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Blanche Audrey Knowles · Prevention of Future Deaths report View report

13 Feb 2024 West Yorkshire (Eastern) J. Hobson

Blanche Audrey Knowles, who had multiple health conditions and was receiving nursing care, suffered burns when an inadequately checked hot drink spilled into her lap. She later became frail and died on 1 September 2023; the burns contributed to her death. The principal concern was that staff had not been adequately informed or trained about cooling burns under running water.

Mouayed Mamoun Bashir · Prevention of Future Deaths report View report

12 Feb 2024 Gwent C. Saunders

Mouayed Mamoun Bashir took an unknown quantity of cocaine and developed symptoms consistent with Acute Behavioural Disturbance (ABD). After police restraint and transfer to an ambulance, he suffered cardiac arrest and died despite CPR and attempts at hospital revival. The report raised concerns about insufficient knowledge of ABD and ambiguity about whether officers recognised or communicated their concerns about it.

Natalie Christina Mountford · Prevention of Future Deaths report View report

12 Feb 2024 Dorset B. Allen

Natalie Christina Mountford was struck by a vehicle while assisting at an earlier collision on an icy road and died at the scene from her injuries. The report raised concerns about repeated collisions at the location, the failure to investigate flowing water during highway inspections, and the absence of a robust process for logging and acting on reports of water leaks onto the highway.

Kazarie T’Calla Kwaku DWAAH-LYDER · Prevention of Future Deaths report View report

9 Feb 2024 Inner North London M. Hassell

Kazarie died after swallowing a googly eye in February 2022; the foreign body was not detected by x-ray or fluoroscopy, and he later became critically ill and was admitted to hospital in April 2023. The report raised concern about the lack of national guidance on investigating suspected swallowed non-radio-opaque foreign bodies when symptoms persist despite negative x-ray and fluoroscopy.

Susan Mary Young · Prevention of Future Deaths report View report

9 Feb 2024 West Sussex, Brighton and Hove P. Schofield

Susan Mary Young died at home on 20 December 2022 after accidentally taking too many prescribed co-codamol tablets over a short period, causing fatal toxicity. The report identified that ambulance staff did not consider possible co-codamol toxicity because they did not have access to her GP records, and stated that earlier recognition and administration of Naloxone could have provided a good chance of survival.

Narjit Gill · Prevention of Future Deaths report View report

9 Feb 2024 Coventry and Warwickshire D. Lakin

Narjit Gill died by hanging on 5 May 2023 after recently receiving mental health support and continuing to express suicidal thoughts. The principal concern was the failure to remove an unspecified item seen during a home visit on 3 May 2023, in light of his continued suicidal ideation.

Thomas GODDERIDGE · Prevention of Future Deaths report View report

8 Feb 2024 Cumbria R. Cohen

Thomas Godderidge, aged 85, died from smoke inhalation after a fire broke out at his home on 16 February 2023. Concerns were raised about unreliable routine liaison between Adult Social Care and care providers when concerns arise about a service user's capacity, and about capacity assessments not consistently accounting for variable or fluctuating capacity.

Jake Brian BAKER · Prevention of Future Deaths report View report

8 Feb 2024 Surrey C. Topping

Jake Baker, who had learning disability and type 1 diabetes, developed diabetic ketoacidosis while staying with his family and died at home on 31 December 2019. The report identified concerns about inadequate pathway planning, risk assessment, information-sharing, diabetes support and advice to his family, as well as failures to assess his capacity and ensure appropriate care-leaver support.

Ethel Doreen Reed · Prevention of Future Deaths report View report

8 Feb 2024 East Riding and Hull S. Robinson

Ethel Doreen Reed fell at home, sustaining rib fractures that caused a pneumothorax and chest infection, and later developed pneumonia and Covid-19 while in hospital. She was discharged to a community rehabilitation centre while described as not medically fit for discharge and died there on 2 March 2023. The report raises concerns about staffing, continuity of care, personal care, leadership and escalation arrangements on a winter-pressure ward, as well as an electronic record system issue affecting identification of authors of discharge-letter changes.

Dayle BATES · Prevention of Future Deaths report View report

8 Feb 2024 Cumbria R. Cohen

Dayle Bates, aged 39, was found dead at his home on 31 August 2023 after ambulance staff were unable to revive him. A post-mortem examination attributed his death to the combined effect of heroin, bromazolam, protonitazene, xylazine and alcohol. The report raises concerns that Recovery Steps were not promptly informed when he stopped collecting methadone, and that pharmacies lacked a direct reporting route and were not obliged to report wider welfare concerns.

Brian JAMES · Prevention of Future Deaths report View report

7 Feb 2024 South Wales Central P. Morgan

Brian JAMES, aged 91, suffered a cerebral haemorrhage after falling out of bed at home and died in hospital on 1 November 2021. There was an approximately nine-hour delay before the ambulance arrived. Concerns included callers not understanding when to call back during delayed ambulance responses and the risk that insufficient welfare calls could result in missed reassessment and regrading of the response.

