6,433 reports
Information drawn from published reports and official responses.
Damion Stanley was found dead in his flat on 4 July 2013 after overdosing principally on methadone and taking other drugs. The concern was that inadequate 24-hour supervision at a homeless residence used by some drug users may have contributed to the death and posed risks to others.
ManagerOwner-manager
Antony Hughes died on 28 February 2012 after consuming cocaine, alcohol and non-prescribed valium and becoming paranoid and highly agitated. He suffered a cardiac arrest while being treated by police and ambulance personnel, and the inquest concluded that the death was due to cocaine toxicity with excited delirium. The principal concern was that police officers were unaware of excited delirium at the time, prompting consideration of whether related awareness training was standard across police forces.
National Crime Agency
Keith Barton, who had Alzheimer’s disease and dementia and was at risk of choking, choked and died while eating breakfast alone in his room at a nursing home on 5 February 2013. The principal concerns included unclear communication of the required level of supervision, periodic rather than constant checks while eating, incomplete incident reporting, and limits on staff access to dysphagia awareness training.
Ashley Gardens Care Centre
Millie Elizabeth Josephine Thompson, aged 9 months, choked while being fed Shepherd’s Pie at a nursery on 23 October 2012. Food lodged in her left main bronchus, leading to a tension pneumothorax and cardiac arrest. Concerns included insufficient paediatric first-aid training and lapsed certification among nursery staff, an incorrect ambulance call allocation, and unsuitable paediatric equipment on the first ambulance.
Department for EducationDepartment of Health and Social CareNorth West Ambulance Service NHS Trust
Kirk Duboise arrived at HMP Durham with documents highlighting self-harm risks, but the documents were not seen and an ACCT was not opened. He was found dead in his cell approximately eight hours after arrival; concerns included the failure to identify the relevant forms and a delay in summoning an ambulance.
Care UKHM Prison Service
Desmond Roy Statton died after suffering a severe allergic reaction shortly after contrast medium was administered for a CT scan. The report raises concerns that radiographers and clinicians could not access allergy and alert information held on other hospital computer systems, and that nursing staff were not sufficiently aware of the risks associated with chlorhexidine.
Derriford Hospital
Karl Doran, a seven-year-old boy volunteering with his father at Beamish Museum, fell from or near a steam roller and was almost immediately crushed by a heavy steel-wheeled trailer. The concern was that Beamish had not carried out appropriate risk assessments or provided direct or indirect managerial supervision for the volunteers’ activities.
Beamish MuseumHealth and Safety Executive
Yuki was a very young child who had a persistent cough and was seen at a walk-in centre and twice by practice nurses, receiving diagnoses of chest infection and courses of antibiotics. She later became unresponsive while with her father and died despite resuscitation efforts. Concerns related to checking her past medical history, guidance for practice nurses to refer children to a doctor, and appointment systems for securing a doctor’s assessment.
St Stephens Gate Medical Practice
Keith Thomas Graham was involved in a road traffic collision after colliding with a bullock while travelling by motorcycle and later died from multiple injuries on 28 May 2012. Concerns included the timing of summoning on-call clinicians, the use of CT scanning for seriously injured trauma patients, and the time between presentation and theatre, as well as a misplaced chest drain that damaged the liver.
North Cumbria Integrated Care NHS Foundation Trust
Archibald Wellbelove died in the early hours of 7 December 2012 after being struck by a taxi on the Kenilworth-bound carriageway of the A452, which was unlit at the time following a change in the County Council’s night-lighting policy. The principal concern was that the Council had not reviewed its night-lighting policy in light of pedestrian use of the road and possible lack of awareness of a footpath.
Warwickshire County Council
Marjorie Evelyne Keogh, a resident of Scraptoft Court Residential Care Home, fell through a first-floor landing balustrade while transferring to breakfast on 6 March 2010 and died the following day from bilateral pneumonia and multiple injuries. Concerns included the assessment of her suitability for a first-floor room, staffing levels and the absence of a manager, inconsistent risk and manual-handling assessments, and the strength and compliance of staircase furniture.
MyMil LimitedScraptoft Court Care Home
Horace Cottom, a serving prisoner at HMP Manchester, died there on 21 June 2012 from pneumonia and heart disease with pseudomembranous colitis, with the inquest concluding that the death was from natural causes. The principal concern was that discharge information from NHS hospitals could take about 10 days to reach the prison and was sometimes incomplete, affecting the timely management of prisoners’ healthcare after hospital discharge.
Department of Health and Social Care
Abdullahi Sharif Abokar, a 22-year-old patient detained under section 3 of the Mental Health Act, was found hanging from smoke alarm wires on a secure mental health ward on 16 June 2012 and died five days after being taken to hospital. Concerns included staff not asking him about suicidal thoughts and significant shortcomings in the conduct of resuscitation, including compromised ventilatory support and uncertainty about airway management.
North London NHS Foundation Trust
Agostino Costa died after an accidental fall in hospital on 12 May 2013, which hastened death from terminal disease. The principal concerns were staff confusion about falls-risk classification and management, inadequate training for a junior doctor, limited sharing of the hospital root cause analysis, and non-mandatory attendance at falls-prevention seminars.
Whittington Health NHS Trust
Karl Olaf Nilsson died minutes after suffering catastrophic injuries in a motorcycle collision at the junction of Victoria Road and the A657 Saltaire Road on 14 October 2012. The report raised concerns that the junction’s layout and the visibility of the STOP sign may have contributed to the fatality, and noted that this was the only junction along Victoria Road where drivers did not have right of way.
Bradford City CouncilNational Highways
Michael James Meyler died in hospital on 1 January 2011 after being found hanging by the neck in his prison cell on 28 December 2010 and sustaining a hypoxic brain injury. The principal concerns were that information about his recent self-harm and suicide risk was not adequately circulated, read, or attached to his ACCT plan, limiting the ability of prison staff and healthcare personnel to make informed decisions about his welfare.
HM Prison ServiceManchester Prison
John William Tugwell, a nursing-home resident aged 79, was found at the bottom of the stairs after an unwitnessed fall and later died from injuries including skull fractures and an extra cranial scalp haematoma. The principal concern was that, despite a documented history of previous falls, he had unsupervised access to two sets of stairs at the home.
Coombe Dingle Nursing Home
The circumstances of Doris Phoebe Miller’s death are not provided in the supplied text. Concerns included the GP surgery’s lack of access to her transferred medical records, ineffective communication about an urgent blood test, and the absence of a pulse oximeter at the surgery.
Care Quality CommissionNHS EnglandRecipient name withheldThe Practice
Christopher Michael SCOTT took pills containing AMT on 21 July 2013 and was admitted to hospital on 22 July 2013. He died on 24 July 2013 after developing multiorgan failure and bronchopneumonia attributable to the toxic effects of AMT. The principal concern was that AMT was a readily available legal drug whose effects could be deadly, with other deaths also appearing to involve AMT.
Home Office
Peter Jeffrey collapsed at home and died on 10 February 2013 after developing a swollen, infected left leg and foot. The report raised concerns that, after scans did not reveal DVT, no effective alternative diagnosis or treatment was considered, and that the open blister was not cultured or swabbed and intravenous antibiotics were not considered. The inquest concluded that the left foot ulcer was not tested and consequently went untreated.
Guy'S and St Thomas' NHS Foundation TrustAccount
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