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Rebecca Jane Hursey · Prevention of Future Deaths report View report

9 Mar 2020 Inner West London F. Wilcox

Rebecca Jane Hursey died at St George’s Hospital on 4 May 2018 after taking an aspirin overdose while detained under Section 3 of the Mental Health Act and receiving care on the Avalon Ward. The report identifies concerns about suicidal-risk information not being verbally communicated during handover, observations and searches not mitigating her self-harm risk, and the prolonged failure to find a suitable alternative placement.

Carl John Newman · Prevention of Future Deaths report View report

6 Mar 2020 Liverpool and the Wirral A. Rebello

Carl John Newman, aged 23, died by suicide after fashioning a ligature around his neck in a prison cell toilet area on 6 October 2017. The report identified concerns about delayed completion of a Day Two Assessment and prison staff’s access to, and records of, current ACCT and SASH training.

Name not published · Prevention of Future Deaths report View report

6 Mar 2020 Inner North London R. Brittain

████████ ingested cocaine, suffered a basilar artery occlusion and posterior stroke, underwent thrombolysis and thrombectomy, and was declared brainstem dead on 13 June 2019. Concerns related to limited public awareness of the stroke risks associated with cocaine use and variation in access to thrombectomy services.

Mr Sanchez-Figueroa · Prevention of Future Deaths report View report

4 Mar 2020 East London N. Persaud

Mr Sanchez-Figueroa, a long-distance lorry driver, suffered a severe head injury after a likely fall from the back of his trailer and died in hospital on 23 December 2018. The concerns included the absence of a hand hold or grab rail for entering trailers, the potential use of an unsecured metal prop/stay for this purpose, and the lack of equipment to assist with required checks inside the lorry.

Shaun Lea Turner · Prevention of Future Deaths report View report

3 Mar 2020 Manchester South A. Mutch

Shaun Lea Turner was found unresponsive at home after ingesting a fatal amount of codeine. The inquest concluded that his death was suicide, with drug toxicity on a background of bronchopneumonia. His family raised concerns about delays in accessing appropriate mental health services and the effect of a missed call from those services.

Eileen Pollard · Prevention of Future Deaths report View report

3 Mar 2020 South Yorkshire (West) A. Combes

Eileen Pollard became unwell with symptoms of a myocardial infarction while receiving respite care at Buckingham Care Home and was later taken to hospital, where she died. During her admission, concerns were raised that her nurse call bell had not been answered or was not working. The report identified that daily call-bell checks were recorded on a pre-populated form, which could result in missed checks or failures not being recorded correctly.

Lee Leslie Carpenter · Prevention of Future Deaths report View report

3 Mar 2020 East London N. Persaud

Lee Leslie Carpenter took his own life on 1 October 2019 after being referred by his GP to mental health services for an urgent review. Concerns included the referral being triaged as non-urgent without a documented rationale or discussion with Mr Carpenter or the GP, a lack of robust risk assessment, care planning and medication review, and the absence of a response when the Home Treatment Team visited his home on the day of his death. The report also identified no system for clearly documenting important clinical triage decisions or identifying the staff member responsible.

Katrina Margaret Mary O’Hara · Prevention of Future Deaths report View report

3 Mar 2020 Dorset B. Allen

Katrina Margaret Mary O’Hara was stabbed by her ex-partner outside her place of work on 7 January 2016 and was pronounced deceased at the scene. The report raises concerns about police handling of non-emergency domestic abuse calls, recognition of a perpetrator’s suicide risk, provision of replacement phones when victims’ phones are seized, and the use and training of the Niche police software system.

Gary Dean Webster · Prevention of Future Deaths report View report

2 Mar 2020 West Yorkshire Eastern K. McLoughlin

Gary Dean Webster died after a boat capsized while he was attempting to retrieve a propane gas cylinder from turbulent water at a weir. He was immersed for approximately 15 minutes, suffered cardiac arrest and multi-organ failure, and died in hospital. The principal concerns were the absence of a suitable risk assessment and approved method statement, ineffective permissioning and competence checks for safety-boat operation, and design shortcomings that exposed workers to hazardous water during debris-retrieval tasks.

HARRY RICHFORD · Prevention of Future Deaths report View report

2 Mar 2020 North East Kent C. Sutton-Mattocks

Harry Richford was born at QEQM on 2 November 2017 and died at William Harvey Hospital on 9 November 2017 after being transferred there. The report describes delays in delivery, shortcomings in the caesarean delivery and neonatal resuscitation, and subsequent hypoxia and brain injury. Substantive concerns included locum recruitment, assessment and supervision; clarity about escalation to consultants; neonatal resuscitation training; record keeping and adherence to guidelines; and inaccurate death notifications and reporting.

