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Allan Davies · Prevention of Future Deaths report View report

9 Jul 2019 Birmingham and Solihull J. Bennett

Allan Davies, who had a history of illicit drug misuse, telephoned 999 after unintentionally taking heroin, crack cocaine and mamba. Although he initially reported breathlessness, the ambulance response was delayed as dispatched ambulances were transferred to higher-category patients; he was later found in cardiac arrest and died, with the medical cause of death recorded as heroin overdose. The substantive concerns were that NHS Pathways triage treated overdose cases too generically, without regard to the drug taken and risk of sudden collapse, and that not all NHS trusts and ambulance services were aware of this deficiency.

Leroy Dacosta Junior Medford · Prevention of Future Deaths report View report

9 Jul 2019 Berkshire H. Connor

Leroy Dacosta Junior Medford, referred to as Junior, was arrested by Thames Valley Police on 1 April 2017 and detained under the drugs SOP after being suspected of concealing drugs. His condition deteriorated in his cell, and resuscitation was unsuccessful; the recorded cause of death was heroin (diamorphine) toxicity. The principal concerns were that officers of all ranks involved did not know that the SOP required observation from inside the cell, and broader concerns about how police training is delivered, monitored, prioritised and taken up.

Alexander Boamah · Prevention of Future Deaths report View report

5 Jul 2019 Inner North London R. Brittain

Alexander Boamah, who had a history of heroin and crack cocaine misuse, was found deceased at his residence on 26 January 2019 after receiving approximately £18,000 in Personal Independence Payment and disengaging from addiction treatment while increasing his reported illicit substance use. The principal concern was the risk that large payments could give individuals at risk through illicit substance use unrestrained access to funds, with no apparent process for treating clinicians to raise concerns with the Department for Work and Pensions.

Keith Winston Battman · Prevention of Future Deaths report View report

5 Jul 2019 West Sussex K. Harrold

Keith Winston Battman was seriously injured when his motorcycle collided with a minibus on the A285 on 10 October 2018, and he died in hospital on 28 October 2018. The report raised concerns that the bend was insufficiently warned by chevrons, the speed-limit sign and faded road markings, and that further improvements to the road may be needed.

Miriam Tighe · Prevention of Future Deaths report View report

4 Jul 2019 Manchester South R. Galloway

Miriam Tighe became a resident of Edge Hill Residential Home in August 2016 and later received hospital and residential nursing care before passing away on 28 February 2017. The report identified concerns that promazine and other sedative or antipsychotic medication continued to be prescribed and administered despite advice to stop promazine, and that communication between GPs and a psychiatrist was insufficient, leading to unsafe prescribing. The investigation recorded that her death followed naturally occurring disease, with high levels of sedation and immobility in the preceding months worsening her frailty.

Mr Thomas Andrew Reid · Prevention of Future Deaths report View report

3 Jul 2019 Derby and Derbyshire E. Serrano

Mr Thomas Andrew Reid, aged 27, died at the roadside from injuries sustained in a road traffic collision on 21 September 2018 while riding his motorbike along the A515 near Sudbury in Ashbourne. The collision occurred as he overtook queued traffic and collided with a tractor turning right into the B5033. Concerns included the possibility that the only advance warning sign for the junction could be obscured by large vehicles, worn junction markings, previous incidents at the location, and uncertainty about action to address the known risk.

John Patrick Doyle · Prevention of Future Deaths report View report

3 Jul 2019 East London N. Persaud

John Patrick Doyle was found deceased at home after a likely fall, having previously been identified as needing a panic alarm that was not in place. He died from starvation ketoacidosis, and concerns were raised about occupational therapists’ training on emergency alarm equipment, ordering processes, compatibility with home telephone systems, and refresher training.

Jennifer Withey · Prevention of Future Deaths report View report

3 Jul 2019 Cornwall and Isles of Scilly A. Cox

Jennifer Withey died from sepsis following infection associated with a spinal fusion operation, after contacting the 111 service three times. During one call, recorded symptoms included inability to weight bear, no urine for 30 hours, and a dead-feeling left arm and leg, but the call was not immediately referred to a clinician. The report raised concerns about the lack of an automatic sepsis alert and separate timeframes operated by the 111 and out-of-hours GP services, which could introduce avoidable delay.

Ezra James BOULTON · Prevention of Future Deaths report View report

1 Jul 2019 Portsmouth and South East Hampshire S. Marsh

Ezra James Boulton, aged two months, died on 20 May 2018 after being found unresponsive while co-sleeping with his mother on a sofa; alcohol had been consumed and he could not be resuscitated. The principal concerns were inadequate continuity of antenatal care, insufficient early safe-sleeping information for parents, and midwives’ lack of awareness about the legal implications of infant deaths involving co-sleeping and alcohol or drugs.

