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Philip Anthony Denning · Prevention of Future Deaths report View report

16 Feb 2016 Nottinghamshire H. Connor

Philip Anthony Denning, who had a history of substance misuse and mental health problems, died from diamorphine intoxication on 23 July 2015 after using heroin. The report raised concerns about fragmented services, limited psychology provision, poor information-sharing between organisations, and a lack of clarity in primary care about accessing appropriate support for people with both substance misuse and mental health needs.

Eric Albert Gaskell · Prevention of Future Deaths report View report

16 Feb 2016 Manchester West R. Griffin

Eric Albert Gaskell attended Royal Bolton Hospital with chest pain on 6 November 2015 and was discharged with a presumed diagnosis of stable angina. He collapsed while working on 8 November 2015 and died at Salford Royal Hospital; the medical cause of death was ischaemic heart disease, coronary artery thrombus and coronary artery atheroma. The report raised concerns that Royal Bolton Hospital’s prescribing policy and pharmacy opening hours could prevent patients from obtaining medication, including potentially lifesaving medication, outside pharmacy opening times.

Adam James Withers · Prevention of Future Deaths report View report

15 Feb 2016 Surrey A. Hewitt

Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.

James Robertson · Prevention of Future Deaths report View report

15 Feb 2016 Portsmouth and South East Hampshire D. Horsley

James Robertson died on 22 July 2015 while resident at Cams Ridge Care Home, after he was last checked at around 13.00 hours and found apparently deceased at around 15.30 hours. Concerns included inaccurate recording of care-check times, delayed recognition of his DNACPR status, and inadequate equipment in the emergency resuscitation pack, particularly the lack of a suction unit.

Peter Charles Tye · Prevention of Future Deaths report View report

15 Feb 2016 Plymouth, Torbay and South Devon I. Arrow

Peter Charles Tye was admitted to Derriford Hospital with pneumonia and respiratory failure, and a central venous line was mistakenly inserted into his carotid artery. He later deteriorated with gram-negative sepsis and died; concerns focused on improving the insertion and removal of central venous lines to reduce deaths from misplaced lines.

Belinda Jane Wise · Prevention of Future Deaths report View report

15 Feb 2016 Leicester City and South Leicestershire L. Brown

Belinda Jane Wise fell backwards when the unmarked rear doors of a lift opened, striking her head. She later developed a large subdural haemorrhage and died five days later. The principal concern was that the lift had no signs or auditory warnings indicating that the rear doors would open, and consideration was given to making the doors more distinguishable and providing an audible warning.

James David Barrett · Prevention of Future Deaths report View report

15 Feb 2016 Portsmouth and South East Hampshire D. Horsley

James David Barrett, who had Alzheimer's dementia, went missing from his home on 7 August 2015 and was found deceased on 13 August 2015. The concerns related to the effectiveness and speed of the missing-person search, including reliance on separate mapping arrangements and the lack of tracking devices for searchers.

Eileen Annie Thompson · Prevention of Future Deaths report View report

15 Feb 2016 Warwickshire D. Clark

Eileen Annie Thompson, who had dementia, fell between her bed and a wall after the bed moved and sustained serious head injuries. She died shortly after admission to hospital. The concerns were that the bed’s inner wheels were not locked because their locking mechanisms were inaccessible against the wall, creating a risk of recurrence for other service users.

Mr. Terence Brooks · Prevention of Future Deaths report View report

12 Feb 2016 Avon P. Harrowing

Mr. Terence Brooks, who was being treated for acute myeloid leukaemia, developed Legionella pneumophila pneumonia and died on 23 July 2015. The report raised concerns that the hospital misinterpreted microbiological testing, conducted its investigation on a false premise, and had no procedure for investigating the cause of a Legionella infection.

Ms. Marilyn Anson · Prevention of Future Deaths report View report

12 Feb 2016 Avon P. Harrowing

Ms. Marilyn Anson had diabetes and end-stage renal failure requiring dialysis, and developed a severe left-foot pressure ulcer. An urgent referral to the ‘hot foot’ clinic was made on 26 February 2015, but the earliest appointment offered was 17 March; the ulcer deteriorated, requiring hospital admission, antibiotics and amputation surgery, and she died after further surgery on 22 March 2015. The concerns included the prioritisation and resourcing of the clinic, coordination between relevant organisations, and guidance and standardisation of referrals.

