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Peter George Garvin · Prevention of Future Deaths report View report

27 Feb 2019 Inner West London F. Wilcox

Peter George Garvin, who was under the care of a Community Mental Health Team while his medication was prescribed by his GP, entered the Regent’s Canal on 31 January 2018 with the intention of taking his own life. The report identifies concerns about communication between the CMHT and GP, insufficient local psychiatric beds, discharge from NHS care after seeking private psychiatric treatment, and the lack of an early carer’s assessment.

Hoshi Jane Naylor · Prevention of Future Deaths report View report

27 Feb 2019 West Yorkshire Eastern O. Longstaff

Hoshi Jane Naylor, aged 12, was struck by a car while crossing the A6120 Leeds outer ring road on 4 January 2018 and died from her injuries in hospital one week later. Concerns included the sparse provision of pedestrian crossing facilities near the collision site and limited illumination of the grass verges, which could restrict motorists’ awareness of pedestrians intending to cross.

Mr Nathan Mooney · Prevention of Future Deaths report View report

26 Feb 2019 Manchester South C. Morris

Mr Nathan Mooney died on 23 May 2017 after developing severe abdominal pain and later collapsing at home. He had previously undergone a splenectomy in which an iatrogenic diaphragmatic defect was repaired; a post-mortem examination determined that he died following colonic herniation and perforation associated with a diaphragmatic defect. The principal concern was Tameside General Hospital’s heavy reliance on locum doctors, with potential adverse effects on continuity of care and effective relationships between clinical teams.

John Thorp · Prevention of Future Deaths report View report

26 Feb 2019 West London C. Wood

John Thorp became seriously ill with pneumonia, required intensive care and ventilation, and later suffered a cardiac arrest from which he could not be resuscitated on 8 February 2018. The inquest identified inconsistency in the prescribing and recording of TED stockings, which may lead to stockings being prescribed but not given and may increase the risk of thromboembolic formation.

Mr Keith Heatley · Prevention of Future Deaths report View report

26 Feb 2019 South Wales Central I. Boyes

Mr Keith Heatley was admitted voluntarily to hospital on 1 May 2018 and transferred to Ward 14, later leaving the family home during home leave on 18 May and being found in the water; the medical cause of death was drowning and the inquest reached an open conclusion. Concerns included the absence in Wales of a policy for reviewing and assessing voluntarily admitted patients before home leave, insufficient guidance for staff, and insufficient procedures for liaising with the family and community psychiatric nurse about preparedness and support.

Mr Geoffrey Jackson · Prevention of Future Deaths report View report

26 Feb 2019 Manchester South C. Morris

Mr Geoffrey Jackson died at Trafford General Hospital on 6 November 2018 following congestive cardiac failure and ischaemic heart disease, with left hip replacement and hospital-acquired pneumonia also recorded. He had an unwitnessed fall after required falls-risk assessments were not completed, although there was no evidence that the fall contributed to or materially hastened his death. Concerns included continuing omissions in falls-risk assessments and nursing records that lacked structured narrative accounts of patients’ conditions.

Danyon Robert Chesters · Prevention of Future Deaths report View report

26 Feb 2019 Manchester South A. Mutch

On 2 July 2018, Danyon Robert Chesters went onto a railway line under Trafford Bridge Road and was struck by a train. The inquest heard concerns about delays in accessing mental health services, the resulting use of private therapy, and a lack of joined-up care and information sharing. It also heard concerns that private therapists might not obtain information about prescribed mental health medication and its impact on therapy.

Christopher Andrew MOSS · Prevention of Future Deaths report View report

26 Feb 2019 Staffordshire South A. Haigh

Christopher Andrew MOSS was a serving prisoner at HMP Featherstone who died on 18 February 2017 from a self-inflicted incision to his left wrist. The principal concern was that appropriate equipment was not initially available to open the cell door during the barricade incident, raising a concern about whether prisons should check that suitable equipment is available for their particular doors.

Lyn Morgan · Prevention of Future Deaths report View report

26 Feb 2019 Swansea and Neath Port Talbot A. Gruffydd

Lyn Morgan died from traumatic injuries in a road traffic collision on 25 April 2013 when a lorry crossed the central reservation of the A465 and collided with Lyn’s vehicle. Concerns were raised that the road barrier redirected the lorry back onto the carriageway contrary to its design, and that the road’s extensive use by heavy vehicles meant similar circumstances could arise again.

Kathleen McGeary · Prevention of Future Deaths report View report

26 Feb 2019 Nottinghamshire S. Haskey

Kathleen McGeary died on 6 March 2018 from a head injury sustained in a fall at Tuxford Manor Care Home after her discharge from hospital. Concerns included inadequate assessment and treatment before discharge, unclear responsibility for discharge decisions, inadequate discharge documentation and communication, and her leaving hospital without prescribed antibiotics.

