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Paul Alexander Meadows · Prevention of Future Deaths report View report

29 Jun 2022 Suffolk P. Taheri

Paul Alexander Meadows was found dead at home on 4 August 2021 after taking a Codeine overdose, against a background of physical health difficulties and deteriorating mental health. The report identified concerns that his mental health crisis was not recognised by the First Response Service on 3 August 2021 and that there was no onward referral for urgent or emergency intervention. It also identified broader concerns about the time available to practitioners to gather information and properly triage and risk assess callers, linked to workload and recruitment pressures.

David Peter Greenfield · Prevention of Future Deaths report View report

27 Nov 2014 County Durham and Darlington A. Tweddle

David Peter Greenfield, aged 29, was admitted to hospital for alcohol detoxification and was found unresponsive in his bedroom less than 24 hours later. The report states that his death involved pre-existing heart disease, respiratory depression linked to obesity and the effects of drugs. Concerns included staff experience and understanding of risks associated with methadone and respiratory depression, and the absence of drug screening for patients admitted for alcohol detoxification, which impeded meaningful risk assessment.

Dawn Patricia GILL · Prevention of Future Deaths report View report

16 Nov 2018 Inner North London M. Hassell

Dawn Patricia Gill, a long-term drug user, died from a methadone overdose after taking illicit drugs while in the Royal London Hospital alongside prescribed medication. Concerns included the absence of a nursing care plan addressing her drug use, the loss of her drug chart, failures to detect her in her room during searches, and confusion about when to alert hospital security after she was thought to be missing.

Seth Curtis Palminder · Prevention of Future Deaths report View report

17 Oct 2022 Hampshire, Portsmouth and Southampton C. Wilkinson

Seth Curtis Palminder died instantly on 6 February 2022 after falling from a road bridge and being struck by southbound vehicles. The report states that he had recently been discharged from mental health care, had taken overdoses of prescribed medication, and impulsively jumped from the bridge intending to take his own life. Concerns included inadequate bridge safety measures, a lack of means to summon help or access mental health support, insufficient CCTV monitoring, and repeated previous crisis incidents and fatalities at the location.

SAIFUR RAHMAN · Prevention of Future Deaths report View report

26 May 2022 Birmingham and Solihull J. Bennett

Saifur Rahman was found in cardiac arrest in his cell at HMP Birmingham on 20 January 2021, was taken to hospital after resuscitation, and died on 23 January 2021. The post-mortem recorded hypoxic/ischaemic encephalopathy associated with external neck compression, and the jury found that his intention was to commit suicide. The report raised concerns about delayed emergency calls, inadequate records of cell history, insufficient cell risk assessments, and the lack of a formal process for prison and mental health staff to inspect and act on cell risks.

Jean Griffiths · Prevention of Future Deaths report View report

15 Mar 2018 Manchester West J. Leaming

Jean Griffiths died at Salford Royal Hospital on 15 July 2017 after displaying symptoms of Acute Interstitial Pneumonitis; her disconnected oxygen lead did not contribute to her death. The report raised concerns about poor oxygen-prescribing practice and the risk to patient safety when supplementary oxygen is given without a valid prescription and target range, although there was no evidence that this contributed to Jean Griffiths’ death.

Margaret Avril Burman · Prevention of Future Deaths report View report

17 Apr 2024 Wiltshire and Swindon D. Ridley

Margaret Avril Burman, who preferred to be known as Avril, died on 13 July 2021 after an unwitnessed fall at Salisbury District Hospital caused a head injury and intracranial bleed. The report raises concerns that falls risk assessments and enhanced care arrangements were inadequate, and that staffing shortages meant no Healthcare Assistant was available to monitor the ward bay. It also identifies a broader concern that elderly hospital patients remain at significant risk of traumatic and fatal falls because appropriate falls mitigation measures are unavailable.

Irene Anne Pearson · Prevention of Future Deaths report View report

19 Jan 2016 Manchester South J. Pollard

Irene Anne Pearson had terminal colon cancer that had spread to other organs and was receiving palliative Matrifen patches. On 19 July 2015, she was found dead in a hot bath at home, apparently still wearing the patch; the stated medical cause of death included opiate toxicity. Concerns included warnings about hot baths and patch removal, advice and communication about opiate medication, unclear prescribing records, and the adequacy of information supplied by the GP practice to the Coroner.

Patricia Ann WALTON · Prevention of Future Deaths report View report

5 Dec 2023 Leicester City and South Leicestershire D. Hocking

Patricia Ann Walton fell while visiting her granddaughter on Christmas Day 2022 and was later admitted to hospital with a fractured right ankle and shoulder injury. She subsequently received warfarin and dalteparin without a clear review or stopping plan; the dalteparin was not stopped when her INR rose above 2, and she later developed a haemorrhage, pneumonia and deteriorating health before dying on 9 January 2023. The principal concern was insufficient medical cover to assess patients’ ongoing care needs over the New Year Bank Holiday period.

Kevin Freely · Prevention of Future Deaths report View report

7 Jun 2018 London (West) S. Ormond-Walshe

Kevin Freely, aged 61, died at home on 12 October 2016 after a lighted cigarette caused his bedclothes to catch fire while he was bedbound and unable to escape. The principal concern was that warnings about the fire hazard associated with paraffin-based emollient skin products were not being heeded by patients and care organisations providing care in people’s homes.

