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Gillian PEACOCK · Prevention of Future Deaths report View report

6 May 2024 County Durham and Darlington J. Thompson

Gillian Peacock died at Darlington Memorial Hospital on 8 March 2023 after suffering a cardiac arrest during an admission for a chest infection. She had been prescribed digoxin and clarithromycin, and although a pharmacist recorded a warning about possible digoxin toxicity, no alternative drug was prescribed and monitoring did not occur until 7 March. The principal concern was that important information in medical records was not sufficiently visible or accessible to clinicians involved in the patient’s care.

Paul David TEMPLETON · Prevention of Future Deaths report View report

4 May 2024 Suffolk P. Taheri

Paul David Templeton died at Ipswich Hospital on 20 April 2023 following termination of life support after asphyxiation. The Jury found that prolonged refusal to eat or drink while detained under the Mental Health Act should have been recognised as action to end his life and as elevating his suicide risk, including by other means. The report raises concern that the response from Norfolk & Suffolk NHS Foundation Trust did not adequately address these failures in suicide risk assessment.

Michael John BURKE · Prevention of Future Deaths report View report

4 May 2024 Suffolk D. Stewart

Michael John Burke, who had advanced lung disease and COPD, died on 2 February 2023 after developing pneumonia and sustaining a fractured neck of femur in a fall on a hospital ward. The principal concern was that Ipswich Hospital lacked adequate arrangements for completing, highlighting and handing over falls-risk assessments, leaving the assessment incomplete when he fell.

Neville Stephen Abbott · Prevention of Future Deaths report View report

3 May 2024 Dorset B. Allen

Neville Stephen Abbott, who lived alone and was known to Adult Social Care and Community Mental Health Services, was found deceased at home on 8 February 2022. He had schizophrenia and atrial fibrillation, and declined prescribed anticoagulant medication. The report raises concerns that Adult Social Care practitioners did not use the Professionals Checklist to assess potential self-neglect or consider convening a Multi-Agency Risk Management Meeting.

Michael Clarke · Prevention of Future Deaths report View report

3 May 2024 Manchester South A. Mutch

Michael Clarke, who had multiple underlying health conditions including end stage renal failure, developed suspected urosepsis after a cystoscopy and died in hospital on 30 July 2023. The report raised concerns about delays in category 3 ambulance responses, the categorisation of a call where sepsis was suspected, and the absence of specific sepsis trigger questions on the ambulance pathway.

Evie Jane DAVIES · Prevention of Future Deaths report View report

2 May 2024 Cheshire V. Davies

Evie Jane Davies was found deceased at home on 2 December 2021 after taking a significant overdose of medication that had not been prescribed to her. The report states that this was likely a deliberate act intended to end her life, amid deteriorating mental health and significant personal stressors. The principal concern was insufficient real-time information sharing between the café71 crisis service, the mental health team and the GP, potentially preventing prompt follow-up of people at risk.

Frederick Martin Gerard Boyd · Prevention of Future Deaths report View report

2 May 2024 Manchester South A. Mutch

Frederick Martin Gerard Boyd, a resident of Lakes Care Home with a long-term catheter, complained of severe abdominal pain on 10 September 2023 and was found unresponsive in bed at about 6am the following day. A postmortem found that he died from peritonitis due to a bladder perforation caused by long-term catheterisation. Concerns included the lack of clear systems for monitoring and escalating care when a resident was unwell, limited documentation, and limited managerial oversight of documentation quality.

Michael Lee DALKIN · Prevention of Future Deaths report View report

2 May 2024 Teesside and Hartlepool C. Bailey

Michael Lee DALKIN was socialising in Stockton on 26 December 2019 and the early hours of 27 December, where he was involved in an incident at Goldie’s Bar involving an empty glass and off-duty door supervisors. He collapsed outside the venue and died in an ambulance. The principal concerns related to the use and recording of door supervisors, including an unlicensed supervisor and inaccurate information about the number of operational and effective supervisors.

Karen THOMASON · Prevention of Future Deaths report View report

2 May 2024 Cumbria R. Cohen

Karen Thomason, aged 52, collapsed at home on 31 October 2023, was discharged from hospital without Cumbria Housing staff being notified, and was found unresponsive at home the following day. Her death was confirmed on 1 November 2023 after she had consumed a substantial amount of alcohol. The concerns included errors in safeguarding documentation, failures to notify housing staff about discharge, and the risk of conflating capacity with an absence of vulnerability or safeguarding concerns.

George Robert DILLON · Prevention of Future Deaths report View report

1 May 2024 Hampshire, Portsmouth and Southampton H. Charles

George Robert DILLON, aged 19, lost control of a VW Golf while driving over a crest on Lee Lane at night on 18 May 2023 and collided with a tree. He suffered catastrophic injuries and died in hospital on 20 May 2023. The report raises concern that the hazard posed by the crest is not readily apparent at night, even to vehicles travelling within the speed limit, and that warning signs are absent.

