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Alan Massam · Prevention of Future Deaths report View report

26 Apr 2021 Manchester South A. Mutch

Alan Massam, a resident with dementia, had repeated falls after moving to a dementia residential home and was twice admitted to hospital. After a traumatic brain bleed and rib fractures were identified, he deteriorated and died in hospital on 24 October 2019. Concerns included inadequate information-sharing between agencies, discharge without effective communication or confirmation that the care home could meet his needs, and the absence of a clear escalation process when he refused medication and fluids.

Flora Marion BABER · Prevention of Future Deaths report View report

13 Aug 2018 Inner North London M. Hassell

Flora Marion Baber was admitted to the Royal Free Hospital from Compton Lodge Care Home on 25 January 2018 with increased confusion, slurred speech and difficulty breathing, and died there about a month later. Concerns included inadequate access to fluids, inappropriate food and eating assistance, delays in speech and language referral and treatment of oral thrush, an apparently sleeping staff member, inappropriate responses to toileting requests, and failure to record her opioid sensitivity across healthcare settings.

Paul Price · Prevention of Future Deaths report View report

18 Sep 2018 Birmingham and Solihull L. Hunt

Paul Price had a history of depression and anxiety, and was found outside his room on 04/06/18 after falling from a window; he was pronounced deceased at hospital, with the medical cause of death recorded as multiple injuries. Concerns included delays in communicating mental-health assessment information to his GP, incompatible IT systems, and a failure to return a call about concerns for his wellbeing.

Ahshiyah Bibi · Prevention of Future Deaths report View report

30 Apr 2017 Birmingham and Solihull E. Brown

Ahshiyah Bibi died at Birmingham Heartlands Hospital on 22 December 2016 after admission with reduced consciousness and acute renal failure. During her treatment, there was a delay in commencing treatment for high potassium and an insulin prescribing and dispensing error. The report identified concerns about missing blood gas results and the absence of a Trust-wide review or system to reduce the risk of similar errors.

CHAND ALI · Prevention of Future Deaths report View report

7 Mar 2019 City of London A. Hewitt

Chand Ali, a 78-year-old man with severe end-stage heart failure and diabetes, was admitted to hospital with fluid overload and decompensated heart failure and died later that day. Cyclizine was administered intravenously despite cautions concerning its use in severe heart failure. Concerns included its routine use without individual risk-benefit assessment, the lack of monitoring of deaths following recent cyclizine use, and the absence of a comprehensive review of alternative antiemetics.

Deanne Naomi Smith · Prevention of Future Deaths report View report

31 Mar 2014 South London R. Palmer

Deanne Smith, who was dependent on drugs and had recently relapsed to using heroin, died on 8 January 2013 after methadone bottles were found at her home. The coroner was concerned that several days’ supply of methadone was dispensed at once over public holidays when the usual pharmacy arrangements were suspended, particularly for drug-dependent individuals who also acquired opiates illegally.

Christopher Edward SIDLE · Prevention of Future Deaths report View report

25 Mar 2024 Norfolk J. Lake

Christopher Sidle had schizophrenia and experienced a deterioration in his mental health during June 2023. After several assessments by mental health services, he was not admitted to hospital; on 1 July 2023 he jumped from a moving taxi, suffered life-threatening head injuries and died on 4 July 2023 after life-sustaining therapies ceased. The report identified inadequate assessments and missed opportunities to provide appropriate and timely care, alongside concerns about crisis-team training, communication, risk assessment, community support, and the shortage of inpatient mental health beds.

Janice Mary Davies · Prevention of Future Deaths report View report

31 Dec 2018 South Wales Central G. Hughes

Janice Mary Davies fell out of bed at home on 19 April 2018, sustaining fractured ribs, and was treated with oramorph before being discharged. She died at home in the early hours of 21 April 2018; the medical cause included morphine toxicity, bilateral rib fractures, chronic obstructive pulmonary disease and chronic kidney disease. Concerns included missing post-dose observations and pain-score documentation, and a lack of formal guidance for prescribing oramorph to patients being discharged.

