Search PFD Monitor

Kevin Anthony Ince · Prevention of Future Deaths report View report

18 Nov 2024 Lancashire and Blackburn with Darwen C. Long

Kevin Anthony Ince was detained under the Mental Health Act 1983 and became unwell at Kem Ple View Hospital on 24 October 2023. He was taken to hospital, where his condition deteriorated, and he died on 25 October 2023 from right ventricular failure caused by acute interstitial pneumonitis associated with vaping-related lung injury. The concerns included insufficient consideration of responses when detained patients refused necessary medical treatment and insufficient action when a detained patient routinely declined food over a prolonged period.

John Edward RILEY · Prevention of Future Deaths report View report

18 Nov 2024 Norfolk J. Lake

John Edward RILEY, who had severely limited mobility and lived in a residential home, was found on the floor with the bed frame under his neck on 8 February 2024 and was declared dead at the scene. The inquest recorded the medical cause of death as a neck fracture following a fall. Concerns were raised that required two-hourly observations were sometimes carried out late, including after action had been taken to reduce delays.

Yemisi Cielto-Opaleye · Prevention of Future Deaths report View report

18 Nov 2024 Inner North London E. Buckett

Yemisi Cielto-Opaleye, a psychiatric inpatient at St Pancras Hospital, died on 13 December 2023 after receiving an Olanzapine depot injection and developing Olanzapine toxicity. The report identified concerns about inadequate pre- and post-injection vital-sign monitoring, unclear staff responsibilities, insufficient escalation and contingency planning, and failures to obtain required approval and provide adequate information about risks.

Emily Jane LEWIS · Prevention of Future Deaths report View report

15 Nov 2024 Hampshire, Portsmouth and Southampton H. Charles

Emily Jane Lewis, aged 15, died at Southampton General Hospital on 22 August 2020 after the high-speed RIB on which she was a passenger collided with a buoy, projecting her into a handhold and causing fatal injuries. The principal concerns included the workload and situational awareness of a lone skipper, inadequate forward visibility and passenger protection, shortcomings in seating and handrail design, insufficient risk assessment and safety management, and confusing or inconsistent regulation of high-speed RIB experience rides.

John COGDON · Prevention of Future Deaths report View report

15 Nov 2024 Teesside and Hartlepool P. Appleton

John Cogdon underwent coronary artery bypass graft surgery on 26 June 2023 and deteriorated before dying on 4 August 2023. Evidence at the inquest raised concern that different hospital wards and departments used fragmented, poorly integrated record-keeping and prescribing systems.

Rachel Alicia Elizabeth RYAN · Prevention of Future Deaths report View report

15 Nov 2024 Birmingham and Solihull S. Brenchley

Rachel Alicia Elizabeth RYAN was treated for a sacral pressure ulcer that became infected and developed into osteomyelitis, alongside deep vein thrombosis and pulmonary embolism. She deteriorated and died on 21 June 2024; the stated medical cause of death was osteomyelitis due to an infected sacral pressure sore, with frailty of old age also recorded. The principal concern was delay and lack of collaboration between specialist teams in arranging a deep tissue biopsy to guide antibiotic treatment.

Yousef Al-Kharboush and 2 others · Prevention of Future Deaths report View report

15 Nov 2024 Inner South London J. Morris

Aviva Otte died in January 2014 after receiving TPN provided and compounded by an NHS establishment; the TPN was, on balance, contaminated with Bacillus cereus. Oscar Barker and Yousef Al-Kharboush died in June 2014 after receiving TPN compounded by a commercial provider that was also contaminated with Bacillus cereus. The principal concerns were unclear or absent requirements for section 10 exempt entities to report adverse-event findings and uncertainty about reporting thresholds and wider dissemination of information that could help other providers assess risks.

Teresa Auriemma · Prevention of Future Deaths report View report

14 Nov 2024 Worcestershire D. Reid

Teresa Auriemma was admitted to hospital after becoming unwell and was treated for aspiration pneumonia, dehydration, acute kidney injury and deranged electrolytes. She received intravenous potassium based on an out-of-date and inaccurate blood test, was given further intravenous potassium without the required monitoring, and subsequently collapsed and died from a fatally high potassium level. The principal concerns were failures to monitor potassium and other electrolytes and to ensure that doctors understood and complied with relevant monitoring policies.

Hannah Mary AITKEN · Prevention of Future Deaths report View report

14 Nov 2024 Surrey A. Loxton

Hannah Mary Aitken died at her supported accommodation on 14 September 2023 after taking an overdose of a poisonous substance obtained with the intention of ending her life. The report raises concerns about the unrestricted domestic and international availability of the substance, the quantities and purity in which it is sold, and the lack of central monitoring or clear responsibility for regulating its use in relation to self-harm.

