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Rachel Bernadette Johnston · Prevention of Future Deaths report View report

26 Mar 2021 Worcestershire D. Reid

Rachel Bernadette Johnston, who had significant physical and learning disabilities, underwent dental surgery and was discharged to Pirton Grange Nursing Home, where she developed aspiration pneumonia and an unsurvivable hypoxic brain injury. She died there on 13 November 2018. The principal concerns were inadequate physiological observations and failure to seek emergency medical assistance, followed by inadequate internal investigation and disciplinary procedures concerning the nurses involved, including delayed reporting to the NMC.

Clara Ellen Freeman · Prevention of Future Deaths report View report

26 Mar 2021 Plymouth, Torbay and South Devon S. Covell

Clara Ellen Freeman suffered an unwitnessed fall at a care home and remained immobilised on the floor for approximately four hours while awaiting an ambulance. She later died in hospital after developing medical complications. The principal concerns related to staff proficiency in caring for her after the fall and communicating relevant information, including changes in her condition, to the ambulance service.

Lee David Marsden · Prevention of Future Deaths report View report

26 Mar 2021 Manchester North M. Cox

Lee David Marsden was struck by a vehicle on the M66 motorway on 20 December 2019 after accessing the carriageway on foot, sustaining fatal injuries. Concerns included delays in activating a 30 mph warning, ineffective communication between Highways England and North West Motorway Police Group, and the absence of an internal review by Highways England.

Azra Parveen HUSSAIN · Prevention of Future Deaths report View report

25 Mar 2021 Birmingham and Solihull E. Brown

Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.

Sheldon Gary Farnell · Prevention of Future Deaths report View report

25 Mar 2021 Sunderland D. DL

Sheldon Gary Farnell, aged 4 years, died at Sunderland Royal Hospital on 26 November 2018 after presenting very unwell and being admitted to hospital. He was discharged before antibiotics could be given for adverse blood test results, and he could not be recalled. The concerns included sepsis recognition and training, the timely prescribing of antibiotics, and providing families with contact details at admission and discharge.

Sean Daniel FEGAN · Prevention of Future Deaths report View report

25 Mar 2021 Nottinghamshire G. Clow

Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.

Bruce Lee Houghton · Prevention of Future Deaths report View report

18 Mar 2021 Manchester North J. Kearsley

Bruce Lee Houghton died at home on 16 April 2020 from combined drug toxicity, with excess paracetamol likely causing liver damage and accumulation of his other medications. The report states that he had not had his annual medication review, and that these reviews did not ask patients about over-the-counter medicines they purchased in addition to prescribed medication.

Benjamin Rajinder O’HARA · Prevention of Future Deaths report View report

17 Mar 2021 Inner North London M. Hassell

Benjamin Rajinder O’Hara died after jumping from the fourth floor balcony of his home on 2 November 2020, following repeated contacts with mental health services and episodes of suicidal thoughts and psychosis. Concerns included that professionals did not ask permission to contact his family, an outdated hospital-admission alert was not reviewed, a review was not a formal mental health assessment, and he had no care co-ordinator or other community mental health team member overseeing his care.

Timothy Julian STEELE · Prevention of Future Deaths report View report

15 Mar 2021 Brighton and Hove V. Hamilton-Deeley

Timothy Julian STEELE was a 28-year-old man with a lifelong history of low mood, depression and suicidal ideation, who made multiple suicide attempts during 2020 and died at his home in Brighton on 10 August 2020. The report identified concerns that his referral was lost, that he was not followed up because of inefficient processes and failure to appoint a Lead Practitioner promptly, and that the Care Programme Approach was not followed. It also identified a fragmented approach to policies across different areas of Sussex.

Jamie Lee Poole · Prevention of Future Deaths report View report

15 Mar 2021 Stoke-on-Trent and North Staffordshire E. Serrano

Jamie Lee Poole, who had received a kidney transplant and was taking immunosuppressant medication, was admitted with low magnesium and calcium levels before collapsing in hospital on 28 June 2017. She died on 2 July 2017 after developing significant brain swelling; the recorded causes included cerebral oedema and electrolyte disarray with calcium and magnesium deficiencies. The report raised concern that routine magnesium monitoring for transplant patients varied between healthcare trust areas.

