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Thomas Alexander Burchell · Prevention of Future Deaths report View report

4 Jan 2016 Plymouth, Torbay and South Devon A. Cox

Thomas Alexander Burchell had a brain tumour and developed progressive seizures after transfer for neurosurgical treatment; the post-mortem medical cause of death was brain swelling and infarction associated with glioblastoma. Concerns included incomplete records of the seizures and inadequate documentation and assessment of earlier headaches and weakness, including delays in processing prior medical records and uncertainty about referral guidance.

Mark Anthony Holdsworth · Prevention of Future Deaths report View report

4 Jan 2016 Central Lincolnshire R. Marshall

Mark Anthony Holdsworth was released from police custody at 00.26 hrs on 23 January 2015 and was later struck by a freight train after being laid on the railway line between Lincoln and Doncaster. The report states that he had recently threatened to kill himself, but this information was not brought to the attention of the arresting officers or custody staff before his release. The investigation concluded that he took his life.

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.

MARGARET CAROLE ANN PEGNALL · Prevention of Future Deaths report View report

31 Dec 2015 Norfolk J. Lake

On 18 May 2015, Margaret Carole Ann Pegnall stepped into the path of a train at Stracey Arms, Norwich, and died from her injuries. Concerns included that the GP surgery’s domestic abuse response flowchart was vague, lacked a domestic abuse-specific questionnaire, and provided no method for staff to recognise when a patient’s call required immediate escalation.

Mollie Bentham · Prevention of Future Deaths report View report

30 Dec 2015 Manchester West A. Walsh

Mollie Bentham died at Rivington View Nursing Home on 1 May 2015 after deteriorating following her transfer there from Darley Court Intermediate Care Centre. Concerns included failures to record and communicate family reports of abdominal pain, inadequate clinical review and documentation, absent or incomplete handovers, and insufficiently detailed multidisciplinary meeting records. The report identified risks to future patients, particularly those unable to communicate their symptoms.

Imran DOUGLAS · Prevention of Future Deaths report View report

29 Dec 2015 Inner South London A. Harris

Imran Douglas died by suicide on 13 November 2013, on the fifth day of his detention at HMP Belmarsh, after being sentenced to 18 years. The report identified concerns about transition and placement arrangements, communication and information-sharing between agencies, access to electronic records, and the adequacy of a medical assessment and response to suicide risk.

CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report View report

24 Dec 2015 Norfolk J. Lake

Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.

Angela Catherine Brealey · Prevention of Future Deaths report View report

24 Dec 2015 Staffordshire South A. Haigh

Angela Brealey was found dead at home on 19 September 2014 after hanging herself. She was receiving treatment from local secondary psychiatric services, but no full assessment by a Consultant Psychiatrist had been carried out. Concerns included the handling and confidentiality of information from third parties, limited multidisciplinary team involvement, and whether pressure on serious incident reviewers reduced the effectiveness of the review.

Rebecca Leanne Shaw · Prevention of Future Deaths report View report

22 Dec 2015 West Yorkshire (Western) M. Fleming

Rebecca Leanne Shaw was riding as a passenger on a motor scooter in Thailand when it was struck by an oncoming pickup truck, and she died from the injuries sustained. Evidence at the inquest raised concerns that the view of oncoming traffic was obstructed and that the road layout lacked a sufficiently deep central reservation, prompting concern about road safety at the location.

Shalini GANESH-RAM · Prevention of Future Deaths report View report

22 Dec 2015 Inner North London M. Hassell

Shalini Ganesh-Ram died in the Royal London Hospital on 11 August 2015 after developing Ogilvie’s syndrome following a Caesarean section, which led to a perforated caecum. The concerns included delayed diagnosis of the perforation, delays in CT scanning and surgical consultation, and inappropriate use of the modified obstetric early warning score to identify sepsis.

Kay Michelle Sheard · Prevention of Future Deaths report View report

21 Dec 2015 North Wales (East and Central) J. Gittins

Kay Michelle Sheard underwent an outpatient procedure under sedation for removal of gall stones from the bile duct and subsequently suffered cardiorespiratory failure. The report raised concern that pulse oximeter alarm settings were routinely fixed at 85% without taking account of the individual patient’s normal oxygen saturation or the extent of a drop from that baseline.

