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Oliver James Billings · Prevention of Future Deaths report View report

28 Nov 2024 Devon, Plymouth and Torbay L. Nicholson

Oliver James Billings, aged 22, was found deceased at home on 6 December 2023 after consuming possibly as many as 266 prescribed 75mg tablets. The report describes concerns that a second prescription was issued without confirming the status of the first, that rapid dispatch limited opportunities to identify or correct the error, and that Oliver was expected to remedy the problem when Pharmacy2U could not be contacted.

Kenneth George Willard KING · Prevention of Future Deaths report View report

27 Nov 2024 Norfolk J. Lake

Kenneth George Willard KING had bilateral leg wounds requiring community nursing care, with delays in some visits and subsequent infection. He was admitted to hospital with cellulitis of both legs and died on 12 November 2023 from septic shock due to bilateral leg cellulitis. Concerns included the absence of a formal structure for physiological observations in community patients and delays in implementing staff training and restrictions on untrained bank staff.

JAY STUART WHITING · Prevention of Future Deaths report View report

26 Nov 2024 Devon, Plymouth and Torbay N. Lane

Jay Whiting, aged 21, died on 7 January 2023 after sustaining fatal injuries when the vehicle he was driving left the road and collided with a mature tree in Plymouth. The report raises safety concerns about mature trees positioned immediately beside Embankment Road, including their potential danger to vehicles and obstruction of pavement users, and notes that Plymouth City Council had not formally assessed the risks or whether action was warranted.

Susan Paley · Prevention of Future Deaths report View report

26 Nov 2024 Manchester South C. Morris

Susan Paley, a resident of Hilltop Court Nursing Home with complex neurological problems and very limited mobility, died after choking on food while eating in bed on 11 May 2024. Concerns included that she had been left without an easily reachable call bell and that care staff did not use a checklist to confirm residents had required aids in place.

Jon-Paul PRIGENT · Prevention of Future Deaths report View report

26 Nov 2024 Derby and Derbyshire P. Nieto

Jon-Paul Prigent died on 30 July 2020 when a soil-laden trailer decoupled from its tractor, overturned, and compressed the car in which he was sitting, causing asphyxiation. The principal concerns were the absence of periodic independent testing for agricultural tractors and trailers, the lack of required safety features to prevent decoupling, and the risks posed by worn, overloaded, and unevenly loaded equipment used on public roads.

Emma Victoria Sanders · Prevention of Future Deaths report View report

26 Nov 2024 Dorset R. Griffin

Emma Victoria Sanders died on 19 March 2023 after being found unresponsive in a hospital toilet with a ligature fashioned from nasal cannula tubing around her neck. The report raised concerns about delays in accessing hospital records and care plans, particularly when patients are placed in cohorting areas, and about the absence of care-plan information from Summary Care Records.

Amy Jade BUTCHER · Prevention of Future Deaths report View report

26 Nov 2024 Suffolk N. Parsley

Amy Jade Butcher was declared deceased on 14 May 2023 after suspending herself with a ligature around her neck during a heightened anxiety crisis. The inquest identified concerns about a confusing, fragmented system for prescribing mental health medication, and about the decision not to prescribe Lorazepam despite its previous effectiveness for Amy.

Elan Gransford Adams · Prevention of Future Deaths report View report

26 Nov 2024 East London N. Persaud

Elan Gransford Adams, a nursing home resident, choked on a burger on 5 February 2024 and died at hospital later that evening. The substantive concerns included poor-quality emergency-call communication, unclear clinical information provided to the ambulance controller, and a faulty resident call bell with limited assurance that staff could hear it during busy periods.

Margaret Mary Feeney · Prevention of Future Deaths report View report

25 Nov 2024 Derby and Derbyshire P. Nieto

Margaret Mary Feeney was found deceased at home after taking excess prescribed medication, with pneumonia also contributing to her death. The principal concern was that prescribing and pharmacy arrangements around longer bank holiday periods allowed excess medication to be supplied to a patient recognised as being at risk of overdose.

Jonathon Paul LAWLOR · Prevention of Future Deaths report View report

25 Nov 2024 Mid Kent and Medway C. Wood

Jonathon Paul LAWLOR was held on remand at HMP Elmley and was found unresponsive in his cell on 19 October 2023. CPR and emergency treatment were provided, but he was declared dead at 11:47 hours; the post-mortem identified cocaine toxicity, and the inquest concluded that he died as a result of an accident. The principal concern was that he had received only two keywork sessions during four months on remand, reportedly because of staff shortages, raising broader concerns about the availability and suitability of keyworking for prisoners.

