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Beryl Holland · Prevention of Future Deaths report View report

25 Feb 2020 Manchester South A. Mutch

Beryl Holland sustained a fractured neck of femur after a fall at the care home where she resided, underwent surgery at Stepping Hill Hospital, continued to decline post-operatively, and died there on 7 July 2019. The concerns related to her prolonged stay in the Emergency Department while awaiting a ward bed, her vulnerability to pressure ulcers, and the absence of national guidance for managing pressure-ulcer risks in Emergency Department settings.

Mary Nelson · Prevention of Future Deaths report View report

24 Feb 2020 Cumbria N. Shaw

Mary Nelson, aged 75, was found deceased on her sofa at home after what appeared to be a sudden death during the night. The inquest concluded that she died from a combination of hypertensive heart disease and the toxic effect of a properly prescribed medication. Concerns included the very high post-mortem Fluoxetine level, possible accumulation during treatment, whether dosage guidance should be revised for older people, and the death not having been reported through the Yellow Card system.

Jake Edmund Lee · Prevention of Future Deaths report View report

24 Feb 2020 Norfolk Y. Blake

Jake Edmund Lee suffered a spinal cord infarction causing loss of feeling and immobility below the waist. After he collapsed at a rehabilitation unit, CPR was not commenced promptly, and the nurse in charge left him in the care of an untrained healthcare assistant while making another call. The principal concerns were the nurse’s lack of training and ability to respond to a collapse, her failure to remain with the patient, and her lack of knowledge about the bed and appropriate CPR and airway procedures.

Anita Loi · Prevention of Future Deaths report View report

21 Feb 2020 South London J. Devonish

Anita Loi, who had Type 1 diabetes, suffered a burn to her left leg in April 2019 that developed into an infected wound. Despite repeated referrals, the community nursing teams did not attend to management of the wound, and she later suffered cardiac arrest and died in hospital on 1 July 2019. The principal concerns were the lack of response to referrals and whether appropriate referral policies and procedures were in place.

LUKE OWEN JACKSON · Prevention of Future Deaths report View report

21 Feb 2020 Mid Kent and Medway S. Hayes

Luke Owen Jackson, who had Becker’s Muscular Dystrophy and a chest infection, was admitted to hospital on 4 December 2019 and suffered a cardiac arrest on 6 December before being transferred to the Evelina Children’s Hospital. He later died on palliative care from hypoxic ischaemic encephalopathy following prolonged cardiac arrest. The principal concerns included recognition and treatment of total-body potassium depletion in a child with myopathy, and the limitations of monitoring oxygen saturation when assessing deterioration.

Andrew Goldstraw · Prevention of Future Deaths report View report

21 Feb 2020 Central Hampshire S. Burge

Andrew Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent his death.

Billy James Jenkins · Prevention of Future Deaths report View report

21 Feb 2020 South London J. Devonish

Billy James Jenkins was found hanging by the neck in a hotel room bathroom on 12 August 2019, following a history of low mood, alcohol and cocaine abuse, suicidal ideation and previous suicide attempts. The concerns included limited information gathering during his mental health assessment, a decision that he did not have a mental health condition without further assessment, inadequate documentation and planning, and possible over-reliance on alcohol and drug use as the explanation for his suicidal ideation. The inquest concluded that he took his own life following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.

Jon David JAMES · Prevention of Future Deaths report View report

20 Feb 2020 South Wales Central R. Knight

Jon David James died on 27 June 2017 after suffering cardiac arrest during restraint following an episode of acute behavioural disturbance associated with cocaine and anabolic steroid use. The principal concern was the absence of specific NICE guidance on acute behavioural disturbance, which the report states would benefit police, paramedics, emergency call handlers and medical professionals.

Zachary James Johnson · Prevention of Future Deaths report View report

18 Feb 2020 Black Country J. Lees

Zachary James Johnson was born in a birthing pool on 15 October 2016 after his foetal heart rate could not be auscultated for approximately 38 minutes because no working waterproof sonicaid was available. He was born floppy and unresponsive, and problems occurred during resuscitation, including incorrect ventilation-to-compression ratios, a period without chest compressions, and an interruption in airway management during transfer to hospital. The concerns included the availability of appropriate monitoring equipment and insufficiently frequent mandatory refresher training in newborn life support skills.

Malika Shammas and Haider Ali · Prevention of Future Deaths report View report

18 Feb 2020 Essex C. Beasley-Murray

Malika Shammas and Haider Ali got into difficulties while bathing in the sea near a groyne at Clacton-on-Sea on 8 August 2019 and both died. The substantive concerns included inadequate or difficult-to-read signage, limited beach surveillance, and whether greater liaison with the RNLI could improve beach safety.

