Search PFD Monitor

John Edward Stiff · Prevention of Future Deaths report View report

18 Apr 2023 East London N. Persaud

John Edward Stiff was admitted to Queen's Hospital after a believed unwitnessed fall and was diagnosed with an undisplaced pelvic fracture. His condition declined, including reduced appetite and a chest infection, and he died at the hospital on 16 November 2022. The report raised concerns that patients with hip and pelvic fractures and age-related co-morbidities would be better cared for by orthogeriatricians, and that limited access to such care could contribute to untimely deaths.

Benjamin James TEAGUE · Prevention of Future Deaths report View report

14 Apr 2023 Northamptonshire A. Pember

Benjamin James Teague died at the scene after his BMW crossed onto the incorrect side of the A5 and collided head-on with an approaching car on 2 August 2021. Evidence at the inquest raised concern about the poor condition of the road, including potholes, which had reportedly deteriorated after repairs.

Mr Darren Clifford Docherty · Prevention of Future Deaths report View report

14 Apr 2023 Staffordshire and Stoke on Trent E. Serrano

Mr Darren Clifford Docherty was released from HMP Stoke Heath without accommodation and was subsequently found hanging from a tree on 10 August 2023. The report raised concern that people released from prison without accommodation may be unable to access GP and community mental health services.

Alexandra Briess · Prevention of Future Deaths report View report

6 Apr 2023 Berkshire H. Connor

Alexandra Briess underwent tonsillectomy, later required surgery for post-operative bleeding, and suffered sudden deterioration and cardiac arrest during anaesthesia on 30 May 2021. She died on 31 May 2021, with the most likely cause identified as an anaphylactic reaction to Rocuronium; there were no concerns about her clinical management. The principal concerns were the lack of national leadership and funding for anaphylaxis work, mandatory reporting of fatal anaphylaxis, and improved national data gathering, research and information sharing.

Thomas Jayamaha · Prevention of Future Deaths report View report

4 Apr 2023 Nottinghamshire E. Didcock

Thomas Jayamaha died by suicide after taking Pentobarbital ordered from a website abroad. He had Autism Spectrum Disorder, longstanding mental health difficulties, suicidal ideation and previous self-harm or suicide attempts, alongside other reported vulnerabilities. The principal concerns were delayed progress on the Trust’s Autism Strategy, insufficient progress with complex case management, and the Serious Incident Investigation process.

Name not published · Prevention of Future Deaths report View report

3 Apr 2023 Blackpool and the Fylde A. Wilson

████████ died at home on 24 September 2022 after becoming unresponsive following a hanging incident; he could not be revived despite resuscitation efforts, and the inquest recorded misadventure. At the time of his death, he was awaiting assessment for autism after a wait of around three years. The report raised concern that delays in assessment and insufficient support placed him and other children at risk, and that earlier diagnosis and support might have avoided his death.

Benjamin James HART · Prevention of Future Deaths report View report

31 Mar 2023 Central and South East Kent P. Harding

Benjamin Hart, aged 25, died by hanging at his mother’s home after contacting the Crisis team three times in the preceding two days and expressing hopelessness and suicidal feelings. The report describes limited contact with the community mental health team, a breakdown in his care-coordinator relationship, and no attempted contact before his death despite the team being notified. A principal concern was severe nursing-staff shortages, which left no capacity to allocate him a replacement care coordinator.

Veronica Jenkins · Prevention of Future Deaths report View report

31 Mar 2023 Surrey A. Crawford

Veronica Jenkins, a 72-year-old woman with metastatic bowel cancer, developed sudden chest pain on 10 May 2022 and died in hospital on 11 May 2022 after suffering two cardiac arrests. The report identified a delayed ambulance response caused by a deficit in operational hours, with concerns that staff shortages and hospital handover delays could recur and compromise patient safety.

Carol Ann Robinson · Prevention of Future Deaths report View report

30 Mar 2023 East London N. Persaud

Carol Ann Robinson died at Queen's Hospital on 8 May 2022 after taking an overdose of medication and being diagnosed with mixed drug toxicity. The principal concerns were that she was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multidisciplinary discussion, or communication with her domiciliary care agency and family about the withdrawal of support.

Rebecca Lisa KIRBY · Prevention of Future Deaths report View report

29 Mar 2023 East Riding and Hull L. Harris

Rebecca Lisa KIRBY died after being struck by a vehicle while crossing Lowgate, Hull, on the evening of 27 August 2021. The report raised concerns about the road remaining open to traffic in a busy area where pedestrians, including people who had been drinking, had to cross among vehicles, taxis and limited crossing facilities. It also expressed concern that the danger in the area had been underestimated and that further incidents could occur without appropriate action.

