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Sharon Louise Kelly · Prevention of Future Deaths report View report

24 Nov 2020 Essex C. Beasley-Murray

Sharon Louise Kelly, who had a long history of mental health and alcohol problems and frequent suicide attempts, informed a family member that she would kill herself on the anniversary of her baby son’s death. On 27 June 2019, an ambulance attended her property but did not enter while awaiting delayed police attendance; when services eventually entered, Ms Kelly was deceased. The concerns included delays and communication between ambulance and police services, risk assessment and police response procedures, and arrangements for urgent mental health assessments.

David Ball · Prevention of Future Deaths report View report

24 Nov 2020 Derby and Derbyshire E. Serrano

David Ball was found deceased at home on 30 June 2019 after taking methadone and venlafaxine with the intention of taking his own life following delusions and paranoia. His discharge care plan was not fully implemented, including the planned community support. Concerns included poor communication between healthcare departments with separate patient records, and no process to ensure that emails were received or acted upon.

Christopher Sparks · Prevention of Future Deaths report View report

24 Nov 2020 Essex C. Beasley-Murray

On 4 April 2019, Christopher Sparks, a HGV driver, was struck by a falling steel balcony frame while he was on the trailer bed during loading. The concerns included the absence of an approved safe loading and lifting plan, a banksman, a clearly marked driver area, and suitable equipment for moving and loading the products.

Claire RICHARDS · Prevention of Future Deaths report View report

23 Nov 2020 County Durham and Darlington C. Oliver

Claire Richards had a history of drugs misuse and mental health issues and died at home after snorting illegally dealt pregabalin and buprenorphine, becoming unresponsive despite emergency services being summoned. The principal concern was the availability of prescription drugs in large quantities for illegal dealing to vulnerable people and the leakage of prescription medication from lawful dispensing into criminal hands.

Elena WELLS · Prevention of Future Deaths report View report

23 Nov 2020 Brighton and Hove C. Palmer

Elena Wells, who had a history of mental health issues, died after placing a ligature around her neck while alone at home awaiting an urgent mental health admission. The report identified unclear responsibility and communication between the Local Authority and Mental Health Trust, and insufficient out-of-hours support and supervision while she waited for a bed.

Jason THOMPSON · Prevention of Future Deaths report View report

20 Nov 2020 County Durham and Darlington L. Hamilton

Jason THOMPSON, a 49-year-old man, collapsed at home after taking a quantity of a substance and died shortly afterwards in Darlington Memorial Hospital on 8 February 2020. The concerns included the ready availability of a lethal substance, including through a popular online platform, and material allegedly describing its use to commit suicide and potentially promoting that method.

Master Yo Li · Prevention of Future Deaths report View report

19 Nov 2020 Surrey A. Crawford

Yo Li was born extremely prematurely on 11 January 2019 and died on 15 January 2019 after an umbilical venous catheter was mal-positioned, resulting in total parenteral nutrition extravasation. Concerns included gaps in professional guidance about a risk factor for mal-positioned catheters, clinicians’ lack of familiarity with updated guidance, and the absence of NICE guidance or a requirement for NHS Trusts to follow the relevant guidance.

PAUL HILLS · Prevention of Future Deaths report View report

19 Nov 2020 North East Kent S. Hayes

Paul Hills was found deceased at home in his garage on 24 April 2020 after suspending himself from a rafter. He had a history of post-traumatic stress disorder, reported episodes and dry runs of self-harm, and was receiving treatment. Concerns included inadequate risk assessment and care-plan updates, failure to document or share escalating risk information, insufficient planning for remote treatment during the COVID-19 pandemic, and limitations affecting local treatment and communication.

John Allan TUCKER · Prevention of Future Deaths report View report

19 Nov 2020 Gwent C. Saunders

John Allan Tucker had significant coronary artery disease, underwent four-vessel coronary artery bypass grafting in 2018, and later died from congestive cardiac failure associated with cardiomegaly, ischaemic heart disease, coronary artery disease, and reported drugs and alcohol intake. Concerns were raised about the nature and extent of basic life support and first aid training provided to Gwent Police staff who may encounter people with respiratory problems.

Michelle Susan Turner · Prevention of Future Deaths report View report

18 Nov 2020 Blackpool and the Fylde T. Holloway

Michelle Susan Turner was found unresponsive at home on 1 June 2019 and died after using heroin, cocaine and tramadol. The substantive concern was that funding for peer support workers might be lost, potentially resulting in the loss of a service described as essential for some people with mental health conditions or alcohol and substance misuse problems.

