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Samantha Singh · Prevention of Future Deaths report View report

2 Jul 2021 East London G. Irvine

Samantha Singh developed a suspected nut allergy, was assessed as having a mixed nut allergy, and was prescribed an EpiPen. On 25 July 2020, she became unwell at home and suffered a cardiac arrest attributable to anaphylactic shock; she could not be resuscitated. The concerns included the miscategorisation of her test results, prescription of only one EpiPen, and lack of referral to an allergy clinic or follow-up appointment.

Henry Boddy · Prevention of Future Deaths report View report

2 Jul 2021 Inner North London R. Brittain

Henry Boddy was found collapsed during a significant fire at his home on 4 November 2020 and died later that day from the consequences of the fire. The fire was later found to have been caused by either unsafe use of candles for lighting or unsafe use or disposal of smoking materials, in the context of longstanding hoarding and an accumulated fire load. The principal concern was a gap in enforcement powers for addressing fire risks in residential properties arising from hoarding behaviour.

Mr Khairul Rahman · Prevention of Future Deaths report View report

2 Jul 2021 Inner North London R. Brittain

Mr Khairul Rahman became unwell during a COVID-19 outbreak at HMP Pentonville, was later admitted to hospital, and died on 22 January 2021 from COVID-19. Concerns included inaccurate or non-contemporaneous documentation of clinical interactions, intervals between observations that did not align with the NEWS2 scoring system, reliance on prisoners to self-report deterioration, and the lack of a clear effective alternative system for monitoring in the prison healthcare setting.

Joan Mary PRESCOTT · Prevention of Future Deaths report View report

30 Jun 2021 Plymouth, Torbay and South Devon I. Arrow

Joan Mary PRESCOTT lived alone, was probably not compliant with her medication and neglected herself, deteriorated, and died in hospital on 9 May 2020. A concern was that safeguarding was not recorded as having been considered during a welfare visit, despite social workers identifying a need for GP involvement and possible admission.

Katie Louisa Locke · Prevention of Future Deaths report View report

29 Jun 2021 Hertfordshire A. McCormick

Katie Louisa Locke was unlawfully killed at Theobalds Park Hotel on 24 December 2015 by forceful and prolonged compression of her neck, accompanied by serious sexual violence. The report identifies concerns about gaps in information held by public bodies, insufficient information-sharing, and inadequate dissemination and understanding of the potentially dangerous persons process, creating a continuing risk that it may not be properly used to protect the public.

Fiona May Humberstone · Prevention of Future Deaths report View report

28 Jun 2021 Essex S. Horstead

Fiona May Humberstone, who had longstanding mental health conditions, alcohol misuse and chronic pain, died at home from an inadvertent overdose of prescribed Oromorph taken with other medication. The concerns included mental health clinicians relying solely on patients’ accounts of their medication and inadequate access to accurate, up-to-date prescribing information between primary and secondary care.

Nicholas Jonathan SPOONER · Prevention of Future Deaths report View report

28 Jun 2021 Brighton and Hove V. Hamilton-Deeley

Nicholas Spooner had a long-standing dual diagnosis of mental ill health and polysubstance abuse and was moved to Brighton for his own safety. He fell from the window of his third-floor room after removing the window restrictors, sustaining multiple potentially survivable injuries, and later died directly as a result of COVID-19 pneumonitis. The principal concern was the need for specialist dual-diagnosis services, including outreach, drop-in and day-centre support for people experiencing mental health crises entwined with substance abuse.

Amy Anne June Ganner · Prevention of Future Deaths report View report

24 Jun 2021 Manchester West S. Nelson

Amy Anne June Ganner, who had complex health conditions and chronic pain, inadvertently ingested an excessive amount of prescribed medication before being discovered on 6 January 2021. The report identified concerns about the combined depressant effects of opioid medicines and the unpredictable loss of tolerance after abstinence; the inquest conclusion was misadventure and the medical cause of death was combined drugs toxicity.

Heather Frances Page · Prevention of Future Deaths report View report

23 Jun 2021 Nottinghamshire G. Clow

On 7 October 2020, Heather Frances Page stepped in front of a train and died in the resulting collision. The report identified concerns about pedestrian crossings requiring people to walk on the tracks, a high number of fatalities, ease of access to the track, and difficulties reducing or rationalising crossings because of local authority opposition.

Netlyn Mae ROBINSON · Prevention of Future Deaths report View report

23 Jun 2021 West Yorkshire Eastern L. Harris

Netlyn Mae ROBINSON returned home on 2 October 2020 after adaptations for her reduced mobility, with three daily care visits. She was found the following morning at the dining table having choked on food. The report identified concerns about the absence of a falls alarm and working telephone, lack of risk assessment and checks for heating, water and smoke alarms, and insufficient processes for assessing whether her home was safe for her return.

