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Frederick William Hall · Prevention of Future Deaths report View report

8 Apr 2014 Manchester South J. Pollard

Four days after a right hemicolectomy, Frederick William Hall was taken for a CT scan without the nasogastric tube that had been ordered to decompress his distended abdomen. He vomited and aspirated gastric contents, developing aspiration pneumonia. The concerns included inadequate training in passing nasogastric tubes, failures to follow clinical instructions, poor monitoring and communication, inadequate record-keeping, and insufficient staffing for the demands on the wards.

Leslie Edmund Harding (Lez) · Prevention of Future Deaths report View report

8 Apr 2014 Plymouth, Torbay and South Devon A. Cox

Leslie Edmund Harding had a history of multiple sclerosis and recurrent pulmonary emboli, and died after collapsing on 28 September 2013. The report raised concerns about the lack of action after he was assessed with chest pain and suspected pulmonary embolus, gaps in anticoagulation prescribing and follow-up, insufficient efforts to address alleged non-compliance, and the absence of a prompt significant events review.

Roger Clive DUGGAN · Prevention of Future Deaths report View report

7 Apr 2014 Exeter & Greater Devon E. Earland

Roger Clive Duggan, aged 61, was in a heightened anxiety state when he left the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours on 11 February 2013. His body was found in the River Exe on 12 February 2013 and he was confirmed deceased at 14.30. Concerns included whether initial ambulance calls were treated sufficiently seriously and whether staff had the necessary training to deal with a mental health crisis.

Jamie Raymond Barlow · Prevention of Future Deaths report View report

7 Apr 2014 Suffolk P. Dean

Jamie Raymond Barlow had been receiving mental health support after concerns were raised about his wellbeing, but communication and coordination between services affected plans for a further assessment. He subsequently failed to attend a GP appointment and was found hanging near his home; concerns included better inter-agency working, clarity about police assistance, and processes for jointly managing mental health assessments where risks were perceived.

William Albert Winter · Prevention of Future Deaths report View report

7 Apr 2014 Central and South East Kent R. Redman

William Albert Winter was admitted to hospital after discharge from St Thomas’ Hospital following surgery for repair of an abdominal aortic aneurysm, and was found unresponsive with rigor mortis at approximately 5am on 26th March 2013. Nursing staff were concerned that he had not been reviewed by the surgical team, and a second set of observations was not carried out or escalated as required amid pressures on the Clinical Decisions Unit.

Eric Laser Matthews · Prevention of Future Deaths report View report

4 Apr 2014 Inner North London R. Brittain

Eric Laser Matthews, born on 26 November 2013, was placed in a baby sling on 24 December 2013 and was later found not to be breathing. He suffered a significant hypoxic brain injury and died on 1 January 2014; the reported concern was that positional asphyxia associated with baby slings may be insufficiently known and publicised to parents.

DANUTA Bronislawa CORBETT · Prevention of Future Deaths report View report

3 Apr 2014 Brighton and Hove V. Hamilton-Deeley

Danuta Bronislawa Corbett jumped from the window of her eighth-floor flat during escorted leave on 4 November 2013 and died. The report raises concerns that decisions about her leave were not documented in accordance with policy and that the agency escort was not given important information about her distress, her home, or her stated threat to kill herself by jumping from it.

Graham Harold WATTS · Prevention of Future Deaths report View report

3 Apr 2014 Brighton and Hove V. Hamilton-Deeley

Graham Harold Watts was discharged from Princess Royal Hospital to his nursing home, where he arrived hypothermic, hypotensive, oedematous and sleepy. The report raised concerns about a flawed discharge process, blank paperwork and a lack of communication with the nursing home and his son. It also recorded evidence that, had he not fractured his hip in a fall, he would not have died when he did.

MELVIN BANDTOCK · Prevention of Future Deaths report View report

3 Apr 2014 County Durham and Darlington A. Tweddle

MELVIN BANDTOCK, aged 55, died after losing control of his motorcycle on black ice and colliding with an oncoming bus on 28 December 2013. The road had not been treated under the local authority’s gritting or salting regime. Concerns included information sharing between Durham Constabulary and the local authority and reviewing procedures to ensure a timely and proportionate response to potentially dangerous road conditions.

