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Vera SPENCER · Prevention of Future Deaths report View report

11 Nov 2024 Derby and Derbyshire S. Lomas

Vera Spencer fell at home and waited approximately 11 hours for an ambulance before being taken to hospital with a fractured hip and chest infection. Her condition deteriorated after surgery, and she died on 11 December 2023; the medical cause of death included pneumonia and a fall. The principal concern was that people who fall at home may wait many hours for paramedic attendance during periods of ambulance service pressure, with no local out-of-hours falls service to assist them off the floor.

Alexander Rogers · Prevention of Future Deaths report View report

8 Nov 2024 Oxfordshire N. Graham

Alexander Rogers died after jumping from a location in Oxford into the River Thames and suffering a fatal head injury; the inquest concluded suicide. In the preceding days, he had experienced alleged social ostracism, including name calling, targeted behaviour, exclusion and rejection. The report identified concerns that social ostrism among students may pose significant risks to mental health and well-being, including through isolation, shame and worthlessness, although it did not find that this culture specifically caused or contributed to Alexander’s death.

Gemma Louise Helen RALPH · Prevention of Future Deaths report View report

8 Nov 2024 Staffordshire and Stoke-on-Trent D. Howe

Gemma Louise Helen Ralph, a Theatre Support Assistant at Cannock Chase Hospital, died at home on 26 January 2024 after inhaling the anaesthetic sevoflurane without intent to end her life. Concerns remained about the monitoring of sevoflurane bottles and the inability to confirm or refute whether the bottle found at her home originated from Cannock Chase Hospital.

Anne Taylor · Prevention of Future Deaths report View report

8 Nov 2024 Manchester West M. Pemberton

Anne Taylor sustained a head injury after banging her head on a bedside cabinet and falling from a bed during a holiday. After initially leaving hospital before assessment because of waiting times, she returned the next day and was diagnosed with a traumatic brain injury involving bilateral acute subdural bleeding and midline shift; she deteriorated and died on 31 July 2024. Concerns included the lack of consideration of investigations during the waiting period, the absence of evidence that her capacity to leave was assessed, and uncertainty about a new procedure for patients leaving before clinical assessment.

Imogen Heap · Prevention of Future Deaths report View report

8 Nov 2024 Blackpool and the Fylde A. Wilson

Imogen Heap, aged 17, died after ingesting a very large quantity of propranolol, with smaller amounts of fluoxetine and paracetamol, and subsequently suffering propranolol toxicity, bradycardia and cardiac arrest. The principal concern was that propranolol remains widely prescribed, including to young people with anxiety, while the risks of overdose may be under-appreciated.

Lacey May Brookman · Prevention of Future Deaths report View report

8 Nov 2024 Inner South London J. Morris

Lacey May Brookman, aged 11, experienced more than a week of abdominal pain and related symptoms before retrocaecal appendicitis was diagnosed after perforation and abscess formation. She underwent surgery and developed severe complications, including coagulopathy, disseminated intravascular coagulation and multiorgan failure, and died on 4 June 2021. Concerns included difficulty recognising retrocaecal appendicitis, and the availability and use of abdominal ultrasound scanning and training for doctors considering the diagnosis.

Daniel PINKNEY · Prevention of Future Deaths report View report

7 Nov 2024 East Riding and Hull P. Marks

Daniel PINKNEY died after his vehicle aquaplaned on surface water while travelling on the A164 on 19 December 2022, crossed into the opposite carriageway and collided with another vehicle. The principal concern was the need for greater awareness of aquaplaning, reduced speed when surface water is present, and basic knowledge of braking and steering; it was noted that the Highway Code was silent on this matter.

Simon Boyd · Prevention of Future Deaths report View report

6 Nov 2024 Manchester South C. Morris

Simon Boyd, who had reported dizziness, lethargy, sweating and later breathlessness, was found unresponsive at home on 1 June 2024 after an ambulance response was cancelled and a routine same-day home visit was arranged. Attempts to revive him were unsuccessful, and the inquest recorded myocardial infarction, coronary artery disease and hypertension. Concerns included ambulance response times not meeting national targets, potentially misleading NHS Pathways wording about ambulance dispatch, and cancellation of an ambulance response without first discussing this with the caller.

Sarah McGreevy · Prevention of Future Deaths report View report

6 Nov 2024 Inner North London S. Bourke

Sarah McGreevy, aged 37, sustained fatal injuries after falling from her sixth-floor balcony on 16 June 2024. It was found more likely than not that she had climbed onto a wooden box to clear a drainpipe and accidentally fallen. The principal concerns were residents’ practice of climbing onto balconies to clear blocked drainpipes, the associated risk of falls, and the absence of remedial works that could allow the practice to continue.

Audrey Margaret Lambert · Prevention of Future Deaths report View report

5 Nov 2024 Manchester South A. Mutch

Audrey Margaret Lambert suffered an accidental fall at home on 25 March 2024, fractured her right proximal femur, underwent surgery and subsequently had significantly reduced mobility while receiving care at Brinnington Hall. She was found unresponsive on 28 May 2024 and died from pulmonary thromboembolism due to deep vein thrombosis. The concern was that there was no national guidance to help primary care clinicians assess whether anticoagulation should be prolonged for elderly, immobile patients after the standard post-operative course.

