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Ellie May Butler · Prevention of Future Deaths report View report

10 Apr 2018 London (South) L. Dobbs

Ellie May Butler was assaulted by her father at her home on 28 October 2013, sustaining fatal head injuries. The inquest concluded that her death was an unlawful killing; the matters of concern are referred to as appended but are not provided in the supplied text.

Darryl Alfred Wayne Rego SOUZA · Prevention of Future Deaths report View report

9 Apr 2018 Northamptonshire H. Shah

Darryl Alfred Wayne Rego Souza died at the scene on 7 October 2017 from fatal chest injuries sustained when the motorcycle he was riding collided with a Mini at a crossroads in Clipston, Northamptonshire. Concerns included compromised visibility at the junction, the lack of a timeframe for planned improvements to signage and rumble strips, a recommendation that Stop signs be considered, and a further accident at the same location around one week before the resumed inquest.

Naseeb Singh Chuhan · Prevention of Future Deaths report View report

9 Apr 2018 West Yorkshire Eastern J. Leach

Naseeb Singh Chuhan was a first-year student at Leeds Beckett University who had a history of borrowing from payday loan companies. Shortly after an unsuccessful attempt to borrow more money, he was found hanging in his student accommodation; concerns included the conduct of payday loan companies and inadequate financial checks.

Miriam Roach · Prevention of Future Deaths report View report

6 Apr 2018 Cornwall and Isles of Scilly G. Davies

Miriam Roach, who had a history of depression, anxiety, alcohol dependency and self-harm, was discharged from hospital on 30 June 2017 after assessment following an overdose. She died by suicide on 1 July 2017 by hanging. The substantive concerns related to aftercare and the absence of arrangements to contact patients discharged home with moderate to high risks of self-harm or suicide.

Casper Blackburn · Prevention of Future Deaths report View report

3 Apr 2018 Manchester South 2018-0094

Casper Blackburn died in the early hours of 1 October 2017 after entering the Bridgewater canal in unclear circumstances; the medical cause of death was drowning. Concern was raised that extremely poor lighting, and the absence of CCTV, made the canal difficult to distinguish from the surrounding grass verge and path, creating a risk of future deaths.

Barbara Haley · Prevention of Future Deaths report View report

3 Apr 2018 Manchester South R. Galloway

Barbara Haley inhaled vomit, saliva, food or liquid while resident at Hilltop Court Care Home, developed a chest infection, and died at Stepping Hill Hospital on 13 October 2017 after suffering a cardiac arrest en route. Concerns included her being provided food unsuitable for her soft diet and being left alone to eat despite having been assessed as at high risk of choking.

Julia Jane MacPherson · Prevention of Future Deaths report View report

1 Apr 2018 South London S. Hayes

Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.

Mr Frank Hayward · Prevention of Future Deaths report View report

29 Mar 2018 Black Country Z. Siddique

Mr Frank Hayward fell at home on 12 November 2017, sustaining an odontoid peg fracture and subdural haemorrhage, and died on 10 December 2017 after his condition declined. The concerns included failures to correctly assess and diagnose his injuries, delays in Trauma and Orthopaedics review and urgent CT scanning, and poor systems and communication in obtaining a cervical collar.

Matthew Luke FAULKNER · Prevention of Future Deaths report View report

29 Mar 2018 Hertfordshire G. Sullivan

Matthew Faulkner was found hanging from his bathroom door handle on the evening of 30 May 2017 and was confirmed dead at 21:57. The report raised concerns about the almost five-hour delay between the emergency call and ambulance attendance, as well as ambulance service demand exceeding available resources and delays handing patients over to hospital.

Ross REEVES · Prevention of Future Deaths report View report

29 Mar 2018 Brighton and Hove V. Hamilton-Deeley

Ross REEVES died after taking more than one week’s worth of Gabapentin, Zomorph and Mirtazapine, which caused profound stupor and respiratory depression; he subsequently developed lobar pneumonia. The principal concern was that his transfer to a new GP was likely unsafe and that better handover information might have led to different prescribing arrangements.

Mrs Margaret Spencer · Prevention of Future Deaths report View report

29 Mar 2018 Black Country Z. Siddique

Mrs Margaret Spencer was treated for a prolapse with a pessary, but a change in IT systems meant that no follow-up review took place after May 2014. Her condition deteriorated, the pessary eroded through her bladder, and she died on 17 December 2017 after developing pneumonia and acute kidney injury. The principal concern was inadequate staff training and administrative failures during the introduction of the new IT system, which led to her follow-up being missed and placed patients at risk of harm.

