Search PFD Monitor

Mrs Kathleen Booth · Prevention of Future Deaths report View report

22 Nov 2023 Staffordshire and Stoke-on-Trent E. Serrano

Mrs Kathleen Booth was admitted to hospital after a fall in her garden on 9 June 2023, sustaining a fractured neck of femur. Surgery was delayed for four days and, after the operation, she deteriorated suddenly and died. The concerns included staffing and funding pressures, limited weekend cover, and the potential disadvantage to patients injured on a Friday.

Gareth Michael Etchells-Heights · Prevention of Future Deaths report View report

20 Nov 2023 South Yorkshire (Western) A. Pountney

Gareth Michael Etchells-Heights experienced deteriorating mental health and psychosis before being admitted to hospital and later moved to a step-down bed at Wainwright Crescent. He died there in the early hours of 24 April 2022 after tying a ligature, with the inquest recording asphyxiation by ligature. Substantive concerns included inadequate discharge information, inconsistent review of medical notes, failure to update risk assessments, and inadequate record keeping.

Susan Ann GLADSTONE · Prevention of Future Deaths report View report

20 Nov 2023 Hertfordshire G. Danbury

Susan Ann Gladstone was admitted to Lister Hospital with pyelonephritis and an extremely elevated INR after taking warfarin and recently prescribed tramadol. She died on 8 January 2021; the principal concern was a potentially fatal interaction between tramadol and warfarin that caused exceptional thinning of her blood and brain bleeding.

Raymond Lionel Eggleton · Prevention of Future Deaths report View report

17 Nov 2023 Wiltshire and Swindon D. Ridley

Raymond Lionel Eggleton died in hospital on 25 January 2023 after falling on a medical unit, sustaining a fractured neck of femur and head injuries, and subsequently developing dysphagia, immobility, delirium and aspiration pneumonia. The principal concerns were that his falls risk assessment did not use all available information about his previous falls and postural hypotension, resulting in inadequate supervision, and that the ward lacked sufficient flexibility and resilience to respond dynamically to vulnerable patients’ enhanced care needs, particularly during night shifts.

Glenn Anthony LOCKWOOD · Prevention of Future Deaths report View report

17 Nov 2023 Inner North London I. Potter

Glenn Anthony Lockwood, a known drug user receiving opiate replacement treatment, was found unresponsive after a suspected overdose on 14 April 2023 and later suffered a cardiac arrest. Despite hospital treatment, he died on 2 June 2023; the inquest concluded that his death was drug related, with mixed drug toxicity recorded as the medical cause. Concerns included whether Pregabalin abuse risks were sufficiently monitored and whether prescribing and record-keeping issues had been fully investigated and addressed.

Sarah Elizabeth READ · Prevention of Future Deaths report View report

17 Nov 2023 Lancashire and Blackburn with Darwen C. Long

Sarah Elizabeth Read had a mechanical mitral valve replacement and required intense anticoagulation. During pregnancy, anticoagulation was adjusted and interrupted following a stroke and a decision to terminate the pregnancy; she then suffered another stroke three days later and did not recover. Evidence raised concern that thrombectomy was unavailable in Lancashire after 5pm, with no regional coordination to ensure access to this urgent treatment.

Terence Charles Scott DUNCAN · Prevention of Future Deaths report View report

16 Nov 2023 Berkshire R. Simpson

Terence Charles Scott Duncan died on 30 October 2022 after he ducked under the skeleton of an articulated lorry trailer obstructing a pedestrian crossing and was run over by its rear nearside tyres when the lorry moved off. The concern was that an extended trailer, despite being unloaded, had a significant gap between its sideguards and wheels, potentially providing less protection to pedestrians and cyclists than a fixed trailer of the same length.

Harry College · Prevention of Future Deaths report View report

16 Nov 2023 Lancashire and Blackburn with Darwen K. Bisset

Harry Colledge, an 84-year-old man, died after his bicycle entered a crack in the carriageway on Island Lane, throwing him from the bicycle and causing fatal injuries. Concerns included highway operatives’ ability to identify defects hazardous to cyclists and the adequacy of maintaining road surfacing affected by natural movement and underlying geological features.

John Joseph SINGLETON · Prevention of Future Deaths report View report

16 Nov 2023 Cheshire K. Ainge

John Joseph Singleton, who was serving a prison sentence at HMP Risley, was found hanging in his locked cell on 1 September 2019 and later died in hospital on 10 September 2019. The report identifies concerns about sporadic medication compliance and the difficulty of detecting non-collection of medication, including the lack of an automated warning flag in the SymStone system. These issues were stated not to have caused or contributed to his death.

Lauren Page Smith · Prevention of Future Deaths report View report

15 Nov 2023 Black Country J. Lees

Lauren Page Smith died at home on 6 January 2023 after paramedics attended to reported vomiting, chest pain and arm pain. An abnormal ECG, including an automated report of an anterior infarct, was interpreted as normal, and she declined hospital attendance after being given that incorrect information. The report raises concerns about ECG interpretation, training and assessment, and the absence of further action or safeguards addressing identified competency and patient-safety risks.

