Search PFD Monitor

Leah BARBER · Prevention of Future Deaths report View report

3 Aug 2023 West Yorkshire (Western) R. Mahmood

Leah BARBER, aged 15, was found deceased at Bolton Woods Quarry on 3 June 2019 after falling from a height of around 30 metres. The inquest concluded that Leah had taken her own life. The principal concern was that Bradford Council had no system or single point of oversight providing an overview of its involvement with Leah and similar deaths, limiting its ability to identify and learn lessons and contributing to a risk of future deaths.

John Neil SHENTON · Prevention of Future Deaths report View report

2 Aug 2023 Shropshire, Telford and Wrekin J. Ellery

John Neil SHENTON, who had limited mobility, fell while stepping onto a descending escalator after the store lift was unavailable and died four days later from his injuries and listed medical conditions. The concerns were that actions identified in an environmental health report remained outstanding and that more should be done to protect vulnerable people who need to use an escalator when a lift is not operating.

Dumile Daniel Thompson · Prevention of Future Deaths report View report

2 Aug 2023 West Yorkshire Eastern J. Wolstenholme

Dumile Daniel Thompson developed Ramipril-induced angioedema, deteriorated after an apparent initial improvement, suffered respiratory collapse causing catastrophic brain injury, and died several days later after life support was withdrawn. The principal concerns included inadequate recognition of the risks and trajectory of ACE inhibitor-induced angioedema, insufficient specialist airway reassessment and monitoring, lack of relevant guidance and training, and limited access to previous medical records affecting medication decisions.

Lee Dryden · Prevention of Future Deaths report View report

2 Aug 2023 South Yorkshire (Western) A. Combes

Lee Dryden had a displaced tracheotomy tube associated with emphysema, and critical scan findings on 15 December 2021 were not followed by successful contact or timely review. He suffered a cardiac arrest on 16 December 2021, resulting in a hypoxic brain injury, and died on 12 January 2022. The principal concerns were failures in communicating and acting on critical imaging findings and the delayed ambulance response to his mother's call.

Edward England Rhodes · Prevention of Future Deaths report View report

1 Aug 2023 Dorset R. Middleton

Edward England Rhodes, who had a history of alcohol misuse, relapsed after a period of abstinence and was found unresponsive on 17 November 2022. Toxicology revealed methadone at a level consistent with severe, possibly fatal toxicity, and the inquest recorded a drug-related death. Concerns included a possible breakdown or misunderstanding between Mr Rhodes and his GP about the steps required for a mental health referral, and the absence of clear written confirmation of respective responsibilities.

David Alistair Andrews · Prevention of Future Deaths report View report

1 Aug 2023 Hertfordshire J. Howell

David Alistair Andrews, a cyclist, collided with a stationary heavy goods vehicle on the A4251, suffered significant traumatic injuries, and died at St George’s Hospital on 12 July 2022. The principal concern was that heavy goods vehicles were permitted to stop to unload on this stretch of road, effectively blocking the southbound carriageway and creating an ongoing risk.

Eileen Marguerite WALSH · Prevention of Future Deaths report View report

31 Jul 2023 Norfolk J. Lake

Eileen Marguerite WALSH, who had dementia and general frailty, fell unwitnessed at Broadland View Care Home, sustained a fractured neck of femur, and died on 3 March 2020. The inquest found that required hourly checks were not completed, her bed was not lowered, and the PIR sensor and pressure mat alarms did not sound; her death was contributed to by neglect. Concerns included incomplete night-working and monitoring arrangements, unreliable or editable care records, unclear policies on sleeping during night shifts, alarms that could not be heard everywhere, and failures to identify and learn from care and safeguarding concerns.

BENJAMIN DAVID MCQUEEN · Prevention of Future Deaths report View report

28 Jul 2023 Dorset R. Ryder

Benjamin McQueen drowned on 14 November 2018 during a military diving exercise in Portland Harbour, Dorset, after experiencing complications during the dive and being recovered unconscious from the seabed. The concerns included the lack of a spare breathing-apparatus cylinder for the stand-by diver, accelerated safety-critical training, the absence of a dedicated defibrillator, and inconsistent minimum safety-pressure guidance for breathing apparatus.

Kirsty Clare TAYLOR · Prevention of Future Deaths report View report

28 Jul 2023 Hampshire, Portsmouth and Southampton C. Wilkinson

Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.

Johanne Blackwood · Prevention of Future Deaths report View report

27 Jul 2023 Essex S. Horstead

Johanne Blackwood, known as Jo, died by suicide on 12 June 2021 after placing herself in the path of a train. The report identified concerns about unclear Care Coordinator handovers and responsibility for oversight after discharge, the absence of an allocated Care Coordinator for several weeks, failure to update her risk assessment, care plan and security plan, and inappropriate over-reliance on family members to keep her safe.