Harry David HALL · Prevention of Future Deaths report View report

1 May 2024 Northumberland A. Hetherington

Harry David Hall, who had a history of depression and recent suicidal ideation, was found dead in the rear garden of his home on 29 May 2023 after sustaining a self-inflicted traumatic head injury from a captive bolt gun. The principal concern was inadequate record keeping about the missed mental-health appointment and the lack of clarity about whether any assessment took place before his death; the report also noted delays in appointments.

Jordan George James Fogg Howarth · Prevention of Future Deaths report View report

1 May 2024 Manchester South A. Mutch

Jordan George James Fogg Howarth, a fit and healthy 25-year-old, was admitted to hospital on 3 April 2023 with an unexplained and deteriorating condition. He was not escalated for critical care review as required, and although a later review identified that he needed urgent ICU admission, this was delayed; he suffered a cardiac arrest on 6 April 2023 and could not be resuscitated. The principal concerns included inadequate coordination and continuity of care, failure to follow escalation policy, insufficient documentation of clinical decisions, and a lack of multidisciplinary discussion.

LILLY GRACE PROCTOR · Prevention of Future Deaths report View report

1 May 2024 West Yorkshire Eastern O. Longstaff

Lilly Proctor, aged 13, collapsed at home in the early hours of 3 April 2022 and died later that day in Pinderfields Hospital from massive pulmonary thromboembolism associated with deep vein thrombosis and hereditary Protein S deficiency. The report raises concerns that there was no child-specific UK screening tool or corresponding NICE guidance for venous thromboembolic disease in children, potentially disadvantaging clinicians diagnosing and treating the condition.

Mohammed AMIN AZIZI · Prevention of Future Deaths report View report

1 May 2024 Norfolk S. Goward

Mohammed Azizi, who had Crohn’s disease and deep vein thrombosis, repeatedly refused food, monitoring, investigations and treatment while in prison and hospital. He died in hospital on 15 May 2023 from cardiac atrophy and failure, with contributing factors including malnutrition, Crohn’s disease, self-neglect and pulmonary thromboembolism and infarction. The principal concerns related to two versions of an ACCT document, apparent signatures that witnesses said they had not added, possible retrospective reconstruction of records, and incomplete disclosure to the court and the PPO.

Laura Gawthorpe · Prevention of Future Deaths report View report

1 May 2024 West Yorkshire Eastern O. Longstaff

Laura Gawthorpe, a voluntary patient at the Becklin Centre in Leeds, left on escorted leave on 13 September 2022 and deliberately fell from a car park, dying instantly from unsurvivable injuries. The report raised concern that fencing and barriers were only partially installed at the level from which she fell, leaving a parapet wall that could still easily be climbed over.

Kellie Marie SUTTON · Prevention of Future Deaths report View report

30 Apr 2024 Cambridgeshire and Peterborough S. Broadfoot

Kellie Sutton died in hospital on 26 August 2017 after suffering irreversible brain injury following a hanging on 23 August 2017. She had been subjected to controlling and coercive behaviour and domestic abuse by her partner. The principal concerns were inadequate understanding of controlling and coercive behaviour, insufficient awareness of the link between domestic abuse and suicide, and uncertainty among frontline officers about the use of DVPNs and DAISU referrals.

Marlin Burrows · Prevention of Future Deaths report View report

30 Apr 2024 Liverpool and the Wirral N. Rheinberg

Marlin Burrows was found collapsed in his cell at HMP Garth on 15 August 2022 and died in the early hours of 16 August 2022 after being semi-conscious for nearly 15 hours. The inquest concluded that he died from multi-organ failure due to serotonin syndrome and drug toxicity, including amitriptyline toxicity. Concerns included unclear welfare-sheet purposes and guidance, poor communication of entries to medical staff, and insufficient joint consideration of the sheet by prison and healthcare services.

Jason PULMAN · Prevention of Future Deaths report View report

30 Apr 2024 East Sussex M. Spencer

Jason Pulman, aged 15, was found dead on 19 April 2022 and the inquest concluded that he died by suicide, by hanging. Evidence indicated that he had not received specialist gender dysphoria treatment while waiting for GIDS and was awaiting further CAMHS assessment. The principal concern was that unclear referral mechanisms and inadequate resources for mental health support during waits for gender services could lead to similar circumstances recurring.

Mohamed Ahmed Hany Ellaboudy · Prevention of Future Deaths report View report

30 Apr 2024 Berkshire H. Connor

Mohamed Ahmed Hany Ellaboudy, known as Moh, died after deliberately placing himself in front of a moving train; his mental state and capacity to form intention were unclear. The report raised concerns about care coordination after discharge from mental health services, reliance on telephone rather than face-to-face appointments, the regularity of multidisciplinary discussions, routes for family to report concerns, and correspondence with primary care.

Sophie HINDMARSH · Prevention of Future Deaths report View report

29 Apr 2024 South Yorkshire (Western) H. Berry

Sophie HINDMARSH had complex needs and required full-time care. After her father called 999 because she was vomiting brown liquid, felt hot to the touch and had a leaking feeding tube, the ambulance arrived 4 hours and 46 minutes after the call; concerns centred on delays in ambulance response and hospital handovers that reduced available ambulance resources.