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Deborah Roberts and Marshall Roberts · Prevention of Future Deaths report View report

11 Jun 2015 Mid Kent and Medway P. Harding

On 1 July 2014, Deborah Roberts stopped her car on the Sheppey Crossing road bridge and it was struck from behind by a van; Deborah and her eight-year-old son, Marshall Roberts, died. Concerns included repeated rear-end collisions involving stationary vehicles, limited forward visibility and high vehicle speeds on the bridge, and the fact that the speed limit remained 70 mph despite a recommendation to reduce it to 50 mph.

Walter Willows · Prevention of Future Deaths report View report

10 Jun 2015 Manchester South J. Pollard

Walter Willows was at home on 3 October 2014 when he choked on a crumpet and asphyxiated. The concern was that his care and feeding plans were reviewed only every three months, although his diet should have been adjusted more frequently to reflect his swallowing ability.

Arti Hasmukh Lakhani · Prevention of Future Deaths report View report

10 Jun 2015 North London A. Walker

Arti Hasmukh Lakhani became unwell after drinking one bottle of e-cigarette fluid at home, was taken to hospital on 11 January 2015, and died on 13 January 2015 despite attempts to save her. The principal concern was that the sale of e-cigarette fluid was not regulated or licensed.

Amanda Susan Harris · Prevention of Future Deaths report View report

10 Jun 2015 North London A. Walker

Amanda Susan Harris fell at her care home, fractured a bone in her right foot, and died in bed on 1 November 2014 after being unable to get out of bed. Concerns included that she was not seen by a doctor before leaving the Minor Injuries Unit, anticoagulant therapy was not considered, and the effects of potential immobility were not assessed when arranging her fracture-clinic appointment.

Darren NEVILLE · Prevention of Future Deaths report View report

10 Jun 2015 Inner North London M. Hassell

Darren Neville died after taking cocaine, experiencing acute behavioural disturbance, and being restrained by police. The principal concern was that police did not sufficiently consider the risks of prolonged restraint, including the risk of death, for a person experiencing acute behavioural disturbance; the extent to which this factor caused his death was unclear.

Lewis Philip Ghessen · Prevention of Future Deaths report View report

9 Jun 2015 North London A. Walker

On 25 September 2011, Lewis Philip Ghessen was chased onto railway tracks at Harrow and Wealdstone Railway Station and was struck and killed by a fast train. The concern was that the RSSB Rule Book allowed trains to be stopped only where a person might damage a train, not where a person might be in danger from a train.

Alice Anne McMeekin · Prevention of Future Deaths report View report

4 Jun 2015 Cumbria D. Roberts

Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

Mr Frederick White · Prevention of Future Deaths report View report

3 Jun 2015 Black Country Z. Siddique

Mr Frederick White suffered a fall at a retirement home on 29 March 2015, sustaining a traumatic spinal cord injury, and died on 2 April 2015. The report identified concerns about failures to recognise symptoms of spinal injury and to immobilise him initially and at hospital, with the inquest finding that these collective failures contributed to his death.

David Glyn Price · Prevention of Future Deaths report View report

1 Jun 2015 Manchester South J. Pollard

David Glyn Price suffered a heart attack in early June 2011 and underwent surgery at Wythenshawe Hospital, during which a swab was inadvertently left inside his body attached to his heart; this gradually formed an abscess. Concerns included continued warfarin prescribing despite missed anticoagulation appointments, poor handwritten clinical records, failure to act on imaging showing a foreign body, and inadequate swab-count procedures.

James Savo · Prevention of Future Deaths report View report

1 Jun 2015 South Yorkshire (Eastern) N. Mundy

James Savo had a longstanding history of depression and died by hanging on 3 December 2013, four days after discharge from inpatient treatment. The concerns identified were insufficient communication with family and carers, inadequate consideration of family concerns and the timing of home-treatment input during discharge planning, and variable understanding and possible inadequacy of the early discharge pathway. The report also identified a lack of effective auditing to ensure communication systems were followed.

