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Thomas Anthony Collins · Prevention of Future Deaths report View report

25 Nov 2015 Manchester South J. Pollard

Thomas Anthony Collins lived in a care home and fell on 22 June 2015, sustaining chest injuries. He was not admitted to hospital at that time, was later admitted on 25 June, and died on 15 July 2015 after treatment for complications including sepsis, pneumonia and respiratory distress. The report raised concerns about paramedic decision-making and the GP’s assessment, including failures to recognise the seriousness of the injury and signs of a flail chest.

Thomas Byron Black · Prevention of Future Deaths report View report

24 Nov 2015 Gwent W. James

Thomas Byron Black collapsed and reported feeling unwell while in HMP Usk, but prison officers did not seek medical advice over the weekend. He later deteriorated after collapsing again on 23 February 2015 and was pronounced dead in hospital; the stated medical cause was pulmonary thrombo-embolus associated with deep vein thrombosis and Factor V Leiden mutation.

Piotr Grzegorz Kucharz · Prevention of Future Deaths report View report

24 Nov 2015 Blackpool and the Fylde A. Wilson

Piotr Kucharz was admitted to a mental health hospital and later found unresponsive after using a cord as a ligature; he died in hospital on 12 October 2014. Concerns included the absence of an effective translation service and a lack of consistency and clarity among staff about what constituted an effective observation, including whether staff should enter a patient’s room and engage verbally.

Jonathan Edward Hawes · Prevention of Future Deaths report View report

24 Nov 2015 Isle of Wight C. Sumeray

Jonathan Edward Hawes died after his motorcycle fell and slid into an oncoming car on Cowleaze Hill on 24 May 2015. He was pronounced dead at 17.15 hours, and the medical cause of death was recorded as multiple injuries. The report raised concern that the 60 mph national speed limit on the road should be reconsidered and that appropriate road signage was not exhibited.

Alan Ludlow · Prevention of Future Deaths report View report

23 Nov 2015 Mid Kent and Medway A. Summers

Alan Ludlow died in hospital after suffering a subdural haematoma following a blow to his face from another resident at his care home, and subsequently developing pneumonia. The principal concern was that relevant information about the incident was not passed to the care home where the other resident was later placed, and that residential placements and changing needs must be appropriately assessed and reviewed.

Mr Frank Mellers · Prevention of Future Deaths report View report

17 Nov 2015 Black Country Z. Siddique

Mr Frank Mellers fell at home on 4 September 2015, fractured his left hip, and was admitted to hospital for surgery. He suffered a cardiac arrest on 17 September 2015 and died that day from congestive cardiac failure, with ischaemic heart disease and the post-operative fracture repair recorded as contributing factors. The concerns included poor communication with his family about his DNAR status and poor communication between nursing and medical staff, including CPR being commenced despite a DNAR being in place.

Christine McNamara · Prevention of Future Deaths report View report

16 Nov 2015 Mid Kent and Medway P. Harding

Christine McNamara was admitted for an elective ERCP, developed symptoms of bowel perforation, deteriorated despite treatment and died at Maidstone Hospital on 27 February 2015. The concerns identified were the absence of a pathway or guideline for post-ERCP complications and limitations on out-of-hours radiography referrals and surgical consultant cover.

EMMA LOUISE BRAY · Prevention of Future Deaths report View report

16 Nov 2015 East London L. Johnson

Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

Nadine Brookes-Walker · Prevention of Future Deaths report View report

16 Nov 2015 Manchester North E. Moloney

Nadine Brookes-Walker died after a fentanyl patch prescribed for severe pain was likely damaged while being removed from its packaging, resulting in an excessive release of fentanyl. The principal concern was that the packaging did not make the serious consequences of using damaged patches sufficiently apparent to patients; difficulties removing patches also suggested a possible manufacturing fault in some batches.

Irene Scholey · Prevention of Future Deaths report View report

13 Nov 2015 West Yorkshire (East) M. Williamson

Irene Scholey, an elderly and vulnerable 73-year-old woman, died from pneumonia and empyema after living permanently with two daughters in a household described as dysfunctional and inappropriate for her wellbeing. The report identified concerns that her wellbeing would have been safeguarded if relevant agencies had been able to access and share information about her home environment, and noted the potential benefit of extending the Multi Agency Safeguarding Hub to elderly and vulnerable adults.

