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Derek Nixon · Prevention of Future Deaths report View report

10 Mar 2016 Stoke-on-Trent and North Staffordshire I. Smith

Derek Nixon was fatally injured after walking in front of a lorry in Leek on 2 April 2015 and was pronounced dead at the scene. The concern was that pedestrians commonly crossed Ball Haye Street at a “Keep Clear” point because railings had been removed, creating a potential road-safety risk; modifications to the area, including possible railings, were requested for consideration.

William Stanley Higgleton · Prevention of Future Deaths report View report

9 Mar 2016 East London N. Persaud

William Stanley Higgleton, who had anti-social personality disorder and mixed anxiety and depressive disorder and was considered at high risk of harm to himself, was found deceased at home on 22 July 2015. The cause of death was recorded as a multiple drug overdose. The principal concerns were the lack of psychotherapy provision for people with anti-social personality disorder and the absence of limits on his access to medication or community mental health support to assist with medication compliance and more frequent assessment.

Robert Walker · Prevention of Future Deaths report View report

9 Mar 2016 South London S. Lynch

Robert Walker, aged 62, died from multiple injuries following a road traffic collision after losing control of his motorcycle on a bend on Old Farleigh Road on 4 August 2015. Concerns included insufficient bend deviation markings, a tree trunk close to the carriageway, and a slippery path leading towards the road.

John William Rogers · Prevention of Future Deaths report View report

8 Mar 2016 North Wales (East and Central) J. Gittins

John William Rogers was admitted to Glan Clwyd Hospital and later found collapsed near his bed following a cardiac arrest. During resuscitation, the defibrillator was set to 2 joules instead of 150 joules, and the error was not reported to the crash team for around 30 to 40 minutes; the report raised concerns that staff qualifications and training were not being kept sufficiently up to date.

Elsie Tindle · Prevention of Future Deaths report View report

8 Mar 2016 Sunderland D. Winter

Elsie Tindle, who had severe depressive disorder with suspected cognitive impairment and a learning disability, received three ECT sessions in February and March 2015. She developed focal seizures and status epilepticus, later appeared to develop aspiration pneumonia, and died on 4 April 2015; the post-mortem recorded anoxic-ischaemic brain damage due to status epilepticus due to ECT. The principal concerns were delays in appointing SOADs and the risk that the urgent s62 MHA powers could become a default position when SOAD appointments were delayed.

Patricia Margaret Thomas · Prevention of Future Deaths report View report

7 Mar 2016 Swansea and Neath Port Talbot P. Bennett

Patricia Margaret Thomas died at Morriston Hospital on 30 October 2013 after suffering an intracerebral haemorrhage, following an episode of unresponsiveness and left-sided weakness. The report identified a potential interaction between Miconazole Gel and Warfarin, a lack of awareness of this interaction among health professionals, and possible difficulties locating clear interaction-checking resources.

Edward Paddon-Bramley · Prevention of Future Deaths report View report

6 Mar 2016 Inner South London J. Morris

Edward Paddon-Bramley was born following prolonged rupture of membranes and developed severe infection, including Group B Streptococcus infection. Despite neonatal care, he died aged 9 days. The report identified differing practices and opinions regarding the treatment of prolonged rupture of membranes and whether pregnant women should be screened for Group B Streptococcus and given intrapartum antibiotics.

Lee Richard Gaunt · Prevention of Future Deaths report View report

4 Mar 2016 Manchester South J. Pollard

Lee Richard Gaunt went to work a night shift at Stalybridge Fire Station on 17 October 2015 and was later found hanging from a tree at the station. The report raised concerns about limited Occupational Health support, delays in accessing a doctor, additional managerial and emergency-response duties following a colleague’s death, and a general failure to provide support staff in stressful situations.

Marjorie Booth · Prevention of Future Deaths report View report

4 Mar 2016 Manchester South J. Pollard

Marjorie Booth fell at home on 21 September 2015 and was initially discharged from hospital after an X-ray failed to identify an impacted hip fracture. The fracture was identified by CT scan the following day, but she subsequently deteriorated and died on 19 October 2015; the report raises concern about the apparent policy of not routinely performing CT scans in such circumstances.

Ranjan Raman · Prevention of Future Deaths report View report

4 Mar 2016 Manchester South J. Pollard

The report states that the deceased was admitted to hospital with low sodium levels and high blood pressure, fell three times, and sustained a head injury followed by a fatal bleed. Concerns included insufficient falls-risk assessment, missing or incomplete neurological observation charts, poor communication between medical and nursing staff, destruction of shift hand-over sheets, and inadequate incident-report details.

