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Frederick Squires · Prevention of Future Deaths report View report

31 Oct 2016 Milton Keynes T. Osborne

Frederick Squires was involved in a low-impact road traffic collision, sustained a head injury, and was discharged home after his warfarin and other medications were stopped. He was later found unwell, diagnosed with an acute ischaemic stroke, and died on 30 December 2014. The principal concern was the lack of guidance for clinicians on when warfarin should be recommenced after a head injury.

James Francis Flynn · Prevention of Future Deaths report View report

31 Oct 2016 Milton Keynes T. Osborne

James Francis Flynn, who had chronic pancreatitis, was discharged home late on 8 December 2015 and was found unresponsive at home the following day; death was confirmed at 18:06. Concerns included discharge while he remained very unwell without a detailed care plan, with his immediate family unaware and no food or provisions available despite his type 2 diabetes, and that inadequate discharge planning and management could put patients’ lives at risk.

Anthony Thomas McManus · Prevention of Future Deaths report View report

31 Oct 2016 Milton Keynes T. Osborne

Anthony Thomas McManus, who was detained under Section 37 of the Mental Health Act and resident at Chadwick Lodge, was found hanging from a bathroom door using a draw string bag after he was not visible during overnight checks on 8 December 2015. Concerns were raised about the unit’s observation system, including observations being conducted at fixed times, some not being carried out, and charts being completed retrospectively.

Barbara Turner · Prevention of Future Deaths report View report

28 Oct 2016 Derby and Derbyshire R. Hunter

Barbara Turner, an 81-year-old woman, was admitted for an elective left total knee replacement and was later found unresponsive. She underwent a CT scan and was admitted to intensive care, where she died on 11 May 2015. The report identified concerns about resuscitation-call criteria, failures to recognise and respond to her critical illness, missed vital-sign observations, and the unsafe arrangements for transporting her to and from the CT scanner.

Alfred Grimshaw · Prevention of Future Deaths report View report

28 Oct 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

Alfred Grimshaw had an unwitnessed fall at a residential care home on 26 May 2016, was admitted to hospital, and was discharged before being readmitted when a fractured hip was identified. He underwent surgery and died from bronchopneumonia on 6 June 2016. Concerns included the failure to obtain a hip X-ray after the fall and inability to mobilise, failure to report a hip fracture visible on an abdominal X-ray, and lack of evidence that requested physiotherapy or occupational therapy reviews occurred before discharge.

Leslie Isaac LERNER · Prevention of Future Deaths report View report

28 Oct 2016 Brighton and Hove V. Hamilton-Deeley

Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.

Samuel Thomas Lindor Carroll · Prevention of Future Deaths report View report

27 Oct 2016 North Yorkshire (West) J. Heath

Samuel Thomas Lindor Carroll contacted emergency services stating that he felt suicidal and wanted to jump off a bridge, and was taken to hospital for a mental health assessment before being discharged. He was later found hanging from a tree and died from asphyxia due to hanging by ligature. The report raised concerns that police and ambulance staff did not ask whether he consented to family or friends being informed, meaning no family or friends were alerted to his hospital attendance or discharge.

Alfie Rose · Prevention of Future Deaths report View report

26 Oct 2016 Birmingham and Solihull L. Hunt

Alfie Rose, aged 17, died on 09 June 2016 following deterioration from obstructive hydrocephalus, severe brain injury and brain stem death. The report identified poor communication between the two hospitals and inadequate guidance and education for clinicians in outlying hospitals as principal concerns. The inquest concluded that earlier detailed MRI scanning, admission and treatment at the Queen Elizabeth Hospital neurosurgical unit would, on balance, have avoided his death.

Jane Louise Reason · Prevention of Future Deaths report View report

25 Oct 2016 Birmingham and Solihull L. Hunt

Jane Louise Reason, a lecturer, collapsed at work on 28 April 2016 and was later declared deceased in hospital; the medical cause of death was recorded as hypertensive heart disease. The inquest highlighted the importance of early defibrillation and CPR and raised concern about the availability and public education surrounding public access defibrillators, particularly in colleges and schools.

