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Kenneth PERKINS · Prevention of Future Deaths report View report

18 Oct 2022 Derby and Derbyshire S. Kaushal

Kenneth Perkins, who had a history of recurrent falls and several co-morbidities, was admitted to Royal Derby Hospital after presenting with left-sided weakness, facial droop and confusion. While confused and lacking capacity, he wandered without assistance despite a risk assessment requiring one carer when mobilising, fell and hit his head, and later died on 11 September 2018 after subarachnoid bleeding could not be treated. The principal concern was the absence of a clear, detailed transfer handover covering his medication, medical history and recurrent falls, and the receiving hospital’s failure to request one, which may have prevented enhanced care and observation being put in place.

Seth Curtis Palminder · Prevention of Future Deaths report View report

17 Oct 2022 Hampshire, Portsmouth and Southampton C. Wilkinson

Seth Curtis Palminder died instantly on 6 February 2022 after falling from a road bridge and being struck by southbound vehicles. The report states that he had recently been discharged from mental health care, had taken overdoses of prescribed medication, and impulsively jumped from the bridge intending to take his own life. Concerns included inadequate bridge safety measures, a lack of means to summon help or access mental health support, insufficient CCTV monitoring, and repeated previous crisis incidents and fatalities at the location.

Adam David Simms · Prevention of Future Deaths report View report

17 Oct 2022 North Lincolnshire and Grimsby P. Smith

Adam David Simms was the sole occupant and driver of a car that lost control after striking standing water on the A18 during heavy rain and collided with an oncoming lorry, causing fatal injuries. Concerns were raised about blocked drainage gullies, extensive standing water on the carriageway, and the absence of an explanation and remedial action to prevent recurrence.

Carl Wright · Prevention of Future Deaths report View report

17 Oct 2022 Nottinghamshire G. Clow

Carl Wright underwent complex cardiac surgery and was later transferred to a rehabilitation unit that was not suited to his condition. An infection and abdominal abscess were not identified promptly, with concerns including reliance on inexperienced junior doctors without easy access to senior input and delays in reviewing blood test results. He developed sepsis and died on 29 October 2021.

Kenneth Goodwin · Prevention of Future Deaths report View report

14 Oct 2022 Manchester South L. Costello

Kenneth Goodwin was admitted to hospital with severe abdominal pain and was being treated for sepsis from gall stones and cholecystitis. After being transferred between wards at night, he fell before a falls risk assessment had been completed on the new ward, developed an acute subdural haematoma, and died on 9 June 2022. Concerns included the lack of required written confirmation of falls-risk handover, the delay in completing the new ward’s falls risk assessment, and inconsistent use of visual falls-risk signs on beds.

Neha Susan RAJU · Prevention of Future Deaths report View report

14 Oct 2022 Surrey A. Loxton

Neha Susan Raju was found deceased by emergency services in her bedroom in Guildford, Surrey, on 10 April 2022 after her family raised concerns that she was not responding to calls or messages. The report identified concerns that a substance was freely available to purchase online in lethal quantities for delivery within the UK, with no protection for vulnerable people before such purchases were made.

Molly Rose Russell · Prevention of Future Deaths report View report

13 Oct 2022 North London A. Walker

Molly Rose Russell, aged 14, was found having hanged herself on 21 November 2017. The report describes her depression and exposure to online content involving self-harm, suicide and other negative material, which was likely to have negatively affected her mental health and contributed to her death. Principal concerns included the lack of age verification, separation between adult and child users, age-specific content controls, algorithmic content provision and parental access or monitoring.

Rebecca Hayward · Prevention of Future Deaths report View report

13 Oct 2022 Nottinghamshire G. Clow

Rebecca Hayward had a history of substance addiction and became homeless after discharge from a care placement on 31 March 2021. She was later provided with hostel accommodation, relapsed into alcohol and substance misuse, and was found deceased on 13 August 2021. Concerns included assessments of people with severe and multiple disadvantage being undertaken by staff with little or no specialist homelessness or substance-misuse experience, and limitations in how changing care needs were assessed when accommodation changed.

Oli Akram Hoque · Prevention of Future Deaths report View report

13 Oct 2022 East London N. Persaud

Oli Akram Hoque developed worsening headaches after receiving his first AstraZeneca COVID-19 vaccination and later suffered seizures; investigations revealed cerebral venous sinus thrombosis, and he died in hospital on 15 April 2021. The principal concern was that the MHRA could not compel the timely production of relevant clinical data needed for robust vaccine safety investigations.

Emma Jane SIMKIN · Prevention of Future Deaths report View report

12 Oct 2022 Lincolnshire P. Cooper

Emma Jane SIMKIN, also known as Emilie Zukiard AFFIN, died on 20 February 2021 after standing in front of a freight train at Railway Lineside, Spitalgate Hill, Grantham, and receiving non-survivable injuries. The report raises concern that people may mask mental illness in front of professionals, who may accept what they are told without sufficiently considering evidence from families, and asks whether policies and training addressing this issue are adequate.

