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Lindsey Tyrrell · Prevention of Future Deaths report View report

29 Jun 2018 Manchester City A. Mazzag

Lindsey Tyrrell, who had undergone an allogeneic stem cell transplant and was immunosuppressed, developed an infection and deteriorated before dying on 3 July 2017. Toxoplasmosis was identified retrospectively in blood and cerebrospinal fluid; the principal concern was that testing for toxoplasmosis was not routinely carried out at the Christie Hospital in comparable transplant patients presenting with signs of infection, and that learning from the incident should be shared nationally.

Rashan Jermaine CHARLES · Prevention of Future Deaths report View report

29 Jun 2018 Inner North London M. Hassell

Rashan Jermaine Charles entered a convenience store after a foot chase, put a package in his mouth, and was restrained and handcuffed during a struggle. He lost consciousness and suffered cardiac arrest; the recorded medical cause of death was cardiac arrest due to upper airway obstruction by a foreign body during restraint. Concerns included recognising choking when it resembles resistance, assessing breathing in stressful conditions, and managing assistance from members of the public.

ASHLEY ERNEST NOTSON · Prevention of Future Deaths report View report

29 Jun 2018 Suffolk P. Dean

Ashley Notson died at age 55 after choking on a piece of meat at the care home where he lived, later dying in hospital from hypoxic brain injury resulting from the choking episode. The inquest raised concerns that the law did not require care-home carers to have first-aid training or to have access to a mobile or portable telephone to summon assistance without leaving the person they were caring for.

Stephen Whitehead · Prevention of Future Deaths report View report

28 Jun 2018 Manchester North L. Hashmi

Stephen Whitehead was admitted with abdominal symptoms on 6 February 2018 and deteriorated despite intensive treatment, dying in hospital on 8 February 2018. The report identified concerns about the absence of a national registry or safety-netting system for biliary stents and the lack of a clear definition of “short-term” use in clinical guidance.

John Robert Maltby Worthington · Prevention of Future Deaths report View report

28 Jun 2018 Stoke-on-Trent and North Staffordshire M. Jones

John Robert Maltby Worthington fell down stairs in late March or early April 2017 and was treated for a head injury, with back and neck pain noted. He was later found to have spinal and rib fractures and pneumonia, and died in hospital on 29 June 2017 from bronchopneumonia, osteomyelitis of the spine and traumatic spinal fracture. The concerns included not undertaking further imaging after the initial fall and not recording a full set of observations or conducting further investigations when he later saw his GP with persistent back pain.

Dudley Vincent Brown · Prevention of Future Deaths report View report

27 Jun 2018 Inner North London S. Bourke

Dudley Vincent Brown had multiple health conditions and his care package was withdrawn after incidents involving threats to carers and a social worker. He was found at home in a state of reduced consciousness during a delayed mental health assessment, taken to hospital with multi-organ failure, and died on 11 January 2018. Concerns included the withdrawal of care without welfare checks, misunderstandings about referral responsibilities, and delays involving the mental health assessment and police risk assessment.

Angela Sandra Ivina West · Prevention of Future Deaths report View report

27 Jun 2018 Inner North London S. Bourke

Angela Sandra Ivina West had end stage kidney disease and underwent gall bladder removal surgery on 6 July 2017. She deteriorated over the following days, with tachycardia, acidosis, hyperkalaemia and hypovolemia, and died after suffering a cardiac arrest on 9 July 2017. Concerns included weekend staffing arrangements, her care on a general surgical ward, and the absence of fluid balance charts in relation to dehydration.

Angela Marion Turner · Prevention of Future Deaths report View report

26 Jun 2018 Manchester West S. Nelson

Angela Marion Turner developed intense pain after a sudden-onset headache, and her son’s call to NHS 111 went unanswered for approximately 45 minutes. She was later assessed at a Walk-In Centre and discharged home, was found collapsed the following day, and died on 10 January 2018 from a subarachnoid haemorrhage; the substantive concern was the inadequate response to the NHS 111 call.

Margaret Megan Evans · Prevention of Future Deaths report View report

26 Jun 2018 North Wales (East and Central) J. Gittins

Margaret Megan Evans fell outside her home on 22 January 2018 and sustained a fractured hip. Delays in ambulance attendance, admission to the emergency department and being seen by an ED doctor left her lying on a concrete path for more than three hours and delayed medical assessment; the report states that it cannot be said these delays contributed to her death, which was recorded as accidental with hospital-acquired pneumonia and a fractured neck of femur.

Vanessa Ferkova and Sylvia Daniel · Prevention of Future Deaths report View report

25 Jun 2018 Coventry R. Brittain

Vanessa Ferkova, aged 2, died after presenting to a walk-in centre with fever and vomiting, developing a rash, and later suffering cardiac arrest; the report states she died from meningococcus septicaemia. Sylvia Daniel, aged 73, presented with symptoms including neck pain, was diagnosed with an ear infection, and was found deceased the following morning; the report states she died from acute meningitis. Concerns included delays and deficiencies in initial assessment and registration, failure to transcribe or retain information provided by families, and an unsafe non-clinical triage and flagging process.

