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Sasha Honey MISHABI · Prevention of Future Deaths report View report

1 Nov 2023 Birmingham and Solihull E. Brown

Sasha Honey MISHABI died at Queen Elizabeth Hospital Birmingham on 18 April 2023 after a cardiac arrest followed by overwhelming bronchopneumonia. He had severe physical and mental health conditions and skin ulcers that were later determined not to have significantly contributed to his death. The inquest identified failures at St Andrew’s Healthcare to complete required pressure-ulcer risk assessments and skin inspections, record them adequately, report lesions, and provide appropriate oversight, as well as failures in governance and serious-incident investigation.

Andrew BOWLES · Prevention of Future Deaths report View report

31 Oct 2023 Birmingham and Solihull A. Samuel

Andrew BOWLES was found face down in a canal on 16 May 2023 after leaving Birmingham City Hospital, where he had been assessed following concerns about his mental health. The medical cause of death was drowning. The principal concern was that the mental health liaison nurse did not have direct access to City Hospital records containing information about command hallucinations and thoughts of self-harm, which may have affected the assessment and potential referral for psychiatric admission.

Shiya Jonathan Barnard Collins · Prevention of Future Deaths report View report

31 Oct 2023 Newcastle and North Tyneside G. Nolan

On 29 April 2022, Shiya Jonathan Barnard Collins sustained a severe leg laceration after kicking a glass door panel and suffered catastrophic blood loss before an ambulance arrived. The principal concern was that the ambulance service’s computer system prevented clinicians from assessing or upgrading the response despite repeated calls indicating that his condition was deteriorating.

Evelyn Ann Burcham · Prevention of Future Deaths report View report

31 Oct 2023 Somerset S. Marsh

Evelyn Ann Burcham, who had dementia and required full care, was tipped from a riser-recliner chair after another resident accessed and operated its remote control while it was unattended. She sustained a severe brain bleed and died ten days later. The principal concern was that the risk of cognitively impaired residents accessing and operating chair controls had not been foreseen, and that the chairs lacked a suitable safety feature to restrict access to the controls.

Eric Sebastian Huber · Prevention of Future Deaths report View report

31 Oct 2023 Exeter and Greater Devon P. Spinney

Eric Sebastian Huber had a history of drug and alcohol use, depression and anxiety, and was considered vulnerable to exploitation and harm. He was discovered deceased on 1 April 2021 after self-inflicted suspension; the report identifies missed opportunities to engage with him, assess his risks and needs, and conduct multi-agency discussions.

Francis Osborne Barnes · Prevention of Future Deaths report View report

27 Oct 2023 Berkshire H. Connor

Francis Osborne Barnes suffered an external iliac artery injury and major haemorrhage during elective hernia repair on 12 March 2022. He underwent amputation at Royal Berkshire Hospital on 14 March and died there on 16 March 2022. The concerns included whether he should have been transferred to a vascular centre sooner, and the Oxford Trust’s failure to investigate, cooperate with other organisations, maintain records, and demonstrate learning from the death.

Geoffrey Alan WHATLING · Prevention of Future Deaths report View report

27 Oct 2023 Norfolk J. Lake

Geoffrey Alan Whatling entered Amberley Hall Care Home for rehabilitation and later became unwell, with deteriorating NEWS2 scores leading to hospital admission on 10 April 2023. He died on 26 April 2023, with the medical cause of death recorded as infective exacerbation of chronic obstructive pulmonary disease, with frailty and old age. Concerns included incomplete food and fluid records, failures to call emergency services when required, inadequate observation frequency, and gaps in care-record documentation and follow-up.

ANDREW ETLERED NICHOLS · Prevention of Future Deaths report View report

27 Oct 2023 Worcestershire N. Lane

Andrew Nichols developed acute disseminated encephalomyelitis after vaccination and spent over a year receiving hospital and neuro-rehabilitation care. His anticoagulation medication was not continued when he was discharged to community care, and he subsequently died from deep vein thrombosis and pulmonary embolism. The principal concerns were unclear responsibility for venous thromboembolism risk assessments between hospitals and community organisations, and inadequate pathways for organisations to identify relevant NICE guidance.

Gerald Roy Cruse · Prevention of Future Deaths report View report

27 Oct 2023 Avon D. Rookes

Gerald Cruse fell from a bed while being assisted to use the toilet in an ambulance cohort area after admission following a fall at home. He sustained multiple rib fractures, a haemopneumothorax and surgical emphysema, later developed pneumonia, and died in hospital. Concerns included inadequate falls-risk assessment and recognition by ambulance staff, a lack of identified learning after investigation, and wider concerns about the organisation of care for older patients requiring both surgical and geriatric medical input.

Kai TAKAGI · Prevention of Future Deaths report View report

27 Oct 2023 Inner West London P. Rogers

Kai Takagi attended Chelsea and Westminster Hospital on 11 June 2021 with severe stomach pain and left before an abnormal blood result, suggestive of acute pancreatitis, was received. The hospital planned to contact him but did not do so, and he was found dead at home on 14 June 2021; the stated medical cause of death was acute peritonitis from a perforated gastric ulcer. Concerns included inadequate tracking and follow-up of patients who leave with outstanding abnormal test results, reliance on oral handover, and incomplete implementation of a clinician-led review system.

