Search PFD Monitor

Nigel Handscomb · Prevention of Future Deaths report View report

1 Aug 2018 Inner South London P. Barlow

Nigel Handscomb was admitted to University Hospital Lewisham after being diagnosed with pneumonia and possibly having suffered a stroke. He was not reviewed by a doctor for 48 hours, opportunities to escalate his care were missed, and he later suffered a cardiac arrest; the inquest concluded that natural causes, including aspiration pneumonia, bronchopneumonia and severe ketoacidosis, involved neglect. Concerns included incomplete and inaccurate GP records, delayed recording, and missing information about examinations, medication and swallowing difficulties.

Jerome Jason Omri JONES · Prevention of Future Deaths report View report

1 Aug 2018 Shropshire, Telford and Wrekin J. Lees

Jerome Jason Omri Jones was a serving prisoner who died in hospital after being found unresponsive in his cell, following suspected use of a synthetic cannabinoid and in the context of a congenital heart defect. The concerns included the absence of guidance for additional checks after repeated NPS use, no clear method for communicating his increased risk to healthcare or prison officers, and limited access by drug workers to relevant medical information.

Cuthbert Anthony Stanley Hingert · Prevention of Future Deaths report View report

1 Aug 2018 Isle of Wight C. Sumeray

Cuthbert Anthony Stanley Hingert was admitted to hospital with shortness of breath and possible acute coronary syndrome, during which duplicate doses of antiplatelet and anticoagulant medications were given. He later became confused, fell and sustained a subdural haematoma, skull fracture and subarachnoid haemorrhage, dying in hospital on 5 March 2017. Concerns included failures to check the medicines database, inappropriate or potentially inappropriate prescribing, delayed documentation, inadequate staff training and failure to report a medication incident according to protocol.

Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report View report

30 Jul 2018 South Wales Central R. Knight

On 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.

Stanford Shirley Bell · Prevention of Future Deaths report View report

30 Jul 2018 West Yorkshire (Western) M. Fleming

Stanford Shirley Bell, who had dementia, fell at Riverview Nursing Home on 22 February 2018 and later died on 2 March 2018 after suffering seizures and an acute on chronic subdural haematoma. Concerns included the absence of hospital discharge papers and written neurological-observation recommendations, and delayed referral from the care home after seizures following head trauma.

Glynn Matthew Storey · Prevention of Future Deaths report View report

27 Jul 2018 County Durham and Darlington L. Hamilton

Glynn Matthew Storey, aged 32, died after falling from a second-floor window while under the influence of alcohol, sustaining fatal injuries. The window was low and lacked a safety guard or opening restrictor, and none of the 40 flats in the development had such safety devices; there was also confusion about whether responsibility for meeting building standards lay with the building control inspector or the builder/owner.

Mrs Natalie Billingham · Prevention of Future Deaths report View report

27 Jul 2018 Black Country Z. Siddique

Mrs Natalie Billingham was admitted to hospital with worsening foot pain, later developed necrotising fasciitis, underwent emergency surgery including a through-knee amputation, and died on the evening of 2 March 2018. The report identified concerns about inadequate communication and delays in reviewing abnormal blood results, recognising sepsis, and administering antibiotics.

Herbert John Bernard Francis · Prevention of Future Deaths report View report

26 Jul 2018 Carmarthenshire and Pembrokeshire J. Layton

Herbert John Bernard Francis was driving towards the A40 when he failed to stop at the junction and collided with an articulated heavy goods vehicle, dying at the scene from injuries sustained in the collision. The concerns identified related to road safety measures, including improved markings and warning signs, changes to filter lanes, and consideration of lower or advisory speed limits.

Astonn Mitchell-Male · Prevention of Future Deaths report View report

26 Jul 2018 Manchester North L. Hashmi

Astonn Mitchell-Male, who had schizophrenia/psychosis and was living in supported accommodation, was found deceased on 1 November 2016 after police and ambulance services had been delayed in responding to a welfare concern the previous evening. The jury found that he died from multiple self-inflicted stab and incise wounds on or around the evening of 31 October 2016 following a deterioration in his mental state. Concerns included the absence of a Trust policy on medication monitoring and compliance, and poor or non-existent record keeping affecting patient safety.

Daniel Young · Prevention of Future Deaths report View report

26 Jul 2018 Inner West London S. Radcliffe

Daniel Young, a fit and healthy university lecturer, was randomly attacked on his way to work on 19 January 2016 and sustained a fatal stab wound to the abdomen. The report raised concerns that GP surgeries did not routinely monitor whether psychiatric patients collected their antipsychotic medication, despite the risk that stopping treatment could lead to relapse and harm to others.

