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Ronald Richard TILLEY · Prevention of Future Deaths report View report

4 Dec 2020 North East Kent J. Andrews

Ronald Richard Tilley presented to hospital on 16 October 2019 with a right ischaemic leg after anticoagulation had been stopped because of concerns about his capacity to manage medication. An assessment of his memory and capacity was completed, but the GP did not receive the communications because another surgery had amended the GP and correspondence address on the Personal Demographic Service; the principal concern was that such amendments do not notify the existing GP.

Roy Adrian CURTIS · Prevention of Future Deaths report View report

4 Dec 2020 Milton Keynes T. Osborne

Roy Adrian CURTIS, who had an autistic spectrum condition, was admitted after declaring an intention to take his own life and was later discharged without a formal multidisciplinary discharge plan. He died by suicide by hanging on or about 18 November 2018, and his body was discovered on 21 August 2019. The report raises concerns about the failure to complete an adult social care assessment and the overly bureaucratic procedure for urgent referrals, which did not give such referrals sufficient priority.

WILLIAM STEVEN ISRAEL · Prevention of Future Deaths report View report

3 Dec 2020 North East Kent S. Hayes

William Israel, aged 23, died after entering Canterbury East Railway Station while intoxicated, stepping onto the track and landing on the live rail at approximately 03:45 hours. Concerns included insufficient and inadequately prominent electrocution warnings, the absence of signage at the palisade gates, unimplemented recommendations for under-platform warning signs, and insufficient assessment of risks associated with public access to the station when unstaffed.

Andrew Paul WESTLAKE · Prevention of Future Deaths report View report

3 Dec 2020 County Durham and Darlington J. Thompson

Andrew Paul WESTLAKE was disembarked from a flight in Turkey while appearing frightened, confused and mentally unwell, and later fell 10.2 metres from the second floor of Dalaman Airport, dying in hospital from his injuries on 29 May 2018. The concerns centred on the lack of airline procedures and staff training for safeguarding vulnerable passengers who are disembarked overseas, particularly those travelling alone and experiencing a mental health crisis.

HOLLY CHEVASSUT · Prevention of Future Deaths report View report

2 Dec 2020 Coventry and Warwickshire T. Leeper

On 31 October 2018, Holly Chevassut was walking along an unlit rural lane when she was hit by apparatus protecting the wing mirror of a passing recovery lorry. The concern was that GRS Recovery continued to operate vehicles with mirrors and guards positioned low and projecting beyond the vehicle, creating a risk of injury or death to people overtaken by them.

Ivan Merryfield O’Neill · Prevention of Future Deaths report View report

2 Dec 2020 East London G. Irvine

Ivan Merryfield O’Neill bled to death during a dialysis appointment after a venous needle became dislodged from his arteriovenous fistula. Concerns included his restlessness and frailty, his position outside a clear line of sight from the nurses’ station, and an alarm that did not promptly alert staff to the bleed.

Anthony Slack · Prevention of Future Deaths report View report

1 Dec 2020 Manchester South A. Mutch

Anthony Slack, who had underlying health issues including asbestos-related pulmonary fibrosis, suffered an unwitnessed fall at a care home and waited over four hours for an ambulance. He later deteriorated, was transferred to hospital, and died on 13 April 2020. Concerns included limited care-home documentation and observations, unclear Covid-19 admission risk assessment and PPE arrangements, and ambulance delays linked to pandemic-related capacity pressures.

Ibrahima YAHAIA · Prevention of Future Deaths report View report

1 Dec 2020 Bedfordshire and Luton E. Whitting

Ibrahima YAHAIA, who had memory issues and was a French non-English-speaking national, was fatally struck by a bus while walking along the designated busway in Luton on 15 January 2020. The concerns included unrestricted pedestrian access to the busway, gaps in fencing and inadequate signage, previous serious incidents, alleged design flaws, and no evidence of steps to prevent further injuries or deaths.

Violet Leona Jackman · Prevention of Future Deaths report View report

1 Dec 2020 Manchester South A. Mutch

Violet Leona Jackman was a baby who was found unresponsive on 17 May 2020 in a bed at her home; the Moses basket in which she had been sleeping had tipped over. Concerns included safe-sleeping advice being given only to her mother despite shared care, a lack of detailed checking of sleeping arrangements, and reduced Health Visitor availability during the first wave of Covid-19.

Brandon-Robert William Collins-Hayward · Prevention of Future Deaths report View report

1 Dec 2020 Dorset R. Griffin

Brandon-Robert William Collins-Hayward was born on 29 May 2019 and died on 7 June 2019, aged 9 days, after developing reduced milk intake, a lip shiver, grumbling noises, jaundice, discharge and breathing difficulties. The principal concerns were the lack of national guidance for observations during early postnatal visits and for assessing a baby when the mother is admitted to hospital with infection or possible sepsis.

