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John Davies · Prevention of Future Deaths report View report

26 Apr 2017 Manchester South A. Mutch

John Anthony Davies had Lewy body dementia and Parkinson’s disease and died on 23 October 2016 after deterioration following an infected pressure sore. Concerns included inadequate risk assessment when his care needs changed, poor communication and information sharing, incomplete records, lack of continuity of care, difficulties securing a suitable nursing home placement, and failures relating to pressure-relieving strategies.

Joleen Linton · Prevention of Future Deaths report View report

25 Apr 2017 Coventry J. Pegg

Joleen Linton died on 3 August 2016 in her room on Spencer Ward, Caludon Centre, after being admitted as an informal patient following an overdose of prescribed drugs. She was discovered deceased at 0800 hours after hourly observations, with concerns about the practicality and reliability of observations, inaccurate recording of her position, reluctance to enter patients’ rooms, and a lack of clarity in the relevant policy.

Linsay Bushell · Prevention of Future Deaths report View report

25 Apr 2017 Liverpool and the Wirral A. Rebello

Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.

Jamie Neil Elliott · Prevention of Future Deaths report View report

25 Apr 2017 Inner North London E. Buckett

Jamie Neil Elliott died by hanging at his home on 18 November 2016, with an inquest conclusion of suicide. Before his death, he had expressed clear, detailed and escalating suicidal ideation and had declined offered voluntary inpatient admission. Concerns included failures to contact his private therapist and to provide a face-to-face psychiatric assessment after his condition deteriorated.

Barry Stuart Hodges · Prevention of Future Deaths report View report

24 Apr 2017 South Yorkshire (Eastern) S. Slater

Barry Stuart Hodges, a 69-year-old man, collapsed with chest pains at a tennis club on 23 August 2016 and died after being transferred to hospital following cardiac arrest. The report identified failures to follow ambulance dispatch and resource-review protocols, insufficient safety-netting and apparent gaps in staff knowledge or training, with available resources not allocated and escalation not undertaken when timescales were breached.

Najeeb Katende · Prevention of Future Deaths report View report

21 Apr 2017 Inner North London E. Buckett

Najeeb Katende collapsed at school while in cardiac arrest and was not defibrillated for about 24 minutes because his initially shockable rhythm was interpreted as non-shockable. He was later defibrillated but died in hospital; the medical cause of death was Sudden Cardiac Death Syndrome. Concerns included the failure to cross-check the rhythm interpretation and the use and interpretation of the defibrillator device.

David Thomas Evans · Prevention of Future Deaths report View report

21 Apr 2017 South Wales Central P. Spinney

David Thomas Evans presented with severe abdominal pain and an ultrasound scan revealed an aortic diameter of 40mm, but no further investigation was conducted and he was discharged. He was later admitted with a ruptured aortic aneurysm, underwent emergency surgery, and died later that day from complications following a ruptured thoraco-abdominal aneurysm. Concerns included inadequate training and supervision for the FAST ultrasound examination, the routine non-retention of scan records, and insufficient escalation of care when a symptomatic patient has an identified abdominal aortic aneurysm.

Mr Errol Mann · Prevention of Future Deaths report View report

20 Apr 2017 London (East) N. Persaud

Mr Errol Mann was admitted to hospital with suspected hyperosmolar hyperglycaemia, sepsis and pulmonary embolism, and later suffered a fatal pulmonary embolism on 7 August 2015. The report identified failures to investigate or exclude pulmonary embolism and to ensure consistent VTE prophylaxis, and raised concerns about inadequate ICU staffing affecting patient care.

Patricia Margherita WEBB · Prevention of Future Deaths report View report

20 Apr 2017 Brighton and Hove V. Hamilton-Deeley

Patricia Margherita WEBB was an 86-year-old woman who was admitted to hospital after which she experienced six falls, fracturing her hip in the sixth fall. The report raised concerns about fall prevention, observation and meaningful activity, footwear and mobility, staffing and ward layout, handover arrangements, resources, and delays in discharge.

Harold Mullins · Prevention of Future Deaths report View report

20 Apr 2017 South Wales Central A. Barkley

Harold Mullins, aged 92, was admitted to hospital after a fall or collapse at home and was found to have a fractured left femur. Following surgical repair, his observations deteriorated, but he was not examined by a clinician in a timely fashion; he later suffered a cardiac arrest and could not be resuscitated. Concerns included the surgical team being unaware of his history of deep vein thrombosis and delays in responding to his deteriorating NEWS scores.

