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Kevin Robert Miles · Prevention of Future Deaths report View report

20 Feb 2019 Leicester City and South Leicestershire D. Hockling

Kevin Robert Miles was undertaking a re-breather diving course at Stoney Cove on 25 September 2018 when he experienced difficulties underwater. He was brought to the surface, but resuscitation attempts failed and he was declared deceased at the scene; the cause of death was recorded as unascertained. The report raised concerns about the absence of a requirement to obtain divers’ GP records or otherwise verify medical advice when assessing fitness to dive, and about the risks to divers and potential rescuers or dive buddies.

Malcolm John Rathmell · Prevention of Future Deaths report View report

20 Feb 2019 Nottinghamshire J. Gillespie

Malcolm Rathmell was admitted after a fall and his pelvic fracture was not diagnosed until several days later. He was incorrectly given warfarin intended for another patient, subsequently suffered retroperitoneal bleeding, and died after developing bronchopneumonia. Concerns included failures to identify the incorrect prescription, the absence of a ward-based pharmacy review, and insufficient implemented action to address the risk of future deaths.

Janice Andrea Keelan · Prevention of Future Deaths report View report

19 Feb 2019 Manchester City N. Meadows

Janice Andrea Keelan, who had chronic and complex health conditions and was at risk of falling asleep or having a seizure in the bath, died by drowning on 14 November 2017. A referral for a walk-in shower was not approved until ten days after her death. Concerns included inadequate consideration of her impaired cognition and mental capacity, failure to prioritise the urgent risk, and insufficient action to involve mental health services to reduce the risk of death.

Dwayne Daniel Ryan Thompson · Prevention of Future Deaths report View report

15 Feb 2019 Manchester South A. Mutch

Dwayne Daniel Ryan Thompson went swimming at the Reservoir at Audenshaw on 28 June 2018, got into difficulties, went underwater, and later died in hospital after suffering a catastrophic brain injury. The inquest heard that the reservoir’s fence was regularly damaged and that its warning signs, although compliant with HSE guidance, had not been shown to take account of the needs and understanding of people with learning disabilities.

Evie Alicia WRIGHT · Prevention of Future Deaths report View report

15 Feb 2019 Avon M. Voisin

Evie Alicia WRIGHT died immediately after walking onto a railway line near Corondale Crossing and being struck by a train on 6 March 2018. The report raised concerns about the long-delayed provision of a footbridge, which was described as enhancing safety and eliminating the risk associated with the crossing.

John SCOTT · Prevention of Future Deaths report View report

14 Feb 2019 Brighton and Hove V. Hamilton-Deeley

John SCOTT’s death was investigated and the inquest concluded that he died from natural causes. The concerns raised related to emergency call handling, including support for callers who are alone, ambulance estimated arrival times, whether lone callers could re-contact the service if they became unresponsive, and questions about symptoms that might indicate an abdominal aortic aneurysm.

John Andrew Mellor · Prevention of Future Deaths report View report

14 Feb 2019 Manchester North N. Flanagan

John Andrew Mellor had diabetes mellitus, chronic kidney disease and deep vein thrombosis, and died on 3 October 2018 after collapsing at home following the discovery of a very low blood count requiring urgent transfusion. The report describes repeated difficulties in arranging required blood tests, with responsibility passed between agencies and no clear shared-care or testing arrangement. It also raises concern that communications about referrals and test requests were not sent directly to primary care, relying instead on the patient to pass on vital information.

Douglas Albert Walter MINNS · Prevention of Future Deaths report View report

14 Feb 2019 Milton Keynes T. Osborne

Douglas Albert Walter MINNS, aged 93, fell at home on 21 August 2018 and made an emergency call. He was attended by ambulance after approximately four hours, taken to hospital with subarachnoid and subdural bleeding, and died there on 22 August 2018. The principal concern was the withdrawal of a falls service and the resulting delay in responding to people who had fallen, particularly amid strains on the ambulance service.

Kenneth George Alfred WHITTINGTON · Prevention of Future Deaths report View report

14 Feb 2019 Brighton and Hove V. Hamilton-Deeley

Kenneth George Alfred Whittington died following an operation, but the supplied text does not provide further circumstances of his death beyond referring to the Record of Inquest. The principal concerns included inadequate instructions and handover about management of his urinary catheter after bladder repair, failure to check a disconnected epidural despite increasing pain, incomplete blood transfusion and discharge documentation, and a delay to the initial operation because no Junior Doctor was present.

Matthew David Hamilton · Prevention of Future Deaths report View report

14 Feb 2019 County Durham and Darlington J. Chipperfield

Matthew David Hamilton died after taking drugs on the day of his release from custody, following a period of abstinence, and was later treated in hospital for the toxic effects of morphine. The report identified concern that people released from custody may be unaware that reduced tolerance increases the risk that previously normal drug consumption may be fatal, and that the deceased had not received the relevant release information.

