Search PFD Monitor

GEOFFREY WILLIAM HILL · Prevention of Future Deaths report View report

2 Jun 2021 Black Country J. Lees

Geoffrey William Hill, aged 82, was admitted to hospital with Covid-19, reduced mobility and general illness, and fell from a trolley bed in the emergency department, sustaining a head injury. He later became unresponsive and died in hospital from a traumatic subdural haemorrhage. Concerns included the absence of a falls risk assessment, trolley rail assessment, advanced observations, mental test and therapy assessment, and the broader lack of national guidance for falls prevention in emergency departments.

Kesia Blaine Waller · Prevention of Future Deaths report View report

1 Jun 2021 Hampshire, Portsmouth and Southampton S. Marsh

Kesia Blaine Waller, aged 17, was found suspended from a ligature at her residential housing unit on 20 January 2020 and died in hospital on 25 January 2020 after life-sustaining treatment was withdrawn following a catastrophic hypoxic brain injury. The concerns included inadequate staff training and equipment to respond to a young person suspended from a ligature, and ineffective communication and implementation of policies and training.

Angela Marie FROST · Prevention of Future Deaths report View report

28 May 2021 Manchester North C. McKenna

Angela Marie FROST was admitted to hospital after a mixed overdose and later went missing with the intention of starving herself to death. She was found at home on 24 August 2020 after taking an intentional overdose of her partner’s old medication; the inquest recorded the medical cause of death as amitriptyline overdose and concluded suicide whilst the balance of her mind was disturbed. The principal concerns included the absence of formal processes for seeking second opinions and inadequate understanding of confidentiality and permissible communication with family members.

SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · Prevention of Future Deaths report View report

28 May 2021 Cambridgeshire and Peterborough N. QC

Sam died by suicide from an overdose of prescribed medication on 2 September 2018, aged 16. Chris died by suicide after deliberately stepping in front of a passing train on 26 January 2019, aged 17. The principal concerns included insufficient overnight support for adolescents cared for at home, shortcomings in local authority support and coordination, reluctance to use a Borderline Personality Disorder diagnosis, and unclear and inadequately implemented procedures for patients absent without leave.

Christine Elizabeth GOULD (Chris) · Prevention of Future Deaths report View report

28 May 2021 Cambridgeshire and Peterborough N. QC

Christine Elizabeth Gould, aged 17, died by suicide on 26 January 2019 after deliberately stepping in front of a passing train near the Cherry Hinton Bypass Level Crossing. The report raised concerns that BTP and Network Rail had too readily assumed a single route of access to the railway and had not sufficiently considered the boundary fence as a credible alternative route, potentially missing opportunities for earlier mitigation.

KEVIN JOHN FITTON · Prevention of Future Deaths report View report

28 May 2021 Brighton and Hove V. Hamilton-Deeley

Kevin Fitton suffered a catastrophic stroke in 2010 and died after a cardiac arrest following fluid overload during his final hospital admission on 12 July 2019. The report identified longstanding concerns about inadequate assessment and support for his acquired brain injury, poor coordination and communication, ineffective implementation of care assessments, and failures to recognise and respond to his substance use, self-neglect and deteriorating health. The inquest concluded that a failure to obtain an urgent echocardiogram represented a missed opportunity to diagnose and treat his cardiac condition, and that the outcome may have been different with a correct diagnosis and more controlled fluid administration.

Peggy COPEMAN · Prevention of Future Deaths report View report

28 May 2021 Norfolk J. Lake

Mrs Peggy Copeman became unresponsive and was declared dead at the scene while being transported by ambulance on the M11. Concerns included delayed recognition of her deterioration, delay in calling emergency services, ineffective CPR because of her position, and inadequate CPR training among the transporting staff.

SAMANTHA JANE GOULD (Sam) · Prevention of Future Deaths report View report

28 May 2021 Cambridgeshire and Peterborough N. QC

Sam took a very large quantity of prescribed medication at home in the early hours of 2 September 2018 and died within at most a couple of hours. The local pharmacy had not been told about a safety plan under which Sam’s parents were responsible for her medication. The report identified a concern that, without national action to ensure pharmacies are involved in medication safety plans for mental health patients aged 16–17, similar fatalities could occur.

Zeyna Partington · Prevention of Future Deaths report View report

27 May 2021 Manchester North J. Kearsley

Zeyna Partington was reported missing on 8 August 2019 and was believed to be at risk of suicide. Her vehicle was detected by ANPR in Derbyshire, but GMP did not become aware of this until 10 August; she was then found deceased in a nearby field after taking an overdose of prescribed medication. The substantive concerns included inadequate understanding of ACT marker levels, delays or gaps in national ANPR notification, and the absence of a fully implemented national system across all forces.

Ryan Gareth TAYLOR · Prevention of Future Deaths report View report

25 May 2021 Cornwall and Isles of Scilly G. Davies

Ryan Gareth TAYLOR died after his vehicle lost control and collided with another vehicle while aquaplaning on converging surface water during heavy rain. The principal concerns were that road drainage allowed surface water from Coliza Hill to converge with water on the A390, a similar aquaplaning incident had occurred previously, and feasible drainage improvements had not yet been implemented.