James Colin Day · Prevention of Future Deaths report View report

7 Feb 2024 Manchester South A. Mutch

James Colin Day, who had developed severe post-traumatic stress disorder after serving in Afghanistan, collapsed and died on Malvern Road on 6 May 2023. The report describes concerns that mental health support for service personnel with severe PTSD, both during service and after discharge, was patchy and difficult to access, and that he used alcohol and prescribed medication to cope with his symptoms.

Mark PRYOR · Prevention of Future Deaths report View report

6 Feb 2024 Derby and Derbyshire P. Nieto

Mark Pryor died at the emergency department of Royal Derby Hospital on 5 September 2020 after suffering an alcohol-withdrawal-related seizure and cardiorespiratory arrest while in police custody. The inquest jury found deficiencies in the health care professionals’ assessment and treatment of his alcohol withdrawal that probably made more than a minimal contribution to his death. The report raises concerns that health care professionals may not receive sufficient training to practise effectively and safely in police custody suites.

O’Shea Medad Dover · Prevention of Future Deaths report View report

6 Feb 2024 North London P. Straker

O’Shea Medad Dover was delivered after a delayed ambulance response to the mother’s emergency call and was subsequently found to have no foetal heart rate. Resuscitation restored circulation, but the inquest narrative stated that O’Shea was likely subjected to acute severe hypoxia and would likely have survived if the call had been correctly categorised and hospital treatment had occurred earlier. The substantive concern was whether national JRCALC guidance should include advice to convey patients to an obstetrics unit when delivery is not progressing.

Paula Elizabeth ELSLEY · Prevention of Future Deaths report View report

6 Feb 2024 Berkshire R. Simpson

Paula Elizabeth ELSLEY was found unresponsive at home on 28 March 2022 and declared deceased. The inquest concluded that she was suffering from undiagnosed lung cancer with a metastatic brain tumour, which led to an abscess that caused her death. Concerns included smoking status not being readily accessible in GP records and NICE guidance on chest X-ray referral thresholds not being routinely considered or formally embedded in practice.

Liam Turner · Prevention of Future Deaths report View report

5 Feb 2024 Manchester City Z. Golombeck

Liam Turner died at HMP Manchester on 6 December 2021 from mixed toxicity involving a psychoactive substance and prescription medication. Concerns were raised that prison officers were not required to have in-date basic first aid training, including CPR, and that 48% of HMP Manchester prison staff had expired training certification.

Emily Kate Harkleroad · Prevention of Future Deaths report View report

5 Feb 2024 County Durham and Darlington R. Sutton

Emily Kate Harkleroad collapsed on 18 December 2022 and died from a pulmonary embolism in the early hours of 19 December 2022. The report states that failures and delays in treatment meant she did not receive anticoagulant treatment that, on a balance of probabilities, would have prevented her death. A further concern was that the Emergency Department’s new computer system lacked the previous clear RAG rating display for quickly identifying critically ill patients, particularly during periods of extreme pressure.

Mr Paz Ogbe-Millar · Prevention of Future Deaths report View report

5 Feb 2024 North London T. Murphy

Mr Paz Ogbe-Millar died on 2 December 2021 after jumping in front of a high-speed train at Harrow and Wealdstone station, during a relapse in cannabis-induced psychosis. Concerns included his discharge from community mental health services, inadequate recording of police information about his self-harm risk, not allowing his mother to remain with him in the Emergency Department, referral-system problems, and insufficient observation arrangements for mental health patients awaiting assessment.

Kyle James GOATER · Prevention of Future Deaths report View report

5 Feb 2024 West Yorkshire (Western) A. Brocklehurst

Kyle James GOATER, aged 25, died at the collision scene on 20 July 2021 after a road traffic collision in which his vehicle struck an RAC van and another vehicle became involved. He suffered chest injuries, developed breathing difficulties and then cardiac arrest; CPR was unsuccessful. The substantive concern was that the layby and vehicle turning into it were not signposted or visible sufficiently in advance of the crest of the hill, limiting the opportunity for an approaching driver to become aware of the hazard and reduce speed.

Abdullah Popalzai · Prevention of Future Deaths report View report

5 Feb 2024 Inner North London S. Bourke

Abdullah Popalzai was a remand prisoner at HMP Pentonville who was found hanging in his cell on 29 November 2019, and his death was confirmed by paramedics. He had acute psychosis and required transfer to a psychiatric unit, but no suitable bed was available for a prolonged period. The principal concern was that acutely psychotic prisoners refusing treatment were being left untreated and at risk of deterioration because suitable psychiatric hospital beds were not becoming available in a timely way.