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Shaun Carter · Prevention of Future Deaths report View report

29 Aug 2017 Gloucestershire C. Saunders

Shaun Carter died after jumping from a dumper truck that went over the edge of a spoil heap at a construction site; he was struck by the truck and suffered catastrophic injuries. The principal concerns were that safety procedures for dumper trucks were not consistently followed, communicated or audited, that there was no process or industry guidance for safely managing spoil heaps, and that drivers may naturally jump from trucks despite instructions to remain seated.

BERYL MARGARET ELIZABETH GOODE · Prevention of Future Deaths report View report

29 Aug 2017 Bedfordshire and Luton I. Pears

Beryl Margaret Elizabeth Goode fell while trying to use a commode, later became confused, and was subsequently found on the floor with an obvious head injury. She was taken to hospital and died on 2 May 2017. The principal concerns were that staff did not consider head injury as a possible cause of her confusion and lacked training to identify or exclude it, including when a resident denied injury.

Sam Antony Crick · Prevention of Future Deaths report View report

25 Aug 2017 Cambridgeshire and Peterborough D. Heming

Sam Antony Crick, aged 24, developed recurrent hydrocephalus and progressively raised intracranial pressure before a catastrophic collapse on 29 February 2016. He underwent emergency neurosurgical intervention but died at Addenbrookes Hospital on 4 March 2016. The concerns included missed radiological and ophthalmological signs of rising intracranial pressure, delays in obtaining and considering important imaging information, and the absence of a serious incident investigation.

Kenneth Arthur Brincombe · Prevention of Future Deaths report View report

25 Aug 2017 Plymouth, Torbay and South Devon C. Saunders

Kenneth Arthur Brincombe, an 81-year-old man with severe mobility and visual impairments, accidentally set fire to himself while smoking on 31 October 2016 and died from his burns. Concerns included carers facilitating smoking without supervision, insufficient training to assess fire hazards, and smoke detectors that would not alert a fire station or enable him to take evasive action.

Joseph Tarnowski · Prevention of Future Deaths report View report

24 Aug 2017 Manchester South C. Morris

Joseph Tarnowski, who was aged 96, fell while getting changed in his bedroom at Hillbrook Grange on 7 April 2017 and sustained a displaced fracture of the neck of his left humerus. He died at Stepping Hill Hospital on 10 April 2017; the inquest recorded the conclusion as Accident, with the medical cause of death including bronchopneumonia, acute heart failure, immobility, and the fall with fractured humerus. Concerns included whether Mr Tarnowski knew that his wireless call-bell could be moved and whether he could move it while relying on a mobility aid, as well as consideration of wearable call bells.

Jonathan Anthony MEANEY · Prevention of Future Deaths report View report

24 Aug 2017 Inner North London M. Hassell

Jonathan Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was made.

Francesca Whyatt · Prevention of Future Deaths report View report

21 Aug 2017 Inner West London K. Monaghan

Francesca Whyatt, who was at known risk from ligatures, was found unconscious with tights around her neck at the Priory Hospital on 25 September 2013 and died in hospital on 28 September 2013. The report identifies concerns about the ward’s four-floor configuration, observation arrangements, control of ligature items, staffing and training, and the lack of clear criteria for investigating ligature and other self-harming incidents as serious untoward incidents.

Jac Evan Davies · Prevention of Future Deaths report View report

21 Aug 2017 Swansea and Neath Port Talbot A. Gruffydd

Jac Evan Davies, aged four, died from smoke inhalation after a house fire at his home on 27 July 2016. The report raised concerns that, unlike in England, landlords in Wales were under no legal duty to install smoke alarms in rented properties or ensure they were working when a tenancy began.

Mr Roger Hamer · Prevention of Future Deaths report View report

21 Aug 2017 Manchester (North) P. Sigee

Mr Roger Hamer fell from his bicycle on Bury New Road, suffering a traumatic brain injury and multiple fractures, and died in hospital from those injuries on 2 April 2016. The inquest jury found that a pothole probably caused his fall. Concerns included inadequate recording and monitoring of carriageway deterioration, a lack of paint markings around potholes, the absence of a duty-of-candour procedure for investigating significant incidents, and proposed highway-management thresholds that might increase risks to cyclists.

Helen Theresa Cannon · Prevention of Future Deaths report View report

16 Aug 2017 Manchester West J. Leeming

Helen Theresa Cannon fell at home on 2 April 2017 and was assisted from the floor by Eldercare emergency responders without medical or paramedic assistance being sought. She had suffered internal haemorrhage from a pelvic fracture sustained in the fall and died two days later; concerns were also identified about inaccuracies in the moving and handling risk assessment and flaws in Eldercare’s subsequent investigation.

