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Alfie Tollett · Prevention of Future Deaths report View report

27 Aug 2024 Devon, Plymouth and Torbay D. Archer

Alfie Tollett, aged seven, died after being trapped between a white VW van and his father’s Kia when a Jaguar I-Pace moved forward in a rugby club car park. The inquest concluded that the death was accidental and recorded blunt force traumatic chest injuries. A principal concern was that the vehicle had no intermediary step between selecting drive or reverse, which may have made it difficult to detect that the incorrect button had been pressed.

Allan Robin Hamilton · Prevention of Future Deaths report View report

23 Aug 2024 Manchester South A. Mutch

Allan Robin Hamilton emailed his GP practice on 14 November 2023 about breathing difficulties, but the email was not responded to until 17 November. He was found unresponsive at home on 19 November and died from lobar pneumonia. The principal concerns were the absence of systems for tracking and triaging email queries and the lack of clear, robust audit and follow-up processes.

Amal Mohamed AHMED · Prevention of Future Deaths report View report

23 Aug 2024 Milton Keynes S. Cummings

Amal Mohamed Ahmed died at the scene after entering the A5 southbound off slip road in the wrong direction and colliding head-on with another vehicle. The other vehicle’s driver later died in hospital, and a passenger suffered life-threatening injuries. The principal concern was that inadequate, poorly positioned and poorly visible signage and the unlit, wide junction allowed drivers to enter the slip road incorrectly; other drivers were observed making the same manoeuvre.

Tracey Julie HAYBITTLE · Prevention of Future Deaths report View report

22 Aug 2024 Milton Keynes S. Cummings

Tracey Julie Haybittle died at the John Radcliffe Hospital after a head-on collision when another driver entered the wrong slip road at the Little Brickhill junction. The report raised concerns that verbal commands from commonly used satnav applications could confuse and direct drivers down the wrong slip road into oncoming traffic, and that this occurred frequently despite remedial measures.

Elise Walsh Deceased · Prevention of Future Deaths report View report

22 Aug 2024 Northumberland A. Hetherington

Elise Walsh had a history of self-harm and suicidal ideation and suffered a severe hypoxic brain injury after an incident in hospital on 12 February 2022. She later developed aspiration pneumonia and died on 7 June 2023. Concerns included a significant note of intent not being made available earlier and complaint forms potentially being handled in a way that could cause important patient information to be missed or delay treatment or intervention.

Beverley Stanisauskis · Prevention of Future Deaths report View report

21 Aug 2024 Manchester North J. Kearsley

Beverley Stanisauskis was admitted to hospital with significant blood loss from gastrointestinal bleeding and likely pneumonia, and died on 18 January 2024 despite treatment. She had a learning disability, lived alone, and had not been seen by her GP practice for 10 years. The principal concern was that primary care did not recognise that her learning disability may have contributed to her lack of engagement, and did not involve the learning disability team or make attempts to communicate with her through a doctor.

Miss Hannah Enola Angela Ayomipo Jacobs · Prevention of Future Deaths report View report

20 Aug 2024 East London S. Radcliffe

Hannah Jacobs, aged 13, died on 8 February 2023 after consuming a dairy milk hot chocolate despite having severe dairy allergies and developing anaphylaxis. She and her mother were not carrying an adrenaline auto-injector, and the available paediatric injector at the pharmacy was an insufficient dosage. The report identified concerns about arrangements for carrying auto-injectors between home and school and the need to educate schools, patients and parents about carrying them.

Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report View report

20 Aug 2024 East London S. Radcliffe

Hannah Enola Ayamo Jacobs, aged 13, developed anaphylactic symptoms after being served a dairy hot chocolate despite her reported dairy allergy and later died following cardiac arrest. The concerns included dental staff not recognising excessive salivation as inability to swallow and a sign of anaphylaxis, possible misunderstanding of symptoms by her mother, and the availability and use of adrenaline auto-injectors during shortages.

Juliette Kirsty SEWELL · Prevention of Future Deaths report View report

19 Aug 2024 Birmingham and Solihull A. Hodson

Juliette Kirsty SEWELL was discovered unresponsive on 16 February 2024 after being missing since 14 February, surrounded by empty medication packets, and was confirmed deceased following a fatal overdose. She had a history of mental health illness and had been awaiting a delayed follow-up appointment with the mental health team. Concerns included outstanding reviews of records for people not seen in over 12 months, ongoing clinical caseload stratification, and the lack of a scheduled review date, with a stated risk of future deaths occurring.

Alan Stanley FALLOWS · Prevention of Future Deaths report View report

19 Aug 2024 Birmingham and Solihull A. Hodson

Alan Stanley Fallows was admitted to hospital after a fall at home and later sustained further unwitnessed falls while an inpatient, including a fracture to his right neck of femur. He subsequently developed severe bilateral aspiration pneumonia and died on 28 March 2024. The principal concerns were delayed completion of a Datix report, unclear automated approval processes, and the use of templates that could result in incorrect or incomplete incident information and missed patient-safety learning.

