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Robert Gordon John Hogg · Prevention of Future Deaths report View report

6 Aug 2015 Buckinghamshire C. Butler

Robert Gordon John Hogg was taken to hospital with cold and temperature symptoms and was assessed and sent home. He later became lethargic and unresponsive in the urgent care centre waiting room, and his death was confirmed on 21 April 2014. An investigation identified concern that NHS Pathways toddler/child pathways were not necessarily identifying very sick children, and this was described as a continuing risk at the inquest.

Darren Brown · Prevention of Future Deaths report View report

6 Aug 2015 Inner South London A. Harris

Darren Brown died by suicide on 3 March 2014 at Lambeth Hospital; the medical cause of death was asphyxia due to ligature compression of the neck. The report described mental health issues, limited social support, family bereavements and an imminent court appearance as contributory factors. A principal concern was whether restricting his contact with his mother and sister properly balanced the risks and needs of a highly vulnerable adult against the reasons for restricting family contact.

Rubel Ahmed · Prevention of Future Deaths report View report

5 Aug 2015 Central Lincolnshire S. Fisher

Rubel Ahmed, who was detained at Morton Hall Immigration Removal Centre, was found hanging in his room on the evening of 5 September 2014 and was pronounced deceased shortly after midnight on 6 September 2014. The concerns included overnight locking of detainees in rooms, the adequacy of detention-awareness training, staff awareness of changes in detainees’ circumstances, insufficient protected time for personal officers, and the use of electrical leads that could be used as ligatures.

Mr Warren · Prevention of Future Deaths report View report

4 Aug 2015 West Sussex B. Dolan

Mr Warren, an elderly and deaf tenant with no known family or friends, was found deceased at home on 29 January 2015 after apparently falling around 24 January and suffering broken ribs, bronchopneumonia and signs of hypothermia. Concerns included the failure to address a hazardous electric heater, the use of a non-urgent police welfare check, insufficient guidance and training for social-work staff, and the absence of a formal review by the relevant councils.

Mr Michael Quinn · Prevention of Future Deaths report View report

3 Aug 2015 Berkshire P. Bedford

Mr Michael Quinn underwent lumbar decompression surgery and was discharged home, but subsequently developed diarrhoea and vomiting, was admitted critically ill, and died despite intensive treatment. The principal concern was confusion and inconsistency about appropriate perioperative blood glucose levels for patients undergoing surgery, including a written policy that did not align with national guidelines and other published research.

Casey Paul GARRETT · Prevention of Future Deaths report View report

30 Jul 2015 Bedfordshire and Luton T. Osborne

Casey Paul Garrett was born at Bedford Hospital on 10 September 2014 and died on 11 September 2014 at 07:10 from perinatal asphyxia. The inquest identified failures to recognise his deteriorating condition and escalate care to expedite delivery, while the stated concerns included insufficient fetal monitoring, misinterpretation of a CTG trace, failure to escalate care, and the suitability of the hospital as a clinical learning environment for student midwives.

Giuseppina Incisivo · Prevention of Future Deaths report View report

30 Jul 2015 West Sussex J. Turner

Giuseppina Incisivo was crossing North Street in Midhurst when she moved in front of a lorry as traffic moved off; she was run over and died at the scene within minutes. The principal concerns were that front blind-spot mirrors may not provide sufficient visibility of pedestrians close to high-fronted vehicles, and that supplementary warning systems and greater awareness may be needed to reduce reliance on such mirrors.

Anthony Dwyer · Prevention of Future Deaths report View report

30 Jul 2015 North London A. Walker

Anthony Dwyer, a vulnerable long-term tracheostomy patient with complex medical needs, collapsed in hospital after removing his tracheostomy tube and suffered a hypoxic cardiac arrest. The substantive concern was the adequacy of guidance to the trust on the general management of long-term tracheostomy patients with complex medical needs.

William Arthur Bows · Prevention of Future Deaths report View report

28 Jul 2015 South Yorkshire (Eastern) 2015-0301

William Arthur Bows, an 85-year-old man, was admitted with increasing shortness of breath, deteriorated despite supportive treatment, and died on 15 January while investigations were ongoing. Concerns were raised about the lack of protocols and guidance for monitoring patients prescribed amiodarone, including liver function, thyroid function, and respiratory difficulties, particularly during the first year of treatment.

Mr. Arthur Cook · Prevention of Future Deaths report View report

27 Jul 2015 Powys, Bridgend and Glamorgan Valleys S. Richards

Mr. Arthur Cook had poor circulation and a chronic open wound that developed into an MRSA-infected category 4 pressure ulcer while he was resident at Four Seasons Healthcare Residential Home. He failed to respond to treatment and died. Concerns included insufficient tissue viability nursing capacity, inadequate pressure-ulcer documentation and repositioning charts, and a lack of integrated skin care across services.

