Search PFD Monitor

Alfie Stone · Prevention of Future Deaths report View report

14 Jan 2022 Northamptonshire J. Harkin

Alfie Stone, aged 12, died after prolonged seizures, status epilepticus, hypoxia and multiple organ failure following admission to hospital. Concerns included paramedics’ lack of training in buccal midazolam, inadequate oxygenation, no suction attempt, and insufficient evidence of training following an earlier Serious Incident Report.

Jan Goodliffe · Prevention of Future Deaths report View report

14 Jan 2022 Essex M. Brown

Jan Goodliffe died on 15 June 2021 several days after taking his own life, following a recent suicide attempt and a history of mental health problems. The report raises concerns that social workers, rather than medically qualified clinicians, assessed him despite information about his suicide risk and recent restart of medication, and that opportunities to obtain qualified medical advice may have been missed.

Darran Busby · Prevention of Future Deaths report View report

13 Jan 2022 Cumbria R. Cohen

Darran Busby was at home with his family on 14 August 2021 and ended his life. Before his death, he had undergone an MRI scan after complaining of headaches, but the result was never reviewed by a clinician. The report raised concerns that weaknesses in the electronic systems could allow radiology results requiring urgent follow-up to be filed without clinical review, potentially creating a risk of future deaths.

Reginald Howard Weston · Prevention of Future Deaths report View report

11 Jan 2022 Avon M. Buckeridge

Reginald Howard Weston died from injuries sustained in a fall on 7 July 2021, after having fallen twice on 4 July 2021. The principal concern was that there was no evidence his falls risk assessment was reviewed and recorded as required, including a timely process for completing the review.

Brendan Eccles · Prevention of Future Deaths report View report

10 Jan 2022 Sunderland D. Winter

Brendan Eccles died on 27 July 2018 at Jubilee Quay in Sunderland following an explosion while working on a pontoon that contained volatile organic compounds. The principal concern was that an external heat source could cause these substances to evaporate and create a flammable range within the pontoon.

Mrs Surekha Pandharinath Shivalkar · Prevention of Future Deaths report View report

7 Jan 2022 East London G. Irvine

Mrs Surekha Pandharinath Shivalkar, aged 78, underwent revision total hip replacement surgery and subsequently developed profound hypotension, multiorgan failure and cardiac arrest, dying despite intensive treatment. Concerns included the absence of a formal preoperative risk assessment tool, poor communication between the surgical and anaesthetic teams, and inadequate systems concerning the senior surgeon’s departure before the operation concluded.

Kyriacos Athanasis · Prevention of Future Deaths report View report

6 Jan 2022 Norfolk C. Wood

Kyriacos Athanasis, an 88-year-old man with frailty and several medical conditions, fell down stairs and sustained an unstable cervical spine fracture. Delays transferring him from an ambulance and diagnosing the fracture were followed by pneumonia, and he died after deteriorating. The principal concerns were emergency department overcrowding, insufficient ambulance patient safety checks, delayed diagnosis and treatment, and resulting risks to patients awaiting ambulance transfer or care.

James EMMERSON · Prevention of Future Deaths report View report

5 Jan 2022 Bedfordshire and Luton S. Cummings

James Emmerson, known as Jamie, was detained under section 136 of the Mental Health Act on 1 February 2019 but was discharged without being interviewed by an Approved Mental Health Professional. He was later detained at a police custody suite and died by hanging at home on 3 February 2019. The principal concern was confusion in the Code of Practice, which led to an interpretation that an Approved Mental Health Professional assessment was not required before discharge, exposing patients to significant risk including self-harm or suicide.

Ian Anthony Charles Miller · Prevention of Future Deaths report View report

5 Jan 2022 Gwent C. Saunders

Ian Anthony Charles Miller was serving a term at HMP Usk and died by suicide in the prison on 21 September 2019 after being told he could not live at the family home or with his father-in-law, could not have unsupervised contact with his children, and might be homeless. The report raised concerns that prisoners were trading prescribed medication at HMP Usk and that unprescribed medication was being ingested, putting other prisoners’ lives at risk.

Richard Paul Victor Sanders · Prevention of Future Deaths report View report

5 Jan 2022 Gloucestershire K. Skerrett

Richard Sanders, an experienced diver aged 52, became unresponsive during a dive to 45 metres on 11 April 2019 and was pronounced deceased at the scene. The concerns included awareness of immersion pulmonary oedema risks, the need for fitness-to-dive medical certification, and methods for removing divers from the water.

Sylvia Frances PRICE · Prevention of Future Deaths report View report

4 Jan 2022 Suffolk N. Parsley

Sylvia Frances Price died after falling down stairs while using toilet facilities at Ufford Park Hotel and Spa, sustaining cerebral haemorrhages and spinal injuries. She later developed aspiration pneumonia while being treated in hospital, which was recorded as the medical cause of death. The report identified inadequate signage for an accessible toilet as a contributing factor and expressed concern that similar deaths could occur because such signage was not required or enforceable.

