Search PFD Monitor

Michael Brian Waite · Prevention of Future Deaths report View report

31 Jan 2023 Essex S. Horstead

Michael Brian Waite, who had learning difficulties and lived in supported accommodation, collapsed after vomiting and drinking water on 19 August 2022. An ambulance was called after a delay, and he was confirmed dead by an attending paramedic. The report raised concerns that Peabody Support Workers providing 24-hour solo support were not required to complete certificated First Aid and Basic Life Support training before undertaking their duties.

Donald Charles Brown · Prevention of Future Deaths report View report

31 Jan 2023 Gloucestershire K. Skerrett

Donald Charles Brown, an 87-year-old man, suffered a fall at home and was later found to have a displaced C2 vertebral fracture with spinal cord compression that had been visible on the initial CT but was not reported. He subsequently developed swallowing difficulties and aspiration pneumonia before dying in hospital; concerns included significant radiology understaffing, a national shortage of radiology trainee posts, expectations for rapid scan reporting, and delayed appointment of call handlers due to cost.

Mr Nathan Forrester · Prevention of Future Deaths report View report

30 Jan 2023 Inner South London A. Harris

Mr Nathan Forrester died in a shared prison cell after consuming illicit drugs, and the jury concluded that he died of a drug-related death. Concerns included delays and insufficient training in removing an unresponsive prisoner from a top bunk for CPR, and gaps in nurses’ CPR, airway-management and handover training in detention settings.

Felice Eileen Grace Banfield · Prevention of Future Deaths report View report

30 Jan 2023 Cornwall and Isles of Scilly A. Cox

Felice Eileen Grace Banfield was admitted with a painful knee and required non-invasive ventilation, but there was a lack of clarity about where and when this could be provided. She was not brought to the attention of respiratory clinicians, deteriorated with mixed respiratory and metabolic acidosis and an acute kidney injury, and died despite treatment. The principal concerns were failures concerning access to non-invasive ventilation, recognition of respiratory risk and deterioration, and provision and monitoring of adequate food, fluids and continuity of care.

Andrew Paul SHIRLEY · Prevention of Future Deaths report View report

27 Jan 2023 Worcestershire D. Reid

Andrew Paul Shirley, a 25-year-old prisoner at HMP Hewell, was found unresponsive in his cell on 23 March 2021, suspended by a ligature, and was pronounced dead at the scene. The inquest found that healthcare and mental healthcare staff failed to sufficiently identify, manage, and share information about his risk of suicide and self-harm, and that these failures probably caused or contributed to his death. Concerns were also raised about staff training on suicide and self-harm risk and the Initial Segregation Health Screen process.

Toby Wilbur Barwick · Prevention of Future Deaths report View report

27 Jan 2023 East London G. Irvine

Toby Wilbur Barwick was born on 24 November 2020 and died in hospital on 12 February 2021 after being found unresponsive while sleeping in a fabric baby carrier. The inquest heard that his parents did not receive advice and documentation from UCLH about SIDS and recommended safe practices, and UCLH could not provide clear evidence that the factors leading to this omission had been remedied.

Jayden Andrew Booroff · Prevention of Future Deaths report View report

27 Jan 2023 Essex S. Hayes

Jayden Andrew Booroff died after absconding from The Linden Centre and being struck by a train on 23 October 2020. The report identified concerns about risk assessments, observation levels, ward security, absconsion procedures, record keeping, medication, and communication between healthcare professionals and emergency services.

Zachary KLEMENT · Prevention of Future Deaths report View report

26 Jan 2023 Surrey A. Loxton

Zachary KLEMENT was found suspended in the bedroom of his supported accommodation on 2 March 2021 and was pronounced deceased by attending paramedics. The report raised concerns about the lack of mental health care and therapies tailored to people with neurodiverse conditions, including the absence of suitable inpatient options, limited continuity from Home Treatment Teams, and the limited availability of psychological interventions.

Matthew Harter DALE · Prevention of Future Deaths report View report

26 Jan 2023 Liverpool and the Wirral K. Ainge

Matthew Harter DALE died after swallowing part of an incontinence pad while unsupervised; the item became trapped in his airway. The death was partly contributed to by a missed opportunity to increase supervision, amid confusion between commissioning and care agencies about the care and supervision that should have been provided.

Andrew Mark Largin · Prevention of Future Deaths report View report

25 Jan 2023 Inner North London M. Hassell

Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.

Rita Maureen TAYLOR · Prevention of Future Deaths report View report

25 Jan 2023 Milton Keynes T. Osborne

Rita Maureen TAYLOR suffered an unwitnessed fall at home and a head injury. Multiple ambulance calls were made, but an ambulance was delayed because no resources were available; she arrived at hospital with a Glasgow Coma Score of 3 and died the same day. The principal concern was insufficient ambulance service resources and the resulting delay, which the inquest conclusion described as causing lost opportunities to admit her and begin treatment.

