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Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report View report

2 Nov 2018 Manchester West T. Brennand

Karl Qolf Jamil Englemak Cassimjee, who had a history of presumed paranoid schizophrenia and psychosis, was found dead on 5 February 2018 after becoming missing and being last seen behaving irrationally and bizarrely. The medical cause of death was hypothermia, and the inquest concluded accidental death. Concerns included an inadequate Mental Health Act assessment, insufficient risk assessment and safety planning, failures to obtain relevant collateral information, and mental health operational systems identified for revision not having been implemented.

Mr Taylor · Prevention of Future Deaths report View report

1 Nov 2018 Worcestershire A. Cox

Mr Taylor suffered a fall at home on 27 July 2018, sustaining a head injury and later being transferred to the Trust. Following a respiratory arrest, chest infection and deterioration, he died in the Trust on 31 July 2018. Concerns included insufficient consultant physician support for neurosurgical patients and an alcohol withdrawal protocol that was difficult to understand, resulting in diazepam being prescribed instead of lorazepam.

Billie Jonathan LORD · Prevention of Future Deaths report View report

1 Nov 2018 Milton Keynes T. Osborne

Billie Jonathan LORD died from suicide on 11 July 2017 after suffering from psychosis, autism and a psychotic illness associated with non-prescription drug use. He had been admitted voluntarily to the Campbell Centre and was being monitored by intermittent 15-minute observations before absconding and entering the path of a high-speed train. The concern raised was that three-bed dormitory accommodation at the Campbell Centre was inappropriate and may have added to the stress experienced by the patient; a review of the accommodation was suggested.

Colette Denise Vivienne Jean DUNN · Prevention of Future Deaths report View report

1 Nov 2018 Milton Keynes T. Osborne

Colette Denise Vivienne Jean Dunn was taken to hospital by ambulance with police officers after threatening to kill herself, but was discharged without a formal Mental Health Act assessment. Later that day, she doused herself with petrol and set fire to herself, sustaining severe burns, and died the following morning. Concerns included the absence of a full mental health assessment before discharge, lack of a clear discharge protocol between relevant agencies, and inadequate facilities in Milton Keynes for people experiencing a mental health crisis.

Stephen Buck · Prevention of Future Deaths report View report

31 Oct 2018 Oxfordshire D. Salter

Stephen Buck died at a construction site in Thame after being struck and pulled underneath the wheels of a reversing vehicle while filling in tickets. The principal concern was the common practice of operatives working close to reversing trucks to issue tickets during spoil removal operations, increasing the risk of injury.

Dorothy Joan Strickley · Prevention of Future Deaths report View report

31 Oct 2018 Leicester City and South Leicestershire L. Brown

Dorothy Joan Strickley underwent emergency surgery for appendicitis on 10 June 2018 and was discharged without the anti-embolic stockings prescribed to her or information about continuing to wear them and seeking urgent medical attention. She became short of breath at home and died 19 days after surgery from a massive pulmonary embolism; concerns included failures to provide the stockings, communicate their use, and ensure discharge documentation and local policy reflected relevant guidance.

Mr Thomas Patrick McAuley · Prevention of Future Deaths report View report

29 Oct 2018 Inner South London A. Harris

Mr Thomas Patrick McAuley was found dead in his prison cell on 23 August 2017. The medical cause of death was bronchopneumonia, with chronic bronchitis and alcohol and drug dependence also recorded. The inquest identified concerns about clinical information from police custody not being available to all prison clinical staff and a lack of clinical observations during the first five days of methadone treatment.

Rosario CORDERO-SANZ · Prevention of Future Deaths report View report

29 Oct 2018 Inner North London M. Hassell

Rosario (known as Charo) Cordero-Sanz died after jumping in front of a train at Bethnal Green Underground Station on 14 July 2018. The concerns included gaps in special police officers’ access to information, understanding of missing-person and mental-health procedures, communication with a non-native English-speaking friend, and the failure to identify her as a high-risk missing person.

KARL BRUNNER · Prevention of Future Deaths report View report

29 Oct 2018 Bedfordshire and Luton M. Oldham

Karl Brunner died after choking on a package of drugs he swallowed while being arrested by police in Bedford on 11 May 2016. The report identified concerns that officers lacked knowledge of the risks of choking during arrest or detention and that the mouth and face guards provided to them were defective and inappropriate for high-risk suspects.

Timothy Alastair Mason · Prevention of Future Deaths report View report

26 Oct 2018 Kent (North-West) R. Hatch

Timothy Alastair Mason became unwell over several days, attended Tunbridge Wells Hospital twice on 16 March 2018, and died later that day after treatment. The inquest recorded the medical cause of death as meningococcal septicaemia and identified concerns about failure to diagnose and treat him, his discharge while seriously unwell, and his not receiving the Men ACWY vaccination. Further concerns related to staff instructions and training and the systems for offering, recording and monitoring vaccination.

