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Steven Phillip Evans · Prevention of Future Deaths report View report

3 Nov 2021 Gwent C. Saunders

Steven Phillip Evans was preparing to fly a glider when its tail plane became dislodged during launch, causing it to crash. He sustained serious injuries and died on 1 August 2019. The principal concern was that ineffective communication between ground crew and aircraft pilots failed to alert those involved to problems with the glider before launch; the report noted that radios may not be in use at other clubs and could put lives at risk in the future.

Angela Margaret O’Donnell · Prevention of Future Deaths report View report

3 Nov 2021 Berkshire H. Connor

Angela Margaret O’Donnell, who had advanced lung cancer, was admitted to hospital with confusion and pain and died in hospital on 14 January 2020. The report identifies incomplete NEWS charting and missed opportunities to escalate her deteriorating condition, while stating that this was not found to have caused her death. The principal concern was reliance on agency nurses, who may not receive the trust’s refresher training and related communications, in the context of wider nursing staff shortages.

Neil Peter Bastock · Prevention of Future Deaths report View report

1 Nov 2021 West Yorkshire Eastern K. McLoughlin

Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.

Shaun Mansell · Prevention of Future Deaths report View report

1 Nov 2021 Stoke-on-Trent and North Staffordshire S. Murphy

Shaun Mansell, aged 50, was found deceased at home after an ambulance response to a 999 call was delayed by 8 hours and 15 minutes. The post-mortem cause of death was acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism, but the medical evidence could not determine whether the delay contributed to his death. The principal concerns were excessive ambulance handover delays at hospital and a welfare call during the delay that involved no direct contact with Shaun and was conducted by a paramedic without prior training for such calls.

Lorraine KARAT · Prevention of Future Deaths report View report

29 Oct 2021 Inner North London M. Hassell

Lorraine Karat, aged 68, died after falling from a second-floor balcony outside her flat, possibly while asleep, following heavy drinking. The balcony had a low parapet and no railing, and access from the flat was not restricted by bars or window restrictors. Concerns included the absence of a risk assessment, warnings about unauthorised balcony use, and measures to prevent access to the balcony.

Jane Lesley Bruce · Prevention of Future Deaths report View report

29 Oct 2021 Leicester City and South Leicestershire P. Mason

Jane Bruce sustained a right tibia and fibula fracture after a fall, underwent surgery, and was receiving community wound care when her condition deteriorated. She presented to hospital with features consistent with sepsis and died the following day. The principal concern was that fragmented community nursing care, lack of wound photographs, and inability to access electronic records contributed to her deterioration not being fully appreciated and delayed escalation for medical review.

Kyle Nicholas James Hurst · Prevention of Future Deaths report View report

26 Oct 2021 North Wales (East and Central) J. Gittins

Kyle Nicholas James Hurst was admitted to Glan Clwyd Hospital on 24 January 2021 after taking an undisclosed quantity of a substance and died there later the same day despite treatment. Concerns included the lack of an adopted protocol for accelerated administration of N-Acetylcysteine and delays in implementing procedures intended to mitigate risks from failures to act on diagnostic results.

Christopher COLLINSON · Prevention of Future Deaths report View report

26 Oct 2021 Birmingham and Solihull R. Ollivere

Christopher Collinson was admitted to Birmingham Heartlands Hospital with suspected deep vein thrombosis and pulmonary embolism, but was not seen by a doctor for several hours. He was prescribed a prophylactic rather than therapeutic dose of Enoxaparin, later suffered a cardiac arrest, and died on 15 June 2021. Concerns related to the patient-allocation system not making it clear when an allocated patient had not been seen, and the electronic prescribing system not requiring a secondary medication check.

Alan Harry Hunter · Prevention of Future Deaths report View report

25 Oct 2021 Manchester South A. Mutch

Alan Harry Hunter was admitted to hospital after a fall, with a urinary tract infection, confusion and delirium. He experienced incorrectly calculated BMI and MUST scores, rapid weight loss, increasing frailty, Covid-19 and a further urinary tract infection before dying at Fernlea Care Home; concerns focused on poor documentation and inadequate monitoring of his diet, weight and nutritional risk.

