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Tracy Dawn WOOD · Prevention of Future Deaths report View report

11 Apr 2022 Norfolk J. Lake

Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident report.

Manhareen Kaur · Prevention of Future Deaths report View report

8 Apr 2022 Inner West London P. Wilcox

Manhareen Kaur, a baby born after a kiwi-assisted delivery, was found collapsed on the postnatal ward and died two days later after resuscitation and transfer to a neonatal unit. The principal concern was that babies at increased risk of early neonatal collapse were not provided enhanced monitoring of breathing, heart rate or oxygen saturations on the postnatal ward, leaving no intermediate monitoring option to support earlier detection and resuscitation.

Saima Usman · Prevention of Future Deaths report View report

8 Apr 2022 Inner West London P. Wilcox

Saima Usman, aged 44, was found deceased at her home following a fire on 8 July 2021. The fire did not contribute to her death; the recorded conclusion was an accidental drug-related death. The substantive concern was that people living in privately rented accommodation in Wandsworth may be at greater risk because the borough did not have a registered landlord scheme requiring smoke and carbon monoxide detectors.

Laura Amy Smallwood · Prevention of Future Deaths report View report

7 Apr 2022 Cornwall and Isles of Scilly A. Cox

On 1 May 2019, Laura Amy Smallwood was unintentionally struck on the back of her neck by an Oss during the May Day festival in Padstow. She deteriorated at the scene, suffered a respiratory arrest, and died from her injuries in hospital on 4 May 2019. The principal concern was the absence of a single Event Organiser for the festival, with resulting gaps in engagement with safety agencies and in legislative oversight of public safety.

Nicholas Tom Rose · Prevention of Future Deaths report View report

7 Apr 2022 Dorset B. Allen

Nicholas Tom Rose, a serving prisoner at HMP Guys Marsh, was found deceased in his cell on 19 May 2019 after consuming “Spice”, with the medical cause of death involving airway obstruction and aspiration of gastric content. The report raised concern that accepting a “grunt” as a verbal response during a welfare check may provide insufficient information to assess a prisoner's welfare and could contribute to future deaths if the practice continued.

Oliver Christopher Lindsay · Prevention of Future Deaths report View report

6 Apr 2022 Manchester South A. Mutch

Oliver Christopher Lindsay was identified as having fetal growth restriction before suffering an unexpected placental abruption at home on 6 September 2020. He was born with ambulance support, received advanced paediatric life support, and was transferred to hospital, where he was found to have a severe hypoxic brain injury and died on 12 September 2020. The principal concerns were delays in obtaining a growth scan because of scanning capacity issues and limited understanding of the risks associated with fetal growth restriction.

Mrs Sandra BARNETT · Prevention of Future Deaths report View report

5 Apr 2022 Lincolnshire P. Cooper

Mrs Sandra BARNETT sustained a traumatic brain injury after an unwitnessed fall downstairs at a holiday let in Grimsby on 16 April 2021. She underwent neurosurgery and intensive care treatment, but did not regain consciousness and died on 21 May 2021; the report raises concerns about whether the holiday home's staircase met regulatory standards and whether remedial work was undertaken.

Beatrice Florence May DAWKINS · Prevention of Future Deaths report View report

5 Apr 2022 Hampshire, Portsmouth and Southampton J. Pegg

Beatrice Florence May DAWKINS died on 20 September 2020 at Queen Alexandra Hospital after suffering an anaphylactic reaction to chloramphenicol administered for a urinary tract infection. The principal concern was that records of her sensitivity to chloramphenicol were not readily accessible or flagged to clinicians before the medicine was administered, creating a future risk to life.

Faizan Qadeer Nazar · Prevention of Future Deaths report View report

4 Apr 2022 West Yorkshire (Western) M. Fleming

Faizan Qadeer Nazar, who had a longstanding history of depression and anxiety, sustained fatal injuries after deliberately lying on a ████████ on 13 September 2021. The inquest found it more likely than not that he intended his own death. Evidence raised concern that Spire Harpenden Hospital did not customarily send written reminders of patients’ forthcoming appointments, prompting consideration of reviewing that practice.

Mandy Jane DICKERSON · Prevention of Future Deaths report View report

3 Apr 2022 Bedfordshire and Luton S. Cummings

Mandy Jane Dickerson attended the Urgent GP Care Centre on 26 April 2020 after several days of diarrhoea and vomiting, but was discharged without assessment by the medical team. She died at home on 30 April 2020 from sepsis. The principal concerns included a non-mandatory and unreliable sepsis template, inadequate recording and communication of key observations, and confusion about referral responsibilities when specialist assessment was requested.

