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Xander Curran-Pass · Prevention of Future Deaths report View report

24 Jul 2019 Manchester South A. Mutch

Xander Curran-Pass was delivered by category C Caesarean Section on 15 September 2018 after reduced fetal movement, delayed induction of labour, and concerning CTG findings. Resuscitation was unsuccessful and he died; post-mortem examination identified poor placental function associated with chronic villitis and thrombotic vasculopathy. The substantive concerns included delays in review and delivery, inadequate monitoring and documentation, and unclear or inconsistent processes for managing induction of labour and reduced fetal movement.

Maureen Woods · Prevention of Future Deaths report View report

24 Jul 2019 Nottinghamshire L. Bower

Maureen Woods died on 26 January 2019 while a patient at the Emergency Department of Bassetlaw District General Hospital after experiencing symptoms consistent with a cardiac event and subsequently suffering cardiac arrest. The report identified concerns about delays in ambulance dispatch for category 2 calls involving possible cardiac events and the failure to administer Amiodarone. It stated that these failings prevented her from having the best possible chance of survival, although it could not be concluded that either caused or contributed to her death.

Barbara Humphreys · Prevention of Future Deaths report View report

23 Jul 2019 South Wales Central I. Boyes

Barbara Humphreys was admitted to Crosfield House in July 2018 and later experienced repeated entrapment of her leg and foot between bed rails and the mattress. She underwent a right lower-leg amputation and died in hospital on 28 November 2018; the reported medical cause was thrombosis and the inquest conclusion was natural causes. The principal concerns included the lack of a bed-rail risk assessment, unsuitable mattresses, staff training, bed-rail policies, care planning, and communication with family about medical attendance, palliative care and DNAR decisions.

Adam Harris · Prevention of Future Deaths report View report

23 Jul 2019 Manchester South A. Mutch

Adam Harris died at Tameside General Hospital on 20 April 2018 from alcohol and cocaine toxicity after collapsing at Ashton Police Station following his arrest and detention. Concerns included the absence of documented triage or risk assessment while prisoners waited in the van dock, lack of searches before transport, unclear handover arrangements, delayed creation of the custody record, and inconsistent evidence about his position in the cell while confused and suspected to be intoxicated.

Richard Patrick Carlon · Prevention of Future Deaths report View report

22 Jul 2019 Birmingham and Solihull L. Hunt

Richard Patrick Carlon, who had paranoid schizophrenia and a history of relapsing after taking illicit substances, was detained under the Mental Health Act after stating that he would kill himself. He later left care, was found at his father’s home, and subsequently stepped in front of a lorry; he died in hospital from polytrauma following the road traffic collision. The concerns included the lack of an approved Mental Health practitioner to conduct an assessment and failures in communication between the police and mental health services after he was found safe and well.

Cherylee Yvette Shennan · Prevention of Future Deaths report View report

19 Jul 2019 Lancashire and Blackburn with Darwen J. Newman

Cherylee Yvette Shennan, a 40-year-old woman, was murdered on 17 March 2014 by a former offender who had subjected her to domestic abuse, including serious violence. The report raised concerns about inadequate inter-agency communication and management of the perpetrator, including the absence of a mandatory process for sharing information when an offender with a known history of domestic abuse was managed at MAPPA Level 1.

Zona Ethel Tebbs · Prevention of Future Deaths report View report

19 Jul 2019 South Yorkshire (Eastern) N. Mundy

Zona Ethel Tebbs, an 88-year-old woman, sustained a garden injury, later developed tetanus, and died in hospital on 5 November 2018 from generalised tetanus and acute on chronic myelopathy. The principal concerns were ineffective communication of changes to tetanus-prone wound guidance, failure to update Green Book guidance, and failure to provide immunoglobulin, which exposed her to an increased risk of developing tetanus and death.

Miss Rebecca Alice QUALT · Prevention of Future Deaths report View report

18 Jul 2019 Cumbria K. Cheema

Rebecca was killed when a trailer detached from a van and collided with her car on the A6 near Shap. The trailer coupling was not fully engaged because of a foreign object in the tow hitch, which could appear engaged on visual inspection. The report raised concerns about the absence of national guidance and the possibility that operators may not check couplers for foreign objects or ensure that the coupling is fully engaged.

Lindsey Bailey · Prevention of Future Deaths report View report

18 Jul 2019 Staffordshire South A. Haigh

Lindsey Bailey was found dead by her father in the garage of her home on 14 January 2019 after hanging herself. She had recently engaged with psychiatric services, and the principal concern was that relevant information was not sufficiently shared with her parents despite her capacity and agreement to information sharing, which could have assisted her treatment path.

