Search PFD Monitor

Christopher Edward SIDLE · Prevention of Future Deaths report View report

25 Mar 2024 Norfolk J. Lake

Christopher Sidle had schizophrenia and experienced a deterioration in his mental health during June 2023. After several assessments by mental health services, he was not admitted to hospital; on 1 July 2023 he jumped from a moving taxi, suffered life-threatening head injuries and died on 4 July 2023 after life-sustaining therapies ceased. The report identified inadequate assessments and missed opportunities to provide appropriate and timely care, alongside concerns about crisis-team training, communication, risk assessment, community support, and the shortage of inpatient mental health beds.

Regina Olufunmilola Ademiluyi · Prevention of Future Deaths report View report

22 Mar 2024 East London G. Irvine

Regina Olufunmilola Ademiluyi was an 83-year-old woman who was bed-bound following surgery for a broken hip and died in March 2024 after declining cognition and physical health, malnutrition, a grade 4 sacral pressure ulcer and an aspiration incident. The report raised concerns that state-funded domiciliary care was not provided, and that the NHS Trust and local authority did not adequately assess or respond to safeguarding, mental-capacity and carer-support concerns.

Finlay Stuart Ian FINLAYSON · Prevention of Future Deaths report View report

22 Mar 2024 East Sussex L. Bradford

Finlay Stuart Ian FINLAYSON died following cardiac arrest at HMP Lewes on 25 January 2019; the stated causes were pulmonary thromboemboli due to deep vein thrombosis, against a background of metastatic carcinoma of the base of the tongue. Concerns included delays and possible omissions in transferring medical information between healthcare systems, poor record keeping, communication failures, delays in accessing healthcare, and failures in the emergency response.

Mary JONES · Prevention of Future Deaths report View report

21 Mar 2024 Cheshire E. Wheeler

Mary Jones was found dead at home on 7 November 2023 after deliberately overdosing on medication with the intent to end her own life. In calculating a fatal dose, she consulted a book advising on suicide methods. The concern was that the book was readily available on Amazon.co.uk, including through expedited delivery, and that this availability could make suicide attempts more effective.

Sarah Elizabeth ADAMS · Prevention of Future Deaths report View report

21 Mar 2024 Berkshire A. McCormick

Sarah Adams was found deceased at home on 19 May 2022 after taking a self-administered overdose of prescribed medication with the intention of ending her life. The report identified care and service delivery issues around her discharge from a voluntary inpatient mental health admission, including a misunderstanding about Crisis Team contact and the provision of five days of medication. It also raised concerns about delays in care planning, the response to her deterioration, and staff training in discharge processes, particularly for out-of-area admissions.

Alan Richard Miles Davies · Prevention of Future Deaths report View report

21 Mar 2024 South Wales Central D. Regan

Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.

Jean WALKER · Prevention of Future Deaths report View report

20 Mar 2024 South Yorkshire (Western) H. Berry

Jean WALKER became unwell at home on 4 November 2022 and was struggling to breathe when her daughter called 999 at 0348. She died before the ambulance arrived at 0542 and was pronounced dead at 0551. The principal concerns were the delayed ambulance response and hospital offloading delays that reduced available ambulance resources; the inquest concluded that the delay resulted in a missed opportunity to provide medical assistance, although it could not be said that earlier intervention would have prevented her death.

Anne Johnston Rowland · Prevention of Future Deaths report View report

20 Mar 2024 Surrey A. Crawford

Anne Johnston Rowland suffered a neck of femur fracture on 27 February 2023 and underwent fixation surgery on 3 March 2023 after waiting for surgery at East Surrey Hospital. Her immobility while waiting contributed to aspiration pneumonia, and she died at the hospital on 31 March 2023. The coroner was concerned that limited theatre capacity, infrastructure risks, and the Trust’s 48-hour surgery metric could delay hip fracture surgery beyond the NICE timeframe and place patients at risk of early death.

Shirley Ann HUNT · Prevention of Future Deaths report View report

20 Mar 2024 York and North Yorkshire A. Norton

On 24 August 2021, Shirley Ann Hunt died instantaneously from multiple injuries after a motorhome tyre deflated and the vehicle collided with a stationary vehicle on the A64 at Barton Hill. The concern was that adults and children over three can travel unrestrained in the rear areas of motorhomes because there is no legal obligation for seat belts to be fitted there, creating a potential risk to life.

Neil Francis Edwards · Prevention of Future Deaths report View report

20 Mar 2024 Gwent C. Saunders

Neil Francis Edwards was admitted to hospital in respiratory failure, was at high risk of falling, and required 1:1 observation. He suffered four falls, including an unobserved fall on 01/05/2023 that caused a hip fracture; after surgery, he suffered a gastrointestinal haemorrhage and died. The principal concerns were that the falls, including the fall contributing to his death, were not investigated and that this left insufficient reassurance about preventing similar deaths.

