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George Daniel TWIDDY · Prevention of Future Deaths report View report

8 Apr 2019 Portsmouth and South East Hampshire D. Clark

George Daniel TWIDDY was found hanging from a tree on 15 November 2017 and died in hospital on 17 November 2017 after suffering an untreatable brain injury. The principal concern was a lack of clarity between the Hampshire AMHP Service and Southern Health NHS Trust’s Early Intervention Psychosis Team about responsibility for providing immediate assistance, leaving his parents and practitioners unclear about where help would come from.

Darren Edward KING · Prevention of Future Deaths report View report

6 Apr 2019 Suffolk N. Parsley

Darren King died at home after an epileptic seizure while in the bath, with drowning recorded as the medical cause of death. The report identified concerns about inadequate follow-up when a high-risk patient with learning disabilities disengages, the lack of a clear escalation process, and the absence of a structured medication review within the care plan.

Jennifer Louise Handy · Prevention of Future Deaths report View report

5 Apr 2019 South Wales Central R. Knight

Jennifer Louise Handy was born at 26 weeks plus 4 days gestation at home on 10th April 2017 and was too premature to survive. The report raised concerns that the doctor involved could not be traced or held to account, which diminished the quality and completeness of the investigation and limited his ability to learn from the issues identified.

Mrs Alice Doris Dixon · Prevention of Future Deaths report View report

5 Apr 2019 Surrey S. Wickens

Alice Doris Dixon attended St Peter’s Hospital for investigation of anaemia and shortness of breath and suffered an anaphylactic shock during a CT scan involving injected contrast dye. She was admitted to intensive care, later treated palliatively, and died from the consequences of the shock. Concerns included inadequate support and communication during consent, incomplete and unclear consent documentation, lack of clinical assessment immediately before the scan, missing information about vulnerabilities, and difficulty observing or hearing her breathing difficulties during the scan.

Raymond Alan Knight · Prevention of Future Deaths report View report

5 Apr 2019 Essex C. Beasley-Murray

Raymond Alan Knight was arrested on suspicion of possessing illicit drugs with intent to supply, taken to Grays Police Station, and collapsed in a holding cell before being pronounced dead at hospital. Toxicological analysis indicated high levels of cocaine in his blood, and the inquest concluded that the death was drug related. The report raised concern that CCTV did not cover the individual holding cells, leaving no photographic record of what happened inside them when officers were not present.

Lesley Ann Armstrong · Prevention of Future Deaths report View report

4 Apr 2019 North Northumberland T. Brown

Lesley Ann Armstrong died at home on 20 July 2016 after taking her own life by hanging. She had believed she remained under suspicion of assault because Northumbria Police did not inform her that its investigation had been discontinued, and the report identified concerns about communication between the police, safeguarding authorities and her employer regarding the investigation’s status.

Julia Luxmore Peto · Prevention of Future Deaths report View report

4 Apr 2019 Inner South London C. Williams

On 16 September 2018, Julia Luxmore Peto was struck by a bus while crossing Deptford Broadway and suffered a catastrophic head injury; she died in hospital the following day. The principal concern was that pedestrians might be distracted or confused by green pedestrian signals visible across the other carriageway at two-stage crossings, with wider concern about similar crossings lacking louvres and road markings to indicate traffic direction.

Mr Alfred Howell · Prevention of Future Deaths report View report

4 Apr 2019 West Yorkshire Eastern J. Hobson

Mr Alfred Howell was admitted to hospital after respiratory deterioration, including bilateral pleural effusions and partial lung collapse. His condition deteriorated, and he suffered a cardiac arrest and died on 5 June 2018. The principal concern was that CT scans took 14 and 12 days to be reported, exceeding the Trust’s five-day target, although the inquest evidence did not indicate that the delays contributed to his death.

Ronald William Lowe · Prevention of Future Deaths report View report

3 Apr 2019 Birmingham and Solihull E. Brown

Ronald William Lowe collapsed at home on 26 October 2018 and died after being found in cardiac arrest. A pulmonary embolus identified on a CT scan was not treated with anticoagulation because reporting was delayed by individual and systemic omissions. The report raised concerns about systems for ensuring radiographers had seen and understood relevant CT standard operating procedures and that their training records were complete and up to date.

Stuart Michael CLARK · Prevention of Future Deaths report View report

3 Apr 2019 Exeter and Greater Devon P. Spinney

Stuart Michael CLARK died shortly after being recovered from a canal on 3 October 2017, after entering the water wearing a rucksack filled with weights. During a hospital admission before his death, he disclosed that he was a vulnerable adult and a suicide risk, but this was not escalated or followed by an assessment of his risk of self-harm or suicide. The report identified that senior clinical staff were not directly informed and that the relevant medical record entry was not available to other staff at the time.