Liam Anthony CLARK · Prevention of Future Deaths report View report

18 Feb 2020 Staffordshire South A. Haigh

Liam Clark died at the scene of a road traffic collision on the A5 at Shenstone on 10 September 2019 after attempting to pass on the nearside of an agricultural vehicle that was turning right. The concern raised was whether improvements were warranted at the junction with Streetway Road, including increased signage or changes to the road layout.

Wayne Lee Millett · Prevention of Future Deaths report View report

18 Feb 2020 Manchester South C. Morris

Wayne Lee Millett, a detained patient at The Priory Hospital, Cheadle, had treatment-resistant schizophrenia treated with Clozapine and died there on 13 February 2019 after escalating abdominal symptoms, collapse and complications including pseudo-obstruction of the small bowel. The report raised concerns that the Care Plan was not followed, that the Priory’s investigation and quality-assurance processes were inadequate, and that care-plan compliance and Clozapine-related monitoring had not been sufficiently reviewed.

Liam Floyd SEAGER · Prevention of Future Deaths report View report

17 Feb 2020 Inner North London M. Hassell

Liam Floyd Seager was knocked over and killed by a transit van at approximately 3am on New Year’s Day 2019 while crossing the A12 southbound underpass. The concerns were the absence of a pedestrian crossing near the collision site, the delay before a traffic management order would prohibit pedestrians crossing there, and the need for preparatory work and a pedestrian crossing at Wick Lane.

Lorraine Anne Molyneaux and James Anthony Lewis · Prevention of Future Deaths report View report

17 Feb 2020 Dorset R. Griffin

On 16 October 2019, Lorraine Molyneaux was struck by a motorcycle while crossing Ringwood Road near Turbary Retail Park and died at the scene. The motorcyclist, James Anthony Lewis, had consumed alcohol, suffered significant traumatic head injuries and died on 22 October 2019. Concerns related to repeated pedestrian collisions at the location, the distance of crossings from nearby bus stops and the adequacy and operation of street lighting.

Joseph James Gingell · Prevention of Future Deaths report View report

17 Feb 2020 Essex C. Beasley-Murray

Joseph James Gingell, who had a long history of mental illness and opioid and benzodiazepine dependence, was found deceased in a hotel near the Dartford Crossing. His cause of death was mixed drug toxicity with alcohol, and he had obtained drugs online without a prescription. Concerns included the toxic effects of combining drugs, self-certification without checks, and allowing patients not to inform their GP, which could remove a safeguard for people with addiction problems.

Marley Hope Slack · Prevention of Future Deaths report View report

14 Feb 2020 Leicester City and South Leicestershire D. Hocking

Marley Hope Slack was born prematurely as the smaller of twins and died on 20 February 2019 after being found unresponsive in her parents’ bed. The report raised concern that the Trust’s prominent co-sleeping advice did not state that premature or low-birth-weight babies should not be co-slept with, and the inquest heard that her sleeping environment presented more than a minimal risk of sudden infant death.

Martin Edward ELLIS · Prevention of Future Deaths report View report

13 Feb 2020 Inner North London M. Hassell

Martin Edward Ellis was electrocuted at the Sir John Compton Dam in Saint Lucia while holidaying there with his family. The concerns included inadequate access restriction and warning signage, exposed live wiring in a galvanised metal conduit, and the lack of an explanation or investigation report about the exposed wire six months after his death.

Donald George ELLIOTT · Prevention of Future Deaths report View report

12 Feb 2020 Lincolnshire P. Cooper

Donald George ELLIOTT was cared for at Glenholme Holdingham Grange and died on 22 February 2019 after a witnessed fall on 31 January 2019, after which he was taken to hospital and later returned to the home. The report raised concerns about staffing levels, staff competence and training, contradictory evidence provided to the inquest, late notification to the coronial service, and the failure of two care-home witnesses to attend under summons.

Gemma Elizabeth Azhar · Prevention of Future Deaths report View report

11 Feb 2020 West Sussex B. QC

Gemma Azhar self-referred to the Time to Talk service while experiencing long-term anxiety and depression and acute distress related to marital problems. Her assessment appointments were cancelled twice; after the second cancellation, she was discharged without an assessment of her current mental state or risk. She was later found hanging at her home, and the inquest concluded that she died by suicide. The report raised concerns that repeated cancellations and communication solely through administrators could leave people at risk, and that the relevant procedure was not consistently documented or communicated.

Joan Howard · Prevention of Future Deaths report View report

10 Feb 2020 South Yorkshire (West) A. Combes

Joan Howard was admitted to hospital on 4 April 2019 with specialist dietary requirements and choked to death on 10 April 2019 after being given a sandwich that should not have been provided. The report identified failures to follow dietary guidance and hospital processes, act on information from her care home, provide appropriate fluids, and escalate concerns about inappropriate food. It found that neglect had contributed to her death.