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Margaret Clement · Prevention of Future Deaths report View report

14 May 2024 Lancashire and Blackburn with Darwen C. Long

Margaret Clement, aged 92, died at Royal Blackburn Hospital on 15 June 2022 after developing significant rectal bleeding, vomiting blood and an upper gastrointestinal bleed following hospital admission after a fall. Concerns included inadequate nursing records and handovers, ineffective prioritisation of urgent tasks, failure to seek urgent clinical assistance for significant rectal bleeding, and inadequate assessment of compliance with procedural changes.

Charlie Hopkins and William Robinson · Prevention of Future Deaths report View report

14 May 2024 Surrey A. Crawford

Charlie Hopkins, aged 18, died at the scene of a road traffic collision on 26 September 2021, while William Robinson, aged 17, died in hospital on 4 December 2021 from injuries sustained in the same collision. The court found that excessive speed and alcohol contributed to the collision. Concerns were raised about risks involving young, new drivers and passengers, and about airbag faults not being identified during MOTs and vehicle servicing because of gaps in testing and diagnostic practices.

Carol Ann DIVALL · Prevention of Future Deaths report View report

14 May 2024 East Sussex R. Redman

Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.

Sally Poynton · Prevention of Future Deaths report View report

14 May 2024 Cornwall and Isles of Scilly A. Cox

Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.

Elvon Paul Randolph Morton · Prevention of Future Deaths report View report

13 May 2024 East London G. Irvine

Elvon Paul Randolph Morton, a 38-year-old man with extensive co-morbidity, was admitted to hospital on 6 December 2022 with abdominal pain, vomiting, diarrhoea, dizziness and shortness of breath. He deteriorated and went into cardiac arrest while awaiting a CT scan under sedation; the inquest concluded that his death was caused by the combined effects of septic shock, oxycodone and lorazepam. Concerns included poor documentation of critical decisions, a flawed decision to sedate him, failures to manage workload pressures safely, and inadequate Trust processes for identifying and reviewing serious incidents.

Ben Christopher Harrison · Prevention of Future Deaths report View report

10 May 2024 North Wales (East and Central) K. Robertson

Ben Christopher Harrison, aged 37, died on 18 December 2020 after being found in cardiac arrest with a ligature around his neck while a voluntary inpatient. During resuscitation, an oxygen cylinder's side valve was not opened, so he was ventilated on room air for approximately 5–10 minutes. The principal concern was that the cylinder's two-valve design was confusing and potentially unsafe in heightened situations, despite staff training and repeated similar incidents.

Mr Terence John Manning · Prevention of Future Deaths report View report

10 May 2024 Blackpool and the Fylde A. Cousins

Mr Terence John Manning, a resident of Haddon Court Rest Home, experienced a choking incident while eating a meal on 22 October 2023 and died in hospital on 24 October 2023. The concerns included inaccurate care records caused by carers carrying forward records from other residents, meaning the records did not reflect the food being given to him, and the absence of a Speech and Language Therapy referral despite a known propensity to eat quickly.

Paul Edward DAY · Prevention of Future Deaths report View report

10 May 2024 Derby and Derbyshire P. Nieto

Paul Edward Day was found collapsed and unresponsive in a prison toilet cubicle on 22 March 2017 after exposure to cold running water from a broken pipe. Prison officers did not attempt CPR because they believed he was in rigor mortis; CPR was started about 15 minutes later, but he subsequently died in hospital in the early hours of 23 March. The principal concern was that national prison CPR guidance included rigor mortis as an exclusion, despite prison officers not being trained to recognise it, creating a risk that CPR could be withheld in prisons without 24-hour healthcare staffing.

Samantha Jane ANGEL · Prevention of Future Deaths report View report

9 May 2024 Hampshire, Portsmouth and Southampton S. Whitby

Samantha Jane Angel was found hanged at her home in Hampshire on 16 September 2022. She was under stress related to a work investigation and had discovered that she had been lied to and her money misused, causing great distress. The concerns included delay in resolving the work investigation, the publication of the allegations among colleagues, and the impact of that publication on her distress.

Sean Patrick O’CONNOR · Prevention of Future Deaths report View report

8 May 2024 Inner North London M. Hassell

Sean O’Connor was electrocuted shortly after 10am on 24 November 2021 while changing a heat pump flow switch terminal during work in London. The report raised concern that lone workers might not receive the checks contemplated by the risk assessment, and that routine site discussions should remind workers whether checks are required during the day.

