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Colm MCCABE · Prevention of Future Deaths report View report

31 Jan 2022 Berkshire H. Connor

Colm McCabe, aged 79, was admitted to hospital with hyperglycaemia after his blood sugar levels were not monitored and insulin administration was not clarified at the care home. He was transferred to hospital on 22 March 2021 and died there on 24 March 2021; the inquest concluded that natural causes were contributed to by neglect. Concerns included staff recruitment, training and appraisal, ineffective auditing, failures to clarify and monitor diabetes care, and the candour and completeness of investigations by the care home.

OSKAR MILES NASH · Prevention of Future Deaths report View report

31 Jan 2022 Surrey R. Travers

Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death investigations.

Jack Stephen TAYLOR · Prevention of Future Deaths report View report

28 Jan 2022 West Sussex R. Simpson

Jack Stephen TAYLOR was a detained inpatient who left escorted leave on 17 March 2021 and was found unresponsive at premises in Worthing on 19 March 2021, where he died despite urgent medical assistance. The report raised concerns about Mill View Hospital’s reliance on police support and failure to consider the full range of powers for returning absconded patients, as well as weaknesses in joint hospital-police AWOL and missing-person procedures that could delay locating and returning high-risk patients.

Barbara YOUNG · Prevention of Future Deaths report View report

28 Jan 2022 Gwent C. Saunders

Barbara Young fell downstairs at home, sustained multiple injuries, developed pneumonia after becoming immobile in hospital, and died on 23 July 2021. The principal concern was that an ambulance took approximately three hours to arrive despite information about her severe injuries and reduced consciousness; the report states that it could not confirm whether the delay contributed to her death, but identified an ongoing risk from delays in timely emergency response.

Mark Anthony Athias · Prevention of Future Deaths report View report

28 Jan 2022 West Yorkshire Eastern K. McLoughlin

Mark Anthony Athias had multiple physical and mental health issues, including recurring urinary infections and problems with a long-term catheter. After difficulties with his catheter on 2 July 2021, he was admitted to hospital, where his condition deteriorated and he died on 6 July 2021. Concerns included a lack of sterile replacement catheters, inadequate monitoring records, and a missing handover record, with risks arising from deficient record keeping.

Manon Edie Jones · Prevention of Future Deaths report View report

28 Jan 2022 South Wales Central D. Regan

Manon Edie Jones, aged 16, died from ligaturing shortly after being admitted to a mental health unit following self-harm and a deterioration in her mental health. The report identified concerns that clinicians did not have access to relevant community and hospital records, that clinical records were not entered contemporaneously in a single record, and that this impaired assessment, observation decisions and safeguarding.

Adam Marshall Elliot STONE · Prevention of Future Deaths report View report

27 Jan 2022 Birmingham and Solihull E. Brown

Adam Marshall Elliot Stone became distressed, agitated and paranoid after using cocaine, displayed signs of acute behavioural disturbance, and died after his condition deteriorated during restraint, ambulance transfer and hospital treatment. The report raised concern that the ambulance-service system did not allow a category 1 response for severe acute behavioural disturbance where restraint was taking place, which it stated was putting lives at risk.

Maria Howell · Prevention of Future Deaths report View report

27 Jan 2022 Essex M. Brown

Maria Howell, a resident of Cranham Court Nursing Home, died in hospital on 28 September 2019 after her RIG tube fell out, reinsertion was delayed, and she later developed peritonitis. The concerns were that the care home lacked qualified nursing staff to reinsert a time-critical RIG tube and that staff did not recognise the need for urgent medical attention when she became critically ill.

Finnian Gabriel Denney Kitson · Prevention of Future Deaths report View report

27 Jan 2022 Manchester City Z. Golombeck

Finnian Gabriel Denney Kitson, who had been diagnosed with anxiety and prescribed medication, took his own life in student accommodation on 8 October 2020, shortly after commencing studies at The University of Manchester. The report’s principal concern was that the UCAS application process did not refer separately and explicitly to mental health illness, which could discourage applicants from disclosing diagnoses and limit access to support when starting university.

Ketheeswaran KUNARATHNAM · Prevention of Future Deaths report View report

26 Jan 2022 West London L. Brown

Ketheeswaran KUNARATHNAM, a refugee detained at HMP Wormwood Scrubs after completing a prison sentence, was found hanging in his cell on 23 February 2018; the inquest concluded suicide. The report identified shortcomings in communication, record keeping, risk assessment, healthcare checks, prison procedures and the timeliness of immigration responses. It also raised concerns about detained prisoners receiving insufficient accessible information and support regarding their immigration and legal matters.

