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Wayne Andrew ROGERS · Prevention of Future Deaths report View report

28 Mar 2019 Isle of Wight C. Sumeray

Wayne Andrew ROGERS, aged 62, died after being thrown from a racing yacht and dragged through the water when a spinnaker sheet became caught around his ankle during Cowes Week. He was rescued, received CPR, and was pronounced dead at hospital; the medical cause of death was drowning. The report raised concerns about ambulance capacity and emergency response arrangements, safety equipment, race abandonment criteria, and the use of continuous sheets on boats.

Justin John BROWN · Prevention of Future Deaths report View report

27 Mar 2019 Suffolk J. Devonish

Justin John Brown was found deceased at his address on 19 February 2016 after police attended following a welfare call. The inquest concluded that he died from ketoacidosis due to diabetes and chronic alcohol abuse, with underlying chronic pancreatitis and bronchopneumonia. A principal concern was that he had been discharged from hospital without confirmed addiction support, and that referral monitoring and communication with the drug service were inadequate.

Ms Donna Williamson · Prevention of Future Deaths report View report

27 Mar 2019 Inner South London A. Harris

Donna Williamson, a 44-year-old woman with mental health, alcohol dependence, mobility and domestic abuse vulnerabilities, died from stab wounds to the chest after being assaulted with a knife by her ex-partner. The principal concerns included the failure to secure her insecure door, failure to inform her that the suspect had been released on bail, and weaknesses in the MARAC process for protecting chaotic and non-engaging individuals.

Christopher William Gibbs · Prevention of Future Deaths report View report

25 Mar 2019 Dorset R. Middleton

Christopher William Gibbs was cycling home from work on the A338 on 3 October 2017 when he was struck from behind by a courier van and died at the scene. The report raised concerns about the lack of cycle lanes and warning signs for cyclists on the fast, busy and unlit dual carriageway, as well as debris making the edge of the carriageway unsafe for cycling.

Nora Theresa Bruton · Prevention of Future Deaths report View report

25 Mar 2019 Birmingham and Solihull A. Hodson

Nora Theresa Bruton was found face down in a pond on 15 November 2018 and was declared deceased at the scene. Post-mortem and toxicological evidence indicated death by drowning while under the influence of alcohol. The report identified concerns about insufficient assessment of the impact of increased alcohol on suicidal thinking and self-risk, lack of referral to Addiction Services, and gaps in communication and recording of crisis calls between mental health teams.

Brian Robert HAVARD · Prevention of Future Deaths report View report

22 Mar 2019 Norfolk Y. Blake

Brian Robert Havard attended the Emergency Department with chest pain and vomiting, was discharged with a diagnosis of musculoskeletal pain, then collapsed in the car and died while being taken back to hospital. The concerns included failure to review ambulance records, inadequate senior review arrangements, and poor record keeping.

Bram Luke Radcliffe · Prevention of Future Deaths report View report

22 Mar 2019 West Yorkshire (Western) M. Fleming

On 8 November 2017, two-year-old Bram Luke Radcliffe was found unresponsive after a marble fireplace surround detached from the wall and struck him. He was taken to hospital but died later that morning from his head injury. Evidence at the inquest indicated that the fireplace surround installation was substandard and dangerous, and raised concerns about the absence of a British Standard for fixing stone fireplace surrounds and their exclusion from building regulations.

Mark Stephen Anthony Simon KUBIAK · Prevention of Future Deaths report View report

22 Mar 2019 Milton Keynes T. Osborne

Mark Stephen Anthony Simon KUBIAK suffered a cardiac arrest and died during transfer from Critical Care at Milton Keynes Hospital to the John Radcliffe Hospital on 25 July 2018. The oxygen supply to his portable ventilator was not connected properly, and the principal concern was that the transfer checklist did not require the oxygen supply to be checked or a tug test to be completed.

John Wright · Prevention of Future Deaths report View report

21 Mar 2019 Oxfordshire D. Salter

John Wright, aged 32, died at Bullingdon Prison on 15 December 2017 after being found partially suspended by an electrical cable in his cell. He had expressed suicidal thoughts and had previously been kept on constant watch, but observations were reduced to twice hourly during reception. The concerns relate to the receipt and sharing of information about heightened suicide risk and the guidance and decision-making processes for reducing observation levels.

Christopher BEVAN · Prevention of Future Deaths report View report

20 Mar 2019 Blackpool and the Fylde T. Holloway

Christopher BEVAN fell from a ladder while working on a garage roof on 14 August 2018 and sustained head injuries. He died at Royal Preston Hospital on 15 August 2018. The principal concern was that ladders were used in potentially unsafe circumstances and in a manner that could present a risk to life, including on a possibly slippery surface, without being footed or secured at the top, and while adopting an awkward position.

