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Mr Malcolm Marshall Shaw · Prevention of Future Deaths report View report

10 Jan 2019 Manchester South C. Morris

Mr Malcolm Marshall Shaw was admitted to Stepping Hill Hospital following a general decline in his condition and later sustained an unobserved fall, resulting in a fractured right femur. He developed bronchopneumonia and died on 20 February 2018; the inquest recorded that his death was contributed to by underlying lung disease. The principal concerns were that the Trust’s original investigation into the fall was fundamentally flawed, that revised investigation training had not yet been introduced, and that frontline staff lacked guidance on promptly capturing evidence about falls.

Michael William Flynn · Prevention of Future Deaths report View report

10 Jan 2019 Manchester South A. Mutch

Michael William Flynn underwent elective hip replacement surgery and required a blood transfusion. He subsequently experienced inadequate Early Warning Score monitoring, failures to follow escalation procedures, incomplete fluid-balance monitoring, and a lack of timely clinical review before suffering cardiac arrest and dying on 17 July 2018.

Diana Faith Gudgeon · Prevention of Future Deaths report View report

9 Jan 2019 Northamptonshire H. Shah

Diana Faith Gudgeon collapsed at home after being diagnosed with a water infection and remained on the floor for a prolonged period. Her call was assessed as requiring a category three response, and substantial delays followed before ambulance attendance, hospital admission and treatment; she died on 25 May 2018 despite treatment for infection and sepsis. The principal concerns were the triage and escalation of her call, shortages of ambulance resources, and the effectiveness of EMAS capacity management arrangements.

Marian Hoskins · Prevention of Future Deaths report View report

9 Jan 2019 City of London A. Hewitt

Marian Hoskins underwent pressure wire testing after a myocardial infarction and coronary stenting, during which an artery was dissected and she subsequently developed a ventricular septal defect. Attempts to repair the defect were unsuccessful or incomplete, and she died from multi-organ failure on 11 January 2017. The principal concern was insufficient discussion of alternative investigations and the absence of a clear system to ensure informed consent was obtained before admission for the procedure.

Mr Nicky Raymond Reilly · Prevention of Future Deaths report View report

4 Jan 2019 Manchester North J. Kearsley

Mr Nicky Raymond Reilly, also known as Mr Mohamed Saeed-Alim, was an inmate at HMP Manchester after spending six years at Broadmoor High Security Hospital. He was found hanging by a ligature in his cell on 19 October 2016 and was pronounced deceased at 14.43. The report raised concerns about the lack of continuation of the Care Program Approach, incomplete multidisciplinary records and coordination, limited psychological input and record keeping, insufficient staff training, separation of mental health and psychology records, and medication-refusal processes.

Flt. Lt. Alexandre Jay Parr · Prevention of Future Deaths report View report

2 Jan 2019 Wiltshire and Swindon D. Ridley

Flt. Lt. Alexandre Jay Parr died after fuel starvation caused loss of engine power during a training flight in a Yak 52 aircraft, followed by a forced landing and crash on 8 July 2016. The report identified concerns about engine-overhaul limits, aircraft safety harnesses, and communicating the appropriate emergency use cycle rate for the fuel primer pump to Yak pilots.

Janice Mary Davies · Prevention of Future Deaths report View report

31 Dec 2018 South Wales Central G. Hughes

Janice Mary Davies fell out of bed at home on 19 April 2018, sustaining fractured ribs, and was treated with oramorph before being discharged. She died at home in the early hours of 21 April 2018; the medical cause included morphine toxicity, bilateral rib fractures, chronic obstructive pulmonary disease and chronic kidney disease. Concerns included missing post-dose observations and pain-score documentation, and a lack of formal guidance for prescribing oramorph to patients being discharged.

David Reginald Bert Stacey · Prevention of Future Deaths report View report

28 Dec 2018 Leicester City and South Leicestershire D. Hocking

David Reginald Bert Stacey died after sustaining chest injuries in a road traffic collision on 27 November 2017. Before the collision, he had been assessed under the Mental Health Act and was left alone after the assessment team departed. Concerns included a failure to communicate that a bed was available, the assessment team leaving before safeguards were in place, and the lack of an identifiable facility for cases of special urgency in Leicestershire.

Mr Gregory Rekowski · Prevention of Future Deaths report View report

28 Dec 2018 Manchester North J. Kearsley

Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.

Joan Wright · Prevention of Future Deaths report View report

28 Dec 2018 Manchester South A. Mutch

Joan Wright, who had poor mobility and was unable to communicate verbally, died at Belmont Residential Home on 16 September 2017; the post-mortem found extensive coronary artery atheroma. The report raised concerns about the incorrect administration and handling of Oramorph, medication management at a care home rated inadequate, and failures to recognise and address safeguarding risks after the medication incident.

