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Dean Gary Saunders · Prevention of Future Deaths report View report

17 Feb 2017 Essex C. Beasley-Murray

Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.

Mr Dokic · Prevention of Future Deaths report View report

17 Feb 2017 Inner West London F. Wilcox

Mr Dokic was travelling by motorcycle on Battersea Park Road on 1 March 2016 in wet conditions when he lost control after entering a blue cycle lane, struck a bollard and sustained fatal injuries. The principal concerns were that the cycle highway surface had reduced grip, potentially creating a hazard for cyclists and other vulnerable road users, particularly at junctions, and that similar dangerous areas might exist elsewhere.

Thomas Josef Green · Prevention of Future Deaths report View report

16 Feb 2017 Manchester South J. Kearsley

Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD services.

ETHELINE DE-GALE · Prevention of Future Deaths report View report

16 Feb 2017 Bedfordshire and Luton I. Pears

Etheline De-Gale fell while mobilising from bed at a care setting on the night of 7/8 March 2016. Hospital admission was declined, follow-up with a doctor did not occur as recommended, and an ambulance attended the following afternoon; she later underwent surgery, contracted bronchopneumonia and died from a pulmonary embolism on 16 March 2016. Concerns included an insufficiently clear care plan, inadequate guidance on risk assessments, limited staffing, and the apparent failure to follow paramedic recommendations.

Derek LEE · Prevention of Future Deaths report View report

14 Feb 2017 Brighton and Hove V. Hamilton-Deeley

Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

David Ivor Alexander · Prevention of Future Deaths report View report

14 Feb 2017 Exeter and Greater Devon L. Brown

David Ivor Alexander, an experienced lorry driver and mechanic, was killed instantly when a loaded trailer overturned onto him during the unloading of animal feed. Concerns included limited understanding and reporting of overturns, inadequate industry guidance and inspection practices for hydraulic ram brackets, and the lack of routine use of inclinometers despite the risk posed by slight gradients.

Wendy Louise Telfer · Prevention of Future Deaths report View report

14 Feb 2017 Exeter and Greater Devon L. Brown

Wendy Louise Telfer died on 20 March 2016 in hospital from an overdose of purchased non-prescribed medication taken five days earlier; the medical cause of death was recorded as liver failure due to paracetamol overdose, with asthma also recorded. The report identified concerns about missed opportunities to keep Wendy safe, confusion about applying the Mental Health Act in a physical care setting, and the lack of an available psychiatric inpatient bed.

Ms Natasha Ford · Prevention of Future Deaths report View report

13 Feb 2017 Black Country Z. Siddique

Ms Natasha Ford was found at Raglan House with a plastic bag over her head secured by shoelaces and died after being taken to hospital. The inquest heard that she had previously placed a plastic bag over her head, after which restrictions on plastic bags were introduced briefly and then removed following a policy change.

Roger Harold Tombs · Prevention of Future Deaths report View report

13 Feb 2017 Birmingham and Solihull E. Brown

Roger Harold Tombs died at Queen Elizabeth Hospital on 4 May 2016 after being admitted following a fall at Sunrise Care Home. He had a history of learning disabilities and an increasing risk of falls; the medical cause of death included bronchopneumonia and severe traumatic brain injury. Concerns included the failure of fall sensor mats to sound an alert and the practice of placing them on top of crash mats, which may reduce their effectiveness.

Mr Raymond Edwards · Prevention of Future Deaths report View report

10 Feb 2017 North Wales (Eastern and Central) N. Jones

Mr Raymond Edwards underwent surgery for ischaemic bowel and later developed an anastomotic leak, sepsis and multi-organ failure; he died on 2 December 2015. The principal concern was the absence of a reliable system for ensuring that histology results reached the named consultant, in this case delaying awareness of amyloidosis.

Rachel Morgan · Prevention of Future Deaths report View report

10 Feb 2017 Manchester South A. Morris

Rachel Morgan, who had post-natal depression with psychotic symptoms and was considered at high risk of suicide, was found with a ligature around her neck on 16 April 2016 and died from severe anoxic brain injury on 24 April 2016. The principal concerns were delays in reviewing her medication, failures to update risk assessments after information about her suicide risk was received, insufficient observation levels, and a lack of clarity about observation procedures.