Mr Peter Lawrence (PL) · Prevention of Future Deaths report View report

1 Jul 2019 Black Country Z. Siddique

Mr Peter Lawrence, a 48-year-old man with paranoid schizophrenia and a history of disengagement from mental health services, was found outside his flat on 8 February 2019 after falling from the balcony and died from traumatic injuries. Concerns included the lack of a joint multi-disciplinary/agency care plan, inconsistent care coordination, and the absence of a coordinated mental health assessment and possible admission when concerns about self-care and disengagement arose.

Andrew Peter McCall · Prevention of Future Deaths report View report

1 Jul 2019 Stoke-on-Trent and North Staffordshire A. Barkley

Andrew Peter McCall was found face down and unresponsive in supported living accommodation on 18 September 2018. A post-mortem examination and toxicology attributed his death to gastric aspiration associated with Pregabalin and Methadone use. The report raised concern that his GP was unaware of his Methadone prescription and could therefore prescribe medications that might be unsuitable or potentially harmful.

Heather Birchall · Prevention of Future Deaths report View report

28 Jun 2019 Wiltshire and Swindon D. Ridley

Heather Birchall, who was homeless and had mental health problems and alcohol dependence, died after consuming excess amounts of medication alongside alcohol; bronchopneumonia also contributed to the mechanism of death. The principal concern was that healthcare professionals assessing people in police custody might lack relevant mental health information because of confidentiality barriers, potentially limiting informed decisions about further care and safeguarding life.

Feni Lee · Prevention of Future Deaths report View report

28 Jun 2019 Inner South London P. Barlow

Feni Lee, who had Behçet’s syndrome, took an excessive quantity of colchicine over a two-week period in September 2017 and died in hospital on 17 September 2017 after developing severe side effects, including liver necrosis. The concerns included the thoroughness of the medication review, the failure to address her loss to hospital follow-up, and delays and ineffective processes for redirecting correspondence between two GP practices.

Macy May Barbara Fletcher · Prevention of Future Deaths report View report

27 Jun 2019 Manchester North J. Robertson

Macy May Barbara Fletcher, a two-year-old child, was found unresponsive at home on 9 January 2019 with a blind cord strangulating her neck and died later that day in hospital. The blind had been fitted before 2014 and had no safety features. The report raised concerns about the lack of oversight and guidance for private landlords regarding updated blind-safety regulations, and the risks posed by older blinds to young children.

Frank Raymond STOCKTON · Prevention of Future Deaths report View report

27 Jun 2019 Blackpool and the Fylde T. Holloway

Frank Raymond Stockton was admitted to hospital with shortness of breath and collapse, later experienced recurrent nosebleeds while receiving oxygen therapy and Warfarin, and died on 22 July 2018 after developing melena and haematemesis. The principal concern was that the risks of epistaxis causing or contributing to death, particularly in patients receiving oxygen therapy or Warfarin or with impaired lung or heart function, may not be generally recognised by clinicians, and that maintaining the INR within its target range may not prevent this risk.

Edir Frederico Araujo DA COSTA · Prevention of Future Deaths report View report

27 Jun 2019 East London N. Persaud

Edir Frederico Araujo DA COSTA died after his airway became obstructed by a plastic bag containing drugs while he was being restrained by police. The report identified concerns about emergency life-support training, supervision and safety-officer roles during restraint, risks associated with plastic bags and CS spray, recognition of agonal breathing, and communication with the ambulance service.

Colin Duncan Whistler Cameron · Prevention of Future Deaths report View report

26 Jun 2019 Gloucestershire K. Skerrett

Colin Duncan Whistler Cameron, aged 60, was killed when a high-speed train struck his vehicle at the Frampton Mansell user-worked crossing on 7 February 2017. Concerns related to the absence of instructions for signallers on how to obtain information from crossing users and whether the crossing should be closed.

Mr Charles Knapp · Prevention of Future Deaths report View report

26 Jun 2019 Surrey A. Crawford

Mr Charles Knapp, who was paraplegic and dependent on care, developed necrotic pressure sores while living at home and later died in hospital on 24 February 2018 from aspiration pneumonia. The concerns included failures by Angel Solutions (UK) Ltd to maintain his hygiene, reposition him, seek medical attention, provide two carers as required, and maintain or supply complete care records; the Coroner was concerned that inadequate care and records could put other service users at risk of future deaths.

Darren McGuin · Prevention of Future Deaths report View report

26 Jun 2019 South Yorkshire (Eastern) S. Slater

Darren McGuin, a serving prisoner at HMP Lindholme, was found unresponsive in his cell on 22 February 2018 and later pronounced deceased. The report identified a delay in starting CPR because the prison officers present had not received basic life support training, and noted that some prison staff had never received such training.

James Owen DELANEY · Prevention of Future Deaths report View report

25 Jun 2019 Norfolk J. Lake

James Owen DELANEY was a resident at Sapphire House Care Home and had insulin-controlled diabetes. He refused insulin on 25 and 26 July 2018 and was unwell on 27 July; he was found unresponsive and pronounced dead on 28 July 2018. Concerns included insufficient regular refresher training on policies and inconsistent procedures for contacting a GP when medication was refused.