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Christopher Bell and 29 others · Prevention of Future Deaths report View report

7 Jul 2017 London (West) Loraine-Smith

Thirty British nationals were killed in a terrorist attack at the Imperial Mahaba Hotel in Sousse, Tunisia, on the morning of 26 June 2015. The concerns identified were whether travel companies had board-level security expertise and whether holiday and travel websites provided sufficiently prominent information about terrorist risks through the Government’s Travel Aware programme.

Catherine Haf Roberts · Prevention of Future Deaths report View report

7 Jul 2017 North Wales (East and Central) N. Jones

Catherine Haf Roberts arrived at hospital by ambulance after becoming unwell with persistent diarrhoea and waited outside before remaining in the emergency department for 58 hours because of capacity and ward-space constraints. Her condition deteriorated after transfer to a medical ward, and she died in hospital on 11 February 2016. The principal concern was the continuing lack of an agreed and effective system plan addressing emergency department admission, resource availability and patient flow, which the report states was placing patients’ lives at risk.

John Ramsden · Prevention of Future Deaths report View report

6 Jul 2017 Manchester West J. Leeming

John Ramsden, who had dementia and was subject to a Deprivation of Liberty Safeguarding Authorisation, resided at Lever Edge Care Home and died of natural causes. Medication prescribed for a suspected urinary tract infection on 8 January 2017 was not delivered or administered until 9 January. The report raised concern that only his eldest daughter was consulted about his care, while his other two daughters were not consulted, particularly about end-of-life care and possible hospital admission.

Cameron Chadwick · Prevention of Future Deaths report View report

6 Jul 2017 Manchester West J. Leeming

Cameron Chadwick was riding a motorcycle on Helvellyn Road, Wigan, on 7 February 2017 when he lost control, fell, and sustained injuries that led to his death. Evidence at the inquest concerned a pothole near the accident site, reportedly measured at 45mm deep, although the exactness of the measurement could not be fully guaranteed.

Rose Workman · Prevention of Future Deaths report View report

6 Jul 2017 Gloucestershire K. Skerrett

Rose Workman, a 76-year-old woman with bilateral leg ulcers and other health problems, was admitted to hospital after a general decline, dehydration and leg ulcers. She developed pneumonia and died at 6.15am on 17 June 2016 despite treatment. The report raised concern about whether district nursing services had sufficient measures to monitor patients’ ongoing conditions effectively, noting periods when Rose’s condition was not tracked because of staff shortages and unclear assessment requirements.

Patricia Norfolk · Prevention of Future Deaths report View report

5 Jul 2017 Manchester North J. Robertson

Patricia Norfolk was admitted to Royal Oldham Hospital after discovery of a fractured neck of femur, following earlier unwitnessed falls and an attendance at the hospital where no X-ray investigation was undertaken. She developed an infection following surgery, deteriorated despite medical intervention, and died from bronchopneumonia after discharge to Braeside Care Home. The principal concern was that patients were not receiving a daily senior clinician review, including during the interim period before recruitment and appointment of appropriate staff.

Mr Roy Lynch · Prevention of Future Deaths report View report

5 Jul 2017 Essex E. McGann

On 10 March 2017, the car driven by Mr Roy Lynch collided with a stationary vehicle on the B184, Dunmow Road, between Great Easton and Great Dunmow. The concerns raised were the limited available view, the absence of restrictions on stopping at that location despite a nearby safe parking area, and the possibility that parking there contributed to the circumstances of the death.

Janet Silva Müller · Prevention of Future Deaths report View report

4 Jul 2017 West Sussex P. Schofield

Janet Silva Müller, a patient detained under Section 2 of the Mental Health Act 1983 at Millview Hospital, died on 13 March 2015 after being found in the boot of a burning car; the circumstances were recorded as unlawful killing following her absconding from hospital. The principal concerns were incomplete and contradictory records, handovers, risk assessments and care plans, inadequate staffing, and insufficient measures to prevent detained patients from absconding.

Sheila Mary Hynes · Prevention of Future Deaths report View report

3 Jul 2017 Newcastle upon Tyne K. Dilks

Sheila Mary Hynes died after an aortic and mitral valve replacement procedure in which a mechanical aortic valve was remounted in an inverted position and re-implanted. The resulting acute heart damage led to her death. Concerns included remounting the valve contrary to the manufacturer’s instructions, inadequate awareness of the associated risks, and directing a scrub nurse without relevant training or experience to remount it.

Joseph Francis De Pellegrino-Farrugia · Prevention of Future Deaths report View report

3 Jul 2017 North Yorkshire (West) R. Turnbull

Joseph Francis De Pellegrino-Farrugia, a 92-year-old man with dementia, was injured when his foot became trapped in the mechanism of his electric reclining chair during a transfer to a commode. He sustained crush injuries and ongoing ulceration and necrosis of his left great toe, and died at home on 20 December 2016; the injury contributed to his death. Evidence raised concern that the chair lacked sensors to detect and release a trapped foot.

