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Samantha MacDonald · Prevention of Future Deaths report View report

5 Feb 2016 Manchester West J. Leeming

On 25 October 2015, 20-year-old Samantha Jane MacDonald jumped from the window of her bedroom on the 14th floor of student accommodation in Salford and died. The window restrictor, which would have prevented the window opening sufficiently, was broken; similar devices in the building had also been found broken, raising concerns about the robustness and assessment of window restrictors in student accommodation.

Douglas Kay · Prevention of Future Deaths report View report

5 Feb 2016 Nottinghamshire E. Didcock

Douglas Kay, an elderly man aged 90, died approximately seven hours after becoming suddenly unwell with a catastrophic bleed from a duodenal ulcer on 22 November 2014. Outstanding concerns included confusion about transferring patients with gastrointestinal bleeding and a lack of awareness among key Bassetlaw Hospital staff about the arrangements for the Doncaster gastrointestinal bleeding service, particularly out of hours.

Carl Alan Dickerson and 3 others · Prevention of Future Deaths report View report

2 Feb 2016 Norfolk J. Lake

On 13 March 2014, four men were travelling in an Augusta Westland AW139 helicopter when it impacted the ground near Gillingham, Norfolk, in dark and foggy conditions. All four died from their injuries. The principal concern was that regulations governing visibility and take-off conditions applied to commercial departures from licensed aerodromes but not to this non-commercial departure from an unlicensed aerodrome, despite a previous accident in similar circumstances.

Michael John Valentine · Prevention of Future Deaths report View report

2 Feb 2016 Plymouth, Torbay and South Devon A. Cox

Michael John Valentine was found deceased on 16 September 2015 after a period in which he disclosed that he was not eating and stated that he had been on hunger strike. The concerns included an urgent mental health assessment referral being rejected without being brought to the relevant clinician’s attention, the failure to make a second referral after he reported not eating for 25 days, and the absence of discussion of these issues in the surgery’s significant events meeting.

Carl Alan Dickerson and 3 others · Prevention of Future Deaths report View report

2 Feb 2016 Norfolk J. Lake

On 13 March 2014, four men died after an Augusta Westland AW139 helicopter impacted the ground near Gillingham, Norfolk, shortly after take-off in dark and foggy conditions. The principal concern was that regulations restricting take-off in such conditions did not apply because the flight was non-commercial and departed from an unlicensed aerodrome.

Baby Ryan Singh Bhogal · Prevention of Future Deaths report View report

2 Feb 2016 Black Country Z. Siddique

Ryan was a healthy baby and toddler who experienced increasingly frequent medical visits and multiple symptoms before being diagnosed with acute myeloid leukaemia and dying on 11 September 2015. The principal concerns were a lack of continuity and overall ownership in GP care, possible missed red flags and opportunities for earlier testing, and hospital systems for reviewing GP medical records.

Carl Alan Dickerson and 3 others · Prevention of Future Deaths report View report

2 Feb 2016 Norfolk J. Lake

On 13 March 2014, four men were aboard a helicopter that impacted the ground near Gillingham, Norfolk, shortly after take-off in dark and foggy conditions; all four died from their injuries. The principal concern was that regulations restricting take-off in such conditions did not apply because the flight was non-commercial and departed from an unlicensed aerodrome, despite a previous accident in similar circumstances and concerns about the regulatory gap.

Marc Jason Stephen Poole · Prevention of Future Deaths report View report

2 Feb 2016 South Yorkshire (Eastern) N. Mundy

Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

LORRAINE SHEILA YOUNGS · Prevention of Future Deaths report View report

1 Feb 2016 Norfolk D. Osborne

Lorraine Sheila Youngs was a detained patient at Hellesdon Hospital who was found unresponsive after wrapping a telephone cord around her neck and died two days later in hospital. The report raised concern that an agreed community care package had not been implemented or followed up, and that there appeared to be no system for monitoring implementation.

Louise Dawn Locke · Prevention of Future Deaths report View report

29 Jan 2016 Central Hampshire G. Short

Louise Dawn Locke, a vulnerable adult with undiagnosed mental problems associated with alcohol dependency, died by suicide after hanging herself at her home in Winchester on 27 May 2015. The concerns included her premature discharge from mental health services without a proper risk assessment or adequate support, and inadequate systems for collating information across agencies to identify and support people at high risk.

