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Marco Antonio Lima De Araujo · Prevention of Future Deaths report View report

3 Mar 2014 Portsmouth and South East Hampshire D. Horsley

Marco Antonio Lima De Araujo entered the sea near the Round Tower in Portsmouth on 26 July 2012 to assist in rescuing two children and was not seen alive again. His body was recovered from Portsmouth Dockyard on 8 August 2012; the inquest concluded that he died in an accident, with drowning as the medical cause. A concern was raised that there was no formal protocol for reporting and coordinating rescue in life-threatening incidents in Portsmouth Harbour.

Kevin Graham Pearson · Prevention of Future Deaths report View report

3 Mar 2014 North Lincolnshire and Grimsby P. Kelly

On 11 June 2013, Kevin Graham Pearson was crushed between a tractor and a stationary trailer while connecting the tractor to a trailer after air pressure was introduced to the trailer’s brakes. The concern was that the company may not have ensured full compliance with relevant guidance or ensured that all drivers understood it.

Carl Andrew Morris · Prevention of Future Deaths report View report

3 Mar 2014 North and West Cumbria R. Chapman

Carl Andrew Morris died from a heart attack with an already compromised heart while diving at Wastwater on 27 January 2013. The report identified concerns that his medical certificate was not up to date for the technical diving courses and that no check was made to ensure compliance with the requirement for a certificate. It also identified a wider concern that compliance with PADI rules for technical diving courses was not effectively policed.

Kirabo Kiwanuka · Prevention of Future Deaths report View report

3 Mar 2014 Inner South London A. Harris

Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.

Margaret Joy Easterfield · Prevention of Future Deaths report View report

3 Mar 2014 Central and South East Kent R. Redman

Margaret Joy Easterfield underwent reversal of an ileostomy loop, developed peritonitis after an anastomotic leak following surgery, and died after readmission to hospital. The concern was that the anastomotic breakdown may have involved technical error and could raise risks of further deaths.

Lauren Marie Brown and Stephen Michael Tilbury · Prevention of Future Deaths report View report

2 Mar 2014 London (East) N. Persuad

Stephen Michael Tilbury died at the scene after losing control of his van on Crow Lane while over the legal alcohol limit and travelling above the speed limit. Lauren Marie Brown was struck by the van on the pavement and died in hospital in the early hours of the following day. The principal concerns were speeding at the bend and whether physical measures should be used to reduce vehicle speeds and manage the risks associated with the kerb.

Peter Norman Nott · Prevention of Future Deaths report View report

28 Feb 2014 Oxfordshire N. Graham

Peter Norman Nott, who had Parkinson's disease and was at very high risk of falls, experienced an unwitnessed fall at a nursing home on 2 September 2013 and died on 8 September 2013 from a subdural haemorrhage and Parkinson's disease. The concerns included that neurological observations after the fall were not undertaken beyond a simple visual examination and that inaccurate information about his consciousness was passed to paramedics.

Richard Philip WHITE · Prevention of Future Deaths report View report

28 Feb 2014 County Durham and Darlington C. Oliver

Richard White was a resident at Hope House who took an overdose of cyclizine and zopiclone on 9 June 2013 and subsequently died from cyclizine toxicity. The concerns were that Hope House’s medication policy was not made known to the prescriber or others involved, was not set out in a protocol or policy statement, and that no such document was available.

Nathan Douthwaite · Prevention of Future Deaths report View report

28 Feb 2014 County Durham and Darlington A. Tweddle

Nathan Douthwaite had a long history of severe constipation requiring repeated hospital admissions and died after emergency admission in December 2010. Autopsy found massive megacolon with abdominal compartment syndrome and a perforated caecum, with Hirschsprung’s disease recorded as an underlying cause. The report raised concerns that a rectal biopsy might have diagnosed Hirschsprung’s disease and identified a need to review relevant guidelines and clinical practices.

Malcolm James Ernest Potter · Prevention of Future Deaths report View report

27 Feb 2014 South and West Cambridgeshire B. Cheney

Malcolm James Ernest Potter, aged 76, was struck and killed by a northbound train while crossing the Dernford railway crossing on 3 October 2013, after a southbound train had passed. The concerns identified were that the pedestrian warning light was positioned before the gate and was not synchronised to account for another approaching train, creating a risk that pedestrians would cross after the light appeared to turn green without seeing a renewed red signal. The crossing was considered unsuitable for the busy railway line, and the report noted that the accident could recur.