David Michael Lee · Prevention of Future Deaths report View report

28 Jun 2017 Manchester North J. Robertson

David Michael Lee was found unresponsive at home on 18 February 2017 after taking a considerable quantity of diphenhydramine and telling the emergency call handler about this during a 999 call. The call was terminated approximately 30 minutes in, and the report identified a missed opportunity to escalate the response before he became unconscious and died prior to the ambulance’s arrival.

Olaseni Lewis · Prevention of Future Deaths report View report

28 Jun 2017 South London S. Lynch

Olaseni Lewis developed an acute psychotic illness, was admitted to hospital, and was later restrained by police and healthcare staff after becoming agitated. He became unconscious and suffered a cardiac arrest. The concerns included prolonged and disproportionate restraint, inadequate police and healthcare training and communication, unclear responsibilities, and failures to respond appropriately to the medical emergency.

Dean Mark Rowland · Prevention of Future Deaths report View report

27 Jun 2017 Staffordshire South M. Jones

Dean Mark Rowland, who had a history of two recent self-harm attempts and depression, was found hanging from a bannister on 21 March 2017, and the inquest concluded that his death was suicide. Concerns included his inability to obtain a GP appointment or telephone consultation for nine days when he wished to discuss increasing his antidepressant medication, and his discharge from the community mental health team after one consultation without a follow-up plan beyond returning to primary care.

Jonathan Daniel Zucker · Prevention of Future Deaths report View report

26 Jun 2017 North London A. Walker

Jonathan Daniel Zucker was found at home on 27 November 2016 after hanging himself with a length of rope from banisters. The principal concern was that no lead clinician or system was in place to oversee and coordinate care provided by the private and NHS mental health services.

Robert Cardwell · Prevention of Future Deaths report View report

23 Jun 2017 Preston and East Lancashire R. Galloway

Robert Cardwell was under the care of a Home Treatment Team but was discharged after information about his missed appointment and request for a further appointment was not passed to the multidisciplinary team. He later expressed suicidal thoughts, described a plan to hang himself using a football scarf, and was found deceased at home on 29 September 2016 after hanging himself. Concerns included failures in communication, failure to discuss or follow up his request for an appointment, and inadequate record keeping during multidisciplinary team meetings.

ANDREW STUART CODLING · Prevention of Future Deaths report View report

23 Jun 2017 Bedfordshire and Luton I. Pears

Andrew Stuart Codling, aged 39, was found hanging at Old Warden Tunnel Woods near Cardington, Bedfordshire, on 26 November 2016. He had previously attempted suicide and was under the care of the Biggleswade Community Health Team. Concerns were raised about the content and timing of the Team’s final call, including that it did not reinforce the availability of other sources of help before Monday morning.

Aston Soulsby · Prevention of Future Deaths report View report

22 Jun 2017 Black Country Z. Siddique

On 1 November 2016, schoolboy Aston Soulsby was struck by a bus while crossing Crankhall Lane, Wednesbury, after narrowly missing a Vauxhall Corsa. He sustained serious traumatic injuries and died in hospital on 7 November 2016. The inquest identified concern that pedestrians waiting in the hatched central area and vehicles passing parked vehicles there may cause confusion and pose risks to pedestrians and motorists.

Linda Jean BARANOWSKI · Prevention of Future Deaths report View report

22 Jun 2017 Hertfordshire G. Sullivan

Linda Baranowski was admitted to hospital with abdominal pain, collapse, skin discolouration and multi-organ failure, and died on 25 February 2016 after treatment at several hospitals. The inquest identified an inflammatory response potentially linked to one or more dietary supplements, including slimming tablets, tea and body cream; the hot slimming cream was highlighted as likely to have contributed. The report noted that these products and similar products remained widely available.

Constance Connolly · Prevention of Future Deaths report View report

22 Jun 2017 Inner South London A. Harris

Constance Connolly died at home on 8 March 2016 from disseminated Nocardia infection, with severe chronic obstructive airways disease also recorded. She declined hospital admission, and planned outpatient investigations were not completed. The report identified concerns about inadequate follow-up, failures in handover and communication, incomplete discharge information, and the failure to arrange a replacement scan appointment, describing these as a system failure in urgent follow-up after discharge from A&E.

Colin James SLUMAN · Prevention of Future Deaths report View report

21 Jun 2017 Exeter and Greater Devon E. Earland

Colin James SLUMAN suffered a burst varicose vein and exsanguinated before emergency services attended. Concerns included that the NHS Pathways protocol did not treat dizziness and being alone as triggers for a rapid response to catastrophic haemorrhage, that call handlers were not clinically trained and relied on the protocol, and that clinical supervision was not continuously available.