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Dominic Robert Noble · Prevention of Future Deaths report View report

1 Jul 2022 West Yorkshire Eastern K. McLoughlin

Dominic Robert Noble was remanded to HMP Leeds on terrorist charges and died there on 15 August 2020 as a result of suicide. He had been identified as requiring psychiatric assessment, but remained on a waiting list without an appointment. Concerns included the adequacy of psychiatric provision at HMP Leeds, delays in accessing psychiatric assessment, and the possibility that limited resources discouraged referrals.

Joan RICHARDSON · Prevention of Future Deaths report View report

1 Jul 2022 Sefton St Helens & Knowsley J. Goulding

Joan RICHARDSON, a frail 98-year-old woman living in supported accommodation, became increasingly unwell at home and was admitted to hospital on 4 May 2020. She had pneumonia, a fractured neck of femur and grade 4 sacral pressure wounds, and died in hospital on 18 May 2020. Concerns included failures to escalate her deterioration and pain, incomplete care planning and risk assessments, inadequate pressure-area care and documentation, and inadequate staff training and escalation procedures.

Shona Christine Michaela Campbell · Prevention of Future Deaths report View report

1 Jul 2022 Manchester City N. Meadows

Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.

Daniel Xavier · Prevention of Future Deaths report View report

1 Jul 2022 East London G. Irvine

Daniel Xavier attended the emergency department on 21 October 2021 with a history of painful haemorrhoids and an accompanying history of constipation. A venous blood gas showed an abnormally high creatinine level, but the result was not considered before he was discharged; he later became increasingly unwell, suffered a cardiac arrest, and could not be resuscitated. The report identified concerns about the failure to act on the blood result, a chaotic referral and inadequate handover, and insufficient consideration of his learning disability when taking his history.

Louise Theresa Bailey · Prevention of Future Deaths report View report

29 Jun 2022 South London J. Landau

Louise Theresa Bailey died after being struck by a police car responding to an incident while she was running across the road to catch a bus. The concern was that the police system and training did not ensure responding drivers had information about whether other units were closer, preventing them from completing a full risk assessment.

Paul Alexander Meadows · Prevention of Future Deaths report View report

29 Jun 2022 Suffolk P. Taheri

Paul Alexander Meadows was found dead at home on 4 August 2021 after taking a Codeine overdose, against a background of physical health difficulties and deteriorating mental health. The report identified concerns that his mental health crisis was not recognised by the First Response Service on 3 August 2021 and that there was no onward referral for urgent or emergency intervention. It also identified broader concerns about the time available to practitioners to gather information and properly triage and risk assess callers, linked to workload and recruitment pressures.

Michael John Vince · Prevention of Future Deaths report View report

27 Jun 2022 East London G. Irvine

Michael John Vince, a patient of the community mental health team receiving treatment for schizo-affective disorder, was found deceased at home on 19 June 2021 after apparently taking an overdose. The concerns included prolonged prescribing of medication for insomnia, lack of meaningful prescription review, failure to share evidence of dependence, and failure to monitor the frequency of PRN administration.

David Anthony Hulme · Prevention of Future Deaths report View report

27 Jun 2022 Plymouth, Torbay and South Devon I. Arrow

David Anthony Hulme had chest symptoms and a right pulmonary abscess, and underwent a right thoracotomy for pneumonectomy on 12 June 2020. After differing pathology opinions identified lymphoma, his condition deteriorated while he remained in intensive care, and he died on 6 March 2021. The concern was that the Pathology Department was significantly under-resourced, including insufficient consultant staffing for thoracic work, affecting timely and accurate diagnosis.

Jessica Louise LAVERACK “Jessie” · Prevention of Future Deaths report View report

27 Jun 2022 East Riding and Hull L. Harris

Jessica Louise LAVERACK “Jessie” had a history of domestic abuse, anxiety and alcohol dependence, and reported suicidal ideation and self-harm before her death. She was found on 2 February 2018, and the medical cause of death was recorded as hanging. The report identified concerns about the lack of a coordinated approach and information sharing between agencies, including for vulnerable people who did not meet the MARAC high-risk threshold.

ZSOLT KIRJAK · Prevention of Future Deaths report View report

24 Jun 2022 Inner West London R. Caller

ZSOLT KIRJAK died on 14 March 2021 after driving his car to a location following prolonged tinnitus, lack of sleep, anxiety and suicidal thoughts. The report raises concerns that his psychiatric assessment and suicide risk assessment were incomplete, that relevant previous self-harm was not adequately investigated, and that it was unclear whether his wife was given an opportunity to contribute to his assessments and management plan.

