Search PFD Monitor

Carl Robert ELLSON · Prevention of Future Deaths report View report

20 Dec 2022 Birmingham and Solihull L. Hunt

Carl Robert ELLSON was found deceased in a wooded area on 16 July 2022 after sustaining a fatal self-inflicted wound. He had been experiencing anxiety and insomnia and had presented with suicidal ideation shortly before his death. The concerns identified were that GP access to urgent mental health reviews was unclear and unsafe, that patients in crisis were expected to initiate contact with mental health practitioners, and that GPs were not fully aware of how to request an urgent psychiatric review.

Mollie Rose Stansfield · Prevention of Future Deaths report View report

19 Dec 2022 East Riding and Hull P. Marks

Mollie Rose Stansfield, aged 22, died on 10 July 2019 after falling at Princes Quay, Hull, following her discharge from a place of safety under section 136 of the Mental Health Act 1983. The report identified failures at Hull Royal Infirmary to understand and correctly implement section 5(2) of the Mental Health Act 1983, with the relevant paperwork being invalid while Mollie was apparently subject to that section and subsequently absconded.

Jack Kn apman · Prevention of Future Deaths report View report

16 Dec 2022 Northamptonshire P. Barlow

Jack Kn apman died shortly after 1am on 23 March 2018 after taking a substantial quantity of dinitrophenol (DNP) for weight loss and body-building, suffering severe cardiotoxicity and a cardiac arrest. The principal concern was that, after DNP is categorised as a poison, unclear responsibility for monitoring and preventing its sale could delay an effective response and put lives at risk.

Zef Max EISENBERG · Prevention of Future Deaths report View report

16 Dec 2022 North Yorkshire and York J. Heath

Zef Max Eisenberg died at Elvington Airfield, York, after losing control of a motor car travelling at approximately 244mph during a National Speed Record attempt. The principal concern was the regulation and assessment of the strength of cars where safety harnesses and reinforcement plates are fitted, after the harness crotch straps detached when the car overturned.

Neal Terence Saunders · Prevention of Future Deaths report View report

15 Dec 2022 Berkshire H. Connor

Neal Terence Saunders was restrained by police for 58 minutes, including 14 minutes in a prone position, after police attended his address following an assault report and concerns about recent cocaine use and paranoid behaviour. He suffered a cardiac arrest while being transported to hospital and died there on 4 September 2020. Concerns included inadequate guidance and training about prolonged restraint, ambulance response expectations, prone transportation, and coordination and training between police and ambulance services.

Fatima Abukar · Prevention of Future Deaths report View report

14 Dec 2022 East London G. Irvine

Fatima Abukar, a 14-year-old girl, died from catastrophic head injuries after the privately owned e-scooter she was riding entered the carriageway and struck a mini-bus. The concerns included e-scooter fatalities and enforcement, the absence of a requirement for riders of legally authorised scooters to wear head protection, and inconsistent or insufficiently prominent warnings about illegal e-scooter use.

Akeem Jevaughn RHODEN · Prevention of Future Deaths report View report

13 Dec 2022 South Wales Central R. Knight

Akeem Jevaughn Rhoden, aged 22, drowned after voluntarily jumping from a rock into the water at Sgwd y Pannwr Waterfall on 5 June 2021; he was not a strong swimmer and his body was recovered the following day. The concerns raised were that warning signs at waterfalls in Waterfall Country were inadequate, absent at the point where he entered the water, overloaded with information, and did not clearly explain the danger posed by the force of the water.

Yvonne Rankin · Prevention of Future Deaths report View report

13 Dec 2022 South Wales Central R. Knight

Yvonne Rankin, aged 68, died at the University Hospital of Wales on 14 January 2021 after an infection at her PEG site returned and she quickly developed sepsis, despite extensive medical treatment. The concerns were that Yvonne and her family did not understand the specific signs of sepsis, which may have delayed calling 999, and whether sepsis information cards could be provided to patients and carers with PEGs or those at known risk of infection in the community.

Tracy Marie BROWN · Prevention of Future Deaths report View report

8 Dec 2022 Hampshire, Portsmouth and Southampton R. Simpson

Tracy Marie BROWN died at home on 5 January 2022 after taking an excessive quantity of some of her prescribed medication. Medication was required to be kept in a locked box because of an identified risk, but a week’s supply was regularly left unsecured and the carers’ digital application did not state that it needed to be stored securely.

Leanne DUNN · Prevention of Future Deaths report View report

8 Dec 2022 County Durham and Darlington J. Chipperfield

Leanne DUNN died after falling from the bridge at Newton Cap; the inquest concluded that her death was suicide. Concerns related to pedestrian access to the bridge parapet and railing, the absence of monitored CCTV and lighting or other detection measures, and the risk of death to people falling or present at the foot of the bridge.

