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ROBERT ENTENMAN · Prevention of Future Deaths report View report

3 Feb 2017 London Inner (South) H. QC

Robert Entenman was an intubated intensive care patient whose humidifier was turned off from around 12.00pm on 22 May 2015 until 6.00am on 23 May 2015. A mucus plug blocked his endotracheal tube, leading to cardiac arrest shortly after 6.00am; he died on 30 May 2015. Concerns included failures to observe that the humidifier was off, the absence of an alarm on the humidifier, delays in identifying and replacing the blocked tube, and possible delays in communicating suction difficulties to doctors.

James Kerry Fox · Prevention of Future Deaths report View report

2 Feb 2017 North London A. Walker

James Kerry Fox, who had been suffering from depression and anxiety, was shot by police officers after opening the door of his flat while holding an air weapon pointed in the officers’ direction. The inquest concluded that the death was lawful killing. The principal concerns included the accuracy of close-range shots, the lack of detailed contingency planning, the availability of less-lethal firearms and enhanced ballistic protection, firearms response tactics, and inconsistencies and lack of national standardisation in police firearms training.

Gordon Arthur · Prevention of Future Deaths report View report

2 Feb 2017 Manchester West R. Griffin

Gordon Arthur underwent a right total hip replacement on 18 August 2016 and subsequently developed an infection at the surgical site, suffered a cardiac arrest, and died on 5 October 2016. The principal concern was the lack of policies governing investigative tests and the notification of results to consultants, which could result in patients not receiving required treatment and a future death.

Dipa Rameshchandra Lad · Prevention of Future Deaths report View report

31 Jan 2017 Nottinghamshire H. Connor

Dipa Lad died after using an item of clothing to ligate on 4 March 2016; the medical cause of death was ligature pressure to the neck. The principal concerns related to differences between national guidance and the local ambulance protocol for stopping resuscitation, including the lack of guidance on when resuscitation was futile, staff awareness and training, and the clarity of the procedure. A further concern related to the technique used by one technician when giving chest compressions.

Frederick Chisnall · Prevention of Future Deaths report View report

30 Jan 2017 Cheshire J. Napier

Frederick Chisnall was subject to a Deprivation of Liberty Order and receiving one-to-one nursing care from agency staff when he died following a myocardial infarction. Concerns were raised about agency staff producing proper documentation, recognising changes in clinical condition, and obtaining urgent medical or nursing help when appropriate; the adequacy of their training was questioned.

David Holman · Prevention of Future Deaths report View report

30 Jan 2017 Cheshire J. Napier

David Holman died instantly on 13 July 2016 after riding his pedal cycle from the pavement into the path of an oncoming HGV on the A556 at Plumley. Concerns were raised about the absence of a cycle lane, an obstructing road-sign support, and a dip in the kerb, which may have contributed to him leaving the footpath and could increase the risk of a similar occurrence.

Margaret Atkinson · Prevention of Future Deaths report View report

30 Jan 2017 County Durham and Darlington A. Tweddle

Margaret Atkinson, who had a long history of mental health illness and was in prison healthcare, was found unresponsive in her cell on 24 January 2016 after staff observed clothing around her neck and delayed entering the cell; she died in hospital on 2 February 2016. The jury found that staff should have entered earlier, and the report identified difficulties in describing such situations and assessing risk when unusual behaviour had become accepted as normal.

Derek Edward Hope THOMAS · Prevention of Future Deaths report View report

27 Jan 2017 Hampshire (North East) A. Bradley

Derek Edward Hope THOMAS was struck by a non-stopping train while using the foot crossing at Bentley station on his mobility scooter on 5 October 2016, sustaining catastrophic injuries. Concerns included that the crossing was unmanned and unprotected, that the only direct warning was the train driver's horn, and that visibility was obscured by a fence.

Frances Olwyn Coppaccini · Prevention of Future Deaths report View report

27 Jan 2017 Kent (North-West) R. Hatch

Frances Olwyn Coppaccini died on 9 October 2012 at Tunbridge Wells Hospital following the birth of her child. The report raised concerns about retained placental tissue after caesarean section, failure to follow the post-partum haemorrhage protocol, supervision of anaesthetic staff, delays in obtaining urgent specialist help, and inadequate hospital note keeping.

Albie Henderson Marlow · Prevention of Future Deaths report View report

26 Jan 2017 Bedfordshire and Luton T. Osborne

Albie Henderson Marlow was delivered by Category 2 Caesarean Section at 37 weeks’ gestation and was recorded as stillborn, although the family stated that he cried. The principal concern was that the mother’s requests for Caesarean delivery during labour were not respected, with the report stating that this placed babies’ lives at risk.

