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John Lomas · Prevention of Future Deaths report View report

1 Oct 2015 Stoke-on-Trent and North Staffordshire M. Jones

John Lomas, a serving soldier, died after a white water rafting boat capsized shortly after launch on the River Inn on 21 June 2012; he was unable to be resuscitated and was certified dead. Concerns included inadequate liaison and risk assessment, the raft exceeding its permitted capacity for the prevailing conditions, launching too close to a stopper, and the absence of preparatory training, a water confidence test, and a safety kayak.

Jean Helen Hannon · Prevention of Future Deaths report View report

30 Sep 2015 Blackburn, Hyndburn and Ribble Valley M. Singleton

Jean Helen Hannon underwent a laminectomy in 2011 for altered sensations in her hands and subsequently became quadriplegic and developed autonomic dysreflexia. The principal concern was that Royal Blackburn Hospital medical records did not sufficiently highlight this potentially life-threatening condition, and the consultant physician was unaware of the previous diagnosis when she was admitted in December 2014.

Ethan Robert Johnson · Prevention of Future Deaths report View report

29 Sep 2015 Milton Keynes T. Osborne

Ethan Johnson was born following an urgent Caesarean section, with no respiratory effort or heart rate, and died after intensive care treatment was withdrawn. The concerns included a lack of effective leadership, support and escalation when an abnormal CTG was identified. The inquest concluded that delayed delivery resulted in a lost opportunity to deliver him earlier and provide further medical treatment.

Parv Patel · Prevention of Future Deaths report View report

29 Sep 2015 North London A. Walker

Parv Patel, aged four, was taken to hospital with an infection and later developed symptoms of heart failure as part of a septic picture. His heart failure was not recognised until later, and intubation precipitated cardiac arrest and death; concerns were raised that PEWS scores may not reflect current research and may distract doctors from recognising serious illness despite a low score.

Lee Anthony Boden · Prevention of Future Deaths report View report

29 Sep 2015 Milton Keynes T. Osborne

Lee Anthony Boden was released from prison to an approved premises in Milton Keynes on 13 February 2015 and was found unresponsive in a bathroom later that night, where drugs and drug paraphernalia were found. He was confirmed dead at 12.10am on 14 February 2015; the stated cause of death was central respiratory depression associated with illicit heroin use. Concerns included limited advance notice of his placement, lack of forward planning, insufficient recognition of his vulnerability, the length of time before he was discovered, and an apparent absence of a protocol for monitoring vulnerable new arrivals.

Harry Pryal · Prevention of Future Deaths report View report

28 Sep 2015 Manchester West A. Walsh

Harry Pryal died on 8 January 2015 after an accidental fall, with the inquest recording bronchopneumonia and traumatic spinal cord injury as the medical cause of death. An X-ray identifying a suspected cervical spine fracture was not reported promptly, and the report raised concerns about communication and record-keeping, conflicting interpretations of a radiology service agreement, access to imaging, and the provision of physical healthcare services.

Tania Salekovna Hristova · Prevention of Future Deaths report View report

28 Sep 2015 Wiltshire and Swindon C. Balysz

Tania Salekovna Hristova had depression and received Citalopram by repeat prescription for five and a half years. She was found hanging by a ligature at home after becoming distressed, and the inquest concluded that her death was suicide. The concerns identified were inadequate review of her medication and mental health, and failure to offer counselling or CBT.

John Frederick Roberts · Prevention of Future Deaths report View report

28 Sep 2015 Essex C. Beasley-Murray

John Frederick Roberts, a pedestrian, was struck by a vehicle in Springfield Road, Chelmsford, on 5 March 2015 and died in hospital the following day. The report raised concern that pedestrians regularly crossed the traffic island and central reservation despite serious risks, while the nearest crossing was not very evident, and called for consideration of a safer junction design.

Mrs Violet Cloudsdale · Prevention of Future Deaths report View report

25 Sep 2015 Cumbria P. O’Donnell

Mrs Violet Cloudsdale fell unattended from a stationary wheelchair on 11 December 2014, sustaining fractures, and died five days later from bronchopneumonia while being treated in hospital. Concerns included the absence of a risk assessment and consent consideration regarding use of the wheelchair lap-belt, uncertainty about whether lap-belts constituted unlawful restraint, and unclear guidance on their use.

Dorothy Delaney · Prevention of Future Deaths report View report

23 Sep 2015 Manchester West R. Griffin

Dorothy Delaney was found collapsed at her care home on 11 June 2015 after being prescribed Rivaroxaban for atrial fibrillation and Clopidogrel for previous transient ischaemic attacks. She was diagnosed with a large intracerebral haemorrhage and died later that day. The principal concern was that both anticoagulant and antiplatelet medications were prescribed without individual specialist advice, increasing the risk of haemorrhage.

