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Alphonso Alexander Shearer · Prevention of Future Deaths report View report

28 Apr 2022 Manchester South A. Mutch

Alphonso Alexander Shearer, who had oesophageal cancer and poor swallowing, was discharged with a catheter after treatment for acute urinary retention. He developed symptoms consistent with a urinary tract infection, was prescribed antibiotics he could not swallow, and later collapsed and died while being transferred to an ambulance; post-mortem examination confirmed urosepsis. Concerns included the lack of a system to identify the need for liquid antibiotics, difficulties with the ASK MY GP communication system, and the absence of a face-to-face GP assessment before his deterioration was recognised.

Vilem Bock · Prevention of Future Deaths report View report

28 Apr 2022 Manchester South A. Mutch

Vilem Bock was admitted to Tameside General Hospital with sepsis and suspected pulmonary embolism, but his CTPA was delayed because arrangements for an interpreter were not made. He developed a large retroperitoneal haematoma while receiving anticoagulation, subsequently developed sepsis, and died after further deterioration. The report raised concern about the lack of clear national protocols to prevent language barriers from obstructing access to care.

Susan Elizabeth Carling · Prevention of Future Deaths report View report

28 Apr 2022 Avon M. Voisin

Susan Elizabeth Carling, a General Practitioner, died by suicide at her home address on 2 January 2022. The report raises concern about suicide among health-service professionals and the need to highlight available support for GPs and this vulnerable professional group.

Natasha Mary ADAMS · Prevention of Future Deaths report View report

27 Apr 2022 Birmingham and Solihull J. Bennett

Natasha Mary ADAMS died by suicide at home on 12 August 2021 after presenting to hospital with recent fleeting suicidal thoughts and being assessed as in crisis. The report identified concerns that her level of mental health care had been downgraded without clinicians following the relevant policy, and that an audit of other patients had not been undertaken four months after it was identified as an action.

Raphael Jeffery Gill · Prevention of Future Deaths report View report

27 Apr 2022 South London J. Landau

Raphael Jeffery Gill was stopped by police, arrested for drug-related offences, and suffered multiple seizures, including seizures in police care and an ambulance. The inquest identified delays in ambulance response and hospital assessment, failure to recognise the combination of seizures and cocaine as a medical emergency, and omission or delay in carrying out a venous blood gas test. The medical cause of death was recorded as multiple seizures associated with an underlying seizure disorder, cocaine and prescribed medication.

Ashlie Timms · Prevention of Future Deaths report View report

26 Apr 2022 East London G. Irvine

Ashlie Timms, a 46-year-old woman living in supported accommodation, died on 20 April 2018 after a fire started when fabric materials came into contact with a portable fan heater. Staff delayed calling the emergency services, did not evacuate her, and the fire safety arrangements, alarm system, evacuation procedures and door lock were identified as concerns.

Kathryn Lynda Millard · Prevention of Future Deaths report View report

25 Apr 2022 Mid Kent and Medway I. Brownhill

Kathryn Lynda Millard fell down stairs at a property where she was working on 10 May 2021 and was admitted to hospital with a fractured spine. She later developed green vomit, suffered a cardiac arrest on 13 May 2021, and could not be resuscitated; the jury recorded pulmonary embolism and deep venous thrombosis as the medical cause of death. Concerns included failure to document and implement a senior clinician’s direction, lack of awareness among nursing staff about anti-embolic stockings, and inadequate recording and communication following a review of her deteriorating presentation.

Millie-Rae Needham · Prevention of Future Deaths report View report

25 Apr 2022 South Yorkshire (Western) A. Combes

Millie-Rae Needham was born on 6 August 2020 and died in the neonatal unit on 9 August 2020 after a 23-minute delay in delivery during which her condition was not adequately monitored. Concerns included the move from consultant-led to midwife-led care without consultation, inadequate foetal heart-rate monitoring, limited discussion of birthing options, and safeguards for patients not receiving continuous monitoring.

Cassian Curry · Prevention of Future Deaths report View report

25 Apr 2022 South Yorkshire (Western) A. Combes

Cassian Curry was born at 28 weeks gestation and died after an umbilical venous catheter was left in a suboptimal position and was not reviewed as planned. The inquest found that the plan to review and pull back the line was not adequately recorded or communicated, including to the care team and Cassian’s parents, and that this contributed to his death. Concerns included staffing burden, the design and suitability of documentation forms, and access to wider regional neonatal support.

Zoe Emma ZAREMBA · Prevention of Future Deaths report View report

25 Apr 2022 North Yorkshire and York including North Yorkshire Western District J. Broadbridge

Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and risk assessment.

Mr Edward Jorge Capovila · Prevention of Future Deaths report View report

25 Apr 2022 Cumbria K. Gomersal

Mr Edward Jorge Capovila, known as Eddy, died on 30 October 2020 from the combined toxic effect of prescribed medication, after administering fentanyl by heating and inhaling it. The report raises concern that relatively little information is available about unusual ways fentanyl can be misused, creating a risk of further deaths if action is not taken.

