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Averil Skoric · Prevention of Future Deaths report View report

15 Nov 2019 Manchester South A. Mutch

Averil Skoric, who had vascular dementia, frailty and very limited mobility, was placed in bed on her back in a care home on 3 March 2018 and found on her front the following day. The report states that she died from positional asphyxia after moving into an unsafe sleeping position. The concern was that there was no clear local or national guidance for safely positioning vulnerable adults during sleep and overnight care.

Francesca Margaux Sio · Prevention of Future Deaths report View report

15 Nov 2019 South London J. Landau

Francesca Margaux Sio died from a massive pulmonary tumour embolism caused by a previously undiagnosed sacro-coccygeal yolk sac tumour. Three days before her death, she waited nearly four hours for a doctor at an urgent care centre before being referred to the paediatric accident and emergency department. Expert evidence raised concern that mixing adult and child patients in urgent care centres risked children deteriorating unnoticed.

Jamil Ahmed · Prevention of Future Deaths report View report

15 Nov 2019 Birmingham and Solihull J. Bennett

On 18 August 2017, Jamil Ahmed’s lorry stopped on the hard shoulder of a smart motorway, and he was fatally injured when another lorry travelling at 55mph collided with it 135 seconds later. The report raised concerns about the use of the hard shoulder as a running lane, including high traffic speeds and volumes, limited escape options, and the suitability of this stretch of motorway given the significant drop beside the hard shoulder.

Mary Josephine Hoare · Prevention of Future Deaths report View report

15 Nov 2019 Birmingham and Solihull E. Brown

Mary Josephine Hoare died on 16 May 2019 at Queen Elizabeth Hospital from catastrophic injuries sustained after deliberately climbing over the balcony of her second-floor apartment and falling. The report raised concerns that she was accepted into unsuitable independent living accommodation without full information about her recent mental health history, adequate suitability assessment, care planning or risk assessments. It also remained a concern that other applicants might be accepted into supported living settings without being fully assessed.

Serena Jane Nicholas · Prevention of Future Deaths report View report

14 Nov 2019 West Yorkshire Eastern K. McLoughlin

Serena Jane Nicholas was born by category 1 emergency Caesarean section on 29 August 2017 after fetal bradycardia and died shortly afterwards at Leeds General Infirmary from intrauterine hypoxia, with the pregnancy also involving a diabetic mother and a fetal heart abnormality. Concerns included disjointed management and a lack of identified consultants overseeing the high-risk pregnancy, as well as inadequate continuity of care and monitoring, meaning reduced fetal activity and the potential desirability of an earlier Caesarean section were not recognised.

Joanna Clare Alice Flynn · Prevention of Future Deaths report View report

14 Nov 2019 Essex C. Beasley-Murray

Joanna Clare Alice Flynn, aged 31, was found slumped over her bed on 26 May 2019 after last being seen on 23 May 2019. The inquest returned an Open conclusion against a background of long-standing prescribed opiate addiction, with concerns about the lack of specialised support and referral pathways for patients needing help to withdraw from addictive prescription drugs, as well as GP training and education.

Edward McGivern · Prevention of Future Deaths report View report

14 Nov 2019 Berkshire A. McCormick

Edward McGivern was cycling to work on Dover Road, Slough Trading Estate, on 9 November 2018 when his bicycle collided with a heavy goods vehicle turning left at a traffic-light-controlled junction. He sustained multiple injuries and died at the scene. The concern was that the road layout and cycle lanes may place cyclists at continuing risk of being struck by motor vehicles turning left at junctions.

Evha Jannath · Prevention of Future Deaths report View report

13 Nov 2019 Staffordshire South M. Jones

Evha Jannath, aged 11, fell into deep water during a water rapids ride at Drayton Manor Theme Park after being projected from a boat and later falling from a wet conveyor belt. She was located and recovered after 18 minutes. The principal concerns included inadequate CCTV monitoring, lack of safety warnings, worn or incomplete signage, insufficient water-rescue training and equipment, and unclear emergency procedures.

Dorothy June MACEY · Prevention of Future Deaths report View report

13 Nov 2019 Mid Kent and Medway S. Hayes

Dorothy June MACEY sustained leg injuries when her legs went through a glass door and was later discharged home with district nurse dressing care. Antibiotics prescribed in September were not received promptly, and concerns were raised about wound assessment, information sharing, record-keeping, sepsis checks, medication monitoring, care planning and a missed visit. She was admitted to hospital for sepsis on 28 September 2018, developed gangrene in her left lower leg, and died at Medway Maritime Hospital on 7 October 2018.

Pamela Moran · Prevention of Future Deaths report View report

12 Nov 2019 Swansea and Neath Port Talbot A. Gruffydd

Pamela Moran died at Morriston Hospital on 17 March 2017 after falling at Tonna Hospital and suffering fractures and a head injury. She developed an acute on chronic intracranial bleed, and the report identified three missed opportunities for a CT head scan, along with inadequate documentation and a system that relied on junior doctors to hand over requests for scans.

