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Mike Fell · Prevention of Future Deaths report View report

5 Mar 2018 Inner North London S. Bourke

Mike Fell underwent elective abdominal aortic aneurysm repair and later suffered cardiac arrest after a trauma-line 3-way tap was found to be open to air. He sustained a cerebral air embolism and intracerebral bleed, and died in hospital in the early hours of 27 October 2017. Concerns included the absence of recorded checks that unused taps were closed to air and the lack of a clamp on the trauma lines.

Emily Jayne Hartley · Prevention of Future Deaths report View report

2 Mar 2018 West Yorkshire Eastern D. Hinchliff

Emily Jayne Hartley, a serving prisoner at HMP New Hall, was found suspended from a torn bed sheet in an out-of-bounds area during exercise on 23 April 2016; her death was confirmed at the scene. Concerns included serious deficiencies in the management, monitoring and recording of self-harm and suicide prevention procedures, weak information sharing and integrated planning, poor supervision, and the lack of a suitable secure therapeutic environment for people with significant mental health problems.

George French Russell · Prevention of Future Deaths report View report

1 Mar 2018 Manchester South A. Mutch

George French Russell was born prematurely at 35 weeks and 1 day following a footling breech birth on 11 January 2017, in poor condition and with severe brain damage. He died on 23 January 2017 after being transferred for neonatal care. Concerns included inadequate information-sharing between services and a lack of sustained expert input during the breech delivery.

Mr Anderton · Prevention of Future Deaths report View report

1 Mar 2018 Warwickshire S. McGovern

The supplied text does not describe the circumstances of Mr Anderton’s death, but states that an inquest concluded with a Narrative Verdict. The principal concern was that medical staff failed to attempt CPR after consulting the wrong set of medical notes.

Andrea McHugh · Prevention of Future Deaths report View report

28 Feb 2018 Northamptonshire A. Pember

Andrea McHugh, who had epilepsy and continued to experience seizures after brain surgery, died after being found floating in the sea while snorkelling during a boat trip in Cuba on 17 June 2016. The report raised concerns that the participant waiver did not mention the dangers of swimming in the sea for people with epilepsy and did not request participants’ past medical history.

Adrian Nicholas KING · Prevention of Future Deaths report View report

27 Feb 2018 Staffordshire South A. Haigh

Adrian Nicholas King became unwell and collapsed after riding a quad bike into the desert during an excursion in Egypt, and died in hospital from kidney failure on 29 May 2017. The principal concerns were that problems with his insurance affected the extent of his medical treatment and that attempts by his family to contact the British consulate for assistance were unsuccessful; it remained unanswered whether he could have been saved.

Rachel Holly Edwards · Prevention of Future Deaths report View report

27 Feb 2018 Suffolk N. Parsley

Rachel Holly Edwards died on 8 May 2017 after an overdose of multiple prescription medicines, following a period of severe and unbearable pain. Concerns identified at the inquest included unclear quantities of discharge medication, inadequate communication of prescriptions to her GP, record-keeping weaknesses, and the absence of a formal patient advocate system to support her when pain-management news and treatment administration increased her hopelessness.

David John Ireland · Prevention of Future Deaths report View report

27 Feb 2018 Exeter and Greater Devon L. Brown

David John Ireland experienced an acute-onset psychosis, forced entry into a house, climbed from a first-floor window while detained by residents, and sustained serious injuries in the fall. He died shortly after admission to hospital; a concern was raised that the crisis team did not advise him or his friend that he could attend the emergency department for an urgent mental health assessment.

Raymond Henry Davidson (Raymond) · Prevention of Future Deaths report View report

27 Feb 2018 Sunderland D. Winter

Raymond Henry Davidson died at home on 10 June 2017 after ambulance responses to urgent and emergency calls did not attend before he stopped breathing. The report identified ongoing ambulance resource shortages and delays in responding to urgent cases, as well as concerns that the initial clinical review was not sufficiently robust because telephone contact was not made directly with Raymond.

Kevan FUNNELL · Prevention of Future Deaths report View report

27 Feb 2018 Brighton and Hove V. Hamilton-Deeley

Kevan Funnell, described as an older man with a head injury, was found lying in a public highway on a freezing night in October 2017. The principal concern was the ambulance service’s delayed response, including concerns that the first two calls were not appropriately progressed or escalated and that the call-handling system was not fit for purpose in this case.

Mrs Kay Morrison · Prevention of Future Deaths report View report

26 Feb 2018 South Yorkshire (Western) C. Dorries

Mrs Kay Morrison underwent necessary surgery at the Royal Hallamshire Hospital on 11 June 2015, developed severe bacterial and fungal infections, and died of sepsis on 21 June 2015. The principal concern was that no proper antibiotic history was obtained, amid insufficient systems for collating such histories, resulting in antibiotics being prescribed for prophylaxis and treatment that were not effective for their intended purpose.