Emma Waring · Prevention of Future Deaths report View report

22 Sep 2015 Manchester North S. Nelson

Emma Waring, aged 23, died after a fire in her rented accommodation on 7 March 2015, having been overcome by toxic smoke while attempting to escape. The principal concern was the need to consider compulsory inclusion of domestic automatic water suppression systems, particularly in residential properties housing vulnerable individuals.

William John Charles Harnell · Prevention of Future Deaths report View report

22 Sep 2015 Plymouth, Torbay and South Devon A. Cox

William John Charles Harnell suffered a fractured left hip while attempting to mobilise from his wheelchair on 22 October 2014, remained in hospital, developed hospital-acquired pneumonia and died on 15 December 2014. Concerns included delays in recognising the difficulties surrounding his discharge, assessing his mental health, approaching suitable nursing homes, and a lack of resources and guidance for managing challenging and vulnerable patients.

Stuart Knight · Prevention of Future Deaths report View report

22 Sep 2015 Central Lincolnshire S. Fisher

Stuart Knight was found unconscious in a road in Wainfleet after apparently falling backwards and hitting his head. There were delays in the arrival of ambulance services, including 1 hour and 24 minutes between the first call and the arrival of the double-crewed ambulance; the report identified these delays as significant and unacceptable. Mr Knight was taken to hospital and died later that day, following a head injury with haemorrhage and skull fracture, with alcohol excess also recorded as a medical cause.

Christianne Shepherd and Robert Shepherd · Prevention of Future Deaths report View report

18 Sep 2015 West Yorkshire (East) D. Hinchliff

Christianne and Robert Shepherd died from carbon monoxide poisoning while staying with their family in holiday accommodation on Corfu in October 2006. The report identified a badly installed and maintained LPG water heater, disconnected safety devices, defective building and piping, and concerns about inadequate tour-operator and hotel health and safety checks. It also raised wider concerns about carbon monoxide safety standards and information for holidaymakers.

Liam SMITH · Prevention of Future Deaths report View report

18 Sep 2015 Worcestershire G. Williams

Liam Smith was admitted to HMP Hewell on 7 August 2014 and died after taking a combination of prescribed and illicitly obtained medication in his cell. The concerns included possible failures to follow mandatory ACCT procedures, inadequate dissemination and recording of medical information, and limited healthcare interaction with high-risk drug users, potentially resulting in warning signs being missed.

Lee Mark Anthony Bates · Prevention of Future Deaths report View report

17 Sep 2015 Inner South London A. Harris

Lee Mark Anthony Bates died at 01.18 on 24 February 2014 in Cambian Churchill London Clinic after ingesting a potentially fatal overdose of Zopiclone in conjunction with benzodiazepines while under one-to-one eyesight observation. The principal concerns were inadequate staff training in one-to-one observation and insufficient coordination between psychiatric and sleep-apnoea specialists about CPAP use, sedative medication risks, and monitoring of patients with severe obstructive sleep apnoea.

FIONA MARGARET PATRICIA LEWIS · Prevention of Future Deaths report View report

17 Sep 2015 Suffolk P. dean

Fiona Margaret Patricia Lewis was admitted to Ipswich Hospital after three weeks of symptoms and died there on 13 September 2014. The cause of death was found to be disseminated carcinoma, with no primary mass identified at post-mortem examination. Concerns were raised about delayed resuscitation following her collapse and whether the healthcare professionals involved had adequate resuscitation knowledge and ability, although it was considered unlikely that this would have altered the outcome.

Adil HABIB · Prevention of Future Deaths report View report

16 Sep 2015 Inner North London M. Hassell

Adil Habib died at HMP Pentonville after swallowing a package containing crack cocaine during a search while subject to control and restraint; he choked on it. The inquest recorded the death as accidental, with acute respiratory failure due to mechanical obstruction of the upper airway by a foreign object. A concern was raised that the 999 caller did not immediately provide the prison gate location for attending paramedics, and that ambulance call-handling systems did not then show alternative gates for all London prisons.

Mr David John James Charles · Prevention of Future Deaths report View report

16 Sep 2015 Essex C. Beasley-Murray

On 29 November 2014, Mr David John James Charles was walking in the carriageway of Cranes Farm Road, Basildon, while under the influence of alcohol when he was struck by two cars and died from multiple injuries. The street lighting was switched off, and the report states that illumination would have improved his chance of being seen and given him a better chance of living.

Karen Clayton · Prevention of Future Deaths report View report

15 Sep 2015 Manchester South J. Pollard

On 2 January 2015, Karen Clayton collided with a pedestrian while cycling in a designated cycle lane in Altrincham and sustained fatal head injuries. The concerns identified included inadequate segregation of pedestrians, cyclists and motor traffic, a confusing contra-flow cycle lane, unclear signage, and weak guidance on pedestrians using cycle paths.