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Patricia Cragg · Prevention of Future Deaths report View report

28 Aug 2018 Plymouth, Torbay and South Devon A. Cox

Patricia Cragg underwent a high-risk percutaneous intervention and subsequently developed extensive haemorrhage after suspected bleeding from the arterial entry point. Her CT scan was delayed for hours because other patients were also awaiting imaging following an unrelated road traffic collision, and she deteriorated and died before surgery. The principal concerns were insufficient CT capacity during simultaneous emergencies and the absence of an internal radiology major incident policy.

Peter Jonathan Gledhill · Prevention of Future Deaths report View report

27 Aug 2018 West Yorkshire (Western) M. Fleming

Peter Jonathan Gledhill was found face down in Hebden Water after an unwitnessed fall down an embankment and was pronounced dead at the scene. The substantive concern was the safety of the pathway along the steep embankment and whether fencing was appropriate.

Karl James Willis · Prevention of Future Deaths report View report

24 Aug 2018 Exeter and Greater Devon L. Brown

Karl James Willis was found deceased at home, with toxicology showing amitriptyline at a concentration within the reported fatal range and morphine sufficient to increase its toxicity. The inquest recorded the medical cause of death as aspiration pneumonitis and amitriptyline and morphine toxicity, with a conclusion of misadventure. Concerns included online access to amitriptyline without adequate checks, the ability to provide inaccurate information, and the option not to inform the patient’s GP.

Jacqueline Dympna JORDAN · Prevention of Future Deaths report View report

24 Aug 2018 Avon M. Voisin

Jacqueline Dympna Jordan died after being struck by a car while crossing a dual carriageway and central reservation at Passage Road, Brentry, Bristol, on 18 November 2017. Concern was raised that a short section of the central reservation lacked a barrier, potentially enabling pedestrians to use it as an informal shortcut despite nearby pedestrian crossings.

Louie Francis Bradley · Prevention of Future Deaths report View report

21 Aug 2018 Manchester West J. Pollard

Louie Francis Bradley died following breastfeeding in bed with his mother, who fell asleep. Concerns included advice to breastfeed in bed while side-by-side with the baby when the mother was fatigued, and incomplete documentation of key information and advice given to the patient.

Kiarah Faith Adora Allen · Prevention of Future Deaths report View report

21 Aug 2018 Birmingham and Solihull L. Hunt

Kiarah Faith Adora Allen was born extremely prematurely and died after an inadvertent total parenteral nutrition fluid overload during a change of treatment, which led to severe metabolic complications and cardiac failure. The report identified unsafe staffing levels, failure to follow the correct procedure, and failure to learn from a previous similar incident. The principal concern was that staffing levels were insufficient when the neonatal unit was full.

Jacob Sulaiman · Prevention of Future Deaths report View report

20 Aug 2018 Inner North London S. Bourke

Jacob Sulaiman died at home on 8 December 2017 after a fire started in his bedroom, causing carbon monoxide poisoning. The principal concerns were that response officers did not have complete or readily accessible information about his contacts with other services, including the outcome of a paramedic visit, which may have affected the assessment and management of his mental capacity.

Enric Albert Alejandro Elliott · Prevention of Future Deaths report View report

14 Aug 2018 Inner West London F. Wilcox

Enric Albert Alejandro Elliott was found not breathing at home on 20 November 2017, was resuscitated and transferred to hospital, and died there on 24 November 2017 at five months old. The report raised concerns that late-booking young and vulnerable mothers could be excluded from Family Nurse Partnership support because of gestational-age referral rules, potentially increasing risks to their children.

Nana Kwabena Boansi BOATENG · Prevention of Future Deaths report View report

13 Aug 2018 Wiltshire and Swindon D. Ridley

Nana Kwabena Boansi BOATENG died at the scene on 24 December 2017 from chest trauma with haemorrhage after his car collided with a DAF light goods vehicle on the A429. The principal concern was that severely worn or absent central road markings and non-functioning cats’ eyes on the bend might have contributed to loss of positional awareness and created a road-safety risk.

Stephen James LAWSON · Prevention of Future Deaths report View report

13 Aug 2018 Bedfordshire and Luton I. Pears

Stephen James LAWSON, aged 62, was witnessed jumping from the fourth floor of the Luke Street Multi Storey Car Park in Bedford and died at the scene. Concerns included the ease of accessing the external barrier wall, the ability to use the crash barrier to cross it, the history of previous jumps, and the limited visibility of Samaritans signs.

