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Keith Nielsen · Prevention of Future Deaths report View report

26 Jun 2023 Surrey A. Crawford

Keith Nielsen fell at home, sustained a head injury while taking Warfarin, and died in hospital on 23 March 2022. The concerns included the handling of his 999 call, including the no-send disposition despite his circumstances, and repeated operation of the ambulance service at Stage 4 of its Surge Management Plan, with demand exceeding available resources and responses not meeting target timeframes.

Stephen Kurt Beadman · Prevention of Future Deaths report View report

23 Jun 2023 West Yorkshire Eastern K. McLoughlin

Stephen Kurt Beadman was a 34-year-old serving prisoner at HMP Wakefield who was found unresponsive after applying a ligature to his neck and died in hospital the following day. The Inquest found that he committed suicide having been bullied by other prisoners. The principal concern was that the prison’s limited consultant psychiatrist resource was insufficient for the complex mental health needs of its prisoner population, creating concern that other deaths may occur.

Mason French · Prevention of Future Deaths report View report

22 Jun 2023 Sunderland D. Winter

Mason French died aged 11 on 25 October 2022 when his bicycle collided with a passenger bus at a concealed junction on Lizard Lane, Whitburn. The report raises concern that, despite safety improvements, cyclists remain at risk in the area without further measures.

Christopher Stevens · Prevention of Future Deaths report View report

22 Jun 2023 Cornwall and Isles of Scilly A. Cox

Christopher Stevens had a history of serious overdose attempts and was admitted to a mental health ward as an informal patient. While the ward was understaffed, he was allowed to take unescorted leave without a nurse completing a risk assessment, and his body was found three days later. The principal concerns were failures in reviewing records, assessing leave-related risk, recognising his non-return promptly, and completing proposed process changes without undue delay.

Lucy Anne Walles · Prevention of Future Deaths report View report

22 Jun 2023 Berkshire H. Connor

Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.

Stephen Norman RICHARDSON · Prevention of Future Deaths report View report

22 Jun 2023 Liverpool and the Wirral A. Rebello

Stephen Norman Richardson died on 28 September 2019 after a self-inflicted ligature incident at the Sid Watkins Unit on 24 September 2019, following extensive brain damage and withdrawal of life support by his family. The report identified concerns including failures to secure an acute mental health bed, missed opportunities relating to treatment and risk assessment, inadequate communication and safeguarding planning, and staff not following the correct emergency response procedure. It also noted an ongoing national shortage of acute psychiatric beds.

Matthew David Harris · Prevention of Future Deaths report View report

21 Jun 2023 Worcestershire D. Reid

Matthew David Harris was found suspended in his cell at HMP Long Lartin on 27 May 2022 and died from his injuries at Alexandra Hospital, Redditch, on 29 May 2022. The inquest concluded that he died by suicide. The principal concern was that recent suicidal ideation disclosed during a police interview was not recorded on the documents accompanying him between police custody, court and prison, potentially leading to the risk of suicide or self-harm being underestimated or ignored.

Jean Frickel · Prevention of Future Deaths report View report

21 Jun 2023 North Wales (East and Central) K. Sutherland

Jean Frickel became unresponsive and died at home on 20 December 2022 after an ambulance call the previous evening and a further call the following morning. Paramedics arrived 13 hours and 3 minutes after the initial call. The report states that the delay denied her the opportunity for possible life-extending treatment and raises continuing concerns about ambulance delays, hospital patient flow, social care deficiencies, and coordination between health services and local authorities.

Joan Mary Corcoran · Prevention of Future Deaths report View report

20 Jun 2023 Manchester South A. Mutch

Joan Mary Corcoran suffered an accidental fall, underwent surgery for a fractured neck of femur, and subsequently developed pneumonia, an infected wound and increasing frailty. After becoming unwell with chest pains, she experienced a 1-hour 5-minute delay for a category 2 ambulance response and died in the ambulance from complications of heart failure while being transported to hospital. The substantive concern was that ambulance response delays were significantly outside target times and reflected wider system pressures, including demand for ambulances and delays at A&E departments.

Michael Brian Sullivan · Prevention of Future Deaths report View report

20 Jun 2023 Manchester South A. Mutch

Michael Brian Sullivan had schizophrenia and bipolar disorder, took lithium, and deteriorated at home before being admitted to Stepping Hill Hospital, where he was found to have pneumonia and lithium toxicity. He deteriorated despite treatment and died in hospital on 17 December 2022. The report raised concerns about delays between referrals to the Crisis Review Team and patient assessments, including uncertainty about referral processes, prioritisation and triage.