Kenneth Roy Bardsley · Prevention of Future Deaths report View report

27 Dec 2018 Manchester South A. Mutch

Kenneth Roy Bardsley died at Salford Royal Hospital on 30 January 2017 from multiple injuries sustained as a passenger in a lift that malfunctioned at Serendipity Care Home. The inquest concluded that his accidental death was contributed to by failure of the lift’s interior door mechanism. Concerns included gaps in lift-engineer qualification requirements, failures to read and act on regulatory examination findings, unclear communication and follow-up processes, and insufficient systems for lift servicing and examination records.

Joyce Phoebe Mary LONG · Prevention of Future Deaths report View report

24 Dec 2018 Buckinghamshire C. Butler

Joyce Phoebe Mary LONG died in hospital at 0034 hours on 11 July 2018 after striking her head at home the previous day and later collapsing. The report raised concern about differing interpretations of the reception policy at Wycombe Hospital, creating a risk that assistance to stabilise a patient's airway could be refused or delayed in similar circumstances.

Cady James Stewart · Prevention of Future Deaths report View report

21 Dec 2018 Manchester South A. Mutch

Cady James Stewart was found dead at her home on 3 June 2018, and the post-mortem found a fatal combination of prescribed drugs. The concern was that opiate medication prescribed to her mother for palliative care remained in Cady Stewart’s possession after her mother’s death, including after Cady had attempted to take her own life, and was used with her own medication.

Name not published · Prevention of Future Deaths report View report

21 Dec 2018 Shropshire, Telford and Wrekin J. Ellery

The deceased had a history of mental health issues, self-harm and two suicide attempts, and was in contact with mental health services until the evening of 30 April 2018 before taking her own life the next morning. Concerns included a prolonged delay in accessing IAPT counselling and difficulties with the electronic recording, risk assessment and progress-note systems.

Ms Mihaela Lazar and Ms Dorina Zangari · Prevention of Future Deaths report View report

21 Dec 2018 London (East) S. Radcliffe

Ms Mihaela Lazar and Ms Dorina Zangari died after a fire at their home on 25 January 2017, probably started by clothing overlying a heater, and they were overcome by fire fumes before escaping. Concerns included inadequate fire detection and warning, the lack of a protected means of escape from the upper floor, and missing fire safety measures such as a kitchen door.

William Clifford ATHERTON · Prevention of Future Deaths report View report

21 Dec 2018 Norfolk Y. Blake

William Clifford Atherton was admitted to hospital on 29 May 2017 with abdominal symptoms, urinary retention and poor kidney function. He was discharged despite worsening renal function and deterioration, and died after returning severely unwell with vomiting of faecal matter, a distended abdomen and severe pain; the reported cause was bowel obstruction. Concerns included the lack of senior medical review and nursing observations, failure to recognise warning signs and worsening blood results, and inconsistent early warning score documentation and escalation.

Ms Mihaela Lazar and Ms Dorina Zangari · Prevention of Future Deaths report View report

21 Dec 2018 London (East) S. Radcliffe

Ms Mihaela Lazar and Ms Dorina Zangari died after a fire at their home on 25 January 2017, probably started by clothing overlying a heater, and they were overcome by fire fumes before escaping. Concerns included inadequate fire detection and warning, the lack of a protected means of escape from the upper floor, and missing fire safety measures such as a kitchen door.

Richard John Whale · Prevention of Future Deaths report View report

21 Dec 2018 Manchester South A. Mutch

Richard John Whale died at Salford Royal Hospital after suffering a head injury in a fall down the exit stairs at Old Trafford football ground. The concerns included stewards impeding the exit and obstructing access to handrails, inadequate guidance on steward placement, non-compliance with the stewards’ code of conduct, and a lack of evidence of regular audits. There was also no mechanism to discuss or monitor whether recommendations issued after his death had been followed.

Paul Fairey · Prevention of Future Deaths report View report

21 Dec 2018 Inner South London P. Barlow

Paul Fairey was a pedestrian who was struck by a northbound car on Mayow Rd at about 00.40 on 23 September 2017 and later died from a severe head injury. Concerns included poor visibility caused by tree foliage, a faded road marking, and a speed cushion that could be straddled and was beginning to break up; the evidence also indicated that the car was travelling above the 20mph speed limit.

Diane Greenslade · Prevention of Future Deaths report View report

21 Dec 2018 Gwent W. James

Diane Greenslade was found moaning on her bedroom floor with a chest of drawers on top of her after ambulance responses were delayed. She suffered a cardiac arrest and died, with the inquest concluding that she died from natural causes following a fifteen-and-a-half-hour delay in ambulance intervention. The substantive concerns included the initial call categorisation without clinical assessment, failure to consider escalation or a police welfare check, high ambulance demand and hospital delays, and a nearby rapid response vehicle being unavailable because it was reserved for higher-priority calls.