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Gaia Kima Pope-Sutherland · Prevention of Future Deaths report View report

21 Jul 2022 Dorset R. Griffin

Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.

Muhammad Zayaan ul Hasan · Prevention of Future Deaths report View report

21 Jul 2022 Cambridgeshire and Peterborough S. Goward

Muhammad Zayaan ul Hasan was born on 18 November 2020 and died at home on 21 November 2020, aged three days, after developing poor feeding, sleepiness and abnormal breathing. The principal concern was a lack of national guidance on feeding expectations for low-risk formula-fed babies during the first 72 hours, which may contribute to premature discharge and inadequate information for families about warning signs.

Jade Michelle Hart · Prevention of Future Deaths report View report

20 Jul 2022 Nottinghamshire E. Didcock

Jade Michelle Hart died on 9 July 2018 after giving birth, following a uterine inversion caused by inappropriate management of the third stage of labour. She suffered massive uterine haemorrhage and multiple cardiac arrests, with delayed recognition and management of the bleeding, and the inquest concluded that her death was contributed to by neglect. The report raised concerns about the Trust’s serious incident investigation and insufficient support for newly appointed obstetric consultants.

Colleen Alice FLETCHER · Prevention of Future Deaths report View report

20 Jul 2022 Rutland and North Leicestershire F. Butler

Colleen Fletcher, who was insulin-dependent and cared for in a residential care home, experienced progressively rising blood glucose levels, collapsed into a diabetic coma and died on 29 January 2021. The report raises concerns about the availability of rapid-acting insulin for patients whose glucose levels were previously stable, and the potential delay before increased insulin could be administered or ambulance assistance considered necessary.

Beryl Simcock · Prevention of Future Deaths report View report

19 Jul 2022 Nottinghamshire G. Clow

Beryl Simcock, who lived in a care home because of dementia, suffered several falls, including a fall on 10 June 2021 that caused an impacted fractured neck of femur and led to a severe deterioration in her health. The concerns included inadequate care-plan and risk-assessment reviews, potentially inaccurate records, insufficient oversight, and inadequate information for her family when she was deprived of her liberty.

Ezra Mathew TAMIEM · Prevention of Future Deaths report View report

19 Jul 2022 Bedfordshire and Luton S. Cummings

Ezra Mathew Tamiem was detained at HMP Bedford and held in the healthcare wing because of concerns about his mental state and suicide risk. He was found hanging in his cell on 15 July 2020 and was confirmed deceased by paramedics. The concerns included a ligature point in the cell and a serious failure of the required observation procedure, with only two of five recorded observations performed.

Mr Graham Edgar White · Prevention of Future Deaths report View report

18 Jul 2022 East London G. Irvine

Mr Graham Edgar White was treated for a ureteric stone in November 2019 with an antegrade ureteric stent intended for temporary use. The stent remained in place for 20 months despite deterioration observed on multiple occasions, and was removed after he developed a urinary tract infection and right perinephric abscess. He developed sepsis and died in hospital on 18 August 2021. Concerns included the absence of a stent registry for monitoring and recall, uncertainty about other patients at risk, and delayed identification of the death as a serious incident.

James John Jude Booth · Prevention of Future Deaths report View report

17 Jul 2022 Manchester South A. Bridgman

James Booth, who had longstanding mental ill-health and was detained at The Priory, Altrincham, absconded on 7 October 2020 and was found dead on 14 October 2020; the medical cause of death was hanging. The principal concerns were inadequate security of the ward garden, including the fence, inadequate risk assessments, and failures to communicate and document repeated incidents and emerging risk between shifts.

Darren Jones · Prevention of Future Deaths report View report

17 Jul 2022 Manchester South A. Mutch

Darren Jones, who had severe learning disabilities, a long-term catheter and chronic kidney disease, was admitted to Stepping Hill Hospital after unsuccessful catheter changes in the community and Emergency Department. He deteriorated despite treatment for sepsis and died at the hospital on 22 October 2021. The concerns included pressures on community district nursing services, insufficient recognition of his learning difficulties and support needs in hospital, a dispute between Local Authorities affecting respite care and catheter-care training, and the absence of a commissioned LeDeR review.

Rebecca Jayne Flint · Prevention of Future Deaths report View report

17 Jul 2022 Manchester South A. Farrow

Rebecca Flint was under the care of the Trafford Community Mental Health Team and was found at home on 7 September 2020. The report raised concerns about inconsistent Care Coordinator roles between Trusts and limited Community Mental Health Team resources, including the absence of cover when a Care Coordinator was unavailable.

Kathleen Stewart · Prevention of Future Deaths report View report

17 Jul 2022 Manchester South A. Mutch

Kathleen Stewart fell at her care home and was taken to hospital after reporting groin pain. Her pelvic X-ray was later reported as showing a minimally displaced fracture, but the report was not acted upon; she was discharged without the indicated follow-up and subsequently deteriorated and died. The concerns included the failure to act on the abnormal imaging report and the lack of a specific investigation into the incident and related systems.

