaths report View report

13 May 2022 Manchester West A. Walsh

Michael John Draper and Rafal Wojdyl died from injuries sustained in a road traffic collision at the junction of Cadishead Way and Fairhills Road, Irlam, on 23 June 2021. The concerns related to the junction’s busy layout, a 50 mph speed limit, restricted visibility caused by the bend, bridge, trees and bushes, and the absence of traffic signals.

RITA GIULIANNA NICOLA BRITTEN · Prevention of Future Deaths report View report

13 May 2022 West Yorkshire (Western) J. Broadbridge

Rita Giuliana Nicola Britten, a detained patient, choked while trying to swallow pieces of fresh apple and later died in hospital after life support was withdrawn. The report records concerns about the lack of clear guidance and effective rescue techniques for choking incidents involving overweight, obese or bariatric individuals, including the possible use of inversion techniques and specialist equipment. The jury also recorded concerns about communication and handover, recording and access to key information, incomplete risk assessments, and inadequate first aid training.

Sarah Louise Dunn · Prevention of Future Deaths report View report

12 May 2022 Blackpool and the Fylde L. Rae

Sarah Louise Dunn developed Group A Streptococcus sepsis following an early medical abortion and died in hospital on 11 April 2020 after progressing to toxic shock. The report identified failures to recognise and treat sepsis across primary and secondary care, including delays in assessment, use of sepsis pathways and antibiotics. The principal concern was inadequate awareness and training regarding the risk of sepsis following early medical abortion, creating a risk of avoidable future deaths.

Joan Hoggett · Prevention of Future Deaths report View report

12 May 2022 Sunderland D. Winter

Joan Hoggett died in Sunderland Royal Hospital on 5 September 2018 after being attacked and stabbed multiple times at her place of work. Concerns included insufficient engagement by the Mental Health Trust with the perpetrator’s family, missed opportunities for more proactive engagement, and challenges associated with staff capacity and absence.

Sergio DUNKLEY · Prevention of Future Deaths report View report

12 May 2022 Sefton, St Helens and Knowsley J. Thompson

Sergio DUNKLEY was admitted voluntarily to a mental health ward on 24 July 2020 after threats to end his life. He was last seen alive shortly after midnight on 18 August 2020 and was found to have taken his own life before 1.30am. The report raised concerns about the lack of mandatory requirements for ligature alarms and for checking their placement in newly built mental health units, as well as failures to record observation changes and suicide-risk assessments adequately.

Pauline Keen · Prevention of Future Deaths report View report

12 May 2022 North East Kent J. Andrews

Pauline Keen fell at home in January 2021, sustained an acetabular fracture, and was later transferred to Harrier Lodge Care Home after hospital admission. Her mental health deteriorated, and although assessment under the Mental Health Act concluded that she should be admitted, there was a failure to ensure that the application was made without delay amid uncertainty over bed communication responsibilities. She died on 24 April 2021 from multiorgan failure, sepsis and bronchopneumonia.

Cristofaro PRIOLO · Prevention of Future Deaths report View report

11 May 2022 Inner North London M. Hassell

Cristofaro Priolo, an 80-year-old man with progressive Alzheimer’s dementia who lived in a nursing home, choked on cauliflower cheese on 25 November 2020 and died. The report identifies concerns that his food was not prepared or fed in accordance with his assessed needs, and that staff failed to provide appropriate first aid, recognise cardiac arrest, and attempt effective CPR.

Cynthia Elizabeth Finlay · Prevention of Future Deaths report View report

11 May 2022 Surrey C. Topping

Cynthia Elizabeth Finlay had depression, cognitive difficulties and impulsive personality traits. After an overdose and discharge from hospital, she was assessed by mental health professionals, but no adequate safeguarding plan was put in place while she was awaiting consideration of a Mental Health Act assessment. She was left alone and subsequently died by suicide; expert evidence identified that no protocol governed safeguarding people in this situation who might be alone and at risk in the community.

Freda Mary Lennox · Prevention of Future Deaths report View report

10 May 2022 Surrey K. Henderson

Freda Mary Lennox, an 86-year-old woman with significant idiopathic pulmonary fibrosis and other medical comorbidities, was admitted for an elective total hip replacement and died on 4 November 2020 after experiencing a cardio-respiratory arrest at the end of the procedure. Concerns included incomplete pre-operative assessment, a lack of recent orthopaedic and anaesthetic review before admission, and inadequate resources for a dedicated high-risk anaesthetic assessment service.

