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Victoria Cartwright · Prevention of Future Deaths report View report

17 Jun 2022 Manchester West R. Syed

Victoria Cartwright was pronounced dead on 26 December 2021 in a car park after consuming large amounts of alcohol and developing hypothermia while wearing unsuitable clothing for the weather. The principal concerns were that, despite recommendations for 24-hour care, she was discharged to accommodation considered unsuitable for her complex needs, and that there was insufficient collaborative working between the relevant hospital, mental health, social care and support organisations.

Donald Gore · Prevention of Future Deaths report View report

17 Jun 2022 Avon S. Fox

Donald Gore acquired a Mycobacterium Chimaera infection during open-heart surgery in November 2016 and died after a prolonged delay in diagnosis. The report describes failures to communicate and recognise the infection risk, delays in testing, and treatment for misdiagnosed sarcoidosis. It also raises concerns that the investigation into the incident was inadequate and was not disclosed to the Coroner’s office.

Margaret Florence Joyce Stringer · Prevention of Future Deaths report View report

17 Jun 2022 Blackpool and the Fylde T. Holloway

Margaret Florence Joyce Stringer died by suicide between 18.35 and 19.00 on 10 October 2020 in the bathroom adjoining her room at Nightingales Nursing Home. The inquest found that appropriate precautions were not taken, including the return of an item used as a ligature, and that information about her suicide risk was incomplete and insufficiently recognised. Concerns included the absence of a fail-safe system to restrict access to dangerous items and weaknesses in the collation and transfer of information about suicide risk between services.

Gwynne SAMUEL · Prevention of Future Deaths report View report

17 Jun 2022 Gwent C. Saunders

Gwynne Samuel, a 95-year-old man who lived alone, fell at home and waited approximately 12 hours for an ambulance before being taken to hospital. He developed an acute kidney injury attributed to the prolonged lie, which delayed hip surgery; he subsequently developed a chest infection and died from pneumonia. The principal concern was the ambulance response time for a patient categorised as Amber 2 and whether the clinical effects of a prolonged lie in an elderly person were adequately considered during categorisation.

Amanda Hesketh · Prevention of Future Deaths report View report

17 Jun 2022 Manchester South C. Morris

Amanda Hesketh, who had a complex health history and was prescribed multiple analgesic medicines, became unresponsive in the Emergency Department after presenting with diarrhoea and vomiting and could not be resuscitated. The report identified concerns about the lack of systematic reviews and individual plans for patients receiving multiple analgesics, limited specialist pain-clinic input, and inconsistent use of practice pharmacists.

Lee Anthony CARUANA · Prevention of Future Deaths report View report

16 Jun 2022 Birmingham and Solihull E. Brown

Lee Anthony CARUANA died at the Queen Elizabeth Hospital, Birmingham, on 6 October 2021 after suffering from COVID-19 and experiencing a delay in ambulance attendance. The report identified delays caused by ambulance crews waiting to hand over patients at hospitals, compromising ambulance availability and creating a risk to life.

James Joseph MANNING · Prevention of Future Deaths report View report

16 Jun 2022 West Sussex K. Harrold

James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.

William SAVORY · Prevention of Future Deaths report View report

15 Jun 2022 Surrey A. Crawford

William Savory, a 31-year-old man, was found deceased on 27 January 2020 after leaving a psychiatric hospital and not returning at the agreed time. His death was due to acute fatal alcohol toxicity after drinking a significant amount of alcohol. The Coroner was concerned that not all staff were aware that missing person procedures should be commenced immediately.

Marjorie Walker · Prevention of Future Deaths report View report

15 Jun 2022 Manchester South A. Mutch

Marjorie Walker was found unresponsive in hospital on 27 May 2020 after receiving prescribed gabapentin, morphine and buprenorphine, with post-mortem toxicology finding gabapentin above the therapeutic level. The report describes concerns about an incorrectly completed DNA CPR form, delays in specialist pain-clinic access, and insufficient recognition and monitoring of kidney function when prescribing gabapentin and other pain medication.

Keith Hopwood · Prevention of Future Deaths report View report

15 Jun 2022 Manchester South A. Mutch

Keith Hopwood fainted and felt very unwell before calling an ambulance, reporting chest pain during a later call. He was found unresponsive at home and could not be resuscitated; the medical cause of death was myocardial infarction due to stenotic coronary artery atheroma. The concerns included delays and resource pressures in the ambulance service, failure to upgrade the call category, limitations in the call-handling algorithm, the use of a private ambulance not equipped to deal with a cardiac patient, and the handling of a disconnected call when he was alone.

