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Mandeep SINGH · Prevention of Future Deaths report View report

23 Mar 2016 Teesside C. Bailey

Mandeep SINGH consumed high levels of alcohol and was found unconscious at home at approximately midnight after his wife found him lying on the floor. Although the ambulance call was assessed as R1 with a target response time of 8 minutes, the ambulance arrived after 27 minutes, and Mr Singh died in the ambulance. The investigation identified severe demand and staff shortages, as well as road closures and diversions, as factors in the delay.

Alwyn Ann Head · Prevention of Future Deaths report View report

23 Mar 2016 Mid Kent and Medway P. Harding

Alwyn Ann Head was admitted to hospital after falls caused a fractured femur at the site of a prosthesis. She underwent surgery, developed an MRSA wound infection, deteriorated after further surgery, and died on 20 August 2015. Concerns included failure to establish her MRSA history, lack of prophylactic Teicoplanin, absence of a post-operative wound care plan, inadequate evidence of wound inspection, and meaningless nursing documentation about the wound.

Lincoln James BRADY · Prevention of Future Deaths report View report

23 Mar 2016 Teesside C. Bailey

Lincoln James BRADY was born on 26 August 2014 and was recorded as stillborn, although provisional evidence indicated that he was alive for forty minutes after birth. The principal concern was that conflicting abdominal and vaginal examination results were not followed by further investigation, so breech presentation was not diagnosed and appropriate delivery planning was not undertaken.

June Elsie Parkes · Prevention of Future Deaths report View report

23 Mar 2016 West Yorkshire (Western) M. Burke

June Elsie Parkes became unwell with symptoms of an upper gastrointestinal bleed and was admitted to hospital on 14 December 2014. She later deteriorated and died shortly after being transferred to Huddersfield Royal Infirmary on 17 December 2014. The concerns included delays and gaps in systems for urgent or emergency endoscopy and surgery, monitoring and escalation, record keeping, and the transfer of critically ill patients.

Michael Dean YOUNGHUSBAND · Prevention of Future Deaths report View report

23 Mar 2016 Exeter and Greater Devon J. Tomalin

Michael Dean Younghusband, aged 22, was struck by a train while apparently walking along the railway between Exmouth and Lympstone after drinking alcohol, suffering non-survivable injuries. His family raised concern about the poor state of repair of a nearby crossing, including a metal section standing proud of the track bed that they believed was a potential tripping hazard.

Jane Bell · Prevention of Future Deaths report View report

22 Mar 2016 Blackpool and the Fylde A. Wilson

Jane Bell drowned in a hotel swimming pool after going underwater in the deep end and later died in hospital on 14 August 2014. The principal concern was that the hotel’s arrangements for pool supervision, including CCTV monitoring and infrequent poolside patrols, remained insufficient to prevent future deaths, particularly where staff could be distracted and a child could remain underwater for a fatal period.

Ann Catherine Jacobs · Prevention of Future Deaths report View report

19 Mar 2016 Derbyshire S. Cartwright

Ann Catherine Jacobs was found unresponsive and in asystole in hospital at approximately 3.00am on 25 February 2014, after being treated for severe hypokalaemia. The report identified concerns that potassium monitoring was not carried out every eight hours in accordance with hospital guidance, and that no further blood test was taken after 06.38 on 24 February.

Jonathan James LANDER · Prevention of Future Deaths report View report

18 Mar 2016 Worcestershire G. Williams

Jonathan James Lander was killed on 28 April 2015 when he was struck by a train on tracks near Blackbridge, Worcester Road, Hartlebury. The principal concern was the absence of a policy or procedure for following up individuals seen by one service and then discharged to another service, and that the identified action plan had not been implemented.

Rubana PATHAN · Prevention of Future Deaths report View report

18 Mar 2016 Inner North London M. Hassell

Rubana Pathan was admitted to Homerton University Hospital and was diagnosed with toxic shock syndrome associated with a Staphylococcus aureus infection of an infected breast implant wound. A concern was raised that the absence of pus or localised redness may have contributed to the implant not being recognised as the cause of sepsis, because the responsible toxin can suppress signs of local inflammation.

Mr Philmore Leonard Mills · Prevention of Future Deaths report View report

17 Mar 2016 Berkshire P. Bedford

Mr Philmore Leonard Mills, a 55-year-old patient with significant comorbidities including terminal lung cancer, became confused and aggressive while in hospital and died after police attended and restrained him. The report notes concerns that police training did not identify containment as a tactical option for suspected excited delirium, and did not warn that the restraint manoeuvre could in certain circumstances be fatal.

