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Evelyn Ann Swift · Prevention of Future Deaths report View report

29 Aug 2019 Nottinghamshire E. Didcock

Evelyn Ann Swift became increasingly unwell over several days and contacted her GP surgery repeatedly on 3 January 2019, but a home visit was not arranged until that evening. The assessment was incomplete, her condition was not recognised as severe, and she was not admitted to hospital; she was found deceased at home the following morning. The principal concerns related to unsafe procedures for triage, home-visit allocation, urgent clinical advice, documentation, clinical cover, and review of significant events.

Michael Hoolickin · Prevention of Future Deaths report View report

29 Aug 2019 Manchester North J. Kearsley

Michael Hoolickin was attacked and stabbed in an unprovoked assault on 14 October 2016 and died at Manchester Royal Infirmary on 17 October 2016. The report identifies organisational and management failures in supervising the perpetrator, including failures concerning drug testing, information sharing and provision of relevant information, which resulted in a missed opportunity to initiate recall to prison. The Inquest found that this probably contributed to Michael Hoolickin’s death, although it was not causative of the attack.

Amir Siman-Tov · Prevention of Future Deaths report View report

28 Aug 2019 London (West) S. Cummings

Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

Kay Michelle Martin · Prevention of Future Deaths report View report

27 Aug 2019 Sunderland D. Winter

Kay Michelle Martin, referred to as Kay Richardson, died on 21 September 2018 following a brutal and sustained attack by her husband, who then took his own life. The report raised concern that she had no protection in place between 8 August and 18 September 2018 while her husband was under police investigation without bail conditions or other restrictions, including restrictions concerning the family home keys.

Kim Morris · Prevention of Future Deaths report View report

27 Aug 2019 Leicester City and South Leicestershire L. Brown

Kim Morris died from the consequences of suspension by ligature after being found in the garage at home and resuscitated. The report raises concerns about a lack of continuity within the crisis team, inadequate handover to community psychiatric nursing, and whether the service was suitable to support high-risk individuals. It states that these pressures and service concerns remained unresolved.

Maureen Veronica Martin · Prevention of Future Deaths report View report

26 Aug 2019 Staffordshire South A. Haigh

Maureen Martin was admitted to Queens Hospital with cardiac problems and fell on the ward while attempting to mobilise by herself. She sustained a severe head injury that was not suitable for surgery and died in hospital five days later. A concern was raised that the Nurses’ Station desk was facing the wrong way at the time of her fall, potentially reducing visibility.

Thelma Joyce · Prevention of Future Deaths report View report

23 Aug 2019 Oxfordshire D. Salter

Thelma Joyce commenced chemotherapy for gall bladder cancer, developed a severe reaction, was admitted to hospital and died on 14 February 2019. The principal concern was whether updated guidance and routine testing for DPD deficiency should be introduced for patients due to receive Capecitabine or 5FU chemotherapy.

Mr. Christopher Summerhayes · Prevention of Future Deaths report View report

22 Aug 2019 South Wales Central S. Richards

Mr. Christopher Summerhayes was found deceased at his home address after a significant medical history including double scoliosis, treatment-resistant schizophrenia and a complex regime of around 12 daily medications. The concerns included the prescription of clozapine alongside other medications, substantial weight gain and possible effects on his cardiovascular system, as well as a possible familial lipid disorder. The inquest concluded that the medical cause of death was ischaemic heart disease, with a narrative determination referring to atypical early-onset coronary artery atherosclerosis and complex prescribed medications.

Euan David Brinley ELLIS · Prevention of Future Deaths report View report

22 Aug 2019 Plymouth, Torbay and South Devon I. Arrow

Euan David Brinley ELLIS, who had Marfan’s Syndrome and cardiac vulnerability, attended hospital with chest pains on 19 November 2017 and his GP the following day. He suffered a fatal haemopericardium at home on 23 November 2017. Concerns included limited access to his medical records and assurance that recommendations from a multidisciplinary investigation were being followed.

Tony Mark DUNNE · Prevention of Future Deaths report View report

20 Aug 2019 Inner North London M. Hassell

Tony Mark Dunne, who had alcohol dependence disorder, extreme anxiety and mild depression, died after jumping from a seventh-floor window on 20 February 2019. Earlier that evening, he had been found by police intending to jump and was assessed in an emergency department, but was discharged after refusing informal admission and being deemed not detainable. The principal concern was that, when he later called the Crisis Line, the call taker knew this history but did not ask whether he was feeling suicidal or arrange further hospital support.

Daphne WIGLEY · Prevention of Future Deaths report View report

20 Aug 2019 Mid Kent and Medway S. Hayes

Daphne WIGLEY was admitted to hospital with shortness of breath, cough, weakness, heart problems and a chest infection. She fell on the ward on 22 March 2018, suffered a severe traumatic brain injury and subdural haematoma, received palliative care, and died on 23 March 2018.