Donna Smith · Prevention of Future Deaths report View report

8 May 2024 Worcestershire D. Reid

Donna Smith was found unresponsive in Worcester city centre on 4 March 2023 and later died in hospital from acute alcohol intoxication. The report raises concerns about the lack of formal written guidance governing communication and responsibilities between the CCTV operator and West Mercia Police, which led to neither making an immediate ambulance call. It also notes that a related Memorandum of Understanding had not been formalised, creating a risk to others.

John William BASS · Prevention of Future Deaths report View report

8 May 2024 Surrey K. Hayes

John William Bass, aged 80, died from head and chest injuries after falling from his bicycle into an approaching vehicle on A217 Brighton Road, Tadworth, on 6 December 2022. Concerns were raised that vegetation narrowing the pavement was not identified as a safety concern and that yearly inspections may be insufficient for a route frequently used by cyclists beside a busy road.

Zarah RAVN · Prevention of Future Deaths report View report

8 May 2024 Surrey K. Hayes

Zarah Ravn, aged 49, was found deceased at home on 3 September 2023 from mixed drug toxicity after consuming unprescribed oramorph and oxycodone alongside prescribed quetiapine. The substantive concerns included failures to carry out regular mental health, physical and medication reviews, inadequate monitoring of those reviews, and a lack of follow-up after HRT was prescribed following a reported deterioration in her mental health.

Bobilya Mulonge · Prevention of Future Deaths report View report

8 May 2024 Manchester South L. Costello

Mrs Mulonge became unconscious after developing laboured breathing on 24 November 2022 and was found in cardiac arrest when an ambulance arrived 72 minutes after the call. She died later that day from congestive cardiac failure against a background of hypertensive heart disease, chronic kidney disease and type II diabetes mellitus; the principal concern was that delays in ambulance response times had not been resolved within target ranges because ambulances could not be cleared from Accident and Emergency departments.

Oliver Walter John Stephen BARNETT · Prevention of Future Deaths report View report

8 May 2024 Cheshire A. Frodsham

Oliver Barnett, aged 17, died on 8 December 2022 from an overdose of illicitly obtained drugs after experiencing drug dependence and previous overdoses. The report identified the absence of residential substance misuse treatment facilities in England for people under 18, leaving children to receive community treatment and placing them at greater risk of relapse and death by overdose.

David RILEY · Prevention of Future Deaths report View report

7 May 2024 Warwickshire L. Lee

David Riley developed a pericardial effusion after atrial fibrillation ablation and later suffered a stroke before dying on 10 June 2023. Concerns included inconsistent decisions about pausing Apixaban, delays in restarting it, inadequate communication and continuity of care, and difficulties using computerised clinical records.

Peter Jason FANNING · Prevention of Future Deaths report View report

7 May 2024 Birmingham and Solihull L. Hunt

Peter Jason FANNING, who had cerebral palsy, severe physical impairment, epilepsy and relied on a gastrostomy feeding tube, experienced repeated tube dislodgements and admissions for replacement. He developed pneumonia and died on 19 December 2023; concerns related to limited availability for complex feeding-tube replacements and maintaining nutrition after dislodgement.

Matthew SCOTT · Prevention of Future Deaths report View report

7 May 2024 Derby and Derbyshire S. Kaushal

Matthew James Scott died on 11 March 2023 after losing control of his vehicle on Station Road, Melbourne, when it hit a lengthy defective and subsided section of road filled with ice. The report identifies concerns that the road defect had not been surveyed or addressed by the date of the inquest, despite concerns raised by police and the highways authority.

Colin Waterhouse · Prevention of Future Deaths report View report

7 May 2024 Manchester South A. Mutch

Colin Waterhouse, who had pancreatic cancer and was receiving palliative treatment, was found suspended by a ligature on 11 September 2023; the inquest conclusion was suicide and the medical cause of death was hanging. The report raised concerns that unsuitable social housing and a difficult digital bidding system affected his health and mental wellbeing, while available support lacked the capacity to help him move and the shortage of housing made alternative accommodation unlikely.

Peter Dickens · Prevention of Future Deaths report View report

6 May 2024 Nottinghamshire E. Didcock

Peter Dickens died at Bassetlaw District General Hospital on 22 January 2022 after choking on a sandwich while a resident at The Beeches. The report identified persistent non-compliance with Eating and Drinking guidelines, inadequate recording and monitoring of mealtime strategies, and apparent failure to provide the support funded for Peter.