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Dennis George Redmore · Prevention of Future Deaths report View report

9 Aug 2017 South Wales Central A. Barkley

Dennis George Redmore was admitted to hospital with a blocked catheter and presumed urinary tract infection while receiving palliative treatment for lymphoma. After an unwitnessed fall in hospital on 6 March 2017, he deteriorated, was found to have a subdural haematoma, and died later the following evening. The report identified gaps in neurological observations, delayed response to abnormal observations, and inadequate management to ensure checks were completed; it did not establish that these failures caused or contributed to his death.

Deidre Harvey · Prevention of Future Deaths report View report

8 Aug 2017 South Wales Central C. Woolley

Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

Fallon Alphonsine ABBY · Prevention of Future Deaths report View report

8 Aug 2017 Inner North London M. Hassell

Fallon Alphonsine ABBY died by suicide after jumping from the balcony of her sixth-floor bedroom on 18 February 2017, following recent hospital attendances and discharge to a home treatment team. The report raised concerns that the Roman Ward team did not contact her social worker, meaning potentially valuable information was not shared and social-work support was not available on discharge.

MAYA GRACE KANTENGULE · Prevention of Future Deaths report View report

8 Aug 2017 Norfolk J. Lake

Maya Grace Kantengule, aged 7, was found unresponsive at the bottom of a swimming pool during a birthday party on 1 May 2016 and was declared dead later that day. The concerns included the absence of a separate risk assessment for swimming pool birthday parties, failures to follow safety procedures and check compliance, non-functioning CCTV, limited staff awareness of pool-area health and safety, and a lack of formal health and safety training.

Sharon Ann Halliwell · Prevention of Future Deaths report View report

4 Aug 2017 Manchester West J. Leeming

Sharon Ann Halliwell was found deceased at home on 18 April 2017; the medical cause of death was suspension by ligature and the inquest concluded suicide. The report identified a lack of connectivity between mental health service systems, meaning information indicating suicide risk was not accessed during a later assessment and a psychiatrist referral was not made.

Carly Marie GORDON · Prevention of Future Deaths report View report

4 Aug 2017 Exeter and Greater Devon G. Tomalin

Carly Marie GORDON was admitted to hospital after a failed attempt on her own life and was later found hanging at home on 27 May 2016 after being discharged to her mother's care. The inquest concluded that she took her own life while suffering from depressive disorder and benzodiazepine withdrawal; concerns related to the long-term prescribing and review of benzodiazepines.

Thomas Christall · Prevention of Future Deaths report View report

2 Aug 2017 Brighton and Hove V. Hamilton-Deeley

Thomas Christall’s inquest concluded that he took his own life. Concerns included the lack of a local inpatient detoxification facility, long waiting times, and insufficiently collaborative treatment for people with dual diagnosis, with delays and refusals increasing distress and despair.

Hayley Denise Sheehan · Prevention of Future Deaths report View report

1 Aug 2017 Surrey A. Crawford

Hayley Denise Sheehan collapsed and died at home on 22 November 2016 after unintentionally overdosing on prescription Tramadol; the medical cause of death was Tramadol toxicity. The court found that early requests for repeat prescriptions had not been identified or acted upon, allowing her to obtain a significant amount of excess medication. The principal concern was that the prescription process relied heavily on administrators identifying early requests, while the surgery’s software did not automatically flag them.

Philip James Clayton · Prevention of Future Deaths report View report

31 Jul 2017 Manchester South A. Mutch

Philip James Clayton was a passenger in a Zcar Mini that collided with another vehicle on 24 April 2016, and he died at the scene. The report raises concerns that sellers of high-powered kit-built vehicles are not required to provide a driving course, that such vehicles may not undergo rigorous regular testing after initial approval, and that current legislation permits people with a normal driving licence to drive modified or powerful vehicles regardless of experience.

Michael Bingham · Prevention of Future Deaths report View report

31 Jul 2017 Manchester South A. Morris

Michael Bingham fell down stairs at Hilltop Court Care Home on 22 September 2016 after an emergency door release caused internal secure doors to open. He sustained C1/C2 fractures, was not diagnosed with a CT scan, later developed aspiration pneumonia, and died on 24 September 2016; concerns included door security alarms, guidance and inspection procedures, clarity about CT scans for older people with cognitive impairment, and the resulting risk of further deaths.

