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Daniel AKAM · Prevention of Future Deaths report View report

10 Dec 2019 South Yorkshire (Eastern) G. Gibbs

Daniel Akam, a vulnerable prisoner with a history of depression, self-harm, low mood and anxiety, was found unresponsive in his cell with a rope ligature around his neck and was declared deceased. The report identified concerns about an inadequate final ACCT review, missed and inaccurately recorded observations, and inadequate ACCT training for prison officers.

John Michael WELLS · Prevention of Future Deaths report View report

9 Dec 2019 West Sussex R. Simpson

John Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.

Matthew Colin FITTEN · Prevention of Future Deaths report View report

7 Dec 2019 Suffolk N. Parsley

Matthew Fitten was found deceased at home on 17 April 2020, and toxicology identified a toxic quantity of methadone in his blood. During the COVID-19 pandemic, his methadone collection was changed from three times per week to fortnightly, but he received three large bottles without a measuring jug or instructions for accurately measuring his prescribed daily dose. The report identifies concerns that this increased access to methadone and the lack of suitable dosing arrangements contributed to his death.

Kamil Iddrisu and Youngson Nkhoma · Prevention of Future Deaths report View report

6 Dec 2019 Birmingham and Solihull L. Hunt

Kamil Iddrisu and Youngson Nkhoma collapsed during separate military selection runs at Whittington Barracks and later died after being taken to Good Hope Hospital. Both were found to have sickle cell trait, metabolic acidosis, acute kidney injury and rhabdomyolysis, and the final causes of death remained under investigation. The principal concern was that non-UK candidates may be at serious risk of collapse, harm or death during military exercise without screening for sickle cell trait.

MAUREEN WHARTON · Prevention of Future Deaths report View report

6 Dec 2019 Gateshead and South Tyneside T. Carney

Maureen Wharton contacted ambulance services after stating that she had taken several medications and wanted to end her life. An ambulance arrived at her flat several hours after her first call, by which time she was deceased; a post-mortem attributed her death to the combined effects of Tramadol, Venlafaxine, Zopiclone and alcohol. Concerns focused on the delayed response, the assessment and grading of the calls, and missed opportunities to arrange timely support or assistance from family, other agencies, or emergency services.

Ms Safoora Alam · Prevention of Future Deaths report View report

6 Dec 2019 Black Country Z. Siddique

Ms Safoora Alam had complex physical health problems, ongoing pain and mobility issues, and a history of impulsive overdoses and suicidal thoughts. On 28 January 2019, she set fire to her bed and herself, sustained burns to at least 80% of her body, and died later that day. The principal concerns were inconsistent sharing of documentation between agencies, inadequate joint working and information gathering, and a slow and ineffective urgent referral process when risks to her mental health escalated.

Gemma Louise Macdonald · Prevention of Future Deaths report View report

5 Dec 2019 Suffolk J. Devonish

Gemma Louise Macdonald died on 22 July 2019 after taking a massive overdose of medication at home, including medicines purchased online. The report raised concerns about the availability of large quantities of medication online, whether purchaser suitability was assessed, and whether transactions were limited by quantity and ordering frequency.

Darren WILSON · Prevention of Future Deaths report View report

5 Dec 2019 Lincolnshire T. Brennand

Darren WILSON died at the scene after his car collided with vehicles during an overtaking manoeuvre on 20 April 2019. The inquest heard concerns that the collision location was a known accident hotspot and lacked traffic-calming measures, including a reduced speed limit and double white lines to prevent overtaking.

Gareth Wycliffe WARBURTON · Prevention of Future Deaths report View report

4 Dec 2019 Worcestershire D. Reid

Gareth Wycliffe Warburton had undergone a double lung transplant and was taking anti-rejection medication when he arrived at HMP Hewell. A prescription error resulted in him receiving half his usual dose, and he died after chronic rejection of his transplanted lungs. The report raised concerns about prescription systems, staffing and the handling of important health-related correspondence at the prison.

Jessica Louise Duckworth · Prevention of Future Deaths report View report

4 Dec 2019 West Yorkshire Eastern K. McLoughlin

Jessica Louise Duckworth, aged 23, died after falling from the Scammonden Bridge over the M62 motorway and being struck by passing vehicles. The report raised concern that the bridge was a notorious suicide location and that fencing or other measures should be considered to prevent people falling from it.

Callie Lewis · Prevention of Future Deaths report View report

3 Dec 2019 Central and South East Kent P. Harding

Callie Lewis had chronic suicidal ideation and was actively planning to end her life, later dying by carbon monoxide poisoning after travelling to a remote location. The inquest concluded that her death was suicide by carbon monoxide poisoning contributed to by neglect. A substantive concern was that an online pro-suicide forum provided advice on methods of suicide and on misleading mental health professionals, frustrating assessment and enabling her to take her life.

