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Russell Curwen · Prevention of Future Deaths report View report

24 Apr 2020 Lancashire and Blackburn with Darwen J. Newman

Russell Curwen, a volunteer with the North West Blood Bikes, was fatally injured after riding through a traffic light against the lights while transporting blood samples and colliding with another vehicle on 5 May 2018. The concerns included the lack of traceable NHS ambulance service coordination in dispatching blood-bike vehicles, no clear or auditable determination or review of whether courier journeys constituted emergencies, and no statutory training requirements for riders using high-powered motorcycles with emergency lights and sirens.

Patricia Ferguson · Prevention of Future Deaths report View report

23 Apr 2020 Nottinghamshire G. Clow

Patricia Ferguson had significant mental ill health and received secondary mental health services before her death by suicide. Clinicians considered that direct work with a clinical psychologist would benefit her, but no clinical psychologist was available; the report identified limited clinical psychology provision in community mental health teams as an ongoing risk of preventable future deaths.

Gordon Fenton · Prevention of Future Deaths report View report

23 Apr 2020 Manchester South A. Farrow

Gordon Fenton, a 70-year-old man detained under the Mental Health Act, developed a urinary tract infection and related complications during periods of care between psychiatric and medical services, and died in hospital on 29 June 2019 after a seizure and cardiac arrest. The principal concerns were inadequate information sharing and the lack of a formal joint decision-making process between the two NHS Trusts, with the inquest finding that this prolonged and contributed to ineffective management of his infection.

DAVID CRAIG KERR · Prevention of Future Deaths report View report

22 Apr 2020 Manchester South J. Wells

David Kerr was admitted to hospital after a fall at home and subsequently sustained a fractured neck of femur in a further ward fall after removing his oxygen. He became increasingly unwell and died on 27 April 2019; the inquest recorded accidental death, with respiratory failure and extensive idiopathic pulmonary fibrosis as the medical cause of death. Concerns included poor care on Ward D2, inadequate hydration and fluid recording, and too few clinical observations for a seriously unwell patient.

ALLAN WILLIAM CUNLIFFE · Prevention of Future Deaths report View report

22 Apr 2020 Manchester South J. Wells

Allan Cunliffe, who had bowel problems and mental health issues, became ill on Summers Ward on 17 July 2018 and died in A&E on 18 July 2018 after deterioration associated with a perforated bowel and sepsis. The substantive concerns included poor communication, inadequate recording and calculation of NEWS scores, failures to follow observation protocols, and confusion about oxygen administration, with the jury stating that insufficient record keeping and communication probably led to an avoidable death.

Norman Baxter · Prevention of Future Deaths report View report

22 Apr 2020 Manchester South C. Morris

Norman Baxter was admitted to hospital after becoming unwell at Lynmere Nursing Home on 7 August 2019 and died in hospital the following day. The inquest found that he died as a consequence of complications of Chronic Obstructive Pulmonary Disease and an E. coli infection, with severe sepsis and septic shock also identified. A concern was raised that nursing observation charts were not in use at Lynmere, which may have assisted staff in recognising acute illness or deterioration.

SAM ROBSON PRINGLE · Prevention of Future Deaths report View report

22 Apr 2020 Manchester South J. Wells

Sam Pringle had a long history of mental health problems and died by suicide by hanging on 3 November 2018. The report raised concern that inconsistent prescribing practices and the shared care protocol could delay or prevent access to Lithium for mentally ill patients, with potentially fatal results.

Wendy Margaret Wilkes · Prevention of Future Deaths report View report

20 Apr 2020 Manchester South A. Mutch

Wendy Margaret Wilkes was found at her home on 6 August 2019, with toxicology showing a fatal level of ethanol and concomitant use of gabapentin, zopiclone, diazepam and amitriptyline. Concerns were raised about the absence of a clear system for alert notes and follow-up reviews, and about whether prescribers were aware of her high alcohol use and assessed the risks of mixing alcohol with her medication.

Theo Benjamin Young · Prevention of Future Deaths report View report

20 Apr 2020 Surrey K. Henderson

Theo Benjamin Young was born by emergency caesarean section in a very poor condition after persistent abnormalities in fetal monitoring were not recognised during labour. He suffered non-survivable injuries from intrapartum hypoxia and died three days after delivery. Concerns included failures in staffing, fetal monitoring, escalation and oxytocin management, as well as delays and deficiencies in the subsequent HSIB investigation.

