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Mr Edward Hearn · Prevention of Future Deaths report View report

8 May 2019 Inner South London A. Harris

Mr Edward Hearn died in hospital after a cardiac arrest, with the medical cause of death including sepsis, bronchopneumonia and multiple myeloma treated with chemotherapy. The report identified concerns that a high globulin result was not followed up, that he was discharged without a safe care plan to minimise fall risk during chemotherapy, and that cardiac monitoring requirements for Carfilzomib may not have been sufficiently definitive.

Alexander James Davidson · Prevention of Future Deaths report View report

2 May 2019 Nottinghamshire L. Bower

Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.

Benjamin James Charles MURRAY · Prevention of Future Deaths report View report

2 May 2019 Avon M. Voisin

On 5 May 2018, Ben was found beneath the Clifton suspension bridge after walking onto the bridge, climbing onto the buttress wall and propelling himself forward. The inquest concluded that his death was suicide. The report raised concerns about mental health disclosure by university applicants, the pastoral role of universities during transition to higher education, and the absence of university investigation reports following a student death.

Mr Royston Kemp · Prevention of Future Deaths report View report

2 May 2019 Inner South London A. Harris

Mr Royston Kemp, an 85-year-old care home resident with dementia and a history of fractures and falls, suffered an unwitnessed traumatic fracture of his left femur in February 2016. He was not referred to hospital until two days after signs of injury and died on 20 March 2016 from pneumonia, aspiration and advanced dementia, with the fracture-related immobility identified as a key contributor. Concerns included failure by a nurse to act on leg swelling and temperature differences, establish the care assistant’s concerns, measure vital signs, or escalate for medical assessment and referral.

Scott Marsden · Prevention of Future Deaths report View report

1 May 2019 West Yorkshire Eastern J. Leach

Scott Marsden died after receiving a blow to the chest during a kickboxing bout. The report raised concern that there was no defibrillator at the Marshalls Arts College.

James David FLETCHER · Prevention of Future Deaths report View report

1 May 2019 Blackpool and the Fylde T. Holloway

James David Fletcher died in hospital on 14 July 2018 following peritonitis caused by leakage of gastric contents after PEG tube insertion. The report identifies concerns including failure to consider or detect peritonitis, continued use of the PEG tube despite it being contraindicated, inadequate communication and record keeping, insufficient awareness of post-operative PEG risks, and difficulties ensuring essential medication was available.

Mark Richard HINTON · Prevention of Future Deaths report View report

30 Apr 2019 Shropshire, Telford and Wrekin J. Ellery

Mark Richard HINTON attended A&E with right calf pain and swelling after being advised to attend because of a possible clot. He was discharged before a markedly raised D-Dimer result became available; the inquest recorded pulmonary embolus due to deep vein thrombosis and bleeding duodenal ulcer, with a conclusion of “Preventable Natural Cause”. Concerns included failures in recording and communicating the D-Dimer request and result, delayed testing, inadequate documentation, and other system and process failures.

Clive Anthony Jones · Prevention of Future Deaths report View report

30 Apr 2019 Plymouth, Torbay and South Devon I. Arrow

Clive Anthony Jones drowned after his fishing vessel capsized when an excessive weight in the net caused it to become unstable while he was trapped in the wheelhouse. The concerns included the need for an independent review of UK Search and Rescue operational capability and Coastguard functionality, and a thorough review of Search and Rescue information technology systems.

Georgia Sylvia Nelson · Prevention of Future Deaths report View report

29 Apr 2019 Inner West London F. Wilcox

Georgia Sylvia Nelson, who had treatment-resistant schizophrenia and severe persistent symptoms, stepped in front of a train at Gloucester Road Underground Station on 11 May 2018 and was killed instantly. The report raised concerns about the lack of suitable long-term and rehabilitation housing for young people with severe mental illness, inadequate discharge planning, and missed opportunities to improve treatment and consider rehabilitation before discharge.

David Alan Price · Prevention of Future Deaths report View report

29 Apr 2019 Manchester South A. Mutch

David Alan Price had a long history of alcohol use to cope with mental health difficulties and was found at home on 12 November 2018. The inquest heard that he would have benefited from an integrated mental health counselling and detoxification service, which was not available in Stockport.

Bradley Robert Michael Trevarthen · Prevention of Future Deaths report View report

29 Apr 2019 Wiltshire and Swindon D. Ridley

Bradley Robert Michael Trevarthen, aged 13, was found suspended from a bannister at his home on 10 January 2018 and later died in hospital. The principal concern was the availability and accessibility of online material about self-harm, suicide and suicide methods, which was considered unsuitable for young people and potentially normalising such actions.

