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Terrence Denis George · Prevention of Future Deaths report View report

3 Oct 2017 Cornwall and Isles of Scilly E. Carlyon

Terrence Denis George was admitted with gallstone pancreatitis in August 2015 and later died on 7 January 2016 after a further episode of severe pancreatitis, before the planned gallstone surgery had been scheduled. The report identified inadequate systems at the treating hospital for ensuring timely gallstone surgery and identifying patients whose operations had not occurred within recommended timescales. It also raised concern that few responding acute NHS trusts had local guidance for the surgical pathway and that the timing of surgery had not been prioritised by Trust management.

Helen Yuk Ying BANNISTER · Prevention of Future Deaths report View report

29 Sep 2017 Buckinghamshire C. Butler

Helen Bannister underwent a procedure to insert a PEG feeding tube on 13 May 2016. After discharge, the PEG loosened, causing a leak into her abdomen and an infection; she died of sepsis at Wexham Park Hospital on 17 May 2016. The report identified concerns about incomplete records of care, fluid intake, diet, nutrition, hospital discharge arrangements and aftercare instructions, which could compromise responses to unfolding events.

Pauline Hayston · Prevention of Future Deaths report View report

28 Sep 2017 Manchester West T. Brennand

Pauline Hayston, who had reduced mobility, frailty and recent falls, sustained an unwitnessed fall while attempting to mobilise as an inpatient and later died following a fractured neck of femur and resulting immobility. The concerns identified related to the reliability and fitness for purpose of the Rambledguard falls mats, the suitability of the wireless system when several mats were in use, and the absence of technical instructions for nursing staff about operational problems.

GILLIAN O’KEEFFE · Prevention of Future Deaths report View report

28 Sep 2017 London Inner (West) A. Hodes

Gillian O’Keeffe had a serious mental illness and died at home on 19 March 2017 after taking her own life while the balance of her mind was disturbed. The concerns included her discharge from community mental health services for non-engagement despite family and professional concerns, inadequate communication with her GP and family, and the absence of a clear process for following up urgent concerns or referrals.

Conall Patrick Gould · Prevention of Future Deaths report View report

28 Sep 2017 Birmingham and Solihull E. Brown

Conall Patrick Gould died at Queen Elizabeth Hospital in Birmingham on 13 February 2017 after behaving erratically and collapsing; the medical cause of death was recorded as ecstasy use. The report raised concerns that arrangements for his community mental health follow-up appointment after discharge were not communicated to him or his parents, and that the absence of a clear protocol or written confirmation created a risk that follow-up opportunities could be missed.

Katherine Tracey Vanloo · Prevention of Future Deaths report View report

28 Sep 2017 Warwickshire J. Buckley

Katherine Tracey Vanloo died on 3 January 2016 from catastrophic injuries after falling from her bicycle when it hit an unrepaired pothole and being struck by a car. The report identified delays in repairing the pothole and a lack of systems to track outstanding works and audit whether repairs had been completed and were of adequate quality.

Mrs Pamela Craigie · Prevention of Future Deaths report View report

27 Sep 2017 West London G. Brannigan

Mrs Pamela Craigie died on 19 March 2017 after falling at Cloisters Nursing Home on 24 February 2017 and sustaining an acute subdural haematoma and head injury. The report raised concerns about inconsistent supervision and adherence to her care plan, unclear criteria and processes for referring residents for urgent 1:1 care, delays in urgent assessments, and how residents’ safety was managed while awaiting additional care.

Master Peter Kollar · Prevention of Future Deaths report View report

27 Sep 2017 Inner South London A. Harris

Master Peter Kollar, a young child, presented to hospital with diarrhoea and jaundice but was diagnosed with carotenemia and discharged without blood tests, investigation, admission or consultant escalation. An expert raised concern that jaundice in children after the neonatal period was under-recognised and that failure to escalate a child with jaundice to an appropriate specialist could adversely affect care and be potentially life threatening. Peter died aged 3½ from multi-organ failure with pulmonary haemorrhage following acute liver failure and an unidentified inborn error of metabolism, with viral infections also recorded; the conclusion was natural causes.

Hedley Greenland · Prevention of Future Deaths report View report

26 Sep 2017 South Wales Central A. Barkley

Hedley Greenland, who was residing in a nursing home and had prostate cancer requiring permanent catheterisation, became acutely unwell on 17 December 2016 and died in hospital on 20 December 2016. The inquest concluded that he died from the effects of a urine infection in circumstances where fluid input and catheter output were not adequately monitored for over nine hours. Concerns included the absence of fluid balance monitoring and written handover, inadequate catheter-care training and knowledge, and the absence of evidence that the Catheter Care Bundle was being used.

Rodney Hampshire · Prevention of Future Deaths report View report

26 Sep 2017 Manchester West J. Leeming

Rodney Hampshire underwent bowel surgery at Salford Royal Hospital on 12 May 2017 and was transferred from intensive care to a surgical ward on 15 May. He suddenly deteriorated and sustained a cardiac arrest on 16 May. The substantive concern was a review of whether monitored beds on surgical wards could potentially save lives, although there was no evidence that this would have affected the outcome in this case.