Finley Austin May · Prevention of Future Deaths report View report

26 Jul 2023 East Riding and Hull P. Marks

Finley Austin May was born on 16 February 2021 after delivery using Keilland’s rotational forceps. He developed a high cervical spinal cord injury caused by the forceps and died at Hull Royal Infirmary on 16 March 2021, aged 28 days. The report raises concerns about complications associated with Keilland’s forceps, the training and skill levels needed for their use, and guidance on alternative methods where trusts no longer use them.

Paul Keating · Prevention of Future Deaths report View report

25 Jul 2023 West Yorkshire Eastern O. Longstaff

Paul Keating, aged 59, died on 15 April 2023 in a fire at the flat where he lived alone, from the combined effects of carbon monoxide toxicity and pre-existing heart disease. His flat was the only one in the tower block not connected to the sprinkler system because contractors could not enter without his consent, and smoke detectors had been disabled. The report raised concerns about the absence of statutory power for the local authority to enter the flat to install the sprinkler system.

John David Coles · Prevention of Future Deaths report View report

24 Jul 2023 West London R. Furniss

John David Coles died after a Heathrow Airport Ltd HiLux vehicle struck the British Airways Renault Kangoo he was driving while crossing an uncontrolled taxiway crossing at Heathrow Terminal 5. The concerns included background visual interference affecting the HiLux driver's ability to see the Kangoo and the difficulty of seeing white-coloured vans, including possible consideration of side profile lights for vehicles crossing uncontrolled crossings.

Alan Christopher NIPPARD · Prevention of Future Deaths report View report

24 Jul 2023 Avon M. Voisin

Alan Christopher Nippard was admitted to hospital after a fall and developed a sacral pressure sore during his admission, followed by infection and deterioration. He died on 6 July 2022 after surgery was considered unsuitable. The report identified concerns that the pressure sore was preventable and that basic nursing care, including risk assessment, skin care, repositioning and personal care, was not provided adequately.

Christine Goodfriday Nakaefeero · Prevention of Future Deaths report View report

24 Jul 2023 East London G. Irvine

Christine Goodfriday Nakaefeero was found unresponsive at home on 21 June 2022 and died from a pulmonary embolism caused by a deep vein thrombosis. The report raises concerns that recommended hysterectomy surgery for her uterine fibroids was not arranged, and that the VTE assessment did not account for her large fibroids and use of tranexamic acid.

Philip Martin Evans · Prevention of Future Deaths report View report

22 Jul 2023 North Wales (East and Central) K. Roberston

Philip Martin Evans, aged 38, consumed approximately 200 tablets at home and later went into cardiac arrest at hospital, dying shortly afterwards. The inquest found that missed opportunities to provide treatment probably meant that death occurred when it did. The report also raises concerns about the quality, effectiveness and timeliness of the Health Board’s investigations and the delayed identification of care issues.

Albert Dovey · Prevention of Future Deaths report View report

21 Jul 2023 Manchester South A. Mutch

Albert Dovey suffered an accidental fall at home and was admitted to hospital with rhabdomyolysis, acute kidney injury, heart failure and a fractured clavicle. He became gravely frail and died at Tameside General Hospital on 4 February 2023. The inquest heard concerns about delays in ambulance attendance, ambulance processing at hospital and clinical assessment, with evidence that delays in treating elderly frail patients after a fall increased the risk of death.

Thomas Barton · Prevention of Future Deaths report View report

21 Jul 2023 Manchester South A. Mutch

Thomas Barton was admitted to hospital for a urinary tract infection and remained there while arrangements for additional care at home were organised. He contracted COVID-19 during the delayed discharge, deteriorated with dysphagia and aspiration pneumonia, and was discharged to a nursing home on end-of-life care, where he died. The principal concern was that delays in discharge caused by limited social care availability placed frail elderly patients at increased risk of deconditioning, infection and preventable death.

Corinne Haslam · Prevention of Future Deaths report View report

21 Jul 2023 Manchester South C. Morris

Corinne Haslam died at Tameside General Hospital on 18 March 2022 following complications involving myocardial ischaemia, acute exacerbation of chronic obstructive pulmonary disease, left ventricular hypertrophy and treated pulmonary thromboemboli. Concerns included barriers to obtaining physical-health specialist input for mental-health ward patients, incompatible electronic records between Mental Health and Acute Trusts, and unclear guidance on venous thromboembolism risk assessments.

Marion Nickson · Prevention of Future Deaths report View report

21 Jul 2023 Manchester South A. Mutch

Marion Nickson was admitted to hospital after a fall and later died following an unwitnessed fall in hospital that caused a brain bleed. The principal concern was that observable bay nursing failed because staff left the bay to deal with other tasks, with insufficient staffing, understanding of the risks, and prioritisation of patient observation contributing to the problem.