Alfie Gildea · Prevention of Future Deaths report View report

18 Nov 2020 Manchester South A. Mutch

Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.

KATHERINE MABEL HOGAN · Prevention of Future Deaths report View report

18 Nov 2020 Mid Kent and Medway S. Hayes

Katherine Hogan died at Maidstone Hospital on 31 August 2019 after sustaining a severe head injury and major haemorrhage from a high-impact fall from a trolley in the clinical decision unit. The concerns included staff shortages, the use of an unsuitable area for keeping a patient overnight, and an outstanding request for increased staffing that had not been addressed by the Trust.

Riley John HOLT and 3 others · Prevention of Future Deaths report View report

17 Nov 2020 Staffordshire South A. Haigh

Riley John HOLT, Keegan Jonathan UNITT, Tilly-Rose UNITT, and Ollie UNITT died in a fire at their home in Stafford in the early hours of 5 February 2019 while asleep in their beds. The substantive concern reported was that children under 16, particularly boys, may not respond to conventional smoke alarms, alongside an argument for fire suppression systems in all newly built properties in England.

Sylvia Ruth GRIFFITHS · Prevention of Future Deaths report View report

17 Nov 2020 Staffordshire South A. Haigh

Sylvia Ruth GRIFFITHS, who had dementia and was known to wander from her home, was found dead at home on 27 October 2019 after being overcome by fumes from a fire caused by inappropriate use of an electric kettle. During the inquest, concern was raised about greater communication about and use of fire or smoke alarms particularly directed at people with dementia.

Neil BARRE · Prevention of Future Deaths report View report

17 Nov 2020 Staffordshire South A. Haigh

Neil Barre died at Queen Elizabeth Hospital in Birmingham on 11 September 2020 from burns sustained in a fire at his home in Cannock after he dropped a cigarette while smoking in bed. During the inquest, concern was raised about Staffordshire Fire and Rescue Service being informed when people receiving domiciliary care are not using special fire-safety equipment provided to them, and about communication with care-providing groups.

Daniel Waite · Prevention of Future Deaths report View report

16 Nov 2020 Mid Kent and Medway B. Patel

Daniel Waite was riding a pedal cycle on the A20 Ashford Road when he collided with the rear of a stationary convoy of eight tipper trucks, sustaining fatal injuries and dying at the scene on 3 July 2019. The substantive concern was that the trucks had been directed to stop on the road without parking restrictions, coning, or signage to alert other road users, and that no clearway or similar restriction was in place.

Jean Williams · Prevention of Future Deaths report View report

16 Nov 2020 Lancashire and Blackburn with Darwen R. Galloway

Jean Williams, aged 80, died at Thornton House Care Home between 6.30 a.m. and 8.27 a.m. on 19 November 2017 after her head became trapped between her bed and a chest of drawers, with her neck resting on a bed lever. The report found that the bed lever’s securing strap had not been used. Concerns included bed levers being fitted or adjusted without the patient present, insufficient reporting and training arrangements, and the possible supply or fitting of bed levers without the required strap.

Daniel Bancroft · Prevention of Future Deaths report View report

16 Nov 2020 Cumbria S. Ward

Daniel Bancroft, an ex-serviceman and father of three, became extremely inebriated after a night out and was struck by a motor vehicle while walking along the A66 in the early hours. He died from the resultant injuries. The substantive concerns were the lack of pedestrian warning signage, the rapid acceleration and speed of traffic, and the lack of lighting on the initial stretch of the A66.

Chelsie Violet Greatorex · Prevention of Future Deaths report View report

12 Nov 2020 East London G. Irvine

Chelsie Violet Greatorex took an overdose of prescribed medication on 10 March 2020 and died later that day despite emergency treatment. The report describes concerns about her anxiety as a complainant in a sexual assault case, delays in the investigation, the lack of specialist handling despite her being a child when the alleged assault occurred, and limited support after she contacted police.

Imane Bouasbia · Prevention of Future Deaths report View report

12 Nov 2020 East London G. Irvine

Imane Bouasbia was sexually assaulted on 1 January 2020 and subsequently expressed suicidal thoughts to police. On 3 January 2020, she stepped in front of a moving Central Line tube train at Newbury Park Station and was killed instantly. The principal concerns were failures to communicate her suicidal thoughts, complete a self-harm or suicide risk assessment, and respond adequately to her text message indicating suicidal thoughts.