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Joan Margaret McIndoe · Prevention of Future Deaths report View report

1 Jul 2020 Manchester South A. Mutch

Joan Margaret McIndoe was found unresponsive in the shower at her retirement complex after an alarm was activated and the call centre was unable to contact her. The ambulance call was categorised as a Category 4 response, and concerns were raised about the automatic categorisation of such calls and the lack of clarity about updates after a call centre contacts the ambulance service, particularly while the alarm continued to activate.

Gary Etherington · Prevention of Future Deaths report View report

26 Jun 2020 Inner South London A. Harris

Gary Etherington was found dead in his van after taking an overdose of his wife’s Amitriptyline; the inquest concluded that his death was suicide. The coroner identified failures in the mental health assessment and discharge process, including inadequate investigation of psychotic symptoms and suicide risk, insufficient communication with the GP, and an unreliable Root Cause Analysis that failed to identify these care problems.

Winifred Mary Redfearn · Prevention of Future Deaths report View report

25 Jun 2020 Wiltshire and Swindon D. Ridley

Winifred Mary Redfearn died after falling down the stairs at home, sustaining head and neck injuries and becoming immobile in hospital. She developed a deep vein thrombosis and pulmonary thromboembolism. The principal concern was that resumption of Dalteparin thromboprophylaxis was delayed for more than two and a half days after the CT report, apparently because of the intervening weekend, and that similar delays could contribute to avoidable premature deaths in other cases.

Bethan Naomi Harris · Prevention of Future Deaths report View report

22 Jun 2020 West London S. Cummings

Bethan Naomi Harris was born on 16 November 2018 and died at Shooting Star Hospice on 26 November 2018 after sustaining severe brain injury during a rapidly progressing labour. Concerns included inadequate handover arrangements, lack of specific training, an outstanding team debrief, and limited evidence of reflection or learning after her birth and death.

JOAN WILLIAMS · Prevention of Future Deaths report View report

16 Jun 2020 Bedfordshire and Luton E. Whitting

JOAN WILLIAMS was driving on the A5120 on 19 August 2019 when her car collided head-on with a heavy goods vehicle. She sustained multiple injuries and died in hospital on 3 September 2019. The concerns included that, despite her Alzheimer’s dementia diagnosis and advice to notify the DVLA and stop driving, she continued to drive and the DVLA was not informed; the report also raised whether diagnoses should be referred directly to the DVLA or DVA.

Grant Alexander Macdonald · Prevention of Future Deaths report View report

15 Jun 2020 Liverpool and the Wirral A. Bhardwaj

Grant Alexander Macdonald, aged 27, died on 19 August 2019 after suffering significant injuries in a motorcycle collision with a Mercedes on Hornby Road, Liverpool. Concerns were raised that the junction was unsafe, particularly for vehicles crossing the carriageway to turn, and that there had been a number of collisions there.

Mitica Mihaita Ladunca · Prevention of Future Deaths report View report

9 Jun 2020 Surrey A. Crawford

Mitica Mihaita Ladunca died at St. George’s Hospital on 8 November 2019 after unintentionally stepping into the path of a large vehicle while attempting to cross the A322 in Surrey. The report raised concern that the absence of signage warning drivers about the uncontrolled pedestrian crossing could give rise to a risk of future deaths.

Mildred Horrex · Prevention of Future Deaths report View report

8 Jun 2020 West Sussex P. Schofield

Mildred Horrex suffered an unwitnessed fall while sleeping in a chair at Pelham House on 30 December 2017, sustaining fractures to her C1 and C2 vertebrae, and died in hospital on 18 January 2018. The concerns identified were poor and sometimes inaccurate record keeping, insufficient information for an adequate fall-risk assessment, and discrepancies between medication records and the amount of medication held that were not detected by audits.

Allan Arthur Watt · Prevention of Future Deaths report View report

3 Jun 2020 Cumbria N. Shaw

Allan Arthur Watt became increasingly unwell over several months and was ultimately admitted with an inoperable ischaemic bowel; he died on 20 September 2019. Concerns included delays in medical assessment after admission and a further delay before he received intravenous fluids and antibiotics. The report states that these delays may have denied him any chance of survival, although he may already have been too ill to survive on arrival.

Master Omarian Brooks · Prevention of Future Deaths report View report

29 May 2020 Inner South London A. Harris

Omarian Brooks, a severely disabled boy, deteriorated after being given antibiotics by his parents and died en route to hospital on 27 May, without having had a GP visit. Concerns included the GP apparently being unaware of his deterioration, the absence of a protocol for managing it, and the lack of a patient-specific emergency care protocol. The report states that earlier GP awareness might have led to hospital admission with a real prospect of successfully treating the infection.

