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Emily Corfield · Prevention of Future Deaths report View report

14 Jul 2023 North Wales (East and Central) K. Robertson

Emily Corfield, aged 41, was found deceased at home on 19 September 2021 after a history of alcohol misuse and two hospital admissions for coffee ground vomiting and alcohol withdrawal. The principal concern was the lack of evidence that the alcohol liaison team provided inpatient or outpatient support or that referrals to external organisations were made.

Mr Terence Burns · Prevention of Future Deaths report View report

14 Jul 2023 Blackpool and the Fylde A. Cousins

Mr Terence Burns, a resident of Highgrove Rest Home, was transferred to hospital on 28 October 2022 after his physical condition deteriorated. His blended-diet requirement was not communicated to ambulance services or the hospital, and he was later found unresponsive with food residue in his throat and died. Concerns included inaccurate care-plan information about his nutritional needs and failure to check the documents handed over during transfer.

PETER MARTIN AARON FLEMING · Prevention of Future Deaths report View report

14 Jul 2023 Birmingham and Solihull J. Bennett

Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.

Phoenix Grace CHAPMAN · Prevention of Future Deaths report View report

14 Jul 2023 Inner North London M. Hassell

Phoenix Grace Chapman was born unexpectedly at home and died following cord compression during the second stage of labour. The report identified concerns about differing understandings among clinicians regarding the appropriate response to precipitous labour and about midwives’ views not being sufficiently heard before protocols were established.

Mackenzie COOPER · Prevention of Future Deaths report View report

13 Jul 2023 Nottinghamshire L. Bower

Mackenzie Cooper died on 29 September 2022 after being electrocuted while working at a residential property, resulting in cardiac arrhythmia. During the emergency response, a community public access defibrillator supplied from a local Co-op store could not be used because it was missing its pads. Concerns included the device being supplied in a non-workable condition and the absence of clear systems for maintaining defibrillators and sharing their operational status with ambulance services.

Mohammed Khalid HUSSAIN · Prevention of Future Deaths report View report

12 Jul 2023 Birmingham and Solihull L. Hunt

Mohammed Khalid HUSSAIN was found collapsed on the bathroom floor at his home on 28 November 2022 and was confirmed deceased shortly afterwards. The medical cause of death was determined to be sudden cardiac death in schizophrenia. Concerns included inadequate systems for monitoring, communicating and acting on high clozapine levels and medication changes, as well as deficiencies in internal investigation, understanding of clozapine and pharmacy resourcing.

Luke Anthony Ashton · Prevention of Future Deaths report View report

12 Jul 2023 Leicester City and South Leicestershire I. Cartwright

Luke Anthony Ashton, a 40-year-old man, was discovered deceased at Carnegie House, Swinton, on 22 April 2021, and his death was confirmed at the scene. The inquest found that he had a longstanding gambling disorder and that his gambling activity, deposits and losses were most intensive in the 10 weeks before his death. Concerns included the adequacy of player protection tools, Betfair’s failure to identify his worsening gambling through its monitoring algorithm, and the lack of meaningful intervention or interaction.

MUSTAFA NADEEM · Prevention of Future Deaths report View report

11 Jul 2023 Birmingham and Solihull J. Bennett

On 6 December 2022, 12-year-old Mustafa Nadeem was fatally injured after colliding with a pedestrian while riding a hire e-scooter to school and falling into the path of a bus. The principal concern was that children could easily use hire e-scooters illegally, and that existing precautions and education were ineffective in preventing this.

June Peel · Prevention of Future Deaths report View report

11 Jul 2023 South Yorkshire (Western) A. Pountney

June Peel, a resident at Belle Green Court Care Home, sustained a displaced distal femur fracture that was not identified or medically assessed promptly. She underwent surgery after admission to hospital and did not recover, dying on a palliative care pathway. The principal concerns were failures to follow her care plan, record and hand over information about her knee injury, and seek timely medical attention.

Mr John Michael James · Prevention of Future Deaths report View report

11 Jul 2023 East London N. Persaud

Mr John Michael James was admitted to hospital with malnutrition and a bowel obstruction caused by an adenocarcinoma, and later underwent surgery and intensive care. He died from a pulmonary embolism after three missed doses of prescribed anticoagulation medication; the report raised concern that the refusals were not escalated and that there was no electronic alert to notify medical staff when doses were not administered.