Emma Pring · Prevention of Future Deaths report View report

3 Apr 2022 Mid Kent and Medway C. Wood

Emma Pring, who had a history of serious mental health difficulties and previous suicide attempts, was admitted to hospital for treatment. While wearing anti-████████ clothing and under observations, she used components of the clothing to form a ligature and died from asphyxiation caused by self-application of a ████████. The principal concern was that older versions of the clothing remained in circulation and could be used for self-harm, despite the product changes made after Emma’s death.

Edward Arthur AKROYD · Prevention of Future Deaths report View report

3 Apr 2022 West Yorkshire (Western) M. Burke

Edward Arthur Akroyd was delivered by forceps on 13 January 2018 at Calderdale Royal Hospital after concerns arose during his mother’s labour, including pre-eclampsia and abnormal CTG tracing. He was transferred to Leeds General Infirmary for intensive treatment and died there on 17 January 2018. The principal concerns included inadequate monitoring and treatment of his mother’s elevated blood pressure, incomplete handover and medical records, failure to communicate laboratory results, and delayed recognition and interpretation of non-reassuring CTG findings.

Name not published · Prevention of Future Deaths report View report

1 Apr 2022 Manchester City N. Meadows

The deceased had chronic mental health problems, serious self-neglect and infected wounds, and was detained in hospital under the Mental Health Act. After readmission, a VTE risk assessment, monitoring, records, management plan and further capacity assessments were not undertaken; she suffered a pulmonary thromboembolism and died following a cardio-respiratory arrest on 23 February 2020. The principal concerns included inadequate safeguarding and clinical oversight, failures to implement and audit the VTE policy, and insufficient staff training.

Corrie McKeague · Prevention of Future Deaths report View report

1 Apr 2022 Suffolk N. Parsley

Corrie McKeague disappeared in Bury St Edmunds on 24 September 2016 after entering a commercial waste-bin area, and was later determined to have died in the back of a refuse lorry. The inquest identified concerns including ineffective bin locks and bin searches, lack of safe search equipment for drivers, and poor visibility through the lorry’s viewing window.

Fadzai CHITAKUNYE · Prevention of Future Deaths report View report

31 Mar 2022 Leicester City and South Leicestershire D. Hocking

Fadzai Chitakunye died at Leicester Royal Infirmary on 26 February 2019 from a haemorrhage into her brain tumour. The report also records progression of hepatitis B infection following chemotherapy. A principal concern was the delay in transferring GP records, which may result in important medical history being missed, including hepatitis B information relevant to her treatment.

Name not published · Prevention of Future Deaths report View report

28 Mar 2022 Warwickshire S. McGovern

████████ was found hanging at his home address on 25 July 2021, after receiving mental health support for suicidal ideation and awaiting a Care Co-ordinator. The concerns identified were that the failure to appoint a Care Co-ordinator may have contributed to his death and that significant staffing shortages remained in the North Warwickshire area.

Hayley Smith · Prevention of Future Deaths report View report

28 Mar 2022 North East Kent C. Wood

Hayley Smith developed severe and enduring anorexia nervosa and died on 29 December 2019 after an out-of-hospital cardiac arrest caused by severe hypoglycaemia. The inquest identified inadequate communication and information-sharing between the organisations involved in her care, including failures to share information about her Community Treatment Order.

Natalie Melissa Turner · Prevention of Future Deaths report View report

25 Mar 2022 Blackpool and the Fylde A. Wilson

Natalie Melissa Turner had a long-standing eating disorder and abused laxatives, causing serious illness and repeated hospital admissions. She died at home on 27 October 2020 from the effects of laxative abuse. The concerns included insufficient guidance for GPs managing eating disorder patients who do not engage with treatment, and insufficient guidance for counsellors on when confidentiality should be breached to protect patients at risk of serious harm.

Robert George MURRAY · Prevention of Future Deaths report View report

23 Mar 2022 East Sussex A. Craze

Robert George MURRAY, who had mild dementia and lived in a nursing home, choked on food at breakfast on 10 June 2021 and died. An ambulance was not sent because he had a DNACPR in place; the concern was that those involved did not understand when a DNACPR should not be applied, indicating a need for further training and clarification.

Emily Jane CALDICOTT · Prevention of Future Deaths report View report

23 Mar 2022 Worcestershire D. Reid

Emily Jane Caldicott was admitted to hospital after an overdose and was later found unresponsive after tying a ligature around her neck. She died on 23 March 2020 from pneumonia and cerebral anoxia due to the application of a ligature. The principal concerns were that staff failed to adequately assess her capacity regarding Lorazepam, did not administer it in her best interests, and failed to remove the item used to make the ligature; the jury found these failures probably or possibly contributed to her death and identified a risk of future deaths.