George Benjamin Rimmer · Prevention of Future Deaths report View report

16 Aug 2019 West Sussex P. Schofield

George Benjamin Rimmer was found deceased at home on 25 October 2018 after being prescribed Oramorph for pain following decompression surgery. The concerns included taking the medicine directly from the bottle rather than measuring doses, possible lack of counselling about exceeding the prescribed dose, and insufficient warnings about excess or cumulative dosing.

Martin Leslie Haines · Prevention of Future Deaths report View report

16 Aug 2019 East Sussex A. Craze

Martin Leslie Haines was detained at Lewes Prison and was found dead in his cell on 18 March 2018. He had Type II Diabetes and warning signs of cerebrovascular disease, but the appropriate diagnostic tests were not carried out; alcohol, Venlafaxine and Amitriptyline were later found in his system and considered by the pathologist to have contributed to his death. The principal concerns included inadequate diabetes and cardiovascular monitoring, healthcare falling below community standards, the ability to brew or distil alcohol in prison, a lack of protocols for responding to an unresponsive body, and insufficient communication between healthcare providers and the prison service.

Dr Geraint Brierley Hughes · Prevention of Future Deaths report View report

16 Aug 2019 Cornwall and Isles of Scilly A. Cox

Dr Geraint Brierley Hughes was stabbed once in the chest by his wife at their home on 15 November 2013 and died. The substantive concerns included that a formal carer’s assessment had not been completed and that the case coordinator had not maintained regular contact, resulting in care plans and risk assessments not being regularly updated.

Justin Peter Gallagher · Prevention of Future Deaths report View report

16 Aug 2019 East Sussex A. Craze

Justin Peter Gallagher was received at HMP Lewes on 20 March 2016 and was later found collapsed in his segregation-block cell on 24 May 2016. He was taken to hospital, where he died on 17 June 2016; the post-mortem recorded hypoxic brain injury, cardiac arrest and laryngeal carcinoma with upper airway obstruction among the causes. Concerns included the absence of his previous medical history, a proper care plan and a single clinician responsible for his care, cancelled hospital appointments, missed opportunities to diagnose his cancer, lack of family involvement, and separate healthcare organisations using unconnected database systems.

Dane Lee Pearson · Prevention of Future Deaths report View report

15 Aug 2019 Manchester South A. Mutch

Dane Lee Pearson, who had a history of mental health problems and amphetamine use, was found suspended from a ligature at his home on 13 December 2017. The investigation concluded that the death was suicide, with the medical cause recorded as hanging. Concerns included failures in the issuing and documentation of a Child Abduction Warning Notice, failure to assess or account for his vulnerability, inadequate recording of vulnerability markers, and failure to communicate that criminal proceedings had been discontinued.

David John Smith · Prevention of Future Deaths report View report

14 Aug 2019 Manchester City Z. Golombeck

David John Smith underwent a dual renal transplant involving kidneys from a CMV-positive donor, but the donor’s CMV status was not communicated to him and was incorrectly recorded as negative. He did not receive CMV prophylaxis, later developed CMV infection and ganciclovir resistance, deteriorated, and died on 5 July 2017. The principal concerns were the consent process and failures to communicate and accurately record the donor’s CMV status.

Christopher Carlton Hart · Prevention of Future Deaths report View report

14 Aug 2019 Manchester South C. Morris

Christopher Carlton Hart was found collapsed in a flat fire on 13 January 2019 and later died at Stepping Hill Hospital from complications of injuries sustained in the fire. The likely cause was a discarded cigarette igniting bedding on a sofa. Concerns included the lack of conditions requiring tenants’ furniture to meet relevant fire safety standards and the absence of a formal review of installing sprinklers in housing properties.

Gladys Esme FURNIVAL (known as Esme FURNIVAL) · Prevention of Future Deaths report View report

14 Aug 2019 Cheshire H. Westerman

Esme Furnival had an unwitnessed fall at her sheltered accommodation on 8 July 2018 and was suspended by the waist cord of her dressing gown. Although emergency services were called, an ambulance arrived after a significant delay, and the report raised concern that other emergency services were not used to assist when there were no eyes on the ground.

Karen Jane Burns · Prevention of Future Deaths report View report

12 Aug 2019 Birmingham and Solihull L. Hunt

Karen Jane Burns was found hanging from a basketball net at a park in Birmingham at 06.15 on 23 March 2019, after her ex-partner had reported that she had threatened to kill herself. The inquest concluded that her death was suicide. A serious concern was raised about West Midlands Police resources, particularly at night, and the incorrect grading and non-response of the call reporting the threat.