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Malcolm John Garrett · Prevention of Future Deaths report View report

4 Aug 2022 Manchester South A. Mutch

Malcolm John Garrett, who was immunosuppressed following a bilateral lung transplant, was admitted with a vertebral fracture and subsequently developed pneumonia and other complications. He acquired Covid-19 while an inpatient and died at Stepping Hill Hospital on 23 September 2021; the direct causes were Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia. The concerns included the absence of specific guidance for managing high-risk immunosuppressed patients, expediting discharge or using alternative treatment methods, and monitoring kidney function to avoid opiate toxicity.

Mrs Rita Flynn · Prevention of Future Deaths report View report

3 Aug 2022 Black Country Z. Siddique

Mrs Rita Flynn became ill with flu-like symptoms and was assessed by her GP and New Cross Hospital. Her condition deteriorated, with shortness of breath and haemoptysis, and she was discharged home before blood-test results indicating infection were available; she died at home on 4 February 2022. The inquest found that she died after complications arising from a lung abscess, and the concern identified was that it would have been best practice to wait for the blood-test results before discharge.

Kellum Paul Thomas · Prevention of Future Deaths report View report

3 Aug 2022 Nottinghamshire E. Didcock

Kellum Paul Thomas, aged thirteen, collapsed at home on 9 June 2021 and died after a cardiac arrest caused by ventricular tachycardia deteriorating into ventricular fibrillation. Concerns included an 18-month gap without a functioning REVEAL heart-monitoring device, delayed replacement processes, and a significantly delayed outpatient letter containing medication and investigation information. The report also identified stretched team capacity and resources and stated that necessary actions to address these issues were not confirmed.

NIGEL JOHN SAUNDERS · Prevention of Future Deaths report View report

3 Aug 2022 Nottinghamshire L. Bower

Nigel John Saunders was detained at HMP Lowdham Grange and was found suspended by ligature on 17 November 2018. He was pronounced deceased in hospital on 18 November 2018 following hypoxic brain injury sustained during the suspension. The concerns included failings in his admission to the Segregation Unit, care under the ACCT Plan, and searching before entering the shower area, as well as failures to retain and preserve evidence relevant to investigations of deaths in custody.

Alison June Dallow · Prevention of Future Deaths report View report

3 Aug 2022 Herefordshire H. Bricknell

Alison June Dallow died from a pulmonary thromboembolism due to deep vein thrombosis after a fractured left tibial plateau and reduced mobility associated with the fracture and a knee brace. The concerns included unclear advice about weight-bearing, unclear hospital policy on reducing venous thromboembolism risk for outpatients, and unavailable evidence of information given to the patient.

Stanley HARDY · Prevention of Future Deaths report View report

2 Aug 2022 Newcastle and North Tyneside G. Nolan

On 16 June 2019, Stanley HARDY, a pedestrian, was struck by a coach after crossing Peel Street against a red light and died the following day from serious head injuries. Concerns included the coach driver not applying emergency braking despite seeing him in the carriageway, and emergency braking procedures not forming part of required training for new bus and coach drivers.

Asher William Robert Sinclair · Prevention of Future Deaths report View report

29 Jul 2022 West London L. Brown

Asher William Robert Sinclair was a ventilator-dependent child who died in hospital on 8 October 2019 after life support was withdrawn, following a displaced tracheal tube and a prolonged loss of oxygen. The report identified concerns about inadequate staffing, training, planning, oversight, review and escalation within his complex care package, including that he was left in the care of a sole nurse who did not follow the emergency procedure.

Charles William WHEATLEY · Prevention of Future Deaths report View report

29 Jul 2022 County Durham and Darlington L. Hamilton

Charles William Wheatley died at the scene of a head-on road traffic collision on the A66 on 14 December 2021. The report identified concerns that he had no valid driving licence, had epilepsy and was not taking his anti-epileptic medication regularly, and that the system allows a person to own a car without a driving licence.

Mr Locksley Burton · Prevention of Future Deaths report View report

29 Jul 2022 Inner South London A. Harris

Mr Locksley Burton, an 80-year-old disabled right leg amputee with dementia and other conditions, died in hospital on 24 April 2020 from mixed natural causes including systemic sepsis, Covid-19 pneumonia and osteomyelitis of the left heel. Concerns included inadequate wound inspections and dressing changes after diabetic foot clinic attendance was reduced, insufficient communication and care planning, and no demonstrated process for managing refusal of potentially life-threatening care where capacity was probably lacking.

Christopher Dominic Boughton · Prevention of Future Deaths report View report

29 Jul 2022 Surrey A. Loxton

Christopher Dominic Boughton left home on 3 November 2021 and was later found deceased in a wooded location in Oxshott, Surrey, after friends searched areas he was known to visit. The inquest found that he took his own life by hanging at some point between being dropped off by taxi on 3 November and being found on the morning of 5 November. The principal concern was insufficient direct communication and coordination between bordering police forces when tasking and transferring investigations, which could delay effective action and the sharing of relevant information.

