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Exauce Mbiyi Paoulen · Prevention of Future Deaths report View report

16 Dec 2016 Birmingham and Solihull E. Brown

Exauce Mbiyi Paoulen died at Birmingham Children’s Hospital on 29 June 2016 from injuries sustained when he was struck by a vehicle while crossing Grove Lane, Handsworth. The report raised concerns that vehicle speeds and a frequently occupied parking bay obscured drivers’ views of pedestrians, particularly children, and that there was no pedestrian crossing near the park gates.

Jane Bullock Wilson Stables · Prevention of Future Deaths report View report

15 Dec 2016 South Yorkshire (Eastern) N. Mundy

Jane Bullock Wilson Stables had severe rheumatoid arthritis, was bed bound and experienced poorly controlled pain and pressure sores. Concerns included ineffective communication between nurses and the general practitioner about her pain, and failure to follow the care plan for regular repositioning, with pressure sores significantly deteriorating before her admission to hospital, where she died.

Janet Esme Millar · Prevention of Future Deaths report View report

15 Dec 2016 Cheshire N. Rheinberg

Janet Esme Millar, who had schizophrenia and was detained under section 3 of the Mental Health Act, was admitted to the Rosewood Unit for rehabilitation and later died by suicide, with the medical cause of death recorded as hanging. The report raised concern that some nursing staff may not have been fully engaged in addressing nicotine addiction and that this indicated a possible training deficit alongside the hospital’s non-smoking policy.

Francis James Lea · Prevention of Future Deaths report View report

15 Dec 2016 Leicester City and South Leicestershire L. Brown

Francis James Lea, who was living in a care home, was transferred to a new GP without his family being informed. After a hospital admission for a seizure, his prescribed anti-epileptic medication was not continued because the new GP was unaware of the admission and prescription. The report raised concerns about involving next of kin, recording the rationale and consent or capacity assessment for changing GP, and ensuring a safe transfer of care between the care home and GP surgeries.

Jean Marjorie McHALE · Prevention of Future Deaths report View report

15 Dec 2016 Bedfordshire and Luton T. Osborne

Jean Marjorie McHALE was admitted to hospital in July 2016 with confusion, fever, poor general health and two Grade 4 pressure sores. The inquest concluded that she died from sepsis from infected pressure ulcers. Concerns included inadequate treatment of pressure ulcers, insufficient Tissue Viability Nurse provision, and the need for an urgent review.

Mrs Winifred Elliott · Prevention of Future Deaths report View report

15 Dec 2016 Inner West London F. Wilcox

Mrs Winifred Elliott, a non-weight-bearing resident of Meadbank Care Home, was transferred using a handling belt rather than the required hoist and two-person assistance, resulting in multiple fractures to her left leg. She later died in hospital, with the report stating that the injuries led to and caused her death. The principal concerns were that transfer information had been removed from display, making it harder for staff to access, and that residents might consequently be transferred inappropriately and sustain fatal injuries.

Jaroslaw Rogala (otherwise known as Jarek) · Prevention of Future Deaths report View report

14 Dec 2016 Inner West London F. Wilcox

Jaroslaw Rogala, also known as Jarek, was found deceased by hanging in his bedroom on 3 September 2016 after experiencing suicidal ideation while intoxicated with alcohol. The report raised concern that patients with addiction at risk of suicide may have no inpatient facility available for care and supervision during a crisis.

Liam Day · Prevention of Future Deaths report View report

14 Dec 2016 Dorset R. Middleton

Liam Day left home to go climbing on 15 June 2016 and failed to return; his body was recovered from the water on 28 June 2016, with the cause of death given as hypothermia following a fall into the sea. The report raised concerns about his lack of safety equipment, warm clothing, means of seeking help and specific plans, and highlighted the dangers of cold coastal water to people participating in water-based climbing activities.

Simon John Turvey · Prevention of Future Deaths report View report

13 Dec 2016 Milton Keynes T. Osborne

Simon John Turvey was found hanging in his locked cell at HMP Woodhill on 29 December 2015 and was declared dead by paramedics. The concerns included failures in the Personal Officer scheme and a lack of proactive communication to family members about how to share concerns with the prison, meaning risk factors may have been missed.

Dennis Thomas Lavington · Prevention of Future Deaths report View report

12 Dec 2016 Southampton and New Forest G. Short

Dennis Thomas Lavington, aged 84, was struck by a reversing taxi while crossing a health centre car park using a walking frame. He was admitted to hospital after suffering concussion, later developed hospital-acquired pneumonia and died; concern was raised that the car park layout created a potential conflict between pedestrians and vehicles.