Matthew Christopher Roberts · Prevention of Future Deaths report View report

9 Feb 2017 West Sussex B. QC

Matthew Christopher Roberts, a music student with a history of psychosis and a previous intentional insulin overdose, took a large overdose of insulin and prescribed psychotropic medication after returning to Sussex. He was admitted to intensive care in a coma with significant hypoxic brain damage and later died from a major haemorrhage at the tracheostomy site caused by acute arteritis of the innominate artery. Concerns included failures to log and scrutinise referral faxes, consider written clinical and risk information before assessing urgency, confirm the date of first contact, and formally review the death and seek relevant learning.

Warren Michael Myers · Prevention of Future Deaths report View report

9 Feb 2017 County Durham and Darlington A. Tweddle

Warren Michael Myers died in a fatal road traffic collision on 22 June 2016 while riding a motorised trike on a bend in County Durham. The principal concern was that the warning signage approaching the bend was inadequate.

Anna Larissa Elisabeth Phillips · Prevention of Future Deaths report View report

8 Feb 2017 Cornwall and Isles of Scilly A. Cox

Anna Phillips had a history of mental illness, overdoses and contact with mental health services. On 1 June 2015, after taking an overdose of 2,4 Dinitrophenol obtained over the internet from Turkey, she was admitted to hospital and died later that day. The report raised concerns that the drug was an unlicensed weight-loss compound associated with several fatalities and had been brought into the country by Royal Mail.

DAVID SEAN READ · Prevention of Future Deaths report View report

8 Feb 2017 Norfolk J. Lake

David Sean Read collapsed after injecting heroin on 1 July 2016 and died in hospital on 3 July 2016. Concerns were raised about the handling and timing of his Community Mental Health Team appointments, including that a replacement appointment was scheduled more than 16 weeks after re-referral, during which time he died.

Mrs Sheila Bowling · Prevention of Future Deaths report View report

7 Feb 2017 South Yorkshire (Western) C. OBE

Mrs Sheila Bowling was crossing a road in Sheffield City Centre on 6 November 2013 when she was hit by a First Mainline bus and subsequently died of her injuries in hospital. The report raised concern about the vehicle’s “Drive Clean System”, which promoted smooth driving and recorded sudden braking or steering, and whether its operation or related training warranted improvement.

Natalie Ann Thornton · Prevention of Future Deaths report View report

6 Feb 2017 Manchester North S. Nelson

Natalie Thornton, who had longstanding brittle type 1 diabetes and related complications, began insulin pump therapy in December 2014. On 18 January 2015 she became unwell, collapsed, and died; the inquest concluded that the medical cause of death was diabetic ketoacidosis. Concerns were raised about the adequacy of monitoring and review of blood sugar data after the pump was introduced, including that trends were not analysed, and about variable national support for insulin pump users.

Nuala Seddon · Prevention of Future Deaths report View report

6 Feb 2017 Inner North London R. Brittain

Nuala Seddon developed a hypoxic brain injury after a cardiac arrest on 27 November 2014, following her transfer from ITU to ward-based care, and died on 7 April 2016 after developing pneumonia. The report raised concern that a lack of available telemetry could expose patients discharged from ITU to significant risk of unrecognised deterioration.

Gerome Baon Reyes · Prevention of Future Deaths report View report

3 Feb 2017 Southampton and New Forest G. Short

Gerome Baon Reyes died on 22 May 2016 aboard MV Moonray after activating a goods lift while its door was open; he was dragged up as the lift ascended and sustained fatal head and trunk injuries. The lift had no door limit switch, and concerns were raised about whether recommendations for the lift had been implemented and whether other ships of the same design posed similar risks.

David Robert Griffiths · Prevention of Future Deaths report View report

3 Feb 2017 South Wales Central P. Spinney

David Robert Griffiths died after a pleural drain inserted to treat a pleural effusion penetrated his heart during a procedure at the University Hospital of Wales on 29 September 2016. Concerns included the absence of local protocols and specific training for intercostal drain insertion, and the unavailability of real-time ultrasound guidance despite its support in relevant guidelines.