Barrie Forster · Prevention of Future Deaths report View report

5 Nov 2024 Cornwall and Isles of Scilly A. Cox

Barrie Forster was assaulted on 20 November 2020 by a person who had been released from custody two days earlier, and the inquest recorded multi-organ failure following acute upper gastrointestinal haemorrhage and craniofacial trauma. The report identified failures to assess the risk posed to Barrie and the suitability of the address where the perpetrator intended to live. It also raised a broader concern about inadequate accommodation for people released from custody, resulting in homelessness or placement in unsuitable premises.

Terence William Gillard · Prevention of Future Deaths report View report

5 Nov 2024 West London J. Mellani

Terence William Gillard was struck by a moving vehicle while crossing the A4 Great West Road at an uncontrolled pedestrian crossing on 11 September 2022. He suffered brain and multiple traumatic injuries and died in hospital on 18 September 2022 from a pulmonary embolism. The concern was that the crossing had no pedestrian traffic lights, demand button or sound signals, and that there was no certainty that proposed safety redesigns would be implemented.

James Patrick Boland · Prevention of Future Deaths report View report

5 Nov 2024 Manchester South A. Mutch

James Patrick Boland, known as Jamie, was found unresponsive at home on 19 June 2024 and died from sepsis caused by acute pyelonephritis, against a background of chronic ketamine use. The report raised concerns that ketamine use can cause severe long-term health problems, that users may perceive it as safer because it is classified as a Class B drug, and that increasing illicit use is linked to potentially fatal health problems.

JAGJEET SINGH · Prevention of Future Deaths report View report

4 Nov 2024 Inner North London M. Lee

Jagjeet Singh, who had a history of intravenous substance misuse and mental and physical health problems, injected heroin after leaving hospital and was found deceased the following day with a syringe nearby. The inquest concluded that the death was drug related, with acute respiratory depression and fatal morphine and methadone toxicity identified as causes. The report raised concerns about the lack of an available mental health bed after medical-ward admissions, resulting in temporary accommodation, eviction and at least one night sleeping rough.

Polly Mary Margaret Friedhoff · Prevention of Future Deaths report View report

4 Nov 2024 Oxfordshire D. Salter

Polly Mary Margaret Friedhoff, aged 81, died at John Radcliffe Hospital on 2 December 2022 from injuries sustained after a collision with a pedal cyclist on the path beside the River Thames at Iffley Lock, Oxford. The principal concern was the safety of pedestrians using a narrow shared path that is frequently used by cyclists, including some travelling at significant speed, creating a risk of serious injury or death.

Henry Joseph GRIERSON · Prevention of Future Deaths report View report

4 Nov 2024 West Yorkshire (Western) A. Brocklehurst

Henry Joseph Grierson was last seen at home on 20 April 2024 before leaving the address, later being found in a wooded area and pronounced dead by paramedics at 10:11 hours. The report raised concern that communication between Huddersfield New College, CAMHS and Recovery Steps was not maintained, leaving the college without awareness of his current mental health and his decision, with his family, to discontinue external support.

Janet Brown Townend · Prevention of Future Deaths report View report

4 Nov 2024 East Riding and Hull S. Middleton

Janet Brown Townend, who had diabetes and other comorbidities, developed an infected foot wound that progressed to sepsis despite hospital treatment, and she died on 15 October 2023. Concerns arose about the care provided by carers, including brief visits, failure to escalate poor nutrition, sickness and early warning signs, inaccurate records, and failure to follow up or escalate refusals of care and medical intervention.

Darren Joseph Hope · Prevention of Future Deaths report View report

4 Nov 2024 Coventry and Warwickshire L. Lee

Darren Joseph Hope died on 3 July 2023 after falling from the 10th-floor building where he lived while on unescorted Section 17 leave. The report identifies concerns about verifying leave conditions, ensuring people on leave can contact the facility, and the ability of the reporting system to identify and address patient-safety issues.

Janet Brown Townend · Prevention of Future Deaths report View report

4 Nov 2024 East Riding and Hull S. Middleton

Janet Brown Townend developed an infected foot wound that progressed to sepsis after an injury, and she died in hospital on 15 October 2023 despite antibiotics, surgery and other treatment. Concerns were raised about the care she received and about the subsequent Safeguarding Adult Review, which was described as lacking professional curiosity, family input, appropriate scrutiny and proper documentation.

Neil Michael YATES · Prevention of Future Deaths report View report

4 Nov 2024 Liverpool and the Wirral A. Bhardwaj

Neil Michael Yates, aged 53, died in a drug-related death; the inquest recorded mixed drug toxicity and bronchopneumonia, with chronic obstructive pulmonary disease and cirrhosis also noted. The substantive concern was delays in information about prescriptions from voluntary and NHS organisations reaching GP surgeries, creating a risk that further medication could be prescribed without knowledge of existing prescriptions.