Mervyn Charles Gladstone Leonard HOLBROOK · Prevention of Future Deaths report View report

8 Dec 2022 Birmingham and Solihull A. Hodson

On 16 June 2022, Mervyn Charles Gladstone Leonard Holbrook was knocked from his mobility scooter and run over at a junction after entering the carriageway where a kerb had been worn down. He suffered catastrophic thoracic injuries and was pronounced deceased at the scene. The concern was that the worn and defective kerb could be mistaken for an official crossing point by vulnerable road users, particularly mobility scooter and bicycle users, creating a risk of entering the carriageway unsafely.

Josie Archer-Smith · Prevention of Future Deaths report View report

7 Dec 2022 Mid Kent and Medway J. Dillon

Josie Archer-Smith died on 31 October 2020 from traumatic injuries sustained when the vehicle in which she was travelling as a front seat passenger lost control and collided with a stationary vehicle on the M20. The location had experienced previous collisions apparently associated with water or aquaplaning, and police identified concerns about water running across the carriageway and the need to investigate possible remedial works.

Joan Alison FERGUSON · Prevention of Future Deaths report View report

7 Dec 2022 Newcastle upon Tyne and North Tyneside C. Henley

Joan Alison FERGUSON was discharged home after a short hospital admission and fell during ambulance transfer on 3 May 2022, sustaining open fractures to her left tibia/fibula and distal femur. She underwent surgical repair but died at the Royal Victoria Infirmary on 5 May 2022 from acute on chronic cardiorespiratory failure, with biventricular cardiac hypertrophy and the fractures recorded in the inquest conclusion. The concerns section lists numbered matters of concern but does not provide substantive details.

Daniel Lee Tilley · Prevention of Future Deaths report View report

6 Dec 2022 Cornwall and Isles of Scilly A. Cox

Daniel Lee Tilley was found hanging in Newquay on 7 July 2019 and was later pronounced dead by paramedics. The report identifies concerns about insufficient police staffing and resources, including a four-hour response delay to an emergency call. The inquest concluded that it was possible the delay contributed to the outcome, although the evidence was insufficient to determine whether Daniel intended to take his own life.

Tina Jane Allen · Prevention of Future Deaths report View report

5 Dec 2022 Cornwall and Isles of Scilly G. Davies

Tina Jane Allen, who had severe autism and required 24-hour 1:1 care, choked on high-risk food provided by carers on 13 June 2022 and died in hospital two days later. The report identified persistent understaffing, inadequate staff awareness of her eating and drinking plan, and insufficient management checks as substantive concerns affecting the safe provision and monitoring of care.

Richard Thomas SHANNON · Prevention of Future Deaths report View report

5 Dec 2022 Inner North London M. Hassell

Richard Thomas Shannon was discharged from hospital on 5 January 2022 with an almost completely healed sacral pressure ulcer and was readmitted on 13 January with a severe, necrotic ulcer. The report states that inadequate monitoring of his skin integrity and failures in discharge planning and coordination among hospital, nursing, social care and care-provider services were substantive concerns. He died as a consequence of the severe pressure ulcer, with the medical cause of death including infected sacral pressure ulcer and coccyx osteomyelitis.

Melsadie Adella-Rae Parris · Prevention of Future Deaths report View report

2 Dec 2022 Buckinghamshire I. Wade

Melsadie Adella-Rae Parris, aged three, died on 18 February 2019 after being struck by a fast non-stopping train at Taplow Railway Station while being held by her adult carer, who also died in a deliberate act of self-harm. The principal concern was that children’s services did not adequately respond to information about the carer’s deteriorating mental health: they did not renew a home visit, seek updated family information, or liaise with mental health services, despite existing guidance encouraging those actions.

Lewis Steven Johnson · Prevention of Future Deaths report View report

2 Dec 2022 West Yorkshire Eastern K. McLoughlin

Lewis Steven Johnson was found unresponsive with a neck ligature at HMP Wealstun on 12 December 2019 and later died in hospital following a further cardiac arrest. The report raised concerns about the absence of overnight healthcare staff and the prison officers’ delayed and inadequate response, including lack of CPR, defibrillator use and consideration of the recovery position.

Mary Ebere Nwanyonyiri · Prevention of Future Deaths report View report

1 Dec 2022 East London N. Persaud

Mary Ebere Nwanyonyiri was admitted to Goodmayes Hospital after deterioration in her mental state and was found unresponsive on 19 April 2021; post-mortem investigations found that she died from Covid-19 infection. The report raised concerns about the absence of a written care plan and completed risk assessment, the lack of clear assessment of her capacity to refuse physical observations, and failures to recognise and respond urgently to the severity of her condition.

Daniel-John VARNDELL · Prevention of Future Deaths report View report

29 Nov 2022 Hampshire, Portsmouth and Southampton R. Rhodes-Kemp

Daniel-John Varndell, who was considered at high risk of serious harm and had mental health and drug-use concerns, was released on licence to an approved premise in May 2020. After a licence condition concerning appointments with mental health practitioners was removed without discussion with MAPPA professionals or a mental health practitioner, he absconded following an altercation and was later the subject of an investigation into his death. The report raises concern that unilateral removal of licence conditions could contribute to a future death.