Brian Parry · Prevention of Future Deaths report View report

28 Jul 2022 South Yorkshire (Western) T. Rawden

Brian Parry died at Brunswick Retirement Village on 3 November 2021 after choking on food. The report identified delays in calling emergency services, an emergency cord system that did not alert nearby staff, limited confidence in first-aid training, and no advanced first aider available on site.

Archi Johnson · Prevention of Future Deaths report View report

26 Jul 2022 Exeter and Greater Devon A. Longhorn

Archi Johnson, who had a history of depression, self-harm and suicidal ideation, was admitted voluntarily to a hospital ward on 5 November 2019 after reporting intrusive thoughts of taking his own life. He was found hanging on 7 November 2019; concerns were raised that information about a previous similar suicide attempt was not clearly recorded or shared, which may have affected decisions about his risk level, observation level and the removal of potentially dangerous ligature items.

Hemanta Kumar Rai · Prevention of Future Deaths report View report

26 Jul 2022 South Wales Central R. Knight

Hemanta Kumar Rai, aged 28, drowned in August 2021 after a strong current pulled him underwater towards a waterfall while he was visiting South Wales. The concerns were inadequate and unclear signage warning of the risk of death by drowning, and uncertainty about responsibility for the area.

Kane Thomas Harley Davidson · Prevention of Future Deaths report View report

26 Jul 2022 Manchester North E. Morgan

Kane Thomas Harley Davidson was found unresponsive at his family home on 28 January 2022 and died on 1 February 2022 after suffering extensive widespread diffuse hypoxia pattern of ischaemic brain injury. The report identified concerns about the licensing and inspection of privately rented properties, including inadequate assessment and enforcement of risks from non-compliant internal window blinds and unclear information provided to tenants and landlords.

Stephen John COOMBES · Prevention of Future Deaths report View report

25 Jul 2022 Suffolk N. Parsley

Stephen ‘John’ Coombes died at Addenbrookes Hospital on 3 September 2021 after a single-vehicle collision in which the Porsche he was driving left the road and overturned. The report identifies concern that inadequate signage failed to communicate a temporary 30 mph speed limit, leaving road users unaware of the reduced limit and potentially resulting in further fatalities if similar road defects occur.

Ethan Jake Wright · Prevention of Future Deaths report View report

25 Jul 2022 Suffolk N. Parsley

Ethan Jake Wright died on 18 November 2021 after sustaining serious head injuries when the bicycle he was riding collided with a van in Lowestoft. The principal concern was that the junction where the bridleway joined Higher Drive had severely restricted visibility and no physical barrier or other measure to make cyclists or fast-moving pedestrians slow down before entering the road.

Natalie Mortimer · Prevention of Future Deaths report View report

25 Jul 2022 Mid Kent and Medway B. Patel

Natalie Mortimer died on 21 April 2022 at St Thomas' Hospital after an overdose of colchicine tablets prescribed for gout. She developed multiorgan failure. Concerns included that information about a previous overdose was not added to her GP record and that 100 tablets were prescribed because this was the system default, without an alert identifying the previous overdose.

Michael Shuttleworth · Prevention of Future Deaths report View report

22 Jul 2022 West Yorkshire Eastern O. Longstaff

Michael Shuttleworth sustained fatal head and chest injuries after being struck by a UPS Mercedes Vario Box Van while crossing Bridge Street in Huddersfield on 5 November 2020. The concerns included a large driver-side blind spot that could completely mask a pedestrian, the absence of front or rear audible impact sensors, and appraisal arrangements that did not provide drivers with feedback or refresher training.

Christopher Thomas Ace Ryan · Prevention of Future Deaths report View report

22 Jul 2022 West London L. Brown

Christopher Thomas Ace Ryan was detained under section 3 of the Mental Health Act and absconded from escorted leave on 23 December 2020. He obtained and smoked heroin, developed laboured breathing, lost consciousness, and died despite CPR. Concerns included repeated absconding during escorted leave, access to illicit drugs, unclear boundaries around escorted leave, and the security and smoking arrangements at the hospital car park.

Lewis Martyn POWTER · Prevention of Future Deaths report View report

21 Jul 2022 Cambridgeshire and Peterborough L. Skinner

Lewis Martyn Powter, an IPP offender with emotionally unstable personality disorder and a long history of drug addiction, died from a self-administered overdose on 10 May 2020 after a period of abstinence and reduced drug tolerance. The concern was that there was no policy or guidance encouraging multi-agency meetings to share information about complex-needs IPP offenders, particularly where one care provider lacked access to the shared record system.