The Preventable Deaths Tracker Database contains all published coroners’ Prevention of Future Deaths reports (PFDs) in England and Wales from inception (July 2013) and it is updated every Sunday.
There are over 4,500 coroner reports in the Preventable Deaths Tracker database below.
| date_of_report | ref | deceased_name | coroner_name | coroner_area | category | this_report_is_being_sent_to | report_url | pdf_url | reply_urls | circumstances | concerns | inquest | action | response | legal |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 18/09/2023 | 2023-0342 | Amarjit Singh | Ms Mary Hassell | London Inner North | State Custody related deaths | HM Prison Pentonville | Practice Plus Group | https://www.judiciary.uk/prevention-of-future-death-reports/amarjit-singh-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Amarjit-Singh-Prevention-of-future-deaths-report-2023-0342_Published-1.pdf | Mr Singh’s death was epilepsy related. He was found dead in his cell at HMP Pentonville on the morning of 21 November 2021. In the middle of the night his cellmate had rung the emergency cell bell and told the prison officer who came to the door that Mr Singh had suffered a fit. However, the prison officer did not then seek medical attention for Mr Singh and the cell door remained locked shut for the rest of the night. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. There are many issues about which I would have made a prevention of future deaths report, had I not been told that systems have been radically overhauled since Mr Singh’s death. I heard that the environment in which he was not assessed as he should have been upon entry and re-entry to prison, and in which he was never seen medically as a whole person, has completely changed. The prison officer who did not seek medical attention for Mr Singh was investigated and found guilty of gross misconduct. However, some points remain outstanding. 1. The completion of the cell sharing risk assessment was described by the extremely experienced nurse who completed it, as careless. 2. Though I was told that training for prison staff in how to deal with fits is to be given at HMP Pentonville in October 2023, I heard that there is only a hope that prisoners will also receive some guidance in what to do if their cellmate suffers a fit. Apparently, this has already been implemented in HMP Brixton. 3. Whilst the fact that not all prison officers receive ongoing first aid training is a national resourcing issue, the level of first aid understanding of some prison officers at HMP Pentonville seemed surprisingly low. | On 30 November 2021, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Amarjit Singh, aged 41 years. The investigation concluded at the end of the inquest on 8 September 2023. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 November 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. | |
| 19/09/2023 | 2023-0341 | Stewart Stanley | Mr Philip Spinney | Exeter and Greater Devon | State Custody related deaths | Suicide (from 2015) | Exeter Prison | https://www.judiciary.uk/prevention-of-future-death-reports/stewart-stanley-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Stewart-Stanley-Prevention-of-future-deaths-report-2023-0341_Published.pdf | On 23 June 2020 Mr Stanley was remanded in custody to HMP Exeter. On the night of 9 to 10 July, Mr Stanley’s cellmate found him [REDACTED] seemingly trying to hang himself. He alerted prison staff, who started Prison Service suicide and self-harm prevention procedures (known as ACCT). The staff placed Mr Stanley under constant supervision and moved him to a special cell that allowed an officer to observe him continuously. On 11 July, after a case review it was decided that constant supervision should end and directed that Mr Stanley should now be observed at least once every half an hour during the evening. At around 1.20am on 12 July, the night patrol officer, found Mr Stanley hanging. She called for staff assistance and, when it arrived, they opened the cell, removed the ligature and began chest compressions. Paramedics arrived and took Mr Stanley to hospital, where he died on 14 July. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 15 July 2020 an investigation was commenced into the death of Stewart Stanley. | (1) Consideration should be given to reviewing the process of conducting and recording ACCT observations to ensure accuracy and compliance with relevant policy and guidance. (2) Consideration should be given to reviewing staffing levels, retention, and recruitment to ensure the efficient and safe running of the prison. In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th November 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 15/08/2023 | 2023-0340 | Haik Nikolyan | Mr Crispin Giles Butler | Buckinghamshire | State Custody related deaths | Suicide (from 2015) | HM Prison and Probation Service | https://www.judiciary.uk/prevention-of-future-death-reports/haik-nikolyan-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Haik-Nikolyan-Prevention-of-future-deaths-report-2023-0340_Published.pdf | Haik committed suicide [REDACTED] and was found unresponsive in his cell in the early hours of 11th March 2019 at HMYOI Aylesbury (as it then was). | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) HMP Aylesbury transitioned from a High Security Young Offenders Institution (a role it had undertaken for many years) into a Category C Training Prison after the time in which Haik Nikolyan had been an inmate. This has led to a quite different cohort of prisoners with different and additional issues to be addressed in their management and healthcare needs. Staffing changes have also occurred over the period, although the physical prison infrastructure is largely the same with some wing refurbishments being undertaken from time to time. Healthcare provision is also being undertaken by different providers today. Following the conclusion in March this year of an Inquest into the death of another young prisoner, Anthony McNally, at Aylesbury (which occurred in January 2021), a letter was written by me to the Governor in which I noted, inter alia, that the evolution to Category C status required time and resources and was not without significant challenges going forward. I was then (as now) interested to hear that appropriate resources continued to be sought and deployed by the prison to continue the work, from prison and healthcare perspectives, adapting to the Category C status, ensuring the safety and wellbeing of prisoners, staff and those with cause to visit the prison going forward. Some three months further on, my concerns are heightened to the extent that a death may result in a variety of circumstances through the continuing significant issues HMP Aylesbury is encountering in recruitment and retention of experienced prison staff, particularly Grade 3 officers. Although initial steps are being taken towards implementation of a new neurodiversity plan, including the management of prisoners with autistic traits (pertinent to the circumstances of the death of Haik Nikolyan in 2019) and some recruitment has just taken place, without appropriate resources specifically in this area and within the broader staff cohort, there will be difficulties in maintaining this important work. The evidence heard at this Inquest in July 2023 indicates that general staffing levels are likely to impact upon the operation of the daily regime, training and reaction to individual incidents, against a background of increasing levels of violence and access to illicit substances, resulting from the changing cohort of longer-term and older prisoners within this Category C institution. The indication in evidence was that addressing these issues and continuing to address these issues is a matter for His Majesty’s Prisons and Probation Service, working with HMP Aylesbury. | On 15 March 2019 I commenced an investigation into the death of Haik Patrick NIKOLYAN aged 21. The investigation concluded at the end of the inquest on 12 July 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 15/09/2023 | 2023-0339 | Riya Hirani | Ms Mary Hassell | London Inner North | Child Death (from 2015) | Department of Health and Social Care | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/riya-hirani-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Riya-Hirani-Prevention-of-future-deaths-report-2023-0339_Publication.pdf | Riya died in Great Ormond Street Hospital, having been transferred there from Northwick Park Hospital in Harrow after she presented in cardiac arrest on the evening of 23 December 2023. However, by that point Riya’s condition was irretrievable, and she died five days later. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Riya’s mother took her to hospital a full day before Riya’s fatal collapse, because she believed that Riya was very sick. Unfortunately, the junior doctor who examined and assessed Riya failed to appreciate the severity of her condition. Instead of giving her intravenous antibiotics and admitting her to hospital, he diagnosed a virus and discharged her with advice to take over the counter painkillers and a sheet describing the management of sore throats. I intend to make a PFD report to the medical director of Northwick Park Hospital about the diagnosis and treatment of Riya’s condition. However, I am writing to you both because it seems to me that there is a fundamental issue regarding the lack of appropriate diagnosis and treatment that is apparent locally but relevant nationally. When Riya’s mother took her to hospital, she did so because it seemed to her that this illness was qualitatively very different from any other that Riya had suffered in her nine years. In short, Riya’s mum was convinced that Riya was extremely ill, she articulated clearly and at every stage in hospital why she thought that Riya was extremely ill, and she even questioned the doctor about whether this could be a group A streptococcal infection. (There was a well publicised outbreak at the time and the hospital had actually received an alert about this.) I heard at inquest that, even in the middle of the night, there was a consultant available to give a second opinion if this had been requested by medical personnel. However, no thought was given to seeking a second opinion. I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation. One of the reasons that coroners are local to an area is because this makes them better placed to recognise any local trends. | On 30 December 2022, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Riya Hirani, aged 9 years. The investigation concluded at the end of the inquest yesterday. I made a narrative determination, a copy of which I attach. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 November 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. | |
| 17/09/2023 | 2023-0338 | Kimberley Sampson and Samantha Mulcahy | Ms Catherine Judith Wood | Kent Central and South East | Hospital Death (Clinical Procedures and medical management) related deaths | Royal College of Obstetricians and Gynaecologists | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/kimberley-sampson-and-samantha-mulcahy-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Kimberley-Sampson-and-Samantha-Mulcahy-Prevention-of-future-deaths-report-2023-0338_Published.pdf | S The circumstances in relation to Kimberley Sampson’s death were that she had been fit and well when she became pregnant in 2017. She underwent a caesarean section for failure to progress on 3 May 2018 which was complicated by some bleeding. She went home on 5 May 2018 but was readmitted to Queen Elizabeth the Queen Mother hospital on 10 May 2018 with signs of sepsis and she was treated with broad spectrum intravenous antibiotics. An abdominal collection was drained on 12 May 2018 by way of a laparotomy. Some samples sent to the laboratory had grown gram positive bacteria and she was treated and her antibiotics were adjusted. She became more unwell on 16 May 2018 and her liver was showing signs of failure and a further laparotomy was performed which was essentially negative. She continued to deteriorate and by 18 May 2018 discussions were held with Kings College hospital and advice given by them to commence Acyclovir and she was transferred to Kings College hospital liver unit the following day. By this stage she was 16 days post delivery and showing signs of multiple organ failure with cardiovascular instability, respiratory and liver failure as well as a severe coagulopathy and signs of acute kidney injury. Despite full resuscitative measures including ECMO she died from multiple organ failure as a consequence of her disseminated herpes simplex infection on 22 May 2018. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 12 November 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | ||
| 19/09/2023 | 2023-0337 | Stephen Cassidy | Dr Simon Fox QC | Avon | Alcohol, drug and medication related deaths | Care Home Health related deaths | Digital | North Bristol NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/stephen-cassidy-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Stephen-Cassidy-Prevention-of-future-deaths-report-2023-0337_Published-1.pdf | In 2018 Barnet Hospital in London found Mr Cassidy to be allergic to Ceftriaxone and recorded this fact in his Summary Care Record (an electronic patient record). Mr Cassidy appears to have been unaware of his allergy – probably because he experienced it during a period of encephalitis such that he had no clear memory of it. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. a) There is no provision for clinical staff at SMH to access patients’ Summary Care Record routinely or easily; b) This is despite provision existing for SWAS clinical staff to do so before a patient arrives at hospital; c) There is no provision for the Summary Care Record to be integrated with SMH’s hospital electronic patient record (known as Careflow/Connect) or the primary care electronic patient record (known as EMIS – Egton Medical Information System) – such that the Ceftriaxone allergy automatically appears in SMH’s electronic patient record; d) As a result hospital doctors are ignorant of important clinical information on the patients they are treating; e) This can lead to avoidable patient harm including death. | On 10th March 2023 I commenced an investigation into the death of Stephen William Cassidy. The investigation concluded at an inquest on 18th September 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 14th November 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 18/09/2023 | 2023-0336 | Anthony Friend | Mr David Donald William REID | Worcestershire | Care Home Health related deaths | Bluebird Care | Herefordshire and Worcestershire Health and Care NHS Trust | Divine Health Services | https://www.judiciary.uk/prevention-of-future-death-reports/anthony-friend-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Anthony-Friend-Prevention-of-future-deaths-report-2023-0336_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/Anthony-Friend-Prevention-of-future-deaths-report-2023-0336b_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/Anthony-Friend-Prevention-of-future-deaths-report-2023-0336c_Published.pdf | In answer to the questions “when, where and how did Mr. Friend come by his death?”, I recorded as follows: “On 17.4.23 Anthony Friend, who was living with the effects of a brain tumour and required regular personal care visits at his home in Bromsgrove, sustained a significant head injury after slipping through a sling while being hoisted from a chair to his bed, and striking his head on the frame of the hoist. He was discharged from hospital back home for palliative care, and declined and died there on 20.4.23. The sling being used at the time of the fall had previously been adjudged unsuitable for his care needs, but it was not removed from his property, and no instruction had been given that its use should cease.” | On 25 April 2023 I commenced an investigation and opened an inquest into the death of Anthony John Friend. The investigation concluded at the end of the inquest on 5 September 2023. The conclusion of the inquest was that Mr. Friend died as the result of an accident. | In my opinion action should be taken to prevent future deaths and I believe you, as the Director of Bluebird Care, have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 November. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 22/08/2023 | 2023-0335 | Lawson Bond | Mr David Donald William REID | Worcestershire | Child Death (from 2015) | Other related deaths | Wychavon District Council | https://www.judiciary.uk/prevention-of-future-death-reports/lawson-bond-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Lawson-Bond-Prevention-of-future-deaths-report-2023-0335_Published.pdf | In answer to the questions “when, where and how did Lawson come by his death?”, I recorded as follows: “On 28.3.22 Lawson Bond was attacked and mauled by an adult Rottweiler at his home in Egdon. The Rottweiler was in a field at the address, to which Lawson had gained access from his garden by climbing a gate and unhitching a security chain. He was taken to Worcestershire Royal Hospital, and then to Birmingham Children’s Hospital, where he died from his injuries on the morning of 30.3.22.” The Rottweiler which mauled Lawson was one of eight adult Rottweilers kept by Lawson’s grandmother [REDACTED]. For many years, had been running a business breeding Rottweilers and advertising Rottweiler puppies for sale. She ought to have obtained a licence to carry out these activities, as per The Animal Welfare (Licensing of Activities Involving Animals) (England) Regulations 2018, but had never had one. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – | On 22 April 2022 I commenced an investigation and opened an inquest into the death of Lawson Bond, a child of 2½ years of age. The investigation concluded at the end of the inquest on 21 August 2023. The conclusion of the inquest was that Lawson died as the result of misadventure. | In my opinion action should be taken to prevent future deaths and I believe that you, as Chief Executive of Wychavon District Council, have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 November 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 15/09/2023 | 2023-0334 | Eclipse Morrison | Mrs LINDA KAREN HADFIELD LEE | Warwickshire | Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths | George Eliot Hospital NHS Trust, Nuneaton, Warwickshire | The Secretary of State for Health and Social Care | Royal College of Midwives | Royal College of Obstetricians and Gynaecologists | The National Institute for Health and Care Excellence | https://www.judiciary.uk/prevention-of-future-death-reports/eclipse-morrison-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Eclipse-Morrison-Prevention-of-future-deaths-report-2023-0334_Publised.pdf | The deceased died at 28 hours and 12 minutes on 21 July 2021 at Nottingham City Hospital. She had been transferred from the George Eliot Hospital NHS Trust (GEH) following her birth on 20 July 2021. Prior to Eclipse’s birth, her mother had received ante-natal care at GEH and was receiving treatment for Gestational Diabetes Mellitus. | Eclipse Morrison died on 21 July 2021, the day after her birth on 20 July 2021. A referral was made to the coroner on 27 July 2021 and an investigation commenced into the death of Eclipse Morrison aged one day. The investigation concluded at the end of the inquest on 28 July 2023. The conclusion of the inquest was a narrative conclusion: Eclipse Morrison died from Perinatal Asphyxia. Her mother had been diagnosed with Gestational Diabetes Mellitus (GDM) after a blood test at 21 + 4 weeks. The mother’s blood glucose levels remained high throughout the pregnancy with the insulin dose being increased at each diabetic review. Serial growth ultrasound scans identified that Eclipse’s growth was above the 95th customised centile and at the last scan at 37 + 3 weeks showed increased growth velocity. The mother went into spontaneous labour at 38 + 1 weeks and there was a shoulder dystocia during which there was a fracture of the humerus. Eclipse weighed 5,800g at birth and showed no signs of life. Her Apgar scores were zero at 1, 5 and 10 minutes. Advanced resuscitation was carried out and Eclipse was transferred to the regional neonatal intensive care unit in Nottingham. Eclipse had cardiomegaly as a result of the GDM and her condition was unstable. | In my opinion action should be taken to prevent future deaths and I believe that the addressees have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 10 November 2023. I, the assistant coroner, may extend the period. | |||
