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STEVE MARTIN BRIAN COOKE · Prevention of Future Deaths report View report

8 Aug 2021 Mid Kent and Medway S. Hayes

Steve Martin Brian Cooke had COVID-19 pneumonia following a COVID-19 infection and was found deceased at home on 26 December 2020. He had called an ambulance with extreme shortness of breath and apparent hypoxia, but communication difficulties led to the ambulance being sent to the wrong address and him not being located. Concerns included the failure to obtain his correct address, insufficient communication with his ex-partner, and failure to escalate the matter or review the original call when he could not be found.

Cpl Ryan Lovatt · Prevention of Future Deaths report View report

3 Aug 2021 Oxfordshire D. Salter

Cpl Ryan Lovatt died after falling accidentally and unwitnessed from his seventh-floor hotel balcony in Warsaw in the early hours of 1 August 2019. He had been drinking heavily, was intoxicated with alcohol, and had been pepper sprayed outside a club before being taken to his room. The principal concerns were whether the alcohol policy for Op Cabrit was realistic, workable and understood, and whether the “shark watch” safeguard was formalised and effective.

Pauline McInroy ALLISON · Prevention of Future Deaths report View report

3 Aug 2021 West Sussex R. Simpson

Pauline McInroy Allison died at hospital on 26 March 2021 from significant burns sustained in a house fire after smoking materials came into contact with flammable materials on her bed. She was largely bedbound and unable to escape. The principal concerns were the fire risks associated with emollient creams, smoking in bed, and air mattresses, and whether patients, families and carers were sufficiently aware of these risks and referred for fire safety advice.

Emma Day · Prevention of Future Deaths report View report

3 Aug 2021 Inner South London A. Harris

Emma Day died in the street on 26 May 2017 from multiple stab wounds and was found to have been unlawfully killed. The report describes a history of domestic violence, coercive and controlling behaviour, threats to her life and protective orders that had expired shortly before her murder. Principal concerns included failures to share and record risk information, inadequate domestic-violence training and guidance, and a system failure in handling reports of domestic violence within the Child Maintenance Service.

Mary Ann LINCOLN · Prevention of Future Deaths report View report

2 Aug 2021 West Yorkshire Eastern L. Harris

Mary Ann LINCOLN was admitted to Pinderfields General Hospital on 18 May 2020 and was discovered deceased on the floor of her room on 21 May 2020, with an open fracture of the tibia and fibula. The concerns identified included inadequate overnight checks for vulnerable patients at risk of falls and weaknesses in the circulation and understanding of the bedrails policy.

Amanda DUNN · Prevention of Future Deaths report View report

30 Jul 2021 Staffordshire South A. Haigh

Amanda Dunn died at home on 21 March 2021 from a self-administered overdose of prescribed medication, with the inquest conclusion recording suicide while suffering anxiety and depression. The substantive concern was that alleged harassment by neighbours had been reported to police several times but may not have been taken sufficiently seriously or investigated, although the report notes that only one side of the story was heard.

JAMES MICHAEL NOWSHADI · Prevention of Future Deaths report View report

29 Jul 2021 Cambridgeshire and Peterborough C. Jones

James Michael Nowshadi died after ingesting a substance he had obtained online to end his life, suffering cardiac arrest and being pronounced dead on 1 April 2020. Concerns included insufficient national guidance and information-sharing about the risks of sodium nitrate/nitrite, missed opportunities for learning from the Serious Incident Review, and a lack of guidance for emergency clinicians on the use of methylene blue in cases involving cardiac arrest.

Jacob · Prevention of Future Deaths report View report

28 Jul 2021 Nottinghamshire E. Didcock

Jacob died at eleven months from acute pyelonephritis, following earlier urinary tract sepsis and severe obstruction of both ureters. Investigations identifying the obstruction were not reviewed during his life, and the seriousness of a later infection was not recognised. The report identified concerns including low compliance with paediatric sepsis screening, lack of consultant review before discharge, and inadequate systems for reviewing investigation results.

Carl Lee Walters · Prevention of Future Deaths report View report

28 Jul 2021 Exeter and Greater Devon N. Rheinberg

Carl Lee Walters died suddenly and unexpectedly in his prison cell from a ruptured splenic pseudoaneurysm, with the evidence unable to establish whether it was naturally occurring or trauma related. CCTV footage had not been preserved and only limited cell bell records were kept, meaning key evidence was unavailable and the inquest could not be as full as it otherwise would have been.

Albert Rowlands · Prevention of Future Deaths report View report

26 Jul 2021 North Wales (East and Central) D. Lewis

Albert Rowlands suffered serious injuries in an unwitnessed accidental fall at the residential care home where he lived and died in hospital on 25 November 2020. The principal concerns were inconsistent implementation of falls-prevention measures, possible staffing pressures affecting care, and the risks associated with the distance and obstacles between his room and the nearest toilet.

