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Sally Ellison · Prevention of Future Deaths report View report

27 Apr 2015 North Wales (East and Central) J. Gittins

Sally Ellison contracted legionella while on holiday in Tunisia in mid-May 2012 and died on 1 June 2012 from cardiac arrest, multi-organ failure and legionella pneumonia. Concerns were raised that testing for legionella was not undertaken until 31 May, with confirmation on 1 June, and that this may have delayed optimal treatment; the report also identified the need for earlier testing and a rapid testing and reporting service.

Joshua Steven BROWN · Prevention of Future Deaths report View report

27 Apr 2015 Surrey R. Travers

Joshua Brown died after being struck by a police vehicle on the A31 Hog’s Back shortly after 03.30 on 1 December 2012, in patchy dense fog and reduced visibility. The jury found that the police officer’s speed was inappropriate in the brief period between encountering the fog and the collision, and that Joshua Brown was walking in the carriageway with his back to traffic; both elements contributed to the collision. The report raised concern about the absence of compulsory practical in-car night-time training in national police driver training requirements.

Mrs. Hilda May Harris · Prevention of Future Deaths report View report

24 Apr 2015 Powys, Bridgend and Glamorgan Valleys S. Richards

Mrs. Hilda May Harris, aged 86, suffered a cerebral infarction with an intracerebral haemorrhage on 04.01.15 after an additional INR test was not undertaken while she was taking Warfarin alongside medication for gout. The report identified unreliable systems for booking community INR tests and for notifying or acting on omissions.

PATRICIA LILLIAN CHAPMAN · Prevention of Future Deaths report View report

23 Apr 2015 County Durham and Darlington A. Tweddle

PATRICIA LILLIAN CHAPMAN was a patient at Sedgefield Community Hospital who suffered a severe hypoglycaemic attack on 8 July 2013 and died from another hypoglycaemic attack early the following day. The inquest identified shortcomings in her care and concluded that her death was the avoidable consequence of an avoidable hypoglycaemic episode. A substantive concern was that revised policies did not address obtaining immediate emergency advice from an appropriate expert for community hospital staff.

Efan Robert James · Prevention of Future Deaths report View report

23 Apr 2015 Carmarthenshire and Pembrokeshire J. Layton

Efan Robert James was found unresponsive after being placed in a bed shared by his mother and a friend, and died after being taken to hospital. The report raised concern that government advice about bed-sharing was confusing because assessing whether parents feel “very tired” was considered unrealistic.

Noel Owen JONES · Prevention of Future Deaths report View report

22 Apr 2015 Worcestershire G. Williams

Noel Owen JONES underwent surgery on 2 October 2014 and was later admitted to Hereford County Hospital severely unwell with an internal haemorrhage. He was ultimately transferred by ambulance to Worcestershire Royal Hospital, where he died shortly after arrival, following an apparent four-hour delay in acceptance. Concerns included evidence that earlier acceptance might have enabled survival and that Worcestershire Royal Hospital had no out-of-hours vascular surgery or interventional radiology service.

Laurence Boyens · Prevention of Future Deaths report View report

22 Apr 2015 Inner South London A. Harris

Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.

Jack · Prevention of Future Deaths report View report

22 Apr 2015 Wiltshire and Swindon C. Balysz

Jack, a three-year-old boy, was found at the bottom of his family’s unfenced swimming pool after being left in the care of his 20-year-old brother. The substantive concern was that the lack of UK regulations requiring child-resistant barriers around private swimming pools could contribute to future child drownings.

Eliza Rebecca Bowen · Prevention of Future Deaths report View report

22 Apr 2015 Black Country Z. Siddique

Eliza Bowen, a resident of Springfield House Care Home with complex medical needs, became suddenly unwell on 15 November 2014 and died after developing markedly raised blood glucose, acute kidney injury and metabolic imbalances. The inquest concluded that she died from hyperosmolar non-ketotic coma, a natural cause of death. The principal concerns were that regular blood glucose testing might have identified diabetes sooner and that guidance on diabetes screening and management for patients with relevant risk factors should be available to medical staff.

Howell Glyndwr Fisher · Prevention of Future Deaths report View report

21 Apr 2015 Powys, Bridgend and Glamorgan Valleys A. Barkley

Howell Glyndwr Fisher fell at home, sustained a fractured hip, and later died in hospital on 9 December 2014 after developing an ischemic leg, pneumonia and other health problems. The concerns included at least five falls while he was assessed as being at high risk, insufficient staffing to provide required one-to-one nursing, and inadequate handover and falls-risk assessments between and within hospitals.

