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Joyce Carney · Prevention of Future Deaths report View report

7 Apr 2016 Manchester West A. Walsh

Joyce Carney, who had diabetes and dementia, was knocked to the floor in a hospital corridor by another patient running away from Police Officers. She sustained a fractured neck of femur, underwent surgery, developed infections and deteriorated before dying on 11 February 2015. The principal concerns were the lack of communication and joint risk assessment between Police and Hospital staff, and the absence of protocols to protect other patients, visitors, the public and staff when patients are supervised by Police Officers.

Dorothy Imsson · Prevention of Future Deaths report View report

7 Apr 2016 Preston and West Lancashire J. Adeley

Dorothy Imsson died at Cleveleys Nursing Home on 9 August 2014 from a naturally occurring stroke caused by atrial fibrillation. Her death was contributed to by the absence of pressure care planning by qualified staff, resulting in severe skin ulceration, a shortening of life, and increased pain and suffering. Concerns also included the District Nursing Service's failure to develop an appropriate care plan and alleged failures to follow NMC guidance, record-keeping requirements, and NICE guidelines.

Matthew Colin SARGENT · Prevention of Future Deaths report View report

7 Apr 2016 Worcestershire G. Williams

Matthew Colin SARGENT was a serving prisoner who died in his cell at some time between 25 and 26 September 2014. The jury concluded that he committed suicide and raised concerns about the systematic, accurate and clear sharing of historical and current information between prison and healthcare departments.

Mr Vincent Smith · Prevention of Future Deaths report View report

6 Apr 2016 Sunderland D. Winter

Mr Vincent Smith was admitted to a nursing and care home, experienced unwitnessed falls, was admitted to hospital, and died from a head injury and bilateral pneumonia. Concerns included insufficient assessment and action regarding his vulnerability after his first fall, alongside the need to review admissions and falls-risk assessment policies and staff training.

Milly ZEMMEL · Prevention of Future Deaths report View report

6 Apr 2016 Manchester City N. Meadows

Milly ZEMMEL, who was blind and aged 89, was admitted to hospital after becoming unwell and later suffered falls, including an unwitnessed fall on 1 March 2015 while experiencing acute confusion. She fractured her left femur, was not considered fit for surgery, and died on 3 March 2015. The principal concerns were failures in falls-risk assessment, escalation and handover after an earlier fall, appropriate supervision and observations, and the adequacy of the hospital’s internal investigation.

Monica Elaine Lewis-Hinds · Prevention of Future Deaths report View report

6 Apr 2016 South London S. Lynch

Monica Elaine Lewis-Hinds suffered a seizure at home after midnight on 16 January 2015 and later suffered a further seizure that led to asphyxia, cardiac arrest and death. The concern was that the ambulance call handler did not ascertain the type of seizure, delaying the response, and that the London Ambulance Service triage protocol did not require this question to be asked in all cases.

Mark Richard Seward · Prevention of Future Deaths report View report

5 Apr 2016 Warwickshire D. Clark

Mark Richard Seward died after a pressurised cylinder fractured during workplace testing, ejecting debris that caused a serious head injury. Concerns included unclear definitions of pressure testing and questioned compliance with PUWER and HSE guidance, with evidence that poor practices were replicated elsewhere in the industry.

Kristian Andrew Jaworski · Prevention of Future Deaths report View report

4 Apr 2016 North London A. Walker

Kristian Andrew Jaworski was born following a prolonged instrumental delivery involving ventouse and forceps, followed by an emergency caesarean section. He was born with poor Apgar scores and died five days later; the report identified a concern that vaginal delivery was presumed partly on the basis of cost.

Mr Roy Henry Oakley · Prevention of Future Deaths report View report

1 Apr 2016 Essex E. McGann

Mr Roy Henry Oakley was taken to Orsett Hospital for a routine blood test and, after being told to wait in the coffee shop without a settled collection arrangement, went to the ambulance bays and suffered an accident. He died on 12 June 2015. The report identified concerns that his dementia was not communicated to the transport and phlebotomy services, that no carer had been arranged to attend with him, and that information-sharing limitations may have played some part in his death.

ARTHUR CAXTON MASON · Prevention of Future Deaths report View report

1 Apr 2016 Norfolk J. Lake

On 9 July 2014, Arthur Caxton Mason, aged 21, died after being buried beneath moving grain while cleaning inside a grain bin at Hall Farm. The principal concerns were inadequate staff training in risk assessment, failure to recognise hazards in grain-bin cleaning procedures, and the absence of an emergency plan for hazardous areas on the farm.