Mrs Mary Myfanwy Hollands · Prevention of Future Deaths report View report

21 Dec 2015 North Wales (East and Central) N. Jones

Mrs Mary Myfanwy Hollands, aged 98, sustained an unwitnessed fall at her nursing home and was later found to have a left hip bony injury that had not been identified on the initial X-ray. She deteriorated and died on 27 July 2015. The principal concern was that the system for conveying radiologists’ reports to the Emergency Department was not sufficiently reliable or safe, including failures in paper-report delivery and the lack of a prioritisation or coding system for reports identifying injuries.

Edna May CLEATON · Prevention of Future Deaths report View report

17 Dec 2015 Birmingham and Solihull L. Hunt

Edna May CLEATON died at home after serious pressure sores became septic. The report raised concern that she had not seen a doctor for over three years while receiving repeat citalopram prescriptions, and that systems were needed to ensure appropriate medical reviews before repeat prescriptions were issued.

William Francis Driscoll · Prevention of Future Deaths report View report

16 Dec 2015 Birmingham and Solihull E. Whitting

William Francis Driscoll died at Queen Elizabeth Hospital Birmingham on 30 June 2015 from injuries sustained when a vehicle mounted the pavement and hit him while he was walking. The driver lost control during an epileptic seizure. The report identified serious deficiencies in the DVLA medical assessment process, including limited investigation of health conditions and failure to follow up an identified relevant consultant, which could allow inadequately assessed drivers to continue driving.

Kamrul Hassan RUBEL · Prevention of Future Deaths report View report

15 Dec 2015 Birmingham and Solihull L. Hunt

Kamrul Hassan RUBEL fell from a treadmill at Small Heath Wellbeing Centre on 10 August 2015, sustained a traumatic brain injury, and died despite treatment. Evidence at the inquest raised concern that gym users were not routinely required to attach the treadmill’s emergency cord and that appropriate advice and warnings should be given.

Joyce Beatrice TOZER · Prevention of Future Deaths report View report

15 Dec 2015 Birmingham and Solihull E. Brown

Joyce Beatrice Tozer died after her condition deteriorated dramatically and she suffered cardiac arrest minutes after receiving 100ml of Omnipaque through a central line during an interventional radiology procedure to insert bilateral nephrostomies. The inquest concluded that she died from a reaction to the contrast material, but it could not determine whether this was an allergic response or toxicity. Concern was raised that doses exceeding the manufacturer’s guidance were frequently administered, sometimes through central lines, potentially exposing patients to toxicity risks.

Derek Thomas · Prevention of Future Deaths report View report

15 Dec 2015 County Durham and Darlington C. Oliver

Derek Thomas died by suicide while in HMP Durham after arriving on remand and undergoing reception and first-night induction. Information suggesting suicidal intent was not adequately communicated or identified because of failures involving the SASH and PER forms across escort, prison reception and healthcare staff. The report raised concerns about procedures failing under demanding but foreseeable conditions, unclear inter-agency responsibilities, inadequate tracking of information, and poor interoperability between agencies.

Ruth Hilda Smith · Prevention of Future Deaths report View report

15 Dec 2015 West Yorkshire (Western) M. Burke

Ruth Hilda Smith died on 16 April 2014 at Huddersfield Royal Infirmary after developing a haemothorax following insertion of a central venous line, with sepsis, altered liver function and pneumonia also recorded as causes. Concerns included delays in medical review, inadequate nursing observations, and poor nursing and medical record keeping during the evening of 15 April and early hours of 16 April 2014.

Daniel Brendan Byrne · Prevention of Future Deaths report View report

14 Dec 2015 Milton Keynes T. Osborne

Daniel Brendan Byrne died at Milton Keynes Hospital on 27 February 2015 after being resuscitated following a suicide attempt by hanging in his cell at Woodhill Prison the previous day. The principal concerns were inadequate assessment of the risk of self-harm and suicide by healthcare staff and prison officers, failure to refer him for an urgent mental health assessment, and an inadequate first ACCT case review.

Julie Margaret Rose · Prevention of Future Deaths report View report

14 Dec 2015 Central and South East Kent C. Morris

Julie Margaret Rose, who had long-standing depression, anxiety and Obsessive Compulsive Disorder, was found dead at home on 26 April 2015 after unsuccessful attempts by mental health services to contact her and a delayed police welfare check. The concerns were that the Trust’s protocol was insufficiently clear about when a police welfare check was mandatory for high-risk patients, and that a shift co-ordinator was not familiar with the protocol despite it having been reinforced.