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Marjorie Nesbitt · Prevention of Future Deaths report View report

25 Jul 2016 South Yorkshire (Western) C. Dorries

Marjorie Nesbitt, who was bedbound and living alone with carers attending four times a day, died after a fan heater was turned up and left on overnight, making the room extremely hot. The inquest found that she died from hyperthermia in the presence of ischaemic heart disease and pulmonary emphysema, with old age and frailty as contributing factors. The principal concern was whether carers should receive training on managing similar situations involving heating and no overnight review.

Patricia Ann Cleghorn · Prevention of Future Deaths report View report

25 Jul 2016 Birmingham and Solihull L. Hunt

Patricia Ann Cleghorn, who had suicidal ideation and was awaiting an inpatient mental health bed, was found collapsed at home after receiving diazepam and was declared dead by paramedics on 14 December 2015. The concerns were the lack of an available inpatient bed, allowing her to self-medicate with potentially dangerous drugs despite repeated statements that she intended to overdose, and the absence of a formal risk assessment.

Yogalakshmi Sinnaiah · Prevention of Future Deaths report View report

25 Jul 2016 Portsmouth and South East Hampshire D. Horsley

Yogalakshmi Sinnaiah, aged 58, was struck by a lorry while crossing Dragon Street in Petersfield on 26 January 2016 and sustained instantly fatal multiple injuries. The report raised concern that the lorry’s nearside mirrors left a significant blind spot and that a passenger-side safety lens might have reduced the risk of the collision.

Alfie Wayne Eddie Gray · Prevention of Future Deaths report View report

25 Jul 2016 West Sussex P. Schofield

Alfie Wayne Eddie Gray, aged 7, drowned in a hotel resort pool in Sharm El Sheikh, Egypt, on 7 July 2015 after he went missing while playing in the pool. Concerns were raised that lifeguard provision was inadequate, lifeguards lacked medical training, communication was difficult, and lifeguards were off duty during lunchtime without this being communicated to the family.

Olawale ADELUSI · Prevention of Future Deaths report View report

22 Jul 2016 West London J. Chipperfield

Olawale Adelusi was arrested on 28 October 2014 and, after attempting suicide by hanging at court, was remanded to HMP Wormwood Scrubs, where he was found hanging in his cell on the morning of 3 November. The principal concern was the absence of an effective system for transmitting information relevant to the risk of self-harm and mental health, including information recorded during his police custody and hospital supervision. The inquest jury recorded the failure to transfer information and documentation at each stage as a contributory factor.

Alan George Stead · Prevention of Future Deaths report View report

22 Jul 2016 Staffordshire South A. Haigh

Alan George Stead, a serving prisoner at HMP Dovegate, became ill late on 20 January 2016 and died shortly after arriving at hospital. The principal concern was delays in taking and testing prisoners’ blood samples at HMP Dovegate, which could have serious consequences in some cases.

Stephen John Bird · Prevention of Future Deaths report View report

22 Jul 2016 Buckinghamshire C. Butler

Stephen John Bird underwent surgery for an Achilles tendon injury on 6 May 2016 and died at home on 11 May 2016. The recorded cause of death was pulmonary embolism due to deep vein thrombosis following recent surgery. Concerns included incomplete, inconsistent or conflicting records and an investigation report containing assumptions that conflicted with documentary records.

Nathan Luke Charman · Prevention of Future Deaths report View report

21 Jul 2016 County Durham and Darlington C. Oliver

Nathan Luke Charman died on 5 March 2016 after his car left an untreated, icy road, hit a tree and rolled. The report identified concerns that winter maintenance policy and decision-making did not account for extreme local or changing road conditions, and that the incident had not prompted formal review, learning or information sharing.

ROSEMARIE DEES · Prevention of Future Deaths report View report

19 Jul 2016 London Inner (South) H. QC

Rosemarie Dees died at home on 18 April 2016 after choking on a boiled sweet and losing consciousness. The medical cause of death was recorded as asphyxia caused by a food bolus in the larynx. The report raised concern that use of a supra-glottic airway may be inhibited by an undetected foreign-body airway obstruction.

Patricia Mercieca · Prevention of Future Deaths report View report

19 Jul 2016 Inner West London F. Wilcox

Patricia Mercieca, who had severe COPD and asthma and lived in assisted accommodation, pulled her emergency cord on 14 July 2015 and said that she could not breathe. She arrested shortly afterwards and was found deceased when the ambulance service arrived. Concerns included failures to provide correct information and follow up when she did not respond, to contact the resident manager, and to pass on relevant medical history and information requested by emergency services.

James Kane · Prevention of Future Deaths report View report

19 Jul 2016 County Durham and Darlington A. Tweddle

James Kane was admitted to hospital with gross ascites caused by advanced liver cirrhosis. A drain was inserted without an ultrasound scan on 2 January 2016, and after approximately 7.5 litres of fluid were drained, his condition deteriorated within an hour of the drain being removed; he died later on 3 January 2016. The principal concern was whether ultrasound scanning before drain insertion might have reduced the risk of bowel injury and death, despite there being no local support for changing existing policy or guidance.