| 14/09/2023 | 2023-0333 | Richard Griffiths | Ms Kate Robertson | North Wales (East & Central) | Suicide (from 2015) | Wales prevention of future deaths reports (2019 onwards) | Betsi Cadwaladr University Health Board BCUHB | https://www.judiciary.uk/prevention-of-future-death-reports/richard-griffiths-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Richard-Griffiths-Prevention-of-future-deaths-report-2023-0333_Published.pdf | The circumstances of the death are as follows : Richard Griffiths moved home to the Conwy area from South Gwynedd in October 2022 to live with his mother. He was under the care of the South Gwynedd Community Mental Health Team. For reasons unknown the transfer of care did not occur. Sadly, on 26 March 2023 he was found suspended [REDACTED] . Once he was found he was cut down and the emergency services were also called. He was pronounced deceased at the location. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 30 March 2023 an investigation was commenced into the death of Richard Geraint Griffiths (DOB 12/1/70) who died on 26 March 2023. The investigation concluded at the end of the inquest on 14 September 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 9 November 2023. I, Kate Robertson, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 14/09/2023 | 2023-0332 | Marcel Wochna | Mr Jason Pegg | Hampshire, Portsmouth and Southampton | Child Death (from 2015) | Other related deaths | Hampshire & Isle of Wight Constubulary | https://www.judiciary.uk/prevention-of-future-death-reports/marcel-wochna-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Marcel-Wochna-Prevention-of-future-deaths-report-2023-0332_Published.pdf | Two police officers attended Cobden Marina located on the River Itchen during the early hours of 8th November 2021. It was a dark, cold night, the river temperature was 12 degrees Celsius. The pontoon was unstable causing it to wobble. The police officers found the deceased and another young male on a moored boat. | During the course of the investigation and inquest the evidence revealed matters giving rise to concern in relation to Hampshire & Isle of Wight Constabulary police officers. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. Lack of awareness of Cold Water Shock and the associated immediate risk to life; 2. Lack of awareness of the recognised “Shout, Reach, Throw, Row, Go” procedure ; 3. Lack of awareness of risks associated with the use of handcuffs, particularly so to the rear, when detaining a person near water; Absence of effective dissemination, access and awareness of the Hampshire Constabulary “Working near Water Procedure” and the risks, mitigations and the need for necessary dynamic risk assessments set out therein. | On 17th November 2021 I commenced an investigation into the death of Marcel Maksymilian WOCHNA aged 15. The investigation concluded at the end of the inquest heard between 4th and 13th September 2023 sitting with a jury. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 8th November, 2023. I, HM Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 08/09/2023 | 2023-0331 | Kristopher Tilbury | Mr Jonathan D P Stevens | Hertfordshire | Alcohol, drug and medication related deaths | State Custody related deaths | https://www.judiciary.uk/prevention-of-future-death-reports/kristopher-tilbury-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Kristopher-Tilbury-Prevention-of-future-deaths-report-2023-0331_Published.pdf | The circumstances of death recorded by the jury at the inquest were that Kristopher Corey Jamie Lee Tilbury died of respirato sion as a consequence of smoking [REDACTED] and consuming alcohol whilst detained in his prison cell at HMP The Mount between the evening of 23rd September/early morning of 24th September. He was found with a mobile phone in his hand and drug paraphernalia nearby in his cell with the smell of [REDACTED] in the air. The jury also recorded that despite Mr Tilbury’s known drug and alcohol issues and residing on the prison’s additionally supported Wellbeing Wing, drug paraphernalia was found in his cell including [REDACTED] and evidence of ‘shamboiling’. | Mr Tilbury was serving an 8 year prison sentence. At the inquest evidence was heard from his Probation Officer/Prison Offender Manager that Mr Tilbury recognised and accepted that his drug and alcohol issues had been the trigger to his offending and that he was keen to get support to help him address these issues so that he could rebuild his life upon release. He was placed on the ‘Wellbeing Wing’ so he could have better support for his issues. During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 24th September 2019 Senior Coroner Geoffrey Sullivan commenced an investigation into the death of KRISTOPHER COREY JAMIE LEE TILBURY [age 29). The investigation concluded at the end of a jury inquest on 31st August 2023. The conclusion of the jury at the inquest was that death was a consequence of smoking [REDACTED] and consuming alcohol whilst detained in prison, to which the availability illicit drugs within the Wellbeing Wing contributed. | In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd November 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 13/09/2023 | 2023-0330 | Melissa Kerr | Mrs Jacqueline F Lake | Norfolk | Hospital Death (Clinical Procedures and medical management) related deaths | https://www.judiciary.uk/prevention-of-future-death-reports/melissa-kerr-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Melissa-Kerr-Prevention-of-future-deaths-report-2023-0330_Published.pdf | Melissa Kerr was admitted to Private Medicana Kadikoy Hospital, Istanbul on 19 November 2019 and underwent surgery to harvest fat from the abdomen, thighs and the jowl area of her face. Ms Kerr was not seen by a surgeon or clinician prior to the 19 November 2019. Evidence revealed that Ms Kerr underwent a limited assessment prior to the procedures. The evidence is that Ms Kerr was provided with limited information regarding the risks and mortality rate associated with the procedures. The fat was collected and processed before it was injected into her buttocks; a liposuction procedure and a Brazilian Buttock Lift procedure. During surgery Ms Kerr became unwell. Her condition deteriorated and she was declared dead. There is limited documentary evidence as to the procedures performed. Expert evidence was heard that certain techniques used during the Brazilian Buttock Lift procedure increased the risk of fat embolus occurring, namely the choice of access incision for the augmentation cannula and the decision to inject fat into the superficial muscle. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. Expert evidence was heard that the findings in this case are consistent with findings in other cases where patients have died following autologous fat transfer to the gluteal area during an operation colloquially known as Brazilian Buttock Lift. I understand from the evidence heard that due to the high mortality associated with this procedure a voluntary moratorium on the practice of this procedure has been introduced in the UK. Recommendations for safer practices have emerged that recommend significant changes to practice. 2. I am concerned that patients travelling to Turkey for this procedure are not being made aware of the risks and the high mortality rate associated with this surgery 3. I am also concerned that patients are travelling abroad where there are no or limited controls with regard to such surgery taking place. Evidence was heard there Ms Kerr was not seen by a surgeon before the date of the procedure. There was limited psychological and physical assessment prior to the procedure proceeding. 4. I appreciate the UK Government has no control over what happens abroad. However I am concerned that citizens are travelling abroad for such procedures unaware of the risks involved and that practices are used which are regarded as unsafe in the UK. | On 09 December 2019 I commenced an investigation into the death of Melissa Hannah KERR aged 31. The investigation concluded at the end of the inquest on 12 September 2023. | In my opinion action should be taken to prevent future deaths and I believe YOU (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by November 07, 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 01/08/2023 | 2023-0329 | David Andrews | Mr Jacques Howell | Hertfordshire | Road (Highways Safety) related deaths | Hertfordshire County Council | https://www.judiciary.uk/prevention-of-future-death-reports/david-andrews-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/David-Andrews-Prevention-of-future-deaths-report-2023-0329_Published.pdf | On 21 July 2022 I commenced an investigation into the death of David Alistair Andrews, 63. The investigation concluded at the end of the inquest on 14 July 2023. The conclusion of the inquest was road traffic collision. | In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 October 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |||
| 11/09/2023 | 2023-0328 | Amanda Kramer | Mr graeme Irvine | London East | Hospital Death (Clinical Procedures and medical management) related deaths | North East London Foundation Trust | Department of Health and Social Care | Wood Street Medical Centre | https://www.judiciary.uk/prevention-of-future-death-reports/amanda-kramer-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Amanda-Kramer-Prevention-of-future-deaths-report-2023-0328_Published.pdf | Mrs Kramer was a 56-year-old female known to have suffered with depression since the 1990s. She received a diagnosis of schizoaffective disorder in 2009. Mrs Kramer also suffered with Arthritis and Fibromyalgia for which she was prescribed analgesia. Mrs Kramer was noted to have had multiple emergency admissions to hospital [REDACTED] | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. Zoplicone is a drug licenced for the treatment of short-term insomnia. The risks associated with the drug are first, that it is a central nervous system depressant and second, that patients prescribed the drug can form a dependency upon it. 2. Mrs Kramer was prescribed Zoplicone for 18 years. 3. Despite the deceased being under the care of both a GP and a secondary mental health trust prior to her death. No clear evidence emerged in this inquest that anyone had reviewed Mrs Kramer’s use of this drug even when Mrs Kramer had demonstrated a pattern of high-risk behaviour by deliberately overdosing on prescribed medication. | On 31st December 2022, this court commenced an investigation into the death of Amanda Jane Kramer aged 56 years. The investigation concluded at the end of the inquest on 15th August 2023. The court returned a narrative conclusion; | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 6 November 2023 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. htt p:// www .legislation.gov.uk/ ukpga/2009/25/schedule/ S/ paragra ph/7 htt p:/ / www.le gislat ion. gov.uk/ uksi/ 2013/ 1629/ part / 7/ made | |
| 13/09/2023 | 2023-0327 | Geoffrey Hoad | Mrs Jacqueline F Lake | Norfolk | Emergency services related deaths (2019 onwards) | Hospital Death (Clinical Procedures and medical management) related deaths | East of England Ambulance Service NHS Trust | Department of Health and Social Care | Spire | https://www.judiciary.uk/prevention-of-future-death-reports/geoffery-hoad-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Geoffery-Hoad-Prevention-of-future-deaths-report-2023-0327_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/Geoffery-Hoad-Prevention-of-future-deaths-report-2023-0327b_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/Geoffery-Hoad-Prevention-of-future-deaths-report-2023-0327c_Published.pdf | On 3 August 2022, Mr Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad’s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function. | On 17 August 2022 I commenced an investigation into the death of Geoffrey Douglas HOAD aged 85. The investigation concluded at the end of the inquest on 07 September 2023. | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action | You are under a duty to respond to this report within 56 days of the date of this report, namely by November 06, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 12/09/2023 | 2023-0326 | Isabela Suciu | Mr Andrew Harris | London Inner South | Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths | Royal College of Paediatrics and Child Health | British Association Perinatal Medicine | NHS England | Queen Elizabeth Hospital Trust | https://www.judiciary.uk/prevention-of-future-death-reports/isabela-suciu-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Isabela-Suciu-Prevention-of-future-deaths-report-2023-0326_Published.pdf | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday, 7th November 2023. I, the coroner, may extend the period. If you require any further information or assistance about the case, please contact the case officer, [REDACTED]. | |||||
| 12/09/2023 | 2023-0325 | Rashdah Bhatti | Mr John Gittins | North Wales (East & Central) | Emergency services related deaths (2019 onwards) | Wales prevention of future deaths reports (2019 onwards) | Welsh Ambulance Services NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/rashdah-bhatti-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Rashdah-Bhatti-Prevention-of-future-deaths-report-2023-0325_Published.pdf | As detailed in the narrative conclusion the deceased began bleeding from varicose veins and the extent of the haemorrhage was exacerbated by her being on anticoagulants. An initial 999 call was made at 18.25 and over the course of the next two hours there were a further six calls made before a response was allocated, with the first ambulance arrival on scene at 20.36. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On the 16th of June 2022 an investigation was commenced into the death of Rashdah Waseem Begum Bhatti (DOB 19/05/45) who died at her home in Prestatyn on the 14th of June 2022. The conclusion of the inquest on the 11th of September 2023 was by way of a narrative conclusion in the following terms : | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 7th November 2023. I, John Gittins, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 08/09/2023 | 2023-0324 | Cherry Garland | Mr Rob Sowersby | Avon | Hospital Death (Clinical Procedures and medical management) related deaths | University Hospitals Bristol | Weston NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/cherry-garland-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Cherry-Garland-Prevention-of-future-deaths-report-2023-0324_Published.pdf | It is not necessary to give more detail about the circumstances of death in this case, because the issue I am addressing in this report did not contribute to Ms GARLAND’s death – it was ‘incidental’ to her death, but still extremely important. | During the course of the inquest the evidence revealed matters giving rise to concern as follows Background · I heard evidence that when Ms GARLAND was on the Cardiac High Dependency Unit ‘HDU’ (part of the Intensive Care Unit) she was receiving intravenous antibiotics · When she then transferred from HDU to the Cardiac Ward there was a transcription error, and these antibiotics were accidentally omitted from the list of medications that she should be given on the new ward · As a result Ms GARLAND’s antibiotics were discontinued accidentally · I heard (and accepted) evidence that it would have been reasonable to discontinue antibiotics in any event at the time of Ms GARLAND’s transfer · Notwithstanding that fact, I remain deeply concerned by the circumstances in which the error took place My concerns · I heard evidence from an ICU Consultant (who I found to be both a reliable and an impressive witness), who told me, among other things, that: – “… Transcription errors have always been a problem…” the ideal way to get rid of them would be to have a system [in the rest of the hospital] that speaks to ours – The ICU retains lists of its patients’ medication on a computerised/electronic system – The rest of the wards in the hospital do not operate the same system – The available systems do not speak to each other (to put it in somewhat colloquial terms) – Efforts to address that problem have proved fruitless – As a result, every time an inpatient moves from ICU to another department in the hospital, an appropriately qualified member of staff has to physically transcribe that patient’s medication list – With (for instance) 10 patients moving per day, 15-20 medications per patient, and multiple elements for each medication (name; dose; timing; indication; start date; signature etc.), “at a conservative estimate 1,500 to 2,000 elements [are transcribed] daily” (Coroner’s comment: for obvious reasons this creates enormous potential for human error) – There are a limited number of people who can prescribe (and are therefore able to perform this task); in critical care they are the same people who are responsible for providing care – “We really need a second check… funding for more pharmacists… as a Trust we’ve fallen short of ICU national standards for years in terms of the number of pharmacists per bed and medicines reconciliation” – “I spoke to the Chief Pharmaceutical Officer – he has submitted 5 proposals in the last 7 years to try to get the deficit funded… [without success]” In summary, my view is that the circumstances currently in place create a very real (and known) risk that transcription errors will continue to occur. This in turn endangers patients, and creates a risk that people will die in the future as a result of such errors. It is, sadly, very easy to envisage circumstances in which a patient might not receive essential medication at all, might receive the wrong dose of the medication they need, or might receive the wrong medication altogether, because of a transcription error. In my opinion there is a risk that future deaths will occur unless action is taken, and in the circumstances it is my statutory duty to report to you. | On 31 October 2022 an investigation commenced into the death of Ms Cherry Lynne GARLAND, aged 77. The investigation concluded, at the end of a 2-day inquest, on 17 August 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 07/09/2023 | 2023-0323 | Graham Smith | Mr Simon Brenchley | Birmingham and Solihull | Hospital Death (Clinical Procedures and medical management) related deaths | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/graham-smith-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Graham-Smith-Prevention-of-future-deaths-report-2023-0323_Published.pdf | Graham Smith suffered from Myasthenia Gravis, a rare long-term condition that causes muscle weakness and for which he was prescribed Pyridostigmine by his GP. On 1st March 2023 he was admitted to the Emergency Department of the Queen Elizabeth Hospital in Birmingham with suspected biliary sepsis/ascending cholangitis due to an obstructing bile gall stone as well as a bilateral basal consolidation which was revealed by a chest x ray. Whilst in the ED, he was initially prescribed Tazocin for treatment of the sepsis but was then given a dose of Gentamicin which is in fact contraindicated in patients suffering from Myasthenia Gravis. He was not prescribed his normal Pyridostigmine. On 2nd March he was transferred to a Liver ward for further treatment and arrangements were made for him to undergo an Endoscopic Retrograde Cholangiopancreatography Procedure (‘ERCP’) which could not be done until 3rd March. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. During the course of the inquest I heard evidence from the author of a Serious Investigation Report commissioned by the Trust (University Hospitals Birmingham) that the errors with regard to medication were, in part, due to a lack of awareness on the part of clinicians within the Trust as to the seriousness of Myasthenia Gravis as well as the interaction between Gentamicin and this condition. 2. I also heard evidence from the author of the SI report about a comprehensive action plan that is being put in place to raise awareness within the Trust including the development and issue of a Trust wide patient safety notice in relation to Antibiotic Prescribing in patients with Myasthenia Gravis. 3. However, given the apparent lack of awareness about Myasthenia Gravis amongst clinicians within UHB, a large hospital trust in a significant metropolitan area, I am concerned that there is a risk that a similar lack of awareness could persist amongst clinicians in other areas of the country and that consideration should be given to raising awareness more widely. | On 13 March 2023 I commenced an investigation into the death of Graham Thomas John SMITH. The investigation concluded at the end of the inquest on 24th August 2023. The conclusion of the inquest was; | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 November 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 08/09/2023 | 2023-0322 | Lynsey Smalley | Ms Kate Robertson | North West Wales | Other related deaths | Barts Health NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/lynsey-smalley-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Lynsey-Smalley-Prevention-of-future-deaths-report-2023-0322_Published.pdf | The circumstances of the death are as follows : The deceased was aged 42 at the time of her death on 16 May 2021. She had a past medical history of mixed schitzotypal and emotionally unstable personality disorder with traits of Asperger’s syndrome. She had mobility difficulties and required a bariatric bed due to concerns regarding skin integrity. She lived at home with her brother who cared for her. Lynsey Smalley was known to the Community Mental Health Team (CMHT) since 2005 and had a Care Coordinator who was a Community Psychiatric nurse. She was also open to a Psychiatrist and an Occupational therapist. On 6 April 2021 the CMHT were contacted by Lynsey’s brother who was concerned that Lynsey was acting strangely. A second call was made by her brother with concerns that Lynsey had relapsed and was displaying signs of paranoia, auditory and olfactory hallucinations, irritability, poor sleep and isolating herself in a particular room. A further call was made with reported concerns that Lynsey was lighting candles, had not used her prescribed oxygen and had not been eating, drinking, or sleeping for the past 4 days. It was indicated that there were only certain professionals Lynsey would agree to see but that she had agreed to see the care coordinator the following day. The GP prescribed medication and Lynsey’s brother was advised to contact Police if the situation became difficult. There was a total of 4 calls made by Lynsey’s brother to the out of hours crisis team. In addition, Lynsey’s brother contacted the emergency services for assistance. Police officers attended and a CID16 was completed and sent to the CMHT the following morning. By 9.10am on that same morning the CMHT reviewed the out of hours report. The care coordinator arrived at L’s home at 10.30am. Lynsey was reluctant to engage, and her brother reported concerns including that Lynsey had not slept for several nights, was not eating or drinking. He reported the incident overnight where Police had attended. The Care coordinator returned to the office and discussed with a psychiatrist, who agreed to visit that same day and the Advanced MH practitioner to assess and consider admission. After approximately 10 minutes of the care coordinator leaving Lynsey ignited a fire in the property. Emergency services were contacted. Lynsey was taken to Ysbyty Gwynedd, Bangor where she remained until she passed away on 16th May 2021. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows a. The Health Board provided 3 investigation reports into the death, two of which contained conflicting evidence. One responded to Lynsey’s brother’s complaint. It is clear that there was no strategic plan or collaboration in governance processes. Furthermore, there were a number of proposed actions which took nearly two years to identify and complete. The time it took to identify and complete actions, together with governance processes are matters which I have raised previously with the Health Board in previous Prevention of future Death Reports. If there are such disjointed patient safety and governance processes learning will not be effective and deaths will continue to occur or will occur into the future. A number of individuals and organisations are involved in the care of those under mental health teams or at times have contact with patients e.g. CMHT, Home Treatment Teams, Psychiatrists, Occupational therapists, Care Coordinators, out of hours crisis service (local authority based in Gwynedd), Police, Ambulance Service etc. As medical records remain paper based not all individuals or organisations who need to understand a patient’s circumstances/care/treatment are privy to all aspects of care/treatment. In addition, where a CMHT patient is receiving in-patient mental heath treatment the paper notes are transferred to the hospital setting. There is a risk that notes will become lost in full / in part. Having medical records electronically will not only allow full access to all notes to those who require which will inform future care/treatment but will also ensure effective continuity of care, without the risk of missing or lost notes. I have previously issued a Prevention of Future Deaths Report on this point, a copy of which was also sent to [REDACTED] , Health Minister. | On 18 May 2021 I commenced an investigation into the death of Lynsey Sarah Smalley (DOB 6/3/79) who died on 16 May 2021. The investigation concluded at the end of the inquest on 7 September 2023. A narrative conclusion was recorded with the cause of death as:- 1a Septic Shock 1b Airway burns with inhalation injury | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 3 November 2023. I, Kate Robertson, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 07/09/2023 | 2023-0321 | Sultana Choudhury | Mr graeme Irvine | London East | Hospital Death (Clinical Procedures and medical management) related deaths | Barts Health NHS Foundation Trust | Department of Health and Social Care | https://www.judiciary.uk/prevention-of-future-death-reports/sultana-choudhury-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Sultana-Choudhury-Prevention-of-future-deaths-report-2023-0321_Published.pdf | Sultana Choudhury was diagnosed with Diabetes and chronic kidney disease, she agreed to take part in a research project related to these conditions. On 7th December 2022 she consented to undergo a renal biopsy to harvest sample material in furtherance of the research programme. The procedure was completed after two attempts to take tissue. A week later Mrs Choudhury was admitted into hospital with abdominal pain, haematuria, rapidly worsening acute kidney injury and a positive for gram negative rods in blood cultures. Following diagnostic testing and imaging, Mrs Choudhury was admitted for treatment of a queried diagnosis of pyelonephritis and was administered enoxaparin for VTE risk. Mrs Choudhury was not adequately monitored whilst an inpatient. She died following a cardiac arrest in hospital on 17th December 2022. The cardiac arrest was caused by hypovolaemia which, in turn was caused by a undiagnosed renal haemorrhage the result of the renal biopsy 7 days earlier. The haemorrhage was exacerbated by contraindicated VTE prophylaxis. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. The trust’s failure to diagnose an obvious ongoing renal haemorrhage in a patient with; a recent history of renal biopsy, worsening clinical observations in keeping with hypovolaemia and a plummeting haemoglobin count. 2. The clinical decision to administer VTE prophylaxis in the form of low molecular weight heparin on admission to a patient with a patent bleed, evidenced by haematuria. 3. The failure to adequately monitor Mrs Choudhury during her 3-day admission that allowed her to deteriorate into a preventable peri-arrest state. | On 19th December 2022 this Court commenced an investigation into the death of Sultana Razia Choudhury aged 60 years. The investigation concluded at the end of the inquest on 24th August 2023. The court returned a short form conclusion of accident contributed to by neglect. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd November 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. htt p:// www.legislat ion .gov.uk/ ukpga/ 2009/2 5/ schedule/ 5/ parag raph/7 ht tp:// www.legislat ion .gov.uk/ uksi/ 2013/1629/ part /7 / ma de | |
