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Mary Magdalene Marshall · Prevention of Future Deaths report View report

6 Mar 2015 Manchester West A. Walsh

Mary Magdalene Marshall died in hospital after admission with an incarcerated inguinal hernia and small bowel obstruction, later developing pneumonia and confirmed Clostridium Difficile infection. The principal concerns were limited awareness of GDH-positive results among healthcare practitioners, communication of those results to primary care, and their significance when prescribing antibiotics.

Michael Andrew Pollard · Prevention of Future Deaths report View report

5 Mar 2015 Leicester City and South Leicestershire L. Brown

Michael Andrew Pollard, aged 14, collapsed at home on 23 June 2014 and was admitted with an upper gastrointestinal bleed. He became unresponsive before an endoscopy was arranged and died from massive haemorrhage several hours later on 24 June 2014. Concerns included delays in escalation to senior colleagues, lack of early intensive care involvement, inadequate resuscitation with blood products, and an out-of-date on-call rota that delayed contacting the appropriate consultant.

Archie Haxell · Prevention of Future Deaths report View report

5 Mar 2015 Inner South London P. Barlow

Archie Haxell was born by forceps delivery on 24 March 2013 and suffered a respiratory arrest about two hours after birth. He was transferred to St Thomas’ Hospital, where he died on 29 March 2013. The principal concerns were breakdowns in communication between healthcare professionals, failure to retain observation records, and failure to inform Archie’s parents about concerns regarding his breathing, contributing to delay in recognising his deteriorating condition.

David Andrew Bladen · Prevention of Future Deaths report View report

4 Mar 2015 South Yorkshire (Eastern) N. Mundy

David Andrew Bladen ruptured his right quadriceps tendon after falling down stairs and underwent reconstructive surgery. He received thromboprophylaxis during and shortly after surgery but no extended treatment after discharge, and died on 2 September 2014 from a massive pulmonary embolism. The principal concern was the absence of clear guidance on optimum thromboprophylaxis for patients with restricted mobility due to a brace rather than a cast.

Mr. Brian Francis · Prevention of Future Deaths report View report

4 Mar 2015 Powys, Bridgend & Glamorgan Valleys S. Richards

Mr. Brian Francis was admitted to Princess of Wales Hospital on 5 September 2014 after several days of illness and was treated for presumed chest sepsis. He died of a pulmonary embolism the following day. Concerns included a failed process for recording Consultant attendance and the unavailability of Community medical records, which may have affected assessment and the commencement of anti-coagulation therapy.

Colin Tyson · Prevention of Future Deaths report View report

4 Mar 2015 South Yorkshire (Eastern) N. Mundy

Colin Tyson attempted suicide by carbon monoxide poisoning on 6 August 2014 and was resuscitated. On 11 August 2014, he stepped in front of a high-speed train and died from the impact. The principal concern was that GPs’ interpretation of patient confidentiality could prevent concerned family members from passing on pertinent information about vulnerable people at risk of suicide.

Thomas Luke-Taylor · Prevention of Future Deaths report View report

3 Mar 2015 County Durham and Darlington A. Tweddle

Thomas Luke-Taylor, who had suffered a stroke, fell from his bed while in the Stroke Rehabilitation Ward at Bishop Auckland General Hospital, sustained a head injury and subsequently died. Concerns were raised about incorrect falls-risk assessments, inadequate supervision of a student nurse, and whether certain patients such as stroke patients should be presumed to be at increased risk of falls unless there were good reasons otherwise.

Paige Louise Bell · Prevention of Future Deaths report View report

3 Mar 2015 Sunderland D. Winter

Paige Louise Bell, aged 20, died at Sunderland Royal Hospital on 14 August 2014 after applying a ligature to her neck following an episode of self-harm. The inquest identified contradictions in the observation policy as a contributing factor. Concerns included case notes not being held together or fully transferred with the patient, and the need for consistent observation policies and updated guidance on managing patients with Borderline Personality Disorder.

Peter Jonathan Wright · Prevention of Future Deaths report View report

2 Mar 2015 Staffordshire South A. Haigh

Peter Jonathan Wright, a voluntary patient at St George’s Hospital, died after deliberately cutting an artery in his neck with a broken metal fork. The concerns included understaffing, failure to record necessary observations, a nurse undertaking a drugs round alone contrary to policy, and the lack of an on-site doctor and out-of-hours medical cover.

