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Georgia Dehaney-Perkins · Prevention of Future Deaths report View report

5 Feb 2024 Essex S. Hayes

Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.

Wyllow-Raine Swinburn · Prevention of Future Deaths report View report

3 Feb 2024 Oxfordshire D. Salter

Wyllow-Raine Swinburn became unresponsive at home on 30 September 2022 after being discharged from hospital the previous evening, and died in hospital that day. The concerns related to a seven-minute delay in connecting the 999 call to an emergency call taker and the 31-minute response time for the first paramedic to attend.

Shaun CROSSFIELD · Prevention of Future Deaths report View report

2 Feb 2024 West Yorkshire (Western) A. Brocklehurst

Shaun Crossfield died on 9 August 2022 after his paramotor became uncontrollable during flight and descended in a spiral before impacting the ground. The report raises concerns about damage and repairs to the propeller and control mechanisms, and about the absence of regulatory inspection, certification, licensing and registration for the aircraft type.

Marjorie McEVOY · Prevention of Future Deaths report View report

2 Feb 2024 Liverpool and the Wirral A. Rebello

Marjorie McEvoy died on 21 August 2023 after gastrointestinal haemorrhage following treatment for squamous cell carcinoma, with bronchopneumonia and chronic obstructive pulmonary disease also recorded. The report identified inadequate clinical notation by advanced nurse practitioners, which did not explain her presentation sufficiently to enable escalation of care.

Susan Wendy Bracegirdle · Prevention of Future Deaths report View report

2 Feb 2024 Manchester South A. Mutch

Susan Wendy Bracegirdle, who had limited mobility and lived in a care home, developed a stage 3 pressure ulcer that deteriorated and was associated with osteomyelitis and sepsis. She died in hospital on 9 February 2023 after treatment was unsuccessful. Concerns included inadequate information sharing and joint working between district nurses, care staff, the GP, the family and the Tissue Viability team, which increased the risk that deterioration would not be recognised or managed promptly.

Samuel Thomas Jordan · Prevention of Future Deaths report View report

2 Feb 2024 Exeter and Greater Devon N. Rheinberg

Samuel Thomas Jordan, aged 25, was imprisoned at HMP Exeter and was found hanging in a single-occupancy cell after an incident with his cell mate on 26 March 2020. The inquest concluded that he died by suicide while suffering from mental illness. The jury identified the lack of access to records from a temporary GP practice, including information about his mental health and current medication, as a contributory factor in his death.

Philip David Taylor · Prevention of Future Deaths report View report

2 Feb 2024 North Wales (East and Central) K. Robertson

Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.

Lucas Tyler Pollard · Prevention of Future Deaths report View report

1 Feb 2024 Bedfordshire and Luton S. Cummings

Lucas Tyler Pollard, aged 14, died after sustaining catastrophic injuries in a collision while riding an electric moped on 1 June 2023. Concerns included the failure to dispatch a Critical Care Team promptly, the cancellation of a rapid response vehicle three minutes from the scene under the End of Shift Policy, and the absence of dynamic reassessment despite evidence of his deterioration. The report also raised concern that applying the policy in this way could threaten a patient's life in future situations.

Joy EBANKS · Prevention of Future Deaths report View report

1 Feb 2024 Bedfordshire and Luton S. Cummings

Joy Ebanks lived alone and was found unresponsive at home on 24 May 2023 after taking prescribed oxycodone and pregabalin for pain; she was pronounced deceased at the scene. The medical cause of death was oxycodone toxicity enhanced by pregabalin intake. The report raised concerns about very prolonged prescribing of two dependency-forming drugs, without evidence of a plan to reduce the dosages, and about the limited evidence for their long-term use in chronic pain.

Peter STAJIC · Prevention of Future Deaths report View report

1 Feb 2024 West Yorkshire (Western) C. Oliver

Peter STAJIC died at Calderdale Royal Hospital on 27 February 2022 following a catastrophic haemorrhage after a carotid endarterectomy and subsequent wound infection. The report identifies missed opportunities to recognise a herald bleed and provide specialist vascular intervention, and raises concerns that paramedics had no training or protocol for identifying such a bleed.

Michael Pender and 2 others · Prevention of Future Deaths report View report

31 Jan 2024 Cornwall and Isles of Scilly A. Cox

Michael Pender, Jan Klempar and Paul Mullen drowned at beaches in Cornwall during summer 2020 after entering difficulty in the sea; the beaches would ordinarily have had lifeguards, but none were present at the relevant times following the easing of COVID-19 lockdown restrictions. The principal concerns were difficulties in recruiting and preparing seasonal lifeguards, lack of advance notice to the RNLI about the relaxation of lockdown, difficulties sourcing PPE, and wider uncertainty about responsibility for beach-safety policy and the provision of lifeguards.