John Dickinson · Prevention of Future Deaths report View report

22 Jul 2021 West Yorkshire Eastern S. Watson

John Dickinson was admitted to hospital after falls and treatment for a gall bladder infection, then moved to a care home. He later developed poor nutritional and fluid intake, dehydration, acute kidney impairment and a urinary tract infection, and died on 9 August 2020 while receiving palliative care. Concerns included inconsistent and insufficiently detailed record keeping, failures to document or act on advice about monitoring food and fluid intake, and delayed recognition of deterioration.

Oscar Anthony SEAMAN · Prevention of Future Deaths report View report

21 Jul 2021 Norfolk Y. Blake

Oscar Anthony Seaman, aged 17, was killed after cycling onto the A134 carriageway at a crossroads in Northwold and being struck by a 4x4 vehicle. Concerns included repeated collisions and speeding on the road, reduced visibility at the junction, and the absence of stop signs, with possible measures including speed cameras and a junction mirror discussed.

Ben Buster KING · Prevention of Future Deaths report View report

20 Jul 2021 Norfolk J. Lake

Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

Vinnie William Ord Dodds · Prevention of Future Deaths report View report

20 Jul 2021 Sunderland D. DL

Vinnie William Ord Dodds died at Sunderland Royal Hospital on 14 April 2020 after major shoulder dystocia was recognised following a forceps delivery; he could not be successfully resuscitated. The concerns related to antenatal care, including the lack of national guidance for managing large babies, the content of counselling about shoulder dystocia risks, the timing of glucose tolerance testing, and the omission of the risk of death from shoulder dystocia in current patient information.

Sarah Lewis · Prevention of Future Deaths report View report

19 Jul 2021 County of Dorset D. Rookes

On 16 November 2020, Sarah Lewis was fatally struck by a reversing large goods vehicle while crossing behind it in Weymouth. The principal concern was the blind spot behind large goods vehicles and the absence of a legal requirement for rear cameras, particularly where no banksman is present. The report also noted uncertainty about the possible effect of fluoxetine levels above the therapeutic range.

Rebecca Claire Pykett · Prevention of Future Deaths report View report

17 Jul 2021 Stoke-on-Trent and North Staffordshire E. Serrano

Rebecca Claire Pykett, who had a history of mental health difficulties including PTSD, was found deceased at home on 25 February 2019 after intentionally hanging herself using a tie fashioned into a ligature. The concerns identified included the absence of a system to ensure that a Care Co-Ordinator was allocated, and that the expected care co-ordinator role, including timely patient contact and care planning, was not carried out in her case. The report also describes routine allocation of consultant psychiatrists as a “box ticking” exercise to satisfy the patient record system.

Brian Jackson · Prevention of Future Deaths report View report

16 Jul 2021 Liverpool and the Wirral D. Lewis

Following major heart surgery, Brian Jackson developed symptoms associated with post-operative delirium and, after transfer to a hospital ward, used a ligature to hang himself in a locked bathroom on 23 July 2020. He died at the scene despite prompt medical attention. Concerns included inconsistent recognition of delirium and reliance on the CAM-ICU assessment tool, which may fail to identify some patients at risk, including those presenting with paranoia or hypoactive symptoms.

Chimezie DANIELS · Prevention of Future Deaths report View report

16 Jul 2021 Inner North London M. Hassell

Chimezie Daniels died from SARS CoV-2 infection, with pulmonary sarcoidosis also recorded as a cause. At inquest, concern was raised that CPAP machines may use the same alarm for a minor mask leak and a complete cessation of oxygen supply. Multiple simultaneous alarms in a busy medical ward made it more difficult to identify the cause of Mr Daniels’ low oxygen saturations.

Suzanne Regan · Prevention of Future Deaths report View report

16 Jul 2021 Swansea and Neath Port Talbot C. Phillips

Suzanne Regan was driving on the M4 westbound when her car collided with a concrete bullnose/Armco barrier, travelled along it, overturned and came to rest on its roof. She was pronounced dead at the scene; the concern was that failure to replace old-style barriers risked further deaths and serious injuries, and that modern replacements were available.

Miss Joanna Daly · Prevention of Future Deaths report View report

16 Jul 2021 West Yorkshire Eastern J. Hobson

Miss Joanna Daly was found unresponsive in her cell at HMP New Hall on the morning of 2 June 2019, and her death was confirmed. The inquest jury found that healthcare checks in the First Night Centre had not been carried out adequately and that this could have contributed to her death. The report raises concern about the absence of specific guidance for welfare checks of vulnerable prisoners in the First Night Centre.