Jacqueline Anne CARREY · Prevention of Future Deaths report View report

26 Oct 2023 Milton Keynes T. Osborne

Jacqueline Anne CARREY was admitted to Milton Keynes University Hospital with severe pancreatitis pain, discharged with an excess of medication, and found deceased at home on 25 May 2023; the inquest conclusion was drug related. The principal concern was that risks of medication abuse may not have been clearly recorded or flagged before discharge, raising concerns about medication distribution and patient-record procedures.

Carl FULLALOVE · Prevention of Future Deaths report View report

25 Oct 2023 Cheshire J. Devonish

Carl Fullalove was arrested after being observed jumping on cars, behaving bizarrely and appearing to be under the influence of a substance. He was placed in prone restraint during a search in custody, became non-responsive and suffered cardiac arrest, and subsequently died in hospital. The principal concerns were that signs of acute behavioural disturbance or illness were not recognised, the risks of prone restraint and stimulant drugs were not sufficiently considered, and training did not adequately address calming intervention in an upright position.

Myra Maxfield · Prevention of Future Deaths report View report

25 Oct 2023 Staffordshire and Stoke-on-Trent E. Serrano

Myra Maxfield, aged 89, fell at home, fractured her right hip, and subsequently developed a Grade 4 pressure sore and osteomyelitis. She died in hospital on 12 March 2022 following a further upper gastrointestinal bleed; concerns included delays in pressure-ulcer patients being assessed by the Tissue Viability Team and the lack of weekend availability at Royal Stoke University Hospital.

Federica Cavenati · Prevention of Future Deaths report View report

25 Oct 2023 Inner West London P. Malhotra

Federica Cavenati died on 18 October 2021 after sustaining multiple traumatic injuries from a fall from height while receiving treatment at Chelsea and Westminster Hospital. The report identified contributing service-delivery issues including the absence of recent mental health review, removal of 1:1 mental health observations, and inconsistent antidepressant medication. A substantive concern was the absence in the United Kingdom of intravenous antidepressant medication for patients unable to take it orally for physical reasons.

Bronwen Grace MORGAN (BM) · Prevention of Future Deaths report View report

25 Oct 2023 South Wales Central G. Hughes

Bronwen Morgan, who was under the care of local mental health services, travelled to a hotel on 27 August 2020 and was later found there by emergency services. She was conveyed to hospital, where she died from the toxic consequences of a substance after resuscitation attempts failed. The principal concern was that an online forum and potentially similar sites enabled vulnerable people to discuss, obtain information about, and acquire means for self-harm or suicide.

Frederick POWELL · Prevention of Future Deaths report View report

24 Oct 2023 Lincolnshire P. Cooper

Frederick POWELL died on 6 September 2023 after falling through a glass door at his home and suffering life-threatening injuries from which he did not recover. The inquest raised concern that many properties retained internal glass doors and questioned whether their replacement should be reviewed.

Tracy Gambrill · Prevention of Future Deaths report View report

24 Oct 2023 South Yorkshire (Western) S. Evans

Tracy Gambrill underwent neurosurgery on 7 November 2016 and sustained serious brain injury after excessively deep incisions were made while locating the temporal horn. She died in hospital on 19 November 2016. The principal concern was that it was not current and expected practice to measure the incision from the insular to the temporal horn at appropriate times during the operation.

Jennifer Lydia Campbell · Prevention of Future Deaths report View report

24 Oct 2023 North West Wales K. Robertson

Jennifer Lydia Campbell, aged 73, died on 24 February 2022 after an ERCP referral for obstructing gallstones was not received by the endoscopy department. She became severely unwell and died from infection and pneumonia associated with the obstructing gallstones. The principal concerns were the absence of an investigation into the lost referral, lack of learning or audit to prevent recurrence, and continued reliance on paper-based referrals.

Karlton Donaghey · Prevention of Future Deaths report View report

23 Oct 2023 Newcastle upon Tyne and North Tyneside J. Thompson

Karlton Donaghey, a five-year-old boy, placed a large helium-filled balloon over his head while briefly alone at home on 23 June 2022. He was overcome by helium, suffered a hypoxic brain injury and died in hospital on 29 June 2022; concerns included unrestricted availability of such balloons, limited awareness of their risks to young children, and the absence of a warning on the balloon.

Kirsty Michelle Hendry · Prevention of Future Deaths report View report

20 Oct 2023 Manchester South A. Mutch

Kirsty Michelle Hendry developed headache and vomiting, later deteriorated, and died at Salford Royal Hospital on 11 April 2023. The report describes a subarachnoid haemorrhage caused by a burst aneurysm that was not identified until severe vasospasm and neurological compromise had developed. The principal concerns were limited awareness of the key symptoms in primary care, delayed referral and imaging, and an incorrectly reported CT scan.