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Pauline Howell · Prevention of Future Deaths report View report

9 Aug 2019 Newcastle upon Tyne K. Dilks

On 5 February 2018, Pauline Howell was struck by a bus while crossing Newbridge Street West at the junction with John Dobson Street in Newcastle upon Tyne, sustaining injuries that resulted in her death. The principal concerns were the crossing’s proximity to the junction, its location on a busy bus route, the tight junction design, and the lack of margin for error, with a similar previous pedestrian death reported at the junction.

Joseph Kevin Lafferty · Prevention of Future Deaths report View report

7 Aug 2019 Manchester South C. Morris

Joseph Kevin Lafferty, who had dementia and required 24-hour residential care, left The Cedars Rest Home unsupervised and was found outside the care home with serious injuries after a fall. He was taken to hospital and died on 24 June 2018; the inquest concluded that he died following the fall and access to an area of the grounds not intended for resident access. Concerns included that external areas of registered premises were not required to be routinely included in CQC inspections, and that the ambulance dispatch system did not specifically take the patient’s age into account when determining response speed and acuity.

Carl Richard KLIMYATYS · Prevention of Future Deaths report View report

7 Aug 2019 Brighton and Hove V. Hamilton-Deeley

Carl Richard KLIMYATYS’s body was found at Preston Park Station, where incorrect information about its location was communicated within the Regional Operating Centre. This contributed to an approaching train not being stopped and striking and carrying the body away. The report raises concerns about safety-critical communication training, the handling and verification of emergency information, the use of resources, and outdated contact details in the operating centre.

Joseph Arthur Charles · Prevention of Future Deaths report View report

6 Aug 2019 North London A. Walker

Joseph Arthur Charles fell at home, underwent right elbow surgery, was discharged, and was later found unresponsive in bed by his wife. The concern was that national guidance existed for preventing deep vein thrombosis and pulmonary embolus after lower-limb surgery but not after upper-limb surgery.

Prabhaker Nath Kapoor · Prevention of Future Deaths report View report

6 Aug 2019 Birmingham and Solihull A. Hodson

Prabhaker Nath Kapoor died on 21 November 2018 after aspirating unthickened water left near his bedside while he was in hospital following a fall and fractured humerus. His death was attributed to aspiration pneumonia caused by inhalation of liquid, with frailty also recorded. The report raised concerns that safer-swallowing training and updates to the staff training package had not been completed as planned.

Carol Anne JENNINGS · Prevention of Future Deaths report View report

2 Aug 2019 Norfolk J. Lake

Carol Anne Jennings had multiple comorbidities and was admitted to hospital on 10 January 2019. She developed infected leg ulcers, deteriorated, began end-of-life care on 25 January, and died on 31 January 2019; the inquest recorded septicaemia, infected leg ulcers and hospital-acquired pneumonia as the medical causes of death. Concerns included the handling and follow-up of a Tissue Viability Nurse referral and inadequate wound record keeping.

Rebecca Louise Henry · Prevention of Future Deaths report View report

1 Aug 2019 Manchester West J. Pollard

Rebecca Louise Henry attempted to kill herself, was assessed in hospital and discharged as a voluntary patient who was considered not detainable. Later that day, she stood in front of an oncoming train; the principal concern was communication between mental health professionals and close relatives, particularly how confidentiality may limit the sharing of potentially valuable information.

Deborah Chapman · Prevention of Future Deaths report View report

1 Aug 2019 Manchester South A. Farrow

Deborah Chapman, who had COPD, chronic pain, and continued to misuse heroin and crack cocaine, was found unresponsive at home on 3 March 2019 and was pronounced dead at 7.06am. The post-mortem attributed her death to the combined toxic effects of heroin, oxycodone and pregabalin, together with COPD. Concerns included whether her ongoing illicit drug use and the risks of combining prescribed and illicit drugs had been adequately assessed and recorded when prescribing oxycodone and pregabalin.

Daniel Cameron SHORROCKS · Prevention of Future Deaths report View report

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

Daniel Cameron SHORROCKS discussed ending his life with a friend on 1 January 2018, sent a text stating “Dead at Berry Head”, and was found dead at the foot of a cliff at Berry Head. The report’s concerns relate to the availability of qualified and experienced staff for local authorities with many young people in care, and the integration of care, adolescent mental health, and education pastoral services.

