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James Charles MALLETT · Prevention of Future Deaths report View report

16 Mar 2017 Norfolk Y. Blake

James Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.

Terence James White · Prevention of Future Deaths report View report

16 Mar 2017 Gloucestershire S. Fox

Terence James White died in part from an infection arising from a grade 4 sacral pressure sore that developed at The Grange Care Centre between January and March 2016. Although the pressure sore was documented, there was a substantial absence of records showing treatment measures, particularly turning charts, making it impossible for senior staff to know whether it was being treated properly.

Leah Abby Ratheram · Prevention of Future Deaths report View report

15 Mar 2017 Birmingham and Solihull L. Hunt

Leah Abby Ratheram, who had autism, foetal alcohol syndrome and a history of self-harm, died after being found hanging from a tree on 7 October 2016. The report raised concerns about the lack of coordinated care and unclear responsibility between mental health organisations, ineffective sharing of records and risk information, and uncertainty about the Mental Health Act assessment process.

Michael Roy Mahon · Prevention of Future Deaths report View report

15 Mar 2017 Manchester South A. Mutch

Michael Roy Mahon was found dead at home on 13 September 2016 after a period of deteriorating health and obesity while prescribed clozapine. The inquest heard that he had not received an annual test required for people prescribed clozapine, and that there was no system to identify the missed test or that it had not been noticed during monthly checks. The recorded cause of death was dilated cardiomyopathy, with obesity and clozapine therapy, and alcohol use also listed.

Jack Owen Sheldon · Prevention of Future Deaths report View report

14 Mar 2017 South Yorkshire (Eastern) N. Mundy

Jack Owen Sheldon died in a shed fire after petrol vapours from paint stripping reached a candle flame on 27 October 2016. Concerns included the handling and prioritisation of multiple emergency calls, staff communication and training, appliance mobilisation protocols, and systems for checking appliance availability and location.

Rebecca Anne Evans · Prevention of Future Deaths report View report

14 Mar 2017 North Wales (East and Central) J. Gittins

Rebecca Anne Evans was taken from her care home to Glan Clwyd Hospital on 9 March 2016 because of a declining medical condition caused by a chest infection against a background of Huntington’s Disease. She waited more than seven hours in an ambulance before admission, and the concerns principally related to delays in hospital admission, patient handover, patient flow and the resulting impact on timely treatment and ambulance availability.

Mariana Hungria Bayam Veiga PINTO · Prevention of Future Deaths report View report

14 Mar 2017 Inner North London M. Hassell

Mariana Pinto jumped from the third-floor balcony of her home as a deliberate act, without a proper understanding of what she was doing, after attending the emergency department the previous day. The concerns included whether the crisis team’s limitations and possible symptom worsening had been adequately communicated to her family, and whether the urgent crisis-line call was escalated appropriately.

Daphne Cherry · Prevention of Future Deaths report View report

13 Mar 2017 Gloucestershire K. Skerrett

Daphne Cherry, an 83-year-old care home resident, became dehydrated after reduced fluid intake during an infection and was admitted to hospital with a severe kidney injury. She died on 22 February 2016; the principal concern was whether care home staff could identify when a medical concern required escalation and medical review.

Andrew Terrance John Lownes · Prevention of Future Deaths report View report

13 Mar 2017 Inner West London K. McLoughlin

Andrew Terrance John Lownes was fatally injured on 5 June 2015 when a glass curtain window unit toppled from a transport stillage while he was working on the 17th floor of a construction site in London. The report identified concerns that the consignment lacked written unloading instructions and that the complex banding arrangements made it difficult to identify how the units were secured, creating a risk that a heavy unit could fall during unloading.

James O’Brien · Prevention of Future Deaths report View report

13 Mar 2017 Inner South London P. Barlow

James O’Brien collapsed in his room at Churchill Hospital on the night of 8/9 December 2015 and died at St Thomas’ Hospital on 9 December 2015. Concerns included delays in starting resuscitation, calling an ambulance and bringing the defibrillator, inappropriate defibrillator attachment, inadequate information provided to ambulance services, and failures in staff training, induction and ward familiarity. The inquest concluded that the emergency response by hospital staff was inadequate and that earlier intervention might have made a difference.

