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Christina Lawal · Prevention of Future Deaths report View report

28 Nov 2019 Inner North London S. Bourke

Christina Lawal, who had type 2 diabetes and attended hospital regularly for dialysis, developed abdominal pain at home after returning from dialysis on 23 January 2019. She deteriorated, went into cardiac arrest shortly after paramedics arrived, and her death was confirmed at 23.05. The concerns included the absence of a cordless telephone for making emergency calls and the risk that ambulance triage callers may not provide accurate or updated information when they are not with the patient.

Andrew Richard Hogg · Prevention of Future Deaths report View report

27 Nov 2019 Manchester South C. Briggs

Andrew Richard Hogg, who had Parkinson’s disease and possible dementia, died on 6 May 2019 after a fall at Meadway Court Care Home caused a head injury and subdural haematoma. The principal concerns were the absence of adequate falls assessment, escalation, investigation and proactive measures to reduce the risk after his repeated falls.

David Michael Potts · Prevention of Future Deaths report View report

26 Nov 2019 Norfolk Y. Blake

David Michael Potts fell at home while prescribed apixaban and was admitted with an acute subdural haematoma. Beriplex was prescribed to reverse the apixaban but was not given in a timely manner, and staff did not confirm that it had been administered or establish where he was. His bleed extended; after transfer to a local unit, he declined and died seven days later.

John Thomas Lawler · Prevention of Future Deaths report View report

26 Nov 2019 North Yorkshire and City of York J. Heath

John Thomas Lawler suffered a fractured neck and spinal cord damage during chiropractic spinal adjustment and subsequent mobilisation on 11 August 2017. He died from respiratory depression caused by the traumatic spinal cord injury on 12 August 2017. Concerns included the absence of pre-treatment spinal imaging and mobilisation after he reported loss of sensation in his arms.

Trevor Albert Oakley · Prevention of Future Deaths report View report

26 Nov 2019 Hampshire S. Marsh

Trevor Albert Oakley was found hanging from a bedsheet ligature in his prison cell on 22 October 2018, shortly before he was due to start his trial. The inquest concluded that his death was suicide. The principal concern was that night staff were not immediately informed which prisoners were due in court the following morning, meaning increased self-harm risks might not be identified.

Gareth John Williams · Prevention of Future Deaths report View report

25 Nov 2019 Gwent C. Saunders

Gareth John Williams died at 08.30 on 19 April 2018 from injuries sustained when his motorbike collided with a car while he was overtaking traffic on the A468 near Machen. The report identified travelling in excess of the speed limit and overtaking as contributing to the collision, and raised concern about whether extending double white lines could restrict overtaking on that stretch of road.

Name not published · Prevention of Future Deaths report View report

22 Nov 2019 Cornwall and Isles of Scilly A. Cox

The deceased was reported missing after telling his wife he was going to a supermarket, and was later found hanged in woodland on 30 April 2018. The report considered whether police should have raised the missing-person risk level from medium to high earlier. The concern was that clearer national guidance might support more consistent decision-making in complex cases.

Jonathan Jesutofumi Adebanjo · Prevention of Future Deaths report View report

22 Nov 2019 Inner North London E. Buckett

Jonathan Jesutofumi Adebanjo drowned while swimming at Shadwell Basin after descending into the water by ladder. The concerns identified were that prohibition signs were too small and insufficiently obvious, and did not explain the dangers of poor underwater visibility, an undercurrent, and rubbish or discarded items below the surface.

MAUREEN MILTON · Prevention of Future Deaths report View report

22 Nov 2019 Staffordshire South M. Jones

Maureen Milton, aged 74, died after her clothing caught fire while she was attempting to light a cigarette with a long match; petrol-based emollient cream on her clothing likely accelerated the fire, and she was pronounced dead at the scene. The principal concern was a lack of awareness among medical professionals, carers, victims and families about the fire risks associated with petrol-based emollients.

George Edward Rogers · Prevention of Future Deaths report View report

21 Nov 2019 West Sussex J. Andrews

George Edward Rogers had a diagnosis of body dysmorphic disorder and died on 28 August 2018 after causing a fatal laceration to his chest. Following his transfer between care teams, a Lead Practitioner was not appointed promptly, resulting in a period without treatment or ongoing risk assessment. The principal concern was that such transfer arrangements could delay treatment and leave patients unmonitored.