Grenville Wait · Prevention of Future Deaths report View report

24 Jun 2022 Manchester South C. Morris

Grenville Wait fell while shopping, sustained a fractured sternum, and was later found deeply unconscious at home. He died after an ambulance response that was incorrectly coded as category 2 and arrived around 70 minutes after the 999 call; the principal concern was that target ambulance response times were routinely not being met nationally.

Alun John Davies · Prevention of Future Deaths report View report

23 Jun 2022 Hampshire, Portsmouth and Southampton C. Wilkinson

Alun John Davies died instantly after jumping from the platform at Portchester railway station into the path of a non-stopping train on 4 May 2021. The evidence described acute anxiety and chronic depression, following recent personal difficulties. Concerns included limited staffing, CCTV coverage and platform visibility at the station, as well as insufficient public security and welfare announcements and information about obtaining assistance.

Khalid Seneen Yousef · Prevention of Future Deaths report View report

23 Jun 2022 Birmingham and Solihull J. Bennett

Khalid Seneen Yousef was decapitated during a sustained knife assault at a premises in Birmingham on 4 January 2018. The report identifies concerns that a Liaison and Diversion clinician failed to recognise the perpetrator’s psychosis and refer him for mental health assessment, and that the custody-suite model lacked commissioned psychiatrists, with wider concerns about responsibility, training and supervision.

Mr Peter John Moorby · Prevention of Future Deaths report View report

23 Jun 2022 Cumbria K. Gomersal

Peter John Moorby fell approximately 8–10 feet over a low wall into a beck in an unlit area and sustained severe head injuries. He died in hospital on 5 September 2021. The concern was that the low wall offered little protection from the drop and that the area was unlit at night, creating a risk of future deaths.

Luke Anthony Flynn · Prevention of Future Deaths report View report

22 Jun 2022 North London A. Walker

Luke Anthony Flynn died in hospital on 17 July 2019 after being restrained by members of the public, detained in hospital, and handcuffed to his bed at clinicians’ request. The concern was that there was no Metropolitan Police policy covering the use of handcuffs when medical staff requested them for a hospital patient being treated for a medical condition rather than a mental health condition.

Connor Peter Marron · Prevention of Future Deaths report View report

22 Jun 2022 North London A. Walker

Connor Peter Marron was struck and fatally injured by a train on 2 January 2022 near Hornsey Railway Station after leaving a public house to return to Alexander Palace. Concerns included inadequate lighting and signage near the stream and railway fence, and a fence that was not adequate to prevent access to the railway track.

Derek Holmes · Prevention of Future Deaths report View report

22 Jun 2022 Manchester South C. Morris

Derek Holmes, who had advanced metastatic prostate cancer and congestive cardiac failure, was admitted to hospital with several acute problems and fell while attempting to get out of bed. He sustained a left hip fracture requiring surgery and died after developing vomiting and signs of a chest infection. Concerns included errors in the Trust’s Root Cause Analysis, inadequate formal examination of issues including patient call-bells and delays in obtaining specialist advice, and the grading of the fall’s harm.

Kate Angharad HYATT · Prevention of Future Deaths report View report

21 Jun 2022 West Yorkshire (Western) C. Oliver

Kate Angharad HYATT was pronounced dead at Widdop Road, Hebden Bridge, on 31 October 2021; the inquest concluded that her death was suicide. The principal concern was that hallucinogenic substances were allegedly being dispensed by the Hands of Light Academy to attendees, including potentially mentally unwell people, without proper consideration of their effects, particularly on people experiencing psychosis.

Adele Angel Massoudi · Prevention of Future Deaths report View report

20 Jun 2022 Berkshire H. Connor

Adele Angel Massoudi was born at home on 26 June 2020, transferred to hospital, and died there on 2 July 2020; the recorded cause of death was severe hypoxic ischaemic encephalopathy. The report identified delays in responding to meconium, inadequate fetal heart-rate monitoring, delayed transfer to hospital, inadequate communication with the family, and destruction of the placenta without retaining it for examination. Concerns focused on midwifery training and the retention of placentas for death investigation.

Khalid Abiaz · Prevention of Future Deaths report View report

20 Jun 2022 Swansea and Neath Port Talbot K. Heaven

Khalid Abiaz, a prisoner at HMP Swansea, died in the early hours of 13 September 2016 after being found suspended by a ligature. The report identified concerns that an ACCT was not opened despite suicide warning markers and relevant historical information, and that prison and bank nursing staff may not have received sufficiently frequent or up-to-date ACCT training.