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Imtiaz Mohammed · Prevention of Future Deaths report View report

1 Jun 2018 Birmingham and Solihull L. Hunt

Imtiaz Mohammed died in a serious road traffic collision in Birmingham on 17 December 2017, when a taxi was struck by an Audi travelling at between 94 and 100 mph. Toxicology showed the taxi driver was over the legal drug-driving limit for a cocaine metabolite, and concerns were raised that there was no system to monitor whether taxi drivers were over the drug limit while driving.

Elaine Horrocks · Prevention of Future Deaths report View report

31 May 2018 Manchester West J. Pollard

Elaine Horrocks died after falling down cellar steps at the Rose Hill Tavern when a door was left ajar. The report identified an unsafe method of accessing the cellar and insufficient guarding of the cellar steps against accidental entry by the public.

George Terence Dyson · Prevention of Future Deaths report View report

29 May 2018 West Yorkshire (Western) M. Fleming

George Terence Dyson, who had been diagnosed with Alzheimer’s disease, sustained fatal injuries after jumping from North Bridge, Halifax, on 3 July 2017. Concerns included the need to urgently review protective safety measures on the bridge and consider immediate measures to prevent further similar fatalities.

Brian Leonard Bicat · Prevention of Future Deaths report View report

29 May 2018 West Yorkshire (Western) M. Fleming

Brian Leonard Bicat sustained severe burns at home on 22 September 2017 when his dressing gown caught fire while he was smoking a cigarette. He died later that day from his extensive cutaneous burns, with evidence indicating that paraffin-based emollient creams and ointments increased the speed and intensity of the fire. The principal concerns were that low-paraffin emollients may pose a fire hazard, that warnings were not displayed consistently on packaging or communicated by healthcare professionals, and that related prescribing alerts and incident data were inconsistent or incomplete.

Joan Lunt · Prevention of Future Deaths report View report

29 May 2018 Manchester South C. Morris

Joan Lunt, who had idiopathic pulmonary fibrosis and lived in a nursing home, became seriously unwell on 26 October 2017 and died after being transferred to hospital; the inquest recorded natural causes. Concerns were raised about significant deficiencies in agency care staff’s recording of information on the nursing home’s electronic records system, including unclear staff identification, potential miscommunication, and effects on continuity of care. Evidence also indicated that the issue had apparently been raised previously but assurances that it had been addressed were not reflected in Mrs Lunt’s records.

Neil JONES · Prevention of Future Deaths report View report

25 May 2018 Warwickshire S. McGovern

Neil Jones was ejected from the Bel Air nightclub at the Belfry Resort because he was intoxicated and was subsequently hit by a vehicle at about 1.30am on the A446 outside the resort. The report raised concern about four fatal road traffic collisions at the site over 10 years, despite a reduction in the speed limit, and noted that a casualty reduction scheme was being considered.

Robin Damien Richards · Prevention of Future Deaths report View report

25 May 2018 Somerset T. Williams

Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.

Rosalind Flett · Prevention of Future Deaths report View report

24 May 2018 South London S. Lynch

Rosalind Flett, who was detained under section 2 of the Mental Health Act and subject to enhanced observation and regular searches, used a razor blade to make a deep laceration to her neck in full view of nursing staff and died shortly thereafter. The report identified an ambiguity in search policies about whether staff could ask her to remove her bra, despite her history of concealing razor blades and previous incidents of cutting.

Grahame Searby · Prevention of Future Deaths report View report

23 May 2018 West Yorkshire (Western) M. Fleming

Grahame Searby, who had extreme anxiety and depression and was under community mental health supervision, was found hanging at his home on 27 July 2017. The principal concern was that the mental health team lacked access to the GP database through EMIS, limiting information gathering about his care.

Michael BERRY · Prevention of Future Deaths report View report

22 May 2018 Bedfordshire and Luton I. Pears

Michael BERRY was found hanging from a sheet in the Medical Wing of Bedford Prison on 10 March 2017 and later died after life-sustaining treatment was withdrawn following a hypoxic brain injury. The report raised concern that a cell described as a “Reduced Risk Cell” or “Safer Cell” contained an obvious ligature point at an inward-opening window, with possible design solutions to avoid this.

