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Steven Thomas Billington · Prevention of Future Deaths report View report

12 Jul 2016 Manchester West J. Leeming

Steven Thomas Billington died on 25 March 2015 after inhaling products of combustion from a fire at his home, which began when clothing placed on a maiden in front of a gas fire ignited. The mains-powered fire alarm system had been switched off using an unprotected control switch in an accessible communal area, so it did not warn of the fire. The report raised concern that the switch was not required to be inaccessible to unauthorised people, despite it being simple to protect it, for example in a locked cupboard.

Michael Williams · Prevention of Future Deaths report View report

11 Jul 2016 Leicester City and South Leicestershire L. Brown

Michael Williams died by hanging in his locked prison cell on 15 September 2015 while subject to four observations per hour and after he had threatened to take his life, appeared tearful and anxious, and blocked the observation panel. The concerns included missed and predictable observations, the lack of an explanation for missed checks, and an approximately one-hour delay before the cell was opened after he became unobserved.

Thomas William Pearson · Prevention of Future Deaths report View report

4 Jul 2016 South Yorkshire (Eastern) M. Beresford

Thomas William Pearson, a retired coal miner with chronic obstructive pulmonary disease and rheumatoid arthritis, died at Doncaster Royal Infirmary on 11 February 2016 after suffering recurrent pneumonia and debilitating breathlessness. The report raised concern that long-term inhaled fluticasone use increased his risk of pneumonia and may have provided no benefit for patients without a raised eosinophil count, and noted that review of inhaled steroid use would be helpful.

Henry David Hicks · Prevention of Future Deaths report View report

4 Jul 2016 London Inner (North) M. Hassell

Henry David Hicks died after losing control of a moped during a road traffic collision on Wheelwright Street in Islington on 19 December 2014. Two unmarked police cars had been following the moped, and the jury determined that Henry was aware of the police and that this was a police pursuit. The principal concern was that, by implication, the Metropolitan Police Service standard operating procedure for pursuits was not complied with.

George Hedley Punton · Prevention of Future Deaths report View report

1 Jul 2016 Wiltshire and Swindon D. Ridley

George Hedley Punton was a pedestrian walking his dog in Lockeridge, Wiltshire, when he was struck by a car on 21 November 2015. He sustained a serious head injury and died in hospital on 3 December 2015. The report raised concern about the absence of pedestrian pavements and the safety of access to a nearby children’s playground, noting a risk of future deaths unless action is taken.

Daniel James Paylor · Prevention of Future Deaths report View report

1 Jul 2016 Wiltshire and Swindon D. Ridley

Daniel James Paylor, a paramedic with a history of codeine addiction and bipolar disorder, died following an opiate overdose after consuming a bottle of Oramorph kept for his private paramedic work. The report raised concerns about the regulation and control of drugs in secondary paramedic employment, including limited safeguards, auditing, peer supervision and double authorisation.

John Brandon Betteridge · Prevention of Future Deaths report View report

30 Jun 2016 County Durham and Darlington A. Tweddle

John Brandon Betteridge was remanded to HMP Durham on 22 May 2015 and was found dead in his cell on 26 May 2015 after hanging himself. Concerns included gaps in staff training and failures to follow mandatory ACCT procedures, including the closure of the ACCT without healthcare staff present. The inquest found that the absence of his prescription medication and the fact that he was not on an open ACCT probably contributed more than minimally to his death.

Terence Henry Stilges · Prevention of Future Deaths report View report

30 Jun 2016 Birmingham and Solihull L. Hunt

Terence Henry Stilges was admitted to hospital after collapsing, was discharged before an outstanding troponin result was available, and was readmitted with severe shortness of breath and chest pain. He was diagnosed with an acute myocardial infarction and died following a cardiac arrest; the principal concern was that advance preparation of discharge summaries and incorrect discharge instructions could lead to patients being discharged before tests were complete.

Luisa Mendes · Prevention of Future Deaths report View report

30 Jun 2016 Warwickshire T. Leeper

Luisa Mendes was pronounced deceased on 25 October 2012 after a catastrophic abdominal bleed caused by rupture of the spleen, following the deliberate application of force by a third party. The report raised concerns about incident categorisation, handover procedures between control-room staff, and the STORM computer system's handling of unauthorised deferrals. The inquest also identified errors or omissions involving the police response, handover process, deferral of the response, computer-screen configuration, and supervision of the control room.

baby Dominic Smith · Prevention of Future Deaths report View report

30 Jun 2016 Manchester North L. Hashmi

Baby Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping problems.