Steffan Kuenzel · Prevention of Future Deaths report View report

29 Apr 2019 Inner North London S. Bourke

Steffan Kuenzel, who had longstanding alcohol-related problems and previous withdrawal seizures, reduced his alcohol consumption and became unwell before losing consciousness and dying in hospital on 11 November 2018. The inquest concluded that his death was alcohol related, with a cardiac arrest following a 10-day period of alcohol withdrawal. The concerns were that he was advised to reduce his drinking without specific guidance on how to do so, and that he and his partner were unaware of other alcohol-withdrawal symptoms requiring urgent medical treatment besides seizures.

Alfonso Sinclair · Prevention of Future Deaths report View report

29 Apr 2019 Inner West London F. Wilcox

Alfonso Sinclair entered the Victoria Line tunnel at Warren Street station on 31 August 2018 and was struck and killed by a train approximately 19.5 minutes later. The principal concerns were that staff did not identify or track his unusual behaviour on CCTV, that there were no alarms at the platform-end barriers, and that staff working systems and CCTV monitoring could be improved to help prevent similar deaths.

Faye Allen · Prevention of Future Deaths report View report

29 Apr 2019 Manchester South A. Mutch

Faye Allen became unwell after consuming MDMA at an event on 1 May 2016, went into respiratory arrest while being transported to hospital, and died at Manchester Royal Infirmary on 2 May 2016. The inquest considered concerns that guidance on event medical staffing could be interpreted differently, resulting in substantially varying levels of staff available in medical areas.

William John Hignett · Prevention of Future Deaths report View report

26 Apr 2019 Cheshire A. Moore

William John Hignett sustained fatal injuries when his motorcycle collided with an HGV on the A556 Chester Road, Sandiway, on 3 October 2017. The substantive concerns identified were the junction configuration and positioning, street lighting, surrounding vegetation that may have affected visibility, and the applicable speed limit.

Michael Jonathan Davies · Prevention of Future Deaths report View report

25 Apr 2019 Carmarthenshire and Pembrokeshire J. Layton

Michael Jonathan Davies, aged 52, became unresponsive after contacting emergency services about pains down his arms and back and died at home before the ambulance arrived. The inquest recorded that he died from an acute myocardial infarction and that delayed medical treatment may have contributed to his death. The report raised concerns that chest pains and related conditions were categorised as Amber 1 rather than Red, resulting in a response time of up to four hours and potentially putting patients’ lives at risk.

Kerry Hunter · Prevention of Future Deaths report View report

25 Apr 2019 Suffolk N. Parsley

Kerry Hunter died in hospital on 1 May 2016 after administering an overdose of insulin to herself and subsequently deteriorating. She had Borderline Personality Disorder and a history of suicide attempts; although Dialectical Behavioural Therapy was available and she was considered a suitable candidate, it was not provided because this was not recognised at the time. The principal concern was that a proposed requirement for patients to transfer to an Integrated Delivery Team before accessing the new service might prevent some people with Borderline Personality Disorder from receiving needed treatment.

Ioannis AVGOUSTI · Prevention of Future Deaths report View report

24 Apr 2019 Brighton and Hove V. Hamilton-Deeley

Ioannis Avgousti died after an episode involving documented allergy to Co-Amoxiclav, during which the medication was prescribed and administered. The report identified concerns about failure to follow allergy guidance, inadequate communication, failure to act on elevated NEWS observations or escalate care, and staffing pressures during the relevant shift.

Graham Philip Jones · Prevention of Future Deaths report View report

18 Apr 2019 Gloucestershire K. Skerrett

Graham Philip Jones, a 63-year-old man with significant medical conditions, was admitted to hospital with vomiting and abdominal pain and underwent repair of a perforated duodenal ulcer. He suffered several falls in hospital, including a fall that caused a significant head injury; the injury was diagnosed after a delay, and he died on 13 April 2018. The principal concerns related to falls prevention, adherence to the post-falls protocol, review of medication after a fall, and the handover of safety information between wards.

Roger Albert NEAVES · Prevention of Future Deaths report View report

18 Apr 2019 Plymouth, Torbay and South Devon I. Arrow

Roger Albert Neaves fell in his bedroom on 16 October 2018, fractured his left femur, was taken to hospital, deteriorated and died on 18 October 2018. The Coroner was concerned to receive confirmation that recommendations from the Hospital Trust’s Root Cause Analysis had been fulfilled.