Mr Christian Kwame Tuvi · Prevention of Future Deaths report View report

10 Jul 2023 Inner South London A. Harris

Mr Christian Kwame Tuvi, an escalator cleaner aged 44, died at Waterloo Station after the traveller moved while he was in a gap, causing blunt force trauma to the chest. The jury identified inadequate briefing, failure to complete a site-specific risk assessment, failure to give an audible warning, and failures concerning the inching pendant and compliance with the method statement. The report also raised continuing concerns about unresolved responsibility for training and competence to operate the travellator during cleaning.

Mary Elizabeth Jones · Prevention of Future Deaths report View report

10 Jul 2023 North West Wales K. Robertson

Mary Elizabeth Jones had an unwitnessed fall at home on 4 December 2022, followed by a 26-hour ambulance delay and a further 8-hour-23-minute wait on the ambulance outside the Emergency Department. She later deteriorated, an abdominal bleed was diagnosed, and she died on 14 January 2023. The principal concerns were the lengthy ambulance and patient offload delays, and the lack of meaningful evidence about Local Authority involvement in addressing patient-flow problems linked to social care deficiencies.

Harold Wilberforce · Prevention of Future Deaths report View report

10 Jul 2023 East Riding and Hull E. Steele

Harold Wilberforce fell at home on 16 January 2023, sustained a broken hip and was taken to hospital, where he contracted bronchopneumonia and died on 28 January 2023. Concerns included the lack of medical examination after the fall, the pharmacy delivery agent’s lack of awareness of his dementia, the absence of relevant staff training, and unclear roles and responsibilities when elderly service users are found to have fallen.

Christopher Howard SMITH · Prevention of Future Deaths report View report

7 Jul 2023 Nottinghamshire L. Bower

Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.

David Alan LYTH · Prevention of Future Deaths report View report

7 Jul 2023 Cheshire C. Keighley

On 30 November 2021, David Alan Lyth became trapped between two HGV trailers while coupling a new trailer, and his death was confirmed at hospital. The inquest concluded that he died from asphyxia after the trailers rolled away. The principal concern was the provision of regular and periodic training for all drivers on coupling and uncoupling procedures, following evidence of four rollaway incidents involving drivers at 3D Trans Ltd since 2020.

Robert Newton Stevenson · Prevention of Future Deaths report View report

6 Jul 2023 West Yorkshire (Western) M. Fleming

Robert Newton Stevenson, a 63-year-old retired consultant cardiologist and general physician, left home on 30 May 2022 and was later found hanging; resuscitation attempts were unsuccessful. The report raised concern about a possible rare link between ciprofloxacin and suicidal behaviour, including whether prescribing doctors were sufficiently aware of and communicating this potential side effect.

Emlyn Victor Roberts · Prevention of Future Deaths report View report

6 Jul 2023 North Wales (East and Central) J. Gittins

Emlyn Victor Roberts called an ambulance on 13 March 2022 after sudden pain and difficulty breathing, but ambulance attendance was delayed by almost eleven and a half hours; he was found deceased at home on 14 March 2022. The principal concern was the significant and unacceptable delay in ambulance attendance, alongside concerns about continuing delays and inadequate cohesive planning for short-term pressures and longer-term solutions.

Elizabeth Oluwatofunmi AGBEJIMI · Prevention of Future Deaths report View report

6 Jul 2023 Lincolnshire P. Cooper

Elizabeth Oluwatofunmi AGBEJIMI died on 27 June 2021 at Lincoln County Hospital following multiple falls identified by the pathologist as a direct cause of death. Concerns were raised that a venous blood gas sample showing significant respiratory abnormal acidosis was not further investigated, with the deceased dying two weeks later of a respiratory condition; the report questioned whether this involved training or communication.

Mr Oleg Khala · Prevention of Future Deaths report View report

6 Jul 2023 Inner West London F. Wilcox

Mr Oleg Khala, who had complex mental and neurodevelopmental illnesses and was vulnerable, died by hanging after being discharged twice from hospital despite requesting admission because of suicidality and sleeplessness. The principal concerns included generic CATT assessments, discharge without consultant discussion, failure to provide a care coordinator, and insufficient access to neurodevelopmental expertise.

Gordon Harry Renfrew · Prevention of Future Deaths report View report

6 Jul 2023 Nottinghamshire E. Didcock

Gordon Harry Renfrew died at Queens Medical Centre on 14 June 2022 after a severe and extensive stroke caused by a large cerebral infarction. The report identified concerns about limited communication and working relationships between the stroke and neurosurgical teams, limited understanding of NICE guidance on decompression craniectomy, and insufficient opportunities for joint case discussion and learning. It stated that the NICE guidance was not followed and that discussions with the family about the timing of decompression craniectomy should have occurred earlier.