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Laura Jane Medcalf · Prevention of Future Deaths report View report

23 Mar 2022 Manchester South A. Mutch

Laura Jane Medcalf died on 17 February 2021 after being found unresponsive in her mental health ward bed, following a period of repeated self-harm incidents and signs of deteriorating mental health. The investigation concluded that her death was suicide, contributed to by failures to recognise her deteriorating mental health and increased risk, and to take effective steps to reduce that risk. Concerns also included shortages of mental health beds and staffing challenges affecting services.

Zoltan TOROK · Prevention of Future Deaths report View report

21 Mar 2022 Berkshire I. QC

Zoltan TOROK died from multiple injuries after riding his motorcycle into a stationary Land Rover on the M4 motorway on 7 May 2021. The report raises concerns about the absence of a hard shoulder or refuge on the motorway section under conversion to a smart motorway, the distraction caused by the stranded vehicle’s occupants, and risks arising from mixing smart motorways with traditional hard-shoulder motorways.

Mr. Donald Vernon Compton · Prevention of Future Deaths report View report

20 Mar 2022 South Wales Central S. Richards

Donald Vernon Compton, aged 87, was admitted to hospital after developing Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Covid-19, and died on 14 February 2021. The principal concerns were prescribing and dispensing errors involving Co-trimoxazole despite a known trimethoprim allergy, including failures by hospital staff and a GP to identify the risk. A separate medication error involving excessive amiodarone dosing was also identified.

Emiliano Raul Sala · Prevention of Future Deaths report View report

18 Mar 2022 Dorset R. Griffin

Emiliano Raul Sala was a passenger on a flight from Nantes to Cardiff on 21 January 2019 when the aircraft crashed into the sea. He died from fatal head and trunk injuries; the flight was an unauthorised commercial operation. The report raised concerns about illegal flights, their safety risks, and limitations on the Civil Aviation Authority’s investigative and enforcement powers.

Gary OTTWAY · Prevention of Future Deaths report View report

18 Mar 2022 Inner North London M. Hassell

Gary Ottway, aged 41, died after being found in cardiac arrest while detained alone in a seclusion room under constant nursing observation during a severe mental health episode. The report raised concerns about whether observation was constant or effective, delays in entering the room and obtaining emergency equipment, gaps in available medical training and resources, and ineffective chest compressions. The inquest determined that he died from natural causes involving two heart conditions.

James Forryan · Prevention of Future Deaths report View report

18 Mar 2022 Inner North London E. Buckett

James Forryan died aged 29 after deliberately taking a poisonous quantity of pentobarbital medication at a London hotel. Evidence indicated that he had accessed an internet forum promoting suicide, which provided information about drugs, methods and obtaining medication. The principal concerns were the accessibility of suicide-promoting websites and forums and the apparent lack of sufficient regulation or enforcement action against them.

Remi Nana KODUAH · Prevention of Future Deaths report View report

18 Mar 2022 Cheshire H. Westerman

Remi Nana KODUAH was born at Leighton Hospital on 22 November 2018 and died shortly afterwards following ruptured vasa praevia and severe blood loss. The substantive concerns were that the resuscitation area was separate from the operating theatre, affecting communication, and that neonatal and adult bloods were not kept in the resuscitation room.

Billy Longshaw · Prevention of Future Deaths report View report

16 Mar 2022 Manchester South C. Morris

Billy Longshaw died at Stepping Hill Hospital on 7 March 2021 from complications of an undiagnosed sigmoid volvulus, following an earlier Emergency Department assessment at Great Western Hospital. He was allowed to leave without basic blood tests, a diagnosis, or serious abdominal pathology being fully excluded. Concerns included the lack of a detailed investigation by the Trust, flaws in its incident review, and the adequacy of education and practical understanding concerning the Mental Capacity Act 2005.

Aliny Godinho · Prevention of Future Deaths report View report

14 Mar 2022 Surrey R. Travers

On 8 February 2019, Aliny Godinho was attacked and repeatedly stabbed in Ewell, Surrey, and died at the scene despite emergency medical attention. The report states that Surrey Police’s handling of earlier and same-day domestic abuse reports included failures in risk assessment, safeguarding, investigation, supervision, monitoring, call-centre handling and consideration of cultural risk; the inquest found that her death was probably more than minimally contributed to by Surrey Police.

Mrs. Margaret May Lewis · Prevention of Future Deaths report View report

14 Mar 2022 South Wales Central S. Richards

Mrs. Margaret May Lewis was fatally injured on 6 November 2020 when she was struck by a car while crossing the B4398 to re-join the Montgomeryshire Canal towpath. The report identifies concerns about the risk of similar accidents because the road has a 60 mph speed limit, electric cars may be difficult to hear, and pedestrians exercising may wear earphones.

