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Kyle Nel · Prevention of Future Deaths report View report

22 Dec 2021 Dorset S. Nicholls

Kyle Nel, a serving prisoner at HMP Guys Marsh, was found unconscious in his cell on 9 June 2018 and was subsequently declared dead after resuscitation attempts. The inquest recorded the medical cause of death as aspiration of gastric contents associated with synthetic cannabinoid (5F-ADB), also known as “Spice”, use, with a conclusion of misadventure. Concerns included the prison’s handling and recording of welfare concerns raised by families and the ability to pass drugs and other prohibited items between prison units through security fences.

Louise Cooper · Prevention of Future Deaths report View report

21 Dec 2021 Blackpool and the Fylde A. Wilson

Louise Cooper, who had anorexia nervosa and severe malnourishment, died at home on 16 May 2020 after her health declined. The inquest recorded that she had not received the medical monitoring expected after discharge from an eating disorder service. Concerns included the limited availability of sustained supported eating and whether inadequate monitoring contributed to her death.

Saul Richard THOMAS · Prevention of Future Deaths report View report

21 Dec 2021 Worcestershire D. Reid

Saul Richard Thomas died in his cell at HMP Hewell on 19 May 2019 after being transferred there from HMP Birmingham, where he had expressed paranoid thoughts and was undergoing psychiatric assessment. The concerns included failures to open an ACCT document, communicate important mental-health information during the prison transfer, and adequately assess and manage his mental health at HMP Hewell; the inquest found that these failures probably or possibly caused or contributed to his death.

Eva Eileen WHEELER · Prevention of Future Deaths report View report

21 Dec 2021 South Wales Central R. Knight

Eva Eileen Wheeler, aged 82, was an inpatient receiving rehabilitation after a soft tissue hip injury when she developed sigmoid volvulus, leading to abdominal perforation and her death on 17 February 2020. Concerns included a communication error that meant an emergency ambulance was not called for transfer to a major hospital, the patient was given lunch rather than being kept nil by mouth, and there was no clear protocol for joint discussion between medical and surgical registrars.

Maria Susan McGAURAN · Prevention of Future Deaths report View report

20 Dec 2021 Derby and Derbyshire S. Kaushal

Maria Susan McGAURAN had been prescribed codeine and citalopram and died at home on 28 November 2018 due to the combined toxicity of those medications. Concerns were raised that she had hoarded and taken medication erratically, but the Surgery did not undertake a requested medication review or consider alternative pain management earlier.

Oliver Brassington Weston · Prevention of Future Deaths report View report

20 Dec 2021 Lancashire and Blackburn with Darwen J. Adeley

Oliver Brassington Weston was a 17-year-old looked after child placed in a home by Stockton Borough Council. He died at Cumbria View House on the evening of 22 March 2019 following an impulsive act involving ████████. The concerns included deficiencies in the planning, conduct and review of an inspection, failure to consider relevant safeguarding and psychological information, and a lack of guidance about when inspection reports should not be published in exceptional circumstances.

Nichola Jane Lomax · Prevention of Future Deaths report View report

17 Dec 2021 Manchester North J. Kearsley

Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.

Ziggy Dylan MITCHELL-STAGG · Prevention of Future Deaths report View report

17 Dec 2021 Inner North London M. Hassell

Ziggy was born by emergency Caesarean section at Homerton University Hospital on 3 April 2021 in a very compromised state and died a few hours later. The concerns included inconsistent terminology for meconium, a lack of a medical-record entry by the attending obstetric registrar after 3.46am, no local policy on centralised CTG monitoring, and a trust policy providing for fresh-eyes reviews every two hours rather than the hourly national guidance.

JOAN WRIGHT · Prevention of Future Deaths report View report

17 Dec 2021 Manchester West C. Cundy

Joan Wright, aged 91, fell at home, sustained a fractured left femur, and underwent surgery during which a guide wire penetrated her pelvis. She later developed a severe infection in the hip and died at a nursing home on 16 June 2021. The report raised concerns that insufficient workable and accessible IT facilities caused crucial clinical information to go unrecorded, creating a risk to other patients.

David Michael O’Brien · Prevention of Future Deaths report View report

16 Dec 2021 Newcastle upon Tyne and North Tyneside C. Henley

David Michael O’Brien died at North Tyneside General Hospital after falling from his wheelchair, sustaining a hip fracture, and developing bronchopneumonia. Concerns included excessive wheelchair use despite advice that it was for mobility only, inadequate communication and record keeping between care providers, failure to undertake a risk assessment, and advice about the wheelchair not being followed.