Andrew Crane · Prevention of Future Deaths report View report

22 May 2018 Northamptonshire P. Barlow

Andrew Crane suffered a cardiac arrest in his prison cell on 16 November 2016 and died despite resuscitation efforts. The report identified concerns about the response to his complaint of chest pain, including a lack of clarity about when a Code Blue should be called, and the failure to pass information about his lack of breathing and CPR to the ambulance service, which would have changed the response priority.

Carter Isaac Jepson · Prevention of Future Deaths report View report

21 May 2018 Manchester South A. Mutch

Carter Isaac Jepson was found not breathing in his Moses basket on 4 November 2017 and died in hospital later that morning. His death was attributed to natural causes, although the precise cause could not be ascertained. The inquest heard that his mother's psychological distress was exacerbated by the absence of a process or protocol for prescribing medication to stop lactation after his death.

Alfie Scambler-Holt · Prevention of Future Deaths report View report

21 May 2018 Manchester South A. Mutch

Alfie Scambler-Holt, who had cerebral palsy and complex health needs, became seriously unwell at home and was admitted to Stepping Hill Hospital with suspected sepsis. He died after suddenly stopping breathing during treatment. The report identified concerns about differing PEWS scoring systems and escalation processes between trusts because there was no national system.

Caroline Antoinette Scott · Prevention of Future Deaths report View report

21 May 2018 Milton Keynes T. Osborne

Caroline Antoinette Scott, who had depression and thoughts of suicide, was found hanging at home on 30 May 2017 and died in hospital on 2 June 2017. The inquest identified a failure to carry out a mental health assessment after recognising that she was in crisis, resulting in a lost opportunity to refer her for treatment. Concerns were also raised about the adequacy of out-of-hours emergency mental health services and whether emergency referral policy was understood by all medical services in Milton Keynes.

Michalla Jane SWEETING · Prevention of Future Deaths report View report

21 May 2018 Avon M. Voisin

Michalla Jane Sweeting was a remand prisoner undergoing detoxification who was found unresponsive in her cell at 07.00hrs on 2nd June 2016. The medical cause of death was aspiration of gastric content in association with methadone toxicity. Concerns included inadequate response to reported over-sedation, unsatisfactory handover between shifts, inadequate clinical observations, and failures in communication and assessment.

Mwitumwa Ngenda · Prevention of Future Deaths report View report

20 May 2018 West Yorkshire (Western) M. Fleming

On 28 August 2017, Mwitumwa Ngenda climbed over the railings of Scamonden Bridge and jumped onto the M62, sustaining fatal injuries. The principal concern was whether urgent preventative measures should be taken on the bridge to prevent a recurrence.

Henry James Heselton · Prevention of Future Deaths report View report

18 May 2018 Surrey C. Topping

Henry James Heselton died by hanging in a field off Down Lane, Guildford, on 28 September 2016. The report identified concerns about unclear electronic mental health records and poor communication between mental health teams and his general practitioner, which meant relevant information was not available to inform clinical judgement.

BERNARD JOHN FAGG · Prevention of Future Deaths report View report

17 May 2018 Mid Kent and Medway A. Summers

Bernard John Fagg was admitted to hospital with breathlessness and several suspected conditions, including heart failure, anaemia, fast atrial fibrillation and possible asbestos-related interstitial lung disease. After a contrast CT scan and an endoscopy, he developed acute kidney injury and died on 14 December 2017; clinicians attributed the death to contrast-induced nephropathy. The principal concern was whether intravenous fluids should have been considered because the endoscopy, requiring nil by mouth, took place shortly after the contrast CT scan.

Neville Welton · Prevention of Future Deaths report View report

17 May 2018 North Wales (East and Central) J. Gittins

Neville Welton attended Wrexham Maelor Hospital on the evening of 12 December 2017 after referral by his GP. Delays in assessment and treatment, associated with capacity and patient flow problems, staffing issues, and administrative and escalation failures, were followed by deterioration and his death in the early hours of the next morning. Concerns included the delay in completing the Health Board’s investigation and action plan, missed implementation timescales, and wider delays in completing serious incident reviews and action plans.

Lucia CICCIOLI · Prevention of Future Deaths report View report

16 May 2018 Inner West London R. Caller

Lucia CICCIOLI was cycling westbound through the junction of Latchmere Road and Elspeth Road towards Lavender Hill when she lost her balance after travelling over a dip in the road and collided with a MAN lorry. She sustained fatal injuries and died at the scene. The principal concerns were inadequate cycle-lane provision and protection, the junction layout and yellow box, the narrow road, and a dangerous dip in the road requiring urgent repair.