Paul John Welch · Prevention of Future Deaths report View report

15 Jun 2022 Cornwall and Isles of Scilly A. Cox

Paul John Welch was struck by an overhanging tree while walking with his daughter at Sailors Creek on 2 January 2021, suffered a serious head injury and died at the scene. Trees in the area had been omitted from previous surveys, and recommended remedial works had not been carried out, leaving an identified risk to people accessing the foreshore.

Keith Andrew NOTTLE · Prevention of Future Deaths report View report

14 Jun 2022 Nottinghamshire G. Clow

Keith Andrew Nottle died on 5 July 2021 after taking an overdose of two prescribed medications, which the inquest concluded was an accident. Concerns included telephone triage practices that could bypass specialist mental health assessment, the apparent lack of care coordination, and unclear decision-making around his discharge and repeated re-referrals to mental health services.

Hollie Anne RICHARDSON · Prevention of Future Deaths report View report

10 Jun 2022 Bedfordshire and Luton S. Cummings

Hollie Anne RICHARDSON, who was 26, died at Luton and Dunstable Hospital on 27 November 2019 after suffering a cardiac arrest secondary to a massive pulmonary embolism. She had protein S deficiency and a strong family history of blood clots, including fatal cases. The principal concern was that patients diagnosed with protein S deficiency may not be given sufficient information or surveillance about other factors that could increase thromboembolism risk, leaving them potentially unaware of actions to mitigate that risk.

Jennifer Ann DYER · Prevention of Future Deaths report View report

9 Jun 2022 East Sussex J. Healy-Pratt

Jennifer Ann DYER, aged 36, died after her bicycle collided with a van following contact with a defective pothole on the B2188. The pothole had a history of failed repairs and previous concerns about the danger it posed to road users. The report raises concern that its categorisation as a low-risk defect requires significant review, stating that the death was avoidable.

Shirley Alice Moloney · Prevention of Future Deaths report View report

9 Jun 2022 East London N. Persaud

Shirley Alice Moloney, who had longstanding paranoid schizophrenia and severe frailty, was found unresponsive at her care home on 10 December 2020 after suffering three vomits the previous day. The report states that it was likely she died from aspiration pneumonia and that the death was from natural causes. Concerns included the deterioration of her mental health and the lack of community mental health team care in the last nine months of her life, alongside wider concerns about access to older adult psychiatry for care-home residents.

Jack HURN · Prevention of Future Deaths report View report

8 Jun 2022 Birmingham and Solihull E. Brown

Jack Hurn, aged 26, died after developing vaccine-induced immune thrombocytopenia and thrombosis with cerebral venous sinus thrombosis following an AstraZeneca COVID-19 vaccination. Concerns included the absence or non-use of guidance and pathways for timely specialist management of VITT, aspects of his care at Alexandra Hospital, and the apparent inadequacy of the investigation into his care.

Paul Haydn MORRIS and Alison Margaret MORRIS · Prevention of Future Deaths report View report

8 Jun 2022 Herefordshire H. Bricknell

Paul Haydn MORRIS and Alison Margaret MORRIS died together with their family dog in a road traffic collision while crossing the A44 at Crooked Well, Kington, Herefordshire. The report raised concerns about limited visibility at the footpath crossing and invited consideration of foliage, safety barriers, the crossing design or position, traffic speed and signage.

Mr Ian McDonald Taylor · Prevention of Future Deaths report View report

8 Jun 2022 Inner South London A. Harris

Mr Ian McDonald Taylor suffered a cardiac arrest after a physical altercation while in police detention and died in hospital. Concerns included the police officer’s assessment and communication of Mr Taylor’s breathing difficulties, access to his inhaler while awaiting an ambulance, and the exceptionally delayed ambulance response.

Lilian Bernadette BEHRENDT · Prevention of Future Deaths report View report

8 Jun 2022 Norfolk J. Lake

Lilian Bernadette Behrendt, aged 91, deteriorated at her care home on 28 November 2021 and died later that evening after being taken to hospital, where she was diagnosed with chest sepsis. The report raised concerns about an incorrectly graded ambulance call, records describing her as “content” despite deterioration, missing observation results, uncertainty about DNACPR and ReSPECT documentation, and unclear responsibility and accountability within the care home.

Mena Tekloe Marim Teferi · Prevention of Future Deaths report View report

7 Jun 2022 West London L. Brown

Mena Tekloe Marim Teferi died by suicide at home on 10 October 2021, after being referred to a mental health service but not seen or contacted before her death. The service was described as critically under-resourced, with demand substantially exceeding capacity and resulting in failures to meet service obligations.