Ellen Eileen Margaret Kelly · Prevention of Future Deaths report View report

12 Dec 2016 Inner North London E. Buckett

Ellen Eileen Margaret Kelly suffered smoke inhalation injuries in a flat fire on 7 July 2016 after a cigarette was not fully extinguished, and died at St Marys Hospital, Paddington, on 16 July 2016. The substantive concerns were that the flat’s front door lacked a self-closing mechanism and that other doors in the block did not meet the 30-minute fire-resistance standard, potentially allowing fire and smoke to spread more quickly.

Mrs Leesley · Prevention of Future Deaths report View report

12 Dec 2016 South Yorkshire (Western) D. Urpeth

Mrs Leesley died in Northern General Hospital on 25 April 2016 from septicaemia and a urinary tract infection. Evidence at the inquest showed that a safeguarding report made by the GP was not acted upon despite an automated acknowledgment, and it was unclear whether this resulted from human or IT error.

Sheila Stokes · Prevention of Future Deaths report View report

9 Dec 2016 Nottinghamshire H. Connor

Sheila Stokes had a large abdominal aortic aneurysm diagnosed in July 2015 and died at home on 26 January 2016 after it ruptured. The report identified delays in arranging appointments, acting on the radiology alert, discussing the case, and sending information needed for a custom-made graft. It also raised concerns about administrative systems, communication, the trust’s investigation, and the completeness of statements provided to the coroner.

Roy Frederick Lawton · Prevention of Future Deaths report View report

9 Dec 2016 Staffordshire South A. Haigh

Roy Frederick Lawton suffered serious burns after dozing off and dropping a cigar, which ignited his dressing gown and pyjamas at his home on 23 July 2016. He died in hospital on 31 August 2016; concerns were raised about the high inflammability of the dressing gown and whether clothing production, importing or retail practices could reduce the risk or warn customers.

Sandra Brotherton · Prevention of Future Deaths report View report

8 Dec 2016 Manchester South J. Kearsley

Sandra Brotherton was killed at her home on 31 December 2014, shortly after returning from hospital. The inquest heard that she had been the predominant and effectively sole carer for a person with a dual diagnosis of paranoid schizophrenia and Asperger’s Syndrome, who had been alone at home during her hospital stay. Concerns included the lack of a clearly discussed contingency plan, inadequate documentation and sharing of care-plan information with the Personal Assistant, difficulty obtaining an urgent psychiatric appointment, and insufficient follow-up after Sandra requested that he be rehoused immediately.

Rachal Marie Murphy · Prevention of Future Deaths report View report

8 Dec 2016 Manchester South J. Kearsley

Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.

Mary Patricia MULDOWNEY · Prevention of Future Deaths report View report

8 Dec 2016 Inner North London M. Hassell

Mary Patricia Muldowney suffered a spontaneous subarachnoid haemorrhage caused by a ruptured artery and was admitted to East Surrey Hospital on 20 July 2016. Several hospitals refused urgent transfer to specialist neurosurgical care because intensive care beds were unavailable; she was eventually transferred and underwent surgery, but died after her condition deteriorated during transfer. The principal concern was that the lack of an immediately available intensive care bed delayed time-critical surgery, which the report states she probably would have survived if performed promptly.

Ajvir Singh Sandhu and Cameron James Forster · Prevention of Future Deaths report View report

8 Dec 2016 North Yorkshire (East) M. Oakley

On 30 April 2016, Flying Officers Ajvir Singh Sandhu and Cameron James Forster were flying a Slingsby T67 Firefly during aerobatics near Castle Howard when the aircraft entered a spin and crashed, killing both occupants. Concerns included that neither occupant was wearing a parachute, parachutes were not supplied, and that regulations might be needed regarding parachute provision and spin recovery training for light aircraft. Evidence also raised concern that Mr Sandhu’s spin recovery training had taken place on different aircraft rather than the Slingsby Firefly.

Ajvir Singh Sandhu and Cameron James Forster · Prevention of Future Deaths report View report

8 Dec 2016 North Yorkshire (East) M. Oakley

On 30 April 2016, Flying Officers Ajvir Singh Sandhu and Cameron James Forster were flying a Slingsby T67 Firefly during aerobatics near Castle Howard when the aircraft entered a spin and crashed, killing both occupants. Concerns included that neither occupant was wearing a parachute, parachutes were not supplied, and that regulations might be needed regarding parachute provision and spin recovery training for light aircraft. Evidence also raised concern that Mr Sandhu’s spin recovery training had taken place on different aircraft rather than the Slingsby Firefly.

Dominic Adam Travis · Prevention of Future Deaths report View report

7 Dec 2016 Manchester (North) L. Hashmi

Dominic Adam Travis, an 18-year-old man with mental health problems and regular use of cannabis and other substances, died in hospital on 18 May 2015 after suffering catastrophic injuries when he fell or jumped from a derelict mill following an acute psychotic deterioration and absconding from supported accommodation. The concerns raised included whether specialist inpatient provision adequately met the needs of young adults with mental health problems and whether the NHS Trust’s investigation into his care was sufficiently independent, transparent and timely.