Jai · Prevention of Future Deaths report View report

25 Nov 2024 Berkshire H. Connor

Jai was a 36-year-old GP who was found deceased on 27 April 2023 and had taken her own life. She had previously received mental health support, but after discharge from hospital no medium- or long-term plan was put in place and she was not under secondary mental health services at the time of her death. The concerns include the absence of a care co-ordinator or key worker after discharge and the continuing inability of teams using different electronic records systems to access each other’s clinical notes.

Dean John Mark Anthony BRAY · Prevention of Future Deaths report View report

25 Nov 2024 Hampshire, Portsmouth and Southampton R. Spearing

Dean Bray died of acute heart failure on 29 December 2021 while in the seclusion room on Hamtun Ward. The report identified failures to adequately monitor and escalate his high respiratory rate, and concerns about the ability to make emergency calls from the observation room and delays accessing the seclusion area.

Jane BENNETT · Prevention of Future Deaths report View report

24 Nov 2024 Nottinghamshire N. Sharma

Jane BENNETT died in hospital on 8 June 2023 after admission with severe respiratory failure and treatment for interstitial pneumonitis. The report states that mould in her council-provided property may have been causal or contributory to her death, and raises concern that mould in other council-owned properties could pose a risk of future deaths.

Colin Wiles · Prevention of Future Deaths report View report

24 Nov 2024 East Riding and Hull S. Robinson

Colin Wiles, who lived alone and experienced self-neglect and hypothermia, was found collapsed at home and died at Hull Royal Infirmary on 27 March 2023. The principal concerns were that no Vulnerable Adult Risk Management meeting was held despite safeguarding concerns, and that excessive ambulance response and hospital handover times caused delays and lost ambulance capacity.

Nicolette Elizabeth McCARTHY · Prevention of Future Deaths report View report

22 Nov 2024 East Sussex M. Spencer

Nicolette Elizabeth McCarthy was detained in a secure mental health unit after attempts to take her life and remained at risk of suicide. On 19 September 2023, she failed to return from a short period of leave and was not promptly treated as absent without leave; the inquest identified failures in systems and procedures intended to ensure her safety. The report raises concerns that smoke-free policies and unclear guidance may increase the risk of self-harm or suicide for mental health patients on unescorted leave.

Muhammad Esmael and Naemat Esmael · Prevention of Future Deaths report View report

22 Nov 2024 Swansea and Neath Port Talbot K. Heaven

On 1 July 2023, a fire started in an upstairs bedroom of a Council-leased property while three-year-old Muhammad Esmael was inside; Muhammad and his father, Naemat Esmael, died in the fire. The concerns included that the two working smoke alarms were not activated by the fire because it was contained in a closed bedroom, and that bedroom items were removed before all investigations were completed, potentially preventing the cause of the fire from being determined.

Edward John Youde Barnard · Prevention of Future Deaths report View report

21 Nov 2024 Inner South London C. Williams

Edward John Youde Barnard was found deceased in a hotel room on 9 January 2024 after taking a substance described as causing a fatal overdose, with the death concluded to be suicide. The principal concern was that a vulnerable young adult obtained a substance licensed for veterinary use from an illicit source, creating a potential emerging risk of its use in suicide.

Dorothy Jennifer Nias · Prevention of Future Deaths report View report

20 Nov 2024 Cornwall and Isles of Scilly E. Hillson

Dorothy Nias was involved in a road traffic collision on the A39 at Devoran, Truro, after confusing the brake and accelerator pedals in her automatic vehicle. She sustained multiple injuries, experienced a gradual deterioration in her condition and died on 6 November 2023; concerns included her continued driving despite prior minor incidents and the absence of a required medical fitness assessment for drivers over 70.

Charlotte Ann ROSCOE · Prevention of Future Deaths report View report

20 Nov 2024 Manchester West M. Pemberton

Charlotte Ann ROSCOE attended hospital with chest pains and was discharged after a VQ scan found no pulmonary embolism. She was found deceased at home the following day; post-mortem examination identified haemopericardium caused by rupture and dissection of the ascending aorta. Concerns included the missed opportunity to detect the aortic dissection by CT, reliance on outdated observations at discharge, and unclear processes for specifying and communicating scan requests with radiology.

Richard William Brookes · Prevention of Future Deaths report View report

19 Nov 2024 Manchester South A. Morris

Richard William Brookes died on 25 January 2024 after intentionally stepping into the path of an approaching train, following a period of mental health crisis and paranoid thoughts. The report raises concerns about the handling of large arrears payments to vulnerable adults, including inadequate records of assessment calls and insufficient ability to audit whether vulnerability-related safeguards were properly considered.