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Michael HUGGON · Prevention of Future Deaths report View report

8 Jul 2024 Cumbria N. Shaw

Michael Huggon, who had declining health and profound anaemia, became seriously unwell on 6 February 2024. After delays in obtaining urgent medical assistance and a hospital admission was declined, he collapsed in cardiac arrest shortly after midnight and died in hospital on 7 February 2024. The principal concerns were delays and an inadequate handover in responding to the urgent request for help, with concern that earlier assessment and admission might have enabled a blood transfusion and prevented his death.

Harry Peter DUNN · Prevention of Future Deaths report View report

4 Jul 2024 Northamptonshire A. Pember

Harry Peter Dunn died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The report raised concerns about the unavailability and delayed response of ambulance resources, including delays caused by lengthy hospital handovers, and the continuing risk of future deaths from these delays.

Harry Peter DUNN · Prevention of Future Deaths report View report

4 Jul 2024 Northamptonshire A. Pember

Harry Dunn died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The principal concern was that diplomatic personnel based at RAF Croughton were not provided with driver familiarisation or training, and that subsequent training may not have specifically covered the risks of wrong-way driving.

David John Morris · Prevention of Future Deaths report View report

4 Jul 2024 East London G. Irvine

David John Morris, aged 78, developed oesophageal cancer after delays in diagnosis and treatment, later undergoing gastrostomy surgery. He developed a gastrostomy leak, peritonitis and septic shock, and died in hospital on 16 May 2022 after further surgery. The concerns included delayed recognition and treatment of the leak and sepsis, poor clinical records, deficiencies in the investigation, and ineffective controlled-drug management systems.

Michael Trevor Walton · Prevention of Future Deaths report View report

4 Jul 2024 Newcastle and North Tyneside G. Nolan

Michael Trevor Walton died on 13 July 2023 after an aortic cannula became dislodged during coronary artery bypass surgery, causing prolonged interruption of blood flow to his brain and an ischaemic hypoxic brain injury. The report raised concerns that supply issues led to the use of a shorter-tip cannula, which contributed to its dislodgement, and that supply shortages may force surgeons to use sub-optimal equipment, creating an avoidable risk of serious harm or death.

Harry Peter DUNN · Prevention of Future Deaths report View report

4 Jul 2024 Northamptonshire A. Pember

Harry Peter Dunn, aged 19, died shortly after arriving at hospital following a head-on collision between his motorcycle and a car on 27 August 2019. The report raises concern that paramedics cannot access nasal or buccal analgesics that may assist with potentially lifesaving pre-hospital treatment or faster patient extraction when time is critical.

Andrew James STORY · Prevention of Future Deaths report View report

3 Jul 2024 Cheshire J. Devonish

Andrew Story died after drowning while swimming in the sea in Rethymno, Crete, on holiday; a UK post-mortem also identified left ventricular hypertrophy. The report raised concerns that the sea was particularly rough, there were no lifeguards on duty, and there were no red warning markers, signs or flags to indicate the danger.

Lee Francis MCHALE · Prevention of Future Deaths report View report

3 Jul 2024 Manchester South A. Mutch

Lee Francis McHale was admitted to hospital on 23 November 2023 after taking paracetamol tablets the previous day and died at Tameside General Hospital on 25 November 2023. The inquest heard that a gap between his housing benefit and rent, arising from the so-called “bedroom tax”, led to rent arrears and a risk of eviction; he was also worried about moving because an adult former foster child lived with him. The principal concern was the impact of housing benefit rules, rent arrears and threatened eviction on his circumstances before his death.

Sonny James FARRIER · Prevention of Future Deaths report View report

3 Jul 2024 County Durham and Darlington J. Chipperfield

Sonny James FARRIER died after being struck by a car while outside a van that had collided with a tree on an icy stretch of Butsfield Lane. The report identified that, in slippery conditions and without effective mitigation, this section of road presents a risk of death to road users.

Ruth Diane Eggleton · Prevention of Future Deaths report View report

3 Jul 2024 Nottinghamshire A. Bewley

Ruth Diane Eggleton fell in her garden on 2 April 2023 and sustained a head injury with a small subdural haemorrhage. She was taking Rivaroxaban, which was not withheld or reversed, and she was discharged from hospital; the report identified concerns about the lack of an evidence-based protocol for managing DOAC anticoagulation.

Arlo River Phoenix Lambert · Prevention of Future Deaths report View report

2 Jul 2024 Nottinghamshire L. Bower

Arlo River Phoenix Lambert died aged 5 days after sustaining a hypoxic-ischaemic brain injury during the intrapartum period. The report describes multiple missed opportunities to deliver him earlier, alongside systemic failings in clinical guidance, escalation, communication and handover. Concerns included a lack of urgency in the Trust’s antepartum haemorrhage guideline and the absence of a clear system for obtaining early reflective accounts from key staff.

