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Daniel France · Prevention of Future Deaths report View report

16 Feb 2022 Cambridgeshire and Peterborough P. Barlow

Daniel France was a 17-year-old vulnerable teenager living in a YMCA hostel who died by asphyxiation by hanging; the inquest concluded that his death was suicide. The principal concern was that vulnerable young people known to local authorities and mental health services may not receive adequate support while awaiting substantive treatment, particularly where they are assessed as not requiring urgent intervention but face lengthy waits for psychological therapy.

David Clark · Prevention of Future Deaths report View report

15 Feb 2022 Hertfordshire G. Sullivan

David Clark died at Lister Hospital on 5 January 2020 after being readmitted in a drowsy state and in respiratory failure. The report identified concerns that his worsening condition was not accurately assessed or escalated appropriately, NEWS were not calculated or documented accurately, and his treatment was poorly documented. It was unclear whether these matters contributed to his death.

Mr Jason Lennon · Prevention of Future Deaths report View report

15 Feb 2022 East London G. Irvine

Jason Lennon, a 37-year-old man living in supported accommodation, died on 31 July 2019 after being found unresponsive while restrained in a prone position by security officers at the Excel Centre; resuscitation efforts later ceased in hospital. The concerns included failures in community mental health care, including inadequate monitoring, assessment, communication and documentation, and the extent and manner of the restraint used by security officers. The report also identified deficiencies in the Trust’s serious incident action plan and uncertainty about whether regulatory referral had been considered.

Theo Jude BRENNAN-HULME · Prevention of Future Deaths report View report

15 Feb 2022 Norfolk J. Lake

Theo Brennan Hulme, a university student with Asperger’s Syndrome, a history of deliberate self-harm and suicidal thoughts, was found hanging in his room on 12 March 2019 and declared dead at the scene. The report identified concerns about the adequacy and timeliness of his mental health assessment, failure to make reasonable adjustments or involve his family, lack of follow-up after a missed appointment, a persistent culture within the Crisis Resolution Home Treatment Team, and the absence of an immediate review when a person is discharged after assessment.

Norman Barnes · Prevention of Future Deaths report View report

14 Feb 2022 Mid Kent and Medway B. Patel

Norman Barnes died after choking on food while eating lunch at Ashley Gardens Care Centre. His meal was not prepared as minced or moist, contrary to the recommendation in his SALT assessment and care plan. Staff were aware of his Parkinson’s disease but were not aware of, or did not refer to, key information in his care plan and risk assessments.

Matthew McManus · Prevention of Future Deaths report View report

11 Feb 2022 Manchester South A. Morris

Matthew McManus, who had complex mental health and social care needs, died at the scene after sustaining multiple injuries on 9 November 2020. The report concluded suicide and identified a lack of coordinated care, information sharing, joint assessment and risk planning across the agencies supporting him. It raised concern that without a clear pathway for jointly assessing and coordinating care for adults with complex mental health and social care needs, future deaths may occur.

John Paul SKINNER · Prevention of Future Deaths report View report

10 Feb 2022 Hertfordshire G. Danbury

John Paul SKINNER was admitted to Watford Hospital on 15 May 2020 after suffering tonic clonic seizures and was given phenytoin. A verbal communication failure led to 15 mg/kg being heard as 50 mg/kg, resulting in an overdose; he arrested and died. The principal concern was that unclear communication of dosage could lead to foreseeable medication errors in hospitals.

Daphne Holloway and Ivy Spriggs · Prevention of Future Deaths report View report

10 Feb 2022 Hertfordshire G. Sullivan

Daphne Holloway and Ivy Spriggs died in a fire at Newgrange Residential Care Home on 8 April 2017. The fire spread rapidly because of inadequate roofspace compartmentation, and both residents died from fourth degree burns. Concerns were raised that sprinklers are not mandatory in care homes with residents who have limited or no independent mobility, and that such care homes are not classified as Higher Risk Buildings unless they meet height or storey thresholds.

Sheila Elizabeth Steggles · Prevention of Future Deaths report View report

10 Feb 2022 Norfolk Y. Blake

Sheila Elizabeth Steggles, who had reduced mobility and several risk factors for thrombosis, collapsed on 5 November 2019 and died in an ambulance after suffering a cardiac arrest. The cause of death was recorded as acute pulmonary embolus arising from deep vein thrombosis. Concerns included the absence of a documented VTE risk assessment, insufficient consideration of reduced mobility and past DVT, inadequate staff training, and missed opportunities to provide prophylactic heparin.