Sophie Hannah May Boothe · Prevention of Future Deaths report View report

2 Mar 2020 Hampshire (Central) S. Marsh

Sophie Hannah May Boothe had a history of mental health issues and died in a hotel in Hook on 19 June 2019 after an overdose and subsequent contact with mental health services. Concerns were raised that information about her treatment in Australia was not properly reviewed or understood, contributing to the downgrading of her urgent referral, and that poor communication between services led to missed opportunities for assessment and intervention.

Mrs Ibiyemi Ereohah · Prevention of Future Deaths report View report

2 Mar 2020 East London N. Persuad

Mrs Ibiyemi Ereohah attended hospital with abdominal pain and anaemia, and investigations concerning a possible sarcoma were followed by delays and deficiencies in assessment and surgical planning. She underwent a hysterectomy on 30 August 2018 and was subsequently diagnosed with a high-grade uterine sarcoma; she died from metastatic leiomyosarcoma on 17 September 2018. The substantive concerns included inadequate gynae-oncology consultant cover and a delayed consultant review of her fitness for surgery.

Irene Whittingham · Prevention of Future Deaths report View report

28 Feb 2020 Manchester West R. Syed

Irene Whittingham died at The Royal Bolton Hospital on 31 July 2019 from the toxic effects of a Vitamin D overdose. An incorrect discharge prescription recorded Vitamin D as twice daily, and no monitoring advice was provided while she was taking high doses in the community. Concerns included conflicting guidance on blood-level monitoring and software dropdown options that permitted a potentially unsafe dosage.

Lewys Ryan Aidan CRAWFORD · Prevention of Future Deaths report View report

28 Feb 2020 South Wales Central G. Hughes

Lewys Ryan Aidan CRAWFORD was admitted to A&E on 21 March 2019 while likely in the early stages of meningococcal disease and died on 22 March 2019 after transfer to the Paediatric Critical Care Unit. The report identified missed opportunities to recognise sepsis, failure to administer antibiotics before 11:30pm, and concerns about staff training, use of sepsis guidance, terminology, and alternative antibiotic administration methods.

Peter COLE · Prevention of Future Deaths report View report

28 Feb 2020 Hertfordshire G. Sullivan

Peter Cole was an older person with dementia who overdosed on Tramadol, which had been supplied on repeat prescription. The report raised concerns that repeat medication was not being adequately monitored, leading some older or mentally impaired patients to accumulate dangerous quantities of unused prescribed drugs and contributing to waste of healthcare resources.

Mr Kenneth Clarke · Prevention of Future Deaths report View report

27 Feb 2020 Derby and Derbyshire E. Serrano

Mr Kenneth Clarke, a 74-year-old resident of a nursing home with dementia and a high risk of choking, left his room on 23 July 2017, accessed bread that had been left out, choked and died. The inquest identified that the nursing home had no formal policies covering resident observation, food storage, kitchen and cupboard locks, dementia residents, or residents on a liquid food diet.

Mr Mohan Acharya · Prevention of Future Deaths report View report

27 Feb 2020 Northamptonshire H. Shah

Mr Mohan Acharya died at Northampton General Hospital on 8 March 2018 from bronchopneumonia causing sepsis or infection, hypovolemia and cardiac arrest. The report raised concerns about emergency department crowding, which is associated with increased mortality among admitted patients and was reported to cause approximately 500 deaths per year.

Jack Postle · Prevention of Future Deaths report View report

26 Feb 2020 Hertfordshire G. Sullivan

Jack Postle was delivered by emergency caesarean section on 29 September 2017 after two missed opportunities for earlier delivery, and died on 5 October 2017 following treatment in a specialist neonatal unit. The principal concerns were insufficient capacity at the maternity unit to provide safe care and guidance that limited the availability of caesarean section in some circumstances.

Mr. Thomas REILLY · Prevention of Future Deaths report View report

25 Feb 2020 Brighton and Hove V. Hamilton-Deeley

Mr Thomas REILLY visited Beachy Head on 1 October 2019 intending to jump, but changed his mind after receiving support. A safeguarding alert was delayed and then sent to an individual mailbox rather than the appropriate generic mailbox; it was actioned after Mr Reilly had been found dead early on 3 October. The report identified a missed opportunity to prevent his suicide and stated that the safeguarding system was fundamentally flawed and needed urgent review.

Elaine Rose Renshaw · Prevention of Future Deaths report View report

25 Feb 2020 Manchester South A. Mutch

Elaine Rose Renshaw was found unresponsive at home, resuscitated and taken to Tameside General Hospital, where she died on 8 July 2019 after attempts to reverse the effects of morphine were unsuccessful. The inquest identified inaccurate controlled-drug checks and accounting, with concern that the absence of a clear process for recording controlled-drug use could lead to similar problems in other care and nursing homes.