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Susan Sian JONES · Prevention of Future Deaths report View report

20 Oct 2016 Inner North London M. Hassell

Susan Sian Jones suffered a cardiorespiratory arrest at Hornsey Police station while waiting to make a statement about an allegation of historical sexual assault. At inquest, the jury concluded that her death resulted from methadone and alcohol intoxication together with inadequate police policies, procedures and training. The report identified a lack of specific protocol or training for monitoring members of the public in police stations who are not in police custody.

Colin Garth · Prevention of Future Deaths report View report

20 Oct 2016 Manchester West J. Pollard

Colin Garth was diagnosed with colon cancer on 5 May 2016, underwent surgery and Hickman line insertion, was readmitted on 18 June, and died at Royal Bolton Hospital on 19 June 2016. The medical cause of death included sepsis, Hickman line infection and pneumonia, and disseminated colonic carcinoma. Concerns included inadequate written guidance for patients discharged with Hickman or central lines, insufficient staff knowledge of relevant policy, and a syringe driver that failed to alarm when blocked and was reconnected rather than referred for repair or replacement.

Benjamin Orrill · Prevention of Future Deaths report View report

19 Oct 2016 Leicester City and South Leicestershire C. Swann

Benjamin Orrill died on 12 June 2016 following a fall from Lee Circle NCP car park, Leicester; the inquest concluded that the death was suicide. He had been reviewed by an advanced nurse practitioner after feeling suicidal, and the report identified concerns about the lack of a regulatory body and appraisal or revalidation processes for advanced nurse practitioners, with potential implications for patient safety.

John Graham SMITH · Prevention of Future Deaths report View report

18 Oct 2016 Manchester (City) J. Harkin

Mr Smith was discharged home after admission following a fall, despite concerns about his dementia, incontinence, mobility, difficult stairs and ability to care for himself and his wife. He was readmitted after another fall at home, underwent surgery for a fractured neck of femur, developed aspiration pneumonia and died. The principal concerns were inadequate risk assessment and questioning before discharge, including insufficient consideration of his toileting needs and the difficult staircase.

Isaac John Walter Brocklehurst · Prevention of Future Deaths report View report

18 Oct 2016 West Yorkshire (Western) M. Fleming

Isaac was playing on a ride-on plastic bike when he travelled through a gap in a low brick wall and into the path of a Scania tipper lorry, sustaining fatal injuries. The report raised a concern about the safety of existing pedestrian gaps in the perimeter wall, as children played in the communal grassed area.

Captain James Michael Bedford · Prevention of Future Deaths report View report

18 Oct 2016 South Yorkshire (Western) C. Dorries

Captain James Michael Bedford, a senior long-haul airline pilot, developed a left-leg deep vein thrombosis and later collapsed after a flight from China. He suffered a pulmonary embolus and cerebral events, followed by an acute cerebral haemorrhage after treatment with heparin, and died on 30 June 2015. Concerns included differing hospital practices regarding lower-leg scanning for DVT and whether a full-leg scan at his first attendance might have provided an opportunity for treatment.

Mr Vinod Kumar · Prevention of Future Deaths report View report

17 Oct 2016 Black Country Z. Siddique

Mr Vinod Kumar became seriously ill after developing flu-like symptoms and sustaining a graze to his right arm in a fall. He was diagnosed with sepsis secondary to necrotising fasciitis and died shortly after surgery on 10 August 2016. The concerns related to the initial emphasis on the fall, the lack of further observations or blood tests for about three hours, and whether he should have remained under observation before triage categorisation.

Brandon Aubrey ARNOLD · Prevention of Future Deaths report View report

14 Oct 2016 Bedfordshire and Luton I. Pears

Brandon Aubrey ARNOLD, a 15-year-old boy, was riding a motorcycle along a pavement without a crash helmet when he lost control, collided with a lamp-post and metal railings, and later died in hospital from his injuries. The report raised concern about motorcycles using pathways in the area, including the risk of death to pedestrians using the pathway appropriately.

Peter John Keep · Prevention of Future Deaths report View report

14 Oct 2016 Surrey K. Henderson

Peter John Keep, an 82-year-old man, was admitted after a fall and underwent pacemaker insertion for Mobitz type 2 heart block. During the difficult procedure he received several sedative and analgesic doses, lost his airway, and suffered cardiac tamponade from perforation of the right ventricle; he later had a cardiac arrest and died in intensive care. The principal concerns included inappropriate and inconsistent sedation, inadequate sedation policies and training, and a lack of action plans for procedure intolerance, airway loss, or difficulty placing the pacemaker wire.

Tyrone Lock · Prevention of Future Deaths report View report

13 Oct 2016 Shropshire, Telford and Wrekin J. Ellery

Tyrone Lock left a hotel wearing only boxer shorts and socks on a cold, windy night and was found deceased two days later in a pond. The jury concluded that he should have been classified as a vulnerable person rather than an absconder, and that a second helicopter request should have been made; it identified police failings contributing to his death.

