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Elaine Bradbrook · Prevention of Future Deaths report View report

14 Feb 2018 Nottinghamshire H. Connor

Elaine Bradbrook suffered a severe ischaemic stroke, deteriorated into a deep coma, underwent a craniectomy, and died at Queen’s Medical Centre on 27 April 2017. Concerns included failures to escalate and monitor her deterioration, reassess her condition before transfer, and reduce risks during transfer, including transfer with an unprotected airway and without clinical escort. The report also raised concerns about the trust’s failure to investigate the circumstances, fulfil its duty of candour, and support or properly represent witnesses during the inquest.

Ms Angela Caroline Byrne · Prevention of Future Deaths report View report

13 Feb 2018 Inner West London F. Wilcox

Ms Angela Caroline Byrne, who had a long history of drug misuse and was prescribed methadone alongside other medication, died at home on 29 July 2017 after taking an accidental overdose of prescribed and illicit drugs. The principal concerns related to risk assessment and planning, application of staff training, communication between inpatient and community services, separate clinical records, and shared rather than core-team care for patients with complex needs.

John William Sloan · Prevention of Future Deaths report View report

12 Feb 2018 London Inner (South) C. Williams

John William Sloan died by suicide on 16 August 2017 after hanging himself while alone at home. He had been receiving mental health care for anxiety, depression, sleeplessness and suicidal ideation. The principal concerns were that he was not asked about suicidal thoughts or plans at his last face-to-face contact, and that information from his daughter about his distress was not recorded or acted upon.

Margaret Elizabeth Clark · Prevention of Future Deaths report View report

10 Feb 2018 Lancashire and Blackburn with Darwen S. Jones

Margaret Elizabeth Clark suffered an oesophageal tear during a transoesophageal echocardiogram on 9 May 2017 and later died of sepsis resulting from the tear on 12 August 2017. The report raised concern that Ecolab sheaths used for the procedure may have created increased resistance and contributed to fatal oesophageal tears, and suggested reviewing their use.

Gail Ann Bannister · Prevention of Future Deaths report View report

9 Feb 2018 Worcestershire A. Cox

Gail Ann Bannister had a long history of fluctuating mental health and experienced deterioration after her father’s illness and death. She died by suicide, with the medical cause of death recorded as hanging. Concerns included that her care coordinator did not see her after appointment, undermining the intended care arrangement, and that it took several hours for her husband to reach the care team during a crisis because of a known single-phone-line problem.

Howard Winter · Prevention of Future Deaths report View report

8 Feb 2018 South Wales Central G. Hughes

Howard Winter, a resident of Daffodils CH with vascular dementia and frequent falls, fell on 23 August 2017, sustained a serious head injury, was diagnosed with a spinal fracture on 11 September, developed pneumonia and died in hospital on 16 September 2017. The principal concern was that recorded neck and back pain following his initial attendances was not escalated to a doctor for reassessment, investigation and diagnosis, potentially contributing to an adverse outcome if repeated.

Evelyn Fisher · Prevention of Future Deaths report View report

6 Feb 2018 Plymouth, Torbay and South Devon D. Archer

Evelyn Fisher, aged 61, was struck by a vehicle that mounted the kerb while she was walking along a pavement in Paignton. She sustained a catastrophic head injury, never regained consciousness, and died from head injury. Concerns included the driver’s dementia and the reliance on self-reporting when renewing driving licences for older drivers, with no statutory requirement for objective testing before automatic renewal.

MAVIS JEANNE REVES · Prevention of Future Deaths report View report

6 Feb 2018 Bedfordshire and Luton I. Pears

On 1 July 2017, Mavis Jeanne Reves pulled her Careline cord because she had a dry mouth and was struggling to breathe. Paramedics reached her flat after delays involving the building’s automated entry system and key safe, and performed CPR. The concerns included limitations of the analogue Careline system, delays in emergency access and connection time, and difficulties identifying the master key.

Michael John Spencer · Prevention of Future Deaths report View report

5 Feb 2018 South Yorkshire (Western) A. Forrest

Michael Spencer died from a fatal midbrain haemorrhage while being treated with Rivaroxaban as part of a clinical trial. The concern was that Andexanet alfa, a specific reversal agent for Factor Xa inhibitor anticoagulants, was not available in the UK, although the evidence stated that its availability would not have changed the outcome in Mr Spencer’s case.

Barbara Caroline Ellis · Prevention of Future Deaths report View report

2 Feb 2018 Gloucestershire K. Skerrett

Barbara Caroline Ellis, who had significant physical and mental health difficulties and a history of suicide attempts, died after jumping from an overbridge on 4 April 2017; she was pronounced deceased on 6 April 2017. The report identified a cross-border care concern involving her GP and healthcare in Herefordshire and social care in Gloucestershire, which resulted in her being unable to access therapeutic services from either commission.