Joe Peter Robinson · Prevention of Future Deaths report View report

15 Mar 2021 Manchester South A. Mutch

Joe Peter Robinson became unwell and collapsed near Ashton Canal in the early hours of 14 June 2020, and attempts to resuscitate him were unsuccessful. The post-mortem examination found that he died from a combination of MDMA and ketamine. The concerns included the absence of first-aid or paramedic facilities at a large unlicensed gathering, and uncertainty about whether lessons concerning policing plans had been shared and embedded across other force areas.

James Kenneth Herbertson · Prevention of Future Deaths report View report

15 Mar 2021 West Sussex P. Schofield

James Kenneth Herbertson took his own life after being struck by a train near Crawley train station on 10 April 2019. Concerns included unsuitable discharge accommodation and failures to recognise and act on signs of a mental health relapse, including not referring him to the crisis team or providing additional support.

Lesley Powell · Prevention of Future Deaths report View report

12 Mar 2021 Brighton and Hove G. Tisshaw

Lesley Powell was hit by a motor vehicle while crossing the A2100 Battle Hill and died at hospital on 4 January 2020. The report identified the absence of a safe crossing point and a history of seven incidents on or near the road between August 2016 and December 2019, including fatal and serious-injury incidents.

Elizabeth Robinson · Prevention of Future Deaths report View report

12 Mar 2021 Gwent C. Saunders

Elizabeth Robinson, an 87-year-old woman at Ysbyty Ystrad Fawr for rehabilitation after hip surgery, fell and sustained a fatal head injury on 21 October 2019. Concerns included inadequate falls-risk assessment and documentation, staffing levels that nurses considered insufficient to deliver safe care, and nursing staff not having seen the internal investigation findings more than a year after her death.

Emma Kate DORMAN · Prevention of Future Deaths report View report

11 Mar 2021 West Yorkshire, Western Division A. Howard

Emma Kate DORMAN died by asphyxiation by hanging on 24 February 2020 after being allowed leave from the Priestley Unit, Dewsbury & District Hospital. The leave was changed at short notice because of bed availability, and the planned visit by the Home Based Treatment Team did not take place. Concerns included non-clinical influence over the leave decision and the lack of psychologist input on the ward for more than three years.

Edward Lewis BILBEY · Prevention of Future Deaths report View report

10 Mar 2021 Derby and Derbyshire R. Hunter

Edward Lewis Bilbey died at Kings Mill Hospital on 24 March 2017 after collapsing in a boxing ring following intensive training. The inquest found that his death resulted from an undiagnosed heart condition combined with metabolic disturbance associated with intense physical training and rapid weight loss by dehydration. The report raised concerns that Boxing England lacked systems to monitor and enforce child protection and safeguarding compliance, and that this issue might be more widespread among national sporting bodies.

Joan Elizabeth Rutter · Prevention of Future Deaths report View report

8 Mar 2021 Blackpool and the Fylde A. Wilson

Joan Elizabeth Rutter, aged 94, was found unresponsive after an unwitnessed fall beside her bed at the rest home on 23 October 2020; the fall resulted in a fatal spinal fracture. The report identified concerns about poor overnight record keeping, staffing and the delivery of night care, and an unplugged falls mat that did not alert staff to her movement.

Rodney Gates · Prevention of Future Deaths report View report

8 Mar 2021 Mid Kent and Medway K. Thomas

Rodney Gates, aged 84, was struck by an HGV while crossing a road and sustained a fracture of the right proximal femur. He deteriorated from bleeding while on a hospital ward and died on 6 April 2018 despite treatment and resuscitation attempts. Concerns included missed clinical observations, low nursing staffing levels, reliance on agency nurses, limited staff experience and skills, and insufficient equipment.

Yvonne COPLAND · Prevention of Future Deaths report View report

8 Mar 2021 Isle of Wight C. Sumeray

Yvonne COPLAND died at the scene after a collision involving the car in which she was a rear-seat passenger, a double-decker bus and a silver Mini Cooper at the junction of Forest Road and Whitehouse Road on the Isle of Wight. The report raises concerns that the junction has poor visibility and a deceptive layout, has a history of serious collisions, and may not be made significantly safer by hedge realignment alone.

Adam Joseph Brunskill · Prevention of Future Deaths report View report

8 Mar 2021 Black Country J. Lees

Adam Joseph Brunskill fell approximately 8 metres through a fragile glass rooflight while working on a warehouse roof and died the following day from a devastating brain injury. Concerns included his lack of prior roofing experience, accredited training and supervision, together with inadequate safety barriers, designated walkways, safety netting, structured training, supervisory arrangements and appraisal systems.