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Faiza Hassan AHMED · Prevention of Future Deaths report View report

20 Jan 2016 Inner North London M. Hassell

Faiza Hassan Ahmed died by stepping in front of a train after contact in the preceding two days with the Metropolitan Police Service, the London Ambulance Service and the Poplar Job Centre. The report states that the matters of concern were encompassed within the jury’s attached narrative determination, but does not provide further substantive detail.

Leslie Alan Summerfield · Prevention of Future Deaths report View report

20 Jan 2016 Manchester South J. Pollard

Leslie Alan Summerfield was admitted to Trafford General Hospital in late June 2015 and suffered a subdural haematoma following relatively minor trauma during the last two weeks of his life; the pathologist concluded that the injury occurred while he was in hospital. Concerns were raised about the lack of urgent endoscopy at Trafford, the ambulance transfers to and from Manchester Royal Infirmary, and the potential for this to have caused unnecessary discomfort or weakened him.

Steven Leslie Rogers · Prevention of Future Deaths report View report

20 Jan 2016 Manchester South J. Pollard

Steven Leslie Rogers was admitted to Stepping Hill Hospital on 20 August 2015 with reduced consciousness and confusion and a history of unstable type 1 diabetes. His long-acting Levemir insulin was accidentally omitted during his admission, and he was discharged by a consultant who had not seen him; he was found dead at home two days later, having died from diabetic keto-acidosis. The substantive concerns were the discharge process and the omission and subsequent alteration of his insulin regimen.

Lee Stewart Rushton · Prevention of Future Deaths report View report

19 Jan 2016 Liverpool and the Wirral A. Rebello

Lee Stewart Rushton died aged 24 on 28 January 2015 after being found hanging from a ligature fashioned from a blanket in a cell at HMP Liverpool. The jury identified concerns including inadequate management of a recognised risk of self-harm or suicide, insufficient mental health and drug-dependency care, failures in ACCT procedures and communication, and missed opportunities to increase observations. The report also raises the need to clarify how ACCT care plans should be managed when a cell-sharing risk assessment indicates that a prisoner should be housed alone.

Irene Anne Pearson · Prevention of Future Deaths report View report

19 Jan 2016 Manchester South J. Pollard

Irene Anne Pearson had terminal colon cancer that had spread to other organs and was receiving palliative Matrifen patches. On 19 July 2015, she was found dead in a hot bath at home, apparently still wearing the patch; the stated medical cause of death included opiate toxicity. Concerns included warnings about hot baths and patch removal, advice and communication about opiate medication, unclear prescribing records, and the adequacy of information supplied by the GP practice to the Coroner.

Norah Mary Fairhurst · Prevention of Future Deaths report View report

18 Jan 2016 Manchester West R. Griffin

Norah Mary Fairhurst died after being struck by a large goods vehicle while crossing a road away from a puffin crossing in Ashton in Makerfield on 8 August 2015. The principal concern was that large goods vehicles registered before 26 January 2008 were not required to have Class VI front mirrors, creating blind spots in which pedestrians or cyclists directly in front of the vehicle could not be seen.

Jasmine Ruby Lapsley · Prevention of Future Deaths report View report

15 Jan 2016 North West Wales N. Jones

On 19 August 2016, six-year-old Jasmine Lapsley choked on a grape while on holiday in Morfa Nefyn and died at 23.58 hours despite resuscitation efforts. The report identified concerns about gaps in overnight air support, the lack of a reliable Community First Responder rota and communication system, the need for sufficient local responders, and resource planning during seasonal population increases in rural and remote areas.

Lee Joseph Rigby · Prevention of Future Deaths report View report

14 Jan 2016 Manchester West A. Walsh

Lee Joseph Rigby, who had Parkinsonism, swallowing difficulties and other disabilities, died in hospital on 7 October 2015 after choking while eating a sausage roll at his residence. The concerns included him being left unobserved while the sole support worker answered the door, staff not fully understanding the requirement to visually observe him while eating and drinking, and training and procedures not adequately addressing these risks.

Arenijus Nedzelskis · Prevention of Future Deaths report View report

13 Jan 2016 South Lincolnshire A. Forrest

Arenijus Nedzelskis, a lorry driver experiencing financial difficulties linked to spending on synthetic cannabinoids, was found hanging after an argument with his partner. The concerns were that 5F AKB-48 and 5F PB-22 were not controlled under the Misuse of Drugs Act 1971 and that he had not reported his chronic misuse of cannabinoid receptor agonists to the DVLA Medical Branch.

