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Francis Robert Beech · Prevention of Future Deaths report View report

12 Dec 2017 Birmingham and Solihull L. Hunt

Francis Robert Beech had a conservatively treated right ankle fracture and was discharged to a nursing home, where monitoring and care planning for his plaster cast were not arranged. Infection signs were present by 1 July 2017 but were not investigated promptly, and he later developed a severely infected compound fracture and pressure sores before dying from bronchopneumonia contributed to by chronic obstructive pulmonary disease and the infected fracture site.

Sidonio Eugenio TEIXEIRA · Prevention of Future Deaths report View report

12 Dec 2017 Worcestershire G. Williams

Sidonio Eugenio TEIXEIRA was murdered in prison by another prisoner. Inquest concerns included the adequacy of intelligence, reporting, analysis and analyst training, ongoing audit, and the sharing of lessons from a critical internal report with appropriate staff.

Irene Winifred BAKER · Prevention of Future Deaths report View report

11 Dec 2017 Avon S. Fox

Irene Winifred BAKER died following an operation for a fractured hip, which evidence suggested occurred at Rosewood Lodge Nursing Home, although the nursing home had no record of it. Concerns included failures to revise mobility care plans, undertake monthly mobility reviews, and contact a GP or call an ambulance when she was documented as unable to bear weight.

Roger Albert Saxby · Prevention of Future Deaths report View report

8 Dec 2017 Brighton and Hove V. Hamilton-Deeley

Roger Albert Saxby died from natural causes, to which delay in treatment and lack of urgency contributed. Concerns included inadequate staffing and resources at Royal Sussex County Hospital, delays in transfer and thrombolysis, and an unstructured discussion about his subsequent care, including two hub-to-hub transfers within 36 hours.

Stuart Andrew WALLS · Prevention of Future Deaths report View report

8 Dec 2017 East Riding and Kingston Upon Hull M. Mellun

Stuart Andrew WALLS was found dead in his room on 12 March 2017 after being last seen alive the previous morning. The inquest concluded that he died from drug poisoning caused by the combined effects of prescribed medication, with concern that multiple central-nervous-system medicines could have a synergistic effect on respiration even when taken at prescribed doses.

Paul Eric GANDER · Prevention of Future Deaths report View report

8 Dec 2017 Brighton and Hove V. Hamilton-Deeley

Paul Eric GANDER’s death was investigated, with the inquest concluding on 27 November 2017 with a narrative conclusion. The principal concern was that, during weekends and out-of-hours, the Consultant Orthopaedic and Trauma Surgeon could not access other departments’ electronic hospital records, and that authorised personnel should have full access to all hospital records.

BENJAMIN THOMAS GOODRUM · Prevention of Future Deaths report View report

8 Dec 2017 Norfolk J. Lake

Benjamin Thomas Goodrum, who had schizophrenia and Asperger’s syndrome and lived in the community with support from several organisations and his parents, was found clearly deceased in his flat on 27 June 2016. Concerns included the absence of a person with overall responsibility for him, the failure to appoint a replacement Care Co-Ordinator, and the incomplete implementation of an investigation recommendation concerning allocation of a Lead Care Professional or Care Co-Ordinator.

Mrs Violet Levine Nelson · Prevention of Future Deaths report View report

7 Dec 2017 Berkshire P. Bedford

Mrs Violet Nelson collapsed suddenly at home and died on 17 September 2016; a post-mortem examination identified a ruptured thoracic aortic aneurysm. The report raised concerns that earlier ultrasound findings were not overseen by a Consultant Radiologist and did not recommend referral to a Vascular Surgeon or CT examination, and that GPs may not have been aware of the significance of a suprarenal aortic aneurysm.

Kenneth Cottam · Prevention of Future Deaths report View report

7 Dec 2017 Derby and Derbyshire A. Crawford

Kenneth Cottam, an 89-year-old resident of Coxbench Hall Residential Home, sustained a subdural bleed after one of two reported falls and died in hospital on 13 April 2016. The court heard that no falls risk assessment was carried out and that staff did not consider a possible link between his confusion and an earlier fall, while concerns were raised about the clarity, robustness and consistent implementation of falls prevention and management procedures.

Joshua James Alexander Hamill · Prevention of Future Deaths report View report

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

Joshua James Alexander Hamill, who was known to mental health services and had previously self-harmed, was reported as threatening to kill himself in the early hours of 5 June 2016. Police re-categorised the matter as a domestic incident and left him alone; he was later found dead at Flint Castle as a result of hanging. The concerns were that police training was ineffective in identifying mental health issues and that a “Concern for Safety” could be closed as a domestic incident without a recorded resolution regarding the safety and welfare of the person at risk.