Matthew Marc GROOM · Prevention of Future Deaths report View report

12 Nov 2015 Inner North London M. Hassell

Matthew Marc Groom stood in front of a lorry after spending seven hours in the emergency unit of Whittington Hospital, where he was seen by emergency medicine and mental health staff. Concerns included delays in his mental health assessment, prescribed diazepam not being administered, inadequate planning for his possible departure, failure to seek urgent hospital security assistance, and incomplete communication with police.

Guy Jeffrey Robinson · Prevention of Future Deaths report View report

12 Nov 2015 Manchester North L. Hashmi

Guy Jeffrey Robinson, a 31-year-old man with mental and physical health problems, left a mental health ward on leave on 10 July 2014 and did not return. He was found deceased outdoors on 15 July 2014; the inquest found the cause of death to be multiple drug toxicity and exposure. Concerns included delay and inadequate familiarity with the AWOL protocol, and a lack of direct inpatient access to Clinical Psychology services.

Christopher George Connor · Prevention of Future Deaths report View report

12 Nov 2015 Powys, Bridgend and Glamorgan Valleys A. Barkley

Christopher George Connor had been socialising at a public house before leaving in the early hours and being found collapsed and unresponsive on a pavement near his home. An ambulance took over 1 hour and 15 minutes to arrive, and the principal concern was the delay in ambulance attendance.

Alexander Stuart Hadley and Steffan Robert Vernon · Prevention of Future Deaths report View report

11 Nov 2015 North West Wales D. Jones

On 5 June 2015, Alexander Stuart Hadley and Steffan Robert Vernon drowned while swimming in a pool below a waterfall at Llanberis. The concern was that people were unaware of the dangerous currents and other hazards, creating a risk of further deaths, and that warning signage was needed.

David Alan White · Prevention of Future Deaths report View report

11 Nov 2015 Inner North London J. Devonish

David Alan White was admitted to hospital with significant pain from arterial vascular disease and later sustained two unwitnessed falls, the second causing fractures to his right hip and shoulder. He underwent emergency surgery and subsequently remained seriously unwell before dying on 26 June 2015. Concerns included the failure to record or act on reported confusion associated with Heparin, lack of supervision despite identified falls risks, and inadequate review and action on nursing records.

Carl Hughes · Prevention of Future Deaths report View report

6 Nov 2015 Blackburn, Hyndburn and Ribble Valley M. Singleton

On 2 August 2015, Carl Hughes fell from his motorcycle during a novice motocross event and was run over by another competitor, sustaining fatal back fractures. The principal concern was that body protection was not mandatory, and the report states that wearing it might have prevented the fatal injuries.

Mr Brian James SHILLINGLAW · Prevention of Future Deaths report View report

6 Nov 2015 Brighton and Hove V. Hamilton-Deeley

The supplied text does not provide the circumstances or date of Mr Brian James SHILLINGLAW’s death. The principal concerns relate to the creation, updating and use of care plans and risk assessments, communication and coordination among staff, observation policy, and recording and communicating Deprivation of Liberty Safeguarding status.

Vera Hilda Williams · Prevention of Future Deaths report View report

6 Nov 2015 North East and North Central Wales N. Jones

Vera Hilda Williams attended the Emergency Department on several occasions with different symptoms and was later found by CT scan to have a ruptured aorta associated with an oesophageal rupture. She died at Glan Clwyd Hospital on 28 October 2015. The report raised concerns that Emergency Department staff did not have a digital central record of patients’ previous attendances, symptoms and treatment, requiring reliance on patient accounts and retrieval of paper notes, which could delay access to accurate information.

Michael Patrick Joseph LOGUE · Prevention of Future Deaths report View report

4 Nov 2015 Birmingham and Solihull L. Hunt

Michael Patrick Joseph Logue underwent biliary reconstruction surgery and was later admitted to hospital, where he died a few hours later on 11 June 2015. The post mortem identified sepsis from a liver abscess following the reconstruction, and a concern was raised that a GP did not carry out a physical examination during a home visit when he was complaining of feeling unwell and pain five days after surgery.

David John Pooley · Prevention of Future Deaths report View report

3 Nov 2015 Essex C. Beasley-Murray

David John Pooley, aged 66, was admitted to hospital after attempting to hang himself and was later found hanging in a ward toilet; his death was confirmed on 20 May 2015. Concerns included the absence of a named nurse until the day before his death and the resulting failure to carry out appropriate risk assessments, care planning and reviews.