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Daniel David Rennoldson · Prevention of Future Deaths report View report

17 Jun 2021 Sunderland D. DL

Daniel died at home on 11 November 2020 after expressing suicidal intentions and contacting mental health services and the police. Concerns included there being no contingency for more than one face-to-face response at a time and no mechanism to identify cases that had not progressed, with almost 12 hours elapsing before someone visited his home.

Zainab Adam Bargo Hashim and Tafaoul Abdullilia Abdulkarim · Prevention of Future Deaths report View report

16 Jun 2021 Stoke-on-Trent and North Staffordshire E. Serrano

Zainab Adam Bargo Hashim died on 2 October 2017 and Tafaoul Abdullilia Abdulkarim died two days later after inhaling fire fumes while attempting to flee a fire through the communal area of their block of flats. The report identified concern that residents were unaware of the council’s “Stay Put” policy and that the policy’s communication had not been changed after the incident, creating a risk of future deaths.

William Stanton RUTHERFORD · Prevention of Future Deaths report View report

16 Jun 2021 North Northumberland and South Northumberland A. Hetherington

William Stanton RUTHERFORD was a temporary resident receiving one-to-one care at Baedling Manor Care Home and died in hospital on 5 January 2021 after sustaining multiple rib fractures and developing pneumonia following a fall. Concerns were raised that staffing levels were below the minimum requirement and that record keeping did not accurately reflect residents’ needs or incidents.

Ian Hall · Prevention of Future Deaths report View report

14 Jun 2021 Manchester South A. Mutch

Ian Hall, who had Alzheimer’s disease and was vulnerable, was admitted to hospital after a fall. A medicines reconciliation identified that amitriptyline had been dispensed instead of his prescribed atenolol; he subsequently choked on medication, developed aspiration pneumonia, tested positive for Covid-19, and died from aspiration pneumonia and Covid-19 pneumonitis. Concerns included the unclear cause of the dispensing error and the checks in place to prevent inadvertent dispensing to vulnerable adults whose carers administered the medication.

Brian Fredrick Mottram · Prevention of Future Deaths report View report

11 Jun 2021 Manchester South A. Mutch

Brian Fredrick Mottram was found unresponsive at home on 15 November 2020 after feeling unwell for over a week. He had reported symptoms including shortness of breath, cough and a tight chest during a telephone GP consultation, but was not seen face to face. The concerns included the predominantly telephone-based appointment policy, the possible failure to identify Covid-19, and uncertainty about how high-risk patients were identified for additional assessment.

Clive Edward Rivers · Prevention of Future Deaths report View report

10 Jun 2021 Manchester South A. Mutch

Clive Edward Rivers was admitted to hospital after a fall, contracted Covid-19 while awaiting discharge, and died at home after being discharged to sheltered accommodation with a care package and a requirement to isolate. Concerns included his not being vaccinated while an inpatient, delays in discharge planning during which he contracted Covid-19, and an assessment framework that did not appear to account for his vulnerability to rapid deterioration while isolating at home.

Emiel Ariel Malinski · Prevention of Future Deaths report View report

10 Jun 2021 Manchester South C. Morris

Emiel Ariel Malinski attended a miniature rifle range on 2 November 2020, where he fired a rifle in the direction of his right temple and later died in hospital. The report recorded that he died as a consequence of suicide and raised concerns about the limited regulation of miniature rifle ranges, including the absence of requirements for supervision, secure weapons, ammunition control and first-aid provision.

Marc David Bennett · Prevention of Future Deaths report View report

9 Jun 2021 Plymouth, Torbay and South Devon I. Arrow

Marc David Bennett was distressed by his children being taken into foster care and took his own life at home on 24 May 2020, having fashioned a ligature. The report identified concerns about communication between Devon Partnership Trust staff and Children’s Services during child protection investigations or care proceedings, and about ensuring appropriate support for parents receiving mental health services.

Denton Donovan DUHANEY · Prevention of Future Deaths report View report

9 Jun 2021 West Yorkshire Western Division M. Burke

Denton Donovan Duhaney was admitted to hospital with physical and mental health concerns and was assessed as being at high risk of further mental health deterioration. He self-discharged without assessment by the hospital’s in-house psychiatric team or notification to the community treatment team, and was found dead at home several days later; the recorded cause of death was hanging (asphyxia), with a conclusion of suicide. The substantive concerns included failures in psychiatric assessment, discharge protocol, communication about the self-discharge, and follow-up arrangements.

Nicholas James O'BRIEN · Prevention of Future Deaths report View report

9 Jun 2021 Hampshire, Portsmouth and Southampton J. Pegg

Nicholas James O'BRIEN died in hospital on 30 June 2020 after suffering traumatic head and neck injuries while kite-surfing. The report raised concern that a radio intercom device attached to his helmet remained in place when kite rigging became entangled around it, preventing the kite from being depowered and dragging him through the water and across ground; it noted that similar helmet-mounted devices may present the same concern.