James Neil COCKBURN · Prevention of Future Deaths report View report

2 Jul 2024 Manchester South A. Mutch

James Neil Cockburn had severe aortic stenosis and was awaiting assessment for suitability for open heart surgery when he suffered a myocardial infarction and died at home on 26 May 2023. The report identified delays in cardiology appointments and essential tests, together with communication delays between NHS trusts caused by separate IT systems, as substantive concerns affecting treatment planning and decision-making.

Caroline Diane Harris · Prevention of Future Deaths report View report

2 Jul 2024 Oxfordshire N. Graham

Caroline Diane Harris, who had a long-standing diagnosis of severe mental illness, was found deceased at home on 26 July 2023, and a medical cause of death could not be ascertained because of decomposition. Information about her declining mental health, refusal of medication and concerns raised by police was not shared with the Adult Mental Health Team, which limited its ability to supervise and follow her up. The principal concern was that important information was not shared between agencies and that appropriate interventions may consequently not have been made.

Debra BATES · Prevention of Future Deaths report View report

28 Jun 2024 Derby and Derbyshire S. Huntbach

Debra Bates was found dead at home on 15 June 2023. Post-mortem toxicology found prescribed medication at above therapeutic levels, and the evidence indicated that a mixture of medication had an enhanced sedative and respiratory depressant effect. A prior recommendation to change her prescriptions from weekly supplies to a three-day and four-day cycle was not implemented; concerns included the continuation of weekly prescribing and insufficient investigation of how to implement the proposed approach safely.

Emily Rose Collishaw · Prevention of Future Deaths report View report

27 Jun 2024 Outer South London A. Harris

Emily Rose Collishaw, who was aged 35, was found dead in her flat on 6 September 2023 in non-suspicious circumstances. She had alcohol dependency and had been receiving mental health and substance misuse support, but was awaiting an inpatient rehabilitation placement. Concerns included delays and insufficient coordination and support, particularly the prolonged wait for residential rehabilitation and the associated risks to patients.

Paul Byron Holmes · Prevention of Future Deaths report View report

27 Jun 2024 Cornwall and Isles of Scilly S. Covell

Paul Byron Holmes sustained fractured ribs and a fractured sternum in a road traffic collision on 4 April 2022, followed by hospitalisation, delirium, dehydration and declining health. He died at home on 29 May 2022 after returning for palliative care. Concerns included inadequate doctor-to-doctor handover and recording of the treatment plan during a hospital transfer, and a prescription error that delayed intravenous fluids.

Norman Leadbeater · Prevention of Future Deaths report View report

27 Jun 2024 Manchester North C. McKenna

Norman Leadbeater, who had advanced Parkinson’s disease, vascular dementia and presumed liver cancer, developed aspiration pneumonia after being advised to have thickened fluids and died on 14 January 2024. Concerns were identified that his prescribed thickener was not listed on the Medication Administration Record and that his care plan lacked sufficient detail for staff to administer thickened fluids safely and correctly. A recommended audit of medication records had still not been completed four and a half months later, and no completion timescale was provided at the inquest.

John Kenneth PARRY · Prevention of Future Deaths report View report

27 Jun 2024 Leicester City and South Leicestershire C. Mason

John Parry, aged 72, was admitted to Leicester Royal Infirmary on 4 July 2023 after feeling unwell and later suffered two unwitnessed falls. He died on 7 July 2023 after a spontaneous intracerebral bleed was diagnosed. The inquest raised concerns that neurological observations after the falls were not carried out in accordance with hospital policy, the calculations were inaccurate, and a CT head scan that should have occurred within one hour was not performed. A separate concern concerned communication and information-sharing when prescribing warfarin.

Michelle Patricia Moore · Prevention of Future Deaths report View report

26 Jun 2024 Somerset S. Marsh

Michelle Patricia Moore, who had a longstanding history of anxiety and an acute deterioration in her mental health, was found deceased at home on 31 October 2023. The inquest concluded with a short-form conclusion of suicide, with the medical cause of death recorded as compression of the neck and suspension by a ligature. The principal concerns were a lack of continuity and joined-up care between treatment for menopausal symptoms and mental health care, and an apparent absence of guidance, training and policy concerning links between menopause and mental health decline.

Marjorie Joyce Michael · Prevention of Future Deaths report View report

26 Jun 2024 Gwent C. Saunders

Marjorie Joyce Michael fell at a residential home and lay on the floor for over 14 hours while waiting for an ambulance. She was taken to hospital on 4 September 2023 and died on 6 September 2023; the inquest recorded hypostatic pneumonia following the fall and long lie, with her death contributed to by the delayed ambulance response. The report raises concerns about continuing delays in ambulance responses, including delays in releasing emergency ambulances from acute hospitals.