David Scott Green · Prevention of Future Deaths report View report

1 Feb 2018 Essex C. Beasley-Murray

David Scott Green died in an accident while driving a dumper truck over a mound of earth; the ground gave way and the vehicle toppled forward, trapping him underneath. The concerns identified were the apparent lack of a safe system of work, widespread non-use of vehicle seat belts, and inadequate checking of seat-belt use.

Aaron George Nordass-Lacey · Prevention of Future Deaths report View report

31 Jan 2018 Dorset R. Griffin

Aaron George Nordass-Lacey died on 13 October 2016 after falling from his bicycle on the A35 Barrack Road, Christchurch, and being struck by a motor vehicle. The principal concerns relate to the safety of pedestrians and cyclists on Barrack Road, including road-crossing behaviour, vehicle speeds, barriers, and unclear cycle-lane signage.

Michael Vukovic · Prevention of Future Deaths report View report

29 Jan 2018 Inner South London P. Barlow

Michael Vukovic, who was suffering psychosis, jumped from a second- or third-floor balcony on 8 July 2017 and sustained an L1 vertebral fracture. He suffered a cardiac arrest and hypoxic brain damage after admission to hospital, and died on 11 July 2017. The principal concerns were that he was not seen by the Home Treatment Team, that follow-up with a drug and alcohol service was not checked, and that he was discharged without follow-up.

Joan Elizabeth Betteridge · Prevention of Future Deaths report View report

26 Jan 2018 Central Hampshire K. Harold

Joan Elizabeth Betteridge, aged 88, died during surgery for a displaced fractured neck of femur after a series of falls and delays in identifying the fracture. She developed bradycardia shortly after bone cement was inserted and was pronounced dead despite resuscitation attempts; the post-mortem identified bone cement implantation syndrome, with ischaemic heart disease as a contributory condition. The concerns included delays in requesting and progressing repeat X-rays and a radiology review system that did not identify the fracture promptly.

Mrs. Riaz Begum · Prevention of Future Deaths report View report

26 Jan 2018 Manchester South A. Morris

Mrs. Riaz Begum developed a bile leak and sepsis following a laparoscopic cholecystectomy, and later developed acute pancreatitis after an ERCP to repair the leak. She died on 16 July 2017 despite treatment for sepsis and multi-organ failure. Concerns included delays in CT-guided drainage and ERCP, insufficient radiology capacity, inadequate escalation, and the potential impact of consultant leave on ERCP availability.

Vanessa Ferkova · Prevention of Future Deaths report View report

26 Jan 2018 Coventry R. Brittain

Vanessa Ferkova, aged 2, attended a GP walk-in centre with fever and vomiting and later developed a rash. She was subsequently recognised as very unwell and likely suffering from meningococcal septicaemia, went into cardiac arrest in an ambulance, and died after unsuccessful resuscitation. The principal concern was that the walk-in centre did not provide clinical triage or a required timeframe for initial assessment, despite concerns that earlier observations could have identified and treated shock.

Andrew Stephen Finlay · Prevention of Future Deaths report View report

26 Jan 2018 Sunderland D. Winter

Andrew Stephen Finlay, aged 54, collapsed at home on 13 December 2016 and died there the following day. Although expert evidence indicated that the delay in dispatching and arriving with an ambulance did not affect the outcome, concerns remained about delays in emergency ambulance responses, including ongoing paramedic vacancies.

Sharon Rose Grierson · Prevention of Future Deaths report View report

25 Jan 2018 Cumbria D. Roberts

Sharon Rose Grierson, aged 44, underwent elective surgery to remove a benign vocal cord polyp and developed laryngospasm during extubation. Endotracheal tubes were twice placed in the oesophagus rather than the trachea, leading to oxygen deprivation, hypoxic brain injury and her death. Concerns included failure to appreciate capnography readings, lack of coordination and situational awareness, and limited experience of senior staff in crisis situations.

David Squire · Prevention of Future Deaths report View report

25 Jan 2018 Black Country E. Serrano

David Squire, a detained patient at The Priory Lakeside View Care Home, took his own life by hanging in Fibbersley Nature Reserve on 25 July 2018 after leaving escorted off-ground leave for a cigarette and not returning. Concerns were raised that smoke-free hospital guidance required smoking patients who refused nicotine replacement to begin leave off grounds, without the staged observation process used for non-smoking patients, and that the guidance did not adequately account for risks in mental health hospitals.

Ms. Sandra Miller · Prevention of Future Deaths report View report

25 Jan 2018 Avon P. Harrowing

Ms. Sandra Miller, who had multiple health conditions and required a urinary catheter, became unwell with sepsis and was admitted to hospital on 15 June 2016. The catheter had been left open to drain, with its end in or near faecal matter, and was found to be dirty and blocked. She died in hospital on 21 June 2016; the medical cause of death was pneumonia, with E. coli septicaemia due to a urinary tract infection and heart failure also recorded. The concerns were that open-ended catheter drainage had continued, and that safe catheter-care procedures and staff training were inadequate.