Search PFD Monitor

JORDAN MICHAEL AIRA · Prevention of Future Deaths report View report

30 Mar 2020 Surrey C. Topping

Jordan Michael Aira was electrocuted after walking onto the railway lines at Ashford Station in the early hours of 23 March 2019. The concerns included inadequate physical barriers, the location of the emergency telephone, warning signs that did not explicitly warn of immediate death from touching the live rail, and no national curriculum requirement to teach pupils about the risk posed by live rails.

KAREN JANE BINGHAM · Prevention of Future Deaths report View report

30 Mar 2020 Surrey C. Topping

Karen died by hanging at her home on 18 November 2017 after contacting police and ambulance services. The jury identified concerns about the safeguarding plan used when she was informed that her perjury allegation was being filed, including insufficient information gathering, failure to involve mental health services, and inadequate multi-agency planning. The report also identified concerns about police mental health training and the understanding between police and ambulance services of each other’s triage and dispatch processes.

Mr. Joseph John MOCHAN (otherwise Joseph John LOPEZ) · Prevention of Future Deaths report View report

25 Mar 2020 Brighton and Hove V. Hamilton-Deeley

Joseph John Mochan, otherwise Joseph John Lopez, was living in a tent in Brighton and died on 11 October 2019. The inquest concluded that the death was misadventure and drug-related. The report raised concerns about homelessness and the lack of coordinated access to safe accommodation, hygiene, food, warmth, and healthcare services.

Dudley Stanley HOWE · Prevention of Future Deaths report View report

25 Mar 2020 Norfolk J. Lake

On 6 October 2017, Dudley Stanley HOWE was struck by a lorry while crossing Station Road, Attleborough, and died from his injuries. The substantive concerns relate to the lack of mandated HGV training on Class VI mirrors and the inconsistent provision of Safe Urban Driving or Vulnerable Road User Awareness training.

Simon Anthony Delahunty · Prevention of Future Deaths report View report

24 Mar 2020 North London A. Walker

Simon Anthony Delahunty took an overdose of medication prescribed for another patient, which had been left at an address as part of end-of-life care. The principal concern was that there were no arrangements or guidance for collecting or disposing of unused end-of-life prescription medication.

Sonny Bob Parmar · Prevention of Future Deaths report View report

24 Mar 2020 North London A. Walker

Sonny Bob Parmar, aged three, was struck by a car after entering the road near a Pelican crossing while walking with his mother, and died from his injuries at Whittington Hospital. The principal concern was that there was no speed limitation on the road adjacent to the school, unlike in other areas where traffic is slowed during children’s arrival and departure times.

Danny James Holt-Scarpens · Prevention of Future Deaths report View report

24 Mar 2020 Manchester West R. Syed

Danny James Holt-Scarpens was found dead at home on 10 October 2019 after using a rope as a ligature to hang himself, having left goodbye notes. The concerns raised included inadequate interagency information sharing and the failure to make contemporaneous records or document decision-making, including the capacity assessment, during a crisis team telephone assessment.

Kelly Marie SUTTON · Prevention of Future Deaths report View report

24 Mar 2020 Hertfordshire G. Sullivan

Kelly Sutton was found hanging at her home on 23 August 2017 and died in hospital on 26 August 2017. The inquest concluded that her suicide was contributed to by domestic abuse. A principal concern was that non-crime information relevant to safeguarding potential domestic abuse victims was not available as a national police resource.

Lewis Charles Francis · Prevention of Future Deaths report View report

23 Mar 2020 Exeter and Greater Devon N. Rheinberg

Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.

John Francis GREGORY · Prevention of Future Deaths report View report

20 Mar 2020 Inner North London M. Hassell

John Francis Gregory died after developing acute kidney injury associated with low oral fluid intake, in the context of Alzheimer’s disease and old age. Concerns included inadequate encouragement and monitoring of drinking in hospital rehabilitation and residential care, inaccurate fluid-intake records, and failures to escalate or respond to his deterioration at Muriel Street Resource Centre.

John Ashley · Prevention of Future Deaths report View report

16 Mar 2020 West Sussex P. Schofield

John Ashley took his own life while suffering a deterioration in his mental illness, according to the inquest conclusion. The report identified concerns about failures to update his care and treatment plan, record and share key information, review his deterioration and medication non-compliance, and provide adequate clinical oversight and cover arrangements.

