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Douglas Paul Oak · Prevention of Future Deaths report View report

24 Oct 2019 Dorset R. Griffin

On 11 April 2017, Douglas Paul Oak displayed erratic and frantic behaviour in Poole and was restrained by police after presenting with symptoms of Acute Behavioural Disturbance (ABD). An ambulance request was initially categorised as Category 3, and Douglas went into cardiac arrest before paramedics arrived; he died in hospital the following day. The report raised concerns about inadequate awareness and training on ABD, the lack of national guidance for police and ambulance services, ambulance call prioritisation, sedation, and communication between emergency services.

Kenneth John Daly · Prevention of Future Deaths report View report

23 Oct 2019 Inner North London S. Bourke

Kenneth John Daly, who had chronic pain and anxiety and was prescribed multiple medications, was found dead at home on 4 December 2018. The inquest concluded that his death was drug related, involving multi-drug toxicity, after he overdosed on Morphine, Dihydrocodeine and Codeine alongside Pregabalin and benzodiazepine medication. Concerns included unclear guidance about using multiple opioid medications together and the absence of tailored written advice for Mr Daly.

Mr Paul Mclean · Prevention of Future Deaths report View report

22 Oct 2019 South Wales Central G. Hughes

Mr Paul Mclean died on 9 October 2018 after prolonged status epilepticus, following an emergency call to the Welsh Ambulance Service on 22 July 2018. The initial call was downgraded from code red to amber, resulting in an approximately 80-minute response instead of the anticipated 15–20 minutes; the jury found that the extended response contributed to prolonged status epilepticus and his subsequent death. The principal concerns related to seizure-call question scripting and categorisation, recognition of airway problems, and communication pathways between the ambulance service, prison healthcare operators, and hospital clinicians.

Nigel Byron Abbott · Prevention of Future Deaths report View report

22 Oct 2019 Birmingham and Solihull J. Bennett

On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.

Harold Chukwudemu Uzomechina · Prevention of Future Deaths report View report

21 Oct 2019 West London C. Inyama

Harold Chukwudemu Uzomechina died in prison on 24 April 2016 after being found unresponsive in his cell and not responding to CPR. The inquest concluded that he died a drug-related death, with failure to recognise signs of cardio-respiratory depression contributing. Concerns included inadequate overnight physical monitoring and differing levels of care and attention for detainees in the substance misuse unit compared with those formerly on an ACCT.

Lauren Victoria Finch · Prevention of Future Deaths report View report

21 Oct 2019 Manchester West R. Galloway

Lauren Victoria Finch, aged 23, died on 24 September 2018 after suspending herself from a bedroom door while detained as a patient at Atherleigh Park Hospital; she suffered a significant brain injury and later died in hospital. The principal concerns included inadequate suicide-risk assessment and review, inappropriate observation levels and practices, failures in the anti-barricade system, and delayed clinical record entries.

Sharon Jamela Reeve · Prevention of Future Deaths report View report

21 Oct 2019 West Yorkshire Eastern K. McLoughlin

Sharon Jamela Reeve developed a persistent headache, underwent investigations and was discharged after an electronic referral to a tertiary neurosurgical unit. She was found unresponsive on 10 March 2018, underwent emergency surgery and died on 14 March 2018. The principal concerns were unclear referral pathways, incomplete and ineffective communication between hospitals, delays in specialist review, and inadequate clarity about the electronic referral system.

Elisa Fuller · Prevention of Future Deaths report View report

17 Oct 2019 Gloucestershire K. Skerrett

Elisa Fuller was delivered by elective Caesarean section at 36 weeks gestation on 9 February 2018 and later developed respiratory distress. During intubation, she suffered an idiosyncratic reaction to suxamethonium that triggered cardiac arrest, and resuscitation was unsuccessful. Concerns related to the escalation of concerns by junior staff and understanding of the need to retain placentas after delivery for a specified period.

Victor James Hall · Prevention of Future Deaths report View report

16 Oct 2019 Manchester West R. Syed

Victor James Hall died at Salford Royal Hospital on 29 June 2018 after being admitted with shortness of breath and an exacerbation of chronic obstructive pulmonary disease. He was mistakenly administered Phosphate Polyfusor instead of prescribed sodium bicarbonate after dispensing, pharmacy checking and ward checking errors, although the post-mortem and toxicology evidence concluded that the medication error played no role in his death. Concerns were raised about the similar Polyfusor product design and about medication-checking, recording, dispensing, training and supervision procedures.

Mr Derek Weaver · Prevention of Future Deaths report View report

15 Oct 2019 Inner South London A. Harris

Mr Derek Weaver was admitted to hospital with community-acquired pneumonia and an empyema, which required surgery. He died on 31 May 2018 after becoming septic and developing a systemic inflammatory response following delayed transfer for surgery. The principal concern was that the 14-day transfer delay, related to exceptional pressure on bed capacity, contributed to his death and that similar risks could recur during referral surges without additional capacity.

