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Reginald George KEY · Prevention of Future Deaths report View report

24 Jan 2018 Stoke-on-Trent and North Staffordshire M. Jones

Reginald George KEY underwent surgery and was discharged from hospital on 1 December 2016. He was reportedly very unwell when delivered home after a delay in patient transport and was readmitted on 4 December with sepsis. He underwent further procedures and died on 10 December 2016; concerns were raised about his discharge condition, the delay in transport, and whether his deterioration could have been identified or whether paramedics could have returned him to hospital.

Caliel Arlington SMITH-KWAMI · Prevention of Future Deaths report View report

22 Jan 2018 London (East) N. Persaud

Caliel Arlington Smith-Kwami suffered a profound hypoglycaemic episode around 28 hours after birth and later died on 17 August 2016 from persistent neonatal hyperinsulinaemic hypoglycaemia. He was discharged before key test results were obtained, and concerns included failures to notify clinicians that results were delayed or available, unclear responsibility for chasing results, and a missed opportunity to involve community midwives.

William Myers · Prevention of Future Deaths report View report

19 Jan 2018 Manchester West K. McLoughlin

William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.

Master Abdul-Jamal Ottun · Prevention of Future Deaths report View report

18 Jan 2018 Inner South London A. Harris

Master Abdul-Jamal Ottun, a 17-year-old school student, drowned while swimming in Shawnigan Lake, British Columbia, during a school rugby tour on 12 July 2015. The principal concerns were the adequacy of risk assessment and supervision, including the lack of consideration of a lifeguard, the risks of cold open water, the safest entry point, necessary equipment, and rescue arrangements.

Paul Lawrence Hanton · Prevention of Future Deaths report View report

18 Jan 2018 West Sussex P. Schofield

Paul Hanton was an informal patient at Langley Green Mental Health Hospital when he absconded during an escorted walk on 18 April 2016. Eight days later, he jumped in front of a train at Kings Cross Underground Station and died from head injuries. The principal concerns included the information provided during the missing-person call, delays and gaps in police action, inaccessible hospital CCTV, and differing responses to informal and sectioned patients assessed as being at high risk of self-harm or suicide.

Barry John TUCKER · Prevention of Future Deaths report View report

17 Jan 2018 Brighton and Hove V. Hamilton-Deeley

The supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.

Mr Keith James Harwood · Prevention of Future Deaths report View report

16 Jan 2018 Blackpool and the Fylde A. Wilson

Mr Keith James Harwood underwent elective cardiac surgery in July 2014 and subsequently suffered a cardiac arrest and hypoxic brain injury, leaving him in a persistent vegetative state. He later died on 29 December 2016 from the combined effects of bronchopneumonia and a sub-phrenic abscess. Concerns included inadequate recognition of the complexity of his Parkinson’s disease and uncertainty about how hospital staff could obtain timely specialist neurological advice for patients with complex conditions.

Edwin Hooper · Prevention of Future Deaths report View report

16 Jan 2018 Manchester South C. Murray

Edwin Hooper was admitted with multiple serious medical conditions, including decompensated heart failure, kidney disease, sepsis and peripheral vascular disease. After a fall while receiving anticoagulant treatment, he sustained a traumatic intracranial bleed and progressively deteriorated before receiving palliative care and dying on 15 November 2016. The principal concern was whether patients with head injuries who are taking anticoagulants undergo CT scanning in accordance with NICE guidelines, particularly when there are on-site CT scanner service issues.

Antony Richard COUGHTREY · Prevention of Future Deaths report View report

15 Jan 2018 Milton Keynes T. Osborne

Antony Richard Coughtrey, who had been returned to prison after breaching his licence, died by suicide after hanging himself. The concerns included the absence of an internal Probation Service investigation or similar Serious Incident Review and an alleged failure to refer him back to the Parole Board after the licence breach.

David John Buttriss · Prevention of Future Deaths report View report

12 Jan 2018 Cornwall and Isles of Scilly E. Carlyon

David John Buttriss died at home on 9 May 2016 after cutting himself during a mental health crisis, despite medical assistance and resuscitation. The report identified communication problems between the GP and mental health services, separate healthcare record systems that limited access to relevant information, and a lack of clarity about the appropriate crisis-response pathway and the roles of different mental health teams.

Christopher Stewart HUTTON · Prevention of Future Deaths report View report

12 Jan 2018 Manchester South A. Mutch

Christopher Stewart HUTTON, a 48-year-old man who lived alone, was found hanging in an upstairs bedroom on 30 June 2017 after failing to attend a probation appointment. The investigation concluded that his death was suicide, with the medical cause recorded as hanging. A substantive concern was that he had not commenced an intensive probation treatment programme because of high demand and significant backlogs, despite its being a key part of his sentence.