Anthony Paul Nixon · Prevention of Future Deaths report View report

16 Aug 2024 County Durham and Darlington J. Richards

Anthony Paul Nixon, aged 45, was found deceased at his home on 12 June 2023 after a drug overdose involving a combination of substances. The report identified concerns that a pharmacy supplied additional doses of a controlled drug in advance and contrary to the supervised-consumption prescription, leaving him in possession of multiple doses without notifying his drug treatment provider. The inquest concluded that the death was drug related and that the pharmacy’s actions contributed more than minimally by supplying the additional doses.

Kay SIMMONDS · Prevention of Future Deaths report View report

15 Aug 2024 Gwent C. Saunders

Kay Simmonds attended hospital with signs of sepsis arising from an infected haemodialysis central line, developed septic shock, and died on 22 July 2022. Concerns included an incorrect NEWS score calculation, failure to refer her to a senior medical practitioner, observations not being performed in line with NEWS requirements, and her transfer to a hospital without an available ITU bed.

Daniel KLOSI · Prevention of Future Deaths report View report

14 Aug 2024 Inner North London M. Hassell

Daniel died on his fourth presentation in a week to the Royal Free Hospital, with group A streptococcus sepsis recorded as the medical cause of death. Concerns included the delay in obtaining a full set of observations when he was distressed, and electronic records not showing how many times a patient had attended hospital with the same signs and symptoms during the current illness.

Elizabeth Van Der Drift · Prevention of Future Deaths report View report

13 Aug 2024 Inner North London I. Potter

Elizabeth Van Der Drift, who had dementia, accessed brightly coloured laundry detergent capsules on the night of 13/14 March 2024, apparently mistaking them for sweets, and bit into at least one. She was taken to hospital and died on 19 March 2024 despite treatment. The report raised concerns that the product’s colours, appearance and packaging could lead to accidental ingestion by people with dementia or other cognitive impairment, and that its packaging lacked a safety feature making access particularly difficult.

Matthew Clive GALE · Prevention of Future Deaths report View report

13 Aug 2024 County Durham and Darlington S. Connolly

Matthew Clive Gale died on 19 March 2023 after being detained under the Mental Health Act and granted Section 17 leave. The conditions of his leave, including that he should not be left alone, were not properly recorded or communicated to his family. The report raised concern about inconsistent compliance with providing Section 17 leave forms and the removal of a requirement for the accompanying person to sign the form, creating a risk of future deaths.

Kial Ryce Thurman · Prevention of Future Deaths report View report

13 Aug 2024 Staffordshire and Stoke-on-Trent N. Walker

Kial Ryce Thurman died at the scene after the transit van he was driving entered the path of an HGV and then the River Blythe following a loss of control on the A518. The concern was that the 60 mph national speed limit at the bend and bridge at Lower Loxley was too high and carried a risk of future deaths.

Margaret HUNTLEY · Prevention of Future Deaths report View report

13 Aug 2024 Teesside and Hartlepool P. Appleton

Margaret Huntley died on 10 December 2022 after deteriorating with multi-organ failure associated with dehydration, lack of exogenous steroids and Covid-19 infection. The report identifies delays in recognising her need for steroid medication and in prescribing and administering it. Concerns included ambulance staff understanding and triage guidance regarding steroid medication, use of Steroid Emergency Cards, and GP awareness of ambulance-service patient alerts.

Joanita Nalubowa · Prevention of Future Deaths report View report

13 Aug 2024 Inner North London H. Lambert

Joanita Nalubowa died after suspending herself with a ligature shortly after being told she would be discharged to Stockton, away from her family support network and against her wishes. The report raises concern that rigid accommodation criteria and the lack of discretion may create a risk of future deaths where a person's historical area of residence is inappropriate or dangerous and section 117 aftercare does not apply.

Daphne Gillian AUSTIN · Prevention of Future Deaths report View report

13 Aug 2024 Cumbria R. Cohen

Daphne Gillian Austin, who was 71 and had diabetes, was admitted to hospital after a stroke. Her glucose levels were poorly controlled, she became dehydrated, and her fluid balance was not effectively monitored; blood testing was not carried out on 15 or 16 June 2023. She developed an acute kidney injury and then sepsis, and died on 18 June 2023. The principal concern was that planning for safe staffing during industrial action was insufficient, creating a risk of future deaths.

Angela · Prevention of Future Deaths report View report

13 Aug 2024 Berkshire H. Connor

Angela was murdered by her husband at their home on 26 December 2018, aged 41. Before her death, she reported assault and elements of coercive control to Thames Valley Police, but the reported crimes were not recorded or investigated, relevant information was not considered in the risk assessment, and the risk was graded as standard rather than medium. The report raises concerns about frontline understanding of domestic abuse and coercive control, the clarity of the DOM5 risk assessment form, and the non-adoption of a newer domestic abuse risk-assessment tool.