SARAH LYNNE REED · Prevention of Future Deaths report View report

28 Jul 2017 London (City) P. QC

Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.

Pamela Keech · Prevention of Future Deaths report View report

28 Jul 2017 Northamptonshire H. Shah

Pamela Keech, who had end-stage renal failure and received haemodialysis through a leg graft, experienced repeated bleeds from the graft site before being found unconscious with substantial blood loss on 7 July 2015. She died from a catastrophic haemorrhage from the graft site. Concerns included the lack of national guidance and training on predicting and managing fatal graft or fistula haemorrhage, and whether patients with such bleeds are escalated for renal or surgical review.

Liam Hall · Prevention of Future Deaths report View report

27 Jul 2017 Newcastle upon Tyne K. Dilks

On 30 August 2016, 17-year-old Liam Hall drowned after leaving an inflatable dinghy in the sea at Roker Beach, despite having very limited swimming ability. The concerns identified were the absence of warning signage about the risks of entering the water and using inflatable devices, and the absence of lifeguard supervision in the harbour area.

Percy Jacks · Prevention of Future Deaths report View report

27 Jul 2017 South Wales Central A. Barkley

Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.

Sheila Margaret Gaskin · Prevention of Future Deaths report View report

27 Jul 2017 South Wales Central A. Barkley

Sheila Margaret Gaskin was bedbound and living at home with support from carers. After a carer assisted her to light a cigarette in bed on the evening of 20 March 2017, she was found the following morning with burns and soot markings after a fire; concerns included the absence of a prohibition on carers assisting her to smoke in bed and ineffective day-to-day oversight by care management.

Maureen Ann Colclough · Prevention of Future Deaths report View report

27 Jul 2017 Cheshire J. Harkin

Maureen Ann Colclough was found unresponsive at home on 16 December 2016 and was later confirmed deceased by paramedics. The report states that she was likely in a comatose state and that earlier medical intervention could have saved her. The principal concerns were inadequate staff training to recognise an emergency and reliance on presumptions when finding an unresponsive patient in a serious situation.

KENNETH JOHN SWIFT · Prevention of Future Deaths report View report

26 Jul 2017 York City J. Broadbridge

Kenneth John Swift was admitted to York Hospital with community acquired pneumonia and, while assessed as being at risk of falls, fell unaccompanied on 21 April 2017 and fractured his neck of femur. He died in hospital on 28 April 2017. The principal concern was that no falls sensor was immediately available despite his assessed risk and attempts to mobilise without supervision, raising concerns about the potential for similar fall-related harm to other patients.

Songul BOZDAG · Prevention of Future Deaths report View report

26 Jul 2017 Inner North London M. Hassell

Songul Bozdag, who had schizophrenia and other mental health conditions, died after jumping from a tenth-floor window on 9 February 2017. Concerns included missed mandatory reviews, incomplete recording of consultations, failure to record a required care plan approach, an incorrect drug card that left her under-medicated, and the absence of a system safety net to identify these errors.

Mr Robert Dymond · Prevention of Future Deaths report View report

25 Jul 2017 Coventry E. Whitting

Mr Robert Dymond underwent elective left knee replacement surgery on 9 March 2017 and suffered a massive thromboembolic event the following morning, dying on 11 March 2017. Concerns included the management and follow-up of suspected deep vein thrombosis, the apparent failure to communicate the November 2016 DVT investigations and treatment to the surgical and anaesthetic teams, and their omission from the second pre-operative assessment.

GUSTAVO SILVA DA CRUZ and 6 others · Prevention of Future Deaths report View report

24 Jul 2017 East Sussex A. Craze

On 24 June 2016, Gustavo Silva da Cruz and Mohit Dupar entered the sea at Camber Sands; Da Cruz's body was later washed ashore, and Dupar was brought unconscious to the beach and died at Ashford Hospital on 28 July 2016. On 24 August 2016, five young Sri Lankan men entered the sea as the tide came in and all died, with their bodies recovered that day or after the tide receded. The report raises concerns about the lack of formal governance and risk management for beach safety, including lifeguard provision, public education, communication, resources, and whether restrictions on beach use should be considered.