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Christopher Allen MacMORLAND · Prevention of Future Deaths report View report

16 Nov 2016 Portsmouth and South East Hampshire D. Horsley

Christopher Allen MacMORLAND was admitted to hospital with feeding difficulties and later readmitted with abdominal pain and distension; his condition deteriorated and he died on 5 December 2015. The substantive concern was that, despite five requests by consultant gastroenterologists, he was not transferred to a specialist gastroenterology ward, and evidence indicated that such a ward might have affected the outcome.

Pamela Gower · Prevention of Future Deaths report View report

15 Nov 2016 County Durham and Darlington A. Tweddle

Pamela Gower, who had achondroplasia and was a keen parachutist, died after entering a high-speed spin during a level 6 parachute jump and sustaining fatal injuries on impact with the ground. A concern was raised about whether she had been progressed beyond her abilities, particularly in light of the time between her later jumps; this question remained under active consideration by the BPA.

Mr Benjamin Hugh Wylie · Prevention of Future Deaths report View report

14 Nov 2016 Berkshire P. Bedford

Mr Benjamin Hugh Wylie, a 24-year-old man, died after a grease nipple detached while he was tensioning the tracks of a piling rig on a building site, expelling high-pressure grease that caused fatal injuries. Concerns included the machine’s design and pressure-release features, inadequate warnings and guidance, repair and maintenance practices, and possible deficiencies in worker training.

Mr Martyn Watkins · Prevention of Future Deaths report View report

14 Nov 2016 Avon P. Harrowing

Mr Martyn Watkins, who was at high risk of suicide, was admitted to a mental health ward under section 2 of the Mental Health Act on 23 March 2016. He was found hanging from his belt, which had been secured to a fold-up bed in his room, and died in hospital on 1 April 2016. The report identified concerns including the unsafe room environment, inadequate checks for ligature risks, failures in admission procedures, and insufficient communication of specific risks.

David Knight · Prevention of Future Deaths report View report

14 Nov 2016 Cornwall and Isles of Scilly E. Carlyon

David Knight, who was detained under the Mental Health Act for chronic mental health issues, died on 23 May 2015 after walking onto a railway track in front of an oncoming train while on Section 17 leave. Concerns included a limited risk assessment before leave, no notification to local community and home treatment teams, and the difficulties associated with his out-of-county placement, including reduced family involvement and communication challenges.

Margaret Erskin Hare Wakefield · Prevention of Future Deaths report View report

14 Nov 2016 Cornwall and Isles of Scilly E. Carlyon

Margaret Wakefield, who had severe heart and renal disease, deteriorated after a high-risk cardiac procedure and died following a cardiac arrest on 5 February 2016. The report identified concerns about the lack of timely haemofiltration and the need for improved access and contingency planning for critically ill patients requiring it.

Melanie Ellen Lowe · Prevention of Future Deaths report View report

11 Nov 2016 Essex C. Beasley-Murray

Melanie Ellen Lowe, who had been sectioned under the Mental Health Act, was found unresponsive in her room on 2 March and later died in hospital after tissues were found obstructing her airway. The inquest concluded that she killed herself and found that her risk of self-harm or suicide had not been properly assessed or reviewed and that adequate precautions had not been taken. The report also raised concern that the trust’s action plan was too basic and lacked detail and supporting evidence.

Karen Ann Thorne · Prevention of Future Deaths report View report

11 Nov 2016 Manchester West A. Walsh

Karen Ann Thorne died at Salford Royal Hospital on 13 June 2016 following complications associated with Natalizumab treatment for Multiple Sclerosis and subsequent Plasma Exchange treatment for Progressive Multifocal Leukoencephalopathy. PML identified on scans in May and October 2015 was not reported or diagnosed until February 2016, with delays in reporting and treatment adversely affecting her response and prognosis. The report raised concerns about delays in neuroradiology reporting and the national shortage of Radiologists and training positions.

Gareth Willington and Daniel James Willington · Prevention of Future Deaths report View report

10 Nov 2016 Carmarthenshire and Pembrokeshire J. Layton

Gareth Willington and his son Daniel James Willington went out on their fishing boat on 28 April 2016. Gareth was recovered from the sea and pronounced dead at hospital, while Daniel’s body was not recovered; an MAIB report concluded that both men went overboard after Daniel became entangled in a rope and Gareth went to assist him. Neither man was wearing a personal flotation device, and the substantive concern was that wearing such devices on fishing vessels’ working decks was not mandatory.

Gareth Willington and Daniel James Willington · Prevention of Future Deaths report View report

10 Nov 2016 Carmarthenshire and Pembrokeshire J. Layton

Gareth Willington and his son Daniel James Willington went out on their fishing boat on 28 April 2016. Gareth was recovered from the sea and pronounced dead at hospital, while Daniel’s body was not recovered; an MAIB report concluded that both men went overboard after Daniel became entangled in a rope and Gareth went to assist him. Neither man was wearing a personal flotation device, and the substantive concern was that wearing such devices on fishing vessels’ working decks was not mandatory.

