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Brian John COLBY · Prevention of Future Deaths report View report

26 Jun 2024 Inner North London I. Potter

Brian Colby was an in-patient recovering from elective surgery and receiving treatment for aspiration pneumonia when he suffered a spontaneous catastrophic intracranial event on 16 September 2023; he died later that evening after being transferred for assessment and placed on a palliative care pathway. The principal concerns were delays and ineffective communication in recognising and escalating his deterioration, arranging an urgent CT scan, communicating clinical plans, and recording urgent matters. The report also raised concerns about unclear escalation and record-keeping procedures and whether further training had adequately addressed clinicians’ authority to initiate CT scan arrangements.

Nicola Jane Lacey · Prevention of Future Deaths report View report

26 Jun 2024 Herefordshire H. Gregory

Nicola Jane Lacey lived alone and was found dead at her home after she failed to attend work on 30 December 2022; the inquest concluded that her death was suicide. The report raised concern about the need for clear procedures for employers on disclosing colleagues’ ongoing mental health difficulties, for the benefit of the individual and wider public safety.

Raymond Horace Watkins · Prevention of Future Deaths report View report

26 Jun 2024 Manchester North J. Kearsley

Raymond Horace Watkins was admitted to hospital, discharged to his care home after his insulin and other medications had been stopped, and subsequently sought to restart them. Administrative errors meant the insulin prescription was not authorised before his readmission, although expert evidence concluded that prescribing insulin would not have been appropriate in this case and would not have changed the outcome. The substantive concern was a breakdown in communication between the GP and District Nurses, alongside the lack of “Time Critical Medicine” guidance for community settings.

Abdul Jabar Oryakhel · Prevention of Future Deaths report View report

25 Jun 2024 Avon M. Voisin

Abdul Jabar Oryakhel died on 25 September 2022 after falling from the window of his top-floor flat while trying to escape a fire. The fire was caused by overheating and ignition of a lithium-ion battery pack used for an e-bike, and concerns were raised about insufficient understanding of the dangers of such batteries and the absence of a British or European standard controlling the batteries and chargers sold in the UK.

Isobel Lilian Stapleton · Prevention of Future Deaths report View report

25 Jun 2024 South Wales Central D. Regan

Isobel Lilian Stapleton, aged 32, was admitted to hospital for assessment and discharged to her father’s home with home treatment support. On 9 July 2022, she sustained likely self-inflicted injuries at home and died despite paramedic attendance; the inquest concluded that she died from suicide. Concerns included limited access to complete clinical records and a lack of clinical psychologist access for inpatient and home treatment teams, with psychotherapy waiting lists lasting months.

John Howe · Prevention of Future Deaths report View report

25 Jun 2024 Manchester South L. Costello

John Howe, an 81-year-old man with diabetes and peripheral vascular disease, underwent an amputation for diabetic foot sepsis and later died in hospital on 28 May 2023 from hospital-acquired pneumonia against a background of necessary surgery and wound haemorrhage. Concerns included his late discharge home, which resulted in him being left outside while access was addressed, continuing late discharges despite a policy change, ambulance service awareness of discharge timings, and delays and factual inaccuracies in the Serious Incident Review.

Afolabi Oluwafemi OJERINDE · Prevention of Future Deaths report View report

25 Jun 2024 Manchester City Z. Golombeck

Afolabi Oluwafemi Ojerinde died at Wythenshawe Hospital after attending an unmanned Tesco petrol station, using a pay-at-pump facility to obtain petrol, dousing himself in it and setting himself alight. The substantive concerns were that he could use the pump without a motor vehicle or authorised container, and that no staff member was present to approve or deny access, which was automatically permitted following payment.

James Reginald Capstick · Prevention of Future Deaths report View report

25 Jun 2024 Cumbria N. Shaw

James Reginald Capstick died in hospital on 1 October 2022 after sustaining multiple rib fractures during more than 20 minutes of chest compressions when he was not in cardiac arrest, followed by respiratory insufficiency and pneumonia. The report raised concerns about the quality of care at Westmorland Court, the reliability of care records, the absence of a defibrillator at the time, and the failure to recognise signs of life during the resuscitation attempt.

Liam Paul McCarlie · Prevention of Future Deaths report View report

24 Jun 2024 Northamptonshire J. Dixey

Liam Paul McCarlie died by suicide after being found suspended by a ligature on 1 April 2023; death was confirmed shortly after midnight on 2 April 2023. The inquest identified a significant delay in ambulance attendance, which contributed to his death, and an insufficiently clear mental-health support plan while he awaited assessment for the Structured Clinical Management programme. A further concern was that mental-health professionals in the ambulance service’s emergency operations centre did not have access to relevant community mental-health records.

Thomas Joseph GERAGHTY · Prevention of Future Deaths report View report

21 Jun 2024 East Sussex L. Bradford

Thomas Joseph Geraghty entered the sea from a beach at Eastbourne on 28 June 2023 and was later recovered from the water; resuscitation was unsuccessful and his death was confirmed. The inquest concluded suicide. The report raises concern that patients may be deregistered from GP surgeries without adequate review or communication to ensure continued access to vital medication, particularly where no new GP details are provided.