Carl David Roy SMITH · Prevention of Future Deaths report View report

24 Jul 2015 Exeter and Greater Devon E. Earland

Carl David Roy SMITH was found unconscious and without signs of life in his cell at HMP Exeter on 22 November 2012, after being held on remand and receiving medication for seizures and detoxification. His death was concluded to be drug-related, involving methadone toxicity and illicitly obtained methadone. The report identified insufficient custodial and welfare checks and deficient information sharing about those checks for a prisoner on an ACCT and Methadone Stabilisation Programme.

Miriam Joyce Smith-Cox · Prevention of Future Deaths report View report

24 Jul 2015 Cornwall E. Carlyon

Miriam Smith-Cox was found dead on 4 March 2015 at the bottom of stairs, with injuries consistent with a fall. A safeguarding concern about the suitability of her accommodation and living conditions had been raised in December 2014 but was reportedly not received or acted upon, and the reason for her fall was unknown.

Simon Peter REYNOLDS · Prevention of Future Deaths report View report

24 Jul 2015 Avon M. Voisin

Simon Peter REYNOLDS was admitted to Mason Unit at Southmead Hospital on 10 November 2014 after being detained under section 136 of the Mental Health Act. While left alone in his room, he forced a fist-sized ball of paper into his throat, causing him to choke; he later died in hospital on 21 November 2014. Concerns included the absence of a documented admission risk assessment, no computerised admission note by the nurse in charge, and the need to consider guidance or training on observation levels, suicide and self-harm risk assessment, risk management, and communication of risk.

Mr Ashley Aaron Matthews · Prevention of Future Deaths report View report

23 Jul 2015 Black Country D. Urpeth

Ashley Matthews accessed Bescot Traction Maintenance Depot, climbed over a railway bridge and was electrocuted after contacting a high-voltage cable. He died in hospital from extensive full-thickness burns. Concerns included insecure perimeter fencing, inadequate security patrols and a lack of warning signs about the high-voltage cabling.

Lynn POYSER · Prevention of Future Deaths report View report

23 Jul 2015 South Lincolnshire A. Forrest

Lynn POYSER had impaired kidney function and was prescribed Lisinopril while already taking Spironolactone. She was admitted to hospital with severe hyperkalaemia and suffered a cardiac arrest from which she could not be resuscitated. The principal concern was whether guidance on co-prescribing these medicines sufficiently emphasised caution, review, and monitoring of renal function and electrolytes.

Michael Robert Hanlon · Prevention of Future Deaths report View report

23 Jul 2015 Cumbria P. Sharp

Michael Robert Hanlon, a deckhand on a luxury boat, had worked a night watch and the whole of 6 April 2013 without rest or sleep. After returning to the boat at about 11.30 p.m., he was seen on board and later fell from the upper deck, hit the quay and drowned in the harbour. The concerns included difficulties crew members faced entering the boat after 10.00 p.m., possible tiredness from additional shifts, and discrepancies between the deceased’s work pattern and the shift rota and timesheet.

Doreen England · Prevention of Future Deaths report View report

23 Jul 2015 Birmingham and Solihull L. Hunt

Doreen England, an 81-year-old woman with vascular dementia, developed a severe pressure sore during her admission to Rosemary Suite from 20 July 2014 and died on 30 September 2014. The principal concerns were the failure to prepare and implement a care plan despite her high risk, inadequate staff knowledge and training about pressure sore prevention, and insufficient ward leadership and medical cover.

James Gerard McGEOWN · Prevention of Future Deaths report View report

22 Jul 2015 Worcestershire A. Cox

James Gerard McGEOWN died following a road traffic collision after overtaking at well over the 70mph speed limit while under the influence of alcohol and not wearing a seat belt. A road-surface undulation was identified as a potential concern because, at higher speeds, it could cause loss of control and may have contributed to the collision.

Rachel Hollister · Prevention of Future Deaths report View report

21 Jul 2015 Gwent W. James

Rachel Hollister died after suffering a cardiac arrest during surgery for removal of a retained placenta following childbirth at the Royal Gwent Hospital on 13 April 2013. Concerns included staff and porters not following or being unaware of Health Board protocols, and the major obstetric haemorrhage protocol not meeting published guidelines.

Anne Wilson · Prevention of Future Deaths report View report

21 Jul 2015 South London S. Hayes

Anne Wilson had a history of depression, had recently been discharged from psychiatric hospital, and was found deceased in her flat after failing to attend appointments and following concerns raised to the police. The principal concerns were the downgrading of the welfare-check request without informing her GP, inadequate training and guidance under the Metropolitan Police Service welfare-check policy, and failures in communication and joint working between the Metropolitan Police Service and London Ambulance Service.