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Ann GERAGHTY · Prevention of Future Deaths report View report

27 Aug 2021 Birmingham and Solihull A. Hodson

Ann GERAGHTY was admitted to Good Hope Hospital with heart failure and later suffered a cardiac arrest before dying on 30 March 2021 from multiorgan failure associated with congestive cardiac failure and dilated cardiomyopathy. Two periods of ventricular standstill recorded by cardiac telemetry were missed, and concerns were raised that the monitoring system’s self-terminating alarms could pose a risk of future deaths unless addressed.

Elaine Michelle Inns · Prevention of Future Deaths report View report

26 Aug 2021 Manchester South A. Mutch

Elaine Michelle Inns was found dead at her home on 18 January 2021. The inquest heard that she continued to be prescribed powerful painkillers despite significant alcohol use and use of liquid morphine without clearly following dosage instructions; the medical cause of death involved the combined toxic effects of ethanol and prescribed medicines.

James Golds · Prevention of Future Deaths report View report

26 Aug 2021 Manchester South A. Mutch

James Golds was rescued from a flat fire on 28 September 2020 after sustaining significant fire-related injuries and later died in hospital from complications of smoke inhalation. The report raised concerns about limited guidance for managing and escalating fire risks in supported accommodation, the absence of a statutory requirement for sprinklers, and smoke detectors not activating until a cigarette-related fire was well established.

Cherry Rosemary Dunn · Prevention of Future Deaths report View report

26 Aug 2021 Leicester City and South Leicestershire C. Mason

Cherry Rosemary Dunn died after an acute episode at Kirby Ward on 5 November 2018, with the inquest recording pulmonary embolism, deep vein thrombosis and immobility as causes of death. Concerns included bilateral leg swelling not prompting sufficient consideration of deep vein thrombosis, ambiguity in VTE risk assessments, and confusing hospital discharge letters that affected decisions about prophylactic anticoagulation.

Stanislaw Wieslaw ZIELINSKI · Prevention of Future Deaths report View report

24 Aug 2021 Manchester South A. Mutch

Stanislaw Wieslaw Zielinski’s mental health deteriorated after he reported anxiety and insomnia, with care provided through telephone GP appointments and delays in mental health support. On 20 October 2020, he fell from an upstairs window and sustained multiple fractures and a subdural haematoma; he later died from a cardiac arrest due to a pulmonary embolism following hospitalisation and surgery. The concerns included difficulties communicating his deteriorating condition through telephone consultations and delays in receiving mental health support during the Covid-19 period.

Peter Michael HARTE · Prevention of Future Deaths report View report

24 Aug 2021 Birmingham and Solihull A. Hodson

Peter Michael HARTE died on 19 March 2021 in hospital after deterioration from multi-organ failure and sepsis caused by a bacterial skin infection and cellulitis. The principal concern was that skin inspections and monitoring in the care home between 14 and 18 March 2021 were not properly recorded, indicating a possible systemic failure in record-keeping and a risk to vulnerable residents.

Maurice Leech · Prevention of Future Deaths report View report

23 Aug 2021 Manchester South A. Mutch

Maurice Leech had an accidental fall at Thorncliffe Grange Nursing Home, later diagnosed as a femur fracture, and died there on 30 April 2020 after being discharged for palliative care. Concerns included a telephone GP review without physical examination, lack of support when he attended hospital during Covid, the missed fracture, and the absence of NICE guidance for managing femur fractures in elderly patients, including pain management.

Norma Rushworth · Prevention of Future Deaths report View report

23 Aug 2021 Manchester South A. Mutch

Norma Rushworth underwent surgery for diverticulitis and was later readmitted for emergency surgery after developing an abdominal dehiscence associated with an unidentified wound infection. She deteriorated after developing a chest infection and suffering a cardiac arrest, and died at Tameside General Hospital on 10 October 2020. Concerns included limited support and monitoring after discharge, unclear communication with community health professionals and family, and delayed recognition of her deterioration in the community, with pandemic restrictions contributing to communication difficulties.

Thomas Pickering · Prevention of Future Deaths report View report

20 Aug 2021 Suffolk T. Deeming

Thomas Pickering died at the scene of a road traffic collision on 26 August 2020 after his Kia collided with an oncoming Saab while overtaking a VW Golf. The report raises concern about whether additional signage or other preventative measures are needed at the site, described as a blind summit with a history of other collisions.

Sheldon Marshall · Prevention of Future Deaths report View report

20 Aug 2021 Surrey A. Crawford

Sheldon Marshall became seriously ill during a trek to Mount Everest Base Camp after sustaining a fractured left rib, later developing high-altitude pulmonary oedema, bronchopneumonia, acute respiratory distress syndrome and pneumothoraces. He died in intensive care on 17 December 2017 after cardiac arrests and a pleural injury associated with a right chest drain. The concerns identified were insufficient senior clinical input at Mayday Assistance Limited and unclear responsibility between Mayday Assistance Limited and air ambulance providers for patients’ overall medical management, presenting risks of future deaths.

