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Dylan Paul Hill · Prevention of Future Deaths report View report

4 Jan 2018 South Yorkshire (Western) T. Rawden

Dylan Paul Hill died after eating a korma meal containing almond powder contaminated with peanuts at a restaurant in Barnsley, causing an anaphylactic reaction. The report identified concerns about allergen information, ingredient checking and labelling at food premises, and the absence of procedures for reporting non-fatal anaphylactic reactions to Trading Standards and other regulatory authorities.

Margaret Jean Silver · Prevention of Future Deaths report View report

3 Jan 2018 Surrey A. Crawford

Margaret Jean Silver, an 85-year-old resident of a care home, developed pulmonary emboli after Rivaroxaban was discontinued following contradictory medication instructions in her hospital discharge summary. She later experienced reduced mobility, sustained a fractured femur in an assisted fall, developed a chest infection, and died in hospital. Concerns included contradictory discharge medication information, failure to identify that Rivaroxaban had been discontinued, and failures in communicating and implementing recommended discharge support and equipment.

Paul Anthony Daniels · Prevention of Future Deaths report View report

2 Jan 2018 Manchester South A. Mutch

Paul Anthony Daniels died after falling approximately 50 feet from a conifer tree while working as a tree surgeon at Hazel Grove Golf Club. Concerns included the staffing ratio, the groundsman’s lack of aerial-work qualification, and difficult communication between the groundsman and tree surgeons.

Kristina CROSS · Prevention of Future Deaths report View report

2 Jan 2018 Lancashire and Blackburn with Darwen J. Newman

Kristina Cross, aged 72, was admitted on 28 August 2016 after an unwitnessed fall and was later found to have a displaced fracture of the neck of the femur. The fracture was initially misdiagnosed, delaying surgical fixation; she subsequently suffered wound complications and joint dislocations, deteriorated after further surgery, and died on 20 November 2016. The principal concerns were unfilled consultant radiologist posts and delays, or failures, in reporting radiological investigations needed for diagnosis and clinical decision-making.

Mark Nicholas Welsh · Prevention of Future Deaths report View report

28 Dec 2017 Inner North London M. Hassell

Mark Nicholas Welsh died after being knocked over by a lorry while crossing Duke’s Road at its junction with Euston Road in London on 6 July 2017. The report raised concerns about the prolonged delay in improving pedestrian safety at the crossroads, the decision not to install crossings, and the traffic-control statistics used by Transport for London, which did not account for all collisions or reported near misses.

Michael Richard Drewry · Prevention of Future Deaths report View report

28 Dec 2017 Nottinghamshire A. McNamara

Michael Richard Drewry had a history of anxiety and low mood, with deteriorating mental health and episodes involving knives shortly before he was found with a ligature around his neck on 3 April 2017. He sustained fatal injuries, suffered an unsurvivable hypoxic brain injury, and died in hospital on 8 April 2017. The substantive concerns were failures by the Crisis Team to provide consistent and continuous care, make accurate and prompt records, and escalate concerns appropriately and promptly.

Ronald Arthur Farrington · Prevention of Future Deaths report View report

22 Dec 2017 Surrey C. Topping

Ronald Arthur Farrington, who had dementia and Parkinson’s disease and was resident in a nursing home, developed infected sacral pressure sores. He was admitted to hospital with sepsis and died on 21 June 2016; the inquest recorded sepsis caused by infection in the pressure sore, with pneumonia contributing. The substantive concerns included failures to follow and record tissue-viability advice, failure to refer the infection to his general practitioner, inadequate tissue-viability nurse availability, and insufficient independent investigation by the CQC and safeguarding review.

Russell Charles ROBB · Prevention of Future Deaths report View report

22 Dec 2017 Manchester South A. Mutch

Russell Charles ROBB died at Manchester Royal Infirmary on 9 April 2016 after taking a fatal combination of prescribed and non-prescribed drugs with alcohol. The report identified inadequate monitoring and lack of regular medication reviews, no apparent guidelines to limit the quantity of drugs available, and limited information sharing between agencies involved in adult safeguarding.

Margaret Ellen Postill · Prevention of Future Deaths report View report

21 Dec 2017 Manchester South A. Mutch

Margaret Ellen Postill, a resident with dementia at Sunnyside Care Home, fell twice on 2 May 2017 and later developed seizures after a subdural hematoma was identified. She deteriorated over the following weeks, was moved to palliative care, and died on 31 May 2017. Concerns included the lack of evaluation and completed assessment sheets after her return to the care home, and poor-quality documentation at Tameside Hospital concerning the second visit and decision-making.

Sheila ROSS · Prevention of Future Deaths report View report

21 Dec 2017 Brighton and Hove V. Hamilton-Deeley

Sheila ROSS sustained a fatal fall down a flight of stairs at Carlton House Rest Home on 17 September 2017. The report’s principal concern was that no falls risk assessment had been completed despite earlier indicators of vulnerability; the inquest concluded that the death was accidental, to which neglect contributed.