Guy Douglas Scotcheford · Prevention of Future Deaths report View report

31 Jan 2024 Cornwall and Isles of Scilly E. Hillson

Guy Scotcheford had a long history of mental health problems and chronic suicidal ideation. He was found deceased at home in a bath on 1 July 2023, and the cause of death was recorded as asphyxiation, with the conclusion of suicide. The report raised concern that an active website provided practical instructions for ending life, including a link to a company supplying relevant equipment for home delivery.

Sylvia Linda WHITE · Prevention of Future Deaths report View report

30 Jan 2024 East Riding and Hull L. Harris

Sylvia Linda WHITE, aged 92, was found pinned to the floor by an overturned wardrobe after an apparent fall or slip on 13 October 2023 and died in hospital on 28 October 2023 from a traumatic subdural haemorrhage. Concerns were raised that hospital discharge summaries did not adequately record her increased frailty and decreased mobility, resulting in insufficient information for carers’ ongoing risk assessments.

Nicolas Gerasimidis · Prevention of Future Deaths report View report

30 Jan 2024 Cornwall and Isles of Scilly A. Cox

Nicolas Gerasimidis had a history of mental illness manifesting as OCD and anxiety, which deteriorated despite referrals and treatment arrangements. He was found hanged at his home address on 3 June 2023, and the inquest recorded a conclusion of suicide. Concerns included community mental health referrals being rejected, shortages of care coordinators and consultants, a one-year waiting list for psychological treatment, lack of hospital bed availability, and shortcomings in information provided to his family.

Shahzadi Khan · Prevention of Future Deaths report View report

29 Jan 2024 Manchester South A. Mutch

Shahzadi Khan was detained under the Mental Health Act after a manic episode with psychotic symptoms and was discharged from an out-of-area private hospital to her family home. Following inadequate discharge planning, communication problems and a failure to arrange the appropriate community care pathway, she deteriorated and took a fatal overdose of prescribed zopiclone at home. The concerns included the effects of out-of-area placements, poor coordination of local care pathways, and insufficient awareness of menopause as a possible factor in mental health deterioration.

Terence Briney · Prevention of Future Deaths report View report

29 Jan 2024 Manchester South A. Mutch

Terence Briney's health deteriorated from July 2022, including weight loss, lethargy and worsening oesophageal function. He was admitted to hospital in March 2023 and died on 17 March after an acute respiratory event caused by aspirating saliva; the principal concern was that symptoms in older people may be attributed to ageing rather than investigated for potentially treatable conditions.

James Stuart Atkinson · Prevention of Future Deaths report View report

26 Jan 2024 Newcastle and North Tyneside K. Dilks

James Stuart Atkinson, who had a known peanut allergy and asthma, died of anaphylaxis after eating a Chicken Tikka Masala pizza containing peanuts from Dadyal Takeaway Restaurant on 10 July 2020. The report identified concerns about the lack of allergen information from the takeaway, the absence of regular allergy reviews, and the failure to locate his Epi-pen during the reaction.

Paul William BRADLEY · Prevention of Future Deaths report View report

26 Jan 2024 Worcestershire D. Reid

Paul William Bradley was diagnosed with renal cancer in July 2019 and died in hospital on 17 May 2023 after the tumour had become metastatic. The report identified missed follow-up after a urology appointment in March 2021, inadequate systems for tracking missed appointments, and insufficient communication between the urology and vascular teams as substantive concerns.

Jeanine Maria HUGGINS · Prevention of Future Deaths report View report

26 Jan 2024 Norfolk S. Goward

Jeanine Maria Huggins, who was being treated for diffuse large B-cell lymphoma, was admitted with neutropenic sepsis, dehydration and acute kidney injury and initially showed clinical improvement. She was found not breathing during the night of 9 May 2022 and could not be resuscitated; the inquest concluded that she died from natural causes, with coronary artery atheroma and lymphoma on treatment recorded as the medical cause of death. Concerns included the absence of a formal risk assessment for patients placed in side rooms, including assessment of their ability to use a call bell or suitable alternatives, and failures to escalate raised NEWS scores in accordance with guidance.

PAUL ANDREW FREAR · Prevention of Future Deaths report View report

26 Jan 2024 Black Country J. Lees

Paul Andrew Frear died at Queen Elizabeth Hospital, Birmingham, from injuries sustained when he entered the carriageway at a pedestrian crossing during a red pedestrian signal and collided with a vehicle. The report raises concern that the junction layout and pedestrian signals were confusing, particularly because indications were positioned only to the pedestrian’s left and were not visible on the opposite side, creating a risk of further deaths.