Wyndham Richard Thomas · Prevention of Future Deaths report View report

21 Dec 2023 Nottinghamshire L. Bower

Wyndham Richard Thomas was a serving prisoner who was found unconscious in his cell after ligating on 4 November 2018 and died in hospital on 6 November 2018. The substantive concerns were the absence of in-cell ligature-point risk assessments and maps, and the lack of designated safer cells at HMP Nottingham, which reduced opportunities to mitigate the risk of self-harm and death by ligature asphyxiation.

Sheila Winifred Ridgway · Prevention of Future Deaths report View report

16 Jul 2018 Manchester City R. Sohall

Sheila Winifred Ridgway was treated for arterial disease in both legs and later developed a painful, cold, pulseless right leg after stopping dual antiplatelet therapy before a planned loop ECG recorder procedure. She subsequently developed diarrhoea, deteriorating renal function, low blood pressure and multi-organ failure due to sepsis, and died after escalation of treatment was considered futile. The principal concern was inadequate communication between specialty consultants about ongoing risks and treatment requirements.

Gwyneth Ann EDWARDS · Prevention of Future Deaths report View report

5 Feb 2019 Bedfordshire and Luton I. Pears

Gwyneth Ann EDWARDS was admitted to Bedford Hospital on 7 December 2017 and deteriorated after Hydrocortisone and Desmopressin were not dispensed. She developed severe hypernatraemia and died on 14 December 2017 while receiving end-of-life care; the stated cause of death included bronchopneumonia and hypernatraemia, with failure to administer Desmopressin and maintain appropriate fluids. Concerns included gaps in weekend transfer arrangements, NEWS scores not being acted upon, an unverified Mobile Medic review marked complete, staff unfamiliarity with Desmopressin storage, and staffing pressures affecting monitoring and record-keeping.

Afifa Qaisar · Prevention of Future Deaths report View report

10 Mar 2014 Manchester South J. Pollard

Afifa Qaisar was admitted to Tameside General Hospital on 23 June 2013 with collapse and confusion, initially diagnosed as meningitis with sepsis, and died at 20.30 hours the same day. Concerns included uncertainty about whether drugs recorded as given had actually been administered, unavailability of required resuscitation equipment, failure to notify the RMO, delays in platelet and Hb support, an inappropriate response to an apparently non-running saline infusion, and failure to commence fluid balance monitoring or catheterisation.

John Brandon Betteridge · Prevention of Future Deaths report View report

30 Jun 2016 County Durham and Darlington A. Tweddle

John Brandon Betteridge was remanded to HMP Durham on 22 May 2015 and was found dead in his cell on 26 May 2015 after hanging himself. Concerns included gaps in staff training and failures to follow mandatory ACCT procedures, including the closure of the ACCT without healthcare staff present. The inquest found that the absence of his prescription medication and the fact that he was not on an open ACCT probably contributed more than minimally to his death.

Peter O’Donnell · Prevention of Future Deaths report View report

20 Mar 2018 Manchester West S. Nelson

Peter O’Donnell was admitted for an elective right total hip replacement and later developed a chest infection and deteriorated. The report identifies concerns about ineffective communication, irregular observations, inadequate documentation, delayed antibiotics, missed opportunities to escalate care, unclear consultant and junior doctor arrangements, and the absence of transfer protocols for unwell patients. It also raises concerns about private hospitals’ reporting requirements and the reporting of nurses’ retrospective additions to clinical records.

Sultana Choudhury · Prevention of Future Deaths report View report

7 Sep 2023 East London G. Irvine

Sultana Choudhury died in hospital on 17 December 2022 after suffering a renal haemorrhage following a renal biopsy, leading to hypovolaemia and cardiac arrest. The concerns included failure to diagnose the ongoing haemorrhage, administration of VTE prophylaxis despite haematuria, and inadequate monitoring during her admission.

Jane Louise SHILTON · Prevention of Future Deaths report View report

22 Feb 2022 Leicester City and South Leicestershire F. Butler

Jane Louise Shilton, who had severe and enduring mental health difficulties and lived in a residential care home, was found unresponsive in her bedroom and was pronounced dead at the scene. The report raises concerns about the failure to check on her after missed medication, dinner and cigarettes, the absence of overnight proactive checks, and the staff’s response to the medical emergency, including not checking breathing or pulse and not attempting CPR. It also raises concerns about the quality and frequency of first-aid training.

Jamie Peter Norman PILKINGTON · Prevention of Future Deaths report View report

22 Feb 2024 Staffordshire and Stoke-on-Trent A. Barkley

Jamie Peter Norman PILKINGTON died after his vehicle left the road, struck a tree and caught fire in the early hours of 12 March 2023. At the time, he was under the care of Mental Health Services and had been expressing suicidal thoughts. Concerns included failures to complete suicide risk assessments and insufficient exploration and management of issues relevant to his suicide risk during mental health assessments.

Michael Ramon JERVIS · Prevention of Future Deaths report View report

30 Dec 2024 Cornwall and Isles of Scilly G. Davies

Michael Ramon Jervis died at Royal Cornwall Hospital Truro on 16 July 2023 from neutropenic sepsis, a recognised complication of chemotherapy for testicular cancer. The report found a 20-hour delay in administering antibiotics after observations indicated they were required, and identified the absence of a digital alert that could have alerted staff to implement the Sepsis Six bundle.