Naomi Clare Sourbut · Prevention of Future Deaths report View report

26 Feb 2018 Exeter and Greater Devon J. Tomalin

Naomi Clare Sourbut, who had a history of anxiety, depression, self-harm and bulimia, self-administered an overdose of medication, most probably Venlafaxine, and died after developing hypoxic brain injury. Concerns included whether recommendations from a root cause analysis had been considered and implemented, and whether protective factors were put in place after she reported suicidal intent and access to medication.

James Robert Quinton · Prevention of Future Deaths report View report

22 Feb 2018 South Yorkshire (Eastern) N. Mundy

James Robert Quinton collapsed after a period of vomiting and abdominal pain, with the inquest recording splenic rupture and combined morphine and methadone toxicity, alongside rivaroxaban therapy, as the cause of death. He did not respond to resuscitation and supportive measures. Concerns included poor-quality nursing and observation records, and noradrenaline intended as an infusion being administered as an intravenous bolus during resuscitation.

Molly Jean Mills · Prevention of Future Deaths report View report

21 Feb 2018 Nottinghamshire H. Connor

Molly Jean Mills, known as Jean, was involved in a collision with a lorry while turning right on the A6006 near Stanford on Soar on 6 June 2017. She died in hospital on 17 July 2017 after contracting bronchopneumonia associated with rib fractures sustained in the collision. The report identified concerns that the junction layout, incline, obstructed visibility, unclear manoeuvring arrangements and inadequate warnings increased the risk of future collisions and deaths.

Alan MacDONALD · Prevention of Future Deaths report View report

21 Feb 2018 Inner North London M. Hassell

Alan MacDonald was admitted to the Nightingale Hospital on 9 August 2017 after being assessed as too unwell for community care, and was discharged on 23 August after an improvement. He was found hanging at home after the bank holiday weekend, and the inquest determined that he died by suicide. Concerns included continued Addcounsel visits and charges while he was an inpatient, and the failure to address his expressed financial worries or highlight potential NHS care.

Richard Frederick PHILLIPS-SCHOFIELD · Prevention of Future Deaths report View report

21 Feb 2018 Portsmouth and South East Hampshire D. Clark

Richard Frederick PHILLIPS-SCHOFIELD fell from his cycle during a track race on 9 March 2014 and sustained unsurvivable head and chest injuries. He died in hospital on 11 March 2014; the principal concern was that ineffective procedures allowed cyclists to continue riding through the aftermath of the accident, and that formal procedures for halting races were lacking.

Bethany Victory Shipsey · Prevention of Future Deaths report View report

15 Feb 2018 Worcestershire G. Williams

Bethany Victory Shipsey, a young woman with significant mental health difficulties, died by suicide on 15 February 2017 after deliberately ingesting tablets containing dinitrophenol purchased over the Internet. The report identified significant failings in hospital monitoring and supportive care, and raised concern that dinitrophenol was extremely toxic, had no known antidote, and was freely available online.

Charlie Benjamin Craig · Prevention of Future Deaths report View report

15 Feb 2018 Manchester South C. Morris

Charlie Craig, an elite cyclist, was found unresponsive in bed on 21 January 2017 after appearing fit and well the previous evening. The inquest recorded that he died from damage to his heart resulting from a number of myocardial infarctions. A substantive concern was that British Cycling did not undertake health assessments or medical screening before accepting young riders onto its Apprenticeship stage, despite evidence that screening can help identify cardiac abnormalities in asymptomatic young people.

Timothy John Shaw · Prevention of Future Deaths report View report

15 Feb 2018 Essex C. Beasley-Murray

Timothy John Shaw, aged 34, was found collapsed in his prison cell on 28 February 2017 after apparent substance use and died in hospital on 2 March 2017. The report identified concerns about communication, intelligence reporting, access to illegal substances, referrals to psychosocial services, and record keeping.

Mr John Thomas Lambton · Prevention of Future Deaths report View report

14 Feb 2018 Sunderland D. Winter

Tom was admitted to Sunderland Royal Hospital after a series of unwitnessed falls or incidents while in respite care, and was found to have a fractured neck of femur and an active subdural haemorrhage. He underwent surgery and monitoring but deteriorated 18 days after admission following a suspected subdural re-bleed and died on 27 August 2017. The concerns were that care home staff made assumptions about his health, disregarded his request for an ambulance, and communicated insufficiently with the GP.