Search PFD Monitor

Jonathan David Weatherley · Prevention of Future Deaths report View report

2 Jun 2016 Essex C. Beasley-Murray

Jonathan David Weatherley died from injuries sustained in an incident in which the bonding between carbon-fibre blades and an aluminium fork crown failed after he probably applied his front brakes. Concerns were raised about shortcomings in recall notices issued in October 2015 and March 2016, including the need to identify all known problems and potentially affected products and to alert as wide an audience as possible.

Terry Stapleton Latimer · Prevention of Future Deaths report View report

1 Jun 2016 North Lincolnshire and Grimsby P. Kelly

Terry Stapleton Latimer was found dead by hanging at his home on 27 May 2016, and an inquest determined that he died by suicide. A safeguarding notification submitted after police concerns was not acted upon appropriately, including a request to refer the case to Mental Health Services, with evidence of uncertainty about whether such notices required follow-up.

Rhi anne Anoushka Florence BARTON · Prevention of Future Deaths report View report

1 Jun 2016 Surrey K. Henderson

Rhi anne Barton developed severe abdominal pain and vomiting at 35 weeks of pregnancy after previous bariatric surgery and was later found to have a small bowel obstruction. She aspirated during induction of anaesthesia before surgery, developed severe physiological compromise and died in the early hours of 13 February 2015. The principal concerns included delays in investigation, diagnosis and surgical management, lack of consultant supervision, inadequate documentation and fluid monitoring, and insufficient consideration of surgical causes associated with previous bariatric surgery.

Danielle Rhian Robinson · Prevention of Future Deaths report View report

31 May 2016 North Wales (East and Central) J. Gittins

Danielle Rhian Robinson, a 21-year-old detained under section 3 of the Mental Health Act, was found unresponsive with a ligature around her neck at the Heddfan Unit on 13 November 2014 and died on 16 November 2014 despite resuscitation attempts and subsequent treatment. The concerns identified were that observation policies were not being rigorously followed, resulting in missed opportunities to increase observation levels, and that the policy should provide an automatic safety-net response after serious events placing a patient at immediate or imminent risk of harm.

Charlie Mark Jermyn · Prevention of Future Deaths report View report

27 May 2016 Cornwall and Isles of Scilly E. Carlyon

Charlie Jermyn was born at home on 9 May 2015 and developed sleepiness, feeding difficulty and possible respiratory distress. He stopped breathing during a routine visit the following day and died in hospital despite resuscitation attempts. The principal concerns were delayed recognition and referral for suspected sepsis, inadequate telephone triage and recording, insufficient observations, and wider shortcomings in midwifery guidance, equipment and training.

Adetokunbo Ohisaga Ajakaiye · Prevention of Future Deaths report View report

27 May 2016 South Yorkshire (Eastern) M. Beresford

Adetokunbo Ohisaga Ajakaiye was arrested on 13 November 2010, transferred to HMP Doncaster, and later taken to hospital, where he died of malaria early on 25 November 2010. Concerns included healthcare staff’s lack of practical experience and knowledge concerning malaria and tropical diseases, and the failure of medical records from earlier custodial establishments to accompany him to HMP Doncaster.

Esmee Shayla Polmear · Prevention of Future Deaths report View report

27 May 2016 Cornwall and Isles of Scilly E. Carlyon

Esmee Polmear fell ill during a school trip on 1 July 2015, later collapsed and went into cardiac arrest, and was pronounced dead in hospital despite resuscitation attempts. She had pulmonary veno-occlusive disease that was not diagnosed or recognised before her death; concerns included the use of respiratory-rate benchmarks and oxygen monitoring, and recognition and action on red-flag symptoms.

Keenan John WALSH · Prevention of Future Deaths report View report

27 May 2016 Exeter and Greater Devon E. Earland

Keenan John WALSH, a non-swimmer aged 4, drowned in the deep end of a heated swimming pool during a large family party on 23 August 2013. The concerns included the lack of regulation of private holiday lets with swimming pools, the pool’s hazardous profile and limited signage, and inadequate supervision ratios, with adults responsible for supervision being unable to rescue him.

Ian Keith Brown · Prevention of Future Deaths report View report

26 May 2016 Milton Keynes T. Osborne

Ian Keith Brown, who had mental illness and was on remand at HMP Woodhill, was found in his cell with a belt ligature around his neck on 19 July 2015 and was pronounced dead at 14:00 hours. Concerns were raised that recommendations to improve suicide and self-harm prevention, including ACCT case management and a prison-wide strategy, had not been implemented sufficiently, while suicides and self-harm at HMP Woodhill continued to rise.

Mr Matthews · Prevention of Future Deaths report View report

26 May 2016 County Durham and Darlington C. Oliver

Mr Matthews, who had pneumoconiosis and COPD, was admitted to hospital after being found collapsed and later suffered further cardiac arrests before dying on 19 February 2016. The principal concerns were that oxygen was not prescribed or recorded at the required rate, and that there was no system to ensure the oxygen concentrator was working correctly or that damage to it was promptly reported and investigated.