John Christopher Armstrong · Prevention of Future Deaths report View report

12 Jan 2018 Leicester City and South Leicestershire D. Hocking

John Christopher Armstrong, a 70-year-old glider pilot, died on 4 December 2016 after his glider collided mid-air with a Cessna aircraft near Husbands Bosworth Airfield. The concerns included the limitations of visual “see and avoid” collision prevention, the lack of compatible or mandatory electronic conspicuity systems, and the absence of air traffic control at the airfield despite multiple aircraft being nearby.

Pauline May Pryor · Prevention of Future Deaths report View report

12 Jan 2018 Cornwall and Isles of Scilly E. Carlyon

Pauline May Pryor, a resident of Trevornor Nursing Home receiving lithium treatment, was found unwell on 9 July 2015 and died in hospital on 13 July 2015. The report identified concerns that required quarterly blood tests were not carried out because of unclear communication between the nursing home and GP surgery, and that psychiatric advice to reduce and stop lithium was not seen or followed up.

Lee Garfield DANIEL · Prevention of Future Deaths report View report

12 Jan 2018 Isle of Wight C. Sumeray

Lee Garfield DANIEL died in hospital on 8 September 2016 after sustaining massive traumatic injuries in a motorcycle collision on Coach Lane, Brading, followed by impact from a second vehicle. The report raised concerns about the absence of double yellow lines where vehicles could legally park, which required Mr DANIEL to cross onto the wrong side of the road and affected visibility for vehicles turning across the lane.

John Martin Chapman · Prevention of Future Deaths report View report

11 Jan 2018 Lancashire N. Rheinberg

John Martin Chapman was transferred to HMP Wymott on 23 January 2014, and information about two previous self-harm or threatened self-harm incidents was not passed to the reception nurse. He was found hanging in his cell on 21 March 2014; the inquest concluded that he died as a result of accidental hanging. The report identified concerns about the lack of a formal mechanism for sharing relevant self-harm and welfare information between prison and healthcare staff during reception.

Donald John TILL · Prevention of Future Deaths report View report

11 Jan 2018 Stoke-on-Trent and North Staffordshire M. Jones

Donald John TILL, a 68-year-old man with a history of small bowel adenocarcinoma, presented with abdominal pain and vomiting caused by a large bowel obstruction. After emergency surgery on 4 January 2017, he aspirated faeculent material during anaesthesia, developed aspiration pneumonia, deteriorated in intensive care, and died on 5 January 2017. Concerns included unavailable previous medical records, anaesthesia on a ward bed without rapid tilt, problems sourcing suitable bronchoscopy equipment, and the non-use of cricoid pressure and a nasogastric tube before anaesthesia.

John Kevin O’MEARA · Prevention of Future Deaths report View report

10 Jan 2018 London (West) S. Ormond-Walshe

John Kevin O’MEARA suffered respiratory failure and died on 29 March 2016 in a cell at HM Prison Wormwood Scrubs. The report identifies insufficient staffing, inadequate medical monitoring, and a missed opportunity to raise concerns about his health. It also raises concerns about delays in activating emergency codes and the availability of trained passive dogs to help control novel psychoactive substances in prisons.

John Keith Edwards · Prevention of Future Deaths report View report

10 Jan 2018 Staffordshire South M. Jones

John Keith Edwards, aged 64, was admitted to a care home for respite and subsequently suffered falls, seizures, reduced mobility, pressure sores and a rapid decline before dying in a nursing home on 19 December 2016. Concerns included inadequate care-home policies and care, failures to seek medical assistance and recognise deterioration, poor record-keeping, and inappropriate placement for his complex needs.

Marcus Dale Hamilton · Prevention of Future Deaths report View report

6 Jan 2018 Manchester South A. Bridgman

Marcus Dale Hamilton was a long-term service user of Trafford Drug Treatment Services and died from the combined respiratory depressive effects of several drugs taken in slight excess; the conclusion was drug related, with no evidence of deliberate intent. A substantive concern was that, despite planning a 51-day trip to India, he received only a 28-day prescription of MXL and was told he could obtain more there, potentially from the illicit market.

Patrick Stephen Moran · Prevention of Future Deaths report View report

5 Jan 2018 Inner North London J. Devonish

Patrick Stephen Moran was admitted with severe peripheral vascular disease, left foot gangrene and ongoing leg pain. During angiography and angioplasty, he suffered an iliac artery rupture; his left leg became non-viable and was amputated, while his right leg later deteriorated. The report identified concerns about a tenfold insulin dosing error involving use of a standard syringe, the lack of mandatory diabetes and insulin-device training, and the absence of an organisation-wide process to review compliance with safety alerts.