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Sylvia Prichard · Prevention of Future Deaths report View report

25 Oct 2024 Surrey A. Crawford

Sylvia Prichard, a resident of Moorlands Lodge Care Home, had an unwitnessed fall on 28 March 2024 after a delayed response to her call bell and later died in hospital from a traumatic acute subdural haemorrhage. The concerns included the absence of a falls minimisation plan, outdated and conflicting care-plan information, persistent delays in responding to call bells, and inadequate oversight and auditing of these issues.

Wessam al Jundi · Prevention of Future Deaths report View report

25 Oct 2024 West London L. Brown

Wessam al Jundi had severe silicosis and was admitted to Harefield Hospital on 17 May 2024 for a potential lung transplant, but was too unwell and died in hospital on 22 May 2024. The principal concern was that his untreatable lung disease was probably caused by workplace exposure to respirable crystalline silica from artificial stone products, in conditions described as unsafe and lacking adequate dust controls and respiratory protection.

Amanda Jane GAINFORD · Prevention of Future Deaths report View report

24 Oct 2024 Liverpool and the Wirral K. Roberts

Amanda Jane GAINFORD, aged 52, sustained abdominal injuries while detained in a mental health ward and later died at Aintree Hospital on 4 November 2022 from multiorgan failure due to splenic laceration and liver cirrhosis. The inquest identified missed opportunities to provide intravenous fluids and call an ambulance earlier while she had prolonged low blood pressure. It also raised concern that clinicians were not sufficiently aware of the ability to challenge ambulance call categorisation and request a clinical review from the ambulance service.

Patricia Heather Lines · Prevention of Future Deaths report View report

24 Oct 2024 County Durham and Darlington R. Sutton

Patricia Heather Lines became unwell after receiving an intramuscular Vitamin B12 injection into her right shoulder and died in hospital on 23 October 2023 after developing an invasive Group A Streptococcus infection. The report states that the likely source of the infection was the injection, with bacteria introduced from the skin into deeper shoulder tissues. A principal concern was that the administering nurse did not clean the skin, in accordance with existing training and national guidance, despite evidence that alcohol cleaning reduces bacterial counts and that the supporting literature was over 20 years old.

Alice Olivia CLARK · Prevention of Future Deaths report View report

24 Oct 2024 North West Kent R. Hatch

Alice Olivia Clark died after being trapped in a SECAMB ambulance involved in a road traffic collision on the A21 on 5 January 2022. Concerns included complaints about unsafe driving that were not appropriately dealt with, the absence of a formal complaint procedure, and the way ambulance driving standards were assessed.

Aran Sean BRADBURY · Prevention of Future Deaths report View report

24 Oct 2024 Norfolk C. Leach

On 21 August 2023, Aran Sean Bradbury applied a ligature to his neck, suffered cardiac arrest and was taken to hospital, where he died on 25 August 2023 from hypoxic ischaemic brain injury following hanging. The report raised concern that ambulance triage coding may assign Category 3 rather than Category 2 priority to patients with a history of mental illness who have ingested substances, potentially resulting in a longer wait for an ambulance. In this case, there was a two-hour delay between the 999 call and ambulance dispatch.

DECLAN GORDON GERARD MORRISON · Prevention of Future Deaths report View report

23 Oct 2024 Cambridgeshire and Peterborough S. Milburn

Declan Morrison, who had complex care needs and required 24-hour residential care, was detained under the Mental Health Act after no suitable alternative placement could be found. He was found unresponsive after suffering catastrophic brain injuries and died in hospital on 2 April 2022. The principal concerns were the shortage of suitable community and NHS placements and the use of a Section 136 Suite considered inappropriate for his longer-term detention and complex needs.

John Paul Hurst · Prevention of Future Deaths report View report

23 Oct 2024 Sunderland D. Place

John Paul Hurst, who had a history of paranoid schizophrenia and previous suicide attempts, was released from custody on 13 September 2021 after concerns had been raised about his mental health and risk of suicide. He was found near train tracks on 15 September 2021 and died from haemorrhage associated with severe injury to his right leg, consistent with impact with a train. The principal concern was that the electronic custody record inadequately documented the mental-health and suicide-risk concerns, and lacked detailed analysis and reasoning for the CJLD assessment conclusion.

Jean THOMAS · Prevention of Future Deaths report View report

23 Oct 2024 Gwent C. Saunders

Jean Thomas fell at home, fractured her hip, underwent surgical fixation, developed post-operative sepsis, and died in hospital on 26 October 2023. The inquest found that her fluid balance was not monitored by nursing or medical staff despite heart failure, chronic renal failure, signs of acute kidney injury and sepsis; this was determined to be a failure in care and a grave concern.