Anne Shirley Scott · Prevention of Future Deaths report View report

12 Jan 2016 Cornwall E. Carlyon

Anne Shirley Scott had an unwitnessed fall and was found at home on 29 August 2014. She was admitted to hospital with acute kidney injury secondary to rhabdomyolysis, but her renal function deteriorated and she died on 19 September 2014 after discharge for end-of-life care. The principal concern was that care providers using a Telehealth monitoring device lacked the training to understand its information and take appropriate action, including identifying a urinary tract infection linked to confusion and vulnerability to falls.

Colin Keith Williams · Prevention of Future Deaths report View report

11 Jan 2016 Cornwall E. Carlyon

Colin Williams was found dead at his home on 9 April 2013, where he had been lying on the kitchen floor in a state of decomposition. He was known to numerous agencies as a vulnerable adult with complex needs, alcohol misuse and a tendency to self-neglect, but his body was not found for some weeks. Evidence at the inquest described difficulties arising from the number of agencies involved, variable mental capacity and complex or unavailable funding arrangements, which hindered his access to support.

Emily Charlotte Milligan and Nicholas Desmond Robertson Milligan · Prevention of Future Deaths report View report

11 Jan 2016 Cornwall E. Carlyon

On 5 May 2013, Emily Milligan and Nicholas Milligan were fatally injured after being ejected from a powerboat in the Camel Estuary; the boat continued to circle and struck them. The report identified increased speed and power in leisure powerboats as creating additional risks for users.

Emily Charlotte Milligan and Nicholas Desmond Robertson Milligan · Prevention of Future Deaths report View report

11 Jan 2016 Cornwall E. Carlyon

On 5 May 2013, Emily Milligan and Nicholas Milligan were fatally injured after being ejected from a powerboat in the Camel Estuary; the boat continued to circle and struck them. The report identified increased speed and power in leisure powerboats as creating additional risks for users.

Robin Keith Brett · Prevention of Future Deaths report View report

11 Jan 2016 Wiltshire and Swindon C. Balysz

Robin Keith Brett, an 18-year-old man with congenital adrenal hyperplasia, died on 14 June 2014 after being admitted with severe constipation and an addisonian crisis. He did not receive his prescribed steroids, and the concerns identified were that nursing staff failed to notice the missed dose and that prescribing systems lacked an alert for patients taking long-term steroids.

John Reginald Moreton · Prevention of Future Deaths report View report

9 Jan 2016 Stoke-on-Trent and North Staffordshire A. Curzon

John Reginald Moreton, aged 74, died after being struck by a car while crossing the A500 dual carriageway on 15 February 2015. The concern was that a public footpath led pedestrians to a dangerous crossing point without warning signs for pedestrians or motorists, and the report advocated installing warning signs.

Norman Dorn · Prevention of Future Deaths report View report

8 Jan 2016 Cornwall E. Carlyon

Norman Dorn was found presumed dead in an armchair at a residential home after eating a jam sandwich, with food in his mouth. He was known to have swallowing problems, and staff did not remove the food or attempt resuscitation; the report also states that the GP and other emergency services did not attend in a timely manner. The concerns included whether care homes had adequate policies and staff training for recognising or confirming death and for resuscitation.

Stefen Neil BOSWELL · Prevention of Future Deaths report View report

8 Jan 2016 Shropshire, Telford and Wrekin J. Ellery

Following a car-key burglary in Craven Arms on 6 June 2014, Stefen Neil Boswell was involved in a police pursuit and died after the vehicle lost control at Emstrey Island. The jury concluded that he died from multiple injuries due to a road traffic collision. Concerns included differences between local and national police-pursuit policies, communication about travelling on the wrong side of a dual carriageway, and the absence of dash-camera recording from the pursuing police vehicle.

Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report View report

7 Jan 2016 West Sussex E. Bussey-Jones

Joanne Michelle French, also known as Joanne Michelle Hay, was discharged from Meadowfield Hospital on 11 December 2014 after a serious suicide attempt. She was found hanging on 14 December 2014 and could not be revived. Concerns included unclear communication about the discharge assessment, inaccurate assessment notes, and the absence of a process for family members to provide relevant views or information about the early discharge.

Peter Barnes and Matthew Wood · Prevention of Future Deaths report View report

4 Jan 2016 Inner South London A. Harris

A helicopter crashed into a crane at St George’s Wharf, causing non-survivable injuries to the pilot and non-survivable burns to a pedestrian after falling debris and fuel ignited. The report raised concerns about the safety of helicopter routes along the Thames, the planning and safeguarding of tall buildings near the heliport, and the lack of implementation of AAIB Safety Recommendation 2014-30.

Gary Alan Peel · Prevention of Future Deaths report View report

4 Jan 2016 West Yorkshire (Western) M. Fleming

Gary Alan Peel was found dead at the foot of Hewenden Viaduct on 29 June 2015 after falling from the upper viaduct. The substantive concern was whether deterrent measures should be implemented on the viaduct walls, which he had deliberately scaled before jumping.