Sian Marie Hollands · Prevention of Future Deaths report View report

20 Apr 2017 North West Kent R. Hatch

Sian Hollands attended Darent Valley Hospital on 14 November 2015 with breathlessness and chest pain after recent surgery and possible opiate withdrawal. She was later suspected to have a pulmonary embolus, suffered a cardiac arrest, and died on 15 November 2015. The stated concerns included PAR scoring and staff training, doctors not being provided with nurses’ medical notes, and failure to correctly diagnose pulmonary embolism.

Thomas Whitfield · Prevention of Future Deaths report View report

20 Apr 2017 County Durham and Darlington A. Tweddle

Thomas Whitfield was a voluntary patient at Farnham Ward, Lanchester Road Hospital, and was found hanging in his room on the morning of 28 July 2016, shortly after being re-assessed by his Consultant Psychiatrist. The concerns included whether information from his sister about perceived suicide risk was communicated and recorded, and the absence of monitoring or recording of telephone calls that might have clarified what was said.

Charlotte Anne Agnew · Prevention of Future Deaths report View report

20 Apr 2017 City of London A. Hewitt

Charlotte Anne Agnew became psychiatrically unwell and expressed suicidal ideation. After referrals to psychiatric services, her care was not effectively transferred, her suicide risk was not sufficiently assessed or managed, and no care plan was put in place; she died on 25 March 2016 after ingesting high levels of alcohol and medication and jumping in front of a London Underground train. The report identified an ongoing risk that similar failures in timely assessment, treatment, care transfer and suicide-risk management could recur.

Johan Stone Pambou · Prevention of Future Deaths report View report

20 Apr 2017 Birmingham and Solihull L. Hunt

Johan Stone Pambou, who had sickle cell disease, was admitted with severe abdominal and joint pain and later deteriorated, was diagnosed with pneumococcal septicaemia, and died on 11 December 2016. Concerns included failures by the GP practice to act on four hospital letters requesting pneumovax 23 vaccination, and concerns about the vaccine’s availability and whether GPs understood how to access it.

Elaine Talbot · Prevention of Future Deaths report View report

19 Apr 2017 Manchester North L. Hashmi

Elaine Talbot had experienced headaches, nausea and vomiting for approximately three weeks before being taken to hospital on 31 August 2016, where she was diagnosed with migraine and discharged without a CT scan. She returned extremely unwell on 7 September 2016; a CT scan identified a large brain mass, and she died at Fairfield General Hospital the same day following a cardiac arrest. The principal concern was the lack of urgent direct access to CT scanning for primary-care clinicians, which could potentially affect outcomes for others.

David Lee BIRTWISTLE · Prevention of Future Deaths report View report

18 Apr 2017 Avon T. Moore

David Lee Birtwistle died from a pulmonary embolism after being diverted from an accident and emergency assessment two days before his death, meaning further tests were not carried out. Concerns included the absence of NHS 111 referral information for the front door or emergency department and the need for NHS 111 to share information with emergency departments in a user-friendly format.

Daniel Maher · Prevention of Future Deaths report View report

18 Apr 2017 Surrey A. Crawford

Daniel Maher was found hanging at his home on 26 May 2016, and efforts to resuscitate him were unsuccessful. The report raised concerns that significant information about vulnerable individuals may not be readily accessible when mental health services in West Sussex and Surrey are involved, including because of limited access to records and reliance on verbal referrals without routinely shared paperwork.

Mark Craig BANKS · Prevention of Future Deaths report View report

14 Apr 2017 Exeter and Great Devon District E. Earland

Mark Craig Banks, a homeless man with long-term alcohol and mental health problems, died from exposure in an unmade tent near the Tarka Trail in bad weather in the early hours of 23 February 2015; alcohol was a factor. Concerns included failures to contact or correctly grade an ambulance call and insufficient efforts to search for and check on Mr Banks’ wellbeing.

Daniel Campbell · Prevention of Future Deaths report View report

13 Apr 2017 North Northumberland T. Brown

Daniel Campbell, aged 25, died instantly on 24 November 2015 after stepping into the path of a high-speed train between Spittal and Scremerston, Northumberland. The principal concern was that broken, missing or poorly maintained fencing and walls between a public footpath and the railway line created an easy opportunity for impulsive acts of suicide.

Michael John NEWELL · Prevention of Future Deaths report View report

13 Apr 2017 Preston and West Lancashire J. Adeley

Michael John Newell died following an admission involving haemorrhage, decompensated liver failure and associated coagulopathy. Concerns included a lack of awareness among emergency and surgical staff of the significance of his liver failure, inadequate recognition and treatment of hypovolaemia, lack of consultant ENT input, weaknesses in the mortality review process, and nursing documentation and management issues.