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Anthony Offord · Prevention of Future Deaths report View report

8 Sep 2014 South Yorkshire (Western) P. Dorries

Anthony Offord collapsed at a friend's flat on 16 April 2013 and died two days later from hypoxic brain injury following a delay in providing support to a lone responder. The report raised concerns about the lack of consideration of alternative support, the absence of a requirement to involve a manager when a stand-off caused delay, and insufficient training for emergency medical dispatch staff to recognise signs of respiratory difficulty such as snoring in an unresponsive person.

Peter John White · Prevention of Future Deaths report View report

5 Sep 2014 Milton Keynes T. Osborne

Peter John White was involved in a road traffic collision on 2 April 2013 and was taken to Milton Keynes Hospital with serious chest injuries. He became unwell and collapsed while undergoing a CT scan, and died on 3 April 2013 from haemothorax. Concerns included incorrect completion and inadequate checking of the Early Warning Observation Chart, ignored triggers, failures to escalate care, and the absence of a regular audit system.

Kane Samuel Sparham-Price · Prevention of Future Deaths report View report

5 Sep 2014 Manchester South J. Pollard

Kane Samuel Sparham-Price, who had lived much of his life in care and foster homes and had mental health problems, was found hanging at his home after a payday lender took part of the debt from his bank account, leaving him with no money. The concern raised was that payday lenders should be required to leave a statutory minimum amount in a person's account to avoid absolute destitution.

Gillian Crossley · Prevention of Future Deaths report View report

4 Sep 2014 Leicester City and South Leicestershire C. Mason

Gillian Crossley underwent elective bowel surgery, was discharged home, re-admitted the following day in extremis with bowel necrosis and perforation, and died on 28 March 2013 despite further surgery. The concerns included inadequate documentation, inadequate observation and monitoring, failure to properly assess and plan her discharge, and inadequate communication between those responsible for her care.

Hilda Florence Thompson · Prevention of Future Deaths report View report

3 Sep 2014 Surrey M. Fleming

Hilda Florence Thompson, who had limited mobility and a history of falls, was admitted to hospital with breathlessness and later identified as a high falls risk. She collapsed on 19 January 2014, sustained an extensive intracranial injury, and died on 22 January 2014; concerns included an incomplete admission management plan, incorrect initial identification as not being at risk of falls, delayed falls assessment, and poor record-keeping.

Ryan Reece Bramwell and 2 others · Prevention of Future Deaths report View report

3 Sep 2014 Manchester South J. Pollard

Robert John Graham died after his car was struck by an out-of-control Mercedes on the A619 on 13 November 2009. The following day, Ryan Reece Bramwell and Richard Alan Barker were among the occupants of a Ford Escort that aquaplaned while overtaking, collided with an ambulance and entered an embankment. The concerns identified were the placement of tyres with greater tread depth on the front rather than the rear, and limited awareness among Derbyshire police officers of powers to close hazardous roads.

Yohannes Kidane · Prevention of Future Deaths report View report

3 Sep 2014 Birmingham and Solihull L. Hunt

Yohannes Kidane was remanded into custody at Birmingham Prison and was found in his cell with a noose around his neck after previous self-harm incidents. CPR was provided, but he was declared dead on 19 December 2013. The concerns included insufficient night staffing in the healthcare wards, compromised ACCT observations, and the impact of staff not taking breaks on prisoner care and staff wellbeing.

Peter Stanley · Prevention of Future Deaths report View report

2 Sep 2014 South Yorkshire (Western) P. Dorries

Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.

Thomas Charles TAYLOR · Prevention of Future Deaths report View report

1 Sep 2014 Inner North London M. Hassell

Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

Irshad ALI · Prevention of Future Deaths report View report

29 Aug 2014 Inner North London M. Hassell

Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his discharge.

Jude Daniel Kliem · Prevention of Future Deaths report View report

29 Aug 2014 Plymouth, Torbay and South Devon I. Arrow

Jude Daniel Kliem was being treated at Derriford Hospital, where attempts were made to arrange a transfer to Bristol and Southampton. The report identified an apparent breakdown in communication and possible improvement through standardised documentation.