Allan Graham Joslin · Prevention of Future Deaths report View report

17 Jul 2019 Exeter and Greater Devon L. Brown

Allan Graham Joslin was found deceased partially on top of a tent near the North Devon Leisure Centre, Barnstaple, on 23 May 2018, after not being seen or contacted for several days. The report states that referrals for mental health assessment were not facilitated because of his known previous violent behaviour, and that he therefore received no formal assessment or treatment before his death. Concerns included inadequate facilities and policies for safely assessing patients with complex mental health, substance dependency and potential violence-related needs.

ANNABEL NEWPORT · Prevention of Future Deaths report View report

17 Jul 2019 London Inner (South) H. QC

Annabel Newport collapsed shortly after boarding a train on 21 March 2018 and received CPR from passengers, but there was no defibrillator on board. She was taken to hospital after the train reached Waterloo and died two days later from brain damage suffered during cardiac arrest. The principal concerns were the lack of defibrillators, insufficient first-aid awareness among railway staff, and limitations in the operation of the emergency alarm system.

Mr Darren Keith Cumberbatch · Prevention of Future Deaths report View report

16 Jul 2019 Warwickshire D. Henry

Mr Darren Cumberbatch became acutely agitated at a probation hostel and was taken to hospital after police used physical force, Tasers, incapacitant spray and a baton during restraint. He was treated for a suspected cocaine-related drug overdose, developed worsening kidney function and multi-organ failure, and died on 19 July 2017. The report raised concerns that probation hostel staff lacked awareness and training in Acute Behavioural Disturbance, including the importance of information sharing, de-escalation and minimising restraint.

Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report View report

15 Jul 2019 Surrey R. Travers

Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The jury found that failures in Surrey Police’s firearms licensing decisions contributed more than minimally to the deaths. The report also raised concerns about insufficient mandatory training for firearms licensing officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.

Christine Ann Lee and Lucy Daisy Lee · Prevention of Future Deaths report View report

15 Jul 2019 Surrey R. Travers

Christine Ann Lee and Lucy Daisy Lee, mother and daughter, died after being shot with a shotgun at Keepers Cottage Stud on 23 February 2014. The report identified failures by Surrey Police firearms licensing staff to sufficiently investigate and consider relevant information, apply the correct standard of proof, and ensure appropriate senior oversight before returning the perpetrator’s shotgun certificate and shotguns. It also raised concerns about insufficient mandatory training for firearms enquiry officers and an unreliable system for assessing applicants’ medical fitness to hold shotgun certificates.

David Jonathon Jukes · Prevention of Future Deaths report View report

12 Jul 2019 Birmingham and Solihull E. Brown

David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.

Jason Robert Imi and John Carl Shackley · Prevention of Future Deaths report View report

12 Jul 2019 Berkshire A. McCormick

On 2 August 2018, Jason Imi and John Shackley were struck by a motor car while crossing the A329 to return to the Royal Berkshire Hotel, sustaining fatal injuries and dying at the scene. The principal concern was the continuing risk to pedestrians because there was no footpath or street lighting by the hotel, alongside reduced visibility caused by tree canopy and a dip in the road.

ROSA ANN KING · Prevention of Future Deaths report View report

12 Jul 2019 Cambridgeshire and Peterborough N. Moss

Rosa Ann King, a senior carnivore keeper at Hamerton Zoological Park, died on 29 May 2017 after being attacked by a Malayan tiger while exiting the tiger paddock. She had entered while the tiger slides were open, and the report identified concerns about reliance on keeper reliability, fatigue from night-time hand-rearing work, the absence of air-lock type double gates, and lack of access to conventional firearms. The report also raised concerns about insufficient guidance, risk assessment and inspection of these safety arrangements.

Jason Robert Imi and John Carl Shackley · Prevention of Future Deaths report View report

12 Jul 2019 Berkshire A. McCormick

On 2 August 2018, Jason Robert Imi and John Carl Shackley were struck by a motor car while crossing the A329 near the Royal Berkshire Hotel and died at the scene. The report raises concerns about the lack of a footpath and street lighting near the hotel, reduced visibility for motorists, and the continuing risk to pedestrians crossing the road at night.

Carl Sargeant · Prevention of Future Deaths report View report

11 Jul 2019 North Wales (East and Central) J. Gittins

Carl Sargeant was removed from his Welsh Government ministerial role amid allegations of inappropriate behaviour, after which media interest was followed by a deterioration in his mental well-being and he took his own life on 7 November 2017. The report raised concern that high-profile people removed from Government roles may not receive appropriate support, regardless of mental vulnerabilities or the reason for their removal.

Robert Charles Rostron · Prevention of Future Deaths report View report

11 Jul 2019 Manchester West R. Galloway

Robert Charles Rostron, who had Type 1 diabetes and Alzheimer’s disease, became unconscious after an agency nurse administered insulin despite recording a low blood sugar reading of 2.2. He did not recover to his previous baseline and later died in hospital; the inquest found that the insulin administration exacerbated his natural illness. Concerns included the use of agency nurses without formal induction, insufficient knowledge of records and care plans, and an agency nurse being the only qualified nurse in charge of the unit.