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Tedros Habtom KAHSSAY · Prevention of Future Deaths report View report

6 Dec 2016 Inner North London M. Hassell

Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.

Joyce Crompton · Prevention of Future Deaths report View report

6 Dec 2016 Manchester West R. Griffin

Joyce Crompton was found unresponsive on 26 January 2016 after eating, with food in her mouth and nearby, following two earlier witnessed choking incidents. Concerns were raised that referrals to the Speech and Language Therapy team were not made after those incidents and that Belong Village lacked written guidance, systematic checks, and refresher training for such referrals.

Christopher Brennan · Prevention of Future Deaths report View report

5 Dec 2016 South London S. Lynch

Christopher Brennan, aged 15, was a patient at an adolescent psychiatric unit and died on 31 August 2014 after swallowing the lid of a roll-on deodorant, causing acute upper airway obstruction and cardiac arrest. The report identified concerns about the lack of clear and consistent guidance for managing items that could be used for self-harm and the absence of a laryngoscope from the unit’s emergency equipment.

Brian Gerrard · Prevention of Future Deaths report View report

5 Dec 2016 Cheshire N. Rheinberg

Brian Gerrard had moderately severe mixed Alzheimer’s/vascular dementia, depression and intermittent infections, and died after becoming undernourished because he was not eating sufficiently. The inquest concluded that he died from natural causes, namely lack of eating due to dementia. Concerns related to staff understanding and management of best-interests meetings, identification of lack of capacity, and implementation of Deprivation of Liberty Safeguarding procedures, including inaccurate and contradictory information in an application.

Joshua Harry Smith · Prevention of Future Deaths report View report

2 Dec 2016 North Northumberland T. Brown

Joshua Harry Smith, aged 16, fell from cliffs near Spittal Beach and was later swept out to sea while clinging to a rock. He was rescued unconscious and died at Wansbeck General Hospital. The report identified delays in locating him, unclear overall command and coordination, and failure to follow JESIP principles.

Peter Daniel Usher · Prevention of Future Deaths report View report

2 Dec 2016 East London N. Persaud

Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.

Marjorie Cybil Bassendine · Prevention of Future Deaths report View report

30 Nov 2016 Surrey K. Henderson

Marjorie Cybil Bassendine, aged 98, suddenly collapsed while eating breakfast at her care home on 2 October 2015 and died despite resuscitation. The inquest recorded cardiac arrhythmia, long QT syndrome and therapeutic drug use as the medical cause of death. The principal concern was that multiple medications capable of prolonging the QT interval had been prescribed without assessment of her cardiac status, including an ECG, or regular ECG monitoring.

Emma Louise TIMBRELL · Prevention of Future Deaths report View report

30 Nov 2016 Worcestershire G. Williams

Emma Louise TIMBRELL, who had a significant mental health history, died by hanging at her home; the inquest concluded that her death was suicide. A concern was that she might not have been able to afford the out-of-hours telephone call provided for use if her suicidal ideation increased.

Name not published · Prevention of Future Deaths report View report

29 Nov 2016 County Durham and Darlington A. Tweddle

The deceased, who had a history of falls and was assessed as being at risk of falling, was found on the floor after an unwitnessed night and sustained injuries that subsequently led to her death. Concerns included the absence of adequate risk assessments for falls and pressure sores, and the failure to identify that a new mattress was unsuitable for her.

John Atkinson · Prevention of Future Deaths report View report

29 Nov 2016 South Yorkshire (Eastern) N. Mundy

John Atkinson received psychiatric services after contacting the Mental Health Team in crisis in July 2014 and died by suicide by hanging. The report identified concerns about outdated risk assessments, failures to recognise changing presentation and risk, inadequate arrangements when staff left, poor communication, and difficulty accessing Home Treatment Team services.

Robert Lloyd · Prevention of Future Deaths report View report

29 Nov 2016 Cornwall and Isles of Scilly E. Carlyon

Robert Lloyd drowned after becoming motionless and floating face down while swimming at Porthcressa Beach on 30 July 2016. Post-mortem toxicology found a blood alcohol level likely to have affected his cognition. Evidence at the inquest raised concerns about limited face-to-face alcohol-support services on the Isles of Scilly, particularly after the termination of the helicopter service, and the resulting difficulty engaging with service users.