Peter James Michael Unsworth · Prevention of Future Deaths report View report

1 Dec 2020 Surrey C. Topping

Peter James Michael Unsworth had a history of deep vein thromboses and was taking long-term anticoagulant medication before a right hip replacement. After developing an infected hip and undergoing surgery, his anticoagulant dose was reduced following haematological advice that was not recorded in writing; he subsequently developed pulmonary emboli and died at home on 29 July 2018. The principal concern was that the lack of written records may have led to a misunderstanding of the advice given and its significance.

Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report View report

27 Nov 2020 Inner North London M. Hassell

Agnès Marchessou had experienced fragile mental health for four or five years before her death. After her arrest on 4 July 2020, she was knocked over by a bus on 8 July and taken to hospital. The principal concerns were that police did not pass key information about the incident and her stated reasons for stepping into the road to ambulance or hospital staff, did not promptly make relevant enquiries or record her potential vulnerability, and showed confusion about the required process.

Geoffrey Peter Banks · Prevention of Future Deaths report View report

27 Nov 2020 Stoke-on-Trent and North Staffordshire M. Jones

Geoffrey Peter Banks, aged 64, took 44 co-codamol tablets after pulling open a locked medicine cupboard at his assisted accommodation on 1 January 2020. He was admitted to hospital and died on 8 January 2020 from an acute heart attack; the overdose contributed to his death, although it was not possible to determine whether it was accidental or deliberate. Concerns were raised about the lack of safe medication storage for residents needing supervision and about the apparent investigation being perfunctory and conducted by an untrained staff member.

Lee Elliott · Prevention of Future Deaths report View report

26 Nov 2020 Cumbria N. Shaw

Lee Elliott had experienced mental health difficulties and was found deceased in his bedroom on 6 February 2020. The inquest recorded that he had purchased a chemical from an internet supplier and ingested it, causing his death. The principal concerns were the online promotion of the substance as a suicide method and its easy, inexpensive purchase without safeguards.

Eleanor Emily SHERMAN · Prevention of Future Deaths report View report

26 Nov 2020 Warwickshire S. McGovern

Eleanor Emily SHERMAN died at Warwick Hospital on 20 August 2020 after collapsing at home; a CT scan confirmed a subarachnoid haemorrhage. The report identified two misdiagnoses, failure to read the GP referral letter, and systemic problems with access to the GP’s electronic records and the scanning of notes.

John Joseph Jennings · Prevention of Future Deaths report View report

26 Nov 2020 North London A. Walker

John Joseph Jennings died at home from smoke inhalation during a fire on 18 October 2019, before the London Fire Brigade arrived. Concerns were raised that relevant alarm-monitoring and fire-detection standards were not statutory requirements.

Neville Bardoliwalla · Prevention of Future Deaths report View report

26 Nov 2020 North London A. Walker

Neville Bardoliwalla was found at home on 10 March 2020 after hanging himself from two screws in a door frame. Evidence was heard that he had accumulated prescribed controlled medication and that there was no process for collecting and disposing of it.

Thomas William Browne · Prevention of Future Deaths report View report

25 Nov 2020 South Wales Central D. Regan

Thomas William Browne, a highly vulnerable patient dependent on non-invasive oxygen ventilation, was found collapsed in a hospital toilet on 17 July 2018 after being left there unaccompanied. His oxygen cylinder was exhausted when he was found, and the inquest concluded that he died from natural causes. Concerns included the absence of systems to monitor patients dependent on finite oxygen supplies, deficiencies in the root cause analysis, incomplete oxygen-administration training, and the lack of formal procedures for recording when oxygen supplies would expire.

Trinder Kaur Birdi · Prevention of Future Deaths report View report

25 Nov 2020 East London N. Persaud

Trinder Kaur Birdi had a history of depression and personality disorder and was assessed as at high risk of suicide after reporting two paracetamol overdoses. Following assessment by a psychiatric nurse, the risk was reduced to low and a non-urgent Community Mental Health Team referral was made; she was later admitted with acute liver failure and died from the likely effect of self-administered drug toxicity. The principal concern was that her suicide risk was downgraded without consultation with the general practitioner, a documented second opinion, or assessment by a psychiatric doctor, and that safeguards were absent in these circumstances.

Mrs Ann Patricia Ellen Schuetz · Prevention of Future Deaths report View report

24 Nov 2020 Northamptonshire H. Shah

Mrs Ann Patricia Ellen Schuetz died at Northampton General Hospital on 26 June 2018 following an allergic reaction to Ramipril. The report identifies concerns that her known allergy was not recorded across relevant electronic systems, which allowed Ramipril to be restarted and continued to be prescribed.