Michelle Louise Jennings · Prevention of Future Deaths report View report

9 Feb 2022 Manchester South A. Mutch

Michelle Louise Jennings had a history of suicidal thoughts and contact with mental health services. She died after delays in accessing therapy, prosecution following a railway incident, and problems with communication and case ownership between mental health teams. The report identified concerns about therapy waiting lists, referral and discharge arrangements, and how prosecuting authorities account for mental health vulnerability.

Benjamin Lee Stroud · Prevention of Future Deaths report View report

8 Feb 2022 Essex M. Brown

Benjamin Lee Stroud died at his home on 19 March 2021 after an overdose involving multiple drugs, including tramadol and alprazolam, with empty medication blister packets and insulin pens found around him. The report raised concerns that his case was not referred to the multidisciplinary team despite escalating psychosis, that the Care Coordinator made the referral decision without a recorded rationale, and that this practice posed a risk of future deaths.

John David Moore · Prevention of Future Deaths report View report

8 Feb 2022 Essex S. Horstead

John David Moore had a history of homelessness, mental health issues, substance misuse and previous suicide or serious self-harm incidents. He died by suicide on 10 June 2021 while homeless, after no recorded intervention from primary or secondary care since 2020. The report identified concerns about inadequate training and supervision of EPUT Care Coordinators, including shortcomings in record keeping, care planning, communication, recognition of disengagement and escalation of concerns.

Sarah Marie GILBERT-JONES · Prevention of Future Deaths report View report

4 Feb 2022 South Wales Central G. Hughes

Sarah Marie GILBERT-JONES died in the early hours of 29 October 2020 after taking a significant overdose of prescription medication with alcohol. The report raised concerns about delays and inconsistent categorisation in the emergency response, including failure to recognise that treatment was time critical, and about sub-optimal mental health service provision.

Joy Burgess · Prevention of Future Deaths report View report

4 Feb 2022 Manchester South C. Morris

Joy Burgess died by suicide on 9 June 2021 as a consequence of multiple injuries. She had complex mental health difficulties, was experiencing deteriorating mental health and thoughts of self-harm, and had left hospital because she found the ward environment busy and extremely noisy. The concerns identified were that mental health wards could be unsuitable for recovery and that patients experienced lengthy waits for psychological therapies.

Harry Edward Simmons · Prevention of Future Deaths report View report

3 Feb 2022 Plymouth, Torbay and South Devon D. Archer

Harry Edward Simmons, aged 87, was struck by a car while crossing Montpellier Road in Plymouth and later died in hospital from his injuries. The report raised concerns about drivers cutting the junction, the effect of sun on visibility, and the risk of further collisions at the junction; three collisions had occurred there in the previous five years.

Stephen Cloudsdale · Prevention of Future Deaths report View report

3 Feb 2022 Cumbria C. Smith

Stephen Cloudsdale died at the scene after his car collided with an LGV encroaching into the eastbound lane of the A66 in darkness and heavy rain. The concerns identified were the lack of lighting and warning signage, the speed of traffic, and whether the central reservation was wide enough to accommodate large vehicles safely.

Mark Jones · Prevention of Future Deaths report View report

3 Feb 2022 Manchester South A. Mutch

Mark Deardon Jones died at home on 13 November 2020 after a catastrophic haemorrhage at the site of surgery for squamous cell carcinoma of the tongue. Concerns included delays in standard referral pathways and the absence of a national protocol for routinely providing photographs and consistent information to support triage of dental referrals.

Carol Patricia Cole · Prevention of Future Deaths report View report

2 Feb 2022 Dorset R. Griffin

Carol Patricia Cole was found collapsed and unresponsive at home on 15 May 2020 after being prescribed medication and having a history including depression, unstable personality disorder and previous overdoses. The inquest concluded that her death was suicide. Concerns were raised that processes for sharing Public Protection Notices in the Dorset Council area may have resulted in the GP not receiving information about concerns regarding her mental health, creating a missed opportunity for assessment, support or treatment.

Jake Adam Cahill · Prevention of Future Deaths report View report

1 Feb 2022 Cornwall and Isles of Scilly G. Davies

Jake Adam Cahill died by suicide on 14 September 2020 after completing a youth offender service self-assessment form that included questions about self-harm and suicide. The principal concerns were that there was no evidence of consideration being given to discussing these sensitive questions with Jake with a professional beforehand, and that the relevant guidance did not expressly require such consideration to be given and documented.

Eirlys Wynne Roberts · Prevention of Future Deaths report View report

31 Jan 2022 North West Wales K. Sutherland

Eirlys Wynne Roberts, aged 93, suffered a fall at a residential home, fractured her neck of femur, underwent surgery, and died a short time later. The report raised concern about the shortage and lack of timely availability of residential, EMI residential, and EMI nursing placements for elderly people whose cognitive and physical care needs change, potentially putting them at risk.