John Frederick Wherlock · Prevention of Future Deaths report View report

28 Mar 2018 Avon R. Sowersby

John Frederick Wherlock was an inpatient at Bristol Royal Infirmary who was elderly, confused and at high risk of falls. He was left unsupervised while ward staffing was reduced because two staff were taking breaks at the same time, fell and fractured his other hip, and subsequently died. The principal concerns were inadequate cover during simultaneous staff breaks and the continuation of that practice despite it having been criticised in a serious untoward incident report.

Anthony Paine · Prevention of Future Deaths report View report

28 Mar 2018 Liverpool and the Wirral A. Rebello

Anthony Paine, aged 35, was found hanging in his cell at HMP Liverpool after being placed on hourly checks because of mental health concerns and feeling low. CPR was attempted and he was taken to hospital, where he was certified as having died at 17.31 on 19 February 2019. The report text also records a history of mental illness and previous inpatient treatment under section 3 of the Mental Health Act 1983.

Donald Martin · Prevention of Future Deaths report View report

28 Mar 2018 Derby and Derbyshire A. Crawford

Donald Martin, a 96-year-old resident of Langdale Heights Nursing Home with Chronic Obstructive Pulmonary Disease receiving long-term oxygen treatment, was observed struggling to breathe on 14 January 2016 and was pronounced deceased shortly after the ambulance arrived. The court found non-causative deficiencies in the emergency response before the ambulance service arrived. Concerns included whether the nurse in charge understood why or when CPR should be carried out on a flat surface and her lack of knowledge about deflating patient mattresses during an emergency.

Matthew Gayle · Prevention of Future Deaths report View report

27 Mar 2018 Staffordshire South A. Haigh

Matthew Gayle, a serving prisoner at HMP Oakwood, was found dead in his cell on 8 December 2016. The precise cause of death could not be determined, although it was considered likely to have been naturally occurring. The report raised concerns that histology had not been carried out during the post-mortem and about the availability, training, appointment, contractual arrangements and fees of consultant histopathologists undertaking coroners’ autopsies.

Maureen Anne CAMPBELL-SCOTT · Prevention of Future Deaths report View report

27 Mar 2018 London (East) N. Persaud

Maureen Anne Campbell-Scott died from multiple injuries after falling from a ledge at the Exchange Shopping Centre car park on 16 June 2017. The report identified concerns about delays and errors in mental health referrals, delayed communication of medication changes, prescribing that did not always follow specialist directions, and a lack of joint working between mental health services and the GP practice.

Joan Osborne · Prevention of Future Deaths report View report

26 Mar 2018 Nottinghamshire J. Gillespie

Joan Osborne, who had diabetes and advanced dementia, died on 25 August 2017 after repeated difficulties obtaining her blood glucose levels and administering her insulin. The concerns included failures by nursing home staff to seek medical assistance or escalate her missed insulin, inadequate records, failure to recognise her deteriorating condition, and inaccurate blood glucose measurement and treatment on 22 August 2017.

Kenneth Longley · Prevention of Future Deaths report View report

22 Mar 2018 Manchester South R. Galloway

Kenneth Longley died at Tameside Hospital on 9 September 2017 after treatment for acute coronary syndrome and severe aortic stenosis led to an upper gastrointestinal bleed. The report identified delays in sending a cardiology referral letter and a lack of action by the GP practice after the letter and echocardiogram results were received.

Edward Arthur Lundy · Prevention of Future Deaths report View report

21 Mar 2018 Somerset T. Williams

Edward Arthur Lundy, who had a history of depression, was found hanging in a barn on 23 August 2016 and could not be revived. The concerns identified included a lack of continuity in his care, no psychiatric assessment despite a referral indicating this was needed, and insufficient documentation and discussion of care options and risks with his family. The report also states that evidence had not been produced showing that the proposed actions had been implemented or shared nationally.

Barbara Johnson · Prevention of Future Deaths report View report

21 Mar 2018 Manchester South R. Galloway

Barbara Johnson was detained under Section 3 of the Mental Health Act and admitted to the Moorside Unit on 19 April 2017. She suffered a heart attack on 30 April 2017 and was pronounced deceased after resuscitation efforts. The principal concerns included gaps in physical observations and clinical review, deficiencies in handover and emergency-response equipment, and junior doctors’ failure to consider ECG machine printout abnormalities during interpretation.