Margaret Kinsey · Prevention of Future Deaths report View report

23 Oct 2021 Manchester South A. Mutch

Margaret Rose Kinsey, who had significant heart disease, was discharged from Stepping Hill Hospital Emergency Department on 11 December 2020 after presenting with shortness of breath and significant bilateral leg swelling. She collapsed at home the following day and died after attempts to resuscitate her were unsuccessful; post mortem examination found acute left ventricular failure caused by her underlying heart disease. The substantive concerns included limited overnight consultant cover, difficulties supervising an inexperienced junior doctor, and inconsistent documentation of clinical discussions and supervision.

Dorothy Pegg · Prevention of Future Deaths report View report

22 Oct 2021 North Yorkshire (Western) J. Heath

Dorothy Pegg slipped from a shower chair while sitting on a sling and suffered bilateral leg fractures, which contributed to her death. The report identified concerns about the absence of monitoring for compliance with equipment-use instructions and the lack of instructions about when specific prescribed equipment should be used.

Serena Naomi Roberts · Prevention of Future Deaths report View report

22 Oct 2021 Manchester South A. Mutch

Serena Naomi Roberts experienced recurrent very heavy vaginal bleeding and delays in referral, triage and follow-up for specialist gynaecological assessment. She was later found to have ovarian cancer with extensive peritonitis and died from complications including septic shock and intra-abdominal sepsis. The principal concerns included delays in secondary care, poor recognition and application of guidance on heavy bleeding and risk factors, inadequate referral information, and a lack of clear systems to follow up referrals.

Anthony John Larcher · Prevention of Future Deaths report View report

22 Oct 2021 Dorset R. Griffin

On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.

Richard Gordon Franks · Prevention of Future Deaths report View report

21 Oct 2021 West Yorkshire Eastern K. McLoughlin

Richard Gordon Franks was remanded in custody at HMP Leeds and was found dead in his cell on 12 April 2019, after appearing distressed and indicating that he was likely to commit suicide if sentenced to imprisonment. The concerns included that this information was not communicated to prison staff, that he mistakenly believed he had received a five-year sentence, and that no checks were made on him for approximately 10 hours.

Quinn Lias Parker · Prevention of Future Deaths report View report

21 Oct 2021 Nottinghamshire E. Didcock

Quinn Lias Parker was born in very poor condition and died two days later, after remaining extremely unwell from shortly after birth. The placenta was cut into or dissected after his death without discussion with the Coroner, limiting the paediatric post-mortem examination and the investigation into the circumstances and likely cause of death. The report also identifies repeated cases in which placental examination was compromised following early neonatal deaths in Nottingham.

Jamie Francis O'Connor · Prevention of Future Deaths report View report

21 Oct 2021 Leicester City and South Leicestershire D. Hocking

Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.

David Ayontunde Walker · Prevention of Future Deaths report View report

21 Oct 2021 East London N. Persaud

David Ayontunde Walker died on 27 November 2020 after his mental health deteriorated following discharge from hospital. The report identified concerns about repeated changes of care co-ordinator and the failure to obtain and share important risk information between the mental health trusts, resulting in an incomplete discharge risk assessment.

Poppy HARRIS · Prevention of Future Deaths report View report

20 Oct 2021 Milton Keynes T. Osborne

Poppy Harris was born on 23 November 2020 after a protracted labour and delivery using Kielland’s forceps. She was transferred to John Radcliffe Hospital, where a spinal cord injury was discovered, and she died on 24 March 2021. The substantive concerns were the absence of a birth plan or documented treatment preferences and the use of Kielland’s forceps, which the report states caused a catastrophic spinal cord injury.

Freeda GLAUSIUSZ · Prevention of Future Deaths report View report

20 Oct 2021 Inner North London M. Hassell

Freeda Glausiusz died after jumping from her home on 15 May 2021. The report describes concerns that her father’s crisis-line call the previous day was not treated seriously, that the call was not documented appropriately, and that relevant information was not provided promptly to the coroner’s office.

Henry Edward Hullin Doll · Prevention of Future Deaths report View report

20 Oct 2021 Surrey A. Crawford

Henry Edward Hullin Doll, who had a learning disability, Down’s Syndrome and dementia and was at high risk of aspiration and choking, entered the kitchen of his residential care home alone on 21 February 2021, obtained a shortbread biscuit, choked and aspirated on it, and died the following day from aspiration pneumonia. The court found that the risks of him obtaining unsuitable food and eating it unsupervised had not been identified or appropriately prevented. Concerns also related to the way risk assessments were completed and the effectiveness of staff CPR training.