Joan Margaret KNIGHT · Prevention of Future Deaths report View report

22 Oct 2024 Birmingham and Solihull L. Hunt

Joan Margaret Knight underwent treatment for severe coronary artery stenosis, including stent procedures, and developed bleeding, cardiac tamponade and multi-organ failure before dying on 25 May 2024. The report raised concern that the mortality review was completed incorrectly and contained contradictory statements about whether the death was avoidable, potentially limiting learning from cases and creating a risk of future deaths.

Robert TAYLOR · Prevention of Future Deaths report View report

22 Oct 2024 Birmingham and Solihull L. Hunt

Robert TAYLOR, who had prostate cancer, chronic liver disease and later high grade acute myeloid leukaemia, fell in hospital on 11 June 2024 after enhanced nursing observations had been identified as necessary but not put in place. He sustained traumatic subdural and subarachnoid haemorrhages and died on 21 June 2024. Concerns were raised about the lack of enhanced observations and the quality of the Trust’s post-death investigation.

Peter Parker · Prevention of Future Deaths report View report

22 Oct 2024 Swansea and Neath Port Talbot A. Gruffydd

Peter Parker sustained a laceration to his right wrist from broken glass at home and called an ambulance, but the call disconnected and assistance arrived approximately 9½ hours later, after he had died. The principal concern was that the ambulance response exceeded the expected survival time for the injury, with delays attributed to ambulances waiting to hand over patients at emergency departments.

Richard David ROE · Prevention of Future Deaths report View report

22 Oct 2024 Cambridgeshire and Peterborough S. Milburn

Richard David Roe underwent scans that showed evidence of pancreatic cancer, but the recommended review of the scan was not completed. A later scan showed metastatic pancreatic cancer, and he subsequently died. The principal concern was that there was no current system to ensure routine CT scan reports were reviewed and actioned by clinicians.

Henry Michael WILLEMS · Prevention of Future Deaths report View report

21 Oct 2024 Worcestershire D. Reid

Henry Michael WILLEMS collapsed at home in Malvern in the early hours of 12 October 2023 after being unwell with gastritis for 48 hours and was confirmed deceased after paramedics attended. The report identified concern that the ambulance response was substantially delayed, with expert evidence that he would probably have survived if paramedics had attended within the applicable 18-minute mean response time.

Brian BEER · Prevention of Future Deaths report View report

21 Oct 2024 Suffolk P. Taheri

Brian Beer died peacefully in hospital on 1 March 2024 from small bowel ischaemia caused by a superior mesenteric artery blood clot, following hip fracture surgery after an unwitnessed fall. The principal concern was whether current NICE guidance on the duration of post-surgical prophylactic anticoagulation adequately reflects emerging evidence about risks after hip-fracture surgery, particularly in immobile and elderly patients.

Geoffrey Stuart CHENEY · Prevention of Future Deaths report View report

18 Oct 2024 West Yorkshire (Western) I. Pears

Geoffrey Stuart Cheney died by suicide on 16 January 2024 after going home on unescorted leave, securing the door chain, and hanging himself. The principal concern was that an item that could have been used in the hanging was assumed to be irremovable, so no attempt was made to establish whether it could be removed.

Mr Robin Andrew Ward · Prevention of Future Deaths report View report

18 Oct 2024 Northamptonshire H. Shah

Mr Robin Andrew Ward, a 73-year-old man, died by drowning in a bath at the Warren Crisis House on 4 July 2021; the conclusion was that his death was suicide. He had required an acute inpatient mental health bed, but no local bed was available for four days and he was placed at the crisis house as an interim measure. Concerns included pressures on acute and out-of-area mental health bed availability, the lower clinical capacity and lack of ligature safety in crisis houses, and long waiting times for psychological assessment.

Leslie Andrew Swindells · Prevention of Future Deaths report View report

17 Oct 2024 Manchester South A. Mutch

Leslie Andrew Swindells had a complex mental health background and, after his mental health deteriorated, was found unresponsive at home with self-inflicted puncture wounds to the neck. The concerns included assessment by a practitioner with limited mental-health training, lack of appropriate triage and escalation, failure to recognise and mitigate risk, telephone-based assessment, inadequate documentation, and unclear supervision arrangements.

Wilfred John Fitchett and 3 others · Prevention of Future Deaths report View report

17 Oct 2024 North West Wales K. Robertson

On 19 November 2023, a vehicle carrying four young men left the A4085, entered a water-filled drainage ditch and all four died from drowning; the vehicle was found on 21 November 2023. The report raises concerns about the absence of legal restrictions on young or newly qualified drivers carrying young passengers and the risk of further deaths in similar circumstances.

Paul Michael Clark · Prevention of Future Deaths report View report

16 Oct 2024 Manchester South A. Mutch

Paul Michael Clark was found unresponsive at home on 12 May 2024 and died from drug toxicity; the inquest concluded that the death was accidental. The principal concern was that opioid painkillers were prescribed despite his documented previous heroin addiction, without evidence that the risks of reintroducing opioids were considered or monitored, and he subsequently became addicted and took increasing amounts, including non-prescribed opioids.