Flora Shen · Prevention of Future Deaths report View report

29 May 2020 Inner North London J. Stevens

Flora Shen died on 6 January 2020 at Lime House station after falling from the platform and being struck by a train. The report raised concerns about the reliance on members of the public to notice hazards and activate alarms, and about limited CCTV coverage and the response process on the driverless DLR system.

Gillian Louisa DAVEY and Michael PENDER · Prevention of Future Deaths report View report

28 May 2020 Cornwall and Isles of Scilly A. Cox

On 25 May 2020, Gillian Louisa Davey died after a pleasure craft capsized off the north Cornish coast, trapping her underneath, and Michael Pender died after being rescued from the sea off Treyarnon Bay, apparently having been caught in a rip current. The principal concern was that there was no lifeguard cover on any Cornish beach that day, with uncertainty about when professional lifeguard services would resume and concern about further loss of life.

Gillian Louisa DAVEY and Michael PENDER · Prevention of Future Deaths report View report

28 May 2020 Cornwall and Isles of Scilly A. Cox

On 25 May 2020, Gillian Davey, aged 17, was trapped under a capsized pleasure craft near Padstow and could not be resuscitated. On the same day, Michael Pender, aged 63, was rescued after apparently being caught in a rip current while swimming off Treyarnon Bay, but could not be resuscitated. The principal concern was that no Cornish beach had lifeguard cover that day and that beaches remained unguarded, with a fear of further loss of life until professional lifeguard services returned.

Lesley Julie BRASS · Prevention of Future Deaths report View report

27 May 2020 Avon R. Sowersby

Lesley Julie BRASS fell at home, sustained a head injury, and was admitted to hospital after her wound became infected. While an inpatient, she developed severe hyperkalaemia but did not receive the required emergency treatment within the specified timeframe, and she suffered a fatal cardiac arrest. The report raises concerns about failures to recognise, escalate and treat the condition, and about the Plastic Surgery department’s subsequent investigation, openness and willingness to acknowledge mistakes.

Harrison Colin Hassall · Prevention of Future Deaths report View report

12 May 2020 Leicester City and South Leicestershire P. Mason

Harrison Colin Hassall was born pre-term and breech on 12 January 2019 after delayed delivery, and sustained brain damage before dying peacefully in hospital on 14 January 2019. Evidence highlighted concerns that midwives may be permitted to work in the community too soon after qualifying, with insufficient experience, and the University Hospital of Leicester NHS Trust indicated it would review the appropriate grade for community posts.

Barry Wayne Preston · Prevention of Future Deaths report View report

4 May 2020 Manchester South A. Mutch

Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.

Barrie Crawford COPELAND · Prevention of Future Deaths report View report

1 May 2020 County Durham and Darlington J. Thompson

Barrie Crawford Copeland fell down steps in the Broadway Show Lounge aboard the Marella Discovery on 23 August 2018 while looking for a seat, suffering a head injury that ultimately led to his death on 21 September 2018. Concerns were raised that carpet-covered steps and inadequate lighting made the change in floor level difficult to recognise, particularly for infirm people or those with poor eyesight, and that there was no evidence the scene had been examined by TUI.

Evelyn Ross · Prevention of Future Deaths report View report

27 Apr 2020 Manchester South A. Mutch

Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.

Mary Brady · Prevention of Future Deaths report View report

24 Apr 2020 Manchester South A. Mutch

Mary Brady, who had vascular dementia and lived in a care home, was found unresponsive after being left unobserved in a communal area. A used pair of latex gloves was removed from her airway, and she died shortly after midnight on 11 March 2019. Concerns included accessible open waste baskets, improper disposal and insufficient escalation of used gloves, and failures to document and risk-assess her previous ingestion of non-food items or update her care plan.

DEAN GARY GEORGE · Prevention of Future Deaths report View report

24 Apr 2020 Swansea and Neath Port Talbot C. Phillips

DEAN GARY GEORGE was found hanging in his cell at HMP Swansea on 16 March 2016 and the inquest concluded that his death was a suicide caused by hanging. Concerns included unequal access to opiate substitution therapy in Welsh prisons, inadequate risk assessment, insufficient information sharing between medical and prison staff, inadequate ACCT training, and an inequitable opiate detoxification system.