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Jean Mary Cutler · Prevention of Future Deaths report View report

8 Feb 2019 Birmingham and Solihull J. Bennett

Jean Mary Cutler had severe dementia, osteoporosis and no independent mobility, and was at high risk of falling. On 5 October 2018 she fell from her wheelchair at Cole Valley Nursing Home, sustaining a fractured left femur, and died there on 18 October 2018. Concerns included inconsistent use of lap belts, reliance on staff intervention despite understaffing, and inadequate post-incident investigation and falls risk assessment.

Stephen Anthony Kennedy · Prevention of Future Deaths report View report

7 Feb 2019 Birmingham and Solihull L. Hunt

Stephen Anthony Kennedy had a history of emotional unstable personality disorder, depression and frequent self-harm, and his condition deteriorated during 2018. He was found hanging at his home on 08/10/18 and was declared deceased. Concerns included that psychological therapy was unavailable because of service structures and long waiting lists, and that a lack of acute inpatient beds contributed to further episodes of self-harm and suicide attempts.

RUTH PATRICIA WHITMORE · Prevention of Future Deaths report View report

6 Feb 2019 Norfolk J. Lake

Ruth Patricia Whitmore, who had multiple comorbidities, sustained a large haematoma when her leg became caught in a bed rail during hospital care on 7 January 2018. Her condition deteriorated after community care and readmission, and she died on 13 April 2018; concerns included inadequate handover of responsibility and an initial investigation that was not robust or sufficiently thorough.

Gwyneth Ann EDWARDS · Prevention of Future Deaths report View report

5 Feb 2019 Bedfordshire and Luton I. Pears

Gwyneth Ann EDWARDS was admitted to Bedford Hospital on 7 December 2017 and deteriorated after Hydrocortisone and Desmopressin were not dispensed. She developed severe hypernatraemia and died on 14 December 2017 while receiving end-of-life care; the stated cause of death included bronchopneumonia and hypernatraemia, with failure to administer Desmopressin and maintain appropriate fluids. Concerns included gaps in weekend transfer arrangements, NEWS scores not being acted upon, an unverified Mobile Medic review marked complete, staff unfamiliarity with Desmopressin storage, and staffing pressures affecting monitoring and record-keeping.

Mrs Maureen Brown · Prevention of Future Deaths report View report

4 Feb 2019 Derby and Derbyshire E. Serrano

Mrs Maureen Brown was admitted to the Royal Derby Hospital with an infection and was identified as being at high risk of falls. Information from her daughter about her confusion and previous fall was not included in the electronic handover, and Mrs Brown subsequently fell from her bed and suffered a fatal subdural haemorrhage. The report raised concerns that electronic transfer information can omit relevant information needed for effective handover and that national policy still treats it as the only information necessary for transfer.

Daniel Alexander Jeremiah BOWEN · Prevention of Future Deaths report View report

1 Feb 2019 Brighton and Hove V. Hamilton-Deeley

Daniel Alexander Jeremiah BOWEN took his own life, as recorded in the inquest conclusion. Concerns included insufficient use of academic advisors to support him with late work and academic pressures, and flawed communication between university departments, his GP or counsellor, and student support services.

Mary Bertha Johnson · Prevention of Future Deaths report View report

1 Feb 2019 Herefordshire H. Bricknell

Mary Bertha Johnson died at County Hospital, Hereford, on 25 July 2018 after falling on 20 July 2018 and sustaining a periprosthetic fracture of the femur. Concerns included poor communication about feeding and medication before surgery, and the suggestion that porter availability affected the hospital theatres’ ability to carry out operations.

Stephen Keith Harte · Prevention of Future Deaths report View report

1 Feb 2019 Birmingham and Solihull J. Bennett

Stephen Keith Harte was found unresponsive in his room at the Tamarind Centre on 18 August 2018 and could not be resuscitated. A post-mortem found a fatal dose of heroin, and the medical cause of death was recorded as heroin toxicity. The principal concern was that drugs could too easily enter the medium secure unit through routes including unsupervised takeaway deliveries, residents returning from leave, and staff bringing in unscreened food.

Andrew Stephen Carr · Prevention of Future Deaths report View report

31 Jan 2019 Birmingham and Solihull L. Hunt

Andrew Stephen Carr, a prisoner, was found unresponsive in his cell on 29 March 2018 and was pronounced dead at 22:53 after attempts to revive him were unsuccessful. The medical cause of death was recorded as the effects of a synthetic cannabinoid. Concerns included failures to identify and record information about his prior substance use, the known use of the prison plumbing system to pass drugs, and the role of contraband mobile phones in substance misuse.