Terrence Roy Hubert Taylor · Prevention of Future Deaths report View report

21 Jun 2024 Cambridgeshire and Peterborough K. Morton

Terrence Roy Hubert Taylor, an 82-year-old short-term resident of a residential care home, overcame a window restrictor, climbed out of a first-floor window and fell during the early hours of 11 December 2020, sustaining injuries from which he died. The principal concern was that current British Standards for window restrictors address accidental falls but not deliberate attempts to defeat them, and that this limitation and subsequent guidance on stronger restrictors were not generally known or understood by residential care home operators, manufacturers or suppliers.

Kevin Michael Cashin · Prevention of Future Deaths report View report

21 Jun 2024 Manchester North C. McKenna

In the early hours of 20 July 2022, Kevin Cashin, who was experiencing an episode of Acute Behavioural Disturbance after ingesting cocaine, was restrained by police after dropping from a first-floor window. He deteriorated, stopped breathing and was later diagnosed with an unsurvivable hypoxic brain injury, dying that morning. The principal concerns were that officers did not recognise his agonal breathing and cardiac arrest promptly, with the Court also concerned that relevant recognition skills were not covered in the stated police first-aid training curricula.

Lee-Ann Sarah INCE · Prevention of Future Deaths report View report

20 Jun 2024 Manchester South A. Mutch

Lee-Ann Sarah Ince was a victim of domestic abuse in a coercive and controlling relationship and was found unresponsive attached to a ligature on 9 May 2023. The inquest identified concerns that agencies did not fully recognise coercive control, the impact of “love bombing” on her mental health, information shared by her children, or her physical-health-related vulnerability and dependence on the perpetrator.

Shelemiah Pedajah PETERKIN · Prevention of Future Deaths report View report

20 Jun 2024 Birmingham and Solihull A. Hodson

Shelemiah Pedajah PETERKIN was reported missing on 2 October 2023 and was found deceased at home after police forced entry. The inquest concluded suicide following intentional poisoning. Concerns included staffing shortages and delays in mental-health referrals, as well as incomplete early-warning-sign documentation and delayed action to address clinical standards, creating risks of missed assessment, intervention and treatment opportunities.

Yasmin Louise ADAMS · Prevention of Future Deaths report View report

20 Jun 2024 Derby and Derbyshire P. Nieto

Yasmin Louise ADAMS, who had emotionally unstable personality disorder and a history of self-harm, was found suspended and unconscious in her prison cell on 12 November 2016 and died in hospital the next day. Concerns included a 29-minute gap in observation checks, fixed shower rails presenting ligature risks, uncertainty about staff training on personality disorder and learning disability, and the use of cellular confinement for a prisoner on an ACCT.

Nicola FORSTER · Prevention of Future Deaths report View report

20 Jun 2024 Bedfordshire and Luton E. Whitting

Nicola FORSTER, a Metropolitan Police Service Sergeant, was found hanging by a ligature at her home on 28 September 2022, and her death was confirmed by paramedics. The inquest concluded that she intentionally took her own life following a deterioration in her mental health exacerbated by actions of her employer. The report raised concerns about poor management, institutional defensiveness, and a fear among junior officers of speaking out about management.

Susan Margaret Williams · Prevention of Future Deaths report View report

20 Jun 2024 Carmarthenshire and Pembrokeshire P. Bennett

Susan Margaret Williams was admitted to hospital on 14 July 2019 with suspected sepsis and abdominal pain, later deteriorating and dying from cardiorespiratory failure due to lung fibrosis and cor pulmonale. The principal concerns were the lack of recorded medication prescription times, a potential delay in administering antibiotics, and the absence of equivalent medication timing records on the Accident & Emergency Record Card.

Thomas Gibson · Prevention of Future Deaths report View report

19 Jun 2024 Manchester South C. Morris

Mr Gibson was found dead at home on 7 June 2023, with the death attributed to sudden cardiac death due to idiopathic myocardial fibrosis. Eleven days earlier, two ECGs were not recognised as showing complete heart block, and he was discharged from hospital. Concerns included inadequate communication and contextual review of test results, lack of senior review when findings were unexpected, insufficient auditing of ECG interpretation and discharge summaries, and the absence of authoritative national guidance on ECG use and interpretation.

Aaron James DEELEY · Prevention of Future Deaths report View report

19 Jun 2024 Essex S. Hayes

Aaron James Deeley died after deliberately exiting a defective second-floor hospital window on 14 January 2022, sustaining multiple traumatic injuries. The report identified concerns about safeguarding and the removal of 1:1 observation, as well as gaps and confusion in arrangements for patients awaiting a Mental Health Act assessment while receiving physical healthcare.

Selina Samarina · Prevention of Future Deaths report View report

19 Jun 2024 Essex S. Simblet

Selina Samarina, aged 2, was brought to hospital with fever, a rash and irritability, and the sepsis protocol was triggered. She was assessed initially by a very junior doctor, with no differential diagnosis addressing possible sepsis or pneumonia, and was discharged before a suitably senior doctor could review her. The principal concerns were the sufficiency of staffing arrangements and the availability of only 60% of the doctors for the relevant services.