Ronald Reginald BENTLEY · Prevention of Future Deaths report View report

3 Mar 2016 Birmingham and Solihull E. Brown

Ronald Reginald BENTLEY died at Queen Elizabeth Hospital Birmingham on 20 September 2015 following an air embolism during an elective percutaneous closure procedure performed under conscious sedation, which resulted in hypoxic brain injury. The principal concern was that the risk of air entering the vascular system when the patient breathed deeply while the sheath was open had not been recognised, meaning patients at other cardiac centres could remain at risk unless the risk and appropriate safeguards were widely known.

Adam RICE · Prevention of Future Deaths report View report

3 Mar 2016 West Yorkshire Eastern D. Hinchliff

Adam RICE was taken to hospital after being found asleep in a skateboard park, later self-discharged without a CT head scan, and was subsequently detained at a police station after being arrested. He exhibited signs of alcohol withdrawal, collapsed and died in his cell on 12 May 2014. The report identified concerns about communication between hospital staff and police, custody staffing and training, welfare checks, observation levels, handovers and monitoring practices.

Aleeza Ahmed · Prevention of Future Deaths report View report

3 Mar 2016 Manchester South J. Pollard

Aleeza Ahmed was being carried unrestrained in a car driven by her father when the vehicle left the carriageway, overturned and threw her from the vehicle, causing severe head injuries. Concerns included the possible contribution of chamfered kerbs and the absence of a protective barrier on the central reservation to the vehicle’s overturning and trajectory.

STEWART AKINS · Prevention of Future Deaths report View report

3 Mar 2016 Worcestershire D. Reid

On 25 May 2015, Stewart Akins took his own life by placing himself in the path of a train after being released on conditional bail following his arrest. The report raised concerns that his repeated statements indicating a high risk of suicide or self-harm were not communicated to the prosecution or Magistrates’ Court, resulting in the risk being significantly downplayed and no objection to bail being made.

Christopher John Stubbs · Prevention of Future Deaths report View report

3 Mar 2016 West Yorkshire (Western) M. Fleming

Christopher John Stubbs, who had a history of mental ill health and drug misuse, was found suspended from a ligature at his home on 26 July 2015, and the inquest concluded that he died by suicide from hanging. A concern was raised that medication stopped after his earlier overdose was not reviewed by his GP before his death, and about systems for receiving hospital discharge summaries advising on medication review.

Christ Morrison · Prevention of Future Deaths report View report

2 Mar 2016 Inner South London A. Harris

Christ Morrison was born at 24 weeks gestation in 2005 and developed chronic lung disease requiring a tracheostomy. On 10 September 2014, the tracheostomy tube was removed and could not be replaced; despite resuscitation and transfer to a specialist centre, he died on 17 October 2014. The principal concerns were the training required for staff changing children's tracheostomy tubes at home, the absence of medical presence, and the lack of provision for an emergency tracheostomy when replacement failed.

Curt Falk · Prevention of Future Deaths report View report

2 Mar 2016 Inner North London R. Brittain

Curt Falk was diagnosed with squamous cell carcinoma of the tongue and a blood disorder categorised as high-risk myelodysplasia or acute myeloid leukaemia. He underwent curative radiotherapy for the cancer, but this meant the blood disorder was not treatable before his death from acute myeloid leukaemia on 6 July 2015. The report raised concern that vaccination policy did not include vaccinating males against the virus associated with the cancer, creating a risk of future deaths in men from its consequences.

Peter Embra · Prevention of Future Deaths report View report

1 Mar 2016 Warwickshire S. McGovern

Peter Embra’s death was investigated, with the inquest concluding with a Narrative Verdict. The principal concern was that the local authority failed to act on an urgent referral from a GP, resulting in an approximately seven-week delay before a social worker visited him.

Max James Haigh · Prevention of Future Deaths report View report

1 Mar 2016 West Yorkshire Eastern P. Holden

Max Haigh, who had a complex congenital cardiac defect and had undergone cardiac surgery, became unwell with vomiting and deteriorated in hospital. He died on 12 June 2013 after unsuccessful resuscitation; concerns were raised that the surgeon’s operative note lacked potentially vital information for any future surgery.

Derrick Twaite · Prevention of Future Deaths report View report

29 Feb 2016 South Lincolnshire M. Spittal

Derrick Twaite swallowed a Finasteride tablet that remained in a sharp-edged bubble-pack segment, causing a gut perforation that led to his death. The report raised concern that tablets were still being snipped from unit-dose packs and placed in multi-dose compliance aids despite advice from relevant professional bodies.