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Edna Drury Evans · Prevention of Future Deaths report View report

27 Sep 2019 North Wales (East and Central) J. Gittins

Edna Drury Evans became a resident at Emral House Nursing Home after a number of falls and experienced further incidents while resident. Her final unwitnessed fall on 27 April 2019 caused a significant head injury, and she died from a subdural haematoma on 2 May 2019. Concerns included incomplete falls-risk training, her categorisation as medium rather than high risk despite repeated falls, and the absence of evidence of reassessment after further falls or of a policy requiring it.

John SHROSBREE · Prevention of Future Deaths report View report

26 Sep 2019 Milton Keynes T. Osborne

John SHROSBREE was admitted to Milton Keynes University Hospital on 4 June 2019 seriously unwell with high potassium, and later suffered a hyperkalaemic cardiac arrest, hypoxic brain damage and died on 11 June 2019. The concerns included failures to review observations, escalate care, monitor him appropriately and start treatment promptly, with staff shortages identified as a principal concern.

William James Moody · Prevention of Future Deaths report View report

25 Sep 2019 Hampshire S. Marsh

William James Moody, aged 85, intentionally entered the River Itchen from the banks of his home on 19 April 2019 and could not be revived after being taken to Southampton General Hospital. The report raises concerns that Hampshire’s 999 call-handling system may cause delays, missed triage opportunities and inadequate information-sharing between emergency services during mental health crises involving suicidal ideation.

Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER · Prevention of Future Deaths report View report

25 Sep 2019 Inner North London M. Hassell

Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER climbed onto a freight train near Hackney Wick Station in the small hours of 21 March 2019 and were electrocuted. The report identifies concerns about an unrepaired gap in the track perimeter fence, failures to inspect and report it, inadequate internal investigation, and uncertainty about whether there was a national fencing-inspection system failure.

Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER · Prevention of Future Deaths report View report

25 Sep 2019 Inner North London M. Hassell

Benjamin Michael HADDON-CAVE and Patrick Thomas BOLSTER climbed onto a freight train near Hackney Wick Station in the small hours of 21 March 2019 and were electrocuted. The report identifies concerns about an unrepaired gap in the track perimeter fence, failures to inspect and report it, inadequate internal investigation, and uncertainty about whether there was a national fencing-inspection system failure.

Anna Eli Hedman · Prevention of Future Deaths report View report

25 Sep 2019 Inner West London F. Wilcox

Anna Eli Hedman was found drowned in a bath at a hotel while intoxicated with cocaine, against a background of psychological illness and drug misuse. The court found gross failures in the police call handler’s prioritisation of preservation of life and failure to call an ambulance, but found these were not causative of the death. Concerns included short and rushed training for part-time call handlers, insufficient emphasis on preservation of life, and inadequate post-training coaching and mentoring.

Iain Neil MACINNES · Prevention of Future Deaths report View report

24 Sep 2019 Milton Keynes T. Osborne

Iain Neil MACINNES was found hanging at his home in Milton Keynes on 17 January 2019, after his mental health had deteriorated during December 2018. The report identified concerns that his family were not informed about his deterioration or transfer to the Acute Home Treatment Team, and that there was a failure to recognise the extent of his deterioration, resulting in lost opportunities for hospital admission.

Annette Susan HEWINS · Prevention of Future Deaths report View report

24 Sep 2019 South Wales Central G. Hughes

Annette Susan Hewins was detained under the Mental Health Act on 7 February 2017 for assessment and treatment of psychotic symptoms and opiate withdrawal. She was found unconscious in hospital on 8 February 2017 and died despite resuscitation; the post-mortem identified extensive coronary artery atherosclerosis as the likely cause of death. Concerns included inconsistent clinical record-keeping, incorrectly completed NEWS charts, missed observations, inadequate documentation and requesting of an ECG, insufficient detail in observation records, and the absence of a Trust policy for managing opiate-dependent patients in acute admissions.

Mr Francis Hodge · Prevention of Future Deaths report View report

24 Sep 2019 Inner South London B. Ballard

Mr Francis Hodge died on 16 November 2018 at University Hospital Lewisham from a perforated colon, seven days after elective laparoscopic repair of multiple incisional hernias. Concerns were raised that he received inadequate discharge advice and was not told to seek help for breathlessness or persistent pain. It was also reported that no patient information leaflet existed for this type of surgery.

Myla DEVIREN · Prevention of Future Deaths report View report

24 Sep 2019 Cambridgeshire and Peterborough R. Rhodes-Kemp

Myla Deviren, who had congenital intestinal malrotation, developed a volvulus and was found unresponsive on 27 August 2015 after calls to NHS 111 and an out-of-hours service. She was taken to hospital, where resuscitation attempts were unsuccessful, and post-mortem examination revealed small bowel infarction from untreated small intestinal volvulus. The principal concerns were failures to recognise the significance of her symptoms and the need for robust systems, training, paediatric specialist support and precautionary ambulance advice when children may be seriously unwell.