Alison Dawn Evers · Prevention of Future Deaths report View report

2 Mar 2015 West Yorkshire Eastern J. Alam

Alison Dawn Evers, who was dependent on care staff and had swallowing difficulties, suffered hypoxia and cardiac arrest after choking on a sweet given contrary to her dietary support plan. The principal concerns were the lack of a written no-treats policy, the absence of a policy ensuring first-aid-trained staff on every shift, and the level of first-aid training among healthcare support workers.

Malcolm David BURGE · Prevention of Future Deaths report View report

27 Feb 2015 Somerset (West) M. Rose

Malcolm David BURGE died at Southmead Hospital, Bristol, on 28 June 2014 after setting light to himself and his car earlier that day in a car park at Cheddar Gorge, Somerset. The report states that he owed Newham Council £800.69 in overpaid benefits and council tax benefit, and describes difficulties related to his age, mental awareness, and inability to use internet and telephone procedures to communicate with the Council.

Simion Costin · Prevention of Future Deaths report View report

26 Feb 2015 Leicester City and South Leicestershire C. Mason

Simion Costin died at Leicester Royal Infirmary on 25 March 2014 after admission with a self-inflicted neck incision, having attended the hospital twice in the preceding four days and been discharged after mental health assessments. Concerns included inconsistent approaches to patient assessment and the second discharge plan being based on incomplete data, with communication challenges when care crossed hospital or regional boundaries.

Christopher John Butler · Prevention of Future Deaths report View report

24 Feb 2015 Oxfordshire P. Clark

Christopher John Butler died following a house fire on 5 September 2014, from a combination of smoke inhalation and alcohol intoxication. The fire appeared to result from an overheated electrical cable, and concern was raised that similar wiring faults might exist in other properties on the estate and would not necessarily be detected by electrical testing.

Laura Hill · Prevention of Future Deaths report View report

20 Feb 2015 Carmarthenshire & Pembrokeshire G. Lewis

Laura Hill, aged 21, was admitted to a psychiatric ward after a serious overdose and later absconded twice before being found hanging from a tree in a wooded area. The concerns identified included information-sharing failures, stretched staffing, training needs around police handovers, absconding, personality disorders and detention powers, and the ward door policy.

Daniel Stickland · Prevention of Future Deaths report View report

20 Feb 2015 Southampton and the New Forest S. Whitby

Daniel Stickland, aged 17, was found collapsed after falling from his bed at his residential school on 14 May 2014, following two seizures earlier that day. He was taken to hospital and pronounced dead the following day; concerns included inadequate handovers, inaccurate or inaccessible logs, and no clear central method for recording significant medical events.

Michael Joseph Lyons · Prevention of Future Deaths report View report

20 Feb 2015 London (East) N. Persaud

Michael Joseph Lyons had Parkinson’s disease with significant difficulties in balance, speech and swallowing. On 23 September 2014, while being cared for at home, he choked on cheese on toast after it was not cut into small pieces and he was left eating unsupervised, causing his death. Concerns included the absence of an adequate care plan addressing the known choking risk, including food preparation and supervision, and the failure to establish and implement the speech and language therapist’s recommendations.

Richard Jeffrey Jones · Prevention of Future Deaths report View report

20 Feb 2015 Wiltshire and Swindon I. Singleton

Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between mental health services.

Lexie Louise Harrison · Prevention of Future Deaths report View report

20 Feb 2015 West Yorkshire Eastern M. Williamson

Lexie Louise Harrison, who had Infantile Refsum Disease, underwent an unsuccessful attempt to band an oesophageal varix on 30 May 2013, which caused trauma and extensive bleeding. Her condition deteriorated and she died at home on 18 June 2013; the medical cause of death was recorded as liver failure and Infantile Refsum Disease. The concerns included the absence of relevant policies or guidelines at two trusts and a lack of standardisation in practice, including decisions about banding, assessment, post-endoscopy care, management of bleeding, and consultant competence.

Maria Nekrasova · Prevention of Future Deaths report View report

20 Feb 2015 Inner South London P. Matthews

Maria Nekrasova was struck by a licensed taxi while standing in the hatched area in the middle of Westminster Bridge carriageway at about 1.50 am on 4 May 2014, sustaining a severe traumatic head injury from which she died. Concerns included the absence of pedestrian barriers or protection in the carriageway, low and contrasting street lighting, and vehicle headlight glare affecting drivers’ ability to see pedestrians.

Alexander George Ball · Prevention of Future Deaths report View report

19 Feb 2015 Cumbria D. Roberts

Alexander George Ball was found unresponsive at home on the night of 20 February 2014 and died following ingestion of prescription and illicit drugs. The substantive concerns were a lack of communication between the Partnership Trust and other agencies, and the absence of a dedicated Care Co-ordinator.