Search PFD Monitor

Michael Folley · Prevention of Future Deaths report View report

21 Jun 2017 Central Hampshire K. Harrold

Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.

PATRICK NEIL WOODS · Prevention of Future Deaths report View report

19 Jun 2017 Bedfordshire and Luton I. Pears

PATRICK NEIL WOODS was admitted to hospital with a cough, deteriorated while being treated with a Dräger Tiro Anaesthetic Machine, suffered cardiac arrest, and died from hypoxic brain injury on 15 February 2016. Concerns included the hospital’s lack of knowledge about its equipment portfolio, inadequate risk assessment, and ineffective training that meant clinicians were not trained on, or did not recognise the risks of, the machine used.

Russell William Sherwood · Prevention of Future Deaths report View report

16 Jun 2017 South Wales Central P. Spinney

Russell William Sherwood was found deceased in his vehicle after it was swept into flood water on New Inn Road, Bridgend. The concerns related to the Fire Service leaving the scene while flooding continued to pose a risk to life, without closing the road or leaving warning signs, and to limitations in equipment and protocols for road closures.

Katherine Anne Derbyshire · Prevention of Future Deaths report View report

16 Jun 2017 Manchester West T. Brennard

Katherine Anne Derbyshire, who had end stage chronic kidney disease, was admitted on 12 November 2016 after compromised dialysis function and a presumed blockage and infection of her peritoneal catheter. She deteriorated while awaiting transfer for ongoing dialysis, became unfit for transfer, and died on 21 November 2016 after palliative end-of-life medication was prescribed. The concerns included the failure to transfer her, delays in considering temporary dialysis, and inadequate communication and contingency planning between the two hospitals.

Lee Joseph Hastings Swain · Prevention of Future Deaths report View report

16 Jun 2017 Liverpool and the Wirral A. Bhardwaj

Lee Joseph Hastings-Swain, aged 28, was found deceased hanging from a bannister at his home on 30 November 2016. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included inadequate coordination and information-sharing between mental health services, delays in referral, poor clinical records, and insufficiently proactive engagement after his transfer between NHS trusts.

Mrs Macrae · Prevention of Future Deaths report View report

16 Jun 2017 Northamptonshire A. Pember

Mrs Macrae was admitted for elective lumbar spinal surgery and experienced intermittent drops in blood pressure during recovery. The report raises concern that internal haemorrhage was not considered as a possible cause of her instability and that this rare but recognised complication should be understood after similar surgery.

Aaron John Peter McCaffrey · Prevention of Future Deaths report View report

16 Jun 2017 Manchester South R. Galloway

Aaron John Peter McCaffrey had a history of addiction to loperamide and regularly took large quantities. After taking around 250 tablets on 13 January 2017, he collapsed, was admitted to hospital, and died on 19 January 2017; the recorded conclusion was a drug-related death. The principal concern was that there was no apparent limit on the amount of loperamide that could be purchased from a single store, facilitating large-quantity purchases and creating a risk of overdose and death.

Mrs Lily Townsend · Prevention of Future Deaths report View report

15 Jun 2017 Black Country Z. Siddique

Mrs Lily Townsend fell at home, was admitted to hospital with a fractured neck of femur, and died during cemented hemiarthroplasty after her oxygen saturation and blood pressure fell rapidly. Concerns included inadequate recording of her medical history, failure to identify her as being at extremely high risk for major surgery, inadequate consent, and whether an un-cemented operation might have reduced the risks.

Mr Kevin George Mann · Prevention of Future Deaths report View report

15 Jun 2017 East London N. Persaud

Mr Kevin George Mann underwent an Ivor Lewis procedure for oesophageal cancer and subsequently developed a pneumothorax. A Visipaque contrast study was performed despite the pneumothorax, and contrast entered his left main bronchus; his respiratory condition deteriorated and he later died. Concerns included failures to check available imaging and an outstanding chest x-ray request, to stop the procedure when contrast entered the bronchus, and to document the amount of contrast used.

Alaanuloluwa Joseph · Prevention of Future Deaths report View report

14 Jun 2017 West London S. Cummings

Master Alaanuloluwa Joseph died from sepsis, lung abscess and bacterial pneumonia at Great Ormond Street Hospital on 22 December 2015, after admission to Hillingdon Hospital earlier that day. Evidence indicated that fluid intake and output were not accurately monitored and recorded, despite the critical importance of fluid management in sepsis.

Ellie Jay Chappell · Prevention of Future Deaths report View report

14 Jun 2017 South Yorkshire (Eastern) N. Mundy

Ellie Jay Chappell was driving on the A614 on 2 January 2017 when her vehicle struck ice, lost control and collided with an oncoming vehicle; the report states that death was confirmed at the scene. The principal concern was the absence of warning signs about slippery road conditions on a stretch with previous collisions involving slippery roads, creating a risk to future drivers.

