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David Nicholas ALMOND · Prevention of Future Deaths report View report

17 Jul 2024 Manchester South A. Mutch

David Nicholas Almond was diagnosed with thrombophilia and deep vein thrombosis but was not placed on lifelong anticoagulation. After developing breathlessness that was investigated with an X-ray, he collapsed and was found to have a massive pulmonary embolism, dying in hospital on 5 January 2024. The principal concerns were incomplete access to and recognition of relevant GP records, and failure to arrange appropriate follow-up after the negative X-ray.

Lorraine Julia Proctor · Prevention of Future Deaths report View report

17 Jul 2024 Manchester South A. Mutch

Lorraine Julia Proctor had a history of cardiac health issues and was found unresponsive at home on 22 December 2023. A post-mortem identified acute myocardial ischaemia, coronary artery atheroma and ischaemic cardiomyopathy as the direct causes of death. The report raised concerns about lengthy cardiology waiting lists delaying specialist input for patients, although it was stated that an earlier appointment was unlikely to have changed Ms Proctor’s treatment.

Barry John HOWARD · Prevention of Future Deaths report View report

17 Jul 2024 Norfolk S. Goward

Barry John Howard entered flood water at an unbridged ford on 13 December 2023, after warning signs were not visible, and his car was swept into the river. He was found deceased in the almost completely submerged car on 14 December 2023. Concerns included inadequate and poorly positioned warning signs, delayed or insufficient road-closure measures, and other risks associated with the ford and road surface.

Jessica de Souza · Prevention of Future Deaths report View report

16 Jul 2024 Surrey C. Topping

Jessica de Souza, who had bipolar disorder, developed depression after a family bereavement and took her own life by hanging at home on 1 February 2023. Concerns included that aripiprazole was prescribed as monotherapy for both polarities of bipolar disorder, although expert evidence stated it was not effective prophylaxis against depressive relapse. The expert also considered that the guidance relied on by clinicians may have been misleading.

Glenn Jacques and 2 others · Prevention of Future Deaths report View report

16 Jul 2024 County Durham and Darlington J. Chipperfield

Each of three deceased persons died after being struck by a train at ████████ railway station in County Durham, and each was reported to have deliberately entered the train’s path. The report raises concern that the station is a known convenient location for suicide, while not being classified as a hotspot under the stated national definition; the incidents occurred within 12 months.

George Robert DILLON · Prevention of Future Deaths report View report

16 Jul 2024 Hampshire, Portsmouth and Southampton H. Charles

George Robert DILLON, aged 19, lost control of his car on a country road on 18 May 2023 and collided with a tree. He suffered catastrophic injuries and died in hospital on 20 May 2023. The report raised concerns about the understanding, training and procedures for responding promptly to automatic emergency calls from devices indicating a possible collision and risk to life.

Josh Andrew Smith · Prevention of Future Deaths report View report

15 Jul 2024 East Riding and Hull J. Swift

Josh Andrew Smith had longstanding medical complications following quadriplegia from a 2009 road traffic incident. He was found unresponsive and not breathing on 19 December 2022, was diagnosed with hypoxic brain injury, bronchopneumonia and influenza A, and died on 22 December 2022 despite treatment. Concerns included continuing ambulance response delays and hospital handover delays, with response standards and the 15-minute handover target not being achieved.

Phephisa MABUZA · Prevention of Future Deaths report View report

15 Jul 2024 Central and South East Kent P. Harding

Phephisa MABUZA, who had psychosis and had not taken prescribed olanzapine for several months, was found at the base of a location in Dover after apparently falling from height. He had been hearing voices before his death, but the inquest evidence did not establish how he fell or his intention at the time. Concerns included local crisis-response guidance allowing a seven-day response for some presentations when national guidance stated 72 hours, and an operational policy containing incorrect triage response codes.

Megan Davison · Prevention of Future Deaths report View report

15 Jul 2024 Hertfordshire A. McCormick

Megan Davison was found deceased at home on 4 August 2017 after hanging herself with the intention of ending her life. The report identified concerns about her discharge from mental health care, limited integration between physical and mental healthcare, the absence of recognised diagnosis and care pathways for Type 1 Diabetes with Disordered Eating and Diabetic Ketoacidosis, and incomplete information-sharing between healthcare providers.

Owen Donald GARDNER · Prevention of Future Deaths report View report

15 Jul 2024 Suffolk N. Parsley

Owen Donald GARDNER, aged 29, died following a road traffic collision; the medical cause of death was recorded as multiple injuries. The report raises concern that agreed next-of-kin contacts were not consistently informed about appointments or short-notice changes, contributing to missed appointments for a person with limited short-term memory and cognitive deficit, and that no system was in place to facilitate this.