Christopher John Stubbs · Prevention of Future Deaths report View report

3 Mar 2016 West Yorkshire (Western) M. Fleming

Christopher John Stubbs, who had a history of mental ill health and drug misuse, was found suspended from a ligature at his home on 26 July 2015, and the inquest concluded that he died by suicide from hanging. A concern was raised that medication stopped after his earlier overdose was not reviewed by his GP before his death, and about systems for receiving hospital discharge summaries advising on medication review.

Joan Farran · Prevention of Future Deaths report View report

26 Sep 2013 Gateshead and South Tyneside T. Carney

Joan Farran, who had multiple co-morbidities and was cared for by her adult son, died at home from bronchopneumonia due to chronic obstructive pulmonary disease and Alzheimer’s disease. The report states that her death from a potentially treatable pneumonia was contributed to by neglect in obtaining medical support and treatment. Concerns included inadequate coordination and information-sharing between agencies, limited assessment of the home environment, withdrawal of community visits without replacement services, and the cancellation of a GP home visit without further follow-up.

Joseph James Gingell · Prevention of Future Deaths report View report

17 Feb 2020 Essex C. Beasley-Murray

Joseph James Gingell, who had a long history of mental illness and opioid and benzodiazepine dependence, was found deceased in a hotel near the Dartford Crossing. His cause of death was mixed drug toxicity with alcohol, and he had obtained drugs online without a prescription. Concerns included the toxic effects of combining drugs, self-certification without checks, and allowing patients not to inform their GP, which could remove a safeguard for people with addiction problems.

Amanda Coulthard · Prevention of Future Deaths report View report

18 Jan 2017 Cumbria D. Roberts

Amanda Coulthard, who had multiple sclerosis, died on 26 April 2015 after a nasogastric tube entered her right lung and feed and medication were administered into it. She developed aspiration pneumonia. The concerns included failures to follow and implement nasogastric-tube policies and best practice, inadequate checking and training, and insufficient systems to ensure compliance and learn from previous deaths.

Ernest Wayne Smith · Prevention of Future Deaths report View report

14 Dec 2017 Surrey A. Crawford

Ernest Wayne Smith was found deceased in woodland at Chelsham Common, Warlingham, on 13 June 2016. The inquest concluded that the medical cause of death was hanging and recorded a short-form conclusion of suicide. Concerns included failures to arrange or follow up medication reviews and the absence of a clear system for updating GPs about missed appointments and disengagement where the CMHRS medical team was not involved.

Natasha Elizabeth Victoria Abrahart · Prevention of Future Deaths report View report

16 May 2019 Avon M. Voisin

Natasha Elizabeth Victoria Abrahart died on 30 April 2018 after placing a ligature around her neck. She was under the care of a mental health team that had not provided a timely and detailed management plan following several assessments. The report also identifies concerns that follow-up after starting sertraline, including review of suicide risk, did not comply with the cited NICE guideline; the inquest concluded that the death was suicide contributed to by neglect.

Nicholas Kim Harrison · Prevention of Future Deaths report View report

24 Apr 2024 Swansea and Neath Port Talbot K. Heaven

Nicholas Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.

Margaret Walker · Prevention of Future Deaths report View report

25 Mar 2014 Manchester West J. Leeming

Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.

Herbert Chandler · Prevention of Future Deaths report View report

21 Aug 2014 Central and South East Kent R. Redman

Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.

Andrew Patrick Jones · Prevention of Future Deaths report View report

20 Apr 2020 Lancashire and Blackburn with Darwen J. Adeley

Andrew Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.

TERENCE TALBOT · Prevention of Future Deaths report View report

3 Dec 2021 Mid Kent and Medway S. Hayes

Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.

Amir Siman-Tov · Prevention of Future Deaths report View report

28 Aug 2019 London (West) S. Cummings

Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.