Rebecca Marshall · Prevention of Future Deaths report View report

24 Sep 2019 Inner South London B. Ballard

Rebecca Marshall was referred for mental health assessment after escalating self-harm, depression, anxiety and angry outbursts. After moving to university accommodation in London, there was no interagency communication between the mental health services involved in her care, and urgent referrals did not result in a senior review. She was discovered deceased in her room on 27 November 2017, and the inquest concluded that she died as a result of suicide. The principal concerns included missed opportunities in her care and inadequate arrangements for sharing information and ensuring continuity of care between trusts when she moved areas.

Daniel Williams · Prevention of Future Deaths report View report

24 Sep 2019 Inner South London B. Ballard

Daniel Williams died at St Thomas' Hospital on 26 November 2017 after developing complications of gastrointestinal surgery, including infection and sepsis, against a background of significant medical complexity. Concerns included deficient nursing care on a general gastrointestinal ward and a potential limitation in the investigation of Clostridium difficile cases when a patient had recently been transferred from another ward.

Muhammed Saif Abdul Haleem · Prevention of Future Deaths report View report

24 Sep 2019 Manchester North C. McKenna

Muhammed Saif Abdul Haleem was 13 years old and had a severe, life-limiting neurological condition. He became unresponsive at home on 8 December 2018, was found in asystole, and died after resuscitation efforts were terminated; the principal concern was that an outdated DNA-CPR document had remained on the emergency service system for seven years without the knowledge or support of the clinicians involved in his care.

Kristiyan Petrov Danailov · Prevention of Future Deaths report View report

23 Sep 2019 Dorset R. Middleton

Kristiyan Petrov Danailov was found unresponsive at home on 28 July 2018 after purchasing an online product labelled as containing cyanide, and was pronounced deceased at the scene. The inquest concluded that the death was suicide, with the medical cause recorded as consistent with cyanide poisoning. Concerns were raised about checks on the identity and vulnerability of customers purchasing hazardous items online and about industry awareness of the risks.

Ricky Barcock · Prevention of Future Deaths report View report

21 Sep 2019 West Yorkshire (Western) M. Fleming

Ricky Barcock was admitted to a recovery centre for detoxification and rehabilitation and was later found unresponsive in his room after sleeping for several hours. He was found to have died from morphine toxicity, with methadone and diazepam use also recorded. The principal concern was whether resident wellbeing checks should include regular physical checks and rousing clients when necessary.

Karis Florence Braithwaite · Prevention of Future Deaths report View report

20 Sep 2019 East London N. Persaud

Karis Florence Braithwaite, aged 24, died after stepping in front of a fast train on 24 September 2018 following discharge from a Section 136 mental health assessment. The concerns included important risk information from the paramedic and police not being available to the assessment team, and handover information not being adequately documented or transferred into the Trust’s records.

Robert Edward LOWE · Prevention of Future Deaths report View report

20 Sep 2019 County Durham and Darlington J. Chipperfield

Robert Edward LOWE suffered an unwitnessed fall from his bed at Chilton Care Centre on 13 May 2019 and lay undetected for up to two hours. Concerns were raised that pressure mats could be bypassed and that competing audible alarms might prevent important alerts from reaching staff.

Kathryn Mary Barrow · Prevention of Future Deaths report View report

19 Sep 2019 Manchester South C. Morris

Kathryn Mary Barrow was found dead at her home on 7 March 2019, aged 59, after a long history of mental illness and treatment for bipolar affective disorder. A post-mortem did not establish a medical cause of death, and the inquest recorded an Open conclusion. Concerns related to the prescribing of Diazepam, including inadequate documentation or checks, whether access to the medicine illicitly had been considered, and the practice’s lack of a recent review of its prescribing approach.

Irene Collins · Prevention of Future Deaths report View report

19 Sep 2019 Manchester South C. Morris

Irene Collins, who had advanced dementia and other significant health problems, was found dead at her care home on 16 June 2018 with a latex clinical examination glove obstructing her upper airway. The principal concern was that clinical examination gloves were readily accessible to residents, including those with cognitive impairment, and could be disposed of in easily accessible bins.

Mr Bromley · Prevention of Future Deaths report View report

19 Sep 2019 Manchester South C. Morris

Mr Bromley was receiving support from the Home Treatment Team after declining an informal hospital admission. He was found dead on 18 February 2019 at his gym, having suspended himself by the neck with a ligature; the inquest recorded a conclusion of suicide. The concerns related to the Home Treatment Team’s lack of a dedicated Consultant Psychiatrist, uncertainty about recruitment to such a post, and the patchy operation of interim psychiatric access arrangements.