Lee Colin DAVIES · Prevention of Future Deaths report View report

29 Jun 2016 South Wales Central A. Barkley

Lee Colin DAVIES, who was residing at a hostel for homeless people and was known to use illicit drugs intravenously, was found unresponsive in his room the morning after he had been found with a needle in his groin. He was declared deceased by attending paramedics; the inquest conclusion was “Drug Related” and the medical cause of death was recorded as combined drug toxicity and bronchopneumonia. The report raised concern that hostel staff lacked guidance and training on monitoring and safeguarding residents found in circumstances suggesting illicit drug use, creating a risk that residents might be put to bed without ongoing monitoring.

Peter Arthur Rowe · Prevention of Future Deaths report View report

29 Jun 2016 Manchester South A. Bridgman

Peter Arthur Rowe was administered the penicillin-based antibiotic co-amoxiclav despite a GP referral letter recording a penicillin allergy. He developed a worsening rash, was admitted to hospital with toxic epidermal necrolysis, and died on 8 February 2016 following deterioration. Concerns included the deletion of recorded allergy information and reliance on allergy answers despite Mr Rowe’s poor memory and his wife’s lack of knowledge of his allergy.

David Michael little · Prevention of Future Deaths report View report

28 Jun 2016 Manchester South J. Pollard

David Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.

Tommi-Ray Colin Vigrass · Prevention of Future Deaths report View report

28 Jun 2016 Black Country Z. Siddique

Tommi-Ray Colin Vigrass was born prematurely at 28+2 weeks’ gestation and developed respiratory distress requiring ventilator support. Following difficulties with changing and re-inserting his endotracheal tube, he suffered a hypoxic episode and significant brain damage, and died on 13 January 2016. Concerns included the decision-making around extubation and intubation, delayed contact with the tertiary unit, and inadequate handover and preparation.

Anielka Agnes Grace Marie Jennings · Prevention of Future Deaths report View report

27 Jun 2016 Gloucestershire K. Skerrett

Anielka Agnes Grace Marie Jennings, aged 17, was found hanging from a banister at home on 5 February 2015 and was pronounced deceased at 1510 hours. The principal concern was that, when numerous agencies care for a child transitioning to adult services, the absence of a lead or key professional can lead to communication breakdown between agencies.

Richard Hinchliffe · Prevention of Future Deaths report View report

24 Jun 2016 Inner South London P. Barlow

Richard Hinchliffe died on 2 October 2015 after accessing railway tracks between Blackfriars and London Bridge stations and suffering fatal electrocution. Concerns were raised about how securely the barrier to the railway lines was maintained and whether the presence of a person apparently asleep on the platform would have been identified as a safety or security concern.

Beverley Anne Devanney · Prevention of Future Deaths report View report

24 Jun 2016 West Yorkshire (Western) M. Fleming

Beverley Anne Devanney, who had a history of mental ill health and drug and alcohol misuse, jumped from Burdock Way flyover in Halifax on 19 January 2016 after officers attended reports of her standing on the wrong side of the barrier. The inquest concluded that the death was suicide, and raised a concern that there was no formal police training for officers facing such circumstances.

Kirsty Childs · Prevention of Future Deaths report View report

24 Jun 2016 West Yorkshire (Western) M. Burke

Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.

Malcolm Bennett · Prevention of Future Deaths report View report

22 Jun 2016 Manchester South J. Pollard

Malcolm Bennett, a resident of a care establishment, sustained injuries in falls and altercations with other residents. After an alleged assault on 15 December 2015, he was taken to hospital several hours later and died the following day from a head injury; the principal concern was the delay in arranging hospital treatment despite his care plan.

Olive Wilmott · Prevention of Future Deaths report View report

21 Jun 2016 Nottinghamshire S. Haskey

Olive Wilmott was found on the floor of a communal area of a residential care home after suffering a hip fracture. The Inquest concluded that she died from the effects of a urine infection and severe dementia, with the hip fracture a contributory factor. Concerns included possible pushing that was not effectively investigated or referred for safeguarding, and a lack of evidence that required 15-minute observations were provided amid insufficient night-shift staffing.