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George Barry Broadhurst · Prevention of Future Deaths report View report

29 May 2024 Manchester South A. Mutch

George Barry Broadhurst sustained a vertebral fracture in an accidental fall, which was not identified on an initial x-ray review. He later deteriorated with a collapsed lung, pulmonary embolism and an infected fractured vertebra, and died in hospital on 10 October 2023. The principal concerns were delays in radiology reporting and review, and insufficient recognition and escalation of concerning pain and deterioration in the community.

Clara Novella Winter · Prevention of Future Deaths report View report

28 May 2024 South Wales Central K. Burge

Clara Novella Winter underwent elective laparoscopic cholecystectomy and subsequently developed an incarcerated ischaemic bowel with perforation, requiring emergency surgery. She died on 19 November 2022 after being unable to recover. Concerns were raised about post-operative care, including the timeliness of escalation and maintenance of fluid balance charts; related staff training had not been fully rolled out because of resourcing issues.

Christine Rita Booker · Prevention of Future Deaths report View report

28 May 2024 Dorset B. Allen

Christine Rita Booker underwent elective right total hip replacement surgery on 23 February 2023 and became critically unwell after extensive bleeding, subsequently dying at Royal Bournemouth Hospital on 24 February 2023. The report raises concern that the lack of out-of-hours interventional radiology at Dorset County Hospital required urgent patients to be transferred, potentially causing significant delays to life-saving treatment and increasing the risk of death.

David SCOTT · Prevention of Future Deaths report View report

26 May 2024 Cheshire C. Keighley

David Scott attended hospital with a non-healing knee wound and was later diagnosed with peripheral vascular disease and chronic limb-threatening ischaemia. His condition deteriorated, requiring an above-knee amputation and other surgery, and he later developed infected ulcers and osteomyelitis before receiving palliative care and dying on 7 October 2023. The principal concern was that vascular calcification visible on an x-ray was not recorded, potentially delaying investigation and treatment of peripheral vascular disease; concerns were also raised about the failure to refer him to tissue viability nursing during wound deterioration.

Oliver Steeper · Prevention of Future Deaths report View report

24 May 2024 Central and South East Kent K. Hepburn

Oliver Steeper choked on finely chopped pasta bolognaise at a nursery on 23 September 2021 and died on 29 September 2021 after suffering a hypoxic/ischaemic brain injury. The report raises concerns about the number and validity period of paediatric first-aid qualifications available at nurseries, the standard of first aid provided, and staff education and systems for assessing and recording babies’ weaning stages.

Jada Monoja · Prevention of Future Deaths report View report

23 May 2024 Inner South London X. Mooyaart

Jada Monoja, who had a history of chronic paranoid and delusional thinking, disclosed suicidal thoughts on 15 November 2020 and was assessed by mental health services before being accepted by the Home Treatment Team. In the early hours of 17 November 2020, he was found unresponsive after leaving home and could not be resuscitated; the inquest concluded that he died by suicide, likely while experiencing delusional and paranoid thoughts. The principal concerns relate to the use of the online risk assessment tool, including assessments being incomplete, insufficiently dated or signposted, and difficult to identify within chronological records.

Emma Louise MORRIS · Prevention of Future Deaths report View report

21 May 2024 Cheshire S. Murphy

Emma Louise Morris died after deliberately walking in front of a bus on 20 September 2023, following a deterioration in her mental health. A mental health practitioner had assessed that inpatient admission was clinically indicated because of an immediate risk to her safety, but no inpatient bed was available. The concern was that pressure on hospital trusts and the lack of available inpatient mental health beds could put future patients at risk of death when admission is clinically needed.

Colin Neil Duncan MCCALLUM · Prevention of Future Deaths report View report

21 May 2024 Cambridgeshire and Peterborough S. Milburn

Colin Neil Duncan McCallum died after his Ford Focus struck standing water on the A1307 in heavy rain, lost control, collided with a stationary vehicle and entered a treeline. The concern was that, unless the risk of flooding or standing water was reassessed and managed or monitored, future deaths could occur in similar circumstances.

Christine MCDONALD · Prevention of Future Deaths report View report

21 May 2024 Cheshire C. Keighley

Christine McDonald died in hospital on 3 March 2019 after being found unresponsive in her prison cell with a ligature. The report identified concerns about failures in communication and information sharing, failure to assess and respond to her healthcare needs, and failures relating to treatment of her drug dependency. The emergency response code was not used, causing delays in providing emergency equipment and medical treatment, although this was not found to have contributed to her death.

Tracy Frances MCCARTHY · Prevention of Future Deaths report View report

21 May 2024 Inner North London I. Potter

Tracy McCarthy was found deceased at home on 17 July 2023 and died from long-term misuse of amitriptyline; the inquest conclusion was a drug-related death, with amitriptyline toxicity and coronary artery disease recorded. The concerns included prescribing amitriptyline above the maximum suggested dose, failure to flag the overdose risk and stop or appropriately manage the prescription, and changing from daily to monthly prescriptions despite recognised risks.