Shahbaz Salim Bhim and Shana Sutaria · Prevention of Future Deaths report View report

22 Sep 2017 Nottinghamshire A. McNamara

Shahbaz Salim Bhim and Shana Sutaria were travelling in a BMW on the A46 during heavy rain when standing water caused the vehicle to leave the carriageway and enter Fairham Brook. They likely survived the initial collision but were subsequently struck by a van and sustained fatal injuries; concerns included blocked drainage causing standing water and a gap in the vehicle restraint barrier that allowed vehicles to leave the carriageway.

Margaret Olive PINE (Mrs Pine) · Prevention of Future Deaths report View report

21 Sep 2017 Exeter and Greater Devon J. Tomalin

Margaret Olive Pine was the front-seat passenger in a car returning from an evening out when, in poor visibility, the driver took a wrong turn and the car collided with a wall closing off a road. The inquest concluded that Mrs Pine died from injuries received in the road traffic collision. The substantive concern was that there were no signs indicating the road was a dead end and no reflective warning on the wall.

Derek Clifford Dudley · Prevention of Future Deaths report View report

21 Sep 2017 Surrey A. Loxton

Derek Clifford Dudley was found deceased from hypothermia outside the back door of his home on 6 March 2017, after previously activating his community alarm following a fall. Concerns included the call being ended before he had got up, limited follow-up after a later unanswered call, unsupervised trainee operators, the absence of pro forma questions, and insufficient background information for assessing service users’ needs.

Barbara Christine Sturgess · Prevention of Future Deaths report View report

21 Sep 2017 Derby and Derbyshire P. Nielo

Barbara Christine Sturgess, who had advanced dementia and was at high risk of falls, sustained a cervical spinal fracture in a fall at her nursing home on 20 May 2017 and died of bronchopneumonia on 8 June 2017. The hospital did not initially inform the nursing home or GP practice of the fracture or necessary care measures; although this was not evidenced to have contributed to her death, it had the potential to adversely affect her wellbeing and could contribute to death in similar cases.

Peter (Peirce) Cotter · Prevention of Future Deaths report View report

20 Sep 2017 Milton Keynes T. Osborne

Peter (Peirce) Cotter suffered an unwitnessed fall at home on 27 January 2017, sustaining a head injury and fractured hip, and later underwent hip surgery. The principal concern was that clinical decision support software did not appear to recognise the head injury despite his use of anticoagulant drugs.

Kathleen Erica Holme · Prevention of Future Deaths report View report

18 Sep 2017 Cumbria R. Chapman

Kathleen Erica Holme died after a fire at her home in the early hours of 26 March 2017, having been rescued from the property. The fire involved candles and a Glade automatic air freshener, and she died from burns and smoke inhalation. Concerns were raised about the extent and prominence of warnings about using the air freshener near naked flames, including the lack of warnings on the device itself.

Dennis Geoffrey Oldland · Prevention of Future Deaths report View report

18 Sep 2017 Blackpool and the Fylde A. Wilson

Dennis Geoffrey Oldland was found at home with a significant burn injury after being left partially clothed in an armchair near a fire following a care visit lasting approximately seven and a half minutes. He later suffered a stroke and died on 14 December 2016; the medical cause of death included stroke, advanced frailty and burn injury. The principal concern was that care workers might leave vulnerable service users prematurely, without sufficient interaction to identify risks or welfare concerns.

Paul James Maddox · Prevention of Future Deaths report View report

17 Sep 2017 Liverpool and the Wirral A. Rebello

Paul James Maddox was admitted to hospital with vomiting and subsequently developed severe internal bleeding after a fall in haemoglobin was not acted upon. He underwent emergency surgery after deteriorating, but died from massive gastrointestinal bleeding with disseminated intravascular coagulopathy. The principal concern was the missed opportunity to detect, investigate and treat the bleeding, with strategies to prevent recurrence still described as work in progress at the inquest.

Reginald Dixon · Prevention of Future Deaths report View report

15 Sep 2017 Black Country Z. Siddique

Reginald Dixon, a 70-year-old man, suffered an unwitnessed fall downstairs on 26 June 2017, sustaining multiple injuries including a severe head injury. He was taken to hospital after a 57-minute delay from the original emergency call and died the same day. Concerns included the incorrect triage of a later call and insufficient ambulance resources contributing to delays in response times.

David John Lindsey · Prevention of Future Deaths report View report

14 Sep 2017 Essex C. Beasley-Murray

David John Lindsey died at home on 25 July 2017; the stated cause of death was small bowel cancer. His family raised concerns that the trust failed to follow NICE guidelines and its own policies concerning cancer screening, referrals, diagnosis and treatment, after investigations over more than a year without a diagnosis or treatment.