Peter Scott · Prevention of Future Deaths report View report

26 May 2016 Nottinghamshire H. Connor

Peter Scott suffered an aortic dissection at home on 3 December 2015 and experienced a substantial delay in ambulance attendance after a call was prioritised as Green 2. The principal concern was that resource shortages, frequent use of Capacity Management Plans, recruitment problems and delayed hospital handovers posed a serious risk to the public and could contribute to future deaths.

Christopher James B Sears · Prevention of Future Deaths report View report

25 May 2016 Surrey K. Henderson

Christopher James B Sears, a 13-year-old boy, died on 13 November 2014 after a seizure-like episode on a school bus; resuscitation attempts were unsuccessful. The report raised concerns about the absence of Basic Life Support training and emergency protocols for school-bus drivers, delays in calling emergency services, and difficulties alerting the bus company where there was no formal diagnosis.

Patricia Steer · Prevention of Future Deaths report View report

25 May 2016 Inner North London J. Devonish

Patricia Steer became unresponsive on 16 June 2015 while a central venous catheter connection was being changed, after a port was left open to air. The report identified concerns that the staff involved were unaware of the risk of air embolization and that relevant literature or guidance could not be located.

Beverley Lawford John Siddall · Prevention of Future Deaths report View report

24 May 2016 Cornwall E. Carlyon

Beverley Siddall died from multiple injuries after his car left the A3075 near Perranwell on 7 August 2015 and entered a river; he was pronounced dead at hospital on 8 August 2015. At the inquest, concerns were raised that the road layout, safety notices and/or barriers at that location might not have been adequate, following evidence of several vehicles leaving the road at the same point.

Simon Jonathon Klemberg · Prevention of Future Deaths report View report

24 May 2016 Cornwall and Isles of Scilly G. Davies

Simon Jonathon Klemberg died in the early hours of 7 June 2015 following a reckless and impulsive overdose of prescription medication taken to address acute head pain, possibly related to his psychological condition. He had serious mental health problems, and individual psychological therapy recommended in February 2015 was delayed and never commenced. The report raised concerns about psychiatric bed availability, resources and thresholds for the home treatment team, and the prioritisation of high-risk patients awaiting psychological therapy.

William Robert Raymond Nute · Prevention of Future Deaths report View report

24 May 2016 Cornwall and Isles of Scilly E. Carlyon

William Robert Raymond Nute fell while a car was reversing near a shop on 30 June 2015 and sustained a fractured neck of femur. He later developed pneumonia and died on 2 July 2015. Concerns included delays in ambulance attendance and transfer to hospital, inappropriate triage of emergency calls, and delayed notification of the police, leaving him without effective emergency management while lying on a public highway.

Karen Ravenscroft · Prevention of Future Deaths report View report

23 May 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

Karen Ravenscroft fell at home on 11 March 2016 and fractured her left arm and leg. She was assessed as being at high risk of venous thromboembolism but was not prescribed appropriate prophylaxis, subsequently developed a deep vein thrombosis, and died from a fatal pulmonary embolus. Concerns included the absence of thromboprophylaxis, failure to reassess VTE risk or provide mechanical prophylaxis, and limitations in electronically prescribing drugs from the Accident & Emergency Department.

Sadie PETERS and 2 others · Prevention of Future Deaths report View report

23 May 2016 Surrey R. Travers

On 30 December 2014, a fire in a permanent mobile home caused the deaths of Sadie Peters and her two sons, Joseph and George. The fire was most likely caused by a solid fuel burner, and no smoke detector was fitted inside the caravan. The substantive concern was raising awareness among people living in mobile and static caravans about fitting and maintaining functioning smoke detectors.

Samuel Rodney Darren BLAIR · Prevention of Future Deaths report View report

19 May 2016 Inner North London M. Hassell

Rodney Blair, who had a history of paranoid schizophrenia, alcohol dependency, multiple drug use and depression, was remanded in custody at HM Prison Pentonville and was found hanging in his cell on 2 August 2015. The inquest concluded that his death was suicide, with several contributing factors. Concerns included gaps in assessment and management of his mental health and antidepressant treatment, and delays and procedural issues in the prison emergency response.

Ratidzai Kudkawashe SANGARE · Prevention of Future Deaths report View report

18 May 2016 South London S. Lynch

Mrs Ratidzai Kudkawashe Sangare was a detained patient who was found unresponsive on the floor of her room on the morning of her planned discharge, with a dressing gown belt around her neck. The inquest concluded that she died from ligature compression of the neck, between 5.15 and 8.28 a.m. on Millbrook Ward. Concerns included delays in recognising the need for resuscitation and emergency assistance, delayed response to the alarm, and limited telephone access for agency staff.