Mr Maurice Macdonnell · Prevention of Future Deaths report View report

14 Jun 2017 Inner South London A. Harris

Mr Maurice Macdonnell had advanced liver cancer and participated in a clinical trial of Nivolumab. After developing ptosis and fatigue, he received a second dose before the cause of the ptosis had been diagnosed, later becoming progressively weaker and dying after cardiac arrest; the inquest recorded myocarditis and myositis associated with an immune-related adverse reaction. The principal concern was a potential conflict of interest where the doctor deciding whether to administer the treatment was also the research investigator.

Rasikaben Lallubhai CHAUHAN · Prevention of Future Deaths report View report

14 Jun 2017 Northamptonshire H. Shah

Mrs Chauhan, an 84-year-old woman, was engulfed in flames on 27 December 2016 when an oil-burning candle became dislodged from her Hindu shrine and fell onto her sari-type robe. She sustained multiple burn injuries, and a concern was raised about whether awareness of this specific risk had been shared with relevant community and religious organisations at local or national level.

Craig Stuart Hamilton · Prevention of Future Deaths report View report

13 Jun 2017 South Yorkshire (Eastern) N. Mundy

Craig Stuart Hamilton died on 8 December 2016 from acute tramadol toxicity after taking excess Tramadol to relieve chronic pain and sleep before working the next day. The principal concerns were the absence of clear procedures for managing patients who obtain or take more medication than prescribed, and insufficient exploration of medication regimes, alternative pain management, and discussions about exceeding prescribed dosages.

William Joseph WILSON · Prevention of Future Deaths report View report

12 Jun 2017 Manchester South C. Murray

William Joseph WILSON choked on a piece of steak, suffered hypoxic brain damage and remained in a coma before receiving end-of-life care and dying in hospital on 2 February 2017. Concerns included that the designated first aider was not called, there was no clear system for alerting the first aider, and staff attending Mr Wilson were unfamiliar with all life-saving first-aid techniques.

Jeffrey William Matthews · Prevention of Future Deaths report View report

9 Jun 2017 Cumbria K. Cheema

Jeffrey William Matthews suffered fatal injuries when his motorcycle collided with a Nissan Juke at the C2051 crossroads on 26 March 2017. The report raised concerns that the crossroads and Give Way sign were obscured by hedgerows and that warning signage was inadequate, with previously recommended safety measures not implemented due to a lack of resources.

Dennis Allen Teesdale · Prevention of Future Deaths report View report

7 Jun 2017 West Sussex K. Henderson

Dennis Allen Teesdale underwent surgery including insertion of a PEG tube on 17 October 2016 and subsequently developed severe abdominal pain, multi-organ failure and septic shock. He was found to have peritonitis caused by leakage of bowel contents from the PEG tube passing through the bowel, and died on 20 October 2016. Concerns included the insertion and post-operative management of the PEG, delayed recognition and treatment of deterioration, delayed transfer, and limitations in specialist, diagnostic and laboratory services at Queen Victoria Hospital.

Callum Oliver SMITH · Prevention of Future Deaths report View report

7 Jun 2017 Avon M. Voisin

Callum Oliver SMITH was in the care of HMP Bristol when he was found hanging in his cell and died from hanging. The inquest concluded that his death was caused by suicide while he was suffering extreme anxiety and distress. Concerns included inadequate risk assessment and mental health assessment, poor communication and record-sharing, and repeated failures to open an ACCT due to training and staff-understanding issues.

Joyce Violet Rumming · Prevention of Future Deaths report View report

6 Jun 2017 Wiltshire and Swindon D. Ridley

Joyce Violet Rumming attended the Accident and Emergency Department on 11 December 2016 and was given Amoxicillin and Clarithromycin at 01.45 on 12 December 2016; she died just over half an hour later. The stated cause of death was respiratory failure, and the report says this did not appear to be related to an allergic reaction to Amoxicillin. The principal concern was that information about her recorded Amoxicillin allergy was not effectively communicated between systems and staff, resulting in the antibiotic being administered shortly before her death.

Mr George Arthur Cheese · Prevention of Future Deaths report View report

6 Jun 2017 Berkshire P. Bedford

Mr George Arthur Cheese, an 18-year-old man, was found hanging in woodland near his home on 9 April 2015. He had anxiety and depression with suicidal thoughts, and concerns were raised about the amount of Fluoxetine prescribed and the absence of a flag to limit repeat medication supplies.