Mr Simon Timothy Harper · Prevention of Future Deaths report View report

9 Nov 2016 South Yorkshire (Western) S. Slater

Mr Simon Timothy Harper was admitted to hospital with jaundice and abdominal distention and later developed multiple organ failure. During his transfer to intensive care, his portable oxygen cylinder was not turned on; he suffered a cardiorespiratory arrest, was resuscitated, and died after treatment was withdrawn. Concerns included inadequate documented training and lack of a suitable transfer policy for using portable oxygen cylinders.

Mark Adam Yafai · Prevention of Future Deaths report View report

9 Nov 2016 Coventry D. Henry

Mark Adam Yafai was arrested in the early hours of 1 July 2015 after disclosing recent cocaine use, and was found convulsing and frothing at the mouth in his cell. He suffered cardiac arrest and died at hospital; the stated cause of death was acute cocaine toxicity. The report raised concerns that custody policies used unclear terminology and gave too much discretion over healthcare assessment, risk assessment and observation for detainees who had disclosed drug use.

Ozeilivo Andrew AKERELE · Prevention of Future Deaths report View report

8 Nov 2016 Coventry S. McGovern

Ozeilivo Andrew Akerele disappeared, and his body was found 15 months later in a disused graveyard close to the last confirmed sighting of him. The concerns relate to failures to search the area adequately and promptly, failure to follow up a recommendation for a more thorough search, and gaps in communication with the Police Search Advisor. The inquest concluded with a finding of misadventure.

Ms Michelle Ann Lawrence · Prevention of Future Deaths report View report

8 Nov 2016 Inner West London F. Wilcox

Ms Michelle Ann Lawrence died at home on 2 May 2015 from respiratory failure after taking multiple prescription and illegal sedative drugs, following periods in police and private custody. The principal concerns included failures to identify concealed drugs, limited strip-searching and CCTV facilities, inadequate checking of custody-suite toilets, insufficient detail in risk records, and the lack of independent investigation into deaths following release from private custody providers.

Maurice ISAACS · Prevention of Future Deaths report View report

7 Nov 2016 South Wales Central A. Barkley

Maurice ISAACS, who had dementia and other chronic health conditions, was admitted to hospital after deteriorating and suffered multiple falls. He fell from his bed on 12 June 2016, sustained a head injury and died two days later. Concerns included shortcomings in falls-risk assessment, care planning and supervision, as well as failures in carrying out and overseeing neurological observations after the final fall.

William Edward Marson · Prevention of Future Deaths report View report

2 Nov 2016 Wiltshire and Swindon I. Singleton

William Edward Marson, who had breathing difficulties assisted by a ventilator, became anxious after believing the ventilator was not working and died on 18 June 2015. Evidence at the inquest raised concerns that staff had not been adequately trained to use the ventilator, were unaware of the user manual, and lacked information about its correct operation and fault identification.

Michaela Louise Thompson · Prevention of Future Deaths report View report

2 Nov 2016 West Yorkshire (East) D. Hinchliff

Michaela Louise Thompson, who had a history of depression and regular suicidal thoughts, died by self-suspension at home on 1 December 2015. Concerns included inadequate documentation of multidisciplinary team meetings and the failure to record and promptly communicate a distressing telephone call to mental health services on the morning of her death.

Ivy Rebecca Morris · Prevention of Future Deaths report View report

2 Nov 2016 Shropshire, Telford and Wrekin J. Ellery

Ivy Rebecca Morris was born with severe perinatal hypoxic ischaemic brain damage and died at home on 3 May 2016 after becoming unresponsive during a feed. The report identified concerns about foetal heart monitoring, failures to follow midwifery guidelines, and potential delays relating to episiotomy support. The inquest concluded that appropriate monitoring during the second stage of labour would have prevented her death, according to the supplied text.

Emily VOUKELATOU · Prevention of Future Deaths report View report

1 Nov 2016 Inner North London M. Hassell

Emily Voukelatou left North Camden Crisis House after writing notes of intent, travelled to Beachy Head on 30 June 2016, and jumped from the cliff. Concerns included the lack of routine involvement of family members in care and Crisis House’s failure to return her sister’s repeated calls before and after her death.

Trevor Paul Hunking · Prevention of Future Deaths report View report

1 Nov 2016 Plymouth, Torbay and South Devon A. Cox

Trevor Paul Hunking had severe aortic stenosis and was transferred for planned aortic valve replacement and coronary artery bypass grafting after an acute deterioration. He underwent surgery but did not recover and died on 16 June 2015; the report raised a concern about a shortage of Cardiac Intensive Care Unit Specialist Nurses for post-operative patients.