Frederick George DUDLEY · Prevention of Future Deaths report View report

16 Aug 2017 Staffordshire South M. Jones

Frederick George Dudley, aged 90, was struck by a vehicle while crossing the A449 dual carriageway at an uncontrolled pedestrian crossing point after alighting from a bus. The vehicle was travelling above the speed limit, failed to stop, and the driver's view may have been obstructed by other vehicles. Concerns included the crossing's location on a bend, obstructions to visibility, high speed limit, and proximity to several facilities and road users, including an elderly care home and a bus layby.

Christopher Ian Fairhurst · Prevention of Future Deaths report View report

16 Aug 2017 Manchester North L. Hashmi

Christopher Ian Fairhurst, aged 26, was found deceased on a footpath near Spotland Bridge, Rochdale, on 5 December 2016, with empty alcohol bottles and paracetamol packets nearby. The report identified concerns about shortages of GPs, lack of continuity and accessibility of care, inadequate appointment times and GP training, and increasing demand and referral thresholds for adult and children’s Autism and ADHD/ADD services.

Dorothy Webb · Prevention of Future Deaths report View report

16 Aug 2017 Black Country Z. Siddique

Dorothy Webb’s health declined amid falls, suspected neurological events, hyponatraemia and subsequently identified small cell carcinoma of the right lung with liver metastases. She died shortly after aspirating vomited blood and gastric contents following episodes of coffee-ground vomiting. The report identified a missed opportunity to assess a CT scan showing a mass and a failure to note a fracture on an earlier x-ray.

Isabella Pritchard · Prevention of Future Deaths report View report

16 Aug 2017 Berkshire P. Bedford

Isabella Pritchard, aged six, died from catastrophic head injuries after a marble mantelpiece in her home fell and struck her. The report raised concerns that fireplaces and their installation were unregulated, with no applicable quality or safety standard and potential dangers arising from design and inadequate fixing.

Spencer Lloyd Hurst · Prevention of Future Deaths report View report

16 Aug 2017 Black Country Z. Siddique

On the evening of 20 June 2017, 15-year-old Spencer Lloyd Hurst went into a lake with friends, got into trouble while swimming, and went below the surface. His body was recovered by emergency services shortly afterwards and he was pronounced deceased. Concerns included the absence of adequate warnings, fencing, or other measures to mitigate the risks of swimming, despite a similar death at the same location in 2007.

Ian Leak · Prevention of Future Deaths report View report

15 Aug 2017 Manchester South A. Mutch

Ian Leak, who had significant disabilities including serious mobility problems, died in a fire at his flat at Honiton Oaks on 5 March 2017. The principal concern was whether tenants with mobility problems or other difficulties escaping a fire should have external monitoring of individual fire alerts, given the building’s ‘Stay Put’ policy.

Terence Joseph Pimm · Prevention of Future Deaths report View report

14 Aug 2017 Essex C. Beasley-Murray

Terence Joseph Pimm died after leaping from the seventh floor of a car park on 26 August 2016, following recent threats to jump and contact with police, hospital and probation services. The substantive concerns included call handling and record-keeping, guidance and training, assessment of immediate risk, involvement of family members in mental health assessments, information sharing and coordination, and clinicians’ understanding of warrants.

Milan Dokic · Prevention of Future Deaths report View report

11 Aug 2017 London Inner (West) R. Caller

Milan Dokic was travelling by motorcycle on Battersea Park Road on 1 March 2016 in wet conditions when he lost control after entering a blue cycle lane, slid along the road and struck a bollard, sustaining fatal injuries at the scene. The report identified concerns about inadequate systems for determining and monitoring grip levels on Cycle Super Highways and other London roads, and about the effects of adjacent road surfaces with substantially different grip values.

Claire Joan Elizabeth MEDHURST · Prevention of Future Deaths report View report

10 Aug 2017 Mid Kent and Medway P. Harding

Claire Medhurst was admitted after a polypharmacy overdose, was discharged after treatment, and was readmitted with abdominal pain and severe liver abnormalities. Her acute liver failure was not recognised or treated for about six hours before she deteriorated and died on 24 February 2017. Concerns included the lack of cautionary advice about further use of paracetamol or ibuprofen at discharge and the failure of the laboratory to alert clinicians to abnormal results and toxic paracetamol levels.

Mr James Trevor Vinson · Prevention of Future Deaths report View report

9 Aug 2017 Sunderland D. Winter

Mr James Trevor Vinson, aged 72, was admitted to Sunderland Royal Hospital for rehabilitation after treatment for an acute subdural haematoma. He was found after an unwitnessed fall in his hospital room and later died from an intra-peritoneal bleed associated with splenic tears. The concern was that he was not under the close supervision intended despite his assessed falls risk, and that plans for implementing an enhanced care and observation procedure were unclear.