Thomas Hoskin · Prevention of Future Deaths report View report

22 Apr 2022 West London L. Brown

Thomas Hoskin was born by forceps at West Middlesex University Hospital on 8 April 2019 after signs of acute infection during labour. His condition at birth was extremely poor, and despite resuscitation he died in hospital shortly after birth on 9 April 2019. The report identified a lack of specific guidelines for managing fetal infection, which can be fatal or life-changing, as a substantive concern.

JOHN SCOTT MURPHY · Prevention of Future Deaths report View report

22 Apr 2022 Manchester South L. Costello

John Scott Murphy, who had recently tested positive for Covid-19, deteriorated while alone at home and called the ambulance service at 03:20 on 11 July 2021. An ambulance arrived at 05:21, by which time he had died; the inquest concluded that the death was from natural causes, with Covid-19 pneumonitis and hypertensive heart disease recorded. The substantive concerns were delays in paramedics attending Category 2 calls due to staff and vehicle shortages, and ambulances being delayed at Accident and Emergency departments.

Matthew Alexander CASEBY · Prevention of Future Deaths report View report

22 Apr 2022 Birmingham and Solihull L. Hunt

Matthew Caseby was detained under the Mental Health Act after being found on railway lines and in a school playground, and was transferred to the Priory Hospital in Birmingham. He absconded from the hospital courtyard on 7 September 2020 after being left unattended, and was fatally injured after stepping in front of a train on 8 September 2020. The principal concerns included inadequate recording and communication of absconding risks, failure to update risk assessments, lack of a courtyard observation policy and risk assessment, and inadequate courtyard safety.

Name not published · Prevention of Future Deaths report View report

19 Apr 2022 Manchester City N. Meadows

The deceased had mental illness, illicit and prescribed drug misuse, homelessness and a history of contact with mental health services. She was discharged from hospital to community treatment on 13 January 2021 despite concerns about her readiness, inadequate records, risk assessments and mental state examinations, and lack of fixed accommodation. She was found in cardiac arrest on 30 January 2021 and died in hospital on 31 January 2021; the cause of the cardiac arrest could not be determined. The principal concerns included the discharge decision, incomplete clinical documentation, inadequate risk assessment, and failure to consider safeguarding.

Volodymyr KOROL · Prevention of Future Deaths report View report

19 Apr 2022 Surrey A. Crawford

Volodymyr Korol died from a fatal ventricular arrhythmia in his bedroom at Shrewsbury Court Independent Hospital on 1 August 2020, following cardiac and other physical health conditions. The inquest identified concerns including failures to assess his capacity regarding weight management, investigate and manage cardiac and other physical health conditions, share medical information, and escalate abnormal vital signs. The Coroner was concerned that similar practices might be present at another site operated by Whitepost Healthcare Group.

Richard Scott-Powell · Prevention of Future Deaths report View report

19 Apr 2022 Surrey A. Crawford

Richard Scott-Powell, aged 61, suffered a spinal cord injury after a fall at home in March 2020 and later died from COVID-19 pneumonia at Holy Cross Hospital on 18 January 2021. The principal concerns were the lack of recorded escalation of high NEWS2 scores and abnormal vital signs, incomplete recording of observations, and uncertainty about whether appropriate policies and training were in place for taking, recording and escalating vital observations.

Sebastian NOTTAGE · Prevention of Future Deaths report View report

19 Apr 2022 Surrey A. Crawford

Sebastian Nottage, aged 26, was admitted to hospital for acute pancreatitis and left the ward without telling staff shortly before 8am on 30 June 2020. He subsequently sustained fatal injuries after being hit by a London-bound train. The substantive concerns were a lack of clear guidance on completing the admission/discharge booklet, including the completion timeframe, what to do if it was incomplete, and whether information should be checked directly with the patient.

Nora Jane Foulkes · Prevention of Future Deaths report View report

14 Apr 2022 North Wales (East and Central) J. Gittins

Nora Jane Foulkes, an 87-year-old resident of a residential home, was admitted to hospital on 11 April 2021 and died on 16 April 2021. Her untreated hypothyroidism was contributory to her death, which was due to cardiorespiratory failure resulting from bronchopneumonia and an existing cardiac condition. Concerns included the failure to restart and subsequently monitor her hypothyroidism treatment, and the lack of routine medication review during ANP visits because of time constraints.

Hannah Grace Beardshaw · Prevention of Future Deaths report View report

13 Apr 2022 Manchester West R. Syed

Hannah Grace Beardshaw was found hanging at her home on 20 April 2021 after contacting a friend, leaving a note of intent, and researching methods of taking her own life. The concerns identified were delays in escalating and responding to the incident, limited availability of method-of-entry kits, and document-management issues within Greater Manchester Police.