Mr Costel Daniel Stancu · Prevention of Future Deaths report View report

12 Nov 2019 Cheshire P. Sigee

Mr Costel Daniel Stancu died at Royal Stoke University Hospital on 3 April 2019, aged 37, after sustaining injuries in a series of road traffic collisions on the M6 on 29 March 2019. The concerns identified were that the lack of lighting on that section of motorway contributed to the collisions and created an ongoing risk to life, and that the associated risk had not been reassessed following the motorway’s conversion to a smart motorway or the incident.

Jamie Staley · Prevention of Future Deaths report View report

12 Nov 2019 Gwent C. Saunders

Jamie Staley died immediately after being struck by a van when he accidentally wandered onto the A40 near Monmouth after drinking with friends. The inquest identified relatively easy pedestrian access to the A40 and a lack of signs warning pedestrians about or preventing entry onto the slip road as matters for consideration, although the lack of signage was not considered to have contributed to his death.

Amanda Jaye Briley · Prevention of Future Deaths report View report

11 Nov 2019 Leicester City and South Leicestershire L. Brown

Amanda Jaye Briley, who had Asperger’s and a history of serious self-harm attempts, was found unconscious with trousers around her neck in a psychiatric ward on 26 December 2016 and died in intensive care on 28 December 2016. Her observation level had been reduced for Christmas leave and was not reinstated at the previous level after her return. The report also raised concern about the lack of local inpatient provision and commissioning arrangements for people with autism requiring inpatient mental health treatment.

Antonis Tofali Hannides · Prevention of Future Deaths report View report

11 Nov 2019 Avon S. Fox

Antonis Tofali Hannides died on 29 March 2019 from liver and heart disease after undergoing hernia repair and subsequently reattending hospital with confusion. Concerns included the lack of a formal system for managing unexpected reattendance after discharge, inadequate documentation, and failure to inform his consultant immediately.

Mr Sam Spooner · Prevention of Future Deaths report View report

8 Nov 2019 Cheshire P. Sigee

Mr Sam Spooner died at Leighton Hospital on 31 August 2018 after being found unresponsive following an act intended to end his life. The report identified concerns about inadequate multi-agency information sharing, coordination and intervention despite known suicide risk, and excessive reliance on his family to keep him safe.

Charlotte Elizabeth Jacobs · Prevention of Future Deaths report View report

7 Nov 2019 Manchester City R. Galloway

Charlotte Jacobs suffered an accidental fall at home on 11 October 2016, developed a deep tissue injury and sacral ulcer, later suffered a stroke, and died from heart failure and related disease on 31 October 2016. Concerns included the failure to assess her capacity to refuse treatment, fluids and nutrition, an inappropriate transfer to a psychiatric ward while she was physically unwell, continuing uncertainty about the appropriateness of such transfers, and incomplete transfer guidance.

Peter Andrew Connelly · Prevention of Future Deaths report View report

7 Nov 2019 North Wales (East and Central) J. Gittins

Peter Andrew Connelly was transferred to hospital on 19 February 2018, waited several hours for admission and medical examination, was diagnosed with acute pancreatitis, and died on 20 February 2018. The principal concern was continuing extreme pressure and delays in emergency department admission and treatment, which the report stated could place patients’ lives at risk and lead to preventable deaths; the delay was accepted not to have caused or contributed to Mr Connelly’s death.

Sandra Dawne Scott · Prevention of Future Deaths report View report

6 Nov 2019 South Yorkshire (Western) D. Urpeth

Sandra Dawne Scott was prescribed treatment for a urinary infection, but the prescription was not available for collection after changes were made to the electronic prescribing system. She was admitted to hospital with worsening symptoms on 22 April 2019, deteriorated, and died on 23 April 2019. Concerns included the failure to act on hospital urine-test results and the lack of awareness among healthcare professionals of the electronic prescribing system issue; the evidence was that receiving the prescribed or indicated medication would have meant she did not die when she did.

Hazel Maureen Lewis · Prevention of Future Deaths report View report

6 Nov 2019 Manchester North C. McKenna

Hazel Maureen Lewis died in hospital on 28 November 2018 after an unwitnessed fall caused a hip fracture; the medical cause of death was metastatic breast cancer, with the fracture contributing. Concerns were raised about the best-interest decision-making process, including inadequate consultation, failure to formally instruct an IMCA, insufficient exploration of support to help her engage with investigations, and uncertainty about the advocate’s role.

Stuart Clarke · Prevention of Future Deaths report View report

6 Nov 2019 Manchester City R. Galloway

Stuart Clarke presented with breathlessness in February 2018 and underwent a TAVI procedure on 25 June 2019 after a prolonged pathway to treatment. He did not recover following the procedure and died at Wythenshawe Hospital on 27 June 2019. The principal concern was the absence of national guidelines for referral between primary, secondary and tertiary care for patients with known valvular disease, alongside concern about the timeliness of intervention.