Kevin Andrew Heffernan · Prevention of Future Deaths report View report

25 Oct 2016 Hertfordshire G. Danbury

Kevin Andrew Heffernan died after losing control of his BMW in poor weather on the M25 on 27 March 2016, colliding with other vehicles and falling from the motorway. The principal concern was a approximately 16-metre flow of water across the carriageway, which police considered may have contributed to the collision and posed a danger to road users during heavy rain; 18 collisions had been recorded at the location in the preceding five years.

Nihad Ousta · Prevention of Future Deaths report View report

25 Oct 2016 West London C. Inyama

Nihad Ousta was admitted to a mental health ward and suffered visible head trauma on two occasions before deteriorating and undergoing neurosurgical treatment. He was later transferred to a nursing home and then admitted to St George’s Hospital, where he died several months later. The report identified the absence of written guidance or a protocol for managing head injuries, including the frequency and range of general and neurological observations.

Richard Walsh · Prevention of Future Deaths report View report

25 Oct 2016 Inner South London A. Harris

Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

Matthew Llewellyn-Jones · Prevention of Future Deaths report View report

25 Oct 2016 Exeter and Greater Devon L. Brown

Matthew Llewellyn-Jones, who had been detained under section 2 of the Mental Health Act after becoming acutely unwell with psychosis, left a locked hospital ward unaccompanied and was later found hanging by a ligature in the hospital grounds. The concerns included breaches of the ward’s locked door, predictable observations, inadequate collection of information from family and carers, insufficient assessment and observation, inadequate staff induction, and staffing levels that contributed to failings in his care and security.

Ivy Atkin · Prevention of Future Deaths report View report

25 Oct 2016 Nottinghamshire S. Haskey

Ivy Atkin was a resident at Autumn Grange Residential Care Home and died as a result of gross neglect. The Provider and its Nominated Individual were convicted of offences arising directly from her death, and an inquest recorded a conclusion of unlawful killing. Concerns included the Nominated Individual’s failure to provide a DBS certificate and a regulatory loophole affecting the independent assessment of suitability for that role.

Margaret Mary Dempsie · Prevention of Future Deaths report View report

24 Oct 2016 Leicester City and South Leicestershire D. Hocking

Margaret Mary Dempsie, who had advanced dementia and frailty, was admitted to hospital for treatment of infected leg ulcers, later deteriorated with sepsis, and died two days after discharge for end-of-life care. The discharge letter contained inaccurate and incomplete clinical information, including an incorrect reference to aspiration pneumonia and omission of pyelonephritis, raising concerns that vulnerable patients could receive inappropriate care based on incorrect discharge information.

Sally Frances Eveleigh · Prevention of Future Deaths report View report

24 Oct 2016 Somerset T. Williams

Sally Frances Eveleigh, aged 70, died after her vehicle pulled out onto the A358 at the junction with Station Road and collided with a van. The concern was whether a sign indicating previous accidents at the junction should also have prompted a review of the maximum speed for approaching vehicles.

Joan Lilian Green · Prevention of Future Deaths report View report

24 Oct 2016 Central Lincolnshire P. Smith

Joan Lilian Green, aged 77, was killed when the Audi in which she was a front-seat passenger was struck by an HGV while turning across the southbound A1 near Marston, Lincolnshire, on 21 March 2015. The principal concern was that the junction was challenging, with evidence of near misses and other fatal collisions involving vehicles turning across southbound traffic, although no road defects were identified as contributory.

Hunter Jack Macmillan · Prevention of Future Deaths report View report

24 Oct 2016 West London C. Inyama

Hunter Jack Macmillan was taken to the Emergency Department at West Middlesex Hospital after being booked into the Urgent Care Centre, but was not triaged for over 45 minutes as his condition deteriorated. The report raised concerns that staffing levels were insufficient to follow national or local policies for treating suspected sepsis.

Jeff Miles · Prevention of Future Deaths report View report

24 Oct 2016 Somerset T. Williams

Jeff Miles had a history of pulmonary fibrosis, systemic sclerosis, pulmonary hypertension and small airways obstruction, and had been exposed to white spirit during his employment. The report states that his 13-year occupational exposure involved direct skin contact and vapour exposure and resulted in his death from industrial disease, described as fatal scleroderma.

Victoria Georgia Halliday · Prevention of Future Deaths report View report

20 Oct 2016 Leicester City and South Leicestershire L. Brown

Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality disorder.