Mrs Pamela Sunter · Prevention of Future Deaths report View report

20 Mar 2019 South Yorkshire (Western) C. Dorries

Mrs Pamela Sunter died on 1 July 2017 in Northern General Hospital, Sheffield, after developing a rare infection that progressed to abdominal aortic aneurysms arising from aortitis. The report identified potential confusion between urgent ultrasound referrals and two-week-wait consultant appointment referrals, including the continued availability of obsolete forms on a system alongside new forms.

Graham Tailby · Prevention of Future Deaths report View report

19 Mar 2019 Manchester City J. Hobson

Graham Tailby, a patient detained under the Mental Health Act and receiving care on Juniper Ward, was found unresponsive in his room on 22 December 2015 and died despite resuscitation efforts. The inquest found bronconeumonia and combined sertraline and fentanyl toxicity, but it was unclear how the toxicity occurred or developed. A concern was raised that intraosseous drills were not available on crash trolleys, potentially limiting emergency intervention options.

Mark Keith PARRY · Prevention of Future Deaths report View report

19 Mar 2019 Cheshire H. Westerman

Mark Keith Parry died on 2 March 2017 after being struck on the head by an ejected air-suspension component while repairing a heavy goods vehicle. The report raised concern that there were no published Health and Safety Executive guidelines for mechanics and their employers on working with air suspensions on heavy goods vehicles.

Mohammed Shabol AHMED · Prevention of Future Deaths report View report

19 Mar 2019 Suffolk J. Devonish

Mohammed Shabol Ahmed, a long-term illicit drug user with schizophrenia and a learning disability, was found deceased in his prison cell the morning after being returned from hospital following a drug-related collapse. Concerns included the possible interaction between olanzapine and Spice, failures in information-sharing between the prison, healthcare and hospital, and inadequate prison training for drug-related incidents and their aftermath.

Peter David KNIGHT · Prevention of Future Deaths report View report

18 Mar 2019 Norfolk J. Lake

Peter David Knight, who had idiopathic pulmonary fibrosis and was dependent on oxygen, was not connected to portable cylinder oxygen during transfer to a ward and became hypoxic before dying later that evening. The report raised concern about delays in completing and trialling a revised policy for transferring oxygen-dependent patients.

Ellie Jane LONG · Prevention of Future Deaths report View report

18 Mar 2019 Norfolk J. Lake

Ellie Long was receiving community treatment from the Eating Disorder Service and had diagnoses of Anorexia Nervosa and Depression. She was found hanging in her bedroom on 10 December 2017 and died in hospital on 12 December 2017. The principal concerns were incomplete record keeping and disclosure, and inadequate communication and information sharing with external agencies including her GP and school.

Katharine Mary DOWLING · Prevention of Future Deaths report View report

14 Mar 2019 Cheshire A. Moore

Katharine Mary Dowling, who had autism spectrum disorder and co-existing mental health issues, self-ligatured while receiving care on an acute psychiatric ward and died in hospital. The concerns included inadequate integration of autism into care planning, insufficient autism training and specialist input, an inappropriate ward environment, inconsistent observations, and wider variation in national guidance and support.

Meirion James · Prevention of Future Deaths report View report

14 Mar 2019 Carmarthenshire and Pembrokeshire P. Bennett

Meirion James was arrested for assaulting his mother and later became agitated at Haverfordwest Police station. During restraint, he was placed prone, stopped breathing and died from positional asphyxia. The report raised concerns about police restraint training, arrangements for people detained under Section 136 of the Mental Health Act, and training concerning Appropriate Adults.

Tamsin Rebecca Lianne GRUNDY · Prevention of Future Deaths report View report

13 Mar 2019 Norfolk J. Lake

Tamsin Rebecca Lianne Grundy, who had a history of depression and was under the care of Mental Health Services, was found dead at home on 26 July 2018 with a weightlifting bar across her neck. Concerns included her difficulty relating to the more than 25 members of the Crisis Resolution Home Treatment Team involved in her care and the lack of a definitive, timed action or named person responsible for addressing this issue.

Mr Mohammed Hussain · Prevention of Future Deaths report View report

13 Mar 2019 Bedfordshire and Luton E. Whitting

Mr Mohammed Hussain died after setting fire to himself inside a car in Luton on 12 March 2018, following deterioration in his mental health and previous overdoses. Concerns included shortcomings in mental health risk assessments, inadequate application of risk assessment training, and failures to share or highlight important information between staff and care providers.