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Stanley Cummins · Prevention of Future Deaths report View report

4 Apr 2024 County Durham and Darlington J. Richards

Stanley Cummins, aged 84, died at home on 2 September 2022 after a heel pressure ulcer became necrotic and led to sepsis. The inquest identified concerns about failures to provide appropriate pressure relief and offloading advice, make referrals, and implement comprehensive changes to his care, with further training and protocols still described as work in progress.

Meha Carneiro · Prevention of Future Deaths report View report

3 Apr 2024 Nottinghamshire E. Didcock

Meha Carneiro, aged five years and seven months, died at Kings Mill Hospital on 5 December 2022 after collapsing in cardiac arrest following an illness involving fever, cough, abdominal pain, diarrhoea and vomiting. The report identified concerns about insufficient trained paediatric nursing staff, inadequate recognition of the seriousness of her condition, insufficient senior review, and ineffective handover and documentation between staff.

Alan Andrew SOANE · Prevention of Future Deaths report View report

2 Apr 2024 Inner North London I. Potter

Alan Andrew Soane underwent a Whipple’s procedure after an incorrect diagnosis of duodenal cancer and died on 26 June 2023 from known complications of the procedure. The report raises concerns about the absence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings and the wider national shortage of Consultant Histopathologists, which was acknowledged as contributing to the incorrect diagnosis.

Anne HAWKES · Prevention of Future Deaths report View report

2 Apr 2024 South Yorkshire (Eastern) S. Slater

Anne HAWKES was admitted to Rotherham Hospital after a fall and hip fracture, and later developed fluid overload associated with poorly managed cardiac failure. Her surgical wound broke down, with delayed tissue viability referral and an incohesive approach to wound management; she died on 15 July 2023 from multi-organ dysfunction due to an infected hip joint. The stated concerns were delayed cardiology referral and poor communication between surgery, cardiology and tissue viability services.

Andrew Ewin-Ripp · Prevention of Future Deaths report View report

2 Apr 2024 East London N. Persaud

Andrew Ewin-Ripp, who had epilepsy, suffered a fit at home on 1 November 2022, was found in cardiac arrest, and died in hospital on 4 November 2022. The reported cause of death was sudden unexpected death in epilepsy (SUDEP). Concerns included lengthy waits for neurology care, the absence of clear guidance and systems for monitoring, discharge information, and urgent review after seizure recurrence.

Maureen Elizabeth Owens · Prevention of Future Deaths report View report

2 Apr 2024 North Wales (East and Central) J. Gittins

Maureen Elizabeth Owens developed a condition requiring urgent vascular surgery while a patient at Maelor Hospital Wrexham on 6 December 2022. Her transfer was delayed, and she deteriorated after subsequent surgery before dying at Glan Clwyd Hospital on 9 December 2022; concerns included incorrect booking of the urgent transfer and inadequate knowledge across the Health Board about the relevant transport service.

Robert Fuller · Prevention of Future Deaths report View report

2 Apr 2024 South Yorkshire (Eastern) S. Slater

Robert Fuller was admitted to Doncaster Royal Infirmary with increased confusion and later suffered an assault by another patient, causing him to fall and sustain a traumatic brain bleed. He subsequently deteriorated and died on 22 July 2022; the inquest concluded that he died from natural causes, with pathology confirming that the assault-related injuries did not cause or contribute to his death. Concerns included poor record keeping, inadequate communication with the family after the incident, and the lack of a system for agency staff to access and communicate reminders, policies and procedures.

Christopher William Townsend · Prevention of Future Deaths report View report

1 Apr 2024 Worcestershire J. Puzey

Christopher William Townsend died on 8 June 2023 after sustaining multiple chest and abdominal injuries in a motor accident during an organised grass-track motorcycle and side-car race. The report identified concerns about the lack of event-specific risk assessments and a requirement for recorded safety plans at ACU track-racing events, creating a risk of future deaths.

Daniela Vitalia PANI · Prevention of Future Deaths report View report

28 Mar 2024 Berkshire R. Simpson

Daniela Vitalia PANI died on 29 June 2023 after entering a train station, jumping onto the tracks and being struck by a train. Concerns were raised that potential suicide-risk mitigation measures at the station had not been implemented, and that mental-health staff lacked specific guidance and training for situations where service users declined face-to-face 72-hour reviews.

Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report View report

28 Mar 2024 Suffolk D. Stewart

Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.

Francis Ian WILLIAMS · Prevention of Future Deaths report View report

27 Mar 2024 West Sussex, Brighton and Hove N. Armstrong

Francis Williams, who was subject to an imprisonment for public protection sentence, was evicted from accommodation after struggling with alcohol and was facing possible recall to prison. He told his probation officer he intended to kill himself and was found dead from a heroin overdose in a tent in Bognor Regis on 28 January 2023. The report identified concerns about probation officers recognising suicide and self-harm risks among IPP offenders and about processes for suspending and cancelling parole licence supervision.