Miriam STONE · Prevention of Future Deaths report View report

20 May 2024 Derby and Derbyshire S. Lomas

Miriam Stone died on 20 February 2022 after being found with a ligature around her neck in a mental health unit on 18 February, following admission after an overdose. The concerns included uncertainty over responsibility for admission tasks during staff handover, a lack of formal policy protecting handover time, inadequate or incomplete risk and safety assessments, and observations that were not individually assessed and were found likely inappropriate.

Sylvia Eileen Evans · Prevention of Future Deaths report View report

20 May 2024 Gwent C. Saunders

Sylvia Eileen Evans sustained an accidental leg wound at home on 5 September 2023, causing severe haemorrhage, and died at home the following day. She called for an ambulance at 22:56, but the call ended abruptly before the nature of her injuries was conveyed. An ambulance arrived at 07:45, almost 8 hours and 49 minutes after the call was registered, and the report identifies hospital handover delay as contributing in part to the delay.

James Furlong and 2 others · Prevention of Future Deaths report View report

20 May 2024 Central Criminal Court A. Fulford

James Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three deaths.

Lily Precious JAHANY · Prevention of Future Deaths report View report

17 May 2024 Leicester City and South Leicestershire F. Butler

Lily Precious Jahany was an 18-year-old medical student with a complex mental health history who died after taking increased doses of medication and suspending herself by a ligature in her student accommodation. The report identified concerns about the lack of first-aid training among student accommodation staff and failures to obtain and share relevant mental-health risk information, including from private clinicians.

Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report View report

17 May 2024 Greater Lincolnshire J. Wilkes

Jonathan Paul Szczepanski had been prescribed Naproxen regularly for several years without a corresponding proton pump inhibitor or medication reviews addressing the risks of long-term NSAID use. He was admitted with symptoms indicative of a gastrointestinal bleed, did not respond to treatment, and subsequently died. The inquest concluded that he died from a duodenal ulcer, to which Naproxen treatment without a corresponding PPI made a contribution. Concerns included a lack of local prescribing guidance, prescribing software without specific NSAID warning flags, and discharge documentation without relevant warnings.

Antony Waring · Prevention of Future Deaths report View report

17 May 2024 Lancashire and Blackburn with Darwen J. Adeley

Antony Waring died on 24 June 2020 after a suprapubic catheter insertion perforated two loops of small bowel, leading to peritonitis, intensive care admission and subsequent death. The concerns included delays in introducing a standard operating procedure, the proposed use of CT scanning rather than ultrasound, inadequate ultrasound training, chance-based allocation of high-risk patients, and inappropriate research about complication risks.

Luke Mikael PEARCE · Prevention of Future Deaths report View report

16 May 2024 Staffordshire and Stoke-on-Trent K. Dixon

Luke Pearce was found hanging in his cell at HMP/YOI Swinfen Hall on 6 April 2023 and was pronounced dead after staff and paramedics performed CPR. The report identified delays in entering the cell, removing the ligature and starting CPR, and raised concerns that relevant emergency training and guidance, including the use of Code Blue and Code Red communications, was not being delivered to appropriate staff in a timely manner.

Gary David Ash · Prevention of Future Deaths report View report

15 May 2024 East London N. Persaud

Gary David Ash died at Queen's Hospital on 25 June 2019 after developing serotonin syndrome shortly after receiving a general anaesthetic without valid consent. He subsequently received large amounts of intravenous fluid, developed fluid overload and pulmonary oedema, and suffered a cardiac arrest. The principal concerns included knowledge and management of neuroleptic malignant syndrome and serotonin syndrome, use of Dantrolene, fluid monitoring, and potential drug interactions affecting cardiac contractility.

Mr Benjamin Sulzbacher · Prevention of Future Deaths report View report

15 May 2024 Manchester North J. Kearsley

Mr Benjamin Sulzbacher had experienced deteriorating mental health and was admitted to a private hospital after attempting to tie a ligature at home. After discharge, no referral was made to the NHS Home Based Treatment Team, and he died after tying a ligature on 27 September 2023. Concerns included uncertainty among services about NHS discharge support for private inpatients and a lack of understanding at the Priory about the community services available.

James Patrick PEARSON · Prevention of Future Deaths report View report

14 May 2024 Birmingham and Solihull R. Ollivere

James Pearson was struck by a vehicle on 14 June 2023 and later died at a hospice on 22 October 2023 after sustaining traumatic and hypoxic brain injuries, developing pneumonia, and experiencing a prolonged hospital admission. The concerns included undocumented observations, insufficient doctor coverage during his deterioration, and the time needed to obtain blood products; the report also states that an opportunity to provide fluids was missed and that this would probably have prevented his cardiac arrest and subsequent hypoxic brain injury.