Search PFD Monitor

JORDAN LEE ROBERTS · Prevention of Future Deaths report View report

6 Feb 2015 County Durham and Darlington A. Tweddle

JORDAN LEE ROBERTS, aged 17, was playing in the River Wear near Finchale Abbey when he entered a particularly deep area known as the bombhole and was not seen again above the surface. He was found in more than two metres of water by emergency services the next day. The principal concern was that warning signs were inadequate, not readily visible, and did not specifically highlight the danger from the sudden deep water and strong currents.

George Allan Taylor · Prevention of Future Deaths report View report

6 Feb 2015 Cornwall A. Cox

George Allan Taylor, who had a history of mental health issues and previous overdoses, was found hanged at home on 2 July 2013 after leaving a care home and returning home under daily supervision. The report identified concerns about inadequate provision of acute psychiatric beds in Cornwall, with 8 to 12 patients per month typically sent out of county, and noted that a future death could result from this lack of beds in changed circumstances.

Mr Ward · Prevention of Future Deaths report View report

5 Feb 2015 Black Country Z. Siddique

Mr Ward, an 85-year-old care home resident taking warfarin, suffered an unwitnessed fall and head injury on 29 November 2014. He was found unresponsive the following morning and died on 11 December 2014 after a CT confirmed a subdural haematoma. Concerns included staff awareness of the increased bleeding risk associated with head injury while taking warfarin, and the lack of clear policy, training, and escalation procedures for such falls.

Paul Moroney · Prevention of Future Deaths report View report

4 Feb 2015 Manchester South J. Pollard

Paul Moroney attended Tameside Hospital by ambulance on 27 August 2014 with worsening breathing and concern about a blood clot, was discharged with arrangements to return the following day, and later required a second emergency ambulance. Concerns included the lack of monitoring or recording of his oxygen saturations, discontinuation of oxygen before discharge without monitoring, and the absence of previous oxygen-level records when he was readmitted.

Paul Hardy · Prevention of Future Deaths report View report

4 Feb 2015 Nottinghamshire S. Haskey

Paul Hardy was a serving prisoner at HMP Lowdham Grange when his local hospital confirmed that he had urological cancer, which was not the immediate cause of his death. The report identified failures to obtain and process blood and urine samples, to facilitate INR monitoring, and to conduct a Significant Event Analysis, with delays and errors causing unnecessary suffering and distress.

John Ramsay Darling · Prevention of Future Deaths report View report

3 Feb 2015 Isle of Wight J. Matthews

John Ramsay Darling, aged 84, died after his wheelchair rolled over the unguarded edge of a café platform and he sustained a head injury. The principal concern was that the platform had an approximately one-metre drop without a physical barrier, creating risks for wheelchair users, children, buggies and other patrons, particularly because of the platform’s incline and busy conditions.

Shannon Kimberley Gee · Prevention of Future Deaths report View report

3 Feb 2015 Cornwall A. Cox

Shannon Kimberley Gee, aged 16, died as the result of an Accident. The report raised concerns about gaps between mental health services, delays of weeks in resolving disputes over responsibility for treatment, and difficulties transferring medical notes and records.

Alexander Matthew Holt · Prevention of Future Deaths report View report

3 Feb 2015 South Yorkshire (Western) C. Dorries

Alexander Matthew Holt had a history of serious self-harm attempts and died by an impulsive but deliberate act after taking an overdose that was not communicated to staff supervising his accommodation. The concerns included failure to provide intended treatment, failure of a referral process, lack of continuity and information-sharing, and insufficient consideration of risk, including that accommodation staff were unaware of his recent overdose.

Kimberley Lauren Lindfield · Prevention of Future Deaths report View report

2 Feb 2015 Manchester City N. Meadows

Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.

Tanya Christine PAGE · Prevention of Future Deaths report View report

2 Feb 2015 Inner North London M. Hassell

Tanya Christine PAGE took her own life by hanging while detained under a section of the Mental Health Act on Opal Ward of Highgate Mental Health Unit. A principal concern was that staff did not promptly communicate her disclosure of a recent attempted hanging on Sapphire Ward, apparently because of concern that this might be perceived as criticism of Sapphire staff.