Ryleigh Hillcoat - Bee · Prevention of Future Deaths report View report

12 Jul 2024 Blackpool and the Fylde A. Wilson

Ryleigh Hillcoat - Bee died after cardiac arrest from complications of rhabdomyolysis associated with an inherited Lipin-1 deficiency. The report raises concerns about limited awareness of rhabdomyolysis among general paediatricians, scarce clinical guidance, and the risk that future cases in young children may go unrecognised with fatal consequences.

Jason Vaughan HOLLAND · Prevention of Future Deaths report View report

12 Jul 2024 Rutland and North Leicestershire F. Butler

Jason Vaughan Holland, an experienced electrician, became trapped between a scissor lift and containment tray at a height of approximately 20 metres while working at Mercia Park on 10 February 2023. He suffered cardiac arrest and an unsurvivable brain injury, and died at Queens Medical Centre in Nottingham. The principal concern was that standard MEWP competence training did not include practical training or drills for rescue from height, including basket-to-basket rescues.

Judith Maike OBHOLZER · Prevention of Future Deaths report View report

12 Jul 2024 Inner West London E. Oakley

Mrs Obholzer died by suicide on 12 July 2023 after jumping in front of a moving train, following a significant period of worsening depression and anxiety. Concerns included delays in NHS mental-health assessment and waiting-list placement, unclear routes for private practitioners to obtain NHS crisis support, difficulties contacting her GP, and the absence of shared medical notes between private and NHS providers.

Sandra Phillpott · Prevention of Future Deaths report View report

12 Jul 2024 Blackpool and the Fylde A. Wilson

Sandra Phillpott died on 31 October 2023 after developing sepsis and multi-organ failure following E. coli O157 and pneumococcal infections. The report identifies delays in recognising suspected sepsis and providing antibiotics and intravenous fluids, with attention initially focused on ruling out pulmonary embolism and deep vein thrombosis.

Peter Richard DOLAN · Prevention of Future Deaths report View report

11 Jul 2024 Cheshire A. Frodsham

Peter Richard Dolan died in a fire on his canal boat on the Bridgewater Canal on 8 March 2024. The likely ignition source was hot embers from a solid fuel stove, and there was no evidence that a smoke alarm had been fitted. The report raises concern that smoke alarms are not required on all boats, which may increase the risk of fatalities from smoke inhalation or burns.

Mahamoud Hussain Ali · Prevention of Future Deaths report View report

10 Jul 2024 Inner North London S. Naqshbandi

Mahamoud Hussain Ali fell twice in the street on 19 August 2020 and was later detained under the Mental Health Act and transferred to Lea Ward. On 21 August 2020 he was found unresponsive and died in hospital on 26 August 2020. The principal concern was that required 15-minute observations were not conducted or were falsely recorded, and that subsequent Trust action had not been sufficient to ensure observations were conducted and recorded as required.

Richard Michael Fitzgerald · Prevention of Future Deaths report View report

10 Jul 2024 East London N. Persaud

Richard Michael Fitzgerald, a nursing home resident with Alzheimer’s dementia, died in hospital on 26 June 2023 after choking on food and suffering a catastrophic hypoxic brain injury. Concerns included the failure to develop and implement a sufficiently robust care plan addressing unsafe food access and supervision, failure to follow the emergency choking protocol, and an insufficiently thorough care home investigation.

Benjamin Faux · Prevention of Future Deaths report View report

10 Jul 2024 Berkshire H. Godfrey

Benjamin Faux was a taught research Master's student at the University of Reading who had severe mental health difficulties, disengaged from his studies, and took his own life in his student accommodation on or around 5 August 2023. The concerns included inadequate pastoral support and monitoring, the absence of a process to ensure completion of study-suspension arrangements, unclear responsibility for resolving his academic situation, and a lack of University contact with him before his death.

Nancy ROGERS · Prevention of Future Deaths report View report

9 Jul 2024 Cumbria N. Shaw

Nancy ROGERS collapsed on 18 November 2023, attended the emergency department, and was discharged home before being found unresponsive the following morning. The inquest recorded bilateral haemothorax due to a ruptured dissecting aortic aneurysm. Concerns were raised about her discharge after emergency attendance and the reported absence of learning or teaching following a similar death.

Dr Alan William Kingsbury · Prevention of Future Deaths report View report

8 Jul 2024 West Sussex, Brighton and Hove K. Henderson

Dr Alan William Kingsbury, who was extremely frail, died in hospital on 29 October 2023 after excessive bleeding from a chest lesion excision while taking aspirin and clopidogrel, followed by a fall causing a fractured right neck of femur. The report raised concerns about the robustness of guidance on antithrombotic medication, the absence of preoperative assessment and advanced consent, and the wound-closure technique used to achieve haemostasis.