Sidney Brian Alexander · Prevention of Future Deaths report View report

18 Jul 2016 South Lincolnshire P. Cooper

Sidney Brian Alexander, who had a cardiac transplant and other medical conditions, was admitted with several months of diarrhoea and treated for a suspected Crohn’s exacerbation. He later developed respiratory distress with diffuse right-sided infiltrates and died in hospital; a concern was raised that a biopsy report could not be fully completed because there was insufficient room on the form.

Khazna Jane Sara Khalaf · Prevention of Future Deaths report View report

18 Jul 2016 West Yorkshire (Western) M. Fleming

Khazna Jane Sara Khalaf became unwell after ingesting ecstasy at a nightclub in Cologne, was taken to hospital, later collapsed, and died on 20 November 2014 after developing cerebral oedema and hypoxic-ischaemic encephalopathy associated with ecstasy toxicity. The report identified concerns about hospital monitoring and treatment of low sodium levels, and about whether local protocols and guidelines adequately alerted clinicians to the risks and warning signs of ecstasy toxicity.

Sydney Mya Neil · Prevention of Future Deaths report View report

15 Jul 2016 Birmingham and Solihull L. Hunt

Sydney Mya Neil suffered from severe brittle asthma and died at Birmingham Children's Hospital after collapsing at a GP surgery following breathing difficulties. The report raised concerns about inadequate ventilation, lack of suction and lack of oxygen during resuscitation, and whether GP practices have sufficient expertise and equipment for emergencies.

Leilani Chute · Prevention of Future Deaths report View report

15 Jul 2016 West Sussex B. QC

Leilani Chute was delivered by Caesarean section after an unsuccessful trial of instrumental delivery and was in a moribund condition, with terminal bradycardia and no other signs of life. The inquest concluded that she died shortly after birth from hypoxic brain injury and umbilical cord occlusion. The principal concerns were the use of an unendorsed practice of manually pushing back the cervix and inadequate disclosure of relevant risks when obtaining consent for instrumental delivery rather than proceeding directly to Caesarean section.

Margaret Mary Gleeson · Prevention of Future Deaths report View report

15 Jul 2016 Manchester West S. Jones

Margaret Mary Gleeson underwent elective incisional hernia repair and sustained a tear to her mesentery, after which her condition deteriorated and she developed sepsis. She suffered a cardiac arrest during further surgery and died on 4 October 2015; concerns included weekend staffing levels and inaccurate or poorly understood use of the MEWS tool.

Fred Whittaker · Prevention of Future Deaths report View report

14 Jul 2016 Manchester South A. Bridgman

Fred Whittaker, who had schizophrenia and was known to abuse drugs and alcohol, attended hospital with chest pains and drowsiness after taking codeine, alcohol and methadone, but self-discharged and went home. He was found dead in his flat the following morning; the inquest concluded that he died from developing bronchopneumonia and combined codeine, methadone and alcohol toxicity. A principal concern was that Clonazepam was restarted in error after his psychiatrist had requested that it be stopped, reflecting inadequate recording and procedures for discontinued prescriptions.

Patrick Curran · Prevention of Future Deaths report View report

14 Jul 2016 Manchester South A. Bridgman

Patrick Curran was diagnosed with lung cancer, underwent surgery, and was discharged with a chest drain. He was subsequently reviewed at nurse-led appointments without seeing a doctor, and at a four-week post-discharge review was frail, losing weight and struggling to recover. He was admitted with a pneumonia that had been developing for weeks and died in the early hours of 22 February 2016. The principal concerns were the lack of adequate medical oversight of postoperative reviews and the discharge of patients by nursing staff without adequate medical overview.

Mr Harold Goulding · Prevention of Future Deaths report View report

14 Jul 2016 London (East) N. Persaud

Mr Harold Goulding suffered two falls at a care home on 5 and 6 November 2015, followed by a subdural haematoma, seizure and cardiac arrest; he died on 10 November 2015. The concerns included communication failures between the anticoagulation clinic, GP and care home, and the GP not checking the care home’s medication administration record, meaning he was unaware that Mr Goulding was receiving warfarin.

Alice Poppy Madeleine Gross · Prevention of Future Deaths report View report

12 Jul 2016 Inner West London F. Wilcox

Alice Poppy Madeleine Gross, aged 14, was murdered in a sexually motivated attack near the River Brent in Hanwell, Ealing, on or soon after 28 August 2014; her body was discovered concealed and weighted down in the river on 30 September 2014. The principal concerns included inconsistent checking of foreign criminal convictions on arrest, incomplete international conviction data and weaknesses in the border watch-list system.