Anthony Peter Kristian Garrett · Prevention of Future Deaths report View report

21 Apr 2015 Manchester West R. Griffin

Anthony Peter Kristian Garrett collapsed after smoking Cherry Bomb, a substance marketed as herbal incense, after drinking alcohol throughout the day. He was transported to hospital, never regained consciousness, and died the following day. The report raised concerns that synthetic cannabinoids are readily available, commonly sold as herbal incense, and can be dangerous and potentially life-threatening when misused.

Willow Davies · Prevention of Future Deaths report View report

21 Apr 2015 Bedfordshire and Luton T. Osborne

Willow Davies was born at Bedford Hospital on 8 February 2014 and became pale and floppy shortly afterwards; CPR was commenced, and her death was confirmed later that morning. The substantive concerns related to the allocation and support of a newly qualified midwife who had no prior experience assisting with newborn resuscitation, the failure to account for midwives’ experience when allocating women, and the operation of the Supervisors of Midwives system.

Mary Anne Gemma Hanson · Prevention of Future Deaths report View report

21 Apr 2015 Preston and West Lancashire C. Hammond

Mary Anne Gemma Hanson underwent elective surgery to remove a large pituitary tumour on 27 June 2014 and died on 15 August 2014 after developing a postoperative bleed and failing to recover despite further treatment. Concerns included inadequate recording and communication of surgical risks and benefits, lack of patient information materials, incomplete capacity and best-interests documentation, and uncertainty about whether the staff nurse completing the assessment was suitably qualified.

Bruce LONGDEN · Prevention of Future Deaths report View report

21 Apr 2015 Brighton and Hove V. Hamilton-Deeley

Bruce LONGDEN’s death was investigated by an inquest, but the circumstances of the death are referred to separately in the Record of Inquest. The substantive concerns included failures to follow Sussex Partnership Trust protocols, poor communication between trusts, inadequate understanding of his mental health condition and terminology, and delayed reporting of his absconsion to Sussex Police.

Andrew Ralph Mitchell Farrow · Prevention of Future Deaths report View report

20 Apr 2015 Wiltshire and Swindon P. Hatvany

Andrew Ralph Mitchell Farrow died at home on 7 July 2014 as a result of self-administered acute codeine and alcohol toxicity. He had expressed a wish to be admitted to hospital for his own safety, and the concern was that no beds would have been available at Green Lane Hospital Devizes if admission had been needed.

Daniel Lee HODGIN · Prevention of Future Deaths report View report

20 Apr 2015 Shropshire, Telford and Wrekin J. Ellery

Daniel Lee HODGIN was found in the River Severn at Cressage on 31 December 2014, after last being seen alive on 23 November 2014. The inquest concluded that his death was accidental, with the medical cause recorded as immersion in water. Concerns included the failure to close and lock a gate leading to the flooded towpath and the lack of an effective system for notifying Shropshire Council about river levels requiring the gate to be secured.

Patrick Derek Sturivant · Prevention of Future Deaths report View report

17 Apr 2015 Wiltshire and Swindon D. Ridley

Patrick Derek Sturivant was struck by a Mercedes while crossing the A303 near Byway 11 at Stonehenge on 29 August 2014 and died in hospital the following day from an unsurvivable brain injury. The concerns were that public use of the area near Byway 11 for parking and viewing Stonehenge created a risk of similar deaths, and that closing or modifying Byway 11 could shift the risk to Byway 12.

Mark Groombridge · Prevention of Future Deaths report View report

17 Apr 2015 Staffordshire South A. Haigh

Mark Groombridge was in the community on licence from prison when a recall warrant was issued. He was arrested while an inpatient in a psychiatric unit and taken to HMP Dovegate, where he died by suicide on 27 December 2013 after jumping head first from a bed in the prison health care centre. The concerns identified included a lack of direct communication between the local offender manager and the clinician before recall paperwork was issued, and confusion among probation staff about the recall process.

Robert Watt · Prevention of Future Deaths report View report

17 Apr 2015 Mid Kent and Medway P. Harding

Robert Watt had suspected bladder cancer symptoms, including haematuria, weight loss and rectal bleeding, but investigations and specialist review did not identify the cancer until it was advanced and incurable. The report identified concerns about communication of a cancelled haematuria clinic appointment, incomplete medical records, reliance on junior doctors for specialist advice, and the lack of urological review when malignancy was suspected.

Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report View report

16 Apr 2015 Manchester South J. Kearsley

Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.