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Owen Joseph HINDS · Prevention of Future Deaths report View report

7 May 2021 Nottinghamshire L. Bower

Owen Joseph Hinds, a young man with autism and a restricted diet, died from an overwhelming chest infection on 28 February 2020. The report states that chronic liver disease and heart failure probably contributed to his death and that these conditions were not detected during his life. The principal concern was the absence of a specialist service providing long-term dietetic support for autistic people with ARFID symptoms, leaving Owen unable to access the sustained support required.

Alex Louise Shaw · Prevention of Future Deaths report View report

7 May 2021 Stoke-on-Trent and North Staffordshire S. Murphy

Alex Louise Shaw, who had methylmalonic aciduria and chronic kidney failure, died on 22 October 2018 after developing fluid overload, pulmonary oedema and respiratory failure during hospital treatment. The principal concerns were poor communication and documentation of her clinical observations and telephone advice between clinicians at Royal Stoke University Hospital and Birmingham Children’s Hospital, including failure to communicate her rising heart rate.

Corin Bonaparte · Prevention of Future Deaths report View report

7 May 2021 Exeter and Greater Devon N. Rheinberg

Corin Bonaparte, a young man aged 23, was found hanging in his cell at HMP Dartmoor on 28 February 2017 after his former partner ended contact with him during a telephone call. Resuscitation efforts were unsuccessful. Concerns included the failure to open an ACCT after he disclosed deliberate self-harm, suggesting inadequate training, and an eight-minute delay in an ambulance leaving the prison because an escort was being sought.

John Graham Slope · Prevention of Future Deaths report View report

7 May 2021 Norfolk Y. Blake

John Graham Slope underwent treatment including insertion of a salivary bypass tube after developing a fistula following laryngectomy. A tube was later found to be absent, and an abdominal X-ray showed a foreign body in his stomach that was not identified at the time. In August 2020 he was admitted extremely unwell with a perforated small bowel and a foreign body, was too unwell for surgery, and died shortly afterwards. Concerns included poor documentation and the absence of systems to record and identify the tube, as well as failure to document his concerns and obtain a treatment summary from another hospital.

Stacey Camille Alexander-Harriss · Prevention of Future Deaths report View report

7 May 2021 East London N. Persaud

Stacey Camille Alexander-Harriss was bitten by a dog on 15 June 2020, became unwell two days later, and was taken to hospital with suspected sepsis. She suffered a cardiac arrest in the early hours of 18 June 2020 and could not be resuscitated; a later blood culture identified Capnocytophagia canimorsus. The concerns included a knowledge gap among attending doctors about this organism and the risks associated with dog or cat bites, as well as a possible need for greater public awareness.

Helen Spicer · Prevention of Future Deaths report View report

7 May 2021 Cornwall and Isles of Scilly G. Davies

Helen Spicer died at Royal Cornwall Hospital Truro on 4 October 2018 from an unintentional overdose of prescription morphine, against a background of opiate dependency and chronic pain due to fibromyalgia. The report raised concerns about the absence of restrictions and safe-custody requirements for oral morphine, including the lack of a requirement for collection from a community pharmacy to be signed for.

Glenn Macmartin · Prevention of Future Deaths report View report

7 May 2021 Plymouth, Torbay and South Devon I. Arrow

Glenn Macmartin had Bipolar Disorder and an Acquired Brain Injury and required specific care and accommodation. He was placed in a privately owned care home, where concerns were raised about care and suboptimal note keeping; the home later closed. He was admitted to hospital and died there on 1 April 2019.

Stephen Anthony MAGUIRE · Prevention of Future Deaths report View report

5 May 2021 Birmingham and Solihull A. Hodson

Stephen Anthony MAGUIRE collapsed while eating lunch at a mental health facility on 14 September 2020 and died after a mass of chewed meat obstructed his airway, causing approximately 30 minutes without oxygen. The report raised concerns that a staff member's personal incident and threat (PIT) alarm was not charged and that staff, including agency workers, might be unaware of the charging system or insufficiently trained in it.

Sarah Brady · Prevention of Future Deaths report View report

5 May 2021 Black Country J. Lees

Sarah Brady, a 75-year-old woman, was admitted to hospital on 4 August 2020 after being found unresponsive at home following a presumed medication overdose. She deteriorated into multi-organ failure and died in hospital on 8 August 2020. The concerns included prescriptions exceeding the GP’s seven-day limit despite her history of overdose and erratic medication compliance, possible stockpiling of medication, and uncertainty about whether an additional hospital prescription had been fulfilled.