Rex Brook Hall · Prevention of Future Deaths report View report

29 Nov 2016 Birmingham and Solihull E. Brown

Rex Brook Hall died at Solihull Hospital on 28 July 2016 after presenting with right arm pain and atrial fibrillation and subsequently suffering a myocardial infarction and cardiac arrest. Paramedic ECGs showed ST elevation, but this was not recognised or reviewed on arrival at hospital. The principal concern was possible deficiencies in paramedic foundation training, including ECG interpretation, recognition of arm pain as an atypical sign of myocardial infarction, and identification of ST elevation.

Matthew RUSSELL · Prevention of Future Deaths report View report

27 Nov 2016 Surrey R. Travers

Matthew Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.

Timothy Simon Jones · Prevention of Future Deaths report View report

24 Nov 2016 Birmingham and Solihull L. Hunt

Timothy Simon Jones, who had Down syndrome, epilepsy and dementia and required PEG feeding, was admitted to hospital with breathing difficulties and aspiration pneumonia, was discharged and readmitted the same day, and died on 17 July 2016. Concerns included incomplete GP record keeping, unclear communication and documentation of requests for home visits, lack of GP clinical assessment despite deteriorating health and complex needs, a home-visit policy that did not address residents with complex chronic conditions, and antibiotic prescribing for aspiration pneumonia.

Mrs Beryl Farmer · Prevention of Future Deaths report View report

24 Nov 2016 Black Country Z. Siddique

Mrs Farmer was admitted to hospital with severe hypocalcaemia and postural hypotension, fell from her bed and sustained facial and head injuries, and was discharged without a documented falls risk assessment. She was readmitted after developing headaches, was diagnosed with a subdural haemorrhage, later developed seizures, and died; concerns included inadequate falls-risk assessment, moving her to an unmonitored bay, limited neurological observations, and no CT head scan after the fall.

Patrick Richard Steer · Prevention of Future Deaths report View report

23 Nov 2016 Manchester West R. Griffin

Patrick Richard Steer was admitted with abdominal pain, found to have a cancerous bowel tumour, and underwent surgery. He subsequently suffered a myocardial infarction and developed a right sub hepatic abscess before his condition deteriorated and he died. The principal concern was poor communication between the Surgical and Coronary Care teams when patients were under shared care, which could affect treatment.

Flavio Rafael Pizarro · Prevention of Future Deaths report View report

23 Nov 2016 Manchester North J. Robertson

Flavio Rafael Pizarro died after entering the canal at Lock 62 and experiencing difficulties because he was unable to swim. The report identified a lack of warning signs about the dangers of swimming and safety aids at the lock and nearby locks as a concern.

Dennis Plater · Prevention of Future Deaths report View report

21 Nov 2016 Mid Kent and Medway K. Thomas

Dennis Plater died of natural causes at Medway Maritime Hospital on 3 February 2016, following deterioration associated with acute kidney injury, sepsis and metastatic lung adenocarcinoma. The report identified incomplete fluid-balance records, failures in NEWS scoring and escalation by an agency nurse, and concerns about the Trust’s monitoring of agency staff training and compliance.

Frazer Lee George Livesey · Prevention of Future Deaths report View report

21 Nov 2016 Cumbria D. Roberts

Frazer Lee George Livesey died after petrol ignited while he was working on motorcycles in a friend's flat, trapping him inside. He was overcome by fumes, and the principal concern was that window restrictors could not be disabled from inside during an emergency, potentially preventing escape.

Brian Mills · Prevention of Future Deaths report View report

17 Nov 2016 Hertfordshire G. Sullivan

Brian Mills, an 88-year-old man on warfarin, fell at home and sustained multiple injuries, including broken ribs and a bleeding head wound. An ambulance was called, but a rapid response vehicle arrived over two hours later and an ambulance arrived subsequently; he died on 13 April 2016. The principal concern was that consistently high levels of outstanding emergency calls and excessive waiting times could put lives at risk. Evidence heard at the inquest stated that the ambulance delay did not, in this case, cause or contribute to his death.