Search PFD Monitor

Ms Kerry Aldridge · Prevention of Future Deaths report View report

10 Feb 2020 Inner South London A. Harris

Ms Kerry Aldridge was a student police officer who died by suicide after jumping into the path of a train at Sydenham Railway Station on 6 April 2019. The report raised concerns about the lack of established links between police Safeguarding Teams and NHS mental health teams, and about the need for further mental health training and access to non-urgent advice for officers.

Christine Rosemary Neild · Prevention of Future Deaths report View report

10 Feb 2020 Manchester South A. Mutch

Christine Rosemary Neild had significant learning difficulties, dysphagia, and required feeding support. She became very unwell and died at Meade Close on 31 January 2020; the medical cause of death was a sub-acute bowel obstruction associated with an incisional hernia. Concerns included accessible gloves and other non-food items, a failure to escalate an earlier ingestion incident or undertake further risk assessment, and the lack of regular sensors to alert staff when residents got up at night.

Sarah YOUNG · Prevention of Future Deaths report View report

10 Feb 2020 Bedfordshire and Luton E. Whitting

Sarah YOUNG was admitted to Bedford Hospital on 9 April 2019 with headaches, confusion, immobility and fluctuating consciousness, and was later declared to have suffered brain-stem death on 12 April 2019 after an extensive cerebral sinus thrombosis. The principal concerns were delays in medical and neurological review, diagnosis and treatment, including difficulties with the referral system. The Inquest heard that earlier treatment may have increased her chances of survival, but could not be said to have contributed to her death.

Mr Adrian Ashford · Prevention of Future Deaths report View report

7 Feb 2020 Inner South London A. Harris

Mr Adrian Ashford died in Queen Elizabeth Hospital on 15 December 2018 after a massive upper gastrointestinal bleed, with the medical cause of death recorded as upper gastrointestinal bleeding due to chronic peptic ulcer. Concerns included the absence of a systematic process for recording weights and failures to identify or respond to risks of gastrointestinal bleeding, including consideration of gastroenterology referral.

Mark Oliver George Mallinson · Prevention of Future Deaths report View report

7 Feb 2020 West Sussex R. Simpson

Mark Oliver George Mallinson made numerous threats to take his own life over several hours after police sought to arrest him, and he died by suicide between 03.20am and 04.24am on 3 December 2018. The principal concern was that suicide-intervention training designed to save lives was not being provided to all frontline police staff.

Benjamin David Leonard · Prevention of Future Deaths report View report

7 Feb 2020 North Wales (East and Central) D. Pojur

Benjamin David Leonard, aged 16, died at the scene from a head injury after slipping and falling approximately 200 feet while attempting to descend a cliffside path on the Great Orme during a Scout trip on 26 August 2018. The substantive concerns included failures to follow and implement Scout safety policies, the absence of written and dynamic risk assessments, inadequate trip planning and briefing, ineffective leadership and group supervision, and insufficient organisational oversight and training.

David Clark · Prevention of Future Deaths report View report

6 Feb 2020 Lancashire and Blackburn with Darwen N. Cronin

David Clark was detained at Orchard Hospital under section 3 of the Mental Health Act and left on escorted leave on 26 June 2019. He was found in the Lancaster canal the following morning; the reported concerns included incomplete leave documentation, failure to follow the AWOL procedure, inadequate handover and training, and an outstanding action plan.

Marc Antony Cole · Prevention of Future Deaths report View report

6 Feb 2020 Cornwall and Isles of Scilly G. Williams

On 23 May 2017, Marc Antony Cole ingested a substantial amount of cocaine, behaved in a paranoid and psychotic manner, self-harmed and was Tasered three times by police before suffering a cardiac arrest and dying in hospital. The report raised concerns about limited independent data on the lethality and incremental risks of multiple or sustained Taser activations, and whether police advice and training were therefore deficient or incomplete.

Peter Edward SMITH · Prevention of Future Deaths report View report

5 Feb 2020 Shropshire, Telford and Wrekin J. Ellery

Peter Edward SMITH died on 4 March 2019 after relapsing on 20 February 2019. The report identified significant delay in the diagnosis and treatment of his adenocarcinoma, with tests, reports, appointments and discussions taking place consecutively so that surgery was no longer possible by the scheduled date.