Mr Gary Leyland · Prevention of Future Deaths report View report

20 Nov 2019 Manchester North J. Kearsley

Mr Gary Leyland was found deceased in his supported accommodation on 13 November 2019 after taking excessive prescribed medication, with the inquest conclusion recording suicide and morphine toxicity. Concerns included failures to contact medical or mental health services after suicidal thoughts were disclosed, poor documentation and handover information, the use of security staff for welfare checks without clear evidence of training, and the absence of an updated risk assessment.

Nimo Younis · Prevention of Future Deaths report View report

20 Nov 2019 Inner North London M. Hassell

Nimo Younis was detained in a psychiatric intensive care unit and was granted unescorted leave on 24 January 2019, but did not return. She was found at a friend's home the following day after hanging herself. The concerns included shortcomings in communication and understanding between ward staff and the police, the escalation and handling of the missing-person enquiry, the information provided to police decision-makers, and the use of the patient's friends in searching for her.

Helen BARKER · Prevention of Future Deaths report View report

19 Nov 2019 Lincolnshire P. Cooper

Helen BARKER, aged 50, called emergency services on 11 November 2018 reporting suicidal feelings and threatening to take an overdose. Although reviews were recorded as having been undertaken, they did not occur, and paramedics attended 6 hours and 35 minutes after the initial call; she was pronounced dead at home on 12 November 2018. The report raised concerns about implementation of an investigation recommendation and whether an emergency category 3 call could be escalated when the ambulance response time was exceeded.

James Joseph Fennell · Prevention of Future Deaths report View report

19 Nov 2019 Berkshire H. Connor

James Joseph Fennell left a train at Wokingham Station and climbed onto the tracks to cross to the other side. He slipped and made contact with the third rail, resulting in his instant death from electrocution. The principal concern was that warning signs about the risk of electrocution were small, distant, and not visible from the main areas where commuters waited, raising a potential risk at stations nationally.

Shaun William Dewey · Prevention of Future Deaths report View report

19 Nov 2019 Avon M. Voisin

Shaun William Dewey, a remand prisoner, was found hanging in his cell at HMP Bristol and died on 13 April 2018 after suspending himself from a ligature tied to the bed frame. The inquest identified anxiety, depression, separation from family, uncoordinated supervision, erratic medication use, and insufficient application of prison, healthcare and mental health systems as contributory factors. Concerns included whether remand prisoners’ higher risk of self-harm or suicide should be reflected in staff training, prisoner care, ACCT documentation and national guidance.

Katie Croft · Prevention of Future Deaths report View report

19 Nov 2019 Manchester South A. Mutch

Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.

Andrew Peter Wells · Prevention of Future Deaths report View report

19 Nov 2019 Birmingham and Solihull J. Bennett

Andrew Peter Wells, who had anxiety and depression and had repeatedly expressed suicidal thoughts and attempted suicide during a psychiatric admission, left the unit on 27 December 2018. He was later found hanging from a tree, suffered a severe hypoxic brain injury, and died in hospital on 31 December 2018. Concerns included the robustness of the Trust’s root cause analysis process and the inappropriate application of the Mental Health Act, including decisions about detention and observation levels.

Deborah Michelle HEADSPEATH · Prevention of Future Deaths report View report

18 Nov 2019 Suffolk N. Parsley

Debbie Headspeath died suddenly at home on 28 July 2017 from aspiration pneumonitis caused by pancreatitis, which was linked in the report to long-term codeine use. The principal concerns were the lack of a central database for prescription-only medicines, uncoordinated access to codeine from multiple online suppliers, and the ability of some suppliers to operate outside the CQC regulatory regime.

Emma Jayne Langley · Prevention of Future Deaths report View report

18 Nov 2019 Birmingham and Solihull J. Bennett

Emma Jayne Langley developed headache and vomiting after being diagnosed with an ear infection, and an ambulance attended her home. She was not taken to hospital, later collapsed, and was confirmed deceased; post-mortem tests identified Streptococcus pneumoniae and the medical cause of death was acute meningitis. The principal concern was that the process for recording non-conveyance did not adequately communicate to the patient or family that they were rejecting medical advice to admit her to hospital.

Alex Grady · Prevention of Future Deaths report View report

18 Nov 2019 Manchester North C. McKenna

Alex Grady was found deceased in his bed on 26 February 2019 and died from combined toxicity involving prescribed and non-prescribed medication and illicit drugs. Concerns included the adequacy of support and follow-up when alcohol detoxification is managed solely by a GP, and the accessibility of complete prescription information to healthcare practitioners.