Saffra Harriett Winn · Prevention of Future Deaths report View report

27 Mar 2024 South Yorkshire (Western) A. Poutney

On 24 July 2022, Saffra Harriett Winn was found unconscious and not breathing on pavement between two high-rise blocks of flats after falling or jumping from a window of her flat. The report raised concerns that Sheffield City Council had not risk-assessed the windows or safety latches after two tenant fatalities, and lacked a formal process for investigating and assessing risks following catastrophic injuries or deaths in its social housing.

Matthew Terrill · Prevention of Future Deaths report View report

27 Mar 2024 South Yorkshire (Western) A. Poutney

Matthew Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.

Michaela Hall · Prevention of Future Deaths report View report

27 Mar 2024 Cornwall and Isles of Scilly A. Cox

Michaela Hall was stabbed through the eye by her partner on 31 May 2021 and was found deceased the next day; life was formally pronounced extinct on 1 June 2021. The report identified shortcomings in recruitment, pre-sentence reporting and risk assessment, including the partner’s risk being assessed as medium rather than high. It also raised concerns about how Children and Adult Services assessed, recorded, shared and acted on information concerning domestic abuse, safeguarding and potential mental impairment.

Mark Wolfe Kinzley · Prevention of Future Deaths report View report

26 Mar 2024 East London G. Irvine

Mark Wolfe Kinzley, a 61-year-old man with a neurological disorder, mental health problems and a history of self-harm, was found unresponsive at his nursing home on 30 October 2023 after suspending himself by a coat hanger. He died in hospital on 1 November 2023 from complications of the injuries sustained at the nursing home. The concerns included whether the care setting was appropriate, the absence of a formal capacity assessment, and the lack of a mental health assessment despite his history and deteriorating mental state.

Craig John BURFIELD · Prevention of Future Deaths report View report

26 Mar 2024 South Yorkshire (Western) S. Eccleston

Craig Burfield was admitted for surgery for bladder stones on 20 February 2023 and underwent surgery on 23 February 2023. He did not regain consciousness from the anaesthetic and died on 24 February 2023 at Northern General Hospital, Sheffield, following clots in his hydrocephalus shunt and cerebral sinus that caused brain swelling. The report raised concerns that shunt care did not continue into adulthood and that there were no effective transition, transfer, or review pathways for adults with such needs.

Alexander Vitali Lyalyushko · Prevention of Future Deaths report View report

25 Mar 2024 Nottinghamshire A. Bewley

Alexander Vitali Lyalyushko took his own life by hanging at his home on 2 January 2023, where he lived alone. A request from his GP for mental health service involvement in November 2022 was not actioned, and he was not receiving mental health services at the time of his death. The report also identified deficiencies in the initial review and incident investigation following his death, including failure to identify the unactioned request and failure to consult his family.

PATRICIA ANNE VAN DER EYKEN · Prevention of Future Deaths report View report

25 Mar 2024 Cornwall and Isles of Scilly G. Davies

Patricia Anne Van Der Eyken, aged 93, called 999 with chest pain radiating down her left arm on 13 September 2023 and was found deceased when an ambulance arrived two hours and 37 minutes later. The principal concern was a systemic ambulance delay linked to healthcare and social care capacity and handover failures, which the court found likely contributed to her death by preventing lifesaving treatment.

Jacqueline Anne Cobain · Prevention of Future Deaths report View report

25 Mar 2024 Inner South London M. Haste

Jacqueline Anne Cobain deliberately jumped in front of a moving train at Vauxhall London Underground station on 11 September 2021, suffering multiple injuries and dying at the scene. Her questionnaire responses to mental health services contained concerning responses, but the questionnaire was not reviewed until after her death because the system did not recognise that her appointment had been cancelled. The principal concern was the absence of a system or protocol to alert a clinician to review concerning responses when an assessment appointment was delayed by several days or weeks.

ROBERT ANDREW PROWSE · Prevention of Future Deaths report View report

25 Mar 2024 Cornwall and Isles of Scilly G. Davies

Robert Andrew Prowse, who was 86, became unconscious and was suspected of having had a seizure before an ambulance was called. The ambulance arrived after a delay of three hours and 47 minutes, and further delays occurred in transferring him into the emergency department, where sepsis was identified; he died before prescribed antibiotics could be administered. The report identified systemic ambulance and hospital delays, including emergency department crowding and delayed patient handovers, as concerns that likely contributed to preventing lifesaving treatment.