Craig David Royce · Prevention of Future Deaths report View report

20 Dec 2017 Essex C. Beasley-Murray

Craig Royce, who had a history of mental health problems and epilepsy, was found hanging in his prison cell on 24 December 2016. The report identified concerns that a referral to mental health services following an incident of self-harm was not made and that there was no robust documentary system for communicating such referrals. The inquest jury also considered that his risk of self-harm or suicide was not properly reviewed with appropriate precautions taken.

Mrs Lindsey Parker · Prevention of Future Deaths report View report

19 Dec 2017 Manchester North L. Hashmi

Mrs Lindsey Parker had metastatic lung cancer and subsequently developed toxic epidermal necrolysis while receiving medical treatment. Her condition deteriorated on 8 July 2017, with concerns about delayed medical review, inadequate recognition and escalation of deterioration, gaps in observations and fluid-balance recording, lack of continuity in medical care, and the qualifications of out-of-hours coordinators. She died at Salford Royal Hospital on 9 July 2017.

MARK ANTHONY DOYLE · Prevention of Future Deaths report View report

18 Dec 2017 Inner North London H. Williams

Mark Anthony Doyle was found suspended by a ligature attached to his cell window bars on 21 March 2017 and died in hospital on 28 March 2017 from injuries sustained in the suspension. The inquest identified concerns including errors in recording a significant anniversary on his ACCT, his transfer from F Wing, and a delay in responding to his cell bell. Further concerns related to ACCT review and information-sharing practices, unclear criteria and recording for transfers from F Wing, and the lack of mandatory first-aid training for existing prison officers.

Anne Morris · Prevention of Future Deaths report View report

18 Dec 2017 Inner South London C. Williams

Anne Morris died by suicide after hanging herself while alone in a friend’s house on 26 June 2017. The principal concerns were that the Priory Hospital did not contact consented friends or relatives, did not establish a written discharge and follow-up plan, and did not liaise adequately with the relevant Oxleas Home Treatment Team before discharge. Concerns were also raised that the Oxleas team did not obtain a discharge plan or know that Anne had agreed to contact with a friend regarding community support and suicide risk.

Stephen Mark SHAYLOR · Prevention of Future Deaths report View report

18 Dec 2017 Exeter and Greater Devon E. Earland

Stephen Mark SHAYLOR was found hanging in his cell at HMP Exeter in the early hours of 1 January 2014 and was pronounced dead at 03:35. He was on a drug stabilisation regime and subject to healthcare night welfare checks. Concerns included the inadequacy of checks conducted through cell-door hatches, the absence of continuous CCTV monitoring, and the failure to carry out the 02:00 check.

Daniel Watson · Prevention of Future Deaths report View report

18 Dec 2017 North Wales (East and Central) J. Gittins

Daniel Watson was found hanged at his home on 5 June 2017 and was verified dead from hanging. The report identified care and service delivery problems, missed opportunities to improve his mental health, and concerns about staff understanding of risk assessment and escalation towards formal psychiatric assessment.

Pamela Margaret Hands aka Horner · Prevention of Future Deaths report View report

18 Dec 2017 Cornwall and Isles of Scilly E. Carlyon

Pamela Margaret Hands, also known as Horner, fell at home and was admitted to hospital with a periprosthetic femur fracture. After receiving opioid analgesia and a local anaesthetic nerve block, she was not adequately observed, was found unresponsive, and died on 1 December 2015. The principal concerns were inadequate monitoring after the block, insufficient recognition of relative opioid toxicity, and the absence of national guidance on post-procedure monitoring and related risks.

Ernest Wayne Smith · Prevention of Future Deaths report View report

14 Dec 2017 Surrey A. Crawford

Ernest Wayne Smith was found deceased in woodland at Chelsham Common, Warlingham, on 13 June 2016. The inquest concluded that the medical cause of death was hanging and recorded a short-form conclusion of suicide. Concerns included failures to arrange or follow up medication reviews and the absence of a clear system for updating GPs about missed appointments and disengagement where the CMHRS medical team was not involved.

Rebecca Jay ROMERO · Prevention of Future Deaths report View report

13 Dec 2017 Avon M. Voisin

Rebecca Romero died at home on 19 July 2017 after being found with a ligature around her neck, five days after discharge from a psychiatric unit and while under community team care. The report raised concerns about gaps in post-discharge contact and medical review, unclear and inconsistent care planning and risk terminology, communication by text, and arrangements for transferring children between out-of-area and local psychiatric services.

Joseph Peter Dunne · Prevention of Future Deaths report View report

12 Dec 2017 Isle of Wight C. Sumeray

Joseph Peter Dunne, aged 58, was discharged from hospital on 14 July 2015 after presenting with pain and feeling unwell, and was later found collapsed at home on 16 July 2015. He became unresponsive while using the toilet and was pronounced dead at 3.20 p.m.; the medical cause of death was peritonitis due to a perforated duodenal ulcer. The report raises concerns about Information Governance breaches that allowed clinical records, including an abnormal D-dimer result, to be deleted or altered and not seen by treating clinicians.