Adam Alexander Bojelian · Prevention of Future Deaths report View report

5 Feb 2020 West Yorkshire Eastern K. McLoughlin

Adam Alexander Bojelian had profound disabilities and was hospitalised for approximately 17 months before being taken to a hospice on the eve of his death on 24 March 2015. The report identified concerns about the absence of individual nurses’ training records and the lack of a formal written care plan during much of his hospital stay, despite his complex medical needs.

Mr Gordon Gillott · Prevention of Future Deaths report View report

4 Feb 2020 Derby and Derbyshire E. Serrano

Mr Gordon Gillott presented with a ruptured abdominal aneurysm, underwent surgery, and later died from sepsis secondary to a bowel perforation. The principal concern was a substantial ambulance delay in transferring him, caused by resourcing issues, creating a risk of future deaths among acutely ill patients requiring urgent transfers.

Renee Simone Brooks · Prevention of Future Deaths report View report

31 Jan 2020 Birmingham and Solihull J. Bennett

Renee Simone Brooks underwent a final large-volume liposuction procedure on 29 August 2019, suffered cardiac arrest during the procedure, and died in hospital on 30 August 2019. The inquest identified fat embolism syndrome as a recognised but rare complication, with pre-existing cardiac issues contributing. The principal concern was the absence of UK guidance on safe practice for lipoedema-related liposuction, including procedure frequency, fluid volumes, and post-procedure recovery planning.

Ashley WALKER · Prevention of Future Deaths report View report

31 Jan 2020 Warwickshire S. McGovern

Ashley WALKER ingested a substance and was treated by an ambulance crew, who left after being told the scene was hazardous; he was left unattended for 45 minutes and was not breathing when extricated. The concerns included a communication error about the substance involved and the absence of an effective antidote on the ambulance.

Julie Sandra O'Connor · Prevention of Future Deaths report View report

30 Jan 2020 Avon M. Voisin

Julie Sandra O'Connor had a smear test in September 2014 that was reported as normal when it was not, and her cervical cancer was not diagnosed during examinations in August and November 2016. She was diagnosed and treated in March 2017, but her condition deteriorated and she died from metastatic squamous cell carcinoma of the cervix. The report identified concerns about the incorrect smear result and failures to recognise the cancer or the need for further assessment on several occasions.

Thiago Araujo · Prevention of Future Deaths report View report

29 Jan 2020 East London G. Irvine

Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.

Susan Sterland · Prevention of Future Deaths report View report

28 Jan 2020 Northamptonshire P. Barlow

Susan Sterland was brought to Kettering General Hospital on 29 December 2018 with an intestinal obstruction that was not diagnosed, and was admitted after being diagnosed with constipation. Her condition deteriorated, care was not escalated, and she collapsed and died early on 31 December 2018. The principal concern was that she was not seen by a senior doctor despite deterioration and remaining in hospital for about 40 hours; the report states that earlier senior review might have led to investigation and earlier diagnosis.

Beryl Fricker · Prevention of Future Deaths report View report

28 Jan 2020 Dorset B. Allen

Beryl Fricker was struck by a Toyota Yaris while crossing Upwey Avenue in Poole at dusk on 20 November 2018 and died of her injuries in hospital on 30 November 2018. The principal concern was poor street lighting at the junction of Lake Road and Upwey Avenue, particularly its wide and poorly illuminated middle section, which could affect pedestrians, cyclists and other road users.

Helen Jayne SHEATH · Prevention of Future Deaths report View report

27 Jan 2020 Bedfordshire and Luton E. Whitting

Helen Jayne Sheath, who had a recent history of self-harm and suicidal ideation, ingested a fatal dose of sodium nitrate at home and died in hospital on 20 August 2018. Concerns included the initial ambulance call being coded as Category 3 rather than Category 2, subsequent delays in ambulance attendance, and the Community Mental Health Team leaving her home before gaining access despite being alerted to her threats to self-harm.

Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report View report

27 Jan 2020 Inner North London M. Hassell

Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.

Gary Ronald Sloan · Prevention of Future Deaths report View report

22 Jan 2020 Sunderland D. Winter

Gary Ronald Sloan died after his vehicle aquaplaned on surface water, left the Eastbound A690 carriageway, went down an embankment and collided with a tree. Speed and an underinflated tyre were factors, and concerns were raised about repeated collisions at the same location, the possible need to review safety restrictions, and the drainage and surface-water clearance arrangements.