Anthony David RODÈ · Prevention of Future Deaths report View report

25 Jan 2022 Norfolk J. Lake

Anthony David RODÈ was a Coastwatch volunteer who fell from a bank onto a concrete path while using his own strimmer to cut overgrown grass on 24 July 2021, sustaining injuries that led to his death. The principal concern was a dispute between Great Yarmouth Borough Council and Caister-On-Sea Parish Council over responsibility for the land, resulting in neither organisation maintaining it and a volunteer undertaking the grass cutting in unsafe circumstances.

Idris HABIB · Prevention of Future Deaths report View report

24 Jan 2022 Mid Kent and Medway P. Harding

Idris Habib was found suspended in his cell at HMP Swaleside after incidents involving self-harm, a cell fire and statements that he was being bullied and wanted to kill himself. The inquest concluded that he took his own life by hanging, although his intention was unclear. Concerns included medication from a previous occupant being found in the cell, a disconnect between local policy and training on roll checks, and the need to ensure welfare checks were conducted and documented.

Thomas Mark Anthony Moffett · Prevention of Future Deaths report View report

22 Jan 2022 Lancashire and Blackburn with Darwen N. Rheinberg

Thomas Mark Anthony Moffett had probably suffered from diarrhoea and vomiting for up to three weeks before dying from natural causes following a cardiac arrest due to metabolic acidosis. Failures included an unlabelled blood sample, omission of an ECG, and inadequate communication of the patient’s condition and emergency level to ambulance control. The report raised concerns about communication arrangements between healthcare staff, prison control rooms and ambulance control, including the possibility of a wider national problem.

Anthony Walgate and 3 others · Prevention of Future Deaths report View report

21 Jan 2022 East London H. QC

Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor were four young men who were drugged with GHB and murdered. The report raises concerns about serious investigative failings, including how sudden deaths were categorised, the allocation and support of homicide investigations, leadership, recording and review of investigative actions, handwriting verification, death notifications and the response to coroners’ concerns. It also identifies concern that users of the Sleepyboy website could engage escorts without verifying their identities.

Neil Kenneth PARKES · Prevention of Future Deaths report View report

20 Jan 2022 Warwickshire S. McGovern

Neil Kenneth Parkes was found unconscious after an apparent unwitnessed fall in a stairwell on 29 April 2020 and later died in hospital on 14 May 2020. His identity remained unknown throughout his hospital admission despite reports from hospital staff and his parents, and the failure to identify him meant the hospital could not access his previous medical history, which may have assisted his treatment.

Michelle Whitehead · Prevention of Future Deaths report View report

19 Jan 2022 Nottinghamshire E. Didcock

Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

Terance Alfred RADFORD · Prevention of Future Deaths report View report

18 Jan 2022 Nottinghamshire L. Bower

Terance Alfred Radford, aged 87, died at the scene on 19 April 2019 after being struck by a car driven at speed by a male driver. The report identified concerns about the Home Detention Curfew Policy, including the release of prisoners directly from segregation, insufficient assessment of risk to others, and a lack of multi-agency information sharing.

Coco Bradford · Prevention of Future Deaths report View report

18 Jan 2022 Cornwall and Isles of Scilly A. Cox

Coco Bradford, a 6-year-old girl with autism, developed diarrhoea and vomiting, was diagnosed with haemolytic uraemic syndrome, deteriorated despite treatment and died in Bristol on 31 July 2017. The substantive concerns relate to the size and review of intravenous fluid boluses, when to escalate intensive care, and how clinicians should weigh antibiotic treatment when bacterial gastroenteritis and possible sepsis coexist because antibiotics may worsen haemolytic uraemic syndrome.

Luke Richard WILDEN · Prevention of Future Deaths report View report

16 Jan 2022 Bedfordshire and Luton E. Whitting

Luke Richard WILDEN was a vulnerable adult with high functioning autism and ADHD who, after turning 18, was not effectively transitioned from child to adult mental health services or provided with an appropriate social care package. He moved to independent living on 2 January 2020, experienced declining mental health and drug misuse, and was found deceased in his flat on 22 May 2020 after being discharged from psychiatric inpatient care. The principal concerns were inadequate transition arrangements within ELFT and a possible wider national gap in services.

Brian Wareham · Prevention of Future Deaths report View report

14 Jan 2022 Gwent C. Saunders

Brian Wareham was diagnosed with oesophageal dysmotility, which worsened and prevented him from eating sufficiently to maintain his nutritional status; he died at St David’s Hospice on 2 November 2020. The report raised concerns about communication and collaboration between primary and secondary care, including uncertainty about his treatment approach and a breakdown in communication, trust and respect between clinicians.