Stephen James Morris · Prevention of Future Deaths report View report

29 Aug 2014 Blackpool and the Fylde A. Wilson

Stephen James Morris, who had previously been diagnosed with bipolar affective disorder, was found deceased in the bath at his flat on the morning after 16 June 2013. A post-mortem found high levels of mood-stabilising and antidepressant medication, whose combined effects proved fatal; the inquest concluded that he took his own life. The principal concerns were that Mirtazapine was prescribed despite awareness of his diagnosis and its suitability concerns, based on the patient's verbal account rather than confirmation from the mental health team.

Linda Rose Lloyd · Prevention of Future Deaths report View report

29 Aug 2014 Blackpool and the Fylde A. Wilson

Linda Rose Lloyd was found at home after complaining of a headache and was taken to hospital, where she was assessed, underwent a CT scan confirming an acute subdural haemorrhage, and died on 3 January 2014. The report raised concerns that treatment was delayed and that hospital procedures and staffing levels were insufficiently robust to minimise the risk of similar deaths.

Stephen Philip Owen Farrar · Prevention of Future Deaths report View report

29 Aug 2014 Milton Keynes T. Osborne

Stephen Philip Owen Farrar was found hanging in his cell at HMP Woodhill on 12 December 2013 and was pronounced dead later that evening. The report raised concerns that no formal self-harm or suicide risk assessment had been completed on admission despite his previous self-harm history and past mental health problems, and that no formal risk assessment tool was available in prisons.

Lauren Barfoot · Prevention of Future Deaths report View report

28 Aug 2014 Inner South London L. Tagliavini

Lauren Barfoot was a 14-year-old looked-after child who went missing from Micawber House on 22 June 2012 and was later discovered in the porch of her putative father’s home. The report identified concerns about failures to share information, classify the level of risk, conduct an effective search, and hold a timely strategy meeting. The inquest concluded that her accidental death was contributed to by failures in sharing information and pooling and using resources.

Iris May GRIMWOOD · Prevention of Future Deaths report View report

26 Aug 2014 South Lincolnshire A. Forrest

Iris May GRIMWOOD, aged 80, died at Pilgrim Hospital on 8 October 2013 as a result of progressive neurological disease. Concerns were raised about difficulties providing the nursing care she needed, including errors in using semi-automatic thermometers and an attempted application of an antifungal ointment prescribed for oral thrush to her genital region.

MARTIN ARNOLD HILL · Prevention of Future Deaths report View report

22 Aug 2014 Brighton and Hove V. Hamilton-Deeley

MARTIN ARNOLD HILL arrived at A & E on 28 March 2014 after approximately three days of confusion, abdominal pain and vomiting, with raised inflammatory markers. The concerns included delayed antibiotics, failures to refer him to the Critical Care Outreach Team when his NEWS was elevated, inadequate withdrawal treatment, failures in managing constipation, poor handover and communication, and serious omissions in the Medical Administration Record.

Tessa Karen Elizabeth Summers · Prevention of Future Deaths report View report

22 Aug 2014 Portsmouth and South East Hampshire D. Horsley

Tessa Karen Elizabeth Summers, aged 20, was found collapsed in bed after taking an overdose of medication and died at hospital on 9 September 2013. Concerns included the failure to record the rationale for downgrading her self-harm risk assessment and allowing unsupervised access to medication, and the need for more training and support for Shared Lives Carers working with clients with mental health and emotional problems.

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.

JOANNA LYNDSEY GREENSMITH · Prevention of Future Deaths report View report

21 Aug 2014 Gwent W. James

Mrs. Joanna Lyndsey Greensmith was driving on the A465 near Llangua when her vehicle travelled through black ice, left the carriageway and collided with a tree, causing fatal injuries. The road surface had not been treated in accordance with the relevant adverse-weather guidance, and no report had been made of running water across the carriageway at that location.