MARTHA ANNE SEAWARD · Prevention of Future Deaths report View report

2 Feb 2015 Norfolk J. Lake

Martha Seaward, aged 18, was struck and fatally injured by a lorry while crossing the A148 after alighting from a bus at Lodge Hill. Concerns included the dangers of the bus stop and road crossing, with possible safety measures such as a pedestrian refuge, improved visibility, bus stop changes and a speed limit having been considered but not acted upon.

DARREN WRIGHT · Prevention of Future Deaths report View report

2 Feb 2015 Norfolk J. Lake

Darren Wright, aged 35, was found dead in his cell at HMP Norwich on 3 November 2013 after having been admitted to prison in September 2013. The report identified concerns about inconsistent sharing and access to information, the response to a Code Blue notification, and gaps in recent CPR training among attending prison officers.

Simon Richard Tree (Formerly Gary Charles Randall) · Prevention of Future Deaths report View report

30 Jan 2015 Surrey S. Wickens

Simon Tree, a voluntary patient at the Abraham Cowley Unit and known suicide risk, left the unit unsupervised on 17 February 2012 and was found drowned in the River Thames on 18 February 2012. The principal concern was inadequate security and monitoring of the airlock system, which allowed patients to leave by tailgating visitors and created opportunities for unsupervised exit.

ISAAC NASH · Prevention of Future Deaths report View report

30 Jan 2015 North West Wales D. Pritchard

On 29 August 2014, 12-year-old Isaac Nash was swept out to sea by strong tidal currents while playing in shallow water at Aberffraw Bay, and his body was never found. The report raised concern that the estuary area had strong currents that were not identifiable to beach users without local knowledge and was not signposted.

Michael Gerard McCrorY · Prevention of Future Deaths report View report

30 Jan 2015 The Wirral A. Rebello

Michael Gerard McCrory died on 16 July 2013 after intentionally driving his car into a tree; he was the sole occupant. The report identifies concerns about inadequate care, treatment, supervision and failure to appreciate and respond to his stated suicide risk. It also raises concerns about recording patients’ whereabouts during level 1 observations and uncertainty about staff training and support.

John Michael Matthews · Prevention of Future Deaths report View report

29 Jan 2015 Manchester South J. Pollard

John Michael Matthews died from natural causes, with the medical cause recorded as aspiration pneumonia associated with haemorrhagic hydrocephalus and spontaneous subarachnoid haemorrhage. Concerns included triage without the ambulance Patient Report Form, a locum doctor’s inability to access the complete computerised system, failure to institute neurological observations, and an unnecessary and partly unexplained delay in obtaining a head CT scan.

Phyllis Eleanor Barlow · Prevention of Future Deaths report View report

29 Jan 2015 Cardiff & Vale of Glamorgan C. Woolley

Phyllis Eleanor Barlow, who was taking warfarin, fell and struck her head in a GP surgery car park on 29 September 2014 but was not admitted to hospital. She fell again at home the following day, sustaining a subdural haemorrhage and hip fracture, and died on 8 November 2014; the concern was that GP surgeries were not sufficiently aware of NICE guidance requiring hospital admission and CT scanning after a head injury in a person taking warfarin.

Brian Marks · Prevention of Future Deaths report View report

29 Jan 2015 Manchester South J. Pollard

Brian Marks had motor neurone disease and, in the last stages of life in hospital, was being fed and given medication via a PEJ tube after aspirating and contracting pneumonia. A nurse mistook the PEJ tube for a PEG tube, and the report identified that the similar appearance of the tubes could lead to confusion and that they should be differentiated using colour coding.

Margaret Emily Flemming · Prevention of Future Deaths report View report

29 Jan 2015 Bedfordshire and Luton T. Osborne

Margaret Emily Flemming, a care-home resident with dementia, was seen by a doctor and prescribed antibiotics over 17–18 January 2015, and died peacefully at the care home the following day. The report raised concerns about delays in completing a Best Interests Assessment after an urgent Deprivation of Liberty Safeguarding Authorisation request, while she remained vulnerable and confused.

Katherine Liana Bonaventura · Prevention of Future Deaths report View report

28 Jan 2015 Surrey A. Hewitt

Katherine Liana Bonaventura, a patient detained under the Mental Health Act, returned to the Abraham Cowley Unit on 7 December 2012 after overnight leave with a concealed knife and fatally stabbed herself a few hours later. The principal concerns were that relevant information about her leave was not elicited from her family member, her mental state was not assessed sufficiently and immediately on return, and there was no system to ensure thorough consultation and assessment or recording of the assessment outcome.