Sophia Ayuk · Prevention of Future Deaths report View report

20 Jan 2023 East London G. Irvine

Sophia Ayuk, who had treatment-resistant schizophrenia and was an inpatient, became motionless and unresponsive on 18 March 2022, later deteriorated and died despite resuscitation. The inquest narrative attributed her death to a pulmonary embolism following a deep vein thrombosis, and recorded that she had not taken food or drink for at least two days. The principal concerns were that VTE risk was not assessed during either period of inpatient care and that food and fluid intake monitoring was not adequately followed.

Michael John Holmes · Prevention of Future Deaths report View report

20 Jan 2023 West Yorkshire Eastern K. McLoughlin

Michael John Holmes died after being knocked down and trampled by cattle while walking dogs with his wife on a public footpath through a field. The report raised concerns about the risks of walkers, particularly those accompanied by dogs, coming into contact with cattle and calves, and about the management and separation of public footpaths from grazing cattle.

Dorothy Anne Jones · Prevention of Future Deaths report View report

20 Jan 2023 Gwent C. Saunders

Dorothy Anne Jones developed a chest infection and was assessed at home as needing immediate hospital admission. An ambulance did not attend until over nine hours after it was requested, and paramedics found that she had died. The report identified concerns about ambulance response times for Amber 1 patients, chronological allocation without further consideration of clinical need, and an ad hoc process for expediting responses.

Michael ALLEN · Prevention of Future Deaths report View report

19 Jan 2023 Milton Keynes S. Cummings

Michael Allen, an otherwise healthy man, was admitted to Milton Keynes University Hospital with gallstone pancreatitis and died there on 11 April 2021 from acute pancreatitis and liver necrosis resulting from gallstone disease. The report identified concerns about ineffective monitoring, inadequate senior surgical supervision, failure to initiate the sepsis protocol effectively, and delay in calling the ITU team after his deterioration.

Nicholas Dumphreys · Prevention of Future Deaths report View report

19 Jan 2023 Cumbria R. Cohen

Nicholas Dumphreys, a 47-year-old serving police officer, died on 26 January 2020 after the engine of his police BMW failed catastrophically while he was responding to an emergency call on the M6. The vehicle veered across the carriageway, overturned and crashed, causing fatal head injuries. Concerns included the robustness of communication of safety-critical information, the lack of policy to prevent faulty vehicles being auctioned, and the absence of national standards for police garages and mechanics.

Joseph Andrew Price · Prevention of Future Deaths report View report

19 Jan 2023 County Durham and Darlington C. Oliver

Joseph Andrew Price was found dead in his cell at HMP Durham on 20 September 2020, after being remanded there ten days earlier. The pathologist concluded that the medical cause of death was Sudden Cardiac Death, following evidence of a paternal family history of premature cardiac-related deaths. The principal concern was that this family history had not been recorded or elicited during healthcare assessments, making it unavailable to inform possible genetic screening; symptoms before death were also potentially confusable with drug withdrawal and mental or emotional distress.

Lance Scott Walker · Prevention of Future Deaths report View report

19 Jan 2023 West London L. Brown

Lance Scott Walker, an 18-year-old looked-after child, was placed in unregulated accommodation in 2016, where another 18-year-old resident was later placed. Eleven days after they were placed together, the other resident fatally stabbed Lance in the afternoon of 15 August 2016. Concerns included the use and oversight of unregulated accommodation, inadequate assessment and communication of the other resident’s risks and needs, shortcomings in placement and provider due diligence, and failures in information-sharing and management.

Derek Larkin · Prevention of Future Deaths report View report

19 Jan 2023 Dorset S. Nicholls

Derek Larkin was found deceased at home on 2 June 2021 after returning from a care home, and a post-mortem examination demonstrated an overdose of prescription morphine. The report raises concerns that Adult Social Care did not have sufficient information about his prescribed medication, medication management, or concerns raised by family and healthcare professionals, including because its computer system could not communicate with the NHS SystemOne system.

Lyn Mary BRIND · Prevention of Future Deaths report View report

18 Jan 2023 Norfolk J. Lake

Lyn Mary Brind attended her GP on 24 May 2022 and was taken to Queen Elizabeth Hospital, where she waited on an ambulance and had elevated NEWS2 observations. Her oxygen requirement increased without escalation, and no further physiological observations or ECG were undertaken before she deteriorated and died from cardiac failure. The report identified delays in transfer, monitoring, escalation and senior medical assessment, alongside wider overcrowding and bed-capacity pressures at the hospital.