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Valerie Ann Simmons · Prevention of Future Deaths report View report

20 Oct 2023 Cornwall and Isles of Scilly A. Cox

Valerie Ann Simmons developed a large left-thigh haematoma after receiving Fragmin while receiving anticoagulation therapy, was later admitted to hospital, deteriorated and died on 11 January 2023. Concerns included the absence of recorded observations after a change in her presentation and the need for further training on the risks of hypovolaemia in an anticoagulated patient.

Michael Joseph HINDES · Prevention of Future Deaths report View report

20 Oct 2023 Inner North London M. Hassell

Michael Hindes died by suicide after calling 999 because he felt suicidal and being taken to St George’s Hospital for a half-hour mental health assessment before discharge. The principal concerns were that he was not referred to the crisis team despite a likely minimum one-week wait for community mental health follow-up, and that the assessing nurse did not try to persuade him to involve his family, who were unaware of his mental ill health until after his death.

Thomas Doyle · Prevention of Future Deaths report View report

20 Oct 2023 East London G. Irvine

Thomas Doyle, a 90-year-old man, was admitted to hospital with back and chest pain and subsequently developed sepsis while in hospital, dying on 25 January 2023. The concerns included poor clinical records and failure to commence the diagnostic pathway for sepsis when indicated on admission, contrary to local policy and national guidance.

Trevor Coy BAILEY · Prevention of Future Deaths report View report

20 Oct 2023 Inner North London M. Hassell

Trevor Bailey attended hospital with chest pain on 19 April 2023 and was discharged after negative test results, without referral to the rapid access chest pain clinic. He subsequently died from a fatal myocardial infarction on 7 May 2023; the concern was that his recent smoking history and family history of ischaemic heart disease were not elicited, which may have prevented an appropriate referral.

Jill BRICE · Prevention of Future Deaths report View report

20 Oct 2023 West Sussex, Brighton and Hove G. Jones

Jill Brice died on 23 December 2022 at Royal Sussex County Hospital after suffering burn injuries and smoke inhalation when an extractor fan in her sheltered housing caught fire. The substantive concern was that care residents should be reminded to keep their emergency pendants close to them, as Jill Brice was not wearing hers when she died.

Wayne MILNE · Prevention of Future Deaths report View report

19 Oct 2023 Sefton, St Helens and Knowsley J. Goulding

Wayne Milne attended hospital with chest pain on 28 February 2022 but was discharged without required chest-pain assessments and senior review. On 2 March 2022, after reporting further symptoms to his GP practice, he was advised to attend the emergency department, but the nurse did not call 999, escalate to a doctor, or check whether he had obtained urgent care; Wayne was later found deceased at home from haemopericardium due to a dissecting aortic aneurysm. The report identifies concerns about inconsistent procedures for summoning emergency assistance, escalation and follow-up, and awareness of dissecting aortic aneurysm within the practice.

Jason Mark BAYLEY · Prevention of Future Deaths report View report

17 Oct 2023 Birmingham and Solihull V. McKinlay

Jason Mark BAYLEY, who had chronic constipation while detained for treatment at St. Andrew's Healthcare, developed intestinal pseudo-obstruction and died at hospital on 28 December 2022. Concerns included repeated inaccurate recording of medication adherence in the Rio notes, which stated that all medication had been taken when doses of lactulose had been refused, creating a risk that staff might misunderstand whether medication had been taken and fail to plan appropriate care.

Tracey Elizabeth Rose · Prevention of Future Deaths report View report

17 Oct 2023 East Riding and Hull P. Marks

Tracey Elizabeth Rose suffered a right tibial plateau fracture and was discharged with a recommendation for six weeks of dalteparin, but missed up to three doses because of a dispensing issue. She was later admitted with a confirmed pulmonary embolism and died on 25 January 2023 after an embolectomy; the concern was that the missed anticoagulant doses may have significantly contributed to the pulmonary embolism.

Holly May Mullan · Prevention of Future Deaths report View report

17 Oct 2023 Manchester South A. Mutch

Holly May Mullan had longstanding severe abdominal pain and experienced long waits for NHS appointments with gynaecologists and gastroenterologists. She was found attached to a ligature on 7 May 2023, and the inquest heard that prolonged waiting times were causing distress, delays in diagnosis and delays in treatment for people with significant health conditions.

Tyler Jay Ryan · Prevention of Future Deaths report View report

17 Oct 2023 Newcastle upon Tyne and North Tyneside C. Henley

Tyler Jay Ryan, aged 11, was found collapsed in his bedroom on 12 February 2021 and died after resuscitation attempts. Genetic testing identified two RYR2 variants associated with CPVT, following earlier differing pathological opinions. The report raised concerns about delays in paediatric pathology reporting and the delayed identification of families who may need genetic testing, as well as the need for wider use of molecular autopsy and revision of the SUDIC Protocol.

