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Wayne Patrick O'NEILL · Prevention of Future Deaths report View report

26 Oct 2015 Worcestershire A. Cox

Wayne Patrick O'NEILL was a serving prisoner at HMP Long Lartin who collapsed in his cell and died on 2 January 2013. The inquest recorded respiratory failure, bronchospasm following ingestion of propranolol, and asthma as the medical cause of death. Concerns included the prescribing of propranolol despite asthma, the combination of psychotropic medicines with potential cardiac effects, and the failure to undertake an ECG before his death.

Neil Layne Garry · Prevention of Future Deaths report View report

26 Oct 2015 West Yorkshire Eastern M. Williamson

Neil Layne Garry was struck by a motor vehicle while crossing the A6120 Ring Road in Leeds on 10 December 2014 and sustained fatal head injuries. The report raised concern that there was no pedestrian crossing at or near Ramshead Approach, despite the busy road being frequently used by pedestrians.

Carl Robert FOOT · Prevention of Future Deaths report View report

26 Oct 2015 Inner North London M. Hassell

Carl Robert Foot was found hanging in his cell at HMP Pentonville after repeatedly ringing his cell bell. He was found at 3.18pm, resuscitated and died four days later in hospital. The jury found that prison officers responded inadequately to the cell bells, contributing to his death, and identified difficulties in determining how long a prisoner had been waiting and in reviewing the incident promptly.

Samuel William Gale · Prevention of Future Deaths report View report

23 Oct 2015 South Yorkshire (Eastern) J. Sleightholme

Samuel William Gale, aged 18, was received into custody at HMP Doncaster after recent self-harm and a suicide attempt, and was placed on an ACCT with half-hourly observations. The ACCT was closed on 16 May 2014, and he was found hanging the following day; the report raised concern that it was closed without reference to healthcare, chaplaincy, a unit manager, or an officer who had carried out an ACCT review.

Margaret Anne Ferry · Prevention of Future Deaths report View report

23 Oct 2015 Sunderland K. Welsh

Margaret Anne Ferry was admitted to Sunderland Royal Hospital, underwent a planned toe amputation, and subsequently developed deterioration in her skin integrity before dying on 12 May 2015. The report identified unclear responsibilities between hospitals, poor written and oral communication, differing practices and procedures, and a lack of leadership and a cohesive treatment plan.

Hireiti Kufletsion · Prevention of Future Deaths report View report

23 Oct 2015 Birmingham and Solihull E. Brown

Hireiti Kufletsion died at Queen Elizabeth Hospital Birmingham on 20 November 2014 from thrombosis of a mechanical mitral valve during the first trimester of pregnancy. The report identified failures to adequately investigate the valve, seek specialist cardiology advice and prescribe adequate doses of clexane, with concerns that pregnant women with mechanical heart valves may be at risk from insufficient anticoagulation and inadequate clinical understanding of the associated thrombosis risk.

Diane Knight · Prevention of Future Deaths report View report

22 Oct 2015 Exeter and Greater Devon J. Tomalin

Diane Knight, who had a significant history of mental illness and previous attempts to end her life by drug overdose, died by hanging on 3 February 2015 while a voluntary patient at Ocean View Ward, North Devon District Hospital. A towel placed over her room door and window concealed a belt end secured against the door jamb, and concerns were raised that this practice could conceal self-harm attempts and prevent staff from properly monitoring patients.

Glenda Day · Prevention of Future Deaths report View report

22 Oct 2015 Nottinghamshire H. Connor

Glenda Day, who had a history of mental health problems, was admitted following an overdose and later took a fatal overdose after being granted home leave on 12 March 2015. She died on 13 March 2015; the inquest recorded opiate toxicity as the cause of death and suicide as the conclusion. The principal concerns were that home leave was granted without an adequate contemporaneous medical review and updated risk assessment, and that requirements for home leave were not clearly established, communicated, and monitored across the trust.

Richard LACO · Prevention of Future Deaths report View report

22 Oct 2015 Inner North London M. Hassell

Richard Laco died on a building site at the Francis Crick Institute when a landing fell on him while it was being tilted into place. The fitting process used a different methodology from earlier landings, but the method statement, risk assessment and lift plan did not describe the process or provide key safety instructions. The report also raised concerns about inadequate understanding of the planning and approval requirements among some site witnesses.

Harry George Mellor · Prevention of Future Deaths report View report

22 Oct 2015 Nottinghamshire M. Mulrennan

Harry George Mellor, a child with chronic health needs, collapsed unexpectedly on 28 October 2014 and died shortly after arriving at the emergency department. The inquest recorded that he had died from pyelonephritis. Concerns included the lack of a reliable system to identify when a child was de-registered from a GP, potential safeguarding risks when no new GP had been identified, and the paediatric and physiotherapy teams not being informed of the de-registration.

