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Raymond BRATTLEY · Prevention of Future Deaths report View report

2 Aug 2024 East Riding and Hull P. Marks

Raymond BRATTLEY, a heavy cigarette smoker, died at the scene on 8 January 2024 after a fire caused by careless smoking engulfed him in his flat, causing widespread full-thickness burns. The report raises concerns about the risk of cigarette-related fires involving vulnerable people and the potential value of seeking Fire Service advice and considering measures such as metal wastepaper bins and fire-retardant materials.

Lee Spencer PURKIS · Prevention of Future Deaths report View report

1 Aug 2024 West Sussex, Brighton and Hove N. Armstrong

Lee Purkis, aged 54, was found in an advanced state of decomposition on the floor of his home on 9 March 2023, having been there for up to two months; the cause of death was unascertainable. Before his death, he was subject to a mental health treatment requirement, but the receiving Trust was not informed of it and discharged him without learning about it. The report identifies a risk that failures to transfer or oversee such requirements could affect their proper administration in other cases.

Derryck Lynn CROCKER · Prevention of Future Deaths report View report

1 Aug 2024 Norfolk S. Goward

Derryck Crocker underwent a CT-guided lung biopsy on 3 May 2023 and subsequently developed a cerebral air embolism, deteriorated, and died on 10 May 2023. The principal concerns were limited recognition of air embolism following invasive procedures, insufficient training and awareness across medical specialties, and delays in recognition and treatment that may increase the likelihood of death.

Leah Shannon Croucher · Prevention of Future Deaths report View report

1 Aug 2024 Milton Keynes T. Osborne

Leah Shannon Croucher left home to walk to work on 15 February 2019 but did not arrive, and her body was found in a Milton Keynes house in October 2022. The inquest concluded that she was unlawfully killed. The report raises concerns about the supervision of a known repeat sex offender and information sharing between the police and probation service.

Stephen LINDSAY · Prevention of Future Deaths report View report

1 Aug 2024 Cumbria R. Cohen

Stephen Lindsay, who had metastatic oesophageal cancer, pain and concerns about his mental health and suicidal ideation, died by suicide on 28 February 2024. The principal concern was that responsibility for providing his mental health treatment was passed between several teams, creating a risk that people with terminal illness may not receive mental health support during crisis.

Matthew Paul Braben · Prevention of Future Deaths report View report

1 Aug 2024 West London A. van Dellen

Matthew Paul Braben died by asphyxia at HMP Wormwood Scrubs on 16 August 2021 after being found in his cell with his neck, wrists and ankles tied. The report identified concerns including failures to identify and respond to suicide risk, inadequate communication and record-keeping, failures relating to ACCT processes, and the impact of prisoners being held in their cells for up to 23 hours a day.

Kieran Lavin · Prevention of Future Deaths report View report

1 Aug 2024 Birmingham and Solihull J. Bennett

Kieran Lavin, who had experienced worsening depression and suicidal thoughts, died after leaving a mental health unit with his wife for transport to another facility. Shortly afterwards, on the M5 motorway, he exited the vehicle and was struck by vehicles. The principal concerns were that critical suicide-risk information was not recorded or recorded promptly, and that the transport risk assessment and guidance for family transport were inadequate.

Maria Francisca Teixeira de Ceita · Prevention of Future Deaths report View report

31 Jul 2024 North London P. Murphy

Maria Francisca Teixeira de Ceita died in hospital on 4 July 2023 after an unwitnessed fall by her hospital bed that caused a fatal brain injury. The concerns included failure to record and implement planned one-to-one supervision for a patient known to be at risk of falling, and ineffective communication between ward staff.

Susan Pollitt · Prevention of Future Deaths report View report

31 Jul 2024 Manchester North J. Kearsley

Susan Pollitt was admitted to hospital after collapsing at home and developed ascites during her admission. An ascitic drain was inserted, remained in place for 21 hours, and was clamped; she developed bacterial peritonitis and died on 16 July 2023. The principal concerns included the lack of regulatory oversight and national training and competency frameworks for Physician Associates, and limited understanding of their role and responsibilities in managing ascitic drains.

Bethany Paige Langton · Prevention of Future Deaths report View report

30 Jul 2024 Nottinghamshire L. Bower

Bethany Paige Langton, aged 22, was discovered deceased in her bedroom on 18 February 2023 after deliberately ingesting a substance sourced online with the intention of causing her death. The principal concerns were the substance’s easy online availability, limited awareness among businesses that it could be obtained for suicide, and the continued availability of online guidance about sourcing and using it for that purpose.