Angela Jean Kearn · Prevention of Future Deaths report View report

29 Mar 2023 Surrey C. Topping

Angela Jean Kearn, aged 63, collapsed and died while snorkelling in Egypt on 13 January 2020. The inquest identified immersion pulmonary oedema as the cause of death, with hypertension, hormone replacement therapy and use of a full-face snorkel mask each contributing more than minimally. Concerns included limited medical awareness of immersion pulmonary oedema and insufficiently publicised safety warnings about using full-face snorkel masks with cardiovascular or respiratory conditions.

Louis James Rogers · Prevention of Future Deaths report View report

28 Mar 2023 Surrey K. Henderson

Louis James Rogers died after being found unresponsive at home following a period of clinical illness and was pronounced dead on 18 June 2021 despite resuscitation attempts. Autopsy identified a viral infection, and genetic studies confirmed Dravet’s Syndrome. The report raised concerns about the management and investigation of febrile seizures, information provided to parents, paramedic and general practice guidance, and the lack of a coordinated febrile seizure pathway.

Miss Kayleigh BURNS · Prevention of Future Deaths report View report

27 Mar 2023 Warwickshire S. McGovern

Miss Kayleigh Burns, aged 16, ingested nitrous oxide from canisters, developed wheezing, collapsed, was resuscitated and died the following day in hospital. The substantive concern was whether the legal framework for nitrous oxide should be reviewed in light of its seemingly increasing use, particularly by young people.

Aoife Rose McAdam · Prevention of Future Deaths report View report

27 Mar 2023 West Yorkshire (Eastern) O. Longstaff

Aoife Rose McAdam died in Leeds General Infirmary on 4 September 2021 after taking a significant overdose of propranolol. She had sought help shortly after taking the overdose, but two opportunities to send an ambulance sooner were missed. The report’s concerns included her being left with a significant quantity of propranolol after she said she no longer wanted or needed it, and delays in providing help after the overdose.

Jordan Peter Clare · Prevention of Future Deaths report View report

26 Mar 2023 Manchester South A. Farrow

Jordan Peter Clare, who had complex mental health, behavioural and substance-misuse-related needs, died on 26 August 2020 after suspending himself by a ligature at his home while distressed about an unresolved dispute with a neighbour. The principal concern was the absence of a single person or agency to coordinate care, support, information-sharing and safeguarding for vulnerable adults with complex needs who do not fall within existing social care or formal mental health frameworks.

Richard James HILL · Prevention of Future Deaths report View report

24 Mar 2023 Derby and Derbyshire P. Nieto

Richard died at a sports and recreation club after drinking alcohol throughout the day and at a rugby club awards event. He became unresponsive and could not be revived; toxicology identified a level of alcohol capable of causing death. The report raised concerns about harmful alcohol consumption in male sports and the lack of specific alcohol-misuse guidance for grassroots rugby clubs.

Benjamin NELSON-ROUX · Prevention of Future Deaths report View report

23 Mar 2023 North Yorkshire and York J. Heath

Benjamin Nelson Roux, aged 16, was found deceased on 8 April 2020 after taking multiple drugs of abuse; the cause of death was unascertained. Concerns included the lack of suitable accommodation options beyond the county boundary for a homeless 16-year-old Child in Need and the lack of residential substance-misuse treatment facilities for people under 18.

Jade Paula REVELL · Prevention of Future Deaths report View report

23 Mar 2023 Derby and Derbyshire S. Huntbach

Jade Revell died from a sudden cardiac event after being taken to hospital on 25 December 2021, having suffered the event at home. A low potassium result from 27 October 2021 was not communicated to her, resulting in a missed opportunity to treat hypokalaemia and monitor potassium levels. The report raises concerns that the GP computer system may not display all blood results clearly, increasing the risk that abnormal results are missed and not acted upon.

Kenneth Michael Adams · Prevention of Future Deaths report View report

22 Mar 2023 Dorset B. Allen

Kenneth Michael Adams suffered a scalp laceration after an accidental fall on 19 October 2021. He experienced persistent bleeding while taking clopidogrel, but an ambulance did not arrive until 11.56am; he later died in hospital. The principal concerns were that the Medical Priority Despatch System did not adequately account for persistent scalp bleeding, the high blood flow in the scalp, or antiplatelet medication when prioritising the ambulance response.

Ben Christopher Harrison · Prevention of Future Deaths report View report

22 Mar 2023 North Wales (East and Central) K. Sutherland

Ben Christopher Harrison, aged 37, was found in cardiac arrest with a ligature around his neck while a voluntary inpatient and died three days later after being transferred to intensive care. During resuscitation, an oxygen cylinder valve was not opened, so he was ventilated only on room air. Concerns included delays in addressing investigation learning and actions, and an evident lack of overall strategic direction to investigations and learning.