Aryan Akhgar · Prevention of Future Deaths report View report

3 Apr 2019 South Yorkshire (Western) S. Eccleston

Aryan Akhgar, aged 17, died on 6 March 2018 after hanging himself with the intent to take his own life. The report identified a gap in urgent mental health services for 16- and 17-year-olds in Sheffield: although an urgent response was recommended on 9 January 2018, the first visit by mental health professionals did not occur until 15 January 2018. The report also raised concern that funding for additional CAMHS resources was not guaranteed.

Terence Douglas Thornton · Prevention of Future Deaths report View report

3 Apr 2019 Plymouth, Torbay and South Devon A. Cox

Terence Douglas Thornton was admitted to hospital after a fall in which he struck his head, while receiving warfarin. A subtle subdural haemorrhage was missed on the initial CT scan; after discharge and administration of enoxaparin, the haemorrhage expanded catastrophically and he died on 19 September 2017. The concerns included radiology staffing shortages and work pressures, with a consequent risk of similar fatalities.

Tarek Mahmood CHOWDHURY · Prevention of Future Deaths report View report

2 Apr 2019 West London R. Furniss

Tarek Mahmood CHOWDHURY was beaten to death by another detainee while detained at Heathrow Immigration Removal Centre on 1 December 2016. The report identified concerns about information sharing between prisons, the Home Office and immigration removal centres, including the availability of intelligence and other records. It also identified concerns about access to and operation of SystmOne healthcare records during the initial screening of detainees transferred from prison.

Mrs Elsa Reid · Prevention of Future Deaths report View report

2 Apr 2019 Black Country Z. Siddique

Mrs Elsa Reid, a 92-year-old woman, was admitted to hospital after a fall that caused a complex fractured hip and was later discharged to a care home for rehabilitation. She died on 20 December 2018 after developing a pulmonary embolism. The principal concerns were inadequate communication about her mobility and hoisting needs, delays in resolving conflicting instructions, and an insufficient mobility regime that may have increased the risk of complications including pulmonary embolism.

Andrew Robert Frank Clegg · Prevention of Future Deaths report View report

1 Apr 2019 Wiltshire and Swindon N. Rheinberg

Andrew Robert Frank Clegg, a 56-year-old vulnerable individual with corticobasilar degeneration, lived in a specialist care home where problems with the water system allowed legionella bacteria to colonise it. He was infected and died from legionella pneumonia, which the inquest jury concluded resulted from an accident. Concerns included inadequate water-safety design in care homes and insufficient inspector training to identify potential legionella risks.

Alexander Frederick Richard GREEN · Prevention of Future Deaths report View report

1 Apr 2019 Avon M. Voisin

Alexander Green died at Southmead Hospital on 3 October 2017 after falling while out socialising and subsequently being found in the road. He was initially treated as intoxicated, and his head injury was not diagnosed until he suffered a respiratory collapse; the report identifies concerns about ineffective handover and communication, failure to apply head-injury guidance, and assumptions that intoxication explained his condition.

Ozan Allen · Prevention of Future Deaths report View report

1 Apr 2019 Inner North London S. Bourke

Ozan Allen was hit by a car while crossing the junction of Mile End Road and Burdett Road on 16 August 2018 and died in hospital on 20 August 2018 from traumatic brain injury caused by the road traffic collision. Concerns included the junction’s complex layout, lack of pedestrian guard railing, impaired visibility, pedestrians not using staggered crossings as intended, and a history of collisions involving pedestrians.

Ann Corfield · Prevention of Future Deaths report View report

29 Mar 2019 Manchester City A. Mazzag

Ann Corfield was admitted to hospital with a urinary tract infection, low sodium levels and deteriorating mental health, later developing severe psychotic depression, poor oral intake and dehydration. She suffered a cardiac arrest and died after transfer between hospitals. Concerns included inadequate handover about anticoagulation, failure to administer prescribed prophylactic anticoagulation, poor completion of fluid balance charts, and the lack of suitably qualified staff to administer intravenous fluids at Park House.

Colin Bailey · Prevention of Future Deaths report View report

29 Mar 2019 Manchester South C. Murray

Colin Bailey was admitted to hospital following a stroke and later transferred for rehabilitation. After falling and hitting his head while taking anticoagulant medication, he suffered an extensive subarachnoid haemorrhage and died at Tameside General Hospital on 10 April 2018. The concern was that national guidance did not require a CT scan in this situation for all types of anticoagulant medication, although clinicians indicated that scanning should be undertaken regardless of the type used.

Tony Goodridge · Prevention of Future Deaths report View report

28 Mar 2019 Inner North London S. Bourke

Tony Goodridge died after being found unresponsive in his flat following a fire on 19 November 2018; the medical cause was recorded as inhalation of fire fumes and airway burns. The principal concerns were that there was no smoke alarm in the property and that parked vehicles made it more difficult for the London Fire Brigade to reach the property.