Jos Tarse-Joy · Prevention of Future Deaths report View report

31 Dec 2021 Greater Manchester South A. Mutch

Jos Tarse-Joy was born by emergency caesarean section at 41 weeks after his high-risk pregnancy was not explicitly identified to his parents or care team, no induction had been arranged, and CTG monitoring was not used on admission. He was born in very poor condition, sustained severe brain damage following hypoxia, and died at Royal Oldham Hospital on 15 December 2020. The principal concerns included communication and documentation failures, lack of appropriate monitoring and induction planning, unclear escalation processes, and wider issues concerning maternity-service layout and national guidance.

Yousef Ghaleb Makki · Prevention of Future Deaths report View report

31 Dec 2021 Manchester South A. Mutch

Yousef Ghaleb Makki was stabbed in the chest on Gorse Bank Road on 2 March 2019 and died at Manchester Royal Infirmary that day. The inquest heard concerns about a culture among some teenagers of viewing knife possession as impressive, inadequate understanding of its risks, and the ease with which the knife was purchased during school break time.

Mazielle MacKenzie · Prevention of Future Deaths report View report

31 Dec 2021 Lancashire and Blackburn with Darwen P. Holden

Mazielle MacKenzie was a looked after child receiving care in a tier 4 hospital for young people with mental health issues. On 23 June 2018, after leaving the hospital during an organised period of leave and not returning, she was found several hours later and died despite CPR; the inquest conclusion was suicide. Concerns included the absence of a written policy for group leave, inadequate risk assessment and staffing arrangements, and shortcomings in care planning, communication and record-keeping.

Gregory James Barber · Prevention of Future Deaths report View report

24 Dec 2021 West Yorkshire Eastern J. Hobson

Gregory James Barber died on 12 April 2021 after sustaining severe head injuries secondary to blunt force impact; a conclusion of suicide was recorded at the inquest. The British Transport Police identified a weakness in fencing that was considered a likely access point to the railway tracks, and the report states that Network Rail had not provided a meaningful response to the recommended mitigation. The concern was that access to the railway tracks remained insufficiently curtailed at the identified location.

Margaret Rose Toye · Prevention of Future Deaths report View report

23 Dec 2021 East London G. Irvine

Margaret Rose Toye, aged 81, sustained an unwitnessed fall on 10 April 2021, suffered a left neck of femur fracture, underwent surgery on 12 April, and died following a cardiac arrest on 20 April 2021. The principal concern was that she was not assessed for malnutrition using the MUST score system; her records incorrectly recorded a score of 0, and it was considered likely that she would have scored 4, which would have prompted mitigations to maximise her nutritional intake. Contemporary ward audits indicated that one in ten patients were not assessed for malnutrition risk.

Dilys Greta Etchells · Prevention of Future Deaths report View report

23 Dec 2021 West Yorkshire (Western) M. Fleming

Dilys Greta Etchells was found after an unwitnessed fall at her nursing home, later diagnosed with fractures of the left tibia and fibula, and subsequently developed pressure ulcers before dying in hospital on 2 July 2021. The report identified concerns about the absence or documentation of fall-prevention measures, delayed medical referral, inadequate care documentation, handover communications, and wound-management procedures.

William DOLEMAN and 3 others · Prevention of Future Deaths report View report

23 Dec 2021 Nottinghamshire L. Bower

Four patients died following ERCP-related complications within a six-month period. The concerns included inadequate pre-procedure assessment and patient pathways, insufficient recording of procedure vetting, non-personalised consent, and unclear accountability between professionals for vetting and consent.

Sameena Javed · Prevention of Future Deaths report View report

23 Dec 2021 Manchester North C. McKenna

Sameena Javed, aged 33, presented to hospital with severe complications of anorexia nervosa, malnutrition and heart failure, and was subsequently found to have COVID-19 pneumonitis. Despite treatment, she deteriorated and died on 30 May 2021. The principal concern was that the GP practice had no written procedure or guidance to ensure correspondence requiring medical action was brought to a GP’s attention.

Mark Castley · Prevention of Future Deaths report View report

22 Dec 2021 Inner South London A. Harris

Mark Castley died by suicide on 26 June 2019 in St Thomas Hospital after bringing a ████████ into court. The inquest jury identified non-completion of a suicide risk form by the probation officer and non-confiscation of the ████████ by the dock officer as contributing factors. The report raises concern that risks of recurrent impulsive self-harm in the context of sentencing were not fully assessed and that the relevant policy may have required or been interpreted as requiring imminence of risk.