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Maeve Boothby O’Neill · Prevention of Future Deaths report View report

8 Oct 2024 Devon, Plymouth and Torbay D. Archer

Maeve Boothby O’Neill, who had severe ME and was bedbound, died at home on 3 October 2021 after three hospital admissions during 2021. The report identified concerns about the lack of specialist care provision for severe ME, limited research funding and medical training, and insufficient guidance on managing severe ME in the home or community, including nutritional support.

Helen DAVEY · Prevention of Future Deaths report View report

7 Oct 2024 County Durham and Darlington J. Chipperfield

Helen DAVEY died after the mattress platform of an Ottoman-styled gas-lift bed descended unexpectedly while she was leaning over its storage area, trapping her neck and causing positional asphyxia. The principal concern was the existence and use of gas-piston bed mechanisms whose failure presents a risk to life.

John Raymond EYRE · Prevention of Future Deaths report View report

7 Oct 2024 Mid Kent and Medway I. Brownhill

John Raymond Eyre was a serving prisoner whose health deteriorated in 2022, including recurrent neutropenic sepsis, and he died in hospital on 20 November 2022 from pneumonia, with liver disease also recorded. Concerns included the lack of a concrete escalation route when prison healthcare staff challenged his discharge and the absence of national guidance on returning a prisoner to custody when those concerns had not been considered by the consultant.

James Warren Agius · Prevention of Future Deaths report View report

7 Oct 2024 Essex S. Hayes

James Warren Agius was found deceased at home on 17 December 2022 after suspending himself, with the inquest concluding suicide by suspension by ligature. The concerns included significant omissions in his medical records, an incomplete risk assessment following a suicide attempt, differing views about whether he displayed hypomanic symptoms, and no evidence that new national risk-assessment training had been implemented by the Trust.

Bryan Andrews and Mary Andrews · Prevention of Future Deaths report View report

4 Oct 2024 South Yorkshire (Western) T. Rawden

Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.

James Southern · Prevention of Future Deaths report View report

4 Oct 2024 Nottinghamshire S. Wood

James Southern, known as Jimmy, died on 31 May 2023 after being found unresponsive at his home in Nottinghamshire. He had suffered pain and anxiety since a 2002 motorbike accident and died from polydrug toxicity. The report identified errors and delays in care records, including records amended after death, and that he was left without care for months after his care coordinator was absent; concerns also included poor record keeping and communication.

Marina Sharon Young · Prevention of Future Deaths report View report

4 Oct 2024 Lancashire and Blackburn with Darwen J. Adeley

Marina Sharon Young, who had spina bifida and asthma, died after spending 39 hours in the Accident & Emergency Department during an asthma attack. The report describes failures in medical management, escalation to specialist teams, nursing assessment, and provision of care for her complex needs, including catheterisation, pressure-area care and toileting. The concerns include inadequate assessment and management of patients held in A&E beyond the expected time, insufficient asthma expertise, and failures to escalate concerns.

Kevin George Woods · Prevention of Future Deaths report View report

3 Oct 2024 Cornwall and Isles of Scilly G. Davies

Kevin George Woods died on 17 January 2024 after suffering cardiac arrest following a prolonged ambulance delay when no Category 2 ambulance was available. The inquest found that he had an undiagnosed and possibly treatable heart condition and that the delay denied him potentially lifesaving treatment. The principal concerns were continuing ambulance and hospital handover delays, inadequate social care and community healthcare provision contributing to delayed discharges, and the absence of a single organisation responsible for managing the associated patient-safety risks.

Mrs Gabrielle Sarah Anne Steel · Prevention of Future Deaths report View report

3 Oct 2024 East London N. Persaud

Mrs Gabrielle Sarah Anne Steel, who was bed bound and known to smoke in bed and drink alcohol, died after a fire on her bed at her home on 17 October 2023. The fire investigation identified the likely cause as unsafe disposal of smoking materials, and the flame-retardant duvet cover was not on the bed. The principal concerns were poor communication of the fire safety assessment and the absence of a shared written fire risk management plan for those caring for her.

John Turner · Prevention of Future Deaths report View report

3 Oct 2024 Manchester South C. Morris

John Turner died at Tameside General Hospital on 23 August 2023 from a pulmonary embolism due to a deep vein thrombosis, neither of which had been identified when he attended the Emergency Department three days earlier. The concerns included significant deviation from the Manchester Triage System, a requested D-Dimer test not being undertaken, delayed recording of a senior doctor’s findings, and reduced scope to identify atypical major or life-threatening illness during periods of unremitting demand.