John Edward Hill · Prevention of Future Deaths report View report

25 Jun 2018 Dorset R. Griffin

John Edward Hill was found collapsed and unresponsive at home on 26 May 2017, holding a rifle and with a bullet wound to his forehead. The report raised concerns that firearms licensing enquiries did not routinely include family members or others living with the applicant, who might hold important information relevant to the application and prevention of future deaths.

Marjorie McMahon · Prevention of Future Deaths report View report

25 Jun 2018 Manchester South R. Galloway

Marjorie McMahon became increasingly unwell at Cherry Tree House and was taken to hospital on 7 March 2018, where she received treatment before dying on 8 March 2018. The principal concern was the delay in ambulance and paramedic attendance despite her being categorised as a level 2 priority, with an 8-minute guideline response time.

Lauren Amelia Rose SANDELL · Prevention of Future Deaths report View report

25 Jun 2018 London (East) N. Persaud

Lauren Sandell became unwell with headaches, vomiting, aches and pains on 29 September 2016 and became unresponsive at home on 2 October 2016, when her life was pronounced extinct by paramedics. The inquest concluded that she died from meningococcal sepsis (serogroup W135) and fell within the cohort requiring MenACWY vaccination. Concerns included confusion over responsibility for vaccinating children not covered by the school programme, uncertainty about GP responsibilities, and the lack of auditing of systems to identify and protect unvaccinated children before university.

William Lugg · Prevention of Future Deaths report View report

25 Jun 2018 London Inner (North) H. QC

William Lugg lived alone and received daily care visits, but after an unwitnessed fall on or by the morning of 3 March 2018, carers received no answer and he was not found until 6 March 2018, when he was discovered deceased at his residence. The concerns included failures to follow and coordinate failed-visit procedures, inaccurate information about his welfare, inadequate recording of keyholder and call details, insufficient prominence given to contacting police, and the absence of a clear Monday-morning referral-prioritisation system.

MARGARET STEMP · Prevention of Future Deaths report View report

25 Jun 2018 West Sussex P. Schofield

Margaret Stemp, aged 91, was found deceased on 28 December 2017 after she and her sister had fallen and remained on the floor for over seven hours before police assistance. The inquest concluded that she died from natural causes following a long lie on the floor where there had been missed opportunities for medical intervention. Concerns included insufficient ambulance resources, reliance on police for welfare support, failure to recognise worsening circumstances, and no clinical oversight of the decision to stand down the ambulance response.

Andrew Craig · Prevention of Future Deaths report View report

25 Jun 2018 Dorset R. Griffin

Andrew Craig, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell on 16 September 2016. The inquest concluded that the medical cause of death was the toxic effects of buprenorphine and diazepam, with a conclusion of misadventure. The principal concerns were illicit drug use at the prison and weaknesses in the dispensing and monitoring of medication, which could facilitate the redistribution of prescription drugs.

Samuel Patrick CLARKE · Prevention of Future Deaths report View report

22 Jun 2018 Inner North London M. Hassell

Samuel Patrick Clarke, aged 19, accessed a construction site in the early hours of New Year’s Day 2018 and fell from height. He was not found until 2 January 2018 and had died from postural asphyxia following the fall and traumatic injury, with ethanol intoxication also recorded. Concerns included continued unauthorised access through a turnstile, the absence of a company contingency plan to support searches for intruders, and the adequacy of security officers’ torches.

Alexia Awenimi WALENKAKI · Prevention of Future Deaths report View report

22 Jun 2018 Inner North London M. Hassell

Alexia Awenimi Walenkaki died after falling from a rope suspended from a wooden post that collapsed while she was playing in a children’s play area on 17 July 2015. The jury identified the use of inappropriate wood and organisational failure, including a lack of accountability for annual inspections, as causative factors. The coroner was concerned that unclear responsibility and continuity in management structures could lead to recurrence.

David Lee Gomer TRAVERS · Prevention of Future Deaths report View report

22 Jun 2018 Plymouth, Torbay and South Devon S. Covell

Mr Travers was found unresponsive and declared deceased on 27 October 2017 after taking illicit and prescription drugs and alcohol, including heroin. The principal concern was that people could access multiple prescriptions from different GP surgeries, with prescription drugs potentially being used to obtain illicit drugs or entering the illegal drugs market.

John Charles Hazlewood · Prevention of Future Deaths report View report

21 Jun 2018 Leicester City and South Leicestershire L. Brown

John Charles Hazlewood died on 31 January 2017 after self-harming with hand tools and consuming a large amount of white spirit. The report identified concerns about psychiatric clinicians’ access to medical records and documentation, failure to involve his partner in assessing his escalating behaviour, monitoring of revised on-call procedures, and a lack of self-harm training for relevant hospital staff.