Hannah Bampfylde · Prevention of Future Deaths report View report

5 May 2021 Surrey A. Loxton

Hannah Bampfylde was found hanging in the garage of her mother’s home, where she had been staying, and the inquest determined that she took her own life. She had been referred to HATS for mental health input after an overdose, but missed or could not attend assessment appointments and was discharged without being assessed. The report identified unclear responsibility for rebooking missed appointments and a lack of routine notification to GPs when newly referred patients did not engage with the service.

Richard James Ormond · Prevention of Future Deaths report View report

5 May 2021 Worcestershire D. Reid

Richard James Ormond, who had a history of substance misuse while in prison, was found in his cell at HMP Long Lartin in a drug-related cardiac arrest and was declared deceased later that day at hospital. The inquest heard that critical information that he was not breathing and required CPR was not passed to the ambulance service for at least nine minutes, delaying the highest-category emergency response. Concern was raised that prison and healthcare staff might not recognise the need to provide such critical updates in similar circumstances.

Laura Booth · Prevention of Future Deaths report View report

5 May 2021 South Yorkshire (Western) A. Combes

Laura Booth died at the Royal Hallamshire Hospital on 19 October 2016 after becoming unwell during an admission for a routine procedure. The inquest found that inadequate management of her nutritional needs led to malnutrition, which contributed to her death, and that clinical decisions about her care were made without properly involving her or her parents under the Mental Capacity Act. The report also raised concerns about staff understanding and application of the Mental Capacity Act and the use of Laura’s hospital passport.

Shane Adrian GILMER · Prevention of Future Deaths report View report

5 May 2021 County of the East Riding of Yorkshire and City of Kingston-Upon-Hull P. Marks

Shane Adrian GILMER was shot with a crossbow on 12 January 2018 and died shortly after midnight on 13 January 2018 from injuries causing catastrophic blood loss. The principal concern was that crossbows were not subject to the same ongoing ownership controls, records, storage requirements or licensing as firearms and shotguns, despite their lethal capabilities.

William Arthur John SIMONS · Prevention of Future Deaths report View report

4 May 2021 Shropshire, Telford and Wrekin J. Ellery

William Arthur John SIMONS died following two falls while receiving treatment at Royal Shrewsbury Hospital, with the second fall identified as more significant and preventable. Concerns included confusion and communication failures in the Tele-tracking transport system, unclear responsibilities when nursing staff were unavailable to assist a patient, and inadequate awareness of the patient's falls risk.

Ann Mowbray · Prevention of Future Deaths report View report

30 Apr 2021 Warwickshire S. McGovern

Ann Mowbray was unlawfully killed on 17 February 2020 after being stabbed 49 times while sleeping in her home. During the inquest, it was accepted that the Christian Congregation of Jehovah’s Witnesses had no policy for safeguarding vulnerable adult members, and its response about adopting such a policy was unclear.

Alvin Roy Black · Prevention of Future Deaths report View report

30 Apr 2021 Cambridgeshire and Peterborough S. Horstead

Alvin Roy Black, a serving prisoner, died after developing breathing difficulties and chest pains two days after returning from hospital spinal surgery. He suffered a fatal pulmonary embolism and cardiac arrest despite CPR. Concerns included poor hygiene in the prison Health Care Centre and a missed opportunity to review whether anti-coagulation therapy should have been provided after surgery.

Jade Rayner · Prevention of Future Deaths report View report

30 Apr 2021 Manchester South A. Mutch

Jade Nicole Rayner was a vulnerable adult with complex mental and physical health needs, including seizures, alcohol use and fluctuating capacity. She was found unresponsive at home on 30 March 2020 and had a fatal level of prescribed antidepressants and alcohol in her system. Concerns included the absence of an effective multi-agency strategy, failures in recording and investigating a reported sexual offence, and alcohol misuse support that could not meet the needs of a complex case involving underlying trauma.

Rohan Dayal Singh · Prevention of Future Deaths report View report

30 Apr 2021 East London G. Irvine

Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.

Joanna Leven · Prevention of Future Deaths report View report

30 Apr 2021 Manchester South C. Morris

Joanna Leven was found dead at home on 26 March 2020 after self-induced asphyxia, following a deterioration in her mental health after her dog became seriously unwell and was euthanised. The report identified concerns about the absence of a comprehensive mental health assessment, variable access to therapeutic pathways and trauma-focused services, and the risk of information being lost between hospital and mental health liaison records systems.

Eliot Peter Burton · Prevention of Future Deaths report View report

30 Apr 2021 West Yorkshire Eastern K. McLoughlin

Eliot Peter Burton, aged 15, was found drowned at an unmanned hydroelectric plant after entering the site as a trespasser and falling into an outlet channel. The concerns included repeated trespassing by young people, deep uncovered channels with limited or no edge protection, difficult access to the site via the adjacent weir, and limited effective action to reduce the risks to children.