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Trystan Bryant · Prevention of Future Deaths report View report

19 Oct 2018 Plymouth, Torbay and South Devon I. Arrow

Trystan Bryant, who had a history of mental illness and had expressed suicide intent, fell from the Tamar Bridge after leaving an ambulance and crossing barriers, sustaining multiple injuries that resulted in his death on 12 May 2017. The report raised a concern that stationary ambulance doors cannot be locked to prevent egress, which may affect police containment when escorting individuals under Section 136 of the Mental Health Act.

John Edward LEE · Prevention of Future Deaths report View report

19 Oct 2018 Mid Kent and Medway I. QC

John Edward LEE died on the operating table during emergency open repair of a tender abdominal aortic aneurysm, following major blood loss, ventricular tachycardia and cardiac arrest. The report identifies a clerical error that resulted in his urgent vascular appointment being scheduled five weeks later than intended, and concerns about ambiguous appointment wording, insufficient clinical input into urgent bookings and the lack of a checking procedure for errors or misunderstandings of priority.

Anne Roberts · Prevention of Future Deaths report View report

18 Oct 2018 Berkshire R. Sidhu

Anne Roberts died at Prospect Park Hospital, Reading, on 28 September 2017 after choking on a bolus of food consisting of a sandwich and chocolate brownie cake. The report raised concerns about bank-staff training, dissemination and recording of choking-risk information, management of patients eating in bedrooms, and frontline staff training on the interaction between mental disorders and choking risks.

Joseph James GRANTHAM · Prevention of Future Deaths report View report

18 Oct 2018 Manchester South A. Mutch

Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare services.

Jordan Ryan Sheils · Prevention of Future Deaths report View report

16 Oct 2018 West Yorkshire (Western) M. Fleming

Jordan Ryan Sheils went missing from his father’s home on the evening of 3 April 2017 after sending worrying text messages, and his body was found beneath the North Bridge on 4 April 2017. The report concerned measures to deter similar incidents at the bridge, including anti-climbing mesh and prominently displayed CCTV cameras, and noted that their introduction should be expedited.

Jacqueline Oakes · Prevention of Future Deaths report View report

16 Oct 2018 Birmingham and Solihull L. Hunt

Jacqueline Oakes was a vulnerable woman who suffered repeated assaults by a man she met in supported living accommodation. Her body was found in her flat on 14 January 2014, and the man was later convicted of her murder; the medical cause of death was multiple injuries. The principal concern was that no agencies were alerted when a high-risk offender was released after completing his sentence, limiting their ability to manage the risks he posed.

Thomas Philip Lear · Prevention of Future Deaths report View report

11 Oct 2018 Stoke-on-Trent and North Staffordshire M. Jones

Thomas Philip Lear died by suicide on 6 January 2018 after he was found hanging from a fence post at his ex-partner’s property. The report raised concerns that no help with accommodation appeared to have been offered after his release from prison, and that urgent text messages reporting threats to hang himself were sent to an Integrated Offender Manager phone that was unavailable outside Monday to Friday without an apparent divert.

Dean Louis BARRELL · Prevention of Future Deaths report View report

11 Oct 2018 East Sussex J. Healy-Pratt

Dean Barrell was found hanging in his cell at HMP Lewes on 13 February 2017, and the jury concluded that he had died by suicide. He had not been informed that he was due for release on 17 February 2017 and believed he would remain in prison until 29 April 2017. The report identified a seven-day delay in communicating his actual release date as a principal concern, particularly given the vulnerability of prisoners and the potential impact on his death.

Tom Cribley · Prevention of Future Deaths report View report

9 Oct 2018 Liverpool and the Wirral J. Goulding

Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

Alba May Pemberton · Prevention of Future Deaths report View report

9 Oct 2018 North London A. Walker

Alba May Pemberton was born on 10 August 2016 after experiencing hypoxia during the active second stage of delivery and lived for two days. The report identified delayed five-minute heart monitoring and the possible absence of earlier CTG monitoring as concerns, noting that earlier detection and delivery might have resulted in survival. Concerns also included the classification of meconium, use of CTG equipment, obstetric review at birthing centres, and closer multidisciplinary working.

Natasha Charlotte Rose Ednan-Laperouse · Prevention of Future Deaths report View report

8 Oct 2018 London (West) S. Cummings

Natasha Charlotte Rose Ednan-Laperouse, who was allergic to sesame, ate a baguette purchased from Pret-a-Manger that contained unlabelled sesame. She developed an anaphylactic reaction on a flight to Nice and died in hospital shortly after landing on 17 July 2016. The report raised concerns about inadequate allergen labelling, inadequate monitoring of customer allergic reactions, and the needle length and adrenaline dose of some autoinjectors used in emergency treatment.