Sandra Rhoda Marion Wood · Prevention of Future Deaths report View report

12 Feb 2016 North West Kent R. Hatch

Sandra Rhoda Marion Wood was sent to Tunbridge Wells Hospital on 17 April 2015 with a suspected bowel obstruction and was discharged with a diagnosis of UTI and constipation. She was found collapsed at home the following day, taken to Maidstone General Hospital, and died later that day; the post-mortem recorded bowel obstruction due to adhesions. The concerns included the lack of routine weekend CT scanning facilities, the procedure required for urgent scans, and the delay to scanning until after the weekend.

Mr. Joseph Sarkozy · Prevention of Future Deaths report View report

12 Feb 2016 Avon P. Horrowing

Mr. Joseph Sarkozy was found dead in his first-floor bedroom after a fire involving discarded smoking materials and bedding. Fire officers had initially attributed smoke and burning smells from the adjoining property to dust on kitchen light fittings, despite the absence of positive evidence. The principal concern was that this conclusion may have delayed recognition of the fire, and the report called for national dissemination of learning about this risk.

Margaret Hions · Prevention of Future Deaths report View report

12 Feb 2016 Carmarthenshire and Pembrokeshire J. Layton

Margaret Hions was admitted to Glangwili Hospital on 1 July 2013 and later transferred to Prince Philip Hospital, where she died on 27 August 2013. During her admission, a large bruise rapidly expanded after warfarin was replaced with tinzaparin. Concerns were raised about tinzaparin prescribing, monitoring of blood levels, and monitoring creatinine clearance, with the inquest identifying shortcomings in the management of her care at Glangwili Hospital.

Marion Rose HOWES · Prevention of Future Deaths report View report

11 Feb 2016 Brighton and Hove V. Hamilton-Deeley

Marion Rose HOWES died before the inquest concluded on 3 February 2016; the circumstances are referred to in the Record of Inquest. The concerns included failures in discharge communication, coordination and continuity of care, two failed discharges, inadequate communication of a cancer diagnosis, and failure to recognise that she was dying, which was said to have resulted in an undignified and uncomfortable death.

David Granville Oswald Hughes · Prevention of Future Deaths report View report

9 Feb 2016 Leicester City and South Leicestershire C. Mason

David Granville Oswald Hughes was a patient at the Bradgate Unit who was found unresponsive on his bedroom floor at approximately 02:00 on 23 April 2014. The report identified concerns about failures in 15-minute observations, incomplete fluid balance charts, the lack of bedroom call bells, and nursing staff’s understanding of physical illness signs and symptoms.

Eitvydas ZDANYS · Prevention of Future Deaths report View report

9 Feb 2016 Bedfordshire and Luton T. Osborne

Eitvydas ZDANYS, aged 19, died at the scene on 2 August 2015 after a motorcycle collision while intoxicated and carrying a pillion passenger. The report raised concerns that attending police officers were unable to assess his serious injuries or commence potentially life-saving resuscitation, although it concluded that the delay did not contribute to his death.

Christopher Tristam Broom · Prevention of Future Deaths report View report

7 Feb 2016 Cornwall B. Berg

Christopher Broom fell into the water while fishing from the harbour wall at Charlestown on the night of 6 September 2015 and drowned; it was unclear how he fell, and he could not swim. Concerns included there being only one lifebelt, located some distance away and difficult to see, and no lighting at the end of the harbour wall, making the wall’s end and the lifebelt difficult to identify at night.

David MOSTARI · Prevention of Future Deaths report View report

5 Feb 2016 Bedfordshire and Luton T. Osborne

David MOSTARI was admitted to Bedford Hospital on 8 August 2015 with a suspected flare-up of ulcerative colitis, deteriorated, and was found to have a perforated colon with widespread faecal contamination. He died on 10 August 2015 after treatment was withdrawn. The concerns included delays in carrying out urgent imaging following his weekend admission and failures to recognise the seriousness of his condition and take necessary treatment steps.

Isla Peyton LORD · Prevention of Future Deaths report View report

5 Feb 2016 Bedfordshire and Luton T. Osborne

Isla Peyton LORD was born at Harlow Hospital on 4 November 2012 and suffered an immediate post-natal collapse after delivery, resulting in a hypoxic brain injury. She was transferred to Luton and Dunstable Hospital, where treatment was withdrawn following discussions with her parents, and she died on 8 November 2012. The principal concern was the lack of liaison between the hospitals about the delivery plan after possible heart anomalies were identified.

Chentoоri Chanthirakumar · Prevention of Future Deaths report View report

5 Feb 2016 Inner North London M. Hassell

Chentoоri Chanthirakumar, a 24-year-old medical student, died by suicide after being discharged from a period of inpatient mental health treatment. The concerns included the university communicating by email about her examinations rather than arranging a personal meeting, and mental health staff not fully absorbing concerns raised by others because of confidentiality concerns.