John William Pearce · Prevention of Future Deaths report View report

25 Feb 2019 Inner North London E. Buckett

John William Pearce was a frail 90-year-old man who developed a worsening left knee wound after an injury in April 2018 and died in hospital on 21 September 2018. The report identified concerns about delayed hospital referral, insufficient district nursing attendances, reliance on his reluctance to attend hospital, and inadequate systems for recognising and sharing information about worsening wounds.

Steven John Key · Prevention of Future Deaths report View report

25 Feb 2019 Cumbria R. Chapman

Steven John Key died at the scene after lying on a railway track in front of an oncoming train near Oxenholme Station on 14 September 2018. The principal concern was that a low wooden fence was easy to climb, allowing access to the track, where trains travelled at up to 125 mph; replacing it with a heightened palisade gate and fence was identified as reasonably practicable.

Brenda Kathleen GOWAN · Prevention of Future Deaths report View report

25 Feb 2019 East London N. Persaud

Brenda Gowan suffered a moderately severe stroke and was discharged home for a trial period despite being assessed as requiring 24-hour supervision and being at risk of falls. Five days after discharge, she fell near her bed in the early hours and sustained catastrophic head injuries, from which she died. Concerns included insufficient care and equipment, inadequate advice and assessment of night-time falls risk, and failure to reconsider the care plan after the family reported that she was getting up frequently at night.

Dr Polly Joanne Drew · Prevention of Future Deaths report View report

24 Feb 2019 Nottinghamshire E. Didcock

Dr Polly Joanne Drew, aged 35, died by suicide after injecting herself with Propofol and Atracurium acquired from the medical centre where she worked as a duty doctor. The report raised concerns that Central Medical Services’ recruitment process was inadequate, including not obtaining written references or completing a DBS check, despite her access to anaesthetic drugs and working alone.

Jeremy Sutch · Prevention of Future Deaths report View report

22 Feb 2019 Suffolk N. Parsley

Jeremy Sutch, a trainee driller aboard the MV Platinum Explorer, was crushed by a Riser Feeding Machine and later died in hospital from blunt chest trauma. His evacuation to shore was delayed by difficulties using a wheelchair-type extraction stretcher, raising concerns about crew familiarity, suitable equipment, and the lack of specific evacuation drills for casualties who must remain seated.

Mrs Doreen Fell · Prevention of Future Deaths report View report

22 Feb 2019 Cumbria P. O’Donnell

Mrs Doreen Fell died at the scene after being struck by a car while crossing the A590 in Backbarrow on 17 January 2018. The report raised concerns about the 60mph national speed limit, inadequate lighting, and the safety of pedestrians—including elderly people, children, and those with impairments—using the crossing in darkness.

Gabriele Kreichgauer · Prevention of Future Deaths report View report

22 Feb 2019 Inner South London P. Barlow

Gabriele Kreichgauer attended hospital with an infected cat bite, but was discharged without receiving the intended antibiotics and later developed sepsis and died. Concerns included the absence of a final treatment check and the use of an internet resource that led to an incorrect diagnosis and potentially ineffective treatment; the resource also lacked an apparent feedback mechanism for clinicians to raise concerns.

Jason Marshall GREGORY · Prevention of Future Deaths report View report

21 Feb 2019 Southampton and New Forest G. Short

Jason Gregory became involved in a disturbance and was physically restrained by door security staff, including by an arm hold around his neck. He suffered ventricular fibrillation and cardiac arrest, with contributory factors including exertion, excitement, cocaine and alcohol intoxication. The concerns were about delays in relaying serious incidents to police and uncertainty among security staff about how to request police assistance in time-critical situations.

Terrence Arthur Albert Smith · Prevention of Future Deaths report View report

21 Feb 2019 Surrey R. Travers

Terrence Smith died in hospital on 13 November 2013 after developing amphetamine-induced Excited Delirium/Acute Behavioural Disturbance, being subjected to prolonged restraint, and stopping breathing while being transported to hospital. The principal concerns included failures to recognise the condition as a medical emergency, inadequate assessment and training, excessive restraint, delayed conveyance to hospital, and deficiencies in relevant emergency response, clinical, police and custody policies and training.

ROBERT CHARLES CHANDLER · Prevention of Future Deaths report View report

21 Feb 2019 Norfolk J. Lake

Robert Charles Chandler collapsed and suffered a pneumothorax on 24 September 2018. An ambulance arrived 50 minutes after the first telephone call, and he died in hospital on 25 September 2018 from his injury. Concerns included equipment failure and transfer without pain relief or safety straps, incomplete records, inconsistent equipment checks and assistance-seeking, and delayed implementation of investigation recommendations.