Victoria Meppen-Walter · Prevention of Future Deaths report View report

27 Feb 2014 Manchester North L. Hashmi

Victoria Meppen-Walter underwent a dermatological procedure in September 2011 and subsequently experienced constant pain, scarring, social withdrawal and declining mental health. She researched assisted suicide and was later found deceased at her home with a do-not-resuscitate note and white powder residue; the inquest concluded that she had taken her own life, with chloroquine toxicity recorded as the medical cause of death. The principal concerns were the availability and regulation of chloroquine and the risk of associated misuse.

Samuel Eric Shaw · Prevention of Future Deaths report View report

26 Feb 2014 North Northumberland T. Brown

Samuel Eric Shaw, aged 70, died after being struck by a southbound ambulance while crossing the A1 at Haggerston on 29 October 2013. Concerns included the absence of warning signs and a central pedestrian refuge, poor lighting, and the need for pedestrians to cross both lanes of a 60 mph road from the bus stop to Haggerston.

Herta Edith Maria WOODS · Prevention of Future Deaths report View report

26 Feb 2014 Brighton and Hove V. Hamilton-Deeley

Herta Edith Maria WOODS, a 94-year-old woman living alone with carer support, was found after falls at home and admitted to hospital with injuries, dehydration, rhabdomyolysis and renal impairment. She was found deceased in her hospital bed early on 8 August 2013 after being overloaded with fluid. The principal concerns included apparent abandonment in the Acute Medical Unit, inadequate documentation and fluid monitoring, failure to act on the NEWS score, failure to obtain timely senior review, and failure to replace an inappropriate cannula.

Hazel Claire Polkinghorn · Prevention of Future Deaths report View report

26 Feb 2014 Central Lincolnshire S. Fisher

Hazel Claire Polkinghorn, who had a history of mental health difficulties, was found deceased in her flat on 24 April 2013 after taking an overdose of Pentobarbital acquired from the internet. The principal concern was the ease with which she obtained potentially dangerous non-prescribed medication online and the risk of similar deaths unless such websites were screened and closed down.

Sidney Harvey · Prevention of Future Deaths report View report

26 Feb 2014 South Lincolnshire S. Kelly

Sidney Harvey, a 90-year-old man, sustained a severe cut when non-safety glass in a door broke, and the inquest concluded that he died from haemorrhage due to an incised wound of the left forearm. The concerns were the presence of non-safety glass doors in rented properties likely to house elderly people and children, and whether systems existed to replace or make such doors safe.

Bertram Theophilus HAMILTON · Prevention of Future Deaths report View report

26 Feb 2014 Black Country R. Balmain

Bertram Theophilus HAMILTON was a long-term care-home resident who died shortly after receiving insulin despite a recorded blood sugar level of 1.6. Concerns included the nurse appearing not to know that insulin should not be given when blood sugar was so low, and concerns about the nurse's account of events not being supported by contemporaneous documentation.

Sean James Cunningham · Prevention of Future Deaths report View report

26 Feb 2014 Central Lincolnshire S. Fisher

Sean James Cunningham died after ejecting from an aircraft on 11 November 2011 when his parachute failed to deploy, causing fatal injuries in the fall to the ground. Concerns included the risk of strap misrouting affecting ejection-seat safety and the adequacy of systems for urgently disseminating safety-critical information to end users.

Rachel Ann Burke · Prevention of Future Deaths report View report

25 Feb 2014 Inner South London A. Harris

Rachel Ann Burke died in Dole, Nepal, after developing high altitude cerebral oedema and high altitude pulmonary oedema during a Himalayan trek. Concerns included an excessive rate of ascent, failure to use a nearby health post or satellite phone for urgent care, failure to recognise the severity of her illness, and sending her to descend under her own steam with a guide who had inadequate or no training in acute mountain sickness.

Arthur Brockett-Deakins · Prevention of Future Deaths report View report

25 Feb 2014 Inner South London A. Harris

Arthur Brockett-Deakins was born in poor condition on 16 December 2007 after complications during labour and suffered severe disabilities resulting from acute profound perinatal hypoxic-ischaemic encephalopathy. He died at home on 18 October 2011 from respiratory problems. The report identified concerns about failure to escalate an abnormal CTG, administration and monitoring of Syntocinon, CTG interpretation and display of the maternal heart rate, and the organisation and support of a private midwifery-led service.

Stephen John PALMER · Prevention of Future Deaths report View report

25 Feb 2014 Brighton and Hove V. Hamilton-Deeley

Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.