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Thomas Martin Gallagher · Prevention of Future Deaths report View report

11 Aug 2016 Greater Manchester (North) L. Hashmi

Thomas Martin Gallagher, aged 16, died by hanging after leaving home on 10 July 2015 and being found suspended from a tree in a nearby park the following morning. The report identified concerns about police handling of the missing-person call, including 14 unexplained delays, failure to allocate the incident or contact the family during the initial hour, inadequate staffing, and failures to follow relevant procedures.

Anthony John Preston · Prevention of Future Deaths report View report

11 Aug 2016 Rutland and North Leicestershire R. Chapman

Anthony John Preston was admitted to The Priory Hospital in October 2013, discharged home on 11 November 2013, and was admitted to The Bradgate Unit four days later after becoming extremely anxious and depressed. He hanged himself in May 2014. Concerns included the lack of robust documentary evidence that his discharge had been communicated to the Leicestershire Crisis Team, the absence of immediate follow-up, and the resulting lack of support for him and his main carer when he was considered at high risk; the report states that no causal connection was suggested between his death and the discharge arrangements.

Kevin David RITSON · Prevention of Future Deaths report View report

10 Aug 2016 Cumbria D. Roberts

On 4 August 2015, Kevin David RITSON lost control of his motorcycle on a bend on the A595 in Cumbria and died at Preston Hospital from unsurvivable injuries. The report raised concerns about the road surface, including poor adhesion, patched holes and the absence of a chevron warning sign removed after an earlier accident.

Thomas George Jordan · Prevention of Future Deaths report View report

10 Aug 2016 West Yorkshire Eastern D. Hinchliff

Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac symptoms and was admitted to hospital on 6 August 2015. His condition deteriorated, and he died following cardiac arrest at 1955 hours that day; the inquest recorded natural causes. The concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication when he was discharged from hospital, although the report stated there was no evidence that the drug error materially caused or contributed to his death.

Thomas George Jordan · Prevention of Future Deaths report View report

10 Aug 2016 West Yorkshire Eastern D. Hinchliff

Thomas George Jordan, a remand prisoner at Her Majesty’s Prison, Leeds, became unwell with cardiac and other medical problems and died in hospital after suffering cardiac arrest on 6 August 2015. Concerns included continued administration of Digoxin after hospital clinicians requested its discontinuation and a breakdown in communication between the hospital and prison, although the report stated there was no evidence that the drug error materially caused or contributed to his death.

Ben Andrew Collins · Prevention of Future Deaths report View report

10 Aug 2016 Surrey S. Wickens

Ben Andrew Collins was trapped and killed while using a suction excavation machine to excavate a trench beside the M3 Motorway on 27 July 2015. The inquest recorded positional asphyxia, fractured ribs and a fractured femur, with the jury concluding accidental death. Concerns included inadequate emergency operating knowledge and training, the absence of HSE guidance on suction excavation equipment, and servicing and documentation of control panels.

Mr. Rohan Fitzsimons · Prevention of Future Deaths report View report

7 Aug 2016 Avon P. Harrowing

Mr. Rohan Fitzsimons, who had been detained under the Mental Health Act and was receiving inpatient psychiatric care, died after jumping from Clifton Suspension Bridge while on unescorted leave on 25 November 2015. The principal concern was that a necessary Mental Health Act Assessment was delayed for four days because no inpatient bed was available, with evidence that this commonly occurred and that assessments were not carried out until a bed became available.

Susan Elizabeth HAMLETT · Prevention of Future Deaths report View report

4 Aug 2016 Bedfordshire and Luton I. Pears

On 8 March 2016, Susan Elizabeth HAMLETT walked onto a railway line and lay across the tracks, where she was killed instantly by a train. The investigation identified that an access gate provided little deterrence to railway access and that a more substantial fence had not been installed.

Winston Harris · Prevention of Future Deaths report View report

3 Aug 2016 Birmingham and Solihull L. Hunt

Winston Harris, a resident with dementia, left hospital on 17 March 2016 after previously attempting to leave the ward. He was found at a bus stop the following day, severely hypothermic with an acute kidney injury, and died on 22 March 2016; the inquest concluded that he died from dilated cardiomyopathy contributed to by hypothermia and acute kidney injury. Concerns included inadequate documentation of his absconding risk and pending deprivation of liberty application, failure to consider an emergency deprivation of liberty safeguard, and delays in processing the application.

Pamela Gressman · Prevention of Future Deaths report View report

1 Aug 2016 County Durham and Darlington A. Tweddle

Pamela Gressman died following the ingestion of foreign bodies, one or more of which led to a perforation of the colon; the inquest recorded hospital-acquired pneumonia as the medical cause of death. The report raised concern that insufficient consideration was given to the possible physical effects of the ingested objects and that there was no clear treatment and observation plan.