Madeleine Eve SAVORY · Prevention of Future Deaths report View report

15 Nov 2023 Suffolk D. Stewart

Madeleine Savory, aged 15, died on 26 February 2022 after being found ligatured in a bathroom on Bergholt Ward at Ipswich Hospital, following a period during which their whereabouts were unknown. The substantive concerns included the availability of Tier 4 paediatric mental health beds, failures in risk assessment and communication, ward staff understanding of risk, and the implementation of a school safety plan.

Calogero Di Blasi · Prevention of Future Deaths report View report

15 Nov 2023 Avon D. Rookes

Calogero Di Blasi was referred for possible stomach and bowel cancer and underwent investigations including endoscopies and a CT scan. During a further endoscopy, a gastric varix was mistaken for an abnormal area and biopsied, causing a massive bleed; he died on 1 December 2022. The concerns included communication failures between specialist teams, insufficient timeframes for reviewing investigations on the urgent cancer pathway, and limitations in endoscopist training for recognising less common lesions.

Ocean-Leigh Pauline Jean Hayes · Prevention of Future Deaths report View report

15 Nov 2023 South Wales Central R. Knight

Ocean-Leigh Pauline Jean Hayes was aged 4 months when she died at home on 22 December 2021 after co-sleeping with her mother. Concerns included health visitors not always physically reviewing infant sleeping arrangements and potential missed opportunities to risk assess bedding, positioning and other co-sleeping arrangements, and to advise parents about risks.

Lynda BLACKMORE · Prevention of Future Deaths report View report

15 Nov 2023 South Wales Central G. Hughes

Lynda Blackmore had established heart failure and diabetes and developed a painful, bruised and swollen left leg. After becoming acutely unwell, she experienced a delay of about 13 hours before an ambulance took her to hospital, where she was diagnosed with sepsis and died later that day. The principal concern was that ambulance response times were affected by mis-categorisation, resource availability and hospital handover delays, posing a risk to people requiring emergency treatment or hospital conveyance.

Maxwell Frame · Prevention of Future Deaths report View report

14 Nov 2023 West Yorkshire (Western) P. Merchant

Maxwell Frame presented with sepsis caused by a pelvic abscess and bowel obstruction and underwent emergency surgery. A central venous catheter was incorrectly inserted into an artery and was later removed; clot dislodged during removal, causing strokes, after which he received palliative care and died. The report identified concern about the absence of a single national policy for central venous catheter placement.

Gerald Goodwin · Prevention of Future Deaths report View report

14 Nov 2023 Cumbria R. Cohen

Gerald Goodwin, who had Alzheimer’s dementia and had consumed a significant amount of alcohol, was struck by a train while walking along a railway track on 10 November 2022; his death was confirmed at 00:17 on 11 November 2022. The principal concerns were that safeguarding and care-assessment referrals were rejected, closed, or not actioned, with multiple teams and systems failing to communicate effectively and potentially exposing other vulnerable adults to risk.

Roger Adrian Stevenson · Prevention of Future Deaths report View report

13 Nov 2023 Mid Kent and Medway J. Dillon

Roger Adrian Stevenson was found deceased in supported accommodation on 2 May 2022, having last been known to be alive on 30 April 2022; the medical cause of death was fatal toxic morphine intoxication. The report identified concerns that Roger had become lost to mental health services, including a lack of follow-up, delays in care-coordinator allocation, insufficient continuity between services, and limited long-term support for cyclical mental ill health.

Igor Kacper SZALAPSKI · Prevention of Future Deaths report View report

13 Nov 2023 Inner North London M. Hassell

Igor hanged himself in his room at a hostel for homeless young people on 30 April 2023. Concerns included failures to re-contact the crisis team after staff found him drowsy and incoherent, insufficient meaningful staff contact and welfare checks, inadequate engagement with partner agencies and family contact, a lack of self-harm and suicide awareness training, and a chaotic hostel culture.

Bavaniamma Theiventhiran · Prevention of Future Deaths report View report

13 Nov 2023 Surrey A. Crawford

Bavaniamma Theiventhiran, aged 80, fractured her left neck of femur in a fall at home on 26 February 2023 and was admitted to East Surrey Hospital. Although there was no clinical reason to delay surgery, it took place on 2 March 2023, and she died at the hospital on 6 March 2023 after developing acute kidney injury. The Coroner was concerned that East Surrey Hospital was not meeting recommended surgery timeframes for over half of patients with fractured neck of femur, placing such patients at risk of early death.

John Paul Pace · Prevention of Future Deaths report View report

13 Nov 2023 Essex J. Mellani

John Paul Pace was serving a prison sentence at HMP Chelmsford and was receiving methadone as part of a drug detoxification programme. He stopped taking methadone before completing the programme and was found unresponsive at the prison on 22 July 2020; the post-mortem examination concluded that the likely medical cause of death was synthetic cannabinoid misuse. The principal concern was that a new discharge pathway for prisoners who stopped or completed methadone detoxification had not been documented in policies or procedures, creating a risk that monitoring and support would not be provided consistently.