Steven Paul KIRKHAM · Prevention of Future Deaths report View report

18 Aug 2021 South Yorkshire (Eastern) L. Harris

Steven Paul KIRKHAM was an informal resident in Osprey Ward, Swallownest Court, Sheffield, and on 30th April 2019 used a device-fitted door without an alarm sounding. Concerns were raised about a potential “blind spot” in the door alarm system and the possibility that other facilities using these systems had not been informed of the potential danger or of steps taken to address the issue.

Roland Stannard · Prevention of Future Deaths report View report

17 Aug 2021 Suffolk N. Parsley

Roland Stannard died at West Suffolk Hospital after developing a serious sacral pressure sore while resident at Chiltern Meadows Care Home. The report identified concerns about miscommunication over his medication, inadequate care while he remained on a commode overnight, and care staff’s insufficient training to operate specialist equipment intended to prevent or treat pressure sores. It also raised concern about when a care-home resident’s needs should prompt an assessment for nursing care rather than continued social care.

Steven Antonio Regoli · Prevention of Future Deaths report View report

17 Aug 2021 Essex M. Brown

Steven Antonio Regoli died on 26 June 2020 at a Lineside location adjacent to Gipsy Lane following a collision with a train. The report identifies concerns that opportunities for more appropriate help, including inpatient care, were not acted upon, and that there were no systems to support people who did not engage with services, leaving families to provide care alone.

Kumbulani MTOMBENI · Prevention of Future Deaths report View report

16 Aug 2021 West London L. Brown

Kumbulani Mtombeni was found deceased at his home on 25 January 2021, with evidence indicating that he intended to take his own life; the inquest conclusion was suicide and the recorded cause of death was methadone toxicity. The principal concerns were how methadone prescribed to another person came into his possession, whether medication audits identified missing medication, and his access to residents’ prescribed medicines through his work as a senior carer.

Mr Stuart Tokam · Prevention of Future Deaths report View report

13 Aug 2021 East London G. Irvine

Mr Stuart Tokam, who had a documented history of depressive illness and two previous attempts to take his own life, died after hanging himself from railings at Dalaman Airport, Turkey, on 18 September 2020. Concerns included an unacceptable delay in arranging a clinical assessment and the apparent absence of a process to triage referral acuity and expedite assessment where necessary.

Adam Albert John Forrester · Prevention of Future Deaths report View report

11 Aug 2021 Stoke-on-Trent and North Staffordshire M. Jones

Adam Albert John Forrester was last seen leaving a nightclub in the early hours of 12 September 2017 and was later found dead in a recycling plant shed. His injuries were compatible with compaction in a bin lorry or other vehicle, and concerns were raised about single-crewed waste collection in darkness and poor weather, and guidance that did not require checking bins for people.

Hadley John Savory · Prevention of Future Deaths report View report

11 Aug 2021 North East Kent I. Brownhill

Hadley John Savory was discharged from hospital on 25 September 2019, and his presentation later declined in the community. He was found deceased at home on 13 December 2019 after toxicological evidence indicated that he had taken a lethal dose of methadone; concerns included the absence of a multi-agency planning meeting before discharge and unclear multi-agency procedures for supporting patients with concurrent health, substance misuse and social care needs.

Hadley John Savory · Prevention of Future Deaths report View report

11 Aug 2021 North East Kent I. Brownhill

Hadley John Savory was discharged from hospital on 25 September 2019 without evidence of a multi-agency planning meeting, and his care, support and treatment plan was unclear. His presentation later declined in the community, safeguarding referrals did not lead to multi-agency meetings, and he was found dead at home on 13 December 2019; toxicological evidence indicated that he had taken a lethal dose of methadone. The principal concerns related to hospital discharge planning, allocation of care responsibilities, meeting eligible care needs, safeguarding procedures for self-neglect or hoarding, and information sharing where mental capacity may fluctuate.

Alice Beatrice Pettersson · Prevention of Future Deaths report View report

10 Aug 2021 Inner West London S. Radcliffe

Alice Beatrice Pettersson died at Great Ormond Street Hospital London after suffering cord compression due to undiagnosed foramen magnum stenosis associated with achondroplasia. The report identified concerns about the absence of designated referral pathways and national guidance, and about the need for prompt specialist assessment, MRI scanning and sleep studies.

Terence Robert TUTTLE · Prevention of Future Deaths report View report

9 Aug 2021 Norfolk Y. Blake

Terence Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious harm.