James Devenny · Prevention of Future Deaths report View report

25 May 2021 Mid Kent and Medway I. Brownhill

James Devenny died in his cell at HMP Elmley on 2 September 2019, having been found hanging from a light fitting using a bedsheet ligature. The jury identified concerns including staff not being aware of his previous self-harm history, the absence of a medical assessment before his separation from other prisoners, an inappropriate response to mental health referrals, and inadequate access to phones and support services. The report also records concerns about prison officers not being routinely briefed about prisoners’ previous significant self-harm and related patterns of thoughts, feelings, events and behaviours.

Ryan Gareth TAYLOR · Prevention of Future Deaths report View report

25 May 2021 Cornwall and Isles of Scilly G. Davies

Ryan Gareth TAYLOR died after losing control of his Jaguar XF when surface water converged on the A390 during heavy rain, causing aquaplaning and a collision. The principal concerns were inadequate road drainage, a previous similar aquaplaning incident at the same location, and feasible drainage improvements that had not yet been implemented.

Matthew MACKELL · Prevention of Future Deaths report View report

25 May 2021 North West Kent A. Blunsdon

Matthew MACKELL was found dead on 7 May 2020 in Dunorlan Park after suspending himself from a tree using a bedsheet as a ligature. The previous evening, he had telephoned Kent Police stating that he intended to kill himself, but the call was not accurately located or treated as a suicide call. The concerns included inadequate training and procedures for using the enhanced mobile-phone location system, grading suicide calls, and recording and monitoring staff training.

Christopher Lloyd TAYLOR · Prevention of Future Deaths report View report

25 May 2021 Lincolnshire P. Smith

Christopher Lloyd TAYLOR died after falling from his bicycle and being run over by an agricultural crop sprayer on a narrow rural road on 15 June 2020. The principal concern was that a screen mounted inside the sprayer’s cab created a blind spot, preventing the driver from seeing the cyclist; the screen had no function while driving on the public highway and did not need to be fixed in place.

KENNETH SMITH · Prevention of Future Deaths report View report

24 May 2021 Manchester West T. Brennand

Kenneth Smith, who had cognitive impairment and was at high risk of falls, died on 9 November 2020 after falling at a care home and developing acute-on-chronic subdural haematomas. The report raised concerns about reducing his supervision, failing to set a review date, inadequate escalation of care after further falls, and insufficient consideration of medication and mental-health factors in assessing his falls risk.

Roger Edward Humphrey Ballard · Prevention of Future Deaths report View report

24 May 2021 Manchester South A. Mutch

Roger Edward Humphrey Ballard was admitted to hospital with a head injury, and a CT scan showed a contusion and subarachnoid haemorrhage. His anticoagulation medication was not stopped despite neurosurgical advice, and he was later readmitted with a catastrophic bleed. Concerns included unclear reporting and recording of the scan findings and inadequate documentation of clinical decisions, including the decision not to follow specialist advice.

Dyllon Shaun Graham Milburn · Prevention of Future Deaths report View report

21 May 2021 Manchester City Z. Golombeck

Dyllon Shaun Graham Milburn died on 8 October 2019 in the garden of his home in Manchester from asphyxiation using a ligature made from a scarf. He had been prescribed Sertraline and had periods of non-compliance. The report raised concern that the repeat-prescription system did not allow automated alerts to remind patients to request and collect their medication.

Martin Gibbons · Prevention of Future Deaths report View report

21 May 2021 Manchester South A. Mutch

Martin Gibbons attempted to take his own life on 19 March 2020 and was taken to hospital, where he was assessed as needing admission to a psychiatric ward. While waiting for a bed, he left the hospital unobserved and was found dead on 24 March 2020; the inquest concluded suicide. Concerns included differing assessments of risk between acute and mental health trusts, the absence of shared risk assessments and care plans, and delays in obtaining a mental health bed.

Morris REDDINGTON · Prevention of Future Deaths report View report

21 May 2021 Nottinghamshire L. Bower

Morris Reddington died from a rare stroke involving basilar artery thrombosis, likely caused by dissection of the right vertebral artery. The report identified delays in diagnosis and concerns that electronic ambulance handover records were not routinely reviewed, as well as limited out-of-hours access to mechanical thrombectomy. It also raised concerns about the risk of future deaths from failures in patient-information handover and geographical disparities in access to thrombectomy.

Anastasia Ekaterina UGLOW · Prevention of Future Deaths report View report

20 May 2021 Avon M. Voisin

Anastasia Ekaterina Uglow became increasingly unwell during a school trip to New York after having been unwell beforehand. She developed septic shock, collapsed in cardiac arrest and died at Mount Sinai Hospital on 19 December 2019. The principal concern was the need to raise awareness of sepsis in schools, including among staff supervising school trips.