| 06/09/2023 | 2023-0320 | James Jones | Miss Sarah Riley | North West Wales | Hospital Death (Clinical Procedures and medical management) related deaths | Betsi Cadwaladr University Health Board BCUHB | https://www.judiciary.uk/prevention-of-future-death-reports/james-jones-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/James-Jones-Prevention-of-future-deaths-report-2023-0320_Published.pdf | When James Jones was transported to Ysbyty Gwynedd by ambulance on the 27th June 2021, he had a 4-6 day history of abdominal and chest pain with vomiting. He had not opened his bowels for a few days and had reduced urine output. Mr Jones arrived at Ysbyty Gwynedd at 21.33hrs on the 27th June 2021. He was admitted to the Emergency Department’s Red Zone at 22.34hrs and was observed by nursing staff throughout the night. Mr Jones was first seen by a Doctor at 6.18am with the assessment recorded at 07.22am. X-rays were performed and at 7.43am, the suspicion of a small bowel obstruction was confirmed, with evidence of dilated small bowel loops on abdominal Xray. Mr Jones was then referred to the surgical senior house officer who reviewed the X-rays and agreed to further assessment. A decision to perform explorative surgery was made at 12.45pm and Mr Jones was taken to the anaesthetic room in preparation for surgery at 3.20pm. Between his arrival at the hospital and being taken to the anaesthetic room in preparation for explorative surgery, Mr Jones experienced the following delays: – Approximately 10 hours to be seen by a Doctor in the Emergency Department – He was triaged at 22.15hrs on the 27th June 2021 and assigned to triage category 2. The evidence was that the aim is for a Dr to see triage category 2 patients within 10 minutes but the wait for Mr Jones from the point of triage to seeing a Dr was 8.5 hours. – A further four hours for a scan to be performed and the results to be available. – A further 3 and a half hours before he was taken to the anaesthetic room. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Continued pressures within the Accident and Emergency department at Ysbyty Gwynedd will result in: (a) Doctors not having the capacity to review patients in line with the “aim” e.g within 10 minutes for triage category 2 patients. (b) Missed opportunities that may prove fatal (2) Current staffing levels being insufficient to meet demand and safely care for patients Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur. | On 09/06/2022 I commenced an investigation into the death of JAMES JONES. The investigation concluded at the end of the inquest on 30/08/2023. The conclusion of the inquest was: | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd November 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 06/09/2023 | 2023-0319 | Sheila Johnson | Mr Paul Stanford Cooper | Lincolnshire | Care Home Health related deaths | Phoenix Care Centre | https://www.judiciary.uk/prevention-of-future-death-reports/sheila-johnson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Sheila-Johnson-Prevention-of-future-deaths-report-2023-0319_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/2023-0319-Response-from-Phoenix-Care-Centre.pdf | Reported to the coroner by [REDACTED] (Staff Nurse Butterfly Hospice) – Daughter wishing for the coroner to be involved as she believes her mothers death was the consequence of a fall at the care facility. Following fall admitted to Pilgrim Hospital transferred to Hospice. Expected death at the hospice, was admitted on 11-02-2021 I have spoken to the coroners officer [REDACTED] . on 14022021 | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. An inadequate generic falls prevention policy appeared to be in place. 2. Doors to unoccupied rooms were unlocked when they should have been locked. 3.Night light in common places not on. 4. No signage to bell ring in place. 5. Indequate periodic nightly observations recorded at inquest. What adjustments have been made to practice and procedure? | On 19 February 2021 I commenced an investigation into the death of Sheila Rosamund JOHNSON aged 91. The investigation concluded at the end of the inquest on 15 November 2022. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by November 01, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 04/09/2023 | 2023-0318 | Talia Phillips | Mr Stephen Covell | Cornwall and the Isles of Scilly | Alcohol, drug and medication related deaths | Road (Highways Safety) related deaths | The National Institute for Health and Care Excellence | The British National Formulary | https://www.judiciary.uk/prevention-of-future-death-reports/talia-phillips-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Talia-Phillips-Prevention-of-future-deaths-report-2023-0318_Published.pdf | Talia Phillips died as a result of injuries sustained in a head on road traffic collision with an oncoming vehicle. It is likely that she lost control of her vehicle having suffered a cardiac event caused by a significantly elevated level of Fluoxetine in her blood. Evidence from a toxicologist indicated that a chronically high level of fluoxetine may have led to arrhythmia in life and contributed to a collapse at the wheel. Talia was prescribed Fluoxetine by her general practitioner on 22 December 2021 for anxiety. On 31 January 2022 Talia experienced an episode of palpitations and contacted her general practitioner who organised routine blood tests and an ECG. The tests and the ECG were reported as normal, save for slightly low iron levels. The routine tests did not test Fluoxetine levels. | During the course of the inquest, the evidence revealed matters giving rise to concern. in my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows During the course of the inquest I heard that guidance around the prescribing of Fluoxetine did not indicate that fluoxetine levels would should be routinely tested in a patient prescribed Fluoxetine in the event of an episode of palpitations. Such a test may have identified chronically high levels of Fluoxetine. It is requested that guidance in relation to the prescribing of Fluoxetine and management of patients on Fluoxetine should be reviewed to consider in what circumstances a blood test to establish the level of Fluoxetine in the patient’s blood would be advisable. | On 4 August 2022 I commenced an investigation into the death of Talia Evania Phillips. The investigation concluded at the end of the inquest on 9 March 2023. The conclusion of the inquest was a narrative conclusion; | In my opinion action should be taken to prevent future deaths and I believe your organisation the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report,namely by 30 October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 04/09/2023 | 2023-0317 | Emma Morrissey | Ms Jacqueline P Devonish | Cheshire | Other related deaths | Regenesis Health Travel Limited | https://www.judiciary.uk/prevention-of-future-death-reports/emma-morrissey-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Emma-Morrissey-Prevention-of-future-deaths-report-2023-0317_Published.pdf | On 06 July 2022 Emma Louise Morrissey flew to Turkey’s private Termessos Hospital in Antalya for gastric sleeve surgery. Arrangements were made through a health tourism company Regenisis. On 07 July 2022 Emma was operated. The surgeon perforated her abdomen with an instrument. The area was packed to stem the bleed but no platelets for blood clotting were administered causing continued bleeding and her sad death on 08 July 2022 at 12: 45 hours. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 28 July 2022 I commenced an investigation into the death of Emma Louise MORRISSEY aged 44. The investigation concluded at the end of the inquest on 31 August 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by October 30, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 01/09/2023 | 2023-0316 | Harold Pedley | Mr Alan Wilson | Blackpool and Fylde | Hospital Death (Clinical Procedures and medical management) related deaths | Department of Health and Social Care | Lancashire and South Cumbria Integrated Care Board | https://www.judiciary.uk/prevention-of-future-death-reports/harold-pedley-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Harold-Pedley-Prevention-of-future-deaths-report-2023-0316_Published.pdf | In addition to the contents of section 3 above, the following is of note: · This inquest was about a man who, aged 90, died whilst waiting to be seen by a medical professional in hospital. He did not simply arrive at hospital, but had been assessed and then sent there by his GP, who felt, rightly as it turned out, that Derek may have developed an obstruction. He was anticipating Derek would be seen quickly. · He arrived at the Emergency Department, and handed in some paperwork at reception and understandably expected he would not have to wait long to be assessed by doctors who he knew were expecting him. · No-one called for him for almost two hours by which time he had died. · It is correct to say that once a post mortem examination was performed, it was clear that even if he had been assessed immediately upon arrival at hospital his condition was such that surgical intervention was not a realistic possibility and the condition was going to prove terminal. · At the time Derek arrived, as the Hospital Trust’s own internal review of this death explained, such were the pressures on the hospital Trust posed by patient numbers that it was operating at OPEL [Operations Pressure Escalation Level] 4. This is a method used by the NHS to measure the stress, demands, and pressure a hospital is under. OPEL 4 represents the highest level, when a hospital is “unable to deliver comprehensive care, and patient safety is at risk”. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. · Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious risk. · Concern 2 – that there is a risk that the pressures on hospitals become so significant they are used as a default explanation for levels of patient care that fall below what they would wish to deliver. I found that the hospital Trust did not seek to do so in this case, but it seems to me there is a risk this could happen. The pressures are indeed significant, but ultimately this case involves a 90 year old man with what appears to be an acute medical problem finding himself attending his local emergency department, not being spoken to / triaged by a medical professional for almost two hours, and dying by the time he is called for. There is a clear risk that puts patients at risk and it would be remiss of me not to raise it. · Concern 3 – Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been a reluctance on his Friend’s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek’s paperwork and was expecting some assistance imminently which did not arrive. I feel Derek and his Friend thought as they knew doctors had discussed his case with his GP and that his attendance was expected they did not need to raise a concern until it was too late. In actual fact, such are the pressures Emergency Departments are working under, this may not be the case. It is not for me to be prescriptive about what should be done, but unless GPs are provided with a realistic picture about how quickly their patients may be seen once they arrive at hospital (even if they have been in communication with the hospital doctors) their patients may arrive at hospital expecting to be seen quickly, when in reality this may not be the case particularly when the department is under significant pressures. | The death of Harold Derek PEDLEY Otherwise known as Derek PEDLEY on 21.12.22 at Blackpool Victoria Hospital was reported to me and I opened an investigation, which concluded by way of an inquest held on 17th August 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report. Given the approaching holiday period I have extended this period to Friday 27th October 2023. I, the coroner, may extend the period further. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 31/08/2023 | 2023-0315 | Donna Levy | Mr graeme Irvine | London East | Hospital Death (Clinical Procedures and medical management) related deaths | North East London Foundation Trust | London Borough of Redbridge Council | Department of Health and Social Care | https://www.judiciary.uk/prevention-of-future-death-reports/donna-levy-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Donna-Levy-Prevention-of-future-deaths-report-2023-0315_Published.pdf | Donna Levy was housebound. She was admitted to hospital by ambulance as she had become critically unwell. On admission she was observed to present with signs of severe self-neglect. Ms Levy was found to be suffering from a significant number of skin lesions on her chest, armpits, anterior lower legs and the entirety of her posterior lower limbs reaching as far as her sacrum. Ms Levy had moisture lesions on her buttocks and thighs along with an ungradable pressure sore which had become infected. Ms Levy had severely oedematous lower limbs, the skin on her legs and feet had extensive cellulitis which had caused chronic ulceration, discoloration and a tree-bark texture. Her toenails were long, infected and discoloured. The deceased had extensive uterine fibroids that had progressed to the stage that they impeded her mobility and continence. Ms Levy had clinical signs of sepsis and a stage two acute kidney injury. The patient was admitted to hospital by ambulance and underwent surgical debridement of dead ulcerated skin and tissue, following surgery she succumbed to infection despite maximal medical support and died on 14th December 2022. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. Since 2020 Ms Levy had been provided with domiciliary care commissioned by the local authority. At the time of her death twice daily visits were undertaken. Ms Levy was utilising state funded domiciliary care visits to deliver fast food to her home, no personal care was being provided. Carers had escalated to the local authority Ms Levy’s reluctance to accept personal care and raised safeguarding reports regarding Ms Levy’s living conditions. 2. In the two months prior to her final admission into hospital Ms Levy was being regularly assessed by district nurses, the community matron and her GP. Despite the obvious nature of her deteriorating health, no meaningful steps were taken to escalate the care she received to mitigate the risks of her self-neglect. 3. The inquest heard that as Ms Levy was believed to have capacity throughout this period, and consequently it was determined that there were on practical steps that could have been taken to improve the provision of care to her. 4. No formal Mental Capacity Act assessment was ever undertaken or considered. | On 15th December 2022, this Court commenced an investigation into the death of Donna Levy aged 51 years . The investigation concluded at the end of the inquest on 22nd August 2023. The conclusion of the inquest was a narrative conclusion; | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. htt p:/ / www.legislation .gov.uk/ ukpga/ 2009/ 25/ schedule/ 5/ paragraph /7 ht tp :/ / www.legislation .gov .uk/ uksi/ 2013 / 1629/ part / 7/made | |
| 31/08/2023 | 2023-0314 | Nicholas Ledger | Mr Adam Smith | London Inner North | Suicide (from 2015) | College of Policing | Metropolitan Police | https://www.judiciary.uk/prevention-of-future-death-reports/nicholas-ledger-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Nicholas-Ledger-Prevention-of-future-deaths-report-2023-0314_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/2023-0314-Response-from-Metropolitan-Police.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/2023-0314-Response-from-College-of-Policing-.pdf | Mr Leger had been the subject of a Metropolitan Police investigation following a criminal allegation made in March 2022. He was arrested and interviewed under caution at the end of May 2022, following which he was bailed. That bail was converted to RUI (released under investigation) in August 2022. He attended voluntarily a further interview on 5 November 2022. On 23 January 2023, the CPS authorised that he be charged. This led to the generation of a PCR (Postal Charge Requisition) which was posted to him on 16 February 2023. This did not arrive at Mr Leger’s address until after his death. However, Mr Leger learnt of the charge via his solicitor on the morning of 20 February 2023. Sometime between 7:30pm and 10:30pm on 20 February 2023, he took his own life. He had previously attempted to take his own life on 23 March 2022, after he had learnt of the allegation made against him. The investigating officer (OIC) was aware of this as Mr Leger had disclosed it when asked questions regarding his mental health and welfare at the times of the two interviews he attended. Although he had indicated at the times of the interviews that he had no concerns regarding his mental health/welfare, he also stated on 5 November 2022 that his mental health had suffered since the alleged incident. This was the last date that any assessment was made of his mental health. By the time that he was sent the PCR (charging him with an offence that carried a maximum life sentence), he had been “RUI’d” for almost 6 months and it was more than 3 months since there had last been any formal assessment by the police of his mental health and risk of suicide or self-harm. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. I received evidence, in particular from the investigating officer (OIC), who dealt with the investigation into the allegation against Mr Leger, and from an investigator from the Metropolitan Police’s Directorate of Professional Standards (DPS), who conducted an investigation on behalf of the IOPC into the way in which the criminal investigation was undertaken, in particular the consideration of Mr Leger’s welfare and support offered to him. | On 23 February 2023, JDP Stevens, HM Assistant Coroner for Inner North London, commenced an investigation into the death of Nicholas Leger, aged 32 years. The investigation concluded at the end of the inquest on 12 June 2023. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. |
| 30/08/2023 | 2023-0313 | Allison Aules | Ms Nadia Persaud | London East | Child Death (from 2015) | Suicide (from 2015) | North East London Foundation Trust | North East London Health and Care Partnership | Royal College of Paediatrics and Child Health | Royal College of Psychiatrist | Department of Health and Social Care | https://www.judiciary.uk/prevention-of-future-death-reports/allison-aules-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Allison-Aules-Prevention-of-future-deaths-report-2023-0313_Published.pdf | Allison Aules was referred to the mental health team in May 2021 with concerns around evidence of self-harm, low mood, anxiety and enuresis. Her case was inappropriately screened as routine and the referral was triaged 8 weeks later. Allison was not communicated with at this time, but her mother shared a full account of concerns with the triage psychologist. Additional concerns were raised during triage and the matter was taken to a multi-disciplinary team. The team decided that Allison should be assessed face to face. They determined the case to be low risk and placed it in the green zone. The concerns shared with the service should have resulted in a more urgent face to face assessment. The assessment of Allison took place 9 months later. This was not a face-to-face assessment, as directed by the multi-disciplinary team. There was a telephone discussion, initially with Allison’s mother alone. Allison later spoke to the assessor but there was no full assessment of her mental state. There was no full exploration of the concerns raised in the referral and in the triage discussion. There was no evidence of the assessor determining the cause of Allison’s worrying presentation. There was no carefully documented assessment of risk. There was no carefully devised risk management plan. A decision was made to discharge Allison from the mental health team, with no multi-disciplinary review or liaison with the referrer. Allison continued to receive counselling provided at her school, but this concluded at the end of term, on the 15 July 2022. On the 18 July 2022 Allison was found suspended in her bedroom. The failure to provide basic mental health care to Allison contributed to her death. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The Inquest identified multiple failings in the care provided to Allison. The failings occurred within a children and adolescent mental health service which was significantly under resourced. The Inquest heard evidence that the under resourcing of CAMHS services is not confined to this local Trust but is a matter of National concern. The under resourcing of CAMHS services contributed to delays in Allison being assessed by the mental health team. The delay between triage to assessment was 9 months. The Inquest heard evidence that this delay is not unusual within CAMHS teams across the country. There was very little evidence of any consultant psychiatrist leadership within the CAMHS team. The Inquest heard of the difficulties in recruiting suitably qualified psychiatrists to CAMHS teams. The Inquest heard that funding for CAMHS teams within the allocation of funding for general mental health is poor. The Inquest heard that the number of children presenting to CAMHS teams is increasing significantly. The number of referrals of children to the local CAMHS team in the early 2010s was between 10 – 12 per week. The current number of referrals is in the region of 140 patients per week. There is a concern that ongoing under resourcing of CAMHS services (whilst demand continues to increase), will result in future similar deaths. | On 3 August 2022 I commenced an investigation into the death of Allison Vivian Jacome Aules. Allison was 12 years old when she passed away on the 19th July 2022. The investigation concluded at the end of the inquest on the 17th August 2023. The conclusion was that Allison died as a result of suicide, contributed to by neglect. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 22/08/2023 | 2023-0312 | Audrey King | Guy Davies | Cornwall and the Isles of Scilly | Hospital Death (Clinical Procedures and medical management) related deaths | Royal Cornwall Hospital Trust | https://www.judiciary.uk/prevention-of-future-death-reports/audrey-king-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Audrey-King-Prevention-of-future-deaths-report-2023-0312_Published.pdf | Audrey had a previous medical history which included Atrial Fibrillation (AF), which was medicated by an anti-coagulant, apixaban, to reduce the risk of a stroke. On 6 November 2022, Audrey was admitted to RCHT with abdominal pain secondary to femoral hernia obstruction. The apixaban was suspended pending surgery. Audrey underwent surgery for femoral hernia repair, that same day, 6 November 2022. The operation was uneventful. On 9 November 2022 the eldercare consultant reviewed Audrey. The review notes were handwritten on paper medical notes. The eldercare consultant recommended that the surgical team restart Apixaban as soon as safe post operatively. The court heard evidence that the NICE guidance on this subject states Stroke risk associated with atrial fibrillation; Post procedure with immediate and complete haemostasis NOACs can generally be resumed 6–8 h after the end of the intervention. Some surgical interventions carry increased bleeding risk in which case resume anticoagulation 48–72 h post procedure but at the earliest opportunity The apixaban was not restarted. On 11 November 2022 Audrey had a severe stroke secondary to AF. Audrey died as a result of this complication four days later. The court found that whether and when to re-start the apixaban was a decision for the surgical team. The court heard that on the consultant surgeon’s ward round his junior doctor colleague was briefing him, this included reference to the eldercare review paper notes. The junior doctor went through a number of aspects regarding care and treatment but did not refer to the recommendation to re-start apixaban. As a result, the consultant surgeon did not consider whether or not to re-start the apixaban. The court heard that the eldercare team use paper medical notes whilst the surgical team use a digital system, known as NerveCentre. The consultant surgeon stated that the digital system is easier for the surgical team to read because the consultant surgeons can look at the detail on their phone or iPad. The consultant surgeon considered that the different recording platforms contributed to the error of omission in Audrey’s case. Where an ‘important clinical note’ has been handwritten in the handwritten record there is facility for highlighting this on the ‘ward round’ function on Nerve centre. There was no alert that clinical notes had been handwritten in the written notes following the review by the eldercare consultant on 9th November. The court found that apixaban was prescribed on admission and correctly suspended due to bleeding risk in light of pending surgery. There is no evidence of review of this suspension in either medicines reconciliation (10th November) or in the medical records. The court heard that there is no automatic flag on the Electronic Prescribing Medication Administration (EPMA) requiring review of the ongoing suspension of prescribed medication. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 21 November 2022 I commenced an investigation into the death of Audrey King. The investigation concluded at the end of the inquest on 7 August 2023. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 17 October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] | |
| 18/08/2023 | 2023-0311 | Louis Thorold | Mr Simon Milburn | Cambridgeshire and Peterborough | Child Death (from 2015) | Road (Highways Safety) related deaths | Department of Transport | Cambridge County Council | https://www.judiciary.uk/prevention-of-future-death-reports/louis-thorold-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Louis-Thorold-Prevention-of-future-deaths-report-2023-0311_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/Louis-Thorold-Prevention-of-future-deaths-report-2023-0311b_Published.pdf | On 24.01.21 I commenced an investigation into the death of Louis Steven James THOROLD (age 5 months 18 days). The investigation concluded at the end of the inquest on 26.07.23. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by [DATE]. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | |||
| 24/08/2023 | 2023-0310 | Christopher Locke | Mr Aled Wyn Gruffydd | Swansea and Neath Port Talbot | Hospital Death (Clinical Procedures and medical management) related deaths | JD Wetherspoon PLC | https://www.judiciary.uk/prevention-of-future-death-reports/christopher-locke-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Christopher-Locke-Prevention-of-future-deaths-report-2023-0310_Published.pdf | The deceased was Christopher James Locke and he was pronounced dead on the 29th October 2021 at Morriston Hospital, Swansea. The cause of death was hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac. | During the course of the inquest it transpired that there had previously been a scheme undertaken by Wetherspoons allowing staff to undertake additional training including CPR training. The evidence that was heard from a Consultant Intensivist was that the sooner that CPR can be commenced the greater chance that a person is able to survive a cardiac arrest, with minimal if no long lasting disabilities. The inquest concluded that the EMD should have directed staff at the Lord Cradoc to commence CPR and it is understood that compulsory training has been given to all Wetherspoons staff to enable them to comply with EMD instructions. This compulsory training dod not extend to CPR training. It is not the purpose of this report to compel your organisation to provide CPR training to its staff but to make such training available to staff who express an interest. It is recognised that such situations are stressful situations and that it would be unfair to impose compulsory CPR training to staff, however as with all organisations some individuals would welcome the opportunity to benefit from such training. No failings were found against the staff who attended to Christopher that evening and they ought to be commended for their actions. I am concerned that in such cases bar staff at pubs will invariably find themselves in situations where the administering of emergency CPR treatment ought to be administered. The time taken between the beginning of an emergency call and an instruction to commence CPR may deprive a patient of a favourable outcome. Whilst Wetherspoons staff have been trained to comply with EMD instructions there are occasions such as this case where staff could implement CPR of their own accord before being instructed to do so by EMD’s. The training would not only teach staff the correct techniques but educate them of the situations in which CPR should be used. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. In a pub environment there is a greater chance for the public to sustain injuries that requires emergency treatment 2. Ordinary bystanders’ ability to administer emergency treatment may be hindered by their own consumption of alcohol 3. Whilst the primary responsibility of staff is to comply with EMD directions they are deprived of the opportunity to provide lifesaving treatment in circumstances that warrant it if that training is not offered 4. Staff would not know the circumstances that warrant it without the benefit of CPR training. | On the 11th August 2022 I commenced an investigation into the death of Christopher James Locke. The investigation concluded at the end of the inquest on the 24th of August 2023. | In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 25/08/2023 | 2023-0309 | Miss C | Hassan Shah | Northamptonshire | Hospital Death (Clinical Procedures and medical management) related deaths | Resuscitation Council UK | Northampton General Hospital Trust | https://www.judiciary.uk/prevention-of-future-death-reports/miss-c-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Miss-C-Prevention-of-future-deaths-report-2023-0309_Published.pdf | Miss C died at Northampton General Hospital on 5th October 2021. The primary underlying causes are recent weight loss with nutritional deficiencies and interstitial pneumonia. On 4th October 2021 during her deterioration, a doctor should have reviewed but did not do so until later. A review before the cardiac arrest would have provided a chance for enhanced supportive care and an early peri-arrest call might have been activated which could have had a favourable effect on the outcome. There was therefore a missed opportunity in the medical care. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Resuscitation Council UK and NGH NHS Trust should consider a review of their policy in relation to the out of hours availability of Resuscitation Officers. | On 13 October 2021 I commenced an investigation into the death of Miss C, aged 36. The investigation concluded at the end of the inquest on 24 August 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by October 19, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 18/08/2023 | 2023-0308 | William Nichols | Ms Leila Benyounes | Gateshead and South Tyneside | Hospital Death (Clinical Procedures and medical management) related deaths | The Newcastle Upon Tyne Hospitals NHS Foundation Trust | Barts Health NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/william-nichols-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/William-Nichols-Prevention-of-future-deaths-report-2023-0308_Published.pdf | Mr Nichols underwent surgery, a femoral endarterectomy, on 20/11/19, and developed a lymphatic leak and a post-operative infection, from which he was at an increased risk of developing. A week prior to his death, Mr Nicholas suffered a herald bleed due to deep patch infection, and on the evening of 02/01/21 Mr Nichols suffered a fatal catastrophic haemorrhage from the site of the right femoral artery. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – Despite the known catastrophic risks of deep patch infection following endarterectomy and the significance of a herald bleed: (1) Inconsistency in understanding between the hospital and the community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection, or bleeding). (2) The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding). (3) Poor communication from the vascular ward when concerns were raised post- operatively, particularly the concern about bleeding in the wound discharge. | On 07/01/20 an investigation was commenced into the death of William Nichols age 66 years. The investigation concluded at the end of the inquest on 20/04/23. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13/10/23. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 24/08/2023 | 2023-0307 | Jonathan Mann and Margaret Costa | Mrs Samantha Marsh | Somerset | Other related deaths | Civil Aviation Authority | Military Aviation Authority | https://www.judiciary.uk/prevention-of-future-death-reports/jonathan-mann-and-margaret-costa-prevention-of-future-deaths-report-2023-0307_published/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Jennifer-Rackley-Prevention-of-future-deaths-report-2023-0305_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/Jonathan-Mann-and-Margaret-Costa-Prevention-of-future-deaths-report-2023-0307_Published-2.pdf | Mr Mann had held his pilot’s licence since 2000. He had owned his plane, a Cap- 10-B since 2014. He had a current and valid private pilot’s licence which permitted him to fly under Visual Flight Rules (“VFR”). Mr Mann did not possess the skills, experience of ability to fly in cloud; he could only fly in clear skies as he was unable to “instrument fly” and could only fly by reference to what he could see out of the window. His passenger on the day, Mrs Costa, had no flying experience and did not possess a pilot’s licence. She had no active part in the events that unfolded. On 12th August 2021 at 08:04 Mr Mann took off from Watchford Farm, Yarcombe near Taunton, Somerset with Mrs Costa on a planned pleasure trip for the day to the Isle of Sicily. There was no evidence that Mr Mann had used recognised aviation sources to check the weather prior to departure, instead obtaining weather information from news weather-based apps. At around 09:10 the weather conditions deteriorated and so Mr Mann turned back. At around 10:10 found himself at an altitude of 7,500ft flying above cloud, He was not qualified to fly through cloud. He contacted the Distress and Diversion Cell (“D&D Cell”) on the emergency frequency for assistance. Mr Mann began to descend to a lower altitude but he appears to have become spatially disorientated due to the extreme stress of flying in the weather conditions in which he found himself and when he emerged from cloud, the ground was not where he expected it to be. The plane collided with a large oak tree at Lower Colley Farm, Buckland St Mary near Chard, Somerset and was destroyed on impact with both the pilot and passenger being thrown from the wreckage and suffering catastrophic injuries that were incompatible with life. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The D&D cell did not request or receive any critical information about (i) the pilot’s capabilities (i.e that he could not instrument fly and/or fly in cloud); (ii) the plane’s capabilities (i.e. that it was not equipped to allow the pilot to instrument fly) (iii) the weather conditions at the selected diversion aerodrome (to ensure that the weather was more favourable to the conditions at the home aerodrome). Checklists and aide memoires were not used by those on the ground and, consequently, there was a lack of knowledge and/or appreciation of the unsuitability of the selected airport (Exeter) as a viable diversion destination; despite it being the closest in geographic proximity. There was no immediate requirement for urgent assistance as the pilot had fuel for a further 1.5hours of | On the 16th September 2021, my predecessor, Mr Tony Williams, commenced an investigation into the deaths of Jonathan Paul Bost Mann, aged 69 and Margaret Jean Costa, aged 74. | In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 29/08/2023 | 2023-0306 | Mizanur Rahman | Mr Adam Smith | London Inner North | Other related deaths | Product Safety and Standards | https://www.judiciary.uk/prevention-of-future-death-reports/mizanur-rahman-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Mizanur-Rahman-Prevention-of-future-deaths-report-2023-0306_Published.pdf | Mr Rahman died on 9 March 2023 at the Royal London Hospital from the effects of smoke inhalation during a fire which took place in the early hours of 5 March 2023 at the 4th floor multi-occupancy flat where he resided. The fire was found to have been caused by a faulty lithium ion e-bike battery which was charging at the time. The e-bike from which the battery came, which was owned by another occupant of the flat, had been heavily modified, notably including a retro- fitted additional battery cage and motor. I found on the evidence, which included that of a London Fire Brigade Fire Investigation Officer (whose evidence was in turn informed by input from the Chief Scientific Adviser at the Fire Science Department, who had examined the e-bike and remains of the charger\battery), that the fire started with a faulty lithium ion battery, probably a battery and charger which did not match and carried different voltage ratings, leading to thermal runaway and catastrophic failure of the lithium ion battery. Despite attempts by occupants of the flat to prevent the fire’s escalation, this was not possible and the flat quickly filled with toxic smoke necessitating its evacuation. Sadly, Mr Rahman did not successfully evacuate before he was overcome by the smoke, causing his death. | During the course of the investigation, including the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. I have received evidence, in particular from the London Fire Brigade’s Fire Investigation Team: · That Mr Rahman’s death is the ninth nationally in approximately one year, in six fires attributed to faulty lithium ion batteries. · That the number of fires in London attributed to electric powered personal vehicles has risen consistently and significantly over the last six years and now stands at well in excess of 100 per annum. | On 17 March 2023, E Buckett, HM Assistant Coroner for Inner North London, commenced an investigation into the death of Mizanur Rahman, aged 41 years. The investigation concluded at the end of the inquest on 17 August 2023. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. | |
| 06/06/2023 | 2023-0305 | Jennifer Rackley | Mrs Heidi Julia Connor | Berkshire | Care Home Health related deaths | Care UK | https://www.judiciary.uk/prevention-of-future-death-reports/jennifer-rackley-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Jennifer-Rackley-Prevention-of-future-deaths-report-2023-0305_Published.pdf | Jennifer was born on the 22nd of June 1940. She had an extensive past medical history, including cancer, dementia, atrial fibrillation, and previous DVT. She suffered a fall at Queen’s Court Nursing Home in Windsor on the 17th December 2021. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) (1) It seems likely that Jennifer’s bed was in the centre of the room, with one sensor mat only, despite a high falls risk. | I conducted an inquest into the death of Jennifer Evelyn RACKLEY, aged 81 years. The investigation concluded at the end of the inquest on 17 May 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by August 01, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 21/08/2023 | 2023-0304 | Jacqueline Smith | Mrs lydia brown | London West | Alcohol, drug and medication related deaths | Mental Health related deaths | Suicide (from 2015) | Hillingdon Council | Forward Trust | Central and North West London Mental Health Trust | https://www.judiciary.uk/prevention-of-future-death-reports/jacqueline-smith-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Jacqueline-Smith-Prevention-of-future-deaths-report-2023-0304_Published.pdf | Took her own life by an overdose of prescribed medication at home and died in Hillingdon Hospital on 12 August 2022. At the time she was in poor physical health and experiencing considerable anxiety as she was trying, with assistance from the Council, to clear her home of numerous hoarded possessions. She spoke with the single point of access (SPA) crisis telephone service during the evening of 10th August to ask for help, but no mental health assessment was performed and she was not called back by the team as promised. Her neighbour requested a welfare check be performed the next day when she was found collapsed and taken to hospital. | On 16 August 2022 I commenced an investigation into the death of Jacqueline Elizabeth SMITH. The investigation concluded at the end of the inquest . | In my opinion action should be taken to prevent future deaths and I believe you Hillingdon Council have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | ||
| 21/08/2023 | 2023-0303 | David Celino | Mr Kevin McLoughlin | Yorkshire West Eastern | Alcohol, drug and medication related deaths | Child Death (from 2015) | Festival Republic, Leeds City Council | West Yorkshire Police | Home Office | Department for Digital Culture Media and Sport | https://www.judiciary.uk/prevention-of-future-death-reports/david-celino-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/David-Celino-Prevention-of-future-deaths-report-2023-0303_Published.pdf | In August 2022, large numbers of people under the age of 18 were permitted to attend the three day outdoor music event known as the Leeds Festival. This admission policy was accepted by the Leeds City Council who licence the festival and had a statutory duty to protect children from harm and prevent crime. | During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths may occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 2 September 2022, I commenced an investigation into the death of David Joseph Celina, aged 16. The investigation concluded at the end of the Inquest on 17 August 2023. | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report by Monday 13 November 2023 (the normal timescales having been extended to reflect the holiday period). I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroner’s (Investigations) Regulations 2013. | |
| 11/08/2023 | 2023-0302 | Doris Urch | Mr Harry Nathaniel Lambert | London Inner North | Care Home Health related deaths | Globe Court Care Home | https://www.judiciary.uk/prevention-of-future-death-reports/doris-urch-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Doris-Urch-Prevention-of-future-deaths-report-2023-0302_Published.pdf | Doris Irene Urch, aged 90, suffered from Alzheimer’s dementia, and age related macular degeneration, and was known to have a high risk of falls. I was told by [REDACTED], from whom I heard evidence, that the most risky transition was from standing to sitting and that during this transfer the Deceased, due to her visual impairment, would often miss the seat and fall. It was “part of her” which I took to mean an inherent and constant risk. [REDACTED], the care home manager, candidly accepted that “we all knew you had to watch Doris when she sits down”. On 6th Mrs Urch was in the lounge of Globe House when she became distressed, lost her balance and fell. It is clear that Ms Urch was not being supervised or assisted by the only carer present, [REDACTED] , who was “sitting…with the other residents”. [REDACTED] acknowledged that this was a mistake. She was taken to Hospital where a CT scan evinced a large acute left frontal intracranial haemorrhage with extensive longstanding cerebral atrophy. It was decided that surgical intervention was not in her best interests and the focus shifted to palliative care. She passed away on 28th February 2023 at around 03:30 hours. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) The Question and Answer tickbox form for Risk Assessment seemed to me to leave much to be desired. It was excessively binary and meant that those who filled it in did not need to “engage” with the particular patient. (2) The Risk Assessment did not make no recommendations or suggestions as to what to do about the risks identified. (3) Staff seemed unfamiliar with the risk assessment/care plan, which I consider more of a systemic problem. It is unclear if/when care plans were reviewed by staff. (4) The care plan/risk assessment was not updated in light of a fall in November/December 2022. I was concerned that potentially significant developments might not be being taken into account in keeping the care plan under review. (5) The system does not preserve old care plans in their contemporaneous format which is a serious shortcoming which has the potential to hinder future investigations. I encourage that system to be reviewed. | On 3 March 2023 the Senior Coroner, Mary Hassell, commenced an investigation into the death of Doris Urch aged 90 years. The investigation concluded at the end of the inquest on 27 July 2023. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 6th October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. | |