IAN JAMES WEEKS · Prevention of Future Deaths report View report

12 Mar 2020 South Wales Central G. Williams

Ian Weeks was remanded into custody at HMP Cardiff and was later found to have hung himself from the shower rail in his cell, sometime between 20 and 21 October 2017. The concerns included that healthcare staff did not check records showing a recent suicide attempt or notice that he had been prescribed antidepressants, and that there was no effective process for reviewing System 1 records or a suicide and self-harm warning flag.

Mitica Marin · Prevention of Future Deaths report View report

12 Mar 2020 East London G. Irvine

Mitica Marin, aged 35, was found unresponsive at home on 11 April 2019 and died in hospital after prolonged resuscitation attempts. The cause of death was unascertained. The LAS investigation identified a four-minute delay in delivering the first defibrillator shock while Mr Marin was in a shockable rhythm, associated with the defibrillator being used in manual rather than automatic mode.

Jason Pendlebury · Prevention of Future Deaths report View report

12 Mar 2020 Manchester North M. Cox

Jason Pendlebury, a known cocaine user, fell from the roof of a block of flats on 29 September 2018 and died in hospital on 2 October 2018 after sustaining serious injuries. The principal concerns related to communication and information-sharing between Greater Manchester Police, North West Ambulance Service, the GP and mental health professionals about his potential mental health needs and risk.

Rifky GROSSBERGER · Prevention of Future Deaths report View report

11 Mar 2020 Inner North London M. Hassell

Rifky Grossberger became entangled in a metal blind cord in her cot on 31 July 2019 and died five days later after resuscitation. The principal concern was that her parents were unaware of the danger, and that safety information about blind cords may not be consistently provided to new parents by leaflets, healthcare professionals or other sources.

Lynda Pedersen · Prevention of Future Deaths report View report

10 Mar 2020 Central and South East Kent P. Harding

Lynda Pedersen died on 7 September 2018 in hospital from aspiration pneumonitis, pneumonia and fluid overload due to a stricture caused by an adenocarcinoma of the oesophagogastric junction. The adenocarcinoma was not identified during her admission or during earlier medical care following an admission for dysphagia. Concerns included the lack of a pathway for investigating dysphagia caused by a stricture, which contributed to the need to investigate malignancy being lost, and deficiencies in fluid balance charting and recording of fluid output before her death.

Darren John Goddard · Prevention of Future Deaths report View report

9 Mar 2020 South Wales Central S. Richards

Darren John Goddard underwent an elective trans-rectal ultrasound of the prostate and subsequently developed sepsis, becoming acutely unwell and dying on 18 April 2019. The principal concerns included delayed recognition and treatment of sepsis, delays in triage, antibiotics, fluids and critical care, and the information provided about sepsis risks and symptoms following the procedure.

Robert Anthony Brown · Prevention of Future Deaths report View report

9 Mar 2020 Staffordshire South A. Haigh

Robert Anthony Brown, a prisoner at Dovegate, was pronounced dead in his cell on 25 December 2018. The inquest recorded accidental death, with aspiration of gastric contents and synthetic cannabinoid receptor antagonists identified as the causes; a concern was that relevant information held in different prison systems was not available to all staff who might have benefited from it.

Arthur Price Hughes · Prevention of Future Deaths report View report

9 Mar 2020 North Wales (East and Central) J. Gittins

Arthur Price Hughes underwent emergency surgery on 20 October 2014, during which significant bleeding occurred; despite further surgical interventions, the injury sustained resulted in his subsequent death. The report raised concerns about the lack of a recognised protocol for observing, assessing and mentoring newly appointed locum staff, and about reluctance to supplement references with telephone calls to referees.

Roy CAMPBELL · Prevention of Future Deaths report View report

9 Mar 2020 Worcestershire D. Reid

Roy Campbell, who had cardiac problems and dementia, was detained under the Mental Health Act and admitted to a hospital ward in July 2018. He left through an insecure gate after staff on another ward mistakenly treated him as a visitor; after being returned to the ward, he suffered cardiac arrest and died in hospital. Concerns included the risk of detained patients absconding because of inadequate visitor identification and environmental checks that were not properly carried out, embedded in Trust policy, or subject to mandatory staff training.