Mr Raymond Frank POLLARD · Prevention of Future Deaths report View report

25 Jan 2017 Brighton and Hove V. Hamilton-Deeley

Mr Raymond Frank Pollard was admitted to hospital with community-acquired pneumonia and respiratory and renal problems, including metabolic acidosis and high potassium levels. He was discharged to a rehabilitation nursing home without further arterial blood gas checks, a further doctor review, or reassessment before discharge, but became extremely unwell and required urgent hospital treatment. The principal concerns were that the discharge decision was poorly informed, that he was not reviewed for suitability for discharge, and that the failed discharge seriously compromised him.

Geraldine Butterfield · Prevention of Future Deaths report View report

25 Jan 2017 Surrey A. Crawford

Geraldine Butterfield died on 25 July 2015 after choking on food while eating lunch at a nursing home; the cause of death was recorded as asphyxia due to food inhalation. Concerns were raised that some nursing staff did not sufficiently understand or implement the choking policy, and did not sufficiently understand when potentially life-saving treatment should be provided to a person with a DNAR order.

Mrs Kaur · Prevention of Future Deaths report View report

24 Jan 2017 Black Country Z. Siddique

Mrs Kaur had a history of diabetes and recurrent depressive disorder and had used zopiclone for around five years, becoming reliant on it. She died by hanging at her home on 5 November 2017; concerns included her long-term use and apparent addiction to zopiclone and the decision to stop it immediately to prevent serious self-harm, although she subsequently continued receiving it and it was tapered over several weeks.

Mr Ronald Compson · Prevention of Future Deaths report View report

24 Jan 2017 Black Country Z. Siddique

Mr Ronald Compson, who had Parkinson’s disease, was admitted to hospital after confusion and drowsiness and later sustained an unwitnessed fall with a head injury. He subsequently became unresponsive and died from a subdural haematoma; concerns included failure to notify a doctor, vomiting episodes with poor record keeping, and poor communication with his family about the fall.

Teresa Dennett · Prevention of Future Deaths report View report

19 Jan 2017 Nottinghamshire H. Connor

Teresa Dennett suffered a rare type of stroke and was admitted to hospital on 6 February 2016. Attempts were made to arrange urgent neurosurgery, but transfer did not occur before she deteriorated and died later that morning. The principal concerns were the absence of a clear referral pathway for life-saving neurosurgery, inadequate access to diagnostic imaging, and insufficient input from stroke physicians in appropriate cases.

Thomas Coyne · Prevention of Future Deaths report View report

19 Jan 2017 Cheshire J. Pollard

Thomas Coyne consumed alcohol at a stag party, inadvertently entered Earlestown Railway station, accessed the railway lines and was struck by a passing train on 21 May 2016. Concerns were raised that station CCTV did not cover all platform areas and that there was no physical barrier at the end of platform three, allowing access to the tracks.

Michael Parke · Prevention of Future Deaths report View report

18 Jan 2017 Cumbria D. Roberts

Michael Parke, who had chronic liver disease, was admitted to West Cumberland Hospital and had a nasogastric tube inserted. The tube was misplaced into his left lung, an x-ray showing this was misinterpreted, and feeding and medication were administered through the tube before he developed aspiration pneumonia and died. The concerns included staff not following nasogastric-tube policy and systemic failures in policy implementation, training, competency checks, auditing and organisational learning.

Amanda Coulthard · Prevention of Future Deaths report View report

18 Jan 2017 Cumbria D. Roberts

Amanda Coulthard, who had multiple sclerosis, died on 26 April 2015 after a nasogastric tube entered her right lung and feed and medication were administered into it. She developed aspiration pneumonia. The concerns included failures to follow and implement nasogastric-tube policies and best practice, inadequate checking and training, and insufficient systems to ensure compliance and learn from previous deaths.

Shane Dean Hardy · Prevention of Future Deaths report View report

16 Jan 2017 Gloucestershire K. Skerrett

Shane Dean Hardy, a 29-year-old man with a history of substance misuse and involvement with mental health services, died after placing a belt around his neck and being found hanging from a tree on 8 March 2017. The report raised concerns that people with addiction and mental health difficulties can fall between services, and that agencies supporting an individual may not share information or identify a lead agency for communication.

Natalie Gray · Prevention of Future Deaths report View report

13 Jan 2017 Mid Kent and Medway P. Harding

Natalie Gray died after leaving Priority House, where she was an informal patient, and jumping in front of a train at Barming railway station on 21 April 2015. The principal concerns included insufficient risk assessments, inadequate handovers and failures in procedures for informal patient leave, communication of risk, recording third-party information and reporting her absence to police.