Ellie Louise Frances HUNT · Prevention of Future Deaths report View report

20 Mar 2024 York and North Yorkshire A. Norton

Ellie Louise Frances Hunt was travelling in the rear of a motorhome when a front tyre deflated and the vehicle collided with a stationary vehicle on the A64 on 24 August 2021. She suffered multiple injuries that were not survivable; the principal concern was that rear areas of motorhomes may be used by adults and children over three without restraints, potentially creating a risk to life.

Jonathan Harris · Prevention of Future Deaths report View report

20 Mar 2024 Surrey A. Crawford

Jonathan Harris died in the early hours of 27 June 2022 after deliberately suspending himself while suffering a relapse of paranoid schizophrenia. The inquest concluded that his relapse followed reductions in antipsychotic medication and that an inpatient psychiatric bed was unavailable when an assessment was required. The court was concerned about the vacant consultant psychiatrist post and the shortage of inpatient psychiatric beds, which it considered presented a risk of future deaths.

Ian Dixon · Prevention of Future Deaths report View report

19 Mar 2024 Manchester South L. Costello

Ian Dixon, who had confusion, was unsteady on his feet and had a history of falls, was found deceased at the bottom of the stairs in his home on 8 June 2023 after suffering an extensive skull fracture and acute right-sided subdural haematoma. A principal concern was that there was no policy or review process to confirm that urgent equipment requested through the council and Stockport Homes had been installed or to identify delays, and the handrail had not been fitted despite being recorded as complete.

Darnell Errol Hugh Smith · Prevention of Future Deaths report View report

18 Mar 2024 South Yorkshire (Western) T. Rawden

Darnell Errol Hugh Smith, who had cerebral palsy, scoliosis, sickle cell disease and epilepsy, attended hospital with reduced appetite, respiratory symptoms and no bowel movements, and was later admitted to critical care, intubated and ventilated. He died on 23 November 2022 after developing ventilation-associated pneumonia and type 2 respiratory failure. The principal concerns were missed observations, pain monitoring, provision of fluids, and staff not locating or considering his health passport and individualised care plan, creating a missed opportunity to identify deterioration earlier.

Sarah Louise Sutherland · Prevention of Future Deaths report View report

15 Mar 2024 Surrey K. Henderson

Sarah Louise Sutherland had significant mental health difficulties, including suicidal ideation and self-harm, and died by suicide at her home on 17 December 2022. The report identified concerns about the private psychotherapist’s lack of clinical records, assessment and review, risk assessment, therapeutic boundaries, and communication with NHS services.

Romeo Miles Esposito · Prevention of Future Deaths report View report

15 Mar 2024 Avon S. Fox

Romeo Miles Esposito was found unconscious at home, where emergency staff stopped resuscitation and assessed him as dead, although he continued to make respiratory effort and his heartbeat returned before resuscitation resumed. He later died in hospital from a brain injury consequent upon his cardiac arrest; concerns included the failure to recognise the respiratory effort as requiring further assessment and the absence of evidence that staff had been warned or trained against dismissing it as “a release of air”.

Sydney Alex Piper · Prevention of Future Deaths report View report

15 Mar 2024 East London G. Irvine

Sydney Alex Piper, a 69-year-old man living in supported accommodation, left a mental health clinic while inadequately supervised on 23 February 2023 and was discovered deceased in a tent in Epping Forest on 24 March 2023. His death was caused by morphine toxicity, although it was not possible to determine how he was administered morphine or came to be at the site. The concerns were inadequate supervision of a vulnerable person and insufficient monitoring and policing of encampments, which increased the risk of fatal harm.

Joseph Michael Miller · Prevention of Future Deaths report View report

14 Mar 2024 Manchester South A. Mutch

On 31 May 2023, Joseph Michael Miller suffered seizures at home, became unconscious, and did not regain consciousness despite resuscitation attempts. He was declared dead on 5 June 2023 after tests confirmed severe hypoxic brain injury. The report raised concerns that differing ambulance service pathways can lead to inconsistent call categorisation and affect the dispatch of potentially lifesaving attendance.

Zachary Victor TAYLOR-SMITH · Prevention of Future Deaths report View report

14 Mar 2024 Derby and Derbyshire S. Evans

Zachary Taylor-Smith was born preterm after an induced labour and died aged 14 hours at Royal Derby Hospital on 17 November 2022. The inquest found that he contracted an infection and that his death was contributed to by neglect, including failures relating to prophylactic antibiotics, recognition of the duration since rupture of membranes, and treatment of signs of early-onset infection. Concerns included staff understanding of infection indicators, communication between maternity and neonatal teams, systems for ensuring reviews were completed, and the safety of planned inductions given service capacity.

Victor Valentine Costello · Prevention of Future Deaths report View report

14 Mar 2024 Teesside and Hartlepool J. Wharton

Victor Valentine Costello, a resident at Primrose Court Nursing Home, was taken to hospital on 17 February 2020 and died there six days later from naturally occurring disease. Concerns were raised that information about his drinking water despite being nil by mouth and PEG fed was not effectively communicated to staff.