David Stewart MOORE · Prevention of Future Deaths report View report

3 Dec 2019 County Durham and Darlington J. Chipperfield

David Stewart Moore died after being struck by a motor car while crossing an unlit section of the A693 at around 1830hrs on 28 January 2019. The principal concerns were that the location was a natural pedestrian crossing point without street lighting, was in complete darkness, and had a 60mph speed limit, leaving drivers insufficient distance to detect and stop for pedestrians.

Luke Morris Jones · Prevention of Future Deaths report View report

3 Dec 2019 North Wales (East and Central) J. Gittins

Luke Morris Jones, a prisoner at HMP Berwyn, was found unresponsive after smoking a novel psychoactive substance and died on 31 March 2018 despite medical intervention. The report identified concerns about the accessibility and continuing availability of novel psychoactive substances in the prison and the associated risks to health.

Sidney Clarence Baker · Prevention of Future Deaths report View report

2 Dec 2019 Manchester West R. Syed

Sidney Clarence Baker, a frail elderly man with multiple co-morbidities, died at the Royal Albert Edward Infirmary in Wigan after a deterioration in health and treatment for acute kidney injury following a fall. The report raised concerns that required dietician and falls-team referrals were not documented, and that care-plan entries, including weight-monitoring information, were incorrect and record keeping was generally poor.

Archie David SPRIGGS · Prevention of Future Deaths report View report

2 Dec 2019 Shropshire, Telford and Wrekin J. Ellery

Archie David Spriggs was murdered by his mother on the morning of 21 September 2017, during a bitter dispute between his parents and on the day of a scheduled child arrangements hearing. The report’s concerns, based on a Serious Case Review, included referral and decision-making processes, responses to urgent safeguarding information, the impact of prolonged private law proceedings, assessment of separated-parent cases and allegations of domestic abuse, and multi-agency working with fathers and families.

Connor William DAVIES · Prevention of Future Deaths report View report

29 Nov 2019 South Wales Central G. Williams

Connor William Davies was found suspended by a ligature at a residential address on 13 April 2019 and died by hanging; the inquest recorded a verdict of suicide. The principal concern was that repeated cancellations of his mental health appointments did not trigger clinical review for urgent referral, creating a risk that patients in serious need could fall through the net.

Suzanna Jayne Bull · Prevention of Future Deaths report View report

29 Nov 2019 Birmingham and Solihull L. Hunt

Dr Suzanna Bull died after being struck and dragged beneath a 32-tonne lorry while cycling in a designated bus/cycle lane on 9 October 2017. The lorry driver's aftermarket dashboard tray and items placed on it obscured the front and nearside view, creating a blind spot. The substantive concerns were the absence of warnings that such trays can create blind spots and should not be fitted while a vehicle is moving.

LEAH LOUISE CAMBRIDGE · Prevention of Future Deaths report View report

29 Nov 2019 West Yorkshire (East) K. McLoughlin

Leah Louise Cambridge, aged 29, travelled to Izmir, Turkey, for a Brazilian Butt Lift under general anaesthetic and died during the procedure on 27 August 2018. A post-mortem examination found that fat had entered veins in her body, causing a fat embolism. The concerns included continued UK involvement in BBL procedures, inadequate informed consent, and a lack of regulatory intervention and control.

Mrs Brenda McWilliams · Prevention of Future Deaths report View report

29 Nov 2019 Manchester North P. Sigee

Mrs Brenda McWilliams, who had Alzheimer's disease and remained immobile after discharge from hospital to a residential care home, died on 3 January 2019. A post-mortem examination found that she died from a pulmonary thromboembolism caused by a deep vein thrombosis associated with her immobility. The principal concern was that medication to minimise the risk of venous thromboembolism was not continued or prescribed after her hospital discharge despite her recognised high risk and the potentially life-threatening consequences.

Thomas Wedrychowski · Prevention of Future Deaths report View report

28 Nov 2019 Wiltshire and Swindon N. Rheinberg

Thomas Wedrychowski had paranoid schizophrenia and had been prescribed antipsychotic medication for a number of years. Expert evidence indicated that the medication caused diabetes and contributed to morbid obesity; the medical cause of death was recorded as diabetic ketoacidosis and medication-induced diabetes mellitus. Concerns included whether higher-risk patients should receive more frequent diabetes monitoring and whether physical healthcare findings were adequately shared between primary and secondary care providers.