Robert Thomas Wrinch · Prevention of Future Deaths report View report

25 Jul 2018 Manchester South A. Mutch

Robert Thomas Wrinch deteriorated with severe back pain and reduced mobility associated with an undiagnosed metastatic spinal malignancy, and developed bronchopneumonia. The report raised concerns about delays and inadequate tracking in pathology sample processing and reporting, reliance on paper reports, inconsistent departmental tracking systems, incompatible information technology systems between trusts, and pathology backlogs linked to shortages of pathologists.

Aniyah Jasmine Winston · Prevention of Future Deaths report View report

25 Jul 2018 Manchester South A. Mutch

Aniyah Jasmine Winston was delivered vaginally in an undetected breech presentation and was in poor condition at birth after manipulation during delivery. Resuscitation was commenced and ceased at 10:59am. The concerns included the challenges of undetected breech births and the administration of Syntocinon without further review, examination, counselling or a written prescription; professionals involved reportedly felt unable to challenge the decision.

Paul Robert Allan · Prevention of Future Deaths report View report

25 Jul 2018 Inner West London R. Caller

On 16 July 2017, Paul Robert Allan walked onto the track at Oxford Circus tube station and was struck by a westbound train. Concerns included his discharge from the Rochdale Community Mental Health Team without transfer to the corresponding team in Stoke, and a failure to consult or work with drug and alcohol advisory services.

Jane Olive Parker · Prevention of Future Deaths report View report

25 Jul 2018 Manchester South A. Mutch

Jane Olive Parker, who had dementia and a history of choking episodes, was found unresponsive approximately 40 minutes after eating an inappropriate meal unobserved in her room on 24 August 2016. Post-mortem examination found un-chewed food in her airway, and the recorded conclusion was death from aspiration of food, contributed to by neglect. Concerns included poor understanding and preparation of modified diets, and failures to escalate choking episodes to the Speech and Language Team for reassessment.

Taiyah-Grace Sharon Peebles · Prevention of Future Deaths report View report

24 Jul 2018 North East Kent I. Goldup

Taiyah-Grace Sharon Peebles, who was intoxicated, dismounted from a train in the wrong direction at Herne Bay Station, stumbled down an un-barriered platform slope and made contact with a live rail, resulting in her death. The principal concerns were the absence of an end-of-platform barrier and the accessibility of a ground-level live rail, with similar barriers absent on other platforms in the area.

Kathleen Gabrielle Bamforth · Prevention of Future Deaths report View report

20 Jul 2018 West Yorkshire (Western) M. Fleming

Kathleen Gabrielle Bamforth was found unresponsive at home on 28 May 2017 and was confirmed to have died after resuscitation attempts. The cause of death was recorded as the effects of clomipramine toxicity, although the circumstances of the toxicity remained unclear. The substantive concerns were about reviewing prescribing guidelines for clomipramine and considering routine blood screening for patients receiving it long term.

Ruth Marian Perkin · Prevention of Future Deaths report View report

20 Jul 2018 Coventry E. Whitting

Ruth Marian Perkin was admitted to a care home on 9 February 2018, suffered two falls shortly afterwards, and was found to have a right neck of femur fracture after the second fall. She underwent hip repair, later contracted pneumonia, and died on 29 March 2018. The principal concern was that discharge to the care home while her needs were still being assessed, together with staffing and care arrangements, may have increased her risk of falls and death.

Ronald Thomas HARMAN · Prevention of Future Deaths report View report

19 Jul 2018 Brighton and Hove V. Hamilton-Deeley

Ronald Thomas HARMAN was transferred to Newhaven Downs, where his condition deteriorated before he returned to Royal Sussex County Hospital with aspiration pneumonia and died eight days later. Concerns included the Brighton & Sussex University Hospitals NHS Trust’s transfer policy being ignored and care at Newhaven Downs being described as suboptimal.

William George Irvin Watson · Prevention of Future Deaths report View report

19 Jul 2018 Cornwall and Isles of Scilly A. Cox

William George Irvin Watson was admitted with worsening angina, underwent triple coronary artery bypass surgery, and experienced post-operative complications including an infected sternal wound. He died after difficulties and delays in emergency, high-dependency and non-emergency patient transfers. The principal concerns were inadequate ambulance and patient-transport resources, performance gaps, and the potential risk of avoidable deaths or deterioration when transfers are delayed.

Nigel Malloy · Prevention of Future Deaths report View report

19 Jul 2018 Southampton and New Forest G. Short

Nigel Malloy fell from a second-floor window on 29 October 2017 while intoxicated with alcohol, suffered severe head injuries, and died in hospital two days later. He was alcohol dependent and had depressive symptoms, with previous similar falls and multiple hospital admissions, but concerns were raised that there was no information sharing or coordinated treatment plan between the relevant alcohol-support services.