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Amarbai Bhudia · Prevention of Future Deaths report View report

12 Nov 2020 East London G. Irvine

Amarbai Bhudia was admitted to hospital with abdominal pain and vomiting and was managed for a small intestine obstruction using a naso-gastric tube. The tube was not aspirated, and she collapsed and suffered a cardiac arrest caused by aspiration of gastro-intestinal contents; concerns included unclear instructions, lack of nursing guidance and training, and inadequate escalation of concerns about the tube.

Carolyne Senior · Prevention of Future Deaths report View report

11 Nov 2020 South Yorkshire (Western) S. Eccleston

Carolyne Senior died at Barnsley Hospital on 20 January 2019 after three falls while in the hospital’s care, resulting in fractures to both necks of femur. The report raised concerns that her mental health needs were not sufficiently considered in falls risk assessments and that specialist mental health support for hospital staff was inadequate.

Margaret Lilian SALES · Prevention of Future Deaths report View report

11 Nov 2020 Norfolk J. Lake

Margaret Lilian Sales, who was frail and had several comorbidities, was admitted to hospital on 13 December 2019 and died on 4 January 2020 after her health deteriorated. Concerns included incomplete records, difficulties contacting on-call medical staff, and a failure to request GP monitoring of her capillary blood glucose after discharge. The inquest concluded that she died from aspiration pneumonia, the cause of which was not clear from the evidence.

Xuanze Piao · Prevention of Future Deaths report View report

11 Nov 2020 Coventry T. Leeper

Xuanze Piao, a 17-year-old overseas student at Coventry University, was struck by a train near Coventry Railway station on 3 December 2018 and died from catastrophic injuries; the inquest concluded suicide. The principal concerns were that the university did not meet him face to face or contact his guardian or parents before emailing him about the risk of removal from his course, and that no relevant procedure or policy was in place.

Ewan Nathanial Brown · Prevention of Future Deaths report View report

10 Nov 2020 Newcastle upon Tyne and North Tyneside C. Henley

Ewan Nathanial Brown was found dead on 30 April 2019 after absconding while awaiting mental health assessment, following concerns about his behaviour and mental health. The inquest concluded that he died by accidental drowning while experiencing an unassessed and untreated psychotic illness. Concerns included gaps in police and health-service information sharing, multiagency coordination, mental health training, and family contact during the missing-person search.

Leslie Clewarth · Prevention of Future Deaths report View report

10 Nov 2020 West Yorkshire Eastern K. McLoughlin

Leslie Clewarth died in hospital from natural causes, with the Inquest recording aspiration pneumonia, small bowel obstruction, adhesions within the peritoneal cavity, and ischaemic heart disease. Concerns included the loss of his NG tube, an empty syringe driver, an injection administered after death, lack of treatment for a severe coronary condition, and missing or inadequate medical records. The principal substantive concern was that inadequate records made it impossible to corroborate the care and medication provided and created a risk that essential care could be omitted or duplicated.

Joseph Hargreaves · Prevention of Future Deaths report View report

9 Nov 2020 Manchester South A. Mutch

Joseph Hargreaves had an unwitnessed fall at his care home and was admitted to hospital with sepsis due to aspiration pneumonia associated with poor swallowing. He initially appeared to improve but deteriorated rapidly and died on 17 April 2020. The report identified concerns about reduced information-sharing with treating clinicians regarding the events before admission and his baseline and underlying health issues, particularly when family members could not visit during lockdown.

Joey Jenson Walker · Prevention of Future Deaths report View report

9 Nov 2020 Manchester South C. Morris

Joey Jenson Walker was found unresponsive after becoming entangled by the neck in a roller-blind cord and died 18 days later in hospital. The report expressed concern that residential landlords were not required to inspect window coverings or ensure that only safety cords were used in privately rented properties.

Name not published · Prevention of Future Deaths report View report

9 Nov 2020 Surrey C. Topping

The deceased died at home on 29 November 2017 after consuming considerable amounts of alcohol and cocaine and hanging herself with a ligature. Concerns included limited communication between the MARAC process and her general practitioner about domestic abuse risks and safeguarding measures, and the GP not being informed about her children being removed from her care and subsequent care proceedings, or the associated mental health stressors.

Stanley Alfred Babbs · Prevention of Future Deaths report View report

6 Nov 2020 East London N. Persaud

Stanley Alfred Babbs, who had chronic kidney disease, diabetes and heart failure, became unwell after receiving contrast for a CT scan and was diagnosed with contrast-induced acute kidney injury. He was later admitted to hospital and died from sepsis arising from a urinary tract infection on 16 February 2016. The report raised concerns that contrast, a prescription-only medicine, could be administered without a formal prescription, individualised risk/benefit assessment, careful dose consideration or a clearly identified responsible clinician, particularly for patients at high risk of acute kidney injury.