Eirwen Rebecca Hollister · Prevention of Future Deaths report View report

11 Oct 2022 Stoke-on-Trent and North Staffordshire E. Serrano

Eirwen Rebecca Hollister, who had a history of mental health issues and overdoses of prescribed medication, was found deceased at home on 10 May 2022. Evidence at the inquest identified that prescriptions continued after overdoses, and that there was no process to prevent further prescriptions before a full review.

Charles Michael Stringer · Prevention of Future Deaths report View report

10 Oct 2022 Surrey K. Henderson

Charles Michael Stringer, a cyclist, died after hitting a pothole on Church Lane, causing a punctured front tyre and loss of control that resulted in a fatal chest injury. The report raises concerns about Surrey County Council’s lack of documented reflection, changes to pothole-management systems, communication, risk assessment, defect categorisation and timely repairs following his death.

Barbara HOLLIS · Prevention of Future Deaths report View report

7 Oct 2022 Norfolk J. Lake

Barbara Hollis underwent a total left knee replacement and became restless, confused and progressively unwell afterwards. Although an ambulance was requested urgently for transfer to a high dependency unit, the agreed transfer pathway was not followed and attendance was delayed; she died in the early hours of 23 February 2022. The concern was that emergency ambulance availability and response delays could result in future deaths while remedial steps were being assessed.

Charles Stephen Rothwell · Prevention of Future Deaths report View report

5 Oct 2022 Cheshire C. Welch

Charles Stephen Rothwell was diagnosed with a chest infection on 5 January 2022, deteriorated the following day, and died after repeated 999 calls and a delayed ambulance response. The principal concern was that emergency ambulance demand continued to outstrip available capacity, creating a risk of future deaths, with wider pressures across primary, secondary and social care contributing to delays.

Reginald Cauthery · Prevention of Future Deaths report View report

4 Oct 2022 Inner North London S. Bourke

Reginald Cauthery was a frail man with limited mobility who lived alone and died in hospital after sustaining extensive burns in a smouldering fire at his flat. The report raised concerns that his telecare service was not reviewed despite his increased fire risk and deteriorating mobility, and that his smoke alarms were not connected to the telecare system, delaying contact with the Fire Brigade.

Mr George Michael ELLIOTT · Prevention of Future Deaths report View report

4 Oct 2022 Avon R. Sowersby

Mr George Michael Elliott was an 81-year-old inpatient receiving investigation and treatment for an underlying cardiac condition when he fell in hospital on 4 September 2021 and suffered a fatal brain injury, dying on 9 September 2021. The principal concern was that the Patient Safety Investigation overlooked obvious failings in his falls risk assessment and management, including failures to reassess and communicate his risk, thereby missing important patient-safety learning opportunities.

Katharine Mary TYRER · Prevention of Future Deaths report View report

30 Sep 2022 Liverpool and the Wirral D. Lewis

Katharine Mary TYRER died at the scene on 12 April 2018 after being found unresponsive with a ligature in a bathroom on the Lakefield Ward. The report identified concerns about the ward layout limiting observation, inadequate risk assessment, missed opportunities to respond to increased short-term risk, and the absence of a clear protocol for escalation and enhanced monitoring.

Shahan Abu Aman · Prevention of Future Deaths report View report

30 Sep 2022 East London G. Irvine

Shahan Abu Aman, a three-year-old boy, attended hospital on 7 December 2021 with vomiting and diarrhoea and was discharged after assessment, observation and a fluid challenge. He was found unresponsive the following morning and died in hospital; the report identified miscommunication between nursing and medical staff, failure to confirm the most recent observations and PEWS score before discharge, and a pressurised emergency department environment as concerns.

Charlotte Emma Warkcup · Prevention of Future Deaths report View report

29 Sep 2022 Sunderland D. Winter

Charlotte Emma Warkcup died at Sunderland Royal Hospital on 23 December 2021, two days after she was born. The report described concerns about delayed recognition of the severity of her condition, delays transferring her mother to hospital, and delayed access to the delivery suite. It also identified concerns about the safety of standalone midwife-led birthing centres, midwife recruitment and retention, and detection of babies who are small for gestational age.

Ms Aleksandra Markowska · Prevention of Future Deaths report View report

29 Sep 2022 East London N. Persaud

Ms Aleksandra Markowska was found unresponsive on 30 September 2021 after jumping from 21 Gardner Close, and her death was pronounced at the scene. The inquest concluded that she took her own life while suffering from pregnancy-related depression and anxiety, after seeking help but not receiving a review by a perinatal psychiatrist. The principal concern was the lack of direct access for BPAS patients experiencing pregnancy-related mental health decline to perinatal psychiatry teams.