Ronald VOLANTE · Prevention of Future Deaths report View report

28 Jan 2016 Liverpool and the Wirral A. Rebello

Ronald Volante, who had ischaemic heart disease and an enlarged heart, called an out-of-hours alarm monitoring service for help on 5 November 2015. An ambulance was called, but information about his cardiac history was not passed on, and the service did not report a change in his condition when he stopped responding; he was found deceased when the ambulance arrived. The concerns focused on call-handler training, use of medical history, and communicating changes in circumstances to emergency services.

Andrew William Telford Coates and Polly Sarah Connor · Prevention of Future Deaths report View report

28 Jan 2016 Cumbria D. Roberts

On 30 August 2014, an unexplained explosion in the Fireworks Store at Larch Cottage trapped Andrew William Telford Coates and Polly Sarah Connor, and the building was consumed by fire. Both died from a fatal level of carbon monoxide inhalation. Concerns included the suitability and contents of the fireworks store, deficiencies in the licence, and sketchy inspection records, with the store's construction and non-firework contents said to have exacerbated the fire.

Joanna Bowring · Prevention of Future Deaths report View report

27 Jan 2016 Mid Kent and Medway P. Harding

Joanna Bowring had depression, paranoid delusions and suicidal thoughts and was receiving community mental health support. She died by suicide on 1 June 2015 after being struck by a high-speed train on the rail track at Boxley, Kent, with evidence of significant planning. Concerns included the lack of a clear understanding of available services and a care plan after the initial assessment, carers not being routinely included in risk assessments, and carers not being advised about behaviours indicating increased suicide risk.

Rio Andrew · Prevention of Future Deaths report View report

26 Jan 2016 South London S. Lynch

Rio Andrew became unwell after taking MDMA at an illegal rave and was taken to the event medical providers. The inquest concluded that he died from multiple organ failure due to acute MDMA intoxication. Concerns included the lack of regulation of medical assistance at temporary events, poor medical knowledge among private medical staff, the unregulated use of the title “ambulance technician”, and inadequate oversight of training mentors.

Darren Wakefield · Prevention of Future Deaths report View report

22 Jan 2016 Plymouth, Torbay and South Devon I. Arrow

Darren Wakefield died on 12 October 2014 after becoming trapped between a hulk and a harbour wall while evading police officers, and was drowned by a rising tide. The concerns included highlighting the issue nationally and confirming whether IPCC recommendations had been followed, including provision of a standard letter sent to police forces.

Javaid Iqbal · Prevention of Future Deaths report View report

22 Jan 2016 Manchester West K. McLoughlin

Javaid Iqbal, who was working alone as a security guard at a construction site, died after lighting charcoal in a wheelbarrow inside a portacabin when the generator failed and left him without heat or light. The concerns included inadequate response to his reports, insufficient cold-weather clothing, lack of clear instructions for lone working, and the need for written instructions and training concerning welfare, safe temperatures, clothing, and leaving the site.

Elvis Terrence Gene Nelson · Prevention of Future Deaths report View report

21 Jan 2016 Manchester City F. Borrill

Elvis Terrence Gene Nelson was found unconscious in a hotel room on 27 August 2015 and died later that day despite resuscitation. The cause of death was acetylfentanyl toxicity, with concern that users may be unaware they have purchased or used an opioid drug and may therefore be exposed to sedation and respiratory depression.

Leslie Douglas Murray · Prevention of Future Deaths report View report

21 Jan 2016 Inner West London F. Wilcox

Leslie Douglas Murray, who required 1:1 nursing care, fell from his hospital bed when adequate cover was unavailable and sustained injuries that led to his death the following day. The principal concern was insufficient staffing to provide 1:1 care, resulting in preventable falls or other care deficiencies that could cause or contribute to death.

Alice Ada Phyllis Dickenson · Prevention of Future Deaths report View report

21 Jan 2016 Central and South East Kent H. Redman

Alice Ada Phyllis Dickenson died after a lesion, which was in fact a gastric varix, was biopsied during an endoscopy and caused gastrointestinal haemorrhage. The report identified concern that important medical history, including haemochromatosis recorded on the patient questionnaire, was not transferred to the endoscopy assessment information available to the endoscopist.

Derek Edward Hare · Prevention of Future Deaths report View report

20 Jan 2016 Manchester South J. Pollard

Derek Edward Hare underwent a colectomy and later embolization after experiencing severe abdominal pain and rectal bleeding. A subsequent colonoscopy led to failure of the bowel anastomosis, causing loss of bowel content and sepsis; he died after later surgery. The substantive concerns included separate hospital records, repeated refusal of requests for review, and discharge on 6 May 2015 despite abdominal pain when keeping him in hospital might have benefited his care.