Sgt Mark Colin Foley · Prevention of Future Deaths report View report

1 Jun 2015 Cumbria P. Sharp

Sgt Mark Colin Foley died on 4 June 2014 after being ejected from a Land Rover that left the road and rolled over him. The substantive concerns were insufficient driver experience and a practice of vehicle commanders not wearing safety harnesses, together with failure by senior officers to enforce standing orders requiring their use.

Mark Patrick DANIELS · Prevention of Future Deaths report View report

1 Jun 2015 Inner North London M. Hassell

Mark Patrick Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. The principal concerns were failures to carry out and record planned visits, communicate within the team and with crisis houses, progress a crisis-house referral promptly, and consider hospital admission despite identified suicide risk and Mr Daniels stating that he did not feel safe at home.

Ronald Alfred Smith · Prevention of Future Deaths report View report

1 Jun 2015 London (East) N. Persaud

Ronald Alfred Smith was admitted to Queen’s Hospital with a sigmoid volvulus causing bowel obstruction and bowel ischaemia, and died on 2 February 2014 before a flexible sigmoidoscopy could be performed. The principal concern was that staff could not access the equipment out of hours, and that no clear protocol for doing so had been established despite the identified need.

Alison Jane DRAPER · Prevention of Future Deaths report View report

29 May 2015 Avon M. Voisin

Alison Jane Draper, who had a history of mental health problems and previous attempts to self-harm, was found ligatured in her bedroom while on 10-minute observations at Juniper Ward. She sustained an unsurvivable hypoxic brain injury and died from her injuries. Concerns included the absence of a policy for when a patient is not found during a 10-minute observation and how staff should balance hourly checks for multiple patients with 10-minute observations.

Melanie Jane Amundsen · Prevention of Future Deaths report View report

29 May 2015 Sunderland D. Winter

Melanie Jane Amundsen, a vulnerable adult, was found dead in a bedroom on 12 September 2014 after consuming a fatal amount of alcohol. The report raised concerns about employers' and employees' awareness of mental health issues in the workplace, particularly during disciplinary processes, and about the publicity of relevant ACAS guidance.

Elizabeth Anne Lester · Prevention of Future Deaths report View report

29 May 2015 Manchester South J. Pollard

Elizabeth Anne Lester underwent a total knee replacement and was subsequently readmitted to hospital as an emergency. The report raises concern that the ambulance service’s scripted breathing-difficulties assessment did not ask about chest pain, resulting in a green response on the first call; chest pain was identified during a second call, when the response was escalated to red.

Nicholas Gary Stocks · Prevention of Future Deaths report View report

27 May 2015 West Yorkshire (West) M. Burke

Nicholas Gary Stocks was struck and fatally injured by a vehicle after a collision at the junction of Dry Hill Lane and the A635 Barnsley Road in Huddersfield on 27 September 2012. The report raised concerns about damaged and poorly maintained give-way signs and road markings, inadequate reporting and repair systems, highway inspection practices, risk assessment, and coordination between West Yorkshire Police and Kirklees Council.

Mathew Lee Hoare · Prevention of Future Deaths report View report

27 May 2015 Inner South London L. Tagliavini

Mathew Lee Hoare was found on a live rail near Wandsworth Road Train Station after entering Clapham High Street Station and accessing its platforms and tracks after hours. He sustained fatal injuries after being electrocuted and struck by an oncoming train; concerns related to ineffective security equipment and the ease of access through widely spaced yellow tape.

Yusuf ABDISMAD · Prevention of Future Deaths report View report

27 May 2015 Inner North London M. Hassell

Yusuf died from meningococcal septicaemia after his mother called 999 and was advised to call 111; by the time the London Ambulance Service arrived, he was in cardiac arrest. The principal concern was that the emergency medical dispatcher used a potentially confusing method to assess whether Yusuf was conscious, alongside difficulties recognising possible signs of meningitis.

Oliver Asante-Yeboah · Prevention of Future Deaths report View report

27 May 2015 Inner North London R. Brittain

Oliver Asante-Yeboah developed a urinary tract infection and E. coli sepsis after a non-therapeutic circumcision, deteriorated despite treatment and resuscitation attempts, and died. The report raised concern about the lack of formal regulation of non-medical providers of circumcision and stated that the circumcision had contributed to his death.