| 18/08/2023 | 2023-0301 | Juanita Nti | Mr Andrew Harris | London Inner South | Child Death (from 2015) | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/juanita-nti-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Juanita-Nti-Prevention-of-future-deaths-report-2023-0301_Published.pdf | Local partnership work between hospital, general practice and pharmacies has led to revised repeat prescription polices, improved standard operating procedures, a revised paediatric formulary and overall improved safety of paediatric prescribing. One of the paediatricians involved in the tragedy informed the court that a similar incident had occurred in North of England. He understood that the lessons of our fatal incident had not been applied there and that that there was a potential to prevent other deaths by ensuring that the whole of the NHS saw the benefits of local health economy wide paediatric prescribing policies. In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday, 13th October 2023. I, the coroner, may extend the period. If you require any further information or assistance about the case, please contact the case officer, [REDACTED] | |||||
| 15/06/2023 | 2023-0300 | Nicholas Stout | Mr James Edward Thompson | County Durham and Darlington | Alcohol, drug and medication related deaths | https://www.judiciary.uk/prevention-of-future-death-reports/nicholas-stout-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Nicholas-Stout-Prevention-of-future-deaths-report-2023-0300_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/2023-0300-Response-from-Tees-Esk-and-Wear-Valleys-NHS-Foundation-Trust-1.pdf | Nicholas ‘Nicky’ Stout died on 26th July 2021 at Darlington Memorial Hospital due to acute cocaine toxicity and contributed to by coronary artery atheroma. Nicky had mental health issues and was recieving professional support. Nicky was diagnosed with cocaine dependency in 2015. On 26th July 2021 he consumed a large quantity of cocaine. Following symptoms of chest pains his behaviour became increasingly erratic, consistent with acute behavioural disturbance. Despite appropriate interventions from the police and ambulance services, Nicky went into cardiac arrest and subsequently died. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 29/07/2021 10:54an investigation was commenced into the death of Nicholas James STOUT 31/08/1985 00:00:00. The investigation concluded at the end of the inquest on 09/06/2023 00:00. The conclusion of the inquest was that Nicholas ‘Nicky’ Stout died on 26th July 2021 at Darlington Memorial Hospital due to acute cocaine toxicity and contributed to by coronary artery atheroma. Nicky had mental health issues and was receiving professional support. Nicky was diagnosed with cocaine dependency in 2015. On 26th July 2021 he consumed a large quantity of cocaine. Following symptoms of chest pains his behaviour became increasingly erratic, consistent with acute behavioural disturbance. Despite appropriate interventions from the police and ambulance services, Nicky went into cardiac arrest and subsequently died. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by August 10, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 21/06/2023 | 2023-0299 | Matthew Harris | Mr David Donald William REID | Worcestershire | State Custody related deaths | Suicide (from 2015) | Dyfed-Powys Police | https://www.judiciary.uk/prevention-of-future-death-reports/matthew-harris-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Matthew-Harris-Prevention-of-future-deaths-report-2023-0299_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/2023-0299-Response-from-Dyfed-Powys-Police-.pdf | In answer to the questions “when, where and how did Mr. Harris come by his death?”, the jury recorded as follows: “On 27.5.22 Matthew David Harris was found in his cell at HMP Long Lartin having suspended himself [REDCATED]. As a result of his injuries he died on 29.5.22 at the Alexandra Hospital, Redditch. Matthew David Harris had a background of mental health and substance misuse issues.” | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | [the details below are fictional] On 1 June2022 I commenced an investigation and opened an inquest into the death of Matthew David Harris. The investigation concluded at the end of the inquest on 20 June 2023. | In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Constable of Dyfed-Powys Police have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 17/08/2023 | 2023-0298 | Malcolm Unwin | Mr John Gittins | North Wales (East & Central) | Hospital Death (Clinical Procedures and medical management) related deaths | Betsi Cadwaladr University Health Board BCUHB | https://www.judiciary.uk/prevention-of-future-death-reports/malcolm-unwin-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Malcolm-Unwin-Prevention-of-future-deaths-report-2023-0298_Published.pdf | On the 30th of December 2022 the deceased had unwitnessed fall from bed whilst a patient at the hospital resulting in injuries. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On the 23rd of January 2023 an investigation was commenced into the death of Malcolm Ralph Unwin (DOB 15/03/43) who died at Wrexham Maelor Hospital on the 6th of January 2023. The conclusion of the inquest on the 16th of August 2023 was that the death was due to an accident. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 12th October 2023. I, John Gittins, the Coroner, may extend the period. I would be prepared to accept a joint response from all organisations. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 17/08/2023 | 2023-0297 | Shirley Ashelford | Mr christopher paul williams | London Inner South | Other related deaths | Medicines & Healthcare products Regulatory Agency | London Borough of Southwark | Prism Medical UK Ltd | Bureau Veritas UK Ltd | https://www.judiciary.uk/prevention-of-future-death-reports/shirley-ashelford-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Shirley-Ashelford-Prevention-of-future-deaths-report-2023-0297_Published.pdf | Shirley was aged 60 at the time of her death. Following a diagnosis of multiple sclerosis, in 2000, her mobility slowly declined, eventually losing the ability to stand and walk and becoming reliant on a mobility scooter. | From the evidence I received, at the inquest, there are matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. During the inquest I heard evidence of the following matters: · Shirley was an unusual local authority OT service user because she operated her hoist and sling mainly without the assistance of a carer because she wanted to maintain her independence and dignity as much as possible. Because she had mental capacity the OT service respected her wishes. · Shirley’s husband who was the main carer at the time of her death did not receive any training from the local authority in safe usage of the hoist and in particular use of the red emergency pull cord. It was not clear whether Shirley had received any training on the use of the red pull cord when she was provided with the hoist because there was no paperwork confirming training had been delivered. · I found that when Shirley was suspended in the hoist, she did not use the red pull cord, on the underside of the hoist unit, because it had not lowered and because her husband was able to use the hand control to manoeuvre her toward the scooter. He would not be able to do this if the red cord had been pulled because the electric power would switch off. · Higher Elevation reported inspections of the hoist to the AMT but not to the OT department. The AMT, in turn, did not share those reports with the OT department. · The Inspection by Bureau Veritas 30/6/23 only reported to AMT but not the OT dept. The AMT did not share the report with the OT department. I was informed that although the Lifting Operations and Lifting Equipment Regulations 1988 (LOLER) did not apply, nonetheless six-monthly inspections were performed on a voluntary basis. · The last Bureau Veritas inspection was done without access to reports from Higher Elevation and email reports from Shirley to the OT department. Veritas reported there were no problems on its last inspection of 30/6/23 over 2 weeks before the death. That report was made without sight of the Shirley’s report to the OT department, on 9/4/21, and the Higher Elevation report to the AMT on the same day. · I was also told by Shirley’s husband that the same model of hoist in the bathroom had also failed to lower on occasions. · At present the bedroom hoist, and hoists in the bathroom and living room remain in situ at Shirley’s home and are available for inspection. Shirley was a local authority tenant when she died and due to pressure on its housing stock the local authority is anxious to re-let the property to new tenants. Therefore, it is desirable that the hoists are inspected in situ as soon as possible. Otherwise, they will have to be inspected whilst in local authority storage. · I was reassured that the London Borough of Southwark is seeking to introduce guidance to its OT service to ensure the risk of recurrence in future is reduced in relation to service users operating hoist equipment unassisted in their homes. However, given my concern that recurrence should be avoided elsewhere in England and Wales I am reporting this to the MHRA to investigate and if necessary, alert and give guidance to other local authorities regarding the evidence which emerged during my investigation. The MATTERS OF CONCERN are as follows. | On the 27th July 2021 an investigation commenced into the death of Shirley Frances Ashelford, born 30th June 1961, and who died on 20th July 2021. The investigation concluded at the end of the inquest on 9th August 2023. | In my opinion action should be taken to prevent future deaths and I believe your organisations has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by the day month 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 16/08/2023 | 2023-0296 | Odichukwumma Igweani | Dr Séan Cummings | Milton Keynes | Mental Health related deaths | North West Anglia NHS Foundation Trust | BLMK Integrated Care Board | Red House Surgery | https://www.judiciary.uk/prevention-of-future-death-reports/odichukwumma-igweani-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Odichukwumma-Igweani-Prevention-of-future-deaths-report-2023-0296_Published.pdf | At the time of the incident Kelvin Igweani was living at . Prior to the incident on the 26th June 2021 evidence shows Kelvin was suffering undiagnosed mental health problems, which were deteriorating over several months. Attempts by Kelvin’s mother to secure mental health assistance for him were unsuccessful, as no formal assessments were made. His mental health then spiralled significantly in the four days proceeding the incident. On the morning of 26th June 2021, Kelvin became extremely violent, firstly trying to forcefully baptise his partner’s children in the bath. His partner and her daughter were able to flee to knock on the neighbours flat ([REDACTED]) to seek assistance to call the police. His partner was then dragged back [REDACTED]. Kelvin then forcefully regained control of her two year old son and began to progress into holding him under water causing him to become unconscious. On a second successful attempt to flee to the neighbours flat ([REDACTED]), his partner and her daughter asked the neighbours to help save her son as Kelvin was trying to kill him. The[REDACTED]neighbour then went into [REDACTED] to try and save the two year old boy but was bludgeoned to death [REDACTED]. The neighbours [REDACTED] called the police and gave shelter to Kelvin’s partner and her daughter. At this point, the first officer on scene attempted to gain entry after announcing she was police but was unsuccessful, so called for back-up assistance with method of entry equipment. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Out of hours and emergency mental health care for people who are not registered with an NHS GP in Milton Keynes may be obtained by attending the Emergency Department at the Milton Keynes University Hospital where mental health professionals are based. Through Kelvin’s period of deteriorating mental health, which was obvious to those who knew him, his mother made repeated attempts to secure mental health assessment and care for him. She was not directed clearly by the professionals she did have contact with, to take him to the Emergency Department for assistance. There was a gap which Kelvin fell through and he did not receive either mental health assessment or care. It was not possible to say that the failure to receive assessment or care resulted in Kelvin attempting to take the lives of others and succeeding in taking the life of his male neighbour. It was clear that the lack of clear information and direction in regard to how to obtain that mental health assessment or care contributed to Kelvin not presenting for assessment which may possibly have averted the tragic events which unfolded on the 26th June 2021. This in turn raises the prospect that others, in similar predicaments may also be unable to obtain the care required. | On 01 July 2021 I commenced an investigation into the death of Odichukwumma Kelvin IGWEANI aged 24. The investigation concluded at the end of the inquest on 19 April 2023. The conclusion of the inquest was that he was lawfully killed. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by October 10, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 16/08/2023 | 2023-0295 | Absolom Duffy | Ms Marianne Johnson | Lincolnshire | Road (Highways Safety) related deaths | Highways Agency | https://www.judiciary.uk/prevention-of-future-death-reports/absolom-duffy-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Absolom-Duffy-Prevention-of-future-deaths-report-2023-0295_Published.pdf | Absolom Duffy was travelling in his Land Rover Defender motor vehicle on the 8th July 2021 when he exited from Sand Lane, Saxilby onto Doddington Road and collided with another vehicle. Paramedics attended however he died as a result of his injuries. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 16 July 2021 I commenced an investigation into the death of Absolom Adolphus Abraham Zephaniah DUFFY aged 21. The investigation concluded at the end of the inquest on 17 May 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by October 10, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 14/08/2023 | 2023-0294 | Leonard King | Dr Séan Cummings | Milton Keynes | Hospital Death (Clinical Procedures and medical management) related deaths | Association of Ambulance Chief Executives | Royal College Emergency Medicine | The Royal College of General Practitioners | Urgent Health UK | https://www.judiciary.uk/prevention-of-future-death-reports/leonard-king-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Leonard-King-Prevention-of-future-deaths-report-2023-0294_Published.pdf | Mr Leonard Jomo Isaac King died at the Milton Keynes University Hospital on the 4th May 2022 as a result of a hypoxic cardiac arrest secondary to an obstructing epiglotittis. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 12 May 2022 I commenced an investigation into the death of Leonard Jomo Isaac KING aged 37. The investigation concluded at the end of the inquest on 25 April 2023. The narrative conclusion of the inquest was that: Mr Leonard Jomo Isaac King died at Milton Keynes University Hospital on the 4th May 2022 after collapsing with a hypoxic cardiac arrest consequent on blockage of his airway because of epiglottitis. There was a missed opportunity to recognise and escalate his case at the Milton Keynes Urgent Care Centre on the 2nd May 2022. There was a further missed opportunity by South Central Ambulance Service when they were called via 999 to his home on the 2nd May 2022 later that day afternoon, to recognise the fact that he was in a precarious position and removing him to the ED. This was an avoidable death. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by October 10, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 14/08/2023 | 2023-0293 | Linda Oldland | Miss Anna Crawford | Surrey | Care Home Health related deaths | Leonard Cheshire | https://www.judiciary.uk/prevention-of-future-death-reports/linda-oldland-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Linda-Oldland-Prevention-of-future-deaths-report-2023-0293_Published.pdf | |||||||
| 24/08/2023 | 2023-0292 | Gordon Rodger | Mr Robert Cohen | Cumbria | Railway related deaths | Suicide (from 2015) | National Rail Infrastructure Limited | https://www.judiciary.uk/prevention-of-future-death-reports/gordon-rodger-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Gordon-Rodger-Prevention-of-future-deaths-report-2023-0292_Published.pdf | On Thursday 02nd March 2023 at 0714hrs British Transport Police were made aware that the driver of the 2C39 service travelling between Barrow and Carlisle had just reported seeing a human body in the Askam-in-Furness area of Cumbria. The driver explained that he had earlier observed something in that area when travelling between Millom into Barrow, around 0625hrs, but had been unsure what this was. Therefore, when travelling back through the Askam area he had decided to slow the train service down for a better look. On inspection he noted this was a body of a person. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. In the course of the inquest I heard that British Transport Police had recommended to Network Rail that they consider installing “anti trespass treads and gates to the north end of Platforms on Askam station if operationally possible”. By a letter to the Court dated 5th June 2023 Network Rail indicated that they had decided not to take this step. They explained that Askam station is rural, that limited resources dictate which works are prioritised and that there is no history of trespass. In the course of the inquest the court heard that the line in this location is more accessible that might usually be expected, including by stiles in nearby fences associated with a nearby golf club. In the circumstances I am concerned that the line may be readily accessible to individuals who wish to harm themselves. | On 7 March 2023 I commenced an investigation into the death of Gordon Alexander John RODGER. The investigation concluded at the end of the inquest . | In my opinion action should be taken to prevent future deaths and I believe you Network Rail have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report,namely by 19th October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 15/08/2023 | 2023-0291 | Ian Darwin | Mr Jeremy Chipperfield | County Durham and Darlington | Hospital Death (Clinical Procedures and medical management) related deaths | https://www.judiciary.uk/prevention-of-future-death-reports/ian-darwin-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Ian-Darwin-Prevention-of-future-deaths-report-2023-0291_Published.pdf | Death was caused by multiple injuries, Ian Darwin being found below , [REDACTED] Durham. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | In my opinion urgent action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. https://www.legislation.gov.uk/ukpga/2009/25/schedule/5 https://www.legislation.gov.uk/uksi/2013/1629/contents/made | |||
| 14/08/2023 | 2023-0290 | Marie Zarins | Miss Isobel Thistlethwaite | Leicester City and South Leicestershire | Suicide (from 2015) | Leicestershire Partnership NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/marie-zarins-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Marie-Zarins-Prevention-of-future-deaths-report-2023-0290_Published.pdf | Miss Zarins was a 42 year old female who was reported missing by her family and discovered suspended [REDCATED], Leicestershire. Her death was confirmed at the scene by one of the attending paramedics on 24 November 2021 at 16:04hours. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 02 December 2021 I commenced an investigation into the death of Marie ZARINS aged 42. The investigation concluded at the end of the inquest which took place on 13 and 14 July 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by October 15, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 09/08/2023 | 2023-0289 | Rohan Godhania | Mr Tom Osborne | Milton Keynes | Child Death (from 2015) | Other related deaths | NHS England & NHS Improvement | The Food Standards Agency | https://www.judiciary.uk/prevention-of-future-death-reports/rohan-godhania-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/09/Rohan-Godhania-Prevention-of-future-deaths-report-2023-0289b_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/09/Rohan-Godhania-Prevention-of-future-deaths-report-2023-0289_Published.pdf | The deceased consumed a high protein drink on 15th August 2020 and became unwell. He was admitted to West Middlesex Hospital. Advice was taken from the neurologists at Charing Cross Hospital who advised that he should be tested for ammonia. The test was not carried carried out. His condition deteriorated and he died from Ornithine Transcarbamylase Deficiency (OTC) on the 18th August 2020. | On 02 November 2022 I commenced an investigation into the death of Rohan GODHANIA aged 16. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by October 02, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 08/08/2023 | 2023-0288 | Reginald Bourn | Miss Caroline Topping | Surrey | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Health Education England | National Institute for Health & Care Excellence | https://www.judiciary.uk/prevention-of-future-death-reports/reginald-bourn-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Reginald-Bourn-Prevention-of-future-deaths-report-2023-0288_Published.pdf | Mr Bourn had an intestinal blockage on admission to hospital which required the placement of a nasogastric draining tube to decompress his stomach. The first tube came out and a second one was placed by an experienced nurse. Shortly thereafter he suffered an acute event and aspirated one and a half litres of gastrointestinal content into his left lung. A chest X ray was taken. He died shortly thereafter. When read the X ray revealed that the tube had been misplaced in the left lung. He died as a consequence of the aspiration of gastrointestinal content which was in part attributable to the fact that the misplaced tube enabled ingress to the lung of the aspirate, and in part because the stomach content had not been drained. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. The expert and clinical evidence was that the insertion of any nasogastric tube is complicated and misplacement into a lung can occur because of the proximity of the trachea to the oesophagus. | An inquest into the death of Mr Reginald Edwin Bourn was opened on the 12th May 2022 and on the 19th June 2023. The inquest was concluded on the 27th March 2023. Reginald Bourn died at Frimley Park Hospital on the 24th February 2022. | In my opinion action should be taken to prevent future deaths and I believe you[AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 26/06/2023 | 2023-0287 | Anthony Rockall | Mr Crispin Giles Butler | Buckinghamshire | Other related deaths | Prevention of Future Deaths | REDACTED | https://www.judiciary.uk/prevention-of-future-death-reports/anthony-rockall-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Anthony-Rockall-Prevention-of-future-deaths-report-2023-0287_Published.pdf | Tony Rockall died during the early evening of 26th April 2022 at John Radcliffe Hospital, Oxford from the head injury he sustained when he fell from the tailgate of his truck the previous afternoon. The injury was sustained whilst another person was trying to offload a pallet of bricks from the truck at a reclamation yard in Aston Clinton, Buckinghamshire. It is likely that the pallet truck, which appears to have been longer than the depth of tailgate, had become stuck and Tony, who had been standing in a small area at the back corner of the tailgate, fell backwards to the ground whilst the pallet truck was stuck. It is not possible to ascertain whether Tony had a medical event leading to the fall, however his presence on the tailgate was in connection with the unloading of the truck. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 28th April 2022 I commenced an investigation into the death of Anthony William Rockall, aged 68 years. The investigation concluded at the end of the inquest on 15th June 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by August 17, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 29/06/2023 | 2023-0286 | Clinton Fear | Dr Simon Fox QC | Avon | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | UK Health Security Agency | https://www.judiciary.uk/prevention-of-future-death-reports/clinton-fear-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Clinton-Fear-Prevention-of-future-deaths-report-2023-0286_Published.pdf | Mr Fear underwent cardiac valve replacement surgery in November 2012 and during surgery he contracted Mycobacterium Chimaera infection from a Liva Nova heater cooler unit (part of the heart bypass machine). He developed symptoms of Mycobacterium Chimaera in the form of night sweats in 2017/2018, was diagnosed and started on treatment in October 2019, suffered a protracted disabling illness for 3 years and died from the infection in July 2022. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. There is an inconsistency between – Previous Public Health England and current NHS guidance only to notify patients undergoing surgery from January 2013 of the risk of Mycobacterium Chimaera infection And Evidence of patients contracting Mycobacterium Chimaera infection from surgery substantially earlier than January 2013 (at least as far back as 2008); 2. There appears to be no current basis for maintaining a start date of surgery in January 2013 for patient risk notification when there is evidence of infection substantially earlier than this date; 3. Patients who have contracted Mycobacterium Chimaera infection from surgery before January 2013 may be suffering a delay in diagnosis and consequent harm as a result of a lack of notification due to the existing guidelines. | On 26th July 2022 an investigation into the death of Mr. Clinton Peter Fear was commenced. The investigation concluded at the end of the inquest 29th June 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 28/07/2023 | 2023-0285 | Benjamin McQueen | Ernest Ryder, Nominated Judge Coroner | Accident at Work and Health and Safety related deaths | Other related deaths | Prevention of Future Deaths | Service Personnel related deaths | Ministry for Defence | https://www.judiciary.uk/prevention-of-future-death-reports/benjamin-mcqueen-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Benjamin-McQueen-Prevention-of-future-deaths-report-2023-0285_Published.pdf | The circumstances of the death are briefly summarised in the text above. Detailed factual findings in Security Sensitive form are held by MOD and I request that you should have regard to the full Security Sensitive factual findings. | I have been greatly assisted by detailed evidence from MOD on the changes made to the relevant aspects of military diving training since Ben’s death. From that evidence it is very clear that there has been a comprehensive and far-reaching review of policies, practices and organisational structures which will have very significantly reduced the risk of future fatalities. In several areas, the changes made go beyond those recommended by the Defence Safety Authority, and in nearly all other cases the recommendations have been adequately addressed. There are a few areas where there remains technological limitations to the response to the earlier DSA recommendations , but I am satisfied on the evidence I have heard that appropriate technological advances are being rapidly sought, with the risks in the meantime being mitigated by other means. Among over thirty recommendations arising from earlier investigations where extensive action has already been taken, there are four discrete areas in relation to which I assess that the Statutory threshold for me to make a Report to Prevent Future Deaths is met. Accordingly, it is still the case that during the course of the inquest the evidence revealed matters giving rise to conce rn. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you . The MATTERS OF CONCERN are as follows: (1) A stand-by diver was present at the dive exercise and he was deployed to try to find and rescue Ben. However, the stand-by diver had to surface having run out of breathable gas before Ben was found. A spare breathing apparatus cylinder was not carried in the safety boat for the stand-by diver (or other divers) to use in the event that the stand-by diver’s main cylinder ran out. (2) The progression of the dive training in which Ben was engaged was safety-critical. The progression of training was accelerated for several reasons, one of which was a visit by a high-ranking naval officer. The concern of the instructing staff was to polish the drills ahead of that visit and to take the pressure off the dive students by allowing them to practise the dive with relevant equipment ahead of the visit. This acceleration of safety-critical training in part because of such a visit was not appropriate. (3) Ben was lifted unconscious from the sea bed and Cardio Pulmonary Resuscitation was immediately started. A defibrillator was also applied, but this was only available because it was carried by a Harbour Patrol vessel which came to assist. I am concerned that in such safety-critical military diving training, the dive support staff did not have available to them a defibrillator of their own either on the supporting safety boats or on land. This did not cause or contribute to Ben’s death but could lead to future fatalities. (4) There is an inconsistency regarding the minimum safety pressure level for the relevant diver’s breathing apparatus as between the maintenance manual for which DE&S is responsible and all other policy and safety guidance. | On 26 November 2018 the Senior Coroner for Dorset commenced an investigation into the death of BENJAMIN DAVID MCQUEEN, aged 26. The investigation concluded at the end of the inquest held by me as nominated Judge Coroner from 10 to 28 July 2023. | (1) As to carrying a spare breathing apparatus cylinder in safety boats in addition to that carried by the stand-by diver where this is practicable, I am reassured that this appears to be happening in practice in Ben’s former unit. But I have a concern that this does not yet appear in policy guidance and it is a safety concern that may need to be more widely shared in defence. (2) As to avoiding visits by senior ranking Officers or VIP visitors to training courses leading to an acceleration of safety-critical training, I am reassured that action has been taken in Ben’s former unit such that this should not recur in relation to the relevant diving training. But I have a concern as to whether this has been shared more widely amongst other military units. (3) As to the availability of defibrillators, I was informed that they are present at some, but not all, dive sites used by Ben’s former Unit. The risk assessment suggesting that defibrillators are not required because of the age/health profile of those attending the diving training appears to focus upon the risk of myocardial infarction (or similar) from a natural cause or routine exercise, rather than the risk of cardiac arrest / heart arrythmias caused by traumatic injury when carrying out arduous military diving. (4) As to the inconsistency regarding the minimum safety pressure level for the relevant diver’s breathing apparatus, I was informed that the relevant operators would not need to consult the detailed maintenance manual such that confusion should not occur. Nevertheless, I consider that in the sphere of safety-critical dive training, there is an unnecessary residual risk in different figures being given for the minimum safety pressure level for a type of diver’s breathing apparatus. In relation to each of these areas, in my opinion action should be taken to prevent future deaths and I believe that you as the responsible Minister for the Ministry of Defence have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 22 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 04/08/2023 | 2023-0284 | Harry Stobie | Mr Tom Osborne | Milton Keynes | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Milton Keynes University Hospital | https://www.judiciary.uk/prevention-of-future-death-reports/harry-stobie-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Harry-Stobie-Prevention-of-future-deaths-report-2023-0284_Published.pdf | The deceased suffered a stroke on 15th February 2023 and was admitted to Milton Keynes University hospital and transferred to John Radcliffe hospital for a thrombectomy and was repatriated back to Milton Keynes on the 20th February 2023, he underwent a PEG insertion on the 23rd March 2023 caused a large haemoperitoneum that was not recognised at the time. His condition deteriorated and he died on 26th March 2023. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 03 April 2023 I commenced an investigation into the death of Harry Arthur STOBIE aged 77. The investigation concluded at the end of the inquest on 20 July 2023. The conclusion of the inquest was that: Narrative Conclusion – Died as a result of a haemoperitoneum after insertion of a PEG tube, that is a recognised complication of a necessary medical procedure. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by September 29, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 03/08/2023 | 2023-0283 | Leah Barber | Mr Raja Mahmood | Yorkshire West Western | Child Death (from 2015) | Prevention of Future Deaths | Suicide (from 2015) | City of Bradford Metropolitan District Council | https://www.judiciary.uk/prevention-of-future-death-reports/leah-barber-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Leah-Barber-Prevention-of-future-deaths-report-2023-0283_Published.pdf | As per box 3 (immediately above). | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 12 June 2019 I commenced an investigation into the death of Leah BARBER aged 15. The investigation concluded at the end of the inquest on 28 April 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by September 15, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 02/08/2023 | 2023-0282 | John Shenton | Mr John Penhale Ellery | Shropshire, Telford and Wrekin | Other related deaths | Prevention of Future Deaths | The Range | https://www.judiciary.uk/prevention-of-future-death-reports/john-shenton-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/John-Shenton-Prevention-of-future-deaths-report-2023-0282_Published.pdf | On the 17th April 2023 Mr Shenton, together with his wife and son, went to the The Range, Forge Retail Park, Telford TF3 4PB. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On the 25th April 2023 I commenced an investigation into the death of John Neil SHENTON. The investigation concluded at the end of the inquest on the 1st of August 2023 with a conclusion of Accidental Death. | In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 27th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 02/08/2023 | 2023-0281 | Dumile Thompson | Miss Janine Wolstenholme | Yorkshire West Eastern | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/dumile-thompson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Dumile-Thompson-Prevention-of-future-deaths-report-2023-0281_Published.pdf | Mr Thompson was a man of African-American origin. He suffered a reaction to recently prescribed Ramipril medication and developed angioedema on 23 October 2020. He attended hospital at around 09.15hr. ACE Inhibitor induced angioedema was confirmed following assessments by the emergency department he was referred to an ENT consultant who commenced treatment with a plan to admit to ITU and set a low threshold for intubation upon deterioration. Following reassessment by an ITU consultant it was determined admission to that unit was not required and admission to a high observation unit was appropriate. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that: • National Guidance and training for front line/emergency staff did not, and still does not, include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for speciality medicine input with certain types of angioedema. | On 12 November 2020 an investigation was commenced into the death of Dumile Daniel Thompson, aged 49 years, who died on 31 October 2020. The investigation concluded at the end of the inquest on 5 July 2023. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Thursday 28 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 01/08/2023 | 2023-0280 | Edward Rhodes | Richard Thomas Middleton | Dorset | Alcohol, drug and medication related deaths | Prevention of Future Deaths | The Beaufort Road Surgery | https://www.judiciary.uk/prevention-of-future-death-reports/edward-rhodes-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Edward-Rhodes-Prevention-of-future-deaths-report-2023-0280_Published.pdf | Mr Rhodes had a long history of alcohol misuse. He had been admitted to hospital numerous times for alcohol related issues. He lived in supported housing where he was tested regularly for substance misuse. In June 2022 he chose to abstain from alcohol and sought the help and support of agencies to prevent relapse. On 14/7/22 he stated he was over 1 month sober; on 18/8/22 he was 76 days sober; on 2/9/22 he stated he was 90 days sober; and by 16/11/22 he had been abstinent for 4-5 months. At the beginning of November 2022, he relapsed. On 17/11/22 he was found on his partner’s bedroom floor in an unresponsive state and was pronounced dead at the scene. Toxicology revealed the presence of methadone, which was at a level consistent with severe, possibly fatal toxicity for an individual who is naïve to or occasional user of methadone. Mr Rhodes was not on a methadone prescription at the time of his death. | The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. Mr Rhodes wanted to address the underlying causes for his addiction. He wished to be referred to the Mental Health Team for an assessment. He was told by medical professionals that he needed to be 90 days sober. | On the 23rd November 2022, an investigation was commenced into the death of Edward England Rhodes, born on the 9th July 1989. The investigation concluded at the end of the Inquest on the 27th July 2023. | In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, Tuesday 26th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 25/07/2023 | 2023-0279 | Paul Keating | Mr Oliver Robert Longstaff | Yorkshire West Eastern | Other related deaths | Prevention of Future Deaths | Leed City Council | Home Office | https://www.judiciary.uk/prevention-of-future-death-reports/paul-keating-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Paul-Keating-Prevention-of-future-deaths-report-2023-0279_Published.pdf | Paul Keating died on 15th April 2023 from the combined effects of carbon monoxide toxicity and pre-existing heart disease in a fire at the flat where he lived alone. The likely cause of the fire was the careless discarding of smoking materials in his bedroom. As he was entitled to, he had declined to allow contractors to install a sprinkler system in his flat when his local authority landlord was seeking to install such systems in all of their high rise properties following the Grenfell Tower disaster. | During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 28/04/2023 I commenced an investigation into the death of Paul Keating, aged 59 (17/12/1963). The investigation concluded at the end of the Inquest on 20/07/2023. | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 20/09/2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 31/07/2023 | 2023-0278 | Eileen Walsh | Mrs Jacqueline F Lake | Norfolk | Care Home Health related deaths | Prevention of Future Deaths | Broadlane View Care Home | https://www.judiciary.uk/prevention-of-future-death-reports/eileen-walsh-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Eileen-Walsh-Prevention-of-future-deaths-report-2023-0278_Published.pdf | Mrs Walsh had a significant medical history including dementia and general frailty. Mrs Walsh was admitted to Broadland View Care Home on 3 March 2019. Following falls on 5 November 2019 and 12 February 2020 Mrs Walsh’s Care Plan was updated to include steps to mitigate risks by 1. Leaving on hall light, 2. Providing a PIR sensor alarm, 3. Pressure mat alarm, 4. Hourly checks. Mrs Walsh was also provided with a bed which was to be lowered at night to prevent her being able to stand up to get out of bed. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. A Night Working Policy was being prepared but this is still not completed some 3 years following Mrs Walsh’s death. | On 26 June 2020 I commenced an investigation into the death of Eileen Marguerite WALSH aged 97. The investigation concluded at the end of the inquest on 27 July 2023. | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by September 25, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 26/07/2023 | 2023-0277 | Finley May | Mr Paul Vernon Marks | East Riding of Yorkshire and Kingston-upon-Hull | Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Royal College of Obstetricians and Gynaecologists | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/finley-may-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Finley-May-Prevention-of-future-deaths-report-2023-0277_Published-1.pdf | These are set out in my summary and findings of facts which are attached. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) The Hull and East Yorkshire NHS Trust has abandoned the use of Keilland’s forceps since Finley’s death and evidence was heard that other NHS trusts have also done so, Nevertheless, some have retained them. | On 24th May 2021 I commenced an investigation into the death of Finley Austin May, aged 28 days. The investigation concluded at the end of the inquest on 30th June 2023. The narrative conclusion of the inquest was: Finley Austin May was born the 16th of February 2021 having been delivered by use of Keilland’s rotational forceps. He was floppy, bradycardic, and blue at the time of delivery, and underwent resuscitation according to the neonatal life support algorithm. He was treated as a case of hypoxic ischaemic encephalopathy, but his clinical picture was at variance with this condition and he was investigated for other disorders. A MRI scan showed the presence of a high cervical spinal cord injury, which was caused by the use of Keilland’s obstetric forceps. He died at Hull Royal Infirmary, Anlaby Road, Kingston Upon Hull, on the 16th of March 2021 as a result of his spinal cord injury. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Thursday, the 21st day of September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 24/07/2023 | 2023-0276 | Alan Nippard | Mrs Maria Eileen Voisin | Avon | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Royal United Hospitals | https://www.judiciary.uk/prevention-of-future-death-reports/alan-nippard-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Alan-Nippard-Prevention-of-future-deaths-report-2023-0276_Published.pdf | According to Mr Nippard’s GP, Mr Nippard had a medical history which included poorly controlled type 2 diabetes, peripheral vascular disease, ischemic heart disease and chronic kidney disease stage 4. He had also undergone amputations of his toes due to non-healing diabetic ulcers. His daughter, said in evidence that he was admitted to hospital on 30th May 2022 following a fall at home. He said that he’d fallen forward and onto his knee. He was lifted from the floor and onto his bed by his family where he remained until an ambulance was called, when the decision was taken to admit him to the Royal United Hosptial (the RUH) in Bath. He was admitted via the Emergency department, then to the medical assessment unit (MAU), and then onto the Orthopaedic ward – Pierce Ward on 1st June 2022 in the early hours. According to the Consultant Orthopaedic Surgeon, Mr Nippard was initially admitted, with the diagnosis of right knee septic arthritis and an acute kidney injury on top of his chronic kidney disease. Mr Nippard was on antibiotics and on 2nd June 2022 underwent a washout of his knee. On 8th June he had a second washout. By 17th June he was deteriorating, on 20th June his CRP was increasing. He said in his evidence that the pressure sore was first documented by the orthopaedic team on 21stJune, the surgeon described this now as – the bigger source of infection. An MRI was requested but did not take place for 4 days; it was undertaken on 25th June and reported as showing no obvious sacral osteomyelitis it did show that it had locally spread in the soft tissue. By 28th June Mr Nippard was getting worse, his inflammatory markers were going up and now his testicles were swollen, and there was a suspicion was that this was Fournier’s Gangrene and there was a referral made to the Urology team. The orthopaedic surgeon said that as far as the treatment for Mr Nippard’s knee went, he felt they were winning that it was improving that if he hadn’t developed the pressure sore his expectation was that he would have been discharged. He agreed with the medical cause of death proposed. A Consultant Urologist examined Mr Nippard on 28th June, he said that he had evidence of a significant infection, that the only treatment was surgery, and all agreed that surgery was not likely to help, and it would cause Mr Nippard immense suffering in his last days. He explained that the other medical conditions Mr Nippard suffered with caused him to be compromised, if he’d had a stronger heart and kidneys then they would have operated Sadly, after discussions with Urologists, Surgeons, Anesthetists and the Critical care team it was decided that Mr Nippard was not fit for surgery, and he was placed on priorities of care and died on 6th July 2022. It was the view of the doctors who attended the inquest and gave evidence that the pressure sore significantly contributed to Mr Nippard’s death. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. I heard from the Trust’s Lead Tissue Viability Nurse, [REDACTED] had reviewed the notes and provided [REDACTED] opinion on what did happen, and what should have happened, in relation to the nursing care he was provided with. | On 7 July 2022 I commenced an investigation into the death of Alan Christopher NIPPARD. The investigation concluded at the end of the inquest. The conclusion of the inquest was a narrative including a finding of neglect. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 27/07/2023 | 2023-0275 | Johanne Blackwood | Mr Sean Kevan Horstead | Essex | Railway related deaths | Suicide (from 2015) | Essex Partnership NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/johanne-blackwood-prevention-of-future-deaths-report-2/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Johanne-Blackwood-Prevention-of-future-deaths-report-2023-0275_Published.pdf | A central aspect of Jo’s delusional beliefs was that (a) she had not slept for years and (b) that she suffered from a fatal physical health condition. The desperation engendered by her delusional and medically entirely unfounded beliefs led to a number of suicide attempts and both voluntary and compulsory admissions to mental health units. On the pt May 2021 Jo had attempted suicide [REDACTED] , some five weeks later, she would end her life. In the light of this incident her community risk assessment, her care plan and her safety plan were not up-dated – as they had not been since the date of her last discharge as a mental health in-patient on the 18th December 2020. Whilst her high risk of suicide was acknowledged by the community mental health team responsible for her safety – and care, management and treatment – in the community, and notwithstanding the context of the Covid-19 pandemic, I found an inappropriate over-reliance upon her family members, principally her husband and son, to keep Jo safe in the community. This involved the family monitoring Jo 24 hours a day, seven days a week over an extended period and physically preventing her from leaving her home address unaccompanied . This over-reliance was misguided and placed an unfair and unsustainable burden on the family, particularly in the light of a highly concerning text message sent by Jo to her Care Coordinator threatening suicide on the 11th June, the day before she took her own life. Following receipt of the text and seemingly reassured in part by Jo’s apparent retraction of the threat later that day, there was a failure to undertake an urgent face to face assessment by the community team to establish whether a referral to the Crisis Team was necessary; this specific failure possibly contributed to the subsequent death. In the circumstances I concluded that an inappropriate over-reliance upon family members to keep such a vulnerable and high-risk person safe in the community, over an extended period of time, probably contributed to Jo taking her own life on the 12th June 2021. | During the inquest the evidence revealed matters giving rise to concern. Although not identified as causative of the death in this case, in my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. Evidence confirmed a conspicuous lack of clarity as to when, where and by (or between) whom any formal handover of responsibility as Care Coordinator (CC) for Jo took place as between a number of CCs allocated to Jo over a period of many months from the lead up to and following her discharge as an in-patient back to the community team on December 18th 2020 and through to early May 2021. 2. Consequently , the evidence confirmed, despite her clear vulnerabilities, Jo did not have an allocated Care Coordinator for several weeks up to the beginning of May 2021. The evidence also confirmed that the lack of clarity as to the timing and conduct of CC handovers and the absence of an allocated CC to work with Jo (and by extension, her family) was informed by lack of a formal policy or procedure requiring that a full, detailed, formal record of handover between Care Coordinators is to be placed on EPUT electronic records. 3. Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, has the responsibilitv for oversight of patient carefollowing discharge, including responsibility for ensuring adequate and appropriate safety-netting is in place in the event of relapse, where a Care Coordinator is no longer in place/has not been replaced. Please note that this 3rd concern was previously raised by me with – CEO of EPUT (and in very similar terms) in a PFDR dated 25.02.2022 following the death of Stephanie Moyce. 4. The community Risk Assessment, Care Plan and Security Plan for Jo were not updated by a Care Coordinator between December 2020 and Jo’s death. | On 15th June 2021 I commenced an investigation into the death of Johanne Blackwood, aged 55 years. The investigation concluded at the end of the inquest on the 11th May 2023. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Thursday 21 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 27/07/2023 | 2023-0275 | Johanne Blackwood | Mr Sean Kevan Horstead | Essex | Prevention of Future Deaths | Railway related deaths | Suicide (from 2015) | Essex Partnership NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/johanne-blackwood-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Johanne-Blackwood-Prevention-of-future-deaths-report-2023-0275_Published.pdf | A central aspect of Jo’s delusional beliefs was that (a) she had not slept for years and (b) that she suffered from a fatal physical health condition. The desperation engendered by her delusional and medically entirely unfounded beliefs led to a number of suicide attempts and both voluntary and compulsory admissions to mental health units. | During the inquest the evidence revealed matters giving rise to concern. Although not identified as causative of the death in this case, in my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. Evidence confirmed a conspicuous lack of clarity as to when, where and by (or between) whom any formal handover of responsibility as Care Coordinator (CC) for Jo took place as between a number of CCs allocated to Jo over a period of many months from the lead up to and following her discharge as an in-patient back to the community team on December 18th 2020 and through to early May 2021. 2. Consequently , the evidence confirmed, despite her clear vulnerabilities, Jo did not have an allocated Care Coordinator for several weeks up to the beginning of May 2021. The evidence also confirmed that the lack of clarity as to the timing and conduct of CC handovers and the absence of an allocated CC to work with Jo (and by extension, her family) was informed by lack of a formal policy or procedure requiring that a full, detailed, formal record of handover between Care Coordinators is to be placed on EPUT electronic records. 3. Evidence confirmed a conspicuous lack of clarity as to who, amongst EPUT clinicians/staff, has the responsibilitv for oversight of patient care following discharge, including responsibility for ensuring adequate and appropriate safety-netting is in place in the event of relapse, where a Care Coordinator is no longer in place/has not been replaced. Please note that this 3rd concern was previously raised by me with – CEO of EPUT (and in very similar terms) in a PFDR dated 25.02.2022 following the death of Stephanie Moyce. 4. The community Risk Assessment, Care Plan and Security Plan for Jo were not updated by a Care Coordinator between December 2020 and Jo’s death. | On 15th June 2021 I commenced an investigation into the death of Johanne Blackwood, aged 55 years. The investigation concluded at the end of the inquest on the 11th May 2023. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Thursday 21 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 20/07/2023 | 2023-0273 | Andrew Vizard | Mr Michael Wall | Nottinghamshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Nottingham Healthcare Trust | https://www.judiciary.uk/prevention-of-future-death-reports/andrew-vizard-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Andrew-Vizard-Prevention-of-future-deaths-report-2023-0273_Published.pdf | Andrew Vizard was 58 years old when he died on 14 July 2022 at Queen’s Medical Centre, Nottingham. He died from a pulmonary embolism. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Despite there being concerns for an unresponsive patient’s breathing, it took: a) At least 6 minutes to obtain and utilise physical monitoring equipment. b) Nearly ten minutes for a ward doctor to attend the patient. c) Over 10 minutes for an ambulance to be called. Existing staff training and systems of emergency response do not appear to ensure an immediate and effective response in circumstances where there are concerns for a patient’s breathing. Although the delays did not cause or contribute to death in this case, I am concerned that if there are similar delays in similar life-threatening situations in future, deaths will occur. | On 11 November 2022 I commenced an investigation into the death of Andrew Vizard, aged 58 years. The investigation concluded at the end of the inquest which took place before myself as coroner sitting alone on 6 July 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by September 20, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 21/07/2023 | 2023-0272 | Steven Duquemin | Mr Alan Wilson | Blackpool and Fylde | Other related deaths | Prevention of Future Deaths | Northern Care Limited | https://www.judiciary.uk/prevention-of-future-death-reports/steven-duquemin-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/Steven-Duquemin-Prevention-of-future-deaths-report-2023-0272_Published.pdf | In addition to the contents of section 3 above, the following is of note: · Steven Duquemin was a vulnerable man who died at a relatively young age. · During the day he had carers with him as he ate. He was at risk of choking and could eat erratically, even to the extent he may try to ingest non – food items. · At some point overnight he tried to ingest a large piece of raw chicken and choked. He could access food from his fridge at a time when no care staff were present. · He was not checked upon overnight – something a Service Manager told the court should have happened, but it cannot be said this would have altered the outcome. · The location of the flat in which Steven lived [REDACTED] | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows · Entries in care records were inconsistent, some indicating Steven was not at risk of choking when he clearly was at such risk, and indeed one member of staff gave credible evidence that she had on one occasion have to use skills learned at some recent training to assist Steven after he overfilled his mouth with food. | The death of Steven Duquemin on at his home address was reported to me and I opened an investigation, which concluded by way of an inquest held on 28th June 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, and therefore on or before 16th September 2023 . I, the coroner, may extend the period further. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 24/07/2023 | 2023-0271 | John Coles | Richard Furniss | London West | Other related deaths | Prevention of Future Deaths | Heathrow Airport | https://www.judiciary.uk/prevention-of-future-death-reports/john-coles-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/08/John-Coles-Prevention-of-future-deaths-report-2023-0271_Published.pdf | Shortly before 0600 hours on 14 February 2018, the Deceased was driving a British Airways Renault Kangoo across and uncontrolled crossing of Taxiway C at Heathrow Terminal 5. The uncontrolled crossing ran between stands 546/547 and 556/557. Once he had entered that crossing he had to proceed and was not permitted to stop. About 20 metres from the end of the uncontrolled crossing (which was 105 metres in length) a Heathrow Airport Ltd (“HAL”) HiLux vehicle travelling south along taxiway C at 40 mph or more struck his Kangoo on the passenger side, causing the Deceased fatal injuries. The HAL driver of the HiLux had not seen the Deceased’s Kangoo on the crossing. The jury found (and I agree) that an influencing factor in the Hilux driver’s failure to see the Kangoo was was background visual interference. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | An investigation was commenced into the death of JOHN DAVID COLES (date of birth 19 March 1973) on 14 February 2018. The investigation concluded at the end of the inquest on 21 July 2023. The conclusion of the inquest was that the Deceased died of multiple injuries as a result of an Accident. | In my opinion action should be taken to prevent future deaths and I believe you and other officers of HAL have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 September 2023. I, the coroner, may extend the period. Your response should contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 24/07/2023 | 2023-0270 | Christine Nakafeero | Mr graeme Irvine | London East | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/christine-nakafeero-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Christine-Nakafeero-Prevention-of-future-deaths-report-2023-0270_Published.pdf | Christine Goodfriday Nakafeero was found unresponsive at home on the evening of 21st June 2022. Despite the best efforts of her family and emergency services she was declared deceased that evening. Her death was caused by a pulmonary embolism, in turn caused by a deep vein thrombosis. Earlier that day Ms Nakafeero had been discharged from hospital having presented with symptoms of menorrhagia and associated pain and anaemia on 19th June 2022. Whilst an inpatient, Ms Nakafeero was assessed for risk of venous-thrombo-embolism (“VTE”) risk utilising the Trust’s VTE policy, she was categorised as having zero risk of thrombo-embolism. Ms Nakafeero had been diagnosed with uterine fibroids since 2019 and had been prescribed tranexamic acid and pain relief to control the symptoms. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. Ms Nakafeero was assessed at a Gynae-oncology clinic in early 2019. The patient was diagnosed as not suffering from any form of cancer and was therefore referred on to the “benign” gynaecology team. Ms Nakafeero was advised that it was likely that the most effective treatment for her condition was a hysterectomy. It was expected that the likely wait for this treatment would be 6 months. Ms Nakafeero was not allocated an appointment and therefore had not received the necessary surgery by the time of her death in June 2022. Had the surgery been undertaken it is probable that she would not have developed a pulmonary embolism. Although the trust has investigated these circumstances and implemented change, no clear explanation could be offered for why the deceased slipped out of this care pathway. I am not satisfied that the risk of re-occurrence has been properly addressed. 2. The clinicians treating Ms Nakafeero assessed her VTE risk utilising an established algorithm based on national guidance. The assessment was undertaken appropriately but it failed to identify two risk factors which made the formation of a DVT more likely, namely, large uterine fibroids and the use of tranexamic acid. I have concerns that the omission of these factors in the assessment criteria limited the effectiveness of the risk assessment. | On 22nd June 2022 this Court commenced an investigation into the death of Christine Nakafeero, age 56 years. The investigation concluded at the end of the inquest between 20th and 21st July 2023. The court returned a narrative conclusion. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 18th September 2023 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | ||
| 20/07/2023 | 2023-0269 | Stephen Weatherley | Jenny Goldring | London Inner South | Alcohol, drug and medication related deaths | Prevention of Future Deaths | State Custody related deaths | https://www.judiciary.uk/prevention-of-future-death-reports/stephen-weatherley-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Stephen-Weatherley-Prevention-of-future-deaths-report-2023-0269_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/07/2023-0269-Response-from-HM-Inspectorate-of-Prisons.pdf | https://www.judiciary.uk/wp-content/uploads/2023/07/2023-0269-Response-from-HM-Inspectorate-of-Prisons-1.pdf | 1. SW died from the toxic effects of cocaine and methadone whilst detained at HMP Thameside. | During the Inquest, the evidence revealed matters giving rise to concern. A number of these have been addressed and do not require a PFD report. For the record, I have been informed that an upgrade of the cell bell system is agreed and quotes have been requested. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. · Data recording and retention in HMP Thameside /oversight by the Ministry of Justice (“MOJ”). · Absence of a written policy at HMP Thameside if there is a suspected drug swallow. Data recording and retention in HMP Thameside/oversight by MOJ 1. Key documents around decision making by Serco officers in respect of open/closed visits for SW were lost. | The death of Stephen Weatherley (“SW”) was reported to the coroner by HMP Thameside on 24th February 2018.A forensic post-mortem was conducted on 27th February 2018 and the report was completed on 9th July 2018.The medical cause of death of SW was 1a: Combined toxic effects of cocaine and methadone.On 16th March 2018, an Inquest was opened into the death of SW and an Article 2 Inquest was heard between 9th May 2023 and 22nd May 2023 with a jury. The jury concluded with a narrative conclusion and a short-form conclusion of drug-related death.I have considered Prevention of Future Death (“PFD”) evidence and submissions on 12th June 2023 and additional written evidence/submissions between 26th June 2023 and 5th July 2023. | Action should be taken by HMP Thameside and the Ministry of Justice2: 1. Given the deficiencies in record keeping/data retention highlighted during the Inquest, consideration should be given by HMP Thameside and the Ministry of Justice (who oversee the contract) as to whether record keeping and data retention at HMP Thameside has improved sufficiently since 2018. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 19/07/2023 | 2023-0268 | Kenneth Rippon | Miss Janine Richards | County Durham and Darlington | Mental Health related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/kenneth-rippon-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Kenneth-Rippon-Prevention-of-future-deaths-report-2023-0268_Published.pdf | The deceased had a history of mental health difficulties and he, and his family, had been actively seeking professional help for a significant deterioration in his mental heath in the days leading up to his death. These difficulties included self harm and suicidal ideation, as a result of command auditory hallucinations. On the 2nd of May 2022 the deceased presented at hospital via ambulance with a mental health crisis and suicidal ideation, [REDACTED]. He was clear that what would help him would be “to not go home” and that he did not feel safe at home. He was discharged in the absence of any comprehensive assessment, and in the absence of liaison with his family. The clinician assessing him did not have all of the important information to be able to carry out a comprehensive risk assessment, including in relation to recent incidents of self harm. The deceased was seen by his care co ordinator on the 3rd of May 2022. The de- ceased again confirmed that he had drunk bleach on the command of voices, and both he and family were asking for admission. There was no comprehensive assessment. Again the clinician was not aware of important information which should have been taken into account in any assessment of risk, including in relation to self harm. On the 4th of May 2022 the deceased presented at hospital via ambulance [REDACTED]. He told Doctors in the Emergency Department he had done this at the command of voices, that he still felt suicidal, and if discharged he would attempt to take his life again. There was no comprehensive assessment by mental health services and the clinician was not in possession of all relevant information as to risk. The deceased was discharged on the basis that there was no indication of current suicidal ideation at the point of the assessment or objective evidence of psychosis, to his home address, where he had indicated he did not feel safe. Whilst awaiting transport the deceased left the hospital having discarded his mobile phone and was reported missing. He was assessed as medium risk by the Police in the light of information provided by mental health services which had not been up- dated and did not include all risk events. Having left the hospital, the deceased fell or jumped [REDACTED] on the 5th May 2023, despite the efforts of Police officers on the scene. Kenneth’s intention cannot be established although it is known that the deceased was suffering from a deterioration in his mental health in the days leading up to his death, including evidence of auditory command hallucinations to harm himself. Mental health services involved with the deceased, did not carry out comprehensive mental state assessments despite the escalating risks which were known or ought to have been known, and did not fully involve family members in care, safety and dis- charge planning, who were crucial to his safety. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) The serious incident investigation report in this case was not available in this case until the 24.03.2023, over 10 months since the death and around 8 months outside the NHS framework guidance of 60 days for the completion of such, despite repeated requests and a schedule 5 notice being issued to attempt to obtain a copy of the draft report to inform this investigation, which was not complied with. | On the 16th May 2022 an investigation was commenced into the death of Kenneth Rippon, aged 47 years. The investigation concluded at the end of the inquest on 18th July 2023. The conclusion of the inquest was that Kenneth died on the 5th of May 2022 when he jumped or fell from the viaduct at Durham Train station, sustaining fatal injuries.The medical cause of death was multiple injuries. I recorded a narrative conclusion which included my finding that mental health services inadequate response to escalating risks, which were known or ought to have been known, including the failure to include family in assessment and safety/discharge planning contributed, more than minimally, to the death. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] | ||