Stephanie Cave · Prevention of Future Deaths report View report

5 Dec 2017 South Wales Central P. Spinney

Stephanie Cave had a history of deteriorating mental health, self-harm and attempts to end her life, and died after being found with a ligature around her neck on 17 August 2017 while in hospital care. The concerns identified included inconsistent enhanced observations, lack of training and written guidance for conducting and recording observations, and failure to routinely record precise observation times.

Gwendoline Edith Halfpenny · Prevention of Future Deaths report View report

5 Dec 2017 Staffordshire South A. Haigh

Gwendoline Edith Halfpenny fell and broke her left arm on 1 September 2016, was admitted to County Hospital with bowel problems on 6 September, and died in hospital on 13 September after her condition deteriorated and major surgery was performed. The concerns were the lack of surgical cover at County Hospital and differences in monitoring systems, policies and equipment between County Hospital and the Royal Stoke University Hospital.

Dorothy Doreen BREISLIN · Prevention of Future Deaths report View report

4 Dec 2017 Lincolnshire P. Cooper

Dorothy Doreen BREISLIN was admitted to hospital after a fall at home and was initially treated for a pulmonary embolism. A later diagnosis identified a right eighth-rib fracture that led to massive bleeding and her death. Concerns included delays in receiving the Incident Review Report, uncertainty about an apology said to have been provided, and confirmation that the referenced Action Plan had not been implemented.

Gordon Frank Thornhill · Prevention of Future Deaths report View report

4 Dec 2017 South Yorkshire (Eastern) N. Mundy

Gordon Frank Thornhill, a 61-year-old man, developed abdominal pain, attended A&E twice, and collapsed and died at home on 13 April 2017. The report identified incomplete VTE risk assessment, failure to identify that omission, undocumented consultant assessment, and a delay of more than 24 hours in providing thromboprophylaxis; the inquest conclusion was natural causes, with death from pulmonary embolism following DVT development.

Mr Philip John Powell · Prevention of Future Deaths report View report

30 Nov 2017 Black Country Z. Siddique

Mr Philip John Powell, an 83-year-old man with Parkinson’s disease, dementia and a history of strokes, developed a stage 3 pressure ulcer that became infected and deteriorated rapidly. He died after developing sepsis and bronchopneumonia; concerns included delays in ordering Debrisoft and poor communication and systems around the ordering process.

Lindsey Theresa Hassall · Prevention of Future Deaths report View report

30 Nov 2017 Manchester South A. Mutch

Lindsey Theresa Hassall had a history of substance abuse and had sought support from drug and alcohol, mental health and primary care services before her death. After being seen on a bridge, attempting to harm herself and attending a s.136 suite, she was discharged without a referral to relevant mental health services; later information about her contacts was not consistently recorded or accessible. Her body was found on 11 November 2016 suspended by a ligature, and the inquest concluded that she died from suspension from a ligature while under the influence of alcohol and drugs.

Ms Penelope Benton · Prevention of Future Deaths report View report

30 Nov 2017 Black Country Z. Siddique

Ms Penelope Benton, who had a history of paranoid schizophrenia, self-harm and significant pain, died on 12 July 2017 after taking a significant quantity of Tramadol. The principal concern was that her previous Tramadol overdose was not recorded in the hospital discharge letter and was therefore not communicated to her GP, who continued prescribing Tramadol.

Sarah Athermith · Prevention of Future Deaths report View report

30 Nov 2017 Black Country Z. Siddique

On 26 September 2017, Sarah Athermith was struck and fatally injured by a train while crossing the unprotected Wallows Lane railway crossing after stopping for another train. Concerns included the lack of a warning system for approaching trains, the risk of pedestrians becoming confused when trains pass in opposite directions, and the obstruction of drivers’ views by double-height freight carriages.

Christopher Talbot · Prevention of Future Deaths report View report

29 Nov 2017 Preston and West Lancashire N. Rheinberg

Christopher Talbot, a prisoner at Preston Prison, was found with a plastic bag over his head after being identified as vulnerable and at risk of suicide. Resuscitation initially restored breathing and cardiac output, but he later died in hospital. Concerns included inadequate reception training, the absence of a breathing guard during resuscitation, insufficient sharing of information about similar deaths, and failures to request immediate assistance and maintain constant observation.

Edna Marina Collett · Prevention of Future Deaths report View report

28 Nov 2017 Staffordshire South A. Haigh

Edna Marina Collett was admitted to hospital on 10 March 2017 and remained there until her death on 19 May 2017. The report identified delays in arranging a suitable community care package, meaning she stayed in hospital for more than two months despite being fit for discharge, and raised concerns about improving the system for moving patients on from hospital.