Terence Davenport · Prevention of Future Deaths report View report

17 Oct 2023 Manchester South A. Mutch

Terence Davenport, who had severe dementia, was pushed by another resident at Kings Park Nursing Home on 23 May 2022, suffered a fractured neck of femur, and died at Tameside General Hospital on 24 September 2022 after declining following surgery. Concerns included his prolonged stay in an acute hospital because a suitable care placement was unavailable, and inadequate information sharing about the other resident’s aggressive behaviour, which meant risks to staff and residents were not understood.

Marnie Emma Hill · Prevention of Future Deaths report View report

17 Oct 2023 Dorset R. Griffin

Marnie Emma Hill was found collapsed and unresponsive on a bed at a property where she was temporarily residing on 15 May 2022. The report raised concerns that the lack of regulation of counselling could lead to future deaths, including because counsellors are not required to report risks or share records with healthcare professionals.

Claire Twinn · Prevention of Future Deaths report View report

16 Oct 2023 East London G. Irvine

Claire Twinn, a 47-year-old woman with Down’s syndrome, severe learning disability, and complex heart and lung conditions, became unwell and attended hospital with low oxygen saturations and symptoms including cough, sickness, and diarrhoea. She was diagnosed with suspected bilateral pneumonia, discharged on oral antibiotics, and found deceased by her family the following morning. The principal concerns were that she was discharged rather than admitted for monitoring and oxygen therapy, reasonable adjustments and specialised learning disability nursing input were not provided, safety-netting advice was not recorded, and the chest X-ray report was delayed.

Iain Richard Farrell · Prevention of Future Deaths report View report

13 Oct 2023 Dorset B. Allen

Iain Richard Farrell became breathless and exhausted during a led coasteering activity on 26 May 2019, was swept back into the sea by a large wave after reaching a ledge, and was later confirmed deceased despite resuscitation efforts. The principal concerns were the risks of lone guiding, the delayed access to the sole means of communication, and the absence of assessment of participants’ swimming ability and physical fitness during booking.

Peter Carr · Prevention of Future Deaths report View report

13 Oct 2023 North London P. Straker

Peter Carr developed a severe rash and was admitted to North Middlesex Hospital, where he was later found to have a drug reaction consistent with Stevens-Johnson Syndrome. The principal concern was that patients with acute, severe skin conditions may not receive consultant dermatology input, timely biopsy, and ongoing dermatological oversight during an inpatient stay.

John HOARE · Prevention of Future Deaths report View report

12 Oct 2023 West Yorkshire (Western) C. Oliver

John Hoare died at Airedale General Hospital on 31 March 2020 after contracting Covid-19 while detained under the Mental Health Act 1983. The principal concern was a gross failure in lithium prescribing and dispensing after his discharge to a care home, which contributed to deterioration in his mental health and his subsequent detention. The report states that the detention was preventable, although it could not be concluded on the balance of probabilities that it caused his death.

David Hall · Prevention of Future Deaths report View report

12 Oct 2023 Manchester South A. Mutch

David Hall, who had dementia, was admitted to hospital because no safe and suitable social care placement was available and later remained there while awaiting placement. His nutritional needs were not fully met, his swallow deteriorated, and he developed aspiration pneumonia; he also contracted COVID-19 and died in hospital. The principal concern was the shortage of suitable social care placements, which contributed to his hospital admission and delayed discharge.

Norma Kyte · Prevention of Future Deaths report View report

12 Oct 2023 South Yorkshire (Western) M. Whittle

Norma Kyte died on 4 June 2023 after an unwitnessed fall at a nursing home, which resulted in a right supracondylar femoral fracture and subsequent deterioration. Concerns were raised that the sensory mat did not cover the full area beside the bed and would only trigger when directly stood upon, and that it may not have been used in accordance with the manufacturer’s instructions.

Mr Jonathan Michael McCarthy · Prevention of Future Deaths report View report

12 Oct 2023 Northamptonshire H. Shah

Mr Jonathan Michael McCarthy died on 12 August 2018 at University Hospital Coventry and Warwickshire from a cardiac arrhythmia associated with scarring of the heart, while at HMP Onley. Concerns included failures to verify and assess the clinical importance of pre-existing community hospital appointments, the impact of security issues on those appointments, and whether he was fit to transfer or should have been placed on medical hold.

Sarah Elizabeth Holmes · Prevention of Future Deaths report View report

11 Oct 2023 County Durham and Darlington J. Richards

Sarah Elizabeth Holmes, who had a history of mental health difficulties and self-harm, was found dead after discharge home following a mental health assessment; the medical cause of death was recorded as asphyxia. The principal concern was the substantial delay in the Trust’s serious incident investigation, which remained incomplete more than a year after her death and was described as neither timely nor responsive. The report also raised concern that such delays could allow lethal hazards to persist and compromise investigations intended to prevent similar deaths.