Samuel Alban Stanley · Prevention of Future Deaths report View report

12 Mar 2022 North East Kent C. Wood

Samuel Alban Stanley died in hospital on 26 April 2020 from injuries sustained during an episode of high-risk behaviour related to his Prader-Willi syndrome. The report raised concerns about inadequate support for him and his family, limited access to appropriate services, and poor communication between agencies.

Colin Michael SWAIN · Prevention of Future Deaths report View report

10 Mar 2022 Suffolk J. Devonish

Colin Michael Swain was found collapsed in his front garden after drinking alcohol and was later taken to hospital following cardiac arrest and resuscitation. The inquest concluded that he died from hypoxic brain injury due to aspiration of gastric contents following alcoholic intoxication. Concerns included whether ambulance call-handling guidance adequately addressed alcohol intoxication, clearing the mouth and nose after vomiting, and turning an unconscious patient onto their back for CPR.

Tomi Obi Solomon · Prevention of Future Deaths report View report

9 Mar 2022 West Yorkshire, Western M. Fleming

On 1 June 2021, 13-year-old Tomi Obi Solomon voluntarily jumped from a bridge into the river and drowned after struggling to swim. The report raises concerns about the adequacy of safety measures at the bridge and surrounding area, given its popularity with teenagers for swimming and jumping into the water.

Claire COPELAND · Prevention of Future Deaths report View report

8 Mar 2022 County Durham and Darlington J. Chipperfield

Claire Copeland had a break in the continuity of her drug addiction treatment after a physical prescription was delivered unsuccessfully, leaving her unable to obtain medication for the weekend. The inquest concluded that she subsequently consumed drugs, including heroin, and that her death was drug-related. The report identified concerns that the prescription delivery arrangements lacked confirmation, prompt detection of failed delivery, and a fail-safe mechanism to remedy it, creating a risk of discontinuity of important medical treatment.

Michael John Humphries · Prevention of Future Deaths report View report

7 Mar 2022 Surrey J. Russell-Mitra

Michael John Humphries, who was quadriplegic and diabetic, was admitted to hospital on 20 March 2019 with severe sepsis and died on 30 March 2019 after being placed into palliative care. Concerns included the lack of information about the proper use of a Tbar cushion, inadequate wound-care knowledge and documentation, limited access to suitable dressings, and an ineffective initial referral process to tissue viability nurses.

ARTHUR FREDERICK HALL · Prevention of Future Deaths report View report

7 Mar 2022 Surrey J. Russell-Mitra

Arthur Frederick Hall developed a perforation following an elective colonoscopy with polypectomy on 31 January 2018. He was discharged from A&E after presenting with abdominal symptoms, later returned with sepsis and underwent emergency surgery, but died on 2 March 2018 from overwhelming sepsis and multiple organ failure. The principal concerns included inadequate investigation and assessment of possible bowel perforation, unclear discharge advice, failure to obtain surgical input, and missed signs of sepsis.

Jane Elizabeth ALLISON · Prevention of Future Deaths report View report

7 Mar 2022 County Durham and Darlington C. Oliver

Jane Elizabeth ALLISON died in hospital on 20 November 2021 after being admitted with severe type 1 respiratory failure. She had received a 10-day course of nitrofurantoin for a urinary tract infection, and the inquest concluded that she died from the effects of prescribed medication. The principal concern was that BNF guidance did not sufficiently alert clinicians to the risk of sudden pulmonary deterioration or provide adequate monitoring advice in this circumstance.

Josephine Celia BARKER · Prevention of Future Deaths report View report

7 Mar 2022 Surrey J. Russell-Mitra

Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.

JACK WILLIAM RAMSEY RITCHIE · Prevention of Future Deaths report View report

7 Mar 2022 South Yorkshire (Western) D. Urpeth

Jack William Ramsey Ritchie died on 22 November 2017 from multiple injuries after an incident in Hanoi, Vietnam, in which the evidence indicated he intended to take his own life. The report raised concerns about gambling regulation, warnings, information, treatment, professional training, the stigma associated with gambling addiction, and limited education for young people about gambling harms.

Melanie Jane ELMS · Prevention of Future Deaths report View report

7 Mar 2022 Surrey J. Russell-Mitra

Melanie Jane Elms, an informal patient at the Abraham Cowley Unit with a history of schizo-affective disorder and suicidal attempts, left the unit on day leave on 30 January 2018 and was fatally struck by a train. The inquest identified that a mandatory pre-leave risk assessment was not carried out, concerns raised by her husband were not properly recorded or acted upon, and her leave was not adequately documented or managed. The report also raised concerns about the failure to provide the planned care package and the absence of a missing-person plan and contingency planning.