Matthew William Lewis · Prevention of Future Deaths report View report

13 Feb 2019 South Wales Central G. Hughes

Matthew William Lewis died following a hanging on 27 February 2018; the inquest conclusion was suicide and the recorded medical cause of death was hanging. Concerns included confusion and inconsistency in call-handler instructions about whether rescuers should approach him, with the report noting that unclear instructions could cause delay in future incidents. Guidance and training for call handlers in such scenarios were identified as desirable or mandated.

Branko Zdravkovic · Prevention of Future Deaths report View report

13 Feb 2019 Dorset S. Nicholls

Branko Zdravkovic, who was detained at the Immigration Removal Centre, The Verne, was found suspended by a ligature in a toilet cubicle and died on 9 April 2017. The inquest concluded that his death was suicide, with the medical cause recorded as ligature suspension. Concerns were raised that staff were instructed to use ACDT procedures instead of making Rule 35 reports, and that there was no formal procedure for informing the Home Office when a detainee was placed on ACDT.

Sophie Bennett · Prevention of Future Deaths report View report

13 Feb 2019 West London J. Taylor

Sophie Elizabeth Alice Bennett died at Kingston Hospital from injuries caused by applying a ligature at Lancaster Lodge, a care home operated by RPFI. The Jury identified concerns about inadequate governance, staffing, training, documentation, leadership and oversight, and found contributory errors or omissions in risk management, including failure to follow advice to take Sophie to A&E, inadequate observation and poor control of access to ligature items.

Anthony John William Watson · Prevention of Future Deaths report View report

12 Feb 2019 Birmingham and Solihull J. Bennett

Anthony John William Watson, who had recurrent depression and anxiety and was displaying psychosis and suicidal thoughts, died after cutting his wrists and neck and jumping from a first-floor window on 21 October 2018. He sustained an unsurvivable head injury and died in hospital the following day. The principal concern was that no inpatient mental health bed was available locally despite the need for immediate admission, while out-of-area beds were considered too distant, particularly for older patients and their families.

Bryan GRAY · Prevention of Future Deaths report View report

12 Feb 2019 East Riding and Hull R. Baxter

Bryan Gray fell from a third-floor window at The Crossings in Kingston upon Hull on 21 July 2018, sustaining multiple injuries and dying later that day at Hull Royal Infirmary. It was unclear whether a window restrictor was in place or had been broken, and the investigation found that other windows in the building had no restrictors.

Heather Louise Carey · Prevention of Future Deaths report View report

12 Feb 2019 Manchester South A. Bridgman

Heather Louise Carey was admitted to mental health services in July 2017, later took an overdose of paracetamol, and was placed on a 24-week waiting list for Cognitive Analytical Therapy. She hanged herself at home on 20 December 2017. The principal concern was that lengthy waits for psychotherapy and inadequate action to address her high suicide risk may have contributed to her death.

Madeline Constance Staples · Prevention of Future Deaths report View report

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

Madeline Constance Staples, an 86-year-old woman, suffered an unwitnessed fall at her care home on 6 April 2018, sustaining fractures to both legs. Delays in obtaining ambulance assistance and transporting her to hospital meant she remained in pain for several hours. The report raised concerns about repeated unacceptable delays linked to emergency department handovers and unavailable ambulance resources, placing patients’ lives at risk.

Calary Fern Davis · Prevention of Future Deaths report View report

11 Feb 2019 South Wales Central D. Regan

Calary Fern Davis was delivered by emergency Caesarean Section on 31st December 2017 after fetal bradycardia caused hypoxic ischaemic encephalopathy and very serious brain damage, and she later died from that condition. The report identified concerns about failures in the induction pathway, including a lack of planned obstetric review, delay in artificial rupture of membranes, insufficient staffing and leadership, poor communication and safety briefings, and a culture against performing artificial rupture of membranes at night.

Robert Glyn Hughes · Prevention of Future Deaths report View report

11 Feb 2019 Gloucestershire K. Skerrett

Robert Glyn Hughes, a 67-year-old man with a history of low mood, alcohol and diazepam dependence, previous overdoses, and prostate cancer, was found deceased at home on 20 February 2018 after police responded to a concerned friend. The report records a concern that the triangle of care approach, involving permission to contact the patient’s family, was not consistently applied.

PAUL MATTHEW GILLAM · Prevention of Future Deaths report View report

11 Feb 2019 Cornwall and Isles of Scilly G. Davies

Paul Matthew Gillam was found dead at home after consuming alcohol, drugs and six pills of unknown composition. The inquest recorded that he died on 3 June 2018 from the toxic effects of a reckless overdose of non-prescription drugs. The principal concerns related to communication and working arrangements between Addaction and the Community Mental Health Team (CMHT), including the implementation of their service-level agreement and delivery plan.