Jacqueline Emma Brown Scott · Prevention of Future Deaths report View report

17 Mar 2016 Inner West London A. Hodes

Jacqueline Emma Brown Scott was admitted to hospital on 31 March 2015 with worsening shortness of breath and reduced mobility and was treated with a BIPAP machine. The machine was running on battery because of a failed power socket, but this was not recognised before the battery ran out; she died shortly afterwards. Concerns included the machine’s battery warnings and alarms, staff training, ward power provision and the absence of systems to identify power failures.

Helen England · Prevention of Future Deaths report View report

16 Mar 2016 Manchester West J. Leeming

Helen England, who had bipolar affective disorder and was subject to a Community Treatment Order, was found hanging in her home on 26 December 2013 after recent self-harm, hospital discharge and concerns about her safety. The principal concern was that there was no protocol or guidance for mental health nurses on whether to refer discharge decisions to a doctor, particularly when a patient subject to a Community Treatment Order had attended or been admitted to hospital following self-harm.

Steven James May · Prevention of Future Deaths report View report

16 Mar 2016 Nottinghamshire A. McNamara

Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.

Anna Mary Macfie Masson · Prevention of Future Deaths report View report

15 Mar 2016 Central Hampshire G. Short

Anna Mary Macfie Masson, aged 67, died by suicide on 17 November 2015 after jumping into the path of a fast train at Micheldever railway station. The concerns related to whether a screening pathway for routine referrals was robust enough to identify people needing urgent treatment and whether it was applied consistently across equivalent teams.

Margaret Jane METCALFE · Prevention of Future Deaths report View report

14 Mar 2016 Teesside C. Bailey

Margaret Jane Metcalfe fell while resident at Rosedale Care Home on 25 October 2015 and died in hospital on 23 November 2015. Staff were not alerted by either her hand-held buzzer or the specialist bed alarm; they were alerted by hearing a thud after she fell.

Amelia Celestine Calvo · Prevention of Future Deaths report View report

11 Mar 2016 Manchester City F. Borrill

Amelia Celestine Calvo was born prematurely with Edwards Syndrome and oesophageal atresia with a tracheo-oesophageal fistula. During surgery, her endotracheal tube became dislodged, after which she developed severe airway problems, pneumothoraces and bleeding, and died despite resuscitation. Concerns included communication failures about the risk of a difficult airway and the absence of a national guideline for using the airway grading classification in neonatal practice.

Jason Derek Vaughan · Prevention of Future Deaths report View report

11 Mar 2016 South Yorkshire (Eastern) M. Beresford

Jason Derek Vaughan died by suicide by hanging at his home on 23 September 2015. The principal concerns were limitations in the IAPT electronic clinical records, a risk assessment tool that did not capture deterioration below its highest-risk level, and insufficient recognition of factors associated with suicide among middle-aged men and socio-economic groups.

Bradley David Griffiths · Prevention of Future Deaths report View report

11 Mar 2016 Leicester City and South Leicestershire C. Mason

Bradley David Griffiths died on 18 November 2012 after suffering a cardiac arrest at home on 13 November 2012, following two previous Apparent Life-Threatening Events. The cause of the fatal cardiac arrest remained undetermined and the inquest concluded with an open conclusion. A concern was raised that two routine six-week appointments were not kept, and that after Bradley and his mother moved, his location and new GP details were not provided, resulting in his records being sent to “No Trace” storage.

Charles Alan Newby · Prevention of Future Deaths report View report

10 Mar 2016 West Yorkshire (Western) M. Fleming

Charles Alan Newby died after falling from the rear of a boat into the Calder River/Canal on 18 October 2015 while intoxicated with alcohol and not wearing a life jacket; he drowned despite attempts to retrieve him. The substantive concern was whether the installation of life rings at the Lock 19 location was appropriate.

Christine Marie Stevenson · Prevention of Future Deaths report View report

10 Mar 2016 Manchester South J. Kearsley

Christine Marie Stevenson, who had a history of illicit drug use and multiple medical issues, died at home on 21 July 2015. The inquest recorded the cause of death as combined drug toxicity from prescribed and illicit drug use. Concerns were raised about the lack of control over Oramorph prescribing, including the issue of 500 ml, equivalent to 1000 mg, without controls despite evidence that 50 ml could pose a risk to life in a naïve user.