Mr. Kurnathy · Prevention of Future Deaths report View report

14 Nov 2024 Manchester South A. Morris

Mr. Kurnathy was found unresponsive at home on 9 May 2024 and was pronounced dead; autopsy confirmed acute left ventricular failure, with fentanyl and morphine toxicity contributing to the death. Four fentanyl patches were found on his back, exceeding the prescribed amount. The principal concern was that correspondence reporting excessive fentanyl use was not identified by the surgery and did not trigger a medication review, and that the surgery had no specific procedures for flagging or reviewing concerns about fentanyl abuse.

Miranda Emilia Avanzi · Prevention of Future Deaths report View report

14 Nov 2024 Inner North London I. Potter

Miranda Emilia Avanzi was found unresponsive at home on 9 July 2024, partially suspended by a ligature, and her death was verified shortly afterwards. The principal concern was the ready availability online of detailed guides, including pictures and diagrams, giving instructions on ending one’s life by partial hanging, with limited age verification on some sites.

John Robert ELLIS · Prevention of Future Deaths report View report

14 Nov 2024 Hampshire, Portsmouth and Southampton S. Burge

John Robert ELLIS, a veterinary surgeon experiencing personal, financial and work-related stress, died after self-administering a toxic quantity of a drug he had obtained by falsely claiming it was needed to euthanise a dog. The principal concern was that veterinary surgeons could access potentially lethal controlled drugs without adequate verification, scrutiny or safeguards against misuse.

Catherine Sarah Forbes · Prevention of Future Deaths report View report

14 Nov 2024 Oxfordshire D. Salter

Catherine Forbes, aged 57, drowned after falling unwitnessed into the Thames and Kennet Marina late on 31 March 2023; she was unable to climb out using a nearby ladder. The principal concerns relate to the design, length, grip, number, placement and visibility of marina ladders, and to the availability of flotation devices, platforms and alarm systems to help people who fall into the water escape or raise the alarm.

Joel Phillip COLK · Prevention of Future Deaths report View report

13 Nov 2024 West Sussex, Brighton and Hove J. Andrews

Joel Phillip Colk called 999 after ingesting at least 50g of a substance and was attended by an ambulance after the call was upgraded from category 3 to category 2. He was in cardiac arrest on attendance and died at home on 2 October 2023. The concerns include that NHS Pathways did not differentiate overdoses by substance, amount, timing or patient weight, and did not reflect the time-sensitive treatment required for this ingestion; ambulances also did not carry the antidote in the area described.

Andrew Howat · Prevention of Future Deaths report View report

13 Nov 2024 North Wales (East and Central) J. Gittins

Andrew Howat was intoxicated and left by a taxi in an unlit layby on the A483 dual carriageway, where there was no easy means for a pedestrian to leave. Concerns included the driver’s decision to leave him in an unsafe location, the failure to contact police, and a lack of corroborating evidence that drivers were trained in the relevant protocol.

John Frederick Doyle · Prevention of Future Deaths report View report

12 Nov 2024 Coventry and Warwickshire L. Lee

John Frederick Doyle, a kidney transplant recipient, was admitted with rectal bleeding and a persistent cough and was later diagnosed with a severe cytomegalovirus infection after delays in testing, diagnosis and transfer to specialist care. He deteriorated to multiple organ failure and died on 30 December 2023. Concerns included unclear arrangements for contacting specialist centres, sharing information, accessing renal guidance, initiating transfers and coordinating care between specialist and non-specialist hospitals.

Erin Louise TILLSLEY · Prevention of Future Deaths report View report

12 Nov 2024 Suffolk D. Stewart

Erin Louise Tillsley, aged 14, died on 14 July 2023 after being found suspended by a ligature at home; emergency services were unable to resuscitate her. The inquest heard that, after she attended the emergency department following an overdose on 31 December 2022, the relevant NICE guidance and local policy on self-harm assessment and mental health support were not applied, resulting in a missed opportunity for early mental health engagement.

Lisa Gale · Prevention of Future Deaths report View report

12 Nov 2024 Avon S. Fox

Lisa Gale developed Acute Fatty Liver of Pregnancy (AFLP) and later died despite hospital treatment and intensive care. The report raises concerns that markedly abnormal liver-function results were not urgently communicated because reporting thresholds did not account for pregnancy-specific conditions, resulting in a delay in diagnosing AFLP and starting appropriate treatment.

Kirsten Hocking · Prevention of Future Deaths report View report

11 Nov 2024 West Sussex, Brighton and Hove N. Armstrong

Kirsten Hocking, aged 31, died in hospital on 24 May 2023 as a result of a heroin overdose after being released from prison and found in a public toilet. The concerns identified included a lack of specialist rehabilitation accommodation for some women leaving prison, training needs for probation officers arranging accommodation and release plans, and unclear placement-offer and decision-making systems at a specialist accommodation charity.

Alison BINYON · Prevention of Future Deaths report View report

11 Nov 2024 Derby and Derbyshire S. Lomas

Alison Binyon, who had a history of mental health difficulties and self-harm involving ligation, was found unresponsive at her residential home on 11 September 2019 and died on 13 September 2019 after developing a hypoxic brain injury. The report identified concerns about communication and uncertainty around her planned move to step-down accommodation, and about the absence of an internal review after her death.