Ronald Hartley · Prevention of Future Deaths report View report

17 Jul 2022 Manchester South A. Mutch

Ronald Hartley fell in his garden, fractured his neck of femur, underwent surgery, became increasingly frail, and died in hospital on 22 November 2021. His family reported being told that an ambulance would take approximately six hours to attend, so they transported him to hospital themselves, causing him significant pain and discomfort.

Gordon Bernard Hendley · Prevention of Future Deaths report View report

14 Jul 2022 Cumbria N. Shaw

Gordon Bernard Hendley, who had lymphoma and recent lung infection and pulmonary embolism, developed a severe rash most likely caused by Stevens-Johnson Syndrome and died in hospital on 23 January 2022 after maximal treatment. The report identified concerns about delays in medical assessment and treatment, failure to escalate significant blood-test results, lack of specialist dermatology input and prognostic scoring, and the robustness of systems for monitoring and supporting severely ill patients.

Daniel Clements · Prevention of Future Deaths report View report

13 Jul 2022 West Yorkshire Eastern K. McLoughlin

Daniel Clements, aged 27, was taken to hospital by police for a psychiatric assessment on 19 July 2021 and was discharged to his GP after being deemed not to have a mental illness. Later that evening, he ran into the path of a fast-moving train and sustained fatal injuries. The principal concerns were how to keep people displaying suicidal ideation safe when they are not considered mentally ill, and whether agencies adequately supported Mr Clements, who was described as vulnerable and had experienced homelessness and difficulties accessing support and medication.

Barbara PROUDLOVE · Prevention of Future Deaths report View report

12 Jul 2022 Hampshire, Portsmouth and Southampton J. Pegg

Barbara PROUDLOVE died on 4 July 2020 at Southampton General Hospital after developing pneumonia in consequence of cardiac failure and dementia. Elevated morphine and lorazepam levels caused unconsciousness and contributed to her death, and there was a delay in summoning medical assistance. The principal concern was that the carer did not identify the medical emergency promptly and lacked the necessary training, skills and understanding to respond appropriately.

Louise Asha Allen · Prevention of Future Deaths report View report

12 Jul 2022 East London N. Persuad

Louise Asha Allen, who had bipolar disorder and emotionally unstable personality disorder, was discharged from hospital in December 2020 and was regarded as a very high risk to herself. Between February and June 2021, she did not receive necessary mental state assessments or sufficient support, and inaccurate clinical details contributed to unreliable risk assessments. On 12 June 2021, she placed herself in front of a train. The principal concerns related to inadequate care coordination, including insufficient continuity of care, excessive caseloads, staff turnover and insufficient numbers of care coordinators.

Kieran Joseph Kevan CRIMMINS · Prevention of Future Deaths report View report

12 Jul 2022 Carmarthenshire and Pembrokeshire P. Bennett

Kieran Joseph Kevan Crimmins took his own life after discharge from the Crisis and Home Treatment Team, in circumstances where the report found ongoing psychiatric monitoring and support would have been appropriate. The principal concerns were incomplete or inaccurately recorded actions, the way significant information was communicated to him, and apparent gaps in routes back into mental health services and communication between providers.

Seema Pravin HARIBHAI · Prevention of Future Deaths report View report

7 Jul 2022 Inner North London M. Hassell

Seema Haribhai, who had increasingly disabling psoriatic arthritis, took herbal remedies prescribed by an Ayurvedic practitioner and developed liver failure, dying some weeks later. The investigation determined that she died as a consequence of the administration of Ayurvedic medicines intended to treat psoriatic arthritis. Concerns included the practitioner’s failure to recognise the possible harm from the medicines or advise their immediate cessation, the lack of regulation and evidence of quality control, and shortcomings in the GP’s assessment and response to her symptoms and abnormal blood test.

Antony Christopher MCLELLAN · Prevention of Future Deaths report View report

5 Jul 2022 North Yorkshire and York J. Broadbridge

Antony Christopher McLellan was found unresponsive, hanging by a ligature in the garage at his home on 9 July 2021; his death was recognised that afternoon and the inquest concluded that he died by suicide. Concerns included that assessment and formulation of risks and safety did not fully explore the impact of his autism, including how he might communicate distress and risk, and that autism-informed support and services required significant improvement and expansion.

Ann Pickering · Prevention of Future Deaths report View report

4 Jul 2022 South Yorkshire (Western) D. Urpeth

Ann Pickering developed throat-swelling and choking complaints, was diagnosed with severe anxiety and an eating disorder, and was admitted to Kendray Hospital under a section of the Mental Health Act. She later deteriorated physically, was transferred to Barnsley Hospital, and died there on 1 July 2021. The substantive concerns included delays in recognising and inserting an NG tube, delayed acceptance of her transfer by Barnsley Hospital, and a lack of clear transfer policies and procedures for patients under a section.