Michael Sean Heath · Prevention of Future Deaths report View report

2 Oct 2024 Manchester South C. Murray

Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.

Alix Elizabeth Knowles · Prevention of Future Deaths report View report

2 Oct 2024 Staffordshire and Stoke-on-Trent E. Serrano

Alix Elizabeth Knowles, aged 30, attended hospital on 8 December 2023 after attempting to cut her throat and threatening suicide, but was discharged home after a mental health assessment. In the early hours of 9 December 2023, she jumped from a bridge onto the road below and was hit by two motor vehicles. The substantive concerns were that bank staff could not access patient notes before assessments and that different NHS Trusts could not access one another’s patient notes because of incompatible computer systems.

Scott Bradley Davies · Prevention of Future Deaths report View report

1 Oct 2024 Manchester South C. Murray

Scott Bradley Davies collided with a steel barrier while testing a modified motorcycle in Alexandra Park on 2 February 2024. He sustained serious head injuries, never regained consciousness, and died from a traumatic brain injury at Salford Royal Hospital on 8 March 2024. The report raises concern that a matt black locked steel barrier on a legitimate right of way is difficult to see at dusk and in darkness and could cause serious injury or death to users of the thoroughfare.

Ryan James Richard Campbell · Prevention of Future Deaths report View report

1 Oct 2024 Manchester South C. Murray

Ryan Campbell experienced persistent chest pain and underwent medical investigations, but further cardiac imaging was still awaited when he died. The report identified delays associated with the absence of a full suite of cardiac diagnostic imaging equipment at Stepping Hill Hospital, particularly CT or MR angiograms, and the need to switch treatment centres.

Brandon Valrick JOHNSON · Prevention of Future Deaths report View report

1 Oct 2024 Inner West London P. Rogers

Brandon Valrick JOHNSON died of cardio-respiratory failure at his cell in HMP Wandsworth on 12 September 2019, aged 40. He was not discovered deceased until late afternoon despite several attendances at his cell. The report raised concerns about the robustness, timing, recording, oversight and staff training relating to checks intended to establish that prisoners were alive.

Sophie Ann Dean · Prevention of Future Deaths report View report

30 Sep 2024 Inner North London I. Potter

Sophie Ann Dean, who was aged 18, underwent surgery after free air was found in her abdomen and later required re-closure of her abdominal wound. She developed a chest infection and, after the second operation on 4 September 2023, suffered a cardiac arrest and died despite resuscitation efforts. The substantive concerns related to omissions and inadequacies in the medical records and whether the rationale and alternatives to surgery were sufficiently discussed with her parents before consent was given.

JAMES EDWARD TURNER · Prevention of Future Deaths report View report

29 Sep 2024 Cornwall and Isles of Scilly G. Davies

James Edward Turner died instantly on 25 July 2023 after his motorcycle collided with a grain-laden trailer being towed across the B3252. The substantive concerns were road safety at the collision location, including limited visibility for tractor drivers and speeding, and the fact that recommended road-safety improvements had not been implemented.

Maria Patricia Kelly · Prevention of Future Deaths report View report

27 Sep 2024 Inner North London M. Lee

Maria Patricia Kelly, who lived alone and was in poor health, was found deceased at home by police on 15 May 2024 after concerns were raised by neighbours and a housing officer. The report identifies prolonged lack of contact with primary care and mental health services, numerous failed encounters, and no welfare check until the neighbours’ concerns were raised; the inquest determined natural causes.

Charne Nikita Petit · Prevention of Future Deaths report View report

26 Sep 2024 Surrey C. Topping

Charne Nikita Petit suffered psychotic delusions and, after a psychotic breakdown on 26 March 2023, was assessed as meeting the requirements for detention under section 2 of the Mental Health Act. No mental health hospital bed was available, and she was discharged on 31 March without assessment followed by medical treatment in a mental health hospital. She died by suicide on 12 May 2023; the narrative conclusion stated that the lack of a mental health hospital bed more than minimally contributed to her death. Concerns also included the effective detention of patients in general hospitals while awaiting mental health beds.

Jyoti Rao · Prevention of Future Deaths report View report

25 Sep 2024 Manchester South C. Morris

Jyoti Rao died at Tameside General Hospital on 20 February 2024 from hypoxic-ischaemic brain injury due to sepsis against a background of end-stage renal failure and failure of a transplanted kidney. Her death was also contributed to by traumatic nasogastric tube insertion. The principal concern was that complex transplant patients were not allocated a named consultant to support continuity of care and provide a longer-term view when complications arose.