Christopher Allan MURFET · Prevention of Future Deaths report View report

6 Nov 2020 Lincolnshire P. Cooper

Christopher Allan MURFET presented to hospital on three occasions in October and December 2019 after self-harm, taking a knife to his throat, and taking antidepressants. He died by suicide on 29 December 2019, and the principal concern was whether consideration had been given to sectioning him under the Mental Health Act.

Linda Doherty · Prevention of Future Deaths report View report

5 Nov 2020 Surrey A. Crawford

Linda Doherty died in hospital on 7 August 2017 after developing Crohn’s Disease, intestinal failure, malnutrition, sepsis and acute kidney injury. The report identified failures to follow up CT scan findings, recognise and adequately address her nutritional deterioration, and concerns about inaccurate or incomplete nutrition monitoring and the process for placing her on end-of-life care.

Ann Margaret Smith · Prevention of Future Deaths report View report

5 Nov 2020 Essex C. Beasley-Murray

Ann Margaret Smith was admitted to Princess Alexandra Hospital, suffered an unwitnessed fall the following day, sustained a head injury and died four days later. The principal concern was uncertainty about managing anticoagulation after the fall, including the lack of a local protocol for patients over 65 on anticoagulants who sustain head trauma.

Clara Iris Moniatis · Prevention of Future Deaths report View report

3 Nov 2020 Essex C. Beasley-Murray

Clara Iris Moniatis had been unwell for several days and died at Whipps Cross Hospital on 5 May 2019 despite medical treatment; the stated cause of death was previously undiagnosed dilated cardiomyopathy. The concerns related to waiting times for reviewing chest X-ray imaging and the need for a system ensuring that a PEWS alert prompts a timely clinical review.

Michael Robert Collins · Prevention of Future Deaths report View report

30 Oct 2020 East London N. Persaud

Michael Robert Collins died at Whipps Cross Hospital on 4 April 2018 as a result of a ruptured abdominal aortic aneurysm. The report describes delays and errors in identifying, communicating, and acting on the aneurysm, which required ongoing monitoring. Concerns were also raised about the CERNER system not reliably sending results to the appropriate clinician and about the limited visibility of radiology reports for unexpected significant findings.

Sarah Nadine Louise GIBBS · Prevention of Future Deaths report View report

29 Oct 2020 Norfolk J. Lake

Sarah Gibbs died shortly after returning home following a PEG operation and discharge on 17 April 2019; she became unresponsive later that day and was pronounced dead at the scene. The medical cause of death included aspiration of gastric contents, vomiting, and acute peritonitis following recent insertion of the PEG tube. Concerns were raised about communication between teams, particularly the handover of information to night staff, and whether the SBARD communication tool was in use.

Darrell Sharples · Prevention of Future Deaths report View report

28 Oct 2020 Cornwall and Isles of Scilly A. Cox

Darrell Sharples died on 21 July 2018, aged 49. The inquest recorded the medical cause of death as asphyxia due to hanging and concluded that he died by suicide. Concerns included whether information about vulnerable individuals from ViST forms could be appropriately shared with partner agencies, and whether custody staff should access relevant CJLDT assessments before imposing bail conditions and releasing vulnerable individuals.

Reggie -Jay John PAYNE · Prevention of Future Deaths report View report

27 Oct 2020 Milton Keynes T. Osborne

Reggie -Jay John PAYNE was found unresponsive in his cot on 16 December 2020 and was confirmed dead at hospital after attempts at resuscitation. A Group B streptococcal infection was identified at post mortem, and the report raised concerns that Group B strep was not discussed during pregnancy and that screening and intrapartum antibiotics might have been relevant.

Martin Thomas BARRETT · Prevention of Future Deaths report View report

27 Oct 2020 North East Kent J. Andrews

Martin Thomas Barrett took part in a telephone assessment for anxiety on the morning of his death and disclosed suicidal thoughts and planning. A same-day referral for further psychiatric assessment was declined, and this decision was not communicated to him; he was later found hanging at home. The principal concern was that higher-risk patients may not be directly informed when an internal referral is declined, potentially leaving them without timely alternative treatment or safety-netting advice.

Sean Robert Steven Owen · Prevention of Future Deaths report View report

23 Oct 2020 Manchester North C. McKenna

Sean Robert Steven Owen had a history of treatment-resistant paranoid schizophrenia and was recognised as being at significant risk if non-compliant with medication. After medication monitoring arrangements broke down, he self-inflicted a penetrating neck injury on 3 June 2019 and died on 14 June 2019 from his injuries and a chest infection. The report raised concerns that his discharge letter omitted significant information about overdoses, suicidal thoughts and the risks associated with medication non-compliance, and that there was no quality assurance system for such letters.