Martin Thomas Brown · Prevention of Future Deaths report View report

15 Dec 2021 Lancashire and Blackburn with Darwen N. Rheinberg

Martin Thomas Brown collapsed in his cell at HMP Lancaster Farms on 10 December 2018, suffered a cardiac arrest and died despite resuscitation attempts. A post-mortem examination did not establish a cause of death. Concerns related to prison staff training and familiarity with the ERIC system, healthcare liaison with the ambulance service, and communication during medical emergencies.

Hedley Frederick ROBINSON · Prevention of Future Deaths report View report

14 Dec 2021 Milton Keynes T. Osborne

Hedley Frederick ROBINSON died on 14 April 2019 after sustaining multiple stab wounds inflicted in Newport Pagnell on 24 March 2019. The concern identified was that a Mental Health Act section 136 assessment was conducted without full information or discussion with relevant senior police officers and others involved in the assailant’s care, prompting concern about the operation of section 136 procedures in Milton Keynes.

Mrs Hurrun Maksur · Prevention of Future Deaths report View report

13 Dec 2021 East London N. Persaud

Hurrun Maksur, who was 19 weeks pregnant, suffered a seizure and cardiac arrest after developing severe abdominal pain on 6 June 2020. She was treated for suspected pulmonary embolism, but an intra-abdominal bleed from a ruptured interstitial ectopic pregnancy was subsequently discovered; she died during further surgery on 7 June 2020. Concerns included the failure to perform a FAST scan before thrombolysis, the absence of the guidance from national obstetric cardiac arrest guidance, and specific training for obstetricians to identify intra-abdominal bleeding.

Edward Cockburn · Prevention of Future Deaths report View report

10 Dec 2021 Newcastle upon Tyne K. Welsh

Edward Cockburn died after falling from an upper-storey window in a sluice room at Sunderland Royal Hospital on 15 March 2020, suffering injuries from which he later died. The report identified failures in enhanced-care assessments and observations, an unsecured sluice-room door, a failed window restrictor fixing, and significantly substandard staffing. It also raised concerns about staff training and the communication of updated window-restrictor fitting guidance.

James McKeough · Prevention of Future Deaths report View report

9 Dec 2021 West Sussex P. Schofield

James McKeough died after his motorcycle collided with a tractor towing a slurry tanker on 3 February 2020. The report raised concerns that the positioning, brightness and colour of the tanker’s rear flashing LED lights may have masked or confused the tractor’s right indicator, contributing to the collision.

Rebecca Begg · Prevention of Future Deaths report View report

8 Dec 2021 Nottinghamshire E. Didcock

Rebecca Begg died at Heathcotes, Moorgreen, in the early hours of 15 September 2020 after a self-harm incident, and was found unresponsive despite resuscitation. The report identified concerns about monitoring compliance with care plans, the lack of robust incident reviews, untested observation-level support plans, staff involvement in care planning, and communication and escalation arrangements with the NHS trust.

ANTHONY JAMES FITZPATRICK · Prevention of Future Deaths report View report

7 Dec 2021 Manchester South J. Wells

Anthony James Fitzpatrick had a long history of mental health problems and attended local A&E departments on three occasions in the year before his death, with two attendances followed by custody. The report identified inconsistent and inaccurate assessment of risk by healthcare professionals, with unclear risk grades recorded in the electronic custody record and no plan to address the problem despite it being known.

Jonathan Harvey Bayliss · Prevention of Future Deaths report View report

7 Dec 2021 North West Wales K. Sutherland

On 20 March 2018, a Royal Air Force Hawk aircraft crashed at RAF Valley during a training exercise involving a Practiced Engine Failure After Take Off manoeuvre. The engineer, Corporal Jonathan Bayliss, did not eject and was declared dead at the scene. The substantive concerns included the absence of an artificial stall warning capability in the aircraft and simulator training that did not accurately reflect the effects of a smoke pod.

Mr Robert Hammond · Prevention of Future Deaths report View report

6 Dec 2021 Warwickshire S. McGovern

Mr Robert Hammond was found at his home address on 30 January 2021 after receiving treatment from the Trust from 20 December 2020. During the inquest, it was identified that Working with Risk documentation was not completed on approximately the first nine contacts, and the resulting care plan was described as unsatisfactory.

Alexander Charles George Tostevin · Prevention of Future Deaths report View report

6 Dec 2021 Dorset B. Allen

Corporal Alexander Charles George Tostevin died on 18 March 2018 after a significant deterioration in his mental health and while under the care of the Royal Navy Department of Community Mental Health and Welfare Team. A risk management email containing significant disclosures was not seen until the following week, resulting in a missed opportunity to reassess his risk before the weekend. The concerns included the lack of independence of the DCMH, the primacy of its view in multidisciplinary risk assessments, and the absence of a composite risk assessment and care plan.