William John Watson · Prevention of Future Deaths report View report

2 Apr 2014 Isle of Wight C. Sumeray

William John Watson, aged 93, died in hospital after being seriously injured in a head-on road traffic collision while overtaking a coach on the Middle Road, Isle of Wight, on 22 October 2013. The concern was that the road layout and surrounding hedgerows near the bus stop at Tapnell might have affected drivers’ visibility and road safety, particularly in light of other road traffic incidents on that stretch.

Mr John Dodd · Prevention of Future Deaths report View report

2 Apr 2014 Black Country A. Thompson

Mr John Dodd died from a retroperitoneal haemorrhage at Russells Hall Hospital on 21 April 2013, after being admitted through A&E the previous day. Concerns included that his INR was not checked while he was taking Warfarin, a documented temperature rise was not reported to medical staff before discharge, and there was a delay in his first assessment during his final admission, which was said to have delayed investigation and diagnosis.

Vincent Gibson · Prevention of Future Deaths report View report

1 Apr 2014 Gateshead and South Tyneside T. Carney

Vincent Gibson was fatally injured while crossing Whiteleas Way, South Shields, when he was struck by a police vehicle travelling at speed in response to a Grade 1 emergency call. The principal concerns related to inadequate coordination, management, monitoring and control of the incident, including the failure to communicate that the caller remained in contact with the call taker, unclear roles, insufficiently informed risk assessment, resource allocation, route planning and uncertainty about response speed.

Oliver George Hiscutt · Prevention of Future Deaths report View report

1 Apr 2014 Manchester City S. Lewis

Oliver George Hiscutt developed a Group A beta-haemolytic streptococcal infection with a retropharyngeal abscess, followed by catastrophic haemorrhage and cardiac arrests; he died on 7 October 2012. The report raised concern that formal paediatric or child-health training is not mandatory for GPs and that exposure to acute paediatrics during GP training is limited.

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.

Valerie Anne HANCOX · Prevention of Future Deaths report View report

31 Mar 2014 Shropshire, Telford and Wrekin J. Ellery

Valerie Anne HANCOX died from injuries sustained in a collision on the A5 at Burlington, Shifnal, Shropshire, on 14 September 2012. The collision occurred when a tractor and baler obstructed the oncoming carriageway during darkness. Concerns included the bale chute being left lowered, unmarked, and painted matt grey, making it difficult for approaching road users to see.

Roy Joseph Godfrey · Prevention of Future Deaths report View report

31 Mar 2014 London (East) N. Persaud

Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

Dr Rosemary Simpson · Prevention of Future Deaths report View report

28 Mar 2014 Inner North London S. Lynch

Dr Rosemary Simpson was struck by a double-decker bus while crossing Tottenham Court Road at a running pace as the lights changed to flashing amber. The concerns identified were heavy pedestrian and vehicle traffic, pedestrians crossing on flashing lights, and reduced bus visibility caused by the position of the bus stop, which required some routes to cross three lanes.

Susan Edea Poore · Prevention of Future Deaths report View report

28 Mar 2014 Norfolk J. Lake

Susan Edea Poore was fatally injured after being struck by a train on 3 May 2012, after she was seen standing on the railway line near Thains Lane, East Runton. The report raised concerns about her depression deteriorating after prescribed antidepressant medication and whether the medication warning about worsening depression was sufficient.

Lee Hollman · Prevention of Future Deaths report View report

26 Mar 2014 West Sussex K. Henderson

Lee Hollman, who had a long history of intermittently severe mental ill-health, died after taking an overdose of Quetiapine, Trazodone and alcohol on 28 February 2014. The report identified concerns about inaccurate and outdated medical records, the repeat-prescription system, and failure to review patients in line with relevant guidelines.

Caroline Louise Pilkington · Prevention of Future Deaths report View report

25 Mar 2014 Manchester West J. Leeming

Caroline Louise Pilkington was found apparently suffering from a fit at home on 25 April 2013 and required restraint to be removed safely, with police assistance called because ambulance personnel were not trained in control and restraint techniques. The inquest concluded that her death was due to an accident, with the medical cause recorded as propranolol toxicity. The report raised concerns that involving police in such situations could result in clinically untrained officers dealing with unwell patients and could delay removal to hospital, potentially causing harm.