Wayne Boughen · Prevention of Future Deaths report View report

23 Jun 2021 West Yorkshire Eastern J. Hargan

Wayne Boughen was detained at HMP Leeds when he suspended himself from a ligature in his cell on 16 November 2018 and died in hospital the following day. The report raised concerns that HMP Leeds had no certified safer cells meeting national standards, and that he was able to suspend himself using a ligature fashioned from a prison-issued jumper.

Hazel Ann Binks · Prevention of Future Deaths report View report

23 Jun 2021 Derby and Derbyshire P. Nieto

Hazel Binks died on 14 January 2021 after placing a fastened plastic bag over her head, following earlier preparations to asphyxiate herself and leaving a farewell note. The principal concerns were that information about her suicidal thoughts was not passed from the GP practice administration to the GP, that the GP did not undertake a meaningful mental health or risk assessment, and that the practice’s internal review did not identify these issues.

Serena Nicolle · Prevention of Future Deaths report View report

22 Jun 2021 Surrey A. Crawford

Serena Nicolle died in her cell at HMP Bronzefield on 3 September 2018 from ventricular arrhythmia in the context of hypertensive heart disease, with diabetes, sleep apnoea, obesity and stress also recorded. Two prison staff members incorrectly assessed her as breathing after observing movement through the cell hatch, and the Coroner was concerned that this standard procedure may be an unreliable way to check breathing and could create a risk of future deaths.

Rodney John DIXON · Prevention of Future Deaths report View report

21 Jun 2021 East Sussex J. Healy-Pratt

Rodney John Dixon took his own life at home in Eastbourne on 15 July 2019 during the course of a Mental Health Act Assessment, following deterioration in his mental and physical health. The report raised concerns that training on Mental Health Act assessments, patient risk management and assessors was sub-optimal, and that independent clinicians needed reasonable access to patient data before assessments.

Name not published · Prevention of Future Deaths report View report

21 Jun 2021 Plymouth, Torbay and South Devon I. Arrow

The deceased had significant comorbidities, including ischaemic heart disease, and was admitted to hospital for a blood transfusion following a diagnosis of anaemia. An endoscopy to investigate blood loss was abandoned, and on the balance of probability her oesophagus was perforated during the procedure; she developed surgical emphysema, deteriorated and died at Derriford Hospital on 11 December 2017. Concerns included discrepancies in consent for endoscopy, failure to perform or address a ‘sip test’ to exclude aspiration, failure to act on a report indicating a possible dangerous complication, and inadequate record-keeping or transfer of records by senior staff.

Anne BRADLEY · Prevention of Future Deaths report View report

20 Jun 2021 West Sussex R. Simpson

Anne Bradley underwent a colonoscopy that identified and tattooed a tumour, but the tumour was not located where expected during colectomy, requiring removal of a further section of colon. Post-operative complications led to bowel ischaemia and her death. Concerns included the lack of routine use of equipment that could improve tumour localisation and the absence of a formal system for sharing information about incorrect localisation or tattooing problems with endoscopists.

LESLEY MAWBY · Prevention of Future Deaths report View report

18 Jun 2021 Manchester South L. Costello

Lesley Mawby, who had multiple myeloma, developed severe vomiting and diarrhoea after starting chemotherapy and was admitted to hospital. She subsequently experienced malnutrition, electrolyte disturbances, sepsis and upper gastrointestinal haemorrhage, and died from multi-organ failure on 5 October 2020. The report raised concern about staffing shortages in the dietetic team causing delays in assessments and lack of weekend cover.

Leslie Horsfield · Prevention of Future Deaths report View report

18 Jun 2021 Manchester North J. Robertson

Leslie Horsfield, aged 84, was admitted to hospital with a cough and worsening breathlessness and died on 3 October 2020 after vomiting and becoming unresponsive. A post-mortem found food material blocking his left bronchus, and the reported cause of death was asphyxiation from vomited stomach contents. The principal concern was that the admissions assessment tool did not prompt assessors to ask about previous choking episodes, creating a risk that relevant information would be missed.

Andrew Cook · Prevention of Future Deaths report View report

18 Jun 2021 Northamptonshire P. Barlow

Andrew Cook suffered anaphylaxis and cardiac arrest during percutaneous coronary intervention at Kettering General Hospital on 31 March 2019, and resuscitation was unsuccessful. The concerns included under-reporting and limited research into PEG allergy, lack of clear information about PEG in medical equipment and its dose and molecular weight, and inconsistent PEG nomenclature that could cause confusion for clinicians.

Leonard Arthur PRITCHARD · Prevention of Future Deaths report View report

17 Jun 2021 Birmingham and Solihull A. Hodson

Leonard Arthur Pritchard died on 18 February 2021 in Good Hope Hospital after sustaining injuries in an unwitnessed fall from a chair in an A&E cubicle on 12 February 2021. The report raised concerns about an inadequate supply of mobility aids in the emergency department and unclear responsibility and timescales for their assessment, selection and procurement.