George Henry Dicker · Prevention of Future Deaths report View report

13 Mar 2017 North London A. Walker

George Henry Dicker entered the railway tracks and electrical lines at Woodside Park Underground Station on 9 May 2016, where he likely died after contact with the live rail and being struck by a train. The substantive concern was that there was no alarm or warning to the signaller when a person passed through the gate onto the tracks.

Lester John STACEY · Prevention of Future Deaths report View report

10 Mar 2017 Staffordshire South M. Jones

Lester John STACEY, who had hypertrophic cardiomyopathy and bipolar affective disorder, was found hanging in a barn at his home on 23 October 2016 and was certified dead at the scene. Concerns included discharge from mental health inpatient care without follow-up appointments, no attempted visit to re-engage him with services, and a change in medication that does not appear to have been monitored.

Carol Ann Harvey · Prevention of Future Deaths report View report

10 Mar 2017 North Wales (East and Central) J. Gittens

Carol Ann Harvey, aged seventy, was discharged from hospital with care planned at home, but no carers attended after a referral message was left without confirmation that it had been received. She was found the following morning drowsy, vomiting and having suffered significant blood loss, and died in hospital on 9 April 2016 following a paracetamol overdose and a pre-existing cardiac condition. The principal concerns were the lack of a procedure to confirm that referrals had been received and actioned, and delay in implementing a safe hospital discharge procedure.

Mrs Anna Teresa Walker · Prevention of Future Deaths report View report

10 Mar 2017 East London N. Persaud

Mrs Anna Teresa Walker underwent a liver biopsy on 8 July 2016 and suffered a bleed caused by a tear to the hepatic artery. She died in hospital the following morning after a significant delay in detecting the bleed. The principal concerns were that required post-operative checks were not carried out, monitoring responsibilities were unclear, and the appropriate environment for post-operative monitoring was not provided.

Frederick Bevan · Prevention of Future Deaths report View report

9 Mar 2017 Birmingham and Solihull E. Brown

Frederick Bevan died at a care centre on 4 October 2016 from a head injury following a fall at the home on 22 September 2016. The principal concern was that emergency services may not receive an accurate account of an incident when its history is not provided by the witness, potentially affecting treatment.

Billy Wilson · Prevention of Future Deaths report View report

9 Mar 2017 West Yorkshire Eastern D. Hinchliff

Billy Wilson was born at Pinderfields Hospital and died aged three days after suffering hypoxic-ischaemic brain injury and perinatal asphyxia. The report describes continued use and increased dosing of syntocinon despite abnormal foetal monitoring, hyperstimulation and signs of foetal distress. It raises concerns about inadequate training and assessment in cardiotocograph interpretation for student, newly qualified and practising midwives.

Annabel Mae LEWIS · Prevention of Future Deaths report View report

9 Mar 2017 Staffordshire South M. Jones

Annabel Mae LEWIS, aged 15, died by asphyxia from external airway obstruction after placing a plastic bag over her head at home. The report raised concerns about CAMHS referral handling, including the lack of recorded risk assessment, follow-up arrangements, attempts to engage her parents, and proactive support after she declined an appointment because of difficulty accessing the venue.

Peter Norton · Prevention of Future Deaths report View report

9 Mar 2017 Cornwall and Isles of Scilly G. Davies

Peter Norton fell from a bicycle while test riding it inside Halfords St Austell on 21 September 2016, suffered a fatal head injury, and died on 24 September 2016. The concerns included the absence of policies, guidance, a designated safe cycling area, risk assessments and appropriate accident-reporting practices for cycling in-store.

Mr Valdas Jasiunas · Prevention of Future Deaths report View report

8 Mar 2017 East London N. Persaud

Mr Valdas Jasiunas, who had serious underlying health problems including chronic alcohol liver disease and seizures, was arrested and held in police custody on 1 September 2010. He collapsed in his cell the following morning and died in hospital on 2 September 2010. Concerns included the identification and management of alcohol dependency, erroneous custody-record entries that could provide false reassurance, and communication difficulties where English was not the detainee’s first language.

Mrs Kathleen Cooper · Prevention of Future Deaths report View report

8 Mar 2017 Manchester City L. Hashmi

Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.