Anita Graves · Prevention of Future Deaths report View report

20 Jun 2023 Manchester South A. Farrow

Anita Graves, who was aged 92, died on 4 January 2023 after an E. coli urinary tract infection following treatment for hyperthyroidism. The inquest found that she had inadvertently taken more than the prescribed dose of carbimazole, and concerns were raised about the visual similarity of different carbimazole strengths and aspirin, together with the community dispensing process.

Leonard Charles Harmsworth · Prevention of Future Deaths report View report

20 Jun 2023 North Wales (East and Central) K. Sutherland

Leonard Charles Harmsworth died on 18 June 2022 after a fall caused a fractured ankle and immobility, followed by a sudden deterioration after ankle manipulation. The report raised significant concerns about delays in ambulance arrival and hospital handover, although it stated that these delays did not cause or contribute to his death. It expressed concern that such delays were continuing and that deaths could occur in the future.

Nicholas LEGER · Prevention of Future Deaths report View report

19 Jun 2023 Inner North London A. Smith

Nicholas Leger took his own life sometime between 7:30pm and 10:30pm on 20 February 2023, after learning via his solicitor that he had been charged. He had previously attempted to take his own life and had disclosed concerns about his mental health, but there had been no formal police assessment of his mental health or risk of suicide or self-harm for more than three months. The report identified a risk that people charged by Postal Charge Requisition could take their own lives where there was no formal mechanism to assess their mental health and risk at the time of charge.

Vaughan Lee WHALLEY · Prevention of Future Deaths report View report

16 Jun 2023 Manchester North C. McKenna

Vaughan Lee WHALLEY was found unresponsive after being released on bail from police custody and died in hospital on 21 February 2023 despite surgery and supportive care. The principal concerns were that no assessment of his risk of suicide or self-harm on release took place, communication to police about any assessment was unclear, and the practitioner’s contact and subsequent review did not meet best practice or identify learning adequately.

Girmaye Guyo Liban · Prevention of Future Deaths report View report

16 Jun 2023 Manchester City Z. Golombeck

Girmaye Guyo Liban had a long history of mental health illness and substance abuse, was discharged from detention under the Mental Health Act 1983, remained unwell in the community, went missing on 10 November 2020, and his body was found in a reservoir on 26 November 2020. The concern was that the Nearest Relative Power could enable discharge despite a patient continuing to meet the criteria for detention, without a thorough procedure or legal test for clinicians to apply.

Christine Margaret Cumbers · Prevention of Future Deaths report View report

16 Jun 2023 Essex J. Mellani

Christine Margaret Cumbers was admitted to hospital after developing a skin eruption following treatment with Carbimazole for hyperthyroidism. She developed sepsis during the admission, which was belatedly diagnosed and treated due to a lack of continuity of care caused by multiple ward moves, and this more than minimally contributed to her death. The GP practice also identified shortcomings in earlier care but had not implemented the learning from its review by the date of the inquest.

Nicholas James STOUT · Prevention of Future Deaths report View report

15 Jun 2023 County Durham and Darlington J. Thompson

Nicholas “Nicky” Stout died at Darlington Memorial Hospital on 26 July 2021 after consuming a large quantity of cocaine, with acute cocaine toxicity and coronary artery atheroma recorded as factors. The report raised concerns about delays in mental health crisis assessment, incomplete crisis-team triage tools, safeguarding referrals for children, and the absence or incomplete use of safety plans.

Raquel Mellonie Harper · Prevention of Future Deaths report View report

13 Jun 2023 East London N. Persaud

Raquel Mellonie Harper attended Whipps Cross Hospital with shortness of breath and difficulty breathing, but a D Dimer test was not carried out and her condition later deteriorated. She suffered a cardiac arrest and died at the hospital on 25 June 2021. Concerns included inadequate history taking, failure to escalate monitoring after a high NEWS score, and disagreement or unclear wording in the Trust’s pulmonary embolism policy.

Heather FINDLAY · Prevention of Future Deaths report View report

12 Jun 2023 Inner North London M. Hassell

Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.

Marlene McCabe · Prevention of Future Deaths report View report

11 Jun 2023 Blackpool and the Fylde T. Holloway

Marlene McCabe was unlawfully killed in her own home on 4 September 2019 after being struck repeatedly on the head and face with a doorstop, causing catastrophic injuries. The concerns included urgent mental-health referral processes, inconsistent access to and sharing of mental-health records, the risk of substance misuse obscuring mental-health diagnoses, non-communication of material information, and delayed assessment of apparently intoxicated patients.