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Phyllis TROMANS · Prevention of Future Deaths report View report

1 Nov 2024 Birmingham and Solihull V. McKinlay

Phyllis Tromans, a long-term resident with Parkinson’s disease who was in a frail condition, developed a grade 4 pressure ulcer while an inpatient at Queen Elizabeth Hospital and died at Cotteridge House on 24 May 2024. Concerns included an underestimated pressure sore risk assessment, prolonged periods without repositioning, an incomplete wound care plan, and an investigation that did not establish why gaps in care had occurred.

Wayne Anthony BAYLEY · Prevention of Future Deaths report View report

31 Oct 2024 Inner North London M. Hassell

Wayne Anthony Bayley died in HMP Pentonville approximately ten hours after a restraint. His death involved acute chest syndrome, hypoxia, chronic sickle cell lung disease and sickle cell disease; the principal concern was that learning and improvements relating to the care of prisoners with underlying health conditions may not have been shared nationally.

Sebastian Benjamin OLIVER · Prevention of Future Deaths report View report

30 Oct 2024 Birmingham and Solihull A. Hodson

Sebastian Benjamin Oliver was found unresponsive on 29 November 2023 after sustaining an incised wound to his left hand while climbing a spiked fence under the influence of drugs, and he later died in hospital. The report identified concerns about West Midlands Police closing a safe-and-well-check log after Mr Oliver absconded from hospital, relying on an earlier capacity assessment despite a later assessment that he lacked capacity, and about shortcomings in training and communication with ambulance staff.

Lee Armstrong · Prevention of Future Deaths report View report

29 Oct 2024 Cumbria R. Cohen

Lee Armstrong became unwell on 30 January 2024 and, after an initial ambulance-service call, became increasingly unwell before a further call led to an ambulance attending. He suffered an Addisonian Crisis, cardiac arrest and severe brain injury, and died on 2 February 2024. Concerns included the failure of the NHS Pathways system to ask about existing medical conditions, the lack of sharing of information supplied through 111 online with ambulance call handlers, and call handlers' lack of access to relevant medical records.

Jamie Harding · Prevention of Future Deaths report View report

29 Oct 2024 Essex S. Horstead

Jamie Harding attended Basildon Hospital on 3 June 2022 in crisis, with worsening psychotic symptoms, suicidal ideation and several days without sleep. He was discharged home rather than admitted as an inpatient and took his own life within hours after falling from a window. The substantive concerns included failures in assessment, follow-up, medication review, multidisciplinary working, risk assessment, record keeping and communication, alongside weaknesses in systems supporting the First Response Team and access to the Dual Diagnosis pathway.

Margaret Joy Daly · Prevention of Future Deaths report View report

28 Oct 2024 North Wales (East and Central) J. Gittins

Margaret Joy Daly was an in-patient at Wrexham Maelor Hospital and, despite being assessed as at significant risk of falling, received lorazepam after a doctor prescribed it without reviewing her full records. She later had an unwitnessed fall and sustained the injury that resulted in her death; the principal concern was that sedative prescribing could occur without consideration of the patient’s full medical records and risk assessments.

Shirley Ann Hughes · Prevention of Future Deaths report View report

28 Oct 2024 North Wales (East and Central) J. Gittins

Shirley Ann Hughes collapsed at home on 1 June 2024 and, because no ambulance was available, waited more than fifteen hours on the floor before treatment and hospital admission. The principal concern was whether the Medical Priority Dispatch System remained fit for purpose amid ambulance resource pressures, with the coroner concerned that lives were being put at risk.

Kashim ALI · Prevention of Future Deaths report View report

28 Oct 2024 Inner North London I. Potter

Kashim Ali was detained under section 3 of the Mental Health Act 1983 at Mile End Hospital and died on 21 May 2024 after being found unresponsive in bed; attempts at resuscitation were unsuccessful. The concerns identified included failures to escalate NEWS2 scores, shortcomings in one-to-one observation practices, and inaccurate observation records, which were considered to create risks to patient safety and future patients.

Malcolm John TAYLOR · Prevention of Future Deaths report View report

28 Oct 2024 Norfolk J. Lake

Malcolm John TAYLOR, who had expressed self-harm and suicidal intent and was awaiting admission to a mental health hospital, probably entered the sea on 3 or 4 March 2024 and was found on Gorleston beach on 4 March 2024. He died from drowning. The report identified an insufficient number of available mental health hospital beds, with patients awaiting beds at the time of his death and the inquest.

Ian Gilmore HEGARTY · Prevention of Future Deaths report View report

28 Oct 2024 Inner North London I. Potter

Ian Hegarty was admitted to hospital after a fall at home and later sustained an unwitnessed fall in hospital when the allocated staff member left the bay, causing a right femur fracture. His condition deteriorated and he died on 17 June 2024; the principal concern was that the care plan intended to reduce falls risk was not followed, with insufficient reassurance at the time of the inquest that the risk was being addressed.