ROBIN ANDREW JAMES MCEWAN · Prevention of Future Deaths report View report

5 Oct 2018 North Yorkshire J. Broadbridge

On 26 January 2018, Robin Andrew James McEwan was found hanging in the basement of his home after returning from drinks with workmates. He was taken to Harrogate Hospital, where he was considered brain stem dead and died on 2 February 2018 after life support was withdrawn. The concerns included a lack of direct communication between his private therapy service and GP, limited guidance and support during delays in accessing specialist mental health services, and further possible exploration of family support.

Bradley Jordache Morgan · Prevention of Future Deaths report View report

4 Oct 2018 Birmingham and Solihull E. Brown

Bradley Jordache Morgan was declared dead on 13 May 2018 after falling from the eighth-floor balcony of his home; the medical cause of death was multiple blunt injuries. He had a history of mental illness and was considered at high risk of suicide and self-harm, but was not reviewed by the community mental health team after a missed appointment. Concerns included communication and follow-up failures, excessive staff caseloads, and underfunding of mental health services creating a risk to life.

James Ryan McLaren · Prevention of Future Deaths report View report

4 Oct 2018 Sunderland A. Hetherington

James Ryan McLaren was found deceased at a recycling site on 24 December 2017 after he was last seen leaving a nightclub and CCTV showed him walking towards an area containing large commercial waste bins. The report raises concerns about unsecured or inadequately lit bins, the risk of people sheltering inside them, and whether bins can be opened from the inside when locked.

Michael Paul Wheeler · Prevention of Future Deaths report View report

4 Oct 2018 Birmingham and Solihull E. Brown

Michael Paul Wheeler died after jumping from a fourth-floor window at his brother’s home on 26 July 2018, following increasing paranoia and bizarre behaviour. The principal concerns were that he was not reviewed by a psychiatrist, had no treatment plan, and had no planned review on 26 July; broader concerns were raised about pressures on mental health services, including the availability of urgent psychiatric reviews and inpatient beds.

Stephen Peter Jackson · Prevention of Future Deaths report View report

4 Oct 2018 Birmingham and Solihull E. Brown

Stephen Peter Jackson was found deceased at home on 11 August 2018 after sending his mother a text message saying “sorry”; drugs paraphernalia and a suicide note were present, and the provisional cause of death was a diamorphine overdose. The report raised concerns that he was not seen by mental health clinicians after his GP requested an urgent appointment, despite reported low mood and negative thoughts, and that delays and possible under-funding of mental health services posed a risk of future deaths.

William Peter Edge · Prevention of Future Deaths report View report

4 Oct 2018 Birmingham and Solihull E. Brown

William Peter Edge was found hanging in the shed at his home in Birmingham on 18 August 2018, after an ambulance crew attempted resuscitation. He had depression, a history of self-harm, and had attempted to hang himself the previous day before being assessed and discharged with a referral to the home treatment team. Concerns included the home treatment team being unable to return when his wife reported that he was in imminent danger, and wider pressures on inpatient beds and home treatment services, including a stated risk to life when patients cannot be attended as required.

Michael William Cooper · Prevention of Future Deaths report View report

4 Oct 2018 Birmingham and Solihull E. Brown

Michael William Cooper was found dead at home on 22 June 2018 from constriction by a ligature around the neck. The report describes concerns about the lack of face-to-face follow-up and immediate action despite indications of high suicide risk, as well as shortages of inpatient beds, team capacity and funding in mental health services.

Brian Alban Frost · Prevention of Future Deaths report View report

3 Oct 2018 Suffolk N. Parsley

Brian Alban Frost, a 92-year-old retired Roman Catholic priest who lived alone, died after an unwitnessed fall at home on 30 June 2018, sustaining severe head injuries. The report raised concerns about loose kitchen floor tiles presenting a trip hazard and about the inadequacy of welfare checks and health-and-safety risk assessments for retired clergy living in diocesan properties.

Theresa Maria BUTTON · Prevention of Future Deaths report View report

3 Oct 2018 West Yorkshire Eastern K. McLoughlin

Theresa Maria BUTTON underwent a liver transplant, remained in hospital for approximately 15 weeks, suffered multiple complications including a stroke, developed pneumonia, and died on 7 December 2017. Concerns included staffing levels and whether limited nursing capacity affected implementation of treatment plans, nutritional care, communication with family members, and contemporaneous record-keeping.