Joshua Knox-Hooke · Prevention of Future Deaths report View report

1 Aug 2016 London Greater (East) N. Persaud

Joshua Knox-Hooke, a 22-year-old man with psychosis and recent drug use, attended North Middlesex Hospital on 1 December 2014 after cutting his neck and wrist and saying he wanted to kill himself. He left before psychiatric assessment and was later found deceased, partly immersed in Danbury reservoir; the inquest concluded that he died from drowning. Concerns included failure to keep him within eyesight in accordance with hospital policy and wider issues around patients leaving before psychiatric assessment and the handling of the incident.

Miles Benedict Abel · Prevention of Future Deaths report View report

29 Jul 2016 Wiltshire and Swindon I. Singleton

On 14 January 2016, Miles Benedict Abel died after placing a ligature around his neck while at home. The concerns related to the referral process from a GP surgery to the Community Mental Health Team, including the absence of an audit trail confirming that referral faxes were sent and inconsistent follow-up calls to check receipt.

Danny Sweet · Prevention of Future Deaths report View report

29 Jul 2016 Cornwall and Isles of Scilly A. Cox

Danny Sweet, who had a long history of mental health issues, took a staggered paracetamol overdose on 23 October 2015 and died the next day in Treliske Hospital. Concerns included the rapid transfer and discharge between mental health services despite earlier consideration of informal admission, difficulties assessing his inconsistent presentation, inconsistent treatment decisions and records, and an incomplete Serious Incident Report.

Leslie Johnson · Prevention of Future Deaths report View report

28 Jul 2016 Manchester City N. Meadows

Leslie Johnson, who required supported care and had a swallowing assessment recommending a soft diet and supervision, died in hospital after being left unsupervised while eating an egg mayonnaise sandwich. A post-mortem examination found that he died from acute aspiration of food. Concerns included failures to assess or recognise his lack of mental capacity and failures to communicate his care plan and swallowing requirements between community carers and the hospital.

Cerith Wyn Pugh · Prevention of Future Deaths report View report

27 Jul 2016 Carmarthenshire and Pembrokeshire J. Layton

Cerith Wyn Pugh underwent surgery for bowel obstruction in March 2013, experienced a cardiac arrest and further surgery, and had subsequent hospital readmissions. He died on 20 May 2014 after developing bleeding from his ileostomy; the inquest recorded multi-organ failure, ischaemic bowel disease, and cholelithiasis with mechanical jaundice. Concerns included consultant referrals being handled initially by middle grade doctors and liver function tests being declined because testing had been conducted less than three days earlier, without evidence of a mechanism to override that guidance when clinically appropriate.

James Michael HEDGE · Prevention of Future Deaths report View report

27 Jul 2016 South Wales Central A. Barkley

James Michael HEDGE, an 18-year-old type 1 insulin-dependent diabetic, was found deceased in his room at Cardiff University with an insulin pump connected to him. The pump’s insulin cartridge had been fitted incorrectly and leaked, and the inquest recorded diabetic ketoacidosis as the medical cause of death. Concerns included inadequate guidance about the dangers of insulin-pump misuse and insufficient education about the potentially rapid, life-threatening consequences of hyperglycaemia.

Lee Francis Grimes · Prevention of Future Deaths report View report

26 Jul 2016 Manchester West R. Griffin

Lee Francis Grimes, who was known to misuse cocaine and had schizophrenia, was found collapsed and unresponsive at home on 21 March 2016. Before his death, he disclosed on two occasions that he had taken an overdose of prescribed medication, but the disclosures did not result in assessment or treatment, and a message to the Community Mental Health Team was not followed up or acted upon. The report raised concerns about failures in responding to overdose disclosures and referral messages, and about staff training and procedures.

Margaret Emily TUCK · Prevention of Future Deaths report View report

26 Jul 2016 Inner North London M. Hassell

Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

Rebecca Gilbank · Prevention of Future Deaths report View report

26 Jul 2016 Surrey A. Crawford

Rebecca Gilbank, a 25-year-old woman with severe myoclonic epilepsy and significant learning difficulties, was found unresponsive in bed at Clareville Lodge during the early hours of 12 May 2015. Staff were unable to obtain an outside telephone line from the office landline and used a personal mobile phone to call emergency services, while CPR was unsuccessful. The principal concerns were that a required 1.30am check had been missed because staff were attending to other service users, and that staff did not know how to obtain an outside line to emergency services, causing a delay of unknown duration.

Terence Darren ADAMS · Prevention of Future Deaths report View report

26 Jul 2016 Inner North London M. Hassell

Terence Darren Adams committed suicide by hanging himself in his cell at HM Prison Pentonville. Concerns included failures in checking prison escort records, understanding and acting on the first night reception template, exploring his suicidal history, ensuring attendance at a follow-up reception screen, and sharing the root cause analysis needed for learning lessons.