Raymond Griffiths · Prevention of Future Deaths report View report

9 May 2022 Inner West London F. Wilcox

Raymond Griffiths was admitted to St George’s Hospital for coronary artery bypass grafting on 21 May 2013, underwent surgery the following day, developed acute on chronic liver failure post-operatively, and died in intensive care three days later. The inquest concluded that his care was beyond reproach and that his liver failure could not reasonably have been predicted or prevented. The report raised concerns about restrictions on cardiac surgical capacity, diversion of emergency and other patients, damage to public confidence, and the adequacy of the SJR process, which were considered capable of increasing risks to future patients.

Michael Howard Williams · Prevention of Future Deaths report View report

9 May 2022 North Wales (East and Central) J. Gittins

Michael Howard Williams died at the scene after his motorcycle collided with a motor car turning onto the A525 from Green Lane. The inquest evidence indicated that a hedge obstructed the view for vehicles joining the A525, creating an ongoing risk of further collisions and loss of life unless visibility or the road layout is improved.

Trevor Reynolds · Prevention of Future Deaths report View report

6 May 2022 North Wales (East and Central) J. Gittins

Trevor Reynolds died at Glan Clwyd Hospital on 15 May 2021 after a CT scan identified a pulmonary clot that was not acted upon until 10 May, despite the result requiring immediate attention. The inquest found concerns about delays in implementing revised working practices, obtaining staff acknowledgement of the new procedure, and auditing compliance, allowing known risks to patients to continue.

Mr Keith Holmes · Prevention of Future Deaths report View report

5 May 2022 Black Country J. Lees

Mr Keith Holmes was found unresponsive and later confirmed deceased in his room at McHugh House after a fire in the early hours of 30 December 2021. The fire investigation could not determine whether the fire was caused by an electrical fault involving a fridge or by smoking materials igniting clothing or bedding. The principal concerns were the increased fire or accident risk from unmaintained electrical equipment during the Covid-19 pandemic, the failure to reassess that risk, and the absence of a contingency plan for a similar lockdown situation.

Lauren Louise MURDOCK · Prevention of Future Deaths report View report

4 May 2022 Inner North London M. Hassell

Lauren Murdock died from a myocardial infarction at age 27. Concerns included a significantly elevated blood pressure reading that was not recorded in her medical record or brought to the GP’s attention, and errors in assessing clot and cardiovascular risks when prescribing the combined contraceptive pill. She died ten days after the elevated blood pressure reading was taken.

Kate Hedges · Prevention of Future Deaths report View report

3 May 2022 Manchester South C. Morris

Kate Hedges died at Gatley Station on 27 November 2020 as a consequence of injuries sustained in an event that is redacted in the supplied text. The concerns included separate computerised record-keeping systems that could mean staff lacked relevant information for risk assessments and care plans, and an alleged failure to follow safeguarding policy. The report also raised concerns that mental health services were not consistently trauma-informed and that the ward environment could be distressing and difficult for people who had experienced trauma.

Julie Elizabeth Nolan · Prevention of Future Deaths report View report

1 May 2022 North Northumberland and South Northumberland A. Hetherington

Julie Elizabeth Nolan had underlying diabetes, hypertension, chronic kidney disease and peripheral vascular disease, and was admitted to a care home with existing pressure damage to her left foot. She later developed further pressure damage and acute osteomyelitis, deteriorated with breathing difficulties and low oxygen saturations, and died in hospital on 30 January 2022. Concerns included limited documentation of wound management and pressure care, uncertainty about whether care plans were followed, and the Manager and Registered Nurse being the designated nurse for two consecutive days.

Ryan Albert Frederick Merna · Prevention of Future Deaths report View report

1 May 2022 Dorset R. Middleton

Ryan Albert Frederick Merna died from injuries sustained in a knife attack at his home on 14 August 2016. The concerns included that information about the perpetrator possessing a knife and sleeping rough was not probed, recorded, or raised at a care programme meeting, resulting in a missed opportunity to reassess risk.

Jamie Lee Bennett · Prevention of Future Deaths report View report

29 Apr 2022 South Yorkshire (Western) T. Rawden

Jamie Lee Bennett, who had been abstinent from drugs and methadone for approximately eight months, was found unresponsive in his room at Norfolk Park Bail Hostel on 2 May 2020 and was pronounced deceased by paramedics. The report identified concerns about incomplete sharing of his substance-misuse and Naloxone information, reduced support after release, unclear responsibilities and inadequate training and auditing for welfare checks, and a delay in calling emergency services.