Lilian Hursell · Prevention of Future Deaths report View report

1 Apr 2016 Mid Kent and Medway P. Harding

Lilian Hursell died at Pembury Hospital on 6 July 2015 from pneumonia contracted following reduced mobility associated with unstable fractured cervical vertebrae after a fall from bed at Maidstone Care Centre. The concerns included bedrails not being securely engaged and the handling of Lilian Hursell after a significant uncontrolled fall before the extent of her injuries had been assessed.

John Watt · Prevention of Future Deaths report View report

31 Mar 2016 Surrey S. Wickens

John Watt, a 91-year-old man, was struck by a car while attempting to cross the A25 Guildford Road at Abinger Hammer on 27 May 2015 and died from his injuries. The inquest heard that there was no safe or controlled means for pedestrians to cross the road in the village, and raised consideration of providing one.

David Alan CURTIS · Prevention of Future Deaths report View report

31 Mar 2016 Exeter and Greater Devon J. Tomalin

David Alan CURTIS died after his motorcycle collided with a tractor on the A3079 Holsworthy Road near Okehampton, Devon. The inquest conclusion was “Road Traffic Collision”, and the stated medical cause was moving blunt force trauma to the head and chest. The substantive concern was that there was no warning sign for the left-hand bend for motorists approaching from the direction in which the motorcycle was travelling, despite the bend not being visible until the hill crest.

Sheila Slater · Prevention of Future Deaths report View report

31 Mar 2016 South Lincolnshire A. Forrest

Sheila Slater died at the scene of a road traffic collision at the staggered junction of the A16 and B1166 near Crowland, while travelling as a passenger in a car driven by her husband. The report raised concerns about the safety of this junction and other staggered junctions in Lincolnshire, including their history of fatalities and injury-producing collisions.

Steven Nicholson · Prevention of Future Deaths report View report

30 Mar 2016 Newcastle upon Tyne K. Dilks

Steven Nicholson was driving on the A1018 entry slip road in poor visibility when his vehicle struck a large area of standing water, causing him to lose control and sustain fatal head injuries. The substantive concerns were the absence of appropriate lighting and warning signs about flooding on the slip road.

PAMELA JOYCE THURSTON · Prevention of Future Deaths report View report

29 Mar 2016 Norfolk J. Thompson

Pamela Joyce Thurston, a resident of Cedar Care Home with Alzheimer's dementia, choked on toast after being given food following an approximately 17-hour period without eating and without direct supervision. She developed bronchopneumonia and died in hospital two days later. The substantive concerns included her not being given breakfast, the lack of direct supervision while eating, and the response to the choking incident.

Adam Ben Miles · Prevention of Future Deaths report View report

29 Mar 2016 South Yorkshire (Western) D. Urpeth

Adam Ben Miles attended a Christmas party at the Hilton Hotel in Sheffield on 12 December 2015 and drowned after falling into the canal basin. The concerns included smoking being permitted near the canal, the lack of effective barriers separating people from the canal, and the absence of means of escape for anyone who fell in.

Elsie Raper · Prevention of Future Deaths report View report

29 Mar 2016 County Durham and Darlington C. Oliver

Elsie Raper, who had osteoporosis and lived in a care home, suffered multiple falls and fractures, including fractures of the left tibia and fibula after a fall on 21 August 2015. These fractures were not diagnosed until 25 August, during which time she was reported to have been in extreme pain; the cause of death included multiple fractures.

Dorota Agnieszka Kijowska · Prevention of Future Deaths report View report

29 Mar 2016 Essex C. Beasley-Murray

Dorota Agnieszka Kijowska was found hanging at Gosfield ward on 23 March 2015 after returning from weekend leave and expressing threats to harm herself. The report identified concerns that the review outcome was not documented or clearly communicated to her, alongside a jury finding of failures to provide a safe environment and ineffective communication.

Alan George DIMBLEBY · Prevention of Future Deaths report View report

23 Mar 2016 Surrey R. Travers

On 23 July 2015, Alan George Dimbleby died after a self-propelled crop sprayer became unstable and rolled down a steep slope, throwing him from the cabin. The jury found that the slope gradient and absence of a seatbelt materially contributed to his death. The report raised concerns about the absence of operator seat restraints on self-propelled sprayers and related HSE guidance.