Darrell Spear · Prevention of Future Deaths report View report

8 Jun 2021 Manchester South A. Mutch

Darrell Leonard Spear died in a fire at his home on 22 September 2020. The fire was probably accidental and accelerated by extensive hoarding and an open conservatory door. Concerns included poor communication and information sharing between agencies, and the absence of a clear strategy to address the fire risk associated with self-neglect and hoarding.

Susan Margaret ROBERTS · Prevention of Future Deaths report View report

7 Jun 2021 West Yorkshire (Western) A. Howard

Susan Roberts died at Bradford Royal Infirmary on 15 July 2019 after being admitted two days earlier with necrotising fasciitis, without an appreciation of the diagnosis or need for surgical intervention. The concerns included ineffective handover between surgical specialties, the absence of a formal protocol, and lack of engagement by plastic surgeons during the incident and subsequent investigation.

David Conway ORMESHER · Prevention of Future Deaths report View report

4 Jun 2021 Brighton and Hove V. Hamilton-Deeley

David Conway ORMESHER's death was investigated from 5 September 2017, with the investigation concluding at the end of an inquest on 17 May 2021. Concerns identified included the use of the in-car radio and siren, handling of the personal radio, excessive speed, and the need to reinforce driver-training requirements.

Pathushan Sutharsan · Prevention of Future Deaths report View report

4 Jun 2021 West Sussex P. Schofield

On 22 July 2020, Pathushan Sutharsan fell from his bicycle while approaching the junction of the Downs Link and the A281 in West Sussex and was struck by a Heavy Goods Vehicle. The report identified inadequate warning signage and no physical barrier at the junction, which continued to pose a significant risk to cyclists, pedestrians and equestrians despite improvements made after his death.

Angela Rosemary BEST · Prevention of Future Deaths report View report

4 Jun 2021 Inner North London M. Hassell

Angela Best was murdered by her former partner, who was convicted of her murder. The principal concern was that monitoring of his relationship status relied almost entirely on his self-reporting, despite his known history of dishonesty and the assessed increase in risk when he was in a relationship. He was in a relationship with Angela Best for approximately 20 years without detection and killed her when she ended it.

Geoffrey Harrison HUTTON · Prevention of Future Deaths report View report

4 Jun 2021 Worcestershire D. Reid

Geoffrey Harrison Hutton died by suicide in his cell at HMP Long Lartin on 8 February 2019 after hanging himself with a ligature made from a laundry-bag drawstring. He had significant hearing impairment, longstanding mental health and substance misuse issues, and was subject to an ACCT document. The substantive concerns included failures relating to social-care referral and support for his hearing and communication needs, ineffective ACCT case-manager oversight, and insufficient ACCT training for some staff carrying out observations.

Judith VARLEY · Prevention of Future Deaths report View report

2 Jun 2021 West Yorkshire Western Division M. Burke

Judith Varley died during right hip replacement surgery on 2 December 2019 after suffering catastrophic bleeding. The report raised concerns that inaccurate coding of her previous vascular procedures led to an inaccurate referral description, and that it was unclear whether the coding system allowed corrections or whether auditing systems ensured accurate data entry.

Mark Samuel CULVERHOUSE · Prevention of Future Deaths report View report

2 Jun 2021 Milton Keynes T. Osborne

Mark Samuel Culverhouse died in hospital on 24 April 2019 after being found with a ligature around his neck in a segregation cell at HMP Woodhill. The inquest jury concluded that he died from suicide, and that his unlawful detention and the decision to place him in segregation contributed to his death. The report identified concerns about the failure to calculate his release date before his recall and detention.

Catherine Jux · Prevention of Future Deaths report View report

2 Jun 2021 Mid Kent and Medway B. Patel

Catherine Jux died aged 86 on 5 April 2021 while being transported to hospital by ambulance after choking on food at Elvy Court Nursing Home. The substantive concerns were that a risk assessment was not completed within 24 hours of admission, staff did not identify this omission, and the home lacked an adequate auditing process for completed assessments.

Steven Terence Allen · Prevention of Future Deaths report View report

2 Jun 2021 Manchester South A. Mutch

Steven Terence Allen was found unresponsive at home on 25 October 2020, and toxicology found a fatal level of prescribed medication; the medical cause of death was recorded as combined drug toxicity. Concerns included prescribing oxycodone and other medications despite a history of addiction, self-harm and poor use of substances, with telephone consultations during Covid-19 and additional replacement prescriptions sometimes issued with little challenge.