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Luke Marshall ALBISTON O'DONNELL · Prevention of Future Deaths report View report

9 Dec 2024 Liverpool and the Wirral A. Bhardwaj

Luke Marshall Albiston O'Donnell was an 8-year-old boy who died in hospital following a fire at his home. The fire began when an e-bike lithium battery ignited after coming into contact with combustible materials, and the battery-cell failure allowed the fire to develop rapidly. The report raises concerns that the public may not appreciate the life-threatening risks of storing e-bikes and similar appliances in domestic properties, and that communication about these dangers may be insufficient.

Champagauri Bhatt and Dipak Bhatt · Prevention of Future Deaths report View report

6 Dec 2024 North London P. Straker

On 29 March 2023, a fire caused by an electrical fault in a tumble dryer led to inhalation injuries and the deaths of Champagauri and Dipak Bhatt. Concerns included moisture ingress into condensate pumps causing faults and fire, and the need for improved data sharing, product safety standards, fire investigation reporting, risk assessment, and appliance identification.

David Stables · Prevention of Future Deaths report View report

6 Dec 2024 South Yorkshire (Western) M. Whittle

David Stables had a history of mental health issues and attended his GP in February and March 2024 with anxiety, sleep difficulties and poor appetite. The inquest concluded that he died by suicide, with bilateral transection of the ulnar arteries and incised wounds to the wrists. The principal concern was that no mental health or medication reviews were recorded between April 2020 and February 2024, and it was unclear whether reviews had taken place but were not recorded or had not taken place when they should have.

Michael John THOMPSON · Prevention of Future Deaths report View report

6 Dec 2024 Birmingham and Solihull L. Hunt

Michael John THOMPSON underwent hindquarter amputation for chondrosarcoma and later collapsed after vomiting; post-mortem examination found an internal hernia through a peritoneal defect, leading to aspiration. Concerns were raised that the peritoneal defect and repair were not recorded in the operation note, and that the Trust’s investigation did not address this issue or adequately support learning from the death.

Mazeedat Adeoye · Prevention of Future Deaths report View report

5 Dec 2024 East London G. Irvine

Mazeedat Adeoye, a two-year-old girl, drowned on 29 January 2022 after falling into a water-filled plastic refuse bin while playing alone and inadequately supervised in a volunteer carer’s garden. The report identifies concerns about failures by local authority child services to arrange appropriate temporary care, as well as concerns regarding police search procedures, social-worker conduct and supervision, and inadequate record-keeping.

William Albert Nairn Lardner · Prevention of Future Deaths report View report

5 Dec 2024 Dorset R. Griffin

On 30 June 2023, 16-year-old William Albert Nairn Lardner was struck by a vehicle that went through a red light while he was crossing Parley Lane near Bournemouth Airport, sustaining traumatic injuries that led to his death. The report raises concerns about unsafe pedestrian access around the airport, including the absence of footpaths and crossing facilities, limited public transport, and safety issues identified after the death that remained unaddressed.

Patricia CURTIS · Prevention of Future Deaths report View report

4 Dec 2024 Cambridgeshire and Peterborough E. Gray

Patricia Curtis underwent complex cardiac surgery and was transferred to Bedford Hospital, where she deteriorated rapidly and died from a haemothorax identified at post-mortem examination. The report states that a haemothorax was not included in the differential diagnosis when clinical signs first appeared. It also raises concern that non-uniform hospital discharge notes may result in essential information being unavailable after transfer between hospitals, potentially delaying life-saving care and treatment.

Dean Martin Ford · Prevention of Future Deaths report View report

4 Dec 2024 East London N. Persaud

Dean Martin Ford died by suicide on 10 March 2024 after leaving home, buying a length of rope, and being found hanging in Bedfords Park, Romford. Concerns included failures by two mental health teams to carry out a holistic risk formulation, an incorrect assessment of his risk as low, and the absence of audits for risk assessments of people referred but not accepted by the mental health and wellbeing team.

Kayleigh Ann MELHUISH · Prevention of Future Deaths report View report

4 Dec 2024 Avon M. Voisin

Kayleigh Ann Melhuish died on 7 July 2022 after being found hanging in her cell at HMP Eastwood Park and later taken to hospital. The report identifies concerns about staff understanding of neurodiversity, completion of ACCT care plans and support actions, use of constant supervision, and a ligature point in Residential Unit 3. The inquest concluded that suspension by a ligature contributed to the death by neglect.

Mnayea ZMF Al Basman · Prevention of Future Deaths report View report

3 Dec 2024 Inner North London I. Potter

Mnayea ZMF Al Basman, who had significant co-morbidities, underwent a right hemicolectomy for caecal adenocarcinoma and died in hospital on 25 March 2024 after developing sepsis and peritonitis caused by an anastomotic leak. Concerns included failure to escalate aspects of his deterioration to the consultant surgeon, insufficient professional curiosity, inadequate overnight observation planning, and a lack of detail in some records. The report also noted that the events preceding his death had not been subject to an internal investigation, providing little reassurance that these matters had been addressed.