Matthew George Kaliniecki WILLIAMSON · Prevention of Future Deaths report View report

15 Oct 2019 West London C. Murray

Matthew was found locked in a bathroom and had hung himself using a dressing gown cord attached to a wall-mounted radiator, resulting in his death at the scene on 24 October 2018. The report raises concerns about limited opportunities for carers and family members to provide information to mental health teams and unclear coordination between mental health providers, making access to appropriate treatment difficult.

Dev Dilesh Naran · Prevention of Future Deaths report View report

14 Oct 2019 Birmingham and Solihull E. Brown

Dev Dilesh Naran, aged 8, sustained an unsurvivable head injury as a rear-seat passenger when the Toyota Yaris in which he was travelling stopped in a live motorway lane and was struck from behind by a large goods vehicle. Concerns included the risks posed by stopped vehicles in live lanes, the lack of automatic alerts for lone stationary vehicles, and specific safety risks associated with the dynamic hard shoulder on this section of the M6.

César Cuauhtémoc González Barrón · Prevention of Future Deaths report View report

14 Oct 2019 Inner North London M. Hassell

César Cuauhtémoc González Barrón died while performing as a Mexican wrestler at a Lucha Libre event. After he lost consciousness and suffered cardiac arrest, there were delays in recognising the emergency, summoning assistance, starting CPR and providing effective resuscitation. The report also identified inadequate event briefing, unclear emergency roles and procedures, communication difficulties, delayed ambulance access, and a confused handover to ambulance staff.

Abdeslam BENELGHAZI · Prevention of Future Deaths report View report

10 Oct 2019 Avon M. Voisin

Abdeslam BENELGHAZI was detained under Section 2 of the Mental Health Act and was prescribed methadone alongside several other medications, including clonazepam. He died on 9 December 2017; the inquest identified concerns about inappropriate combined prescribing, inadequate monitoring and failure to escalate concerns, including after signs of over-sedation or reduced consciousness.

Ian Thomas Trevor BEAN · Prevention of Future Deaths report View report

10 Oct 2019 Cornwall and Isles of Scilly A. Cox

Ian Thomas Trevor Bean died at Liskeard in Cornwall after taking an overdose of prescribed morphine, and the inquest recorded multidrug toxicity and chronic obstructive pulmonary disease, with suicide as the conclusion. An ambulance was mistakenly dispatched to his father’s address in Nottingham rather than to Mr Bean in Cornwall; although this was accepted at inquest not to have caused the death, it was identified as a fundamental error requiring attention to prevent similar oversights.

Liane Davenport · Prevention of Future Deaths report View report

10 Oct 2019 Cumbria K. Cheema

Liane Davenport had chronic schizophrenia treated with high doses of two antipsychotic medicines, alongside significant coronary artery disease and left ventricular dysfunction, and died at home in Cumbria on 4 December 2019. The principal concern was whether blood-level monitoring should be considered for patients receiving long-term high-dose antipsychotic treatment, particularly as they become older and more frail.

James Frankish · Prevention of Future Deaths report View report

9 Oct 2019 Nottinghamshire E. Didcock

James Frankish died at Beeches Residential Home after vomiting plant material and expelling a hard plant mass from his stomach into his oesophagus, causing sudden obstruction. The principal concerns were that professionals and care staff did not fully understand or manage the dangers of Pica, and that national or professional guidance was lacking on identifying, assessing and managing Pica and monitoring for bezoar development.

EMILY DAISY SIMS · Prevention of Future Deaths report View report

9 Oct 2019 Cornwall and Isles of Scilly G. Davies

Emily Daisy Sims, a 101-year-old care home resident, died after bilateral spiral fractures to both femurs sustained when she was held by the ankles and swung out of bed. The report identified concerns about care plans not being updated to reflect changing needs, inadequate equipment and specialist advice, and insufficient training in equipment use and moving and handling.

Stefan Gareth EVANS · Prevention of Future Deaths report View report

8 Oct 2019 Staffordshire South A. Haigh

Steffan Evans died at the scene of a road traffic collision on 15 January 2019 after the car he was driving collided with another car and then a van. The report raised a continuing concern about the volume and speed of traffic on the B5017 between Needwood and Burton, including the road’s junctions.

Dylan Jay Henty · Prevention of Future Deaths report View report

8 Oct 2019 Cornwall and Isles of Scilly A. Cox

Dylan Jay Henty had a complex medical history including schizophrenia, a cerebral tumour, communication difficulties and seizures. He went missing after declining prescribed medication on 17 February 2018, and his body was found at Fistral beach on 21 February 2018; the cause of death was recorded as multiple injuries, with no evidence explaining the apparent fall or how he entered the sea. Concerns included an unsupervised seizure in a bath, inadequate awareness of hoarding, medication compliance, inconsistent reporting of absconding incidents, and arrangements for monitoring residents at risk of absconding.