Samantha Beach · Prevention of Future Deaths report View report

21 Oct 2015 Gloucestershire K. Skerrett

Samantha Beach developed severe chest pain and intermittent tachycardia shortly after giving birth to her third child, but her symptoms were not appropriately investigated or escalated. She later suffered cardiac arrests and died after surgery for bleeding from a ruptured splenic artery aneurysm. Concerns included inadequate escalation of care, poor sharing of information between community and hospital services, and failure to involve the obstetric department when she attended the Emergency Department.

David Baddeley · Prevention of Future Deaths report View report

21 Oct 2015 Manchester South J. Kearsley

David Baddeley, who had a history of schizophrenia, died at home on 23 June 2015 after tying a ligature around his neck; the cause of death was recorded as hanging, with schizophrenia also noted. Concerns included delays and gaps in transferring and reviewing medical records, incompatibility between electronic systems, and the failure to identify his psychiatric illness and lack of antipsychotic medication during primary-care handovers and checks.

Dorothy Cooper · Prevention of Future Deaths report View report

21 Oct 2015 South Yorkshire (Eastern) N. Mundy

Dorothy Cooper underwent elective surgery on 29 September 2014, after which complications included splenic injury, liver ischaemia and infarction, and poor nutritional status. She later developed overwhelming sepsis and died in hospital on 6 January 2015. The principal concerns were incomplete information in a referral to the receiving team and inadequate procedures for identifying and following up gaps in the clinical history.

Erich Roland Speilmann · Prevention of Future Deaths report View report

20 Oct 2015 Essex C. Beasley-Murray

Erich Roland Speilmann was struck by a vehicle while crossing Alderston Hill, Loughton, on 28 January 2015 and died later that day in hospital. The report identified the quality of the street lighting at the location as a possible contributing concern.

William Abel · Prevention of Future Deaths report View report

20 Oct 2015 Leicester City and South Leicestershire L. Brown

William Abel, who had paranoid schizophrenia and was receiving mental health treatment, died after stepping in front of a train on 9 February 2015. The report raised concerns that he was not given a mental health assessment after being removed from the railway lines the previous night, and that inadequate communication with his family left them unaware of professional concerns about a relapse and the expectation that they would keep him safe.

Kyle David Michael Hull · Prevention of Future Deaths report View report

19 Oct 2015 County Durham and Darlington A. Tweddle

Kyle David Michael Hull, a 15-year-old teenager, suffered fatal injuries after falling through a fragile roof at the Auction Mart. Concerns were raised about limited CCTV coverage and whether more extensive CCTV and monitoring could help identify risks and enable earlier intervention, particularly around dangerous and fragile roofs.

Vasilis KTORAKIS · Prevention of Future Deaths report View report

19 Oct 2015 Inner North London M. Hassell

Baby Vasilis was born in an extremely poor condition following a long labour at Whittington Hospital on 23 May 2015 and died shortly thereafter. The report identified concerns about the timing of Syntocinon, inadequate recording of a management plan, a registrar’s decision regarding passive descent, and failures to involve staff in the investigation and communicate its findings for learning.

James Bewick Graham · Prevention of Future Deaths report View report

17 Oct 2015 County Durham and Darlington A. Tweddle

James Bewick Graham, who had peripheral vascular disease and recurring problems with his left foot, was admitted to hospital after his condition deteriorated, underwent an amputation, and died on 2 November 2014. The report identified concerns about delayed referral to secondary care, poor communication between healthcare professionals, unclear responsibility for making the referral, and administrative failures that meant the referral was not dispatched.

John William BIRD · Prevention of Future Deaths report View report

16 Oct 2015 Inner North London M. Hassell

John William Bird, aged 92, fell at his care home on the evening of 29 April 2014 and later died from the injury sustained. The principal concerns were that the falls risk assessment was not available at the inquest and that the carer who found him appeared unfamiliar with his risk assessment and care plan, despite Mr Bird being assessed as at very high risk of falls.

Adrian Mark Smith · Prevention of Future Deaths report View report

16 Oct 2015 Birmingham and Solihull L. Hunt

Adrian Mark Smith attended hospital after seizures and was later found to have a bilateral frontal brain haemorrhage and sagittal sinus thrombosis. He underwent decompression surgery after a further brain bleed and died on 8 June 2015; the inquest concluded that his death resulted from a complication of heparin treatment. The principal concern was that Good Hope Hospital did not follow specialist advice to undertake an MRI scan to confirm the possible diagnosis.