Andrew Patrick Jones · Prevention of Future Deaths report View report

20 Apr 2020 Lancashire and Blackburn with Darwen J. Adeley

Andrew Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.

Ashley Mark Holden · Prevention of Future Deaths report View report

17 Apr 2020 Lincolnshire P. Smith

On 10 November 2018, HGV driver Ashley Holden was struck by a falling straw bale while collecting bales from a farm and sustained a fatal head injury. The report identified inconsistent guidance and a lack of definitive guidance on stacking, unstacking, loading and strapping bales, creating a risk of unsafe practices and future deaths.

Mrs Patricia McAdam · Prevention of Future Deaths report View report

15 Apr 2020 London (South) S. Ormond-Walshe

Mrs Patricia McAdam was wheelchair-bound with arthritis and peripheral vascular disease and was cared for at home by her daughter. She was admitted to hospital in extremis with severe pressure sores and leg ulcers and died of sepsis on 11 June 2018. The principal concern was that, despite declining contact and care, her repeat prescriptions continued without an obvious regular attempt to assess or check on her, and that patients refusing care should still be regularly assessed.

Millie TAYLOR-NOONAN · Prevention of Future Deaths report View report

15 Apr 2020 Lincolnshire T. Brennand

Millie TAYLOR-NOONAN, aged 18, was struck by a car while crossing the A607 near The Sir William Robertson School on 4 December 2018. She suffered an unsurvivable head injury and died following the collision; concerns included inadequate pedestrian protections, lighting and crossing arrangements near the school.

Allison Louise Bird · Prevention of Future Deaths report View report

9 Apr 2020 West Yorkshire (west) M. Burke

Allison Louise Bird developed a gastro-pulmonary fistula, a recognised but rare complication of bariatric surgery, followed by severe infection and further surgery. Her condition deteriorated after surgery, she underwent emergency surgery on 13 March 2018, and she died on 16 March 2018 despite intensive care support. Concerns included the timing and adequacy of preoperative discussion and consent, monitoring of vital signs, and escalation for clinical review when observations were non-reassuring.

George Townsend · Prevention of Future Deaths report View report

6 Apr 2020 Manchester South A. Mutch

George Townsend, who was receiving long-term antibiotic therapy, developed worsening diarrhoea and was later diagnosed in hospital with Clostridium difficile infection and pneumonia. He died at Trafford General Hospital on 30 August 2019 from multi-organ failure due to bronchopneumonia. The concerns included delayed GP assessment and testing, inadequate escalation from the nurse to a doctor, failure to recognise the risks associated with his health conditions, poor medical record-keeping, and longstanding concerns about GP practice capacity and oversight.

Andrew Spencer Wing · Prevention of Future Deaths report View report

3 Apr 2020 Surrey C. Topping

Andrew Spencer Wing had a history of untreated hypertension and was discharged from hospital after investigations for acute left-sided pain, without a CT aorta being undertaken. He subsequently died from the effects of an aortic dissection. The principal concerns were that the chest X-ray and recognised possibility of aortic dissection should have led to a CT aorta, and that radiographers reviewing X-rays were given sparse clinical information.

Edna May Davenport · Prevention of Future Deaths report View report

3 Apr 2020 Black Country J. Lees

Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.

Ava-May LITTLEBOY · Prevention of Future Deaths report View report

2 Apr 2020 Norfolk J. Lake

Ava-May LITTLEBOY, aged 3, died on 1 July 2018 after an inflatable trampoline exploded at Gorleston beach, throwing her into the air. The report raised concerns about the absence of required inspection and certification arrangements, the lack of publicly recorded information when equipment was unsafe, and the absence of a legal requirement to notify enforcing authorities or use a specified inspection scheme.

Jake Thomas PERRY · Prevention of Future Deaths report View report

1 Apr 2020 Herefordshire H. Bricknell

Jake Thomas PERRY died after water-soluble B-group vitamins were removed from his parenteral nutrition. The report identifies concerns about variation of the parenteral nutrition and communication between hospitals, including local consultant responsibility and specialist consultation.

Michael Frank Bostock · Prevention of Future Deaths report View report

31 Mar 2020 Derby and Derbyshire P. Nieto

Michael Frank Bostock died at Stanage Edge on 12 December 2017 after his paraglider wing collapsed in strong turbulent wind, causing him to crash and sustain fatal chest injuries. Concerns included unclear specifications and pre-flight inspection guidance for speed bar lines, the need to configure speed bar systems for pilots of different sizes and weights, and the limited regulation of paragliding.