Wendy HAMMON · Prevention of Future Deaths report View report

30 Jul 2024 Surrey A. Crawford

Mrs Wendy Hammon was admitted to hospital on 30 August 2022 with abdominal pain, vomiting and a small bowel obstruction caused by adhesions from previous surgery. She developed mesenteric ischaemia and multi-organ failure and died on 9 September 2022. The court was concerned that rising CRP was not recognised, fluid input and output charts were inadequate, and NEWS2 scores were often incomplete, with no reassurance that these matters had been addressed.

Lamarah Grace Scarlett · Prevention of Future Deaths report View report

29 Jul 2024 Gloucestershire K. Skerrett

Lamarah Grace Scarlett, a 12-year-old girl with alternating hemiplegia of childhood, became distressed and experienced breathing difficulties while being transported home from school on 24 September 2021. Her head became hyperextended, obstructing her airway; she arrived home unresponsive and was pronounced deceased despite resuscitation efforts. Concerns included the regulation, training, safety-plan compliance, handovers, first-aid qualifications, assessment, and oversight of operators providing home-to-school transport for children with special educational needs.

Scott Andrew PUNSHON · Prevention of Future Deaths report View report

29 Jul 2024 County Durham and Darlington L. Hamilton

Scott Andrew Punshon, a 36-year-old man, was found deceased on the A689 near Howden Le Wear on 12 August 2023 after being struck by a car while lying in the road. A site investigation identified issues with road markings, signage and lighting.

Colonel John Frederick Codd · Prevention of Future Deaths report View report

29 Jul 2024 Cornwall and Isles of Scilly A. Cox

Colonel John Frederick Codd fell while exiting a taxi after a GP appointment and was taken by ambulance to hospital, where he waited outside for approximately 4 hours and 40 minutes before being admitted to the Emergency Department. He was later found in cardiac arrest and could not be resuscitated; the inquest recorded the cause of death as a massive rectus sheath haematoma and severe coronary artery atherosclerosis. The principal concerns were delays in hospital admission and ongoing Emergency Department crowding, which had the potential to affect future patient care.

Jennifer BUNYAN and Marion BUNYAN · Prevention of Future Deaths report View report

26 Jul 2024 Cambridgeshire and Peterborough D. Heming

Jennifer Bunyan and Marion Bunyan died by drowning on 7 June 2020 after their motor car left the carriageway, rolled onto its roof and became partially submerged in Crease Drain. Jennifer was pregnant, and her unborn daughter, later named Erin Marion Chatten, also died in utero. The report raised concerns about the speed limit, road inspections, highway degradation, delays in remedial action and the absence of an effective barrier preventing vehicles entering the waterway.

Zara Natasha Aleena · Prevention of Future Deaths report View report

26 Jul 2024 East London N. Persaud

Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.

Leia Dorothy Pandora Sampson-Grimbly · Prevention of Future Deaths report View report

25 Jul 2024 North London A. Walker

Leia Dorothy Pandora Sampson-Grimbly, aged 17, jumped from London Bridge into the Thames on 6 November 2024 and died in hospital later that day despite treatment. The report describes her being without preventative treatment amid lengthy waiting lists for a Gender Dysphoria clinic, alongside low mood, gender dysphoria, hostility from some sections of the community and social media links inciting suicide. The principal concern identified was that waiting lists were too long for a first appointment at a Gender Dysphoria clinic.

Danny Jay Anderson · Prevention of Future Deaths report View report

25 Jul 2024 East London N. Persaud

Danny Jay Anderson, who had chronic mental health difficulties and was discharged from hospital to inadequate accommodation without a comprehensive risk assessment or safety plan, was found hanging in his room on 30 March 2023 and pronounced dead at the scene. The report identifies concerns about inadequate risk formulation, over-reliance on Danny’s responses about suicidal ideation, insufficient consideration of his history and circumstances, and the absence of a safety plan before discharge from hospital or community mental health services.

Elizabeth Grace Holder · Prevention of Future Deaths report View report

25 Jul 2024 East London G. Irvine

Elizabeth Grace Holder, an 88-year-old woman recovering in hospital after surgery for a broken hip, fell while using a commode without supervision and died from a fatal intracerebral bleed. The concerns identified were that the Trust failed to prevent a predictable and avoidable fall and that its governance systems failed to identify care failings or act on factors contributing to her death.

David Alfred CURRY · Prevention of Future Deaths report View report

25 Jul 2024 Norfolk J. Lake

David Alfred Curry was admitted with an obstructing left ureteric stone, treated with an emergency ureteric stent, and later underwent ureteroscopy. He developed infection and sepsis following the procedure and died on 1 October 2023. The report raised concerns about delay in receiving the planned procedure, prolonged stent dwell time, limited theatre capacity, and the associated risk of urinary infection and sepsis.