Gary Stephen DUNN · Prevention of Future Deaths report View report

3 Dec 2024 East Riding and Hull L. Harris

Gary Stephen DUNN died instantly after his bicycle collided with a left-turning LGV while he was cycling through the Stoneferry Road/Ferry Lane roundabout in Kingston Upon Hull. Concerns were raised about insufficient signage explaining the changed lane arrangements and inadequate signage informing cyclists of an alternative shared pedestrian and cycle path and Toucan Crossing.

Paul Martin GOBELL · Prevention of Future Deaths report View report

3 Dec 2024 Nottinghamshire S. Burge

The supplied text does not describe the circumstances or date of Paul Martin Gobell’s death. It raises concerns about the absence of a welfare check and ACCT after a First Night Interview was missed, communication about cell-sharing risk, and the lack of Probation input into an assessment of his suitability for open conditions.

Norma Ann Patricia Tellam · Prevention of Future Deaths report View report

2 Dec 2024 Cornwall and Isles of Scilly S. Covell

Norma Ann Patricia Tellam suffered a fall causing a proximal femoral fracture and underwent surgery, followed by rehabilitation and further surgery after problems developed with the metalwork. She later suffered an upper gastrointestinal bleed and died on 16 April 2023. Concerns included transfers between hospitals that did not give sufficient weight to continuity of clinical care and did not return her to the hospital responsible for her orthopaedic follow-up.

Gloria Linton · Prevention of Future Deaths report View report

2 Dec 2024 West Yorkshire East O. Longstaff

Gloria Linton became trapped in the aperture of a commode while being assisted by carers, sustaining multiple rib fractures. She died in hospital from pneumonia, with the rib fractures identified as a direct contributing cause. The principal concern was that carers did not use the Rotanda transfer equipment required by her care plan, despite previous reports and reminders that it should be used.

Alfie HINTON · Prevention of Future Deaths report View report

2 Dec 2024 West Yorkshire (Western) C. Keighley

Baby Alfie Hinton died at Airedale Hospital on 10 May 2019 after complete umbilical cord occlusion led to hypoxic ischaemic brain injury. The report describes delays in induction, fetal monitoring, recognition of bradycardia and preparations for birth. Concerns included how maternal risk information was gathered, recorded and communicated, communication between consultants, and the absence of local policy for time-critical situations.

Elton Deutekom · Prevention of Future Deaths report View report

2 Dec 2024 Inner West London F. Wilcox

Elton suffered acute hypoxic-ischaemic injury following a placental abruption during labour and was delivered by forceps at 04:35 on 12 January 2022; despite resuscitation, he was recognised as life extinct at 05:12. The report identifies failures to recognise and respond to abnormal CTG changes, and raises wider concerns about neonatal death referrals, disclosure of evidence, record-keeping, staffing, supervision and CTG monitoring.

Junior George Powell · Prevention of Future Deaths report View report

2 Dec 2024 Inner West London F. Wilcox

Junior George Powell presented with acute abdominal pain and vomiting, was found to have an aortic dissection with reduced blood flow and intestinal ischaemia, and died at St George’s Hospital on 6 September 2021 after his condition deteriorated. The report identified concern that delays in discharging patients awaiting suitable social care can congest hospital admissions, delay assessment and diagnosis of urgent conditions, and increase the likelihood of death.

Keith David FOORD · Prevention of Future Deaths report View report

2 Dec 2024 East Sussex R. Redman

Keith David FOORD died on 3 May 2022 after suffering an acute type A aortic dissection and undergoing emergency repair. The principal concern was that ambulance transfers for aortic dissection requiring emergency surgery should be categorised as category 1 rather than category 2.

Charlie Anthony OWEN · Prevention of Future Deaths report View report

29 Nov 2024 Berkshire R. Simpson

Charlie Anthony Owen was found deceased in his room at Combermere Barracks on 11 September 2023, after previously making and aborting two attempts to end his life in the context of relationship breakdown. The inquest identified concerns about inadequate sharing of risk-management information, insufficient consideration of welfare checks and protective factors on his return to barracks, and gaps in Army training and Vulnerability Risk Management processes.

Raymond Albert Alfred Reid · Prevention of Future Deaths report View report

28 Nov 2024 Devon, Plymouth and Torbay P. Spinney

Raymond Albert Alfred Reid was admitted to hospital with a catheter-related urinary tract infection, developed pressure sores and pneumonia during a prolonged stay, and died on 1 March 2023. The report identified concerns about gaps in pressure sore prevention, monitoring, documentation, nutritional screening, repositioning, wound follow-up and photography.