Fern-Marie CHOYA · Prevention of Future Deaths report View report

31 Jul 2019 Inner North London M. Hassell

Fern-Marie Choya died from hypovolaemic shock caused by massive intra-abdominal bleeding following rupture of the abdominal gravid uterus during a monochorionic diamniotic pregnancy. Concerns included failure to communicate her pregnancy during the pre-hospital alert and on hospital arrival, a 16-minute delay in recognising the pregnancy and calling the obstetric team, and treatment focused on possible pulmonary embolism before free fluid was identified.

Gladys Margaret Borgogno · Prevention of Future Deaths report View report

31 Jul 2019 Stoke-on-Trent and North Staffordshire S. Murphy

Gladys Margaret Borgogno underwent an ERCP procedure for bile duct stones on 24 April 2018 and was discharged after four hours of observation despite vomiting bile. She was found lifeless the following morning and was confirmed dead on 25 April 2018; concerns related to the length of post-procedure observation after vomiting and the clarity of written advice and documentation about seeking further medical attention.

Mr Alex Blake · Prevention of Future Deaths report View report

29 Jul 2019 Inner South London A. Harris

Mr Alex Blake died from a self-administered heroin overdose while a sectioned in-patient at Lambeth Hospital, sometime before 04.13 on 24 June 2018. The jury found that inadequate observations, unsuitable record sheets, ineffective observations and poor communication meant his death went unnoticed for several hours. Concerns were also raised about unreliable or potentially false accounts and records by staff regarding observations of him before he was found dead.

Alistair Patrick McDonald · Prevention of Future Deaths report View report

29 Jul 2019 Manchester City N. Meadows

Alistair Patrick McDonald, who had disclosed suicidal thoughts and a history of deliberate self-harm, was found dead on 14 May 2018, hanging by a ligature secured to a door frame. The concerns included the assessment and management of his suicidal ideation and self-harm, lack of follow-up and clear referral plans, communication with him and his family, and failure to recognise the wider significance of his presentation.

Sam Michael Carl Grant · Prevention of Future Deaths report View report

26 Jul 2019 Milton Keynes E. Gray

Sam Michael Carl Grant, aged 16, died at home on 09/11/2018 after being found hanging by his sister. The report raised concerns about limited access to lower-level mental health support, incomplete information-sharing between services, and reduced confidential health-information sharing between the school and GP surgery.

William VICKERS · Prevention of Future Deaths report View report

26 Jul 2019 Milton Keynes T. Osborne

William Vickers was found collapsed in his cell at HMP Woodhill on 19 July 2018, was resuscitated and taken to hospital after suffering hypoxic brain damage, and died there on 26 July 2018. The report raised concern about delays in prison staff gaining access and, in particular, the 11-minute delay escorting the ambulance through five sets of gates to reach him.

Gladys May Sayles · Prevention of Future Deaths report View report

26 Jul 2019 West Yorkshire (Western) M. Fleming

Gladys May Sayles was found collapsed after an unwitnessed fall at home and sustained fractures to her C2 and C3 vertebrae. She later received palliative treatment at Overgate Hospice and died there; concerns were identified about guidance, training and communication concerning the use and fitting of her hard collar.

Antony Michael Rogivska · Prevention of Future Deaths report View report

26 Jul 2019 West Yorkshire (Western) O. Longstaff

Antony Michael Rogivska died at the scene of a road traffic collision on 14 December 2016 at the junction between Carr House Road and Cooper Lane. The jury found that factors contributing to the collision included his inexperience as a driver, cannabis use, entering the corner too fast, and not wearing a seat belt. Concerns were raised about a history of road traffic collisions at the junctions and roundabout, and about their safety expressed by local residents and campaigners.

Owen Arron Wynne Williams · Prevention of Future Deaths report View report

25 Jul 2019 West Yorkshire (West) M. Burke

Owen Williams was found unresponsive, suspended by a rope tied to a tree in a secluded wooded area, after accessing A level results that did not meet the grades required for his intended university course; his death was confirmed later that day. The report identified concerns about the lack of national consistency in how and when A level results are released, delays before support is available, UCAS opening later, and the absence of a national requirement to inform parents in advance about the results-release system and potential impact of unexpected results.

Stanislawa Kmiecik · Prevention of Future Deaths report View report

25 Jul 2019 Nottinghamshire L. Bower

Stanislawa Kmiecik entered an inaccessible mezzanine area in a Nottingham store and fell approximately 18 feet through an open space to the basement floor, sustaining multiple injuries and dying at the scene. The concerns identified included public and staff access to the area, lack of warning signage and fall protection, uneven flooring, and the risk of objects falling through the openings onto people below.

Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report View report

24 Jul 2019 Manchester South A. Mutch

Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.