Robert Arthur Davidson · Prevention of Future Deaths report View report

13 Oct 2016 Birmingham and Solihull L. Hunt

Robert Arthur Davidson, who had dementia, Alzheimer’s disease and PICA, died after choking on a plastic glove at a care home on 27 January 2016. The report identified concerns about inadequate transfer of information about his PICA, insufficient staff training and failures in emergency procedures, including calling emergency services and initiating CPR.

Philip David EVANSON · Prevention of Future Deaths report View report

13 Oct 2016 Cheshire A. Moore

Philip David Evanson died at the scene after sustaining multiple injuries when his motorcycle collided with a car on the A49 Tarporley Road on 27 May 2016. The report raised concerns that road markings at the junction with the ‘old’ Tarporley Road were significantly worn and partly indistinct, including markings for a ghost island, lane dividing lines and right-turn arrows.

Roy Patrick Hoey · Prevention of Future Deaths report View report

13 Oct 2016 Liverpool and the Wirral A. Rebello

Roy Patrick Hoey died by hanging using a curtain as a ligature while detained at HMP Altcourse on 4 September 2014. The report identified confusion among witnesses about the interpretation and application of safer custody and ACCT guidance, with potential implications for how risks of suicide or self-harm were assessed and managed in prisons.

Calam Atour · Prevention of Future Deaths report View report

12 Oct 2016 Wiltshire and Swindon D. Ridley

Calam Atour died by suicide in his room at Erlestoke House on 13 May 2015, after hanging himself by a ligature from the window. The inquest identified concerns about staffing shortages, medical support and coordination, the ACCT process, and the adequacy of monitoring and responses to suicide risk. The report also raised concerns that staffing levels and the way staffing requirements were assessed could create unsafe conditions for prisoners and prison officers.

Wayne Wesley Cornlouer · Prevention of Future Deaths report View report

12 Oct 2016 Dorset B. Allen

Wayne Cornlouer was found hanging in his cell on Collingwood Wing at approximately 5.50 am on 24 October 2014. The concern was whether all staff were aware that emergency coding had been added to the Night Orders after his death, following a delay before an ambulance was called.

Rohid SHERGILL · Prevention of Future Deaths report View report

12 Oct 2016 Nottinghamshire H. Connor

Rohid Shergill, who had Duchenne’s muscular dystrophy and was fed through a nasogastric tube, died on 14 March 2016 after the tube was inserted into his lung and was used for feeding and medication. The principal concerns included inadequate checking of the tube position, uncertainty about parental understanding of pH testing, insufficient information-sharing between trusts, unclear care coordination, and possible contamination from repeated syringe use.

Vichai Tonpradit · Prevention of Future Deaths report View report

11 Oct 2016 Hertfordshire G. Sullivan

Vichai Tonpradit died after falling from his motorcycle on the A1(M) and being struck by a heavy goods vehicle and a small hatchback. The report identified a raised section of tarmac as potentially hazardous and a solid white line from a previous road layout as potentially confusing.

Barry THOMPSON · Prevention of Future Deaths report View report

11 Oct 2016 Blackpool and the Fylde C. Doherty

Barry Thompson, an insulin-dependent diabetic, died on 27 February 2016 while a patient on the Acute Medical Unit, after being admitted with sepsis from diabetic foot ulcers and hyperglycaemia. The report identified concerns about failure to provide insulin, fluids, adequate monitoring, antibiotics and medical review, as well as inaccurate and incomplete records and ineffective information sharing during transfer between departments.

Ann Hardman · Prevention of Future Deaths report View report

10 Oct 2016 Isle of Wight C. Sumeray

Ann Hardman attended her GP with a painful swollen left calf and a positive D-Dimer test, but an ultrasound scan at St Mary’s Hospital was suboptimal because of technical limitations associated with her build. On 20 January 2015, after contacting her GP practice about chest pain, she declined advice to call 999 and was shortly afterwards found dead at home. The medical cause of death was pulmonary thromboembolism associated with thrombosis of the deep veins of the left calf. The concern was that the protocol relied on patients returning to their GP to obtain a further scan referral, rather than being automatically advised by the ultrasound department to attend a repeat scan.

Dr Debatra Sircar · Prevention of Future Deaths report View report

7 Oct 2016 Inner South London A. Harris

Dr Debatra Sircar had longstanding alcohol dependency and depression, and died on 20 February 2016 after a fall associated with alcohol intoxication, causing subdural and intracerebral haemorrhage. He had been assessed as unsuitable for home treatment, but a Mental Health Act assessment was scheduled 11 days later, and he died before it took place. Concerns included the delay in securing hospital care and the absence of a clear interim care plan and responsibility for psychiatric monitoring.