Susan Patricia SHIPLEY · Prevention of Future Deaths report View report

28 Oct 2024 North Yorkshire and York C. Cundy

Susan Patricia Shipley, who had critical limb ischaemia and previous amputations, fell from a hospital wheelchair while being transferred between hospitals on 28 January 2024 and fractured her right neck of femur. She underwent further amputations, developed pneumonia, and died in hospital on 4 February 2024. The principal concerns were the lack of documented and appropriate “fit to sit” assessments, the decision to transport her in a wheelchair despite her inability to weight bear, and the potential risk of death to others if similar issues recur.

Chad George ALLFORD · Prevention of Future Deaths report View report

25 Oct 2024 Derby and Derbyshire S. Evans

Chad George Allford died at King's Mill Hospital on 27 October 2021 after placing cocaine in his mouth during a police operation to arrest him for a drug offence. The inquest evidence raised concerns that officers had not received training on this situation, did not warn him of the risks to his life, and were unaware of risks associated with placing their hands in his mouth, including choking.

Mark Stephen Beresford · Prevention of Future Deaths report View report

25 Oct 2024 Nottinghamshire M. Wall

Mark Stephen Beresford died at Bassetlaw District General Hospital on 7 July 2023 after applying a ligature while detained at HMP Ranby, having been discovered unresponsive and resuscitated. The jury found that he was suffering significant mental ill health and identified failings in the assessment and management of his mental health and self-harm risk, ACCT observations, completion of an action plan, response to his cell bell, and staffing. The report also raises concerns about prison leadership’s understanding and assessment of risk and its lack of candour and reflection during the inquest.

George Kyriacos Petrou · Prevention of Future Deaths report View report

25 Oct 2024 Inner North London I. Potter

George Kyriacos Petrou was found deceased in his cell at HMP Pentonville on 1 March 2021 after partially suspending himself by ligature in the bathroom of his cell. The report raised concerns that some mental health in-reach staff placed significant weight on prisoners declining suicide watch or ACCT measures, contrary to guidance, policy and procedures, and that insufficient reassurance was provided that this had been addressed.

Martin Ian Stubbs · Prevention of Future Deaths report View report

25 Oct 2024 West Yorkshire Eastern O. Longstaff

Martin Ian Stubbs was a serving police officer who was arrested, suspended from duty and remained on bail until his death. He died by suicide by hanging at his home on 26 August 2024. The principal concern was the prolonged delay in concluding the internal disciplinary process, which the family believed contributed to his death and might reflect wider resource or management issues.

Chloe Every · Prevention of Future Deaths report View report

25 Oct 2024 East London G. Irvine

Chloe Every died in hospital on 14 May 2019 after complications from a hypoxic cardiac arrest sustained during her admission. The report identified concerns including morphine use without recorded justification, an enema undertaken without informed consent while she was unconscious, inadequate clinical observations, missing records, and failures in incident reporting and governance.

Michael James Crane · Prevention of Future Deaths report View report

25 Oct 2024 Inner North London I. Potter

Michael James Crane lived in supported accommodation and was absent from the Home from 15 January 2024. He attended hospital and later a police station, but left without being reported missing; his body was retrieved from the River Thames on 18 January 2024. The inquest concluded that he drowned, contributed to by no missing person report being made to the police. The report raised concerns about the absence of MPS guidance for frontline officers dealing with people who may be missing but have not yet been reported as such.

Mark Francis ECCLES · Prevention of Future Deaths report View report

25 Oct 2024 Herefordshire H. Bricknell

Mark Francis Eccles died after a vehicle pulled out in front of his motorcycle near a junction while he was travelling on the B4361. The substantive concerns were limited visibility at the junction and that it was subject to the National Speed Limit.

Natasha Johnston · Prevention of Future Deaths report View report

25 Oct 2024 Surrey R. Travers

Natasha Johnston died on 12 January 2023 after being viciously attacked by an unknown number of dogs from a group of eight that she had been walking. The principal concern was the lack of local and national regulation restricting the number and weight of dogs that one person may walk in a public place.

Frank Steve Rios OSPINA · Prevention of Future Deaths report View report

25 Oct 2024 West London L. Brown

Frank Steve Rios OSPINA died by suicide in detention, with the cause of death recorded as ligature compression of the neck and coronary heart disease. The report raised concerns about the failure to make a Rule 35(2) report after apparent suicide attempts, inconsistent understanding of the reporting process, the conduct and oversight of a closed family visit, and difficulties faced by his non-English-speaking mother in arranging visits and telephone calls.