Garry CLARKSON · Prevention of Future Deaths report View report

31 Jan 2019 East Riding and Hull P. Marks

Garry Clarkson died at the scene after a Ford Transit Tipper left the road, entered a ditch and collided with a tree. The report raises concern about multiple fatalities and further accidents on the Westfield Lane carriageway near Hook, described as an accident blackspot.

Sophie Holman · Prevention of Future Deaths report View report

29 Jan 2019 London (East) S. Radcliffe

Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.

Mr Crutchley · Prevention of Future Deaths report View report

28 Jan 2019 Manchester South C. Morris

Mr Crutchley was found dead at the home he shared with his parents, and the post-mortem examination concluded that he died from the combined toxic effects of cocaine and alprazolam. Concerns were raised that the Early Intervention Team lacked specialist drug and alcohol workers and that service users could face significant waits for talking therapies.

Jack Alfie Charlie HUBBARD · Prevention of Future Deaths report View report

28 Jan 2019 Inner North London M. Hassell

Jack Hubbard, aged 18, ingested MDMA at Egg Nightclub in London on the evening of 24/25 August 2018; the investigation recorded the medical cause of death as MDMA toxicity. A concern was raised that the nightclub’s ambulance-calling protocol required the duty manager to be called and a second set of observations to be taken first.

Simon Paul Barber · Prevention of Future Deaths report View report

28 Jan 2019 Nottinghamshire T. Rawden

Simon Paul Barber, who was wheelchair bound due to multiple sclerosis, died on 18 July 2018 from hypoxia due to smoke inhalation after a fire caused by a naked flame contacting his clothing. The principal concerns were inadequate care-provider risk assessments, insufficient consideration of emergency exit and fire risks, and staff failing to report an incident involving a lit cigarette.

Terence Penney · Prevention of Future Deaths report View report

28 Jan 2019 Lincolnshire P. Smith

Terence Penney received fatal injuries in a fire at his home on 21 February 2018. The fire followed the accidental ignition of leaking Iso-butane from a domestic refrigerator when he switched on an electric coffee machine. The principal concern was that similar leaks could occur in other refrigerators, including older units, with potentially similar consequences.

Dennis Peter Alfred Warner · Prevention of Future Deaths report View report

28 Jan 2019 West London S. Cummings

Dennis Peter Alfred Warner died in hospital on 6 December 2016 after falling at home and sustaining a chest injury. The principal concerns were that his advanced dementia affected his ability to understand discharge information, that the emergency department was overcrowded, that chest X-ray could underestimate injury, and that senior review and efforts to contact and recall him were inadequate.

Stephen Pettitt · Prevention of Future Deaths report View report

25 Jan 2019 Newcastle upon Tyne K. Dilks

Stephen Pettitt died following complications during a robotically assisted mitral valve operation on 23 February 2015, the first such operation at the Freeman Hospital and the first performed by the primary surgeon. The operation was prolonged, with a cross-clamp time exceeding six hours, and the report identifies concerns about the absence of guidance on training, proctoring, and patient information for new interventional procedures. The Coroner considered that these issues had wider national implications and that appropriate national guidelines should be considered.

Anne-Marie Nield · Prevention of Future Deaths report View report

25 Jan 2019 Manchester North L. Hashmi

Anne-Marie Nield was a repeat victim of domestic violence who died from multiple injuries after her partner inflicted a violent and sustained attack at her home on 8 May 2016. The report identifies concerns about inadequate police risk assessment, delays, failures to provide support and information, and insufficient understanding and application of domestic abuse policies. It also notes that not all recommendations addressing these shortcomings had been implemented two and a half years after her death.

Gareth Cecil Bickerstaff · Prevention of Future Deaths report View report

25 Jan 2019 Manchester North L. Hashmi

Gareth Cecil Bickerstaff died by hanging after self-ligaturing in the roof space of a Tesco Express while experiencing paranoia and under the influence of drugs and alcohol. The report identified inconsistent wording between national and local ambulance guidance about when the 15-minute period for deciding whether to attempt resuscitation should be calculated, creating potential for misinterpretation and misunderstanding.

Olive JOHNSON · Prevention of Future Deaths report View report

24 Jan 2019 Lincolnshire P. Cooper

Olive JOHNSON died within 24 hours of admission to Pilgrim Hospital on 11 May 2018. The concerns raised relate to the absence of a first responder, emergency response times, how response delays were recorded after regrading, and whether EMAS had sufficient conveying resources to meet its targets.