Andrea Franzosi · Prevention of Future Deaths report View report

25 Oct 2018 Gloucestershire K. Skerrett

Andrea Franzosi, a 52-year-old man, presented to hospital with flu-like symptoms and chest pain, was diagnosed with pleurisy and discharged, and died after collapsing the following day. The report identified concern about the supervision of junior doctors, particularly when patients are discharged without examination by a more senior practitioner.

David Morley Sargeant · Prevention of Future Deaths report View report

25 Oct 2018 Cornwall and Isles of Scilly G. Davies

David Morley Sargeant died on 16 June 2017 from the toxic effects of an intentional overdose of prescribed and controlled drugs, with suspension by a ligature around his neck also recorded. He had a history of chaotic illicit substance misuse and had been referred for assessment of possible ADHD, but specialist services in Cornwall or out of county were unable to diagnose and treat him. The principal concern was the lack of access to specialist ADHD assessment and treatment, including the absence of suitable ongoing medication oversight arrangements.

Eileen Cooke · Prevention of Future Deaths report View report

25 Oct 2018 West Yorkshire Eastern K. McLoughlin

Eileen Cooke, an 80-year-old woman with dementia, frailty, contractures and a fractured left ankle, died in Pinderfields Hospital on 21 December 2017. Concerns included the lack of a best-interests multidisciplinary meeting, her discharge to a nursing home with unresolved medical and care needs, inadequate preparation for wound dressing and pain control, and the risk posed to other patients by precipitously arranged hospital discharges.

Jennifer Anne Lacey · Prevention of Future Deaths report View report

24 Oct 2018 Inner West London F. Wilcox

Jennifer Anne Lacey was found deceased in a hotel room in Morden on 4 June 2018, having consumed a large amount of alcohol and 210 tramadol tablets. The concerns were that potentially dangerous and addictive drugs were freely available over the internet, could be prescribed without contact with the patient’s regular doctor or access to medical records, and might be dispensed by UK pharmacies without further checks.

Catherine Mary GIBBON · Prevention of Future Deaths report View report

24 Oct 2018 Inner North London M. Hassell

Catherine Mary Gibbon suffered a seizure while swimming at a gym on 1 June 2018 and remained face down in the water for around ten minutes. She sustained a hypoxic-ischaemic brain injury following non-fatal drowning and died. Concerns included inadequate pool monitoring and CCTV arrangements, a broken camera, insufficient staff training and emergency equipment, and gaps in first-aid certification systems.

Maximilien Conrad Kohler · Prevention of Future Deaths report View report

24 Oct 2018 Inner West London F. Wilcox

Maximilien Conrad Kohler, known as Max, was found hanging by a belt from a pull-up bar at his home on 5 May 2018 and died despite resuscitation. The report identified concerns about delayed or incorrect diagnosis, over-reliance on questionnaires in assessing diagnosis and self-harm risk, limited services and support for people with ASD and their parents, and shortages of NHS inpatient psychiatric beds for children and adolescents.

Allan Herbert Shepard · Prevention of Future Deaths report View report

23 Oct 2018 South Yorkshire (Western) A. Davies

Allan Herbert Shepard, aged 89, fell at home on 8 February 2018 while being assisted out of his wheelchair and remained trapped in a hoist awaiting help. His breathing deteriorated, and he lost consciousness from positional asphyxiation before the ambulance attended; he died later that day in hospital. The concerns related to responder staffing and policies for single-person units, and to outdated information about Mr Shepard and his family situation held by the call-handling service.

Kalma RAM-HENMAN · Prevention of Future Deaths report View report

23 Oct 2018 Brighton and Hove V. Hamilton-Deeley

Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned treatment.

Nicola Jayne Lawrence · Prevention of Future Deaths report View report

23 Oct 2018 West Yorkshire Eastern J. Leach

Nicola Jayne Lawrence was an inmate at HMP New Hall who was found unresponsive on 24 September 2016 and died despite efforts by prison, healthcare and ambulance staff. The report raised concerns that healthcare staff had not considered the anti-respiratory or depressant effects of her medication, and that some prison staff had not received cardiopulmonary resuscitation training.

Robert Scott McLoughlin · Prevention of Future Deaths report View report

19 Oct 2018 West Yorkshire Eastern J. Leach

Robert Scott McLoughlin, an inmate at HMP Leeds, was found suspended by a ligature on 20 February 2016 and died in hospital on 25 February 2016. The report raised concerns about very low staffing levels, including the absence of a Landing Officer, resulting in ACCT reviews not taking place for several hours.