Flora Marion BABER · Prevention of Future Deaths report View report

13 Aug 2018 Inner North London M. Hassell

Flora Marion Baber was admitted to the Royal Free Hospital from Compton Lodge Care Home on 25 January 2018 with increased confusion, slurred speech and difficulty breathing, and died there about a month later. Concerns included inadequate access to fluids, inappropriate food and eating assistance, delays in speech and language referral and treatment of oral thrush, an apparently sleeping staff member, inappropriate responses to toileting requests, and failure to record her opioid sensitivity across healthcare settings.

Kamal Yahyia AL-HIRSI · Prevention of Future Deaths report View report

13 Aug 2018 Inner North London M. Hassell

Kamal Yahyia AL-HIRSI, a cleaner at a London health club, suffered a cardiac arrhythmia and slipped beneath the water while cleaning the swimming pool on 10 October 2017. Resuscitation attempts were too late to change the outcome. Concerns included dangerous pool-cleaning practices, inadequate water-safety and defibrillator training, ineffective emergency alarms and communication, limited CCTV coverage, and procedures that remained substantially unchanged ten months after his death.

ADITYA PURI · Prevention of Future Deaths report View report

9 Aug 2018 Derby and Derbyshire R. Syed

ADITYA PURI was killed on 23 February 2017 after losing control of his vehicle on the eastbound A50 and colliding with a stationary lorry. The principal concern was that the stretch of the A50 lacked street lighting, with the report noting four additional fatal road traffic collisions there between 2017 and 2018.

Kelly Marie Campbell · Prevention of Future Deaths report View report

9 Aug 2018 Essex C. Beasley-Murray

Kelly Marie Campbell was a 17-year-old girl detained under section 3 of the Mental Health Act at Rochford Hospital. She was found hanging by a ligature made from shoe laces attached to a bathroom light fitting, and the inquest concluded that she killed herself. Concerns included the return of her shoe laces, the need for rigorous policies governing such decisions, and dreary physical surroundings that may have contributed to boredom during the night.

Keith Dransfield · Prevention of Future Deaths report View report

8 Aug 2018 South Yorkshire (Western) D. Urpeth

Keith Dransfield died in Northern General Hospital on 30 September 2017 from cerebral hypoxia due to hanging, with psychiatric depression also recorded. The inquest identified concerns about an inappropriate observation regime, inadequate risk assessment, failure to routinely consult patient records, and insufficient staff training.

Dr Donald Clegg · Prevention of Future Deaths report View report

8 Aug 2018 Manchester North L. Hashmi

Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.

Ian Paul Wolstenholme · Prevention of Future Deaths report View report

8 Aug 2018 Manchester North L. Hashmi

Ian Paul Wolstenholme was found collapsed at home on 17 December 2017 and died later that day. The medical cause of death was combined drug toxicity, with liver cirrhosis and diabetes mellitus also contributing. The report raised concern about the lack of guidance for prescribing highly addictive and potentially harmful drugs together, particularly in cases of polypharmacy.

Mr. Steven John Welch · Prevention of Future Deaths report View report

7 Aug 2018 South Wales Central S. Richard

Mr. Steven John Welch was found at home on 26 December 2017 after a reported fall and head injury, and was later diagnosed with a subarachnoid haemorrhage, hydrocephalus and an aneurysm. His condition deteriorated during delays in assessment, neurosurgical admission and transfer of radiology images for specialist review; he was transferred to Southmead Hospital but died from a pulmonary embolism, with deep vein thrombosis and subarachnoid haemorrhage also recorded in the medical cause of death. The principal concerns included delayed emergency assessment and neurosurgical treatment, lack of interventionist radiology cover, and inadequate facilities for transferring radiological images to hospitals outside Wales.

Ms Susan Joan Elliott (Sue) · Prevention of Future Deaths report View report

6 Aug 2018 Sunderland D. Winter

Ms Susan Joan Elliott died at Sunderland Royal Hospital on 14 September 2017 after a fall, an initially unconfirmed suspected hip fracture, subsequent readmission and surgery. Concerns included that the 4 August x-ray was reportedly ignored, no CT scan was undertaken before discharge, and surgery may have been possible earlier.

Phyllis Margaret LETCHER · Prevention of Future Deaths report View report

6 Aug 2018 Cornwall and Isles of Scilly G. Davies

Phyllis Margaret Letcher died after sustaining a traumatic head injury in an unwitnessed fall down the staircase at Crossroads House Care Home on 2 March 2018; she died on 12 March 2018. The concerns identified were the lack of live CCTV monitoring of the staircase, the absence of key-fob access through the stairgate, and the absence of an alarm if the stairgate was left open.