| 19/07/2023 | 2023-0267 | Shane West | Mr Aled Wyn Gruffydd | Swansea and Neath Port Talbot | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Swansea Bay University Health Board | https://www.judiciary.uk/prevention-of-future-death-reports/shane-west-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Shane-West-Prevention-of-future-deaths-report-2023-0267_Published.pdf | The deceased was Shane Luke West and he was pronounced dead on the 17’h August 2018 at Morriston Hospital, Swansea. The cause of death was multi organ failure caused by cardio respiratory arrest due to increased pressure on the lungs from abdominal distention, which itself was caused by longstanding chronic constipation and fluid build up from his laxative treatment. | During the course of the inquest it transpired that the condition of Shane’s abdomen was changeable. Shane’s learning disability also meant that he was reluctant to report whether he was in any discomfort thus hiding the true picture. The cause of the variable abdomen condition was due to the osmotic laxative treatment filling the abdomen with fluid thus making it distended. Shane was prescribed three sachets of laxative in the morning and three in the evening. On the 15th of August there also appeared to be an instruction for an additional 8 sachets to be administered. The nursing notes state that these were not given due to a maximum of 8 sachets being allowed over a 24 hour period, but the PAN prescription chart appear to be signed as being given. It was not clear therefore whether additional sachets were administered. In any event Professor Colin Johnson acting as an independent expert witness stated that it was not the dosage that was relevant but at what frequency it was given, whether all together or staggered over 24 hours. It was found at inquest that the conservative method of treating the constipation was appropriate and there was insufficient evidence to state that excessive laxatives had been administered, however the combination of a longstanding constipation caused the abdomen to become distended and lose muscle mass meaning that it was inefficient at moving material along the gastro-intestinal tract. A further consequence of longstanding distention was that it was continually pressing against the diaphragm causing Shane to suffer reduced lung function. The additional distention from the colon filling with fluid as a result of the laxative treatment placed additional and unrecoverable strain upon Shane’s respiratory effort. I am concerned that in cases involving patients with learning disabilities (who commonly suffer from chronic constipation) the management of laxative treatment was not monitored closely enough to ensure a safe dose of laxatives. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. There was a contradiction between the nursing notes and the prescription charts as to the amount of laxatives administered on the 15th and 16th of August 2018. 2. Shane was known to hide his physical condition on questioning due to his learning disabilities and saying what he thought people wanted to hear. As such it was difficult for staff to get a true picture of Shane’s condition.. 3. Shane had ongoing respiratory compromise due to his abdominal distension pressing against his diaphragm therefore further distention posed a risk of further loss of respiratory function. 4. It was not clear whether medical professionals appreciated this risk and whether the administering of the laxatives ought to be staggered to allow Shane to receive the prescribed dose but not to the extent of overloading his already distended abdomen with fluid | On the 20th August 2018 I commenced an investigation into the death of Shane Luke West. The investigation concluded at the end of the inquest on the 19th July 2023. The medical cause of death is 1a) multi organ failure 1b) carfdio respiratory arrest 1c) abdominal distention caused by faecal impaction 2 sotos syndrome, scoliosis | In my opinion action should be taken to prevent future deaths and I believe you AND/OR your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 21/07/2023 | 2023-0266 | Corinne Haslam | Mr Chris Morris | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/corinne-haslam-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Corinne-Haslam-Prevention-of-future-deaths-report-2023-0266_Published.pdf | Mrs Haslam died on 18th March 2022 at Tameside General Hospital, Ashton-under-Lyne, as a consequence of complications arising from myocardial ischaemia and an acute exacerbation of Chronic Obstructive Pulmonary Disease, against a background of undiagnosed left ventricular hypertrophy. Mrs Haslam’s death was contributed to by physiological consequences of pulmonary thromboemboli which had been treated, and agitation in the context of severe and enduring mental illness. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. To the Secretary of State for Health and Social Care 1. The court heard evidence as to the barriers which exist and make it difficult for staff working on mental health wards to obtain input from physical health specialists without sending a patient to hospital via the Emergency Department. Whilst there are occasions where review in an Emergency Department is most appropriate, the court also heard evidence that these can be extremely busy and intensive environments which may not be a conducive to delivering care for patients experiencing severe and enduring mental illness; 2. It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems. The absence of such a unified records system creates obstacles as to the transfer of important clinical information between mental health and physical health specialists (and vice versa), with an inherent risk to patient safety arising from such information being held in silos. To the Chief Executive of Pennine Care NHS Foundation Trust 3. It is a matter of concern that ward-based nursing staff do not appear to have been provided with clear and unambiguous guidance as to the circumstances when a risk assessment for | On 8th April 2022, I opened an inquest into the death of Corinne Haslam who died on 18th March 2022 at Tameside General Hospital, Ashton-under-Lyne, aged 55 years. The investigation concluded with an inquest which I heard between 13th and 16th March 2023. The inquest determined that Mrs Haslam died as a consequence of:- 1) a) Acute left ventricular failure; b) Myocardial ischaemia and acute exacerbation of chronic obstructive pulmonary disease c) Left ventricular hypertrophy d) II) Pulmonary thromboemboli (treated); Agitation arising in the context of severe and enduring mental illness The conclusion of the inquest was one of Natural Causes. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action | You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th September 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | ||
| 21/07/2023 | 2023-0265 | Marion Nickson | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | NHS England | Care Quality Commission | https://www.judiciary.uk/prevention-of-future-death-reports/marion-nickson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Marion-Nickson-Prevention-of-future-deaths-report-2023-0265_Published.pdf | Marion Nickson was admitted to Macclesfield Hospital on 26th January 2023 after a fall at her home address. It was identified she had had a heart attack and needed a pacemaker. Whilst at Macclesfield she had a fall on 27th January whilst unobserved in a bay where she should have been observed but she sustained no significant injury. She was transferred to Stepping Hill Hospital as a day patient on 2nd February 2023 for a pacemaker to be fitted. During the fitting she sustained a pneumothorax a recognised complication of the pacemaker fitting. A chest drain was fitted and she was admitted to Stepping Hill Hospital whilst the chest drain was required. On the 12th February 2023 she had an unwitnessed fall but sustained no significant injury, She was identified as having acute coronary syndrome and treated with anticoagulants. On 13th February the chest drain was removed and on 14th February she was deemed to be medically optimised for discharged. She was in a bay where a member of staff should have remained at all times. That did not happen. Whilst unobserved she had an accidental fall when she tried to mobilise independently from her chair. She was sent for a CT scan and a bleed to the brain was identified. She deteriorated rapidly and died at Stepping Hill Hospital on 14th February 2023 as a consequence of her head injury. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The inquest heard evidence that to deal with the risk of falls in patients deemed to be high risk the concept of observable bay nursing had been introduced at both Trusts. At both Trusts Mrs Nickson fell whilst unobserved due to the challenges of maintaining the bays as observed bays. The challenge for both trusts had arisen where staff were required to deal with issues out of the bay and left the bay area. The cause of that was multifactorial and included a lack of understanding of the risk presented by leaving the bay and a need for the staff to complete other urgent tasks due to the demand on ward staff. | On 20th February 2023 I commenced an investigation into the death of Marion Nickson. The investigation concluded on the 6th July 2023 and the conclusion was one of Narrative: Died from the complications of an accidental fall sustained when not observed in hospital exacerbated by necessary anticoagulation therapy and when an inpatient following a pneumothorax a complication of a necessary medical procedure. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 21/07/2023 | 2023-0264 | Thomas Barton | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/thomas-barton-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Thomas-Barton-Prevention-of-future-deaths-report-2023-0264_Published.pdf | Thomas Barton lived independently at his home address. He developed a urinary tract infection and required hospital treatment. He was admitted on 15th November 2022 to Wythenshawe hospital and then moved to Trafford General Hospital. He responded to treatment. To facilitate his discharge he needed additional support at home and remained in Trafford General Hospital whilst care arrangements were organised. Whilst waiting for the package of care to be put in place he developed COVID 19 in hospital. As a consequence he deteriorated and developed dysphagia as a consequence of his frailty which led to him developing aspiration pneumonia. Despite treatment he became increasingly frail. He was discharged on end of life care to Flixton Manor Nursing Home on 24th January 2023 and died there on 27th January 2023. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The inquest heard that the delayed discharge of Mr Barton from hospital was due to the challenges of putting an appropriate social care package in place. The evidence before the inquest was that delayed discharges such as Mr Barton’s put the lives of frail elderly patients at risk as it is far more likely that they will become deconditioned and develop and infection if they spend unnecessary time in hospital. The evidence was that delayed discharges such as Mr Barton’s were not uncommon due to the demand on social care and the availability of suitable care. | On 1st February 2023 I commenced an investigation into the death of Thomas Barton. The investigation concluded on the 27th June 2023 and the conclusion was one of Narrative: Died from complications of aspiration pneumonia following a prolonged hospital stay contributed to by COVID which he contracted when discharge was delayed. The medical cause of death was 1a) Frailty; 1b) Aspiration Pneumonia on a background of Dysphagia; II) Covid, Urinary Tract Infection | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | ||
| 20/07/2023 | 2023-0263 | Albert Dovey | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/albert-dovey-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Albert-Dovey-Prevention-of-future-deaths-report-2023-0263_Published.pdf | Albert Dovey had an accidental fall in his home address. He was found on the floor at his home address. He was admitted to Tameside General Hospital where he was found to have rhabdomyolysis. His oxygen requirement was significant. He had an acute kidney injury and required a blood transfusion. He had heart failure. He was treated with antibiotics. He was found to have fractured his clavicle which further reduced his mobility. He became gradually frailer as a consequence of his reduced mobility in combination with his heart failure despite treatment. On 4th February 2023 he died at Tameside General Hospital. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 10th February 2023 I commenced an investigation into the death of Albert Dovey. The investigation concluded on the 30th June 2023 and the conclusion was one of Narrative: Accidental death exacerbated by underlying heart failure. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 20/07/2023 | 2023-0262 | Marianne Erika | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/marianne-erika-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Marianne-Erika-Prevention-of-future-deaths-report-2023-0262_Published.pdf | Marianne Erika Oldham was admitted via ambulance to the Emergency Department at Tameside General Hospital on 16th December at 17:33. She was triaged at 17:52. She presented with a history of vomiting and abdominal pain. She was triaged into Category 3 (urgent) which recommends clinical assessment within 60 minutes. She was not clinically assessed until 02:46 – 9 hours after her arrival. The delay was due to the demand on the department and was not unusual at that time. The abdomen was distended and guarded. A decision was made that she needed antibiotics and a CT scan. The antibiotics were not prescribed until 04:21 and administered at 04:50. The CT scan was ordered at 04:13. The delay was due to the clinical demands on the department. The scan took place at 05:11 and at 05:44 it was reported on. The scan showed a sigmoid colon perforation. She was referred to the surgical team who saw her at 06:50. A conservative treatment plan was put in place. She was moved to a surgical ward where she began to rapidly deteriorate with her NEWS 2 score rising to 16 at 08:55. Her NEWS 2 had been 1 at triage and 3 at 23:53 and 04:13. She died at Tameside General Hospital on 17th December just after 9am from peritonitis. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The inquest heard evidence that the very significant delay for Mrs Oldham to be seen by a clinician was due to the demand on Emergency Department Services. The inquest was told that delays of this length (9 hours) for patients who had been triaged to be seen within 60 minutes were not uncommon throughout the winter period across Greater Manchester and more widely. The demand was due to the volume of patients and the number of staff available to see and treat them. The delay was compounded by the shortage of radiographers and radiologists nationally meaning that even when a decision is taken for a scan it can take some time 9 an hour in this case) for it to take place and then reported on. In the time that Mrs Oldham was waiting to be seen she deteriorated very significantly meaning that by the time it was understood what the issue was she was very unwell and did not respond to conservative treatment which was all she was well enough for by that point. | On 28th December 2022 I commenced an investigation into the death of Marianne Erika Oldham. The investigation concluded on the 6th June 2023 and the conclusion was one of Narrative: Died from the complications of a perforation of the sigmoid colon where the perforation was not identified until 12 hours after her arrival in the Emergency Department and treatment was delayed as a consequence. The medical cause of death was 1a) Peritonitis; 1b) Stercoral Perforation of Sigmoid Colon; 1c) Intra-abdominal Adhesions; II) Ischaemic Heart Disease | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 14th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 20/07/2023 | 2023-0261 | Elliott Harratt | Ms Alison Patricia Mutch OBE | Greater Manchester South | Child Death (from 2015) | Prevention of Future Deaths | Greater Manchester Integrated Care | https://www.judiciary.uk/prevention-of-future-death-reports/elliott-harrett-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Elliott-Harrett-Prevention-of-future-deaths-report-2023-0261_Published.pdf | Elliott James Harratt’s mother went into early labour with him. He was born at the family home and transferred to Tameside General Hospital. He was 20 plus 4 weeks gestation. He died at Tameside General Hospital on 29th January 2023 from extreme prematurity | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 1st February 2023 I commenced an investigation into the death of Elliott James Harratt. The investigation concluded on the 26th June 2023 and the conclusion was one of Natural causes. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 14th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 20/07/2023 | 2023-0260 | Peter Harris | Ms Alison Brydie Hewitt | London City | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/peter-harris-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Peter-Harris-Prevention-of-future-deaths-report-2023-0260_Published.pdf | My findings as to the circumstances of the death, as recorded on the Record of Inquest, were as follows: 1. On the 11th May 2022 Peter Harris was admitted to Queens Hospital, Romford and was found to have a large pericardial effusion and a diagnosis of stage 4 metastatic lung cancer was made. The condition was untreatable but palliative chemotherapy was planned. However, on the 27th May 2022 and the 3rd June 2022, the Deceased was re-admitted with non- resolving pneumonia which was treated with anti-biotics. His symptoms worsened and he was found to have a recurrent pericardial effusion and, on the 5th June 2022, he was transferred to St. Bartholomew’s Hospital, London for a “pericardial window” to be performed. However, before going to theatre, the Deceased suffered a cardiac arrest. He was resuscitated and intubated, and he underwent an emergency pericardiocentesis before transfer to the Intensive Treatment Unit. Despite support, attempts to wean the Deceased from sedation were unsuccessful, and he developed multi-organ failure and died at 17.30 hours on the 10th June 2022. In 2020, whilst being investigated by the colorectal service at Queens Hospital, a CT scan performed in November 2020 raised the possibility of a malignant process in the lung but this report was not seen by the clinical team. If it had been seen, it is likely that annual review and monitoring would have been arranged and this may have enabled the lung tumour which subsequently developed to have been diagnosed and treated before it reached stage 4. There was, therefore, a lost opportunity to monitor for and, possibly, to diagnose and treat, the lung cancer. However, it is possible that the tumour, which probably developed quickly, would not have been found even by annual review. Consequently, on the evidence, it is not possible to ascertain whether monitoring probably would, or would not, have prevented the Deceased’s death. | Background: 1. The evidence at the inquest showed that the results of two separate scans performed on the Deceased, both of which had concerning outcomes, were not seen and acted upon in a timely manner. 2. First, on the 8th October 2020, a Consultant Colorectal Surgeon at Queens Hospital requested a CT scan of the Deceased’s thorax, abdomen and pelvis because the Deceased had reported significant weight loss and other symptoms. The radiologist’s report on the scan, dated the 8th November 2020, mentioned findings of multiple lung nodules and included a differential diagnosis of lung metastases. This outcome was never seen by the requesting clinician, nor any other clinician (including the Deceased’s General Practitioner). I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy; I was told that “the reporter would not raise this as an incidental finding because malignancy was already queried and would expect the referring clinician to review results”. The Consultant Colorectal Surgeon told me, however, that his understanding of the system was that he would be alerted to any finding or suspicion of malignancy. Further, although the Deceased had subsequently been given three outpatients appointments, the error was not picked up through these because all three appointments were cancelled by the hospital and the Deceased was not seen by the colorectal team again. 3. Secondly, a further CT scan of the Deceased’s thorax was undertaken on the 9th April 2022, but the formal report (suspicious for lung cancer) was not made until the 24th May 2022, and this resulting in delay in the Deceased being seen on the cancer pathway by the respiratory team. It seems that the delay in reporting was because a second hospital number had been used for the Deceased when the scan was performed in an external CT scanner located on the King George Hospital site. 4. At the inquest, I heard oral evidence from [REDACTED] , and I received documentary evidence, explaining the changes which have been made since the Deceased’s death. The documentation received included an 11 point Action Plan, supported by evidence as to the action that has been taken. On the basis of that evidence, I am satisfied that most of the concerns relating to the Deceased’s scan reporting and other management have been addressed. 5. I do, however, have two ongoing concerns about the system in place for the communication of concerning radiological findings. Steps have been taken to improve the system previously in place. In particular, I have been provided with a copy of the Trust’s new “Radiology Unsuspected Cancers and Critical Findings Protocol” which, I am told, has now been approved, and will be adopted, by the Radiology Clinical Leads and Clinical Governance Leads across North East London. I was also told that a new electronic scan requesting and reporting system will “go live” in August 2023, and that this will enable unexpected cancers and other incidental critical findings to be “red-flagged” directly to the requesting team. The system will also have an “acknowledgment option” enabling the referring doctor to click on a read receipt for all radiology reports. The MATTERS OF CONCERNS are as follows: Concern 1: The Trust’s new policy is concerned with ensuring that unexpected cancer or other critical radiological findings are highlighted to the requesting team. However, the evidence at the inquest suggested that requesting team were not alerted to the suspicious outcome of the Deceased’s November 2020 scan because it was an expected finding; as stated above, I was told that the radiologist’s report was not escalated or alerted to the clinical or multi-disciplinary teams because the requesting form had indicated that the scan was to rule out malignancy and the outcome was not, therefore, treated as unexpected. I am concerned, therefore, that the same could happen again, despite the changes which have been made. I did not consider that [REDACTED] was able to address this concern satisfactorily in his evidence. Concern 2: The new electronic system is introducing a “read receipt” feature which, if used, would enable identification of reports which have not been opened and read by the requesting team in a timely manner. I am concerned, however, that the use of the read receipt is optional as this will inevitably undermine the extent to which any monitoring system will be able to spot and identify unread reports. I did not consider that either [REDACTED], nor the Consultant Colorectal Surgeon from whom I heard evidence about the plans for monitoring in the surgical department of Queens Hospital, were able to address this concern satisfactorily in their evidence. | I commenced an investigation into the death of Peter John Harris, aged 73 years, who died at St. Bartholomew’s Hospital, London on the 10th June 2022. The investigation concluded at the end of the inquest on the 11th July 2023. | In my opinion action should be taken to prevent future deaths by addressing the concerns set out above and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by the 14th September 2023. I, as coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 19/07/2023 | 2023-0259 | Michael Amesbury | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Greater Manchester Integrated Care | https://www.judiciary.uk/prevention-of-future-death-reports/michael-amesbury-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Michael-Amesbury-Prevention-of-future-deaths-report-2023-0259_Published.pdf | Michael Kevin Amesbury had an extensive cardiac history. He was becoming increasingly unwell as a consequence. On 24th October 2022 he had a trans-oesophageal echocardiogram that confirmed he had severe mitral regurgitation. He was referred to Wythenshawe Hospital for surgical assessment. Whilst awaiting assessment he became increasingly unwell. He was prescribed Dapagliflozin medication which led to a rapid rise in his ketones and he became increasingly unwell. He was admitted to Tameside General Hospital on 30th November 2022 .Whilst an in-patient at Tameside General Hospital he became unresponsive. Cardiopulmonary resuscitation was undertaken during which there was severe vomiting of gastric contents. He died at Tameside General Hospital on 30th November 2022. Post-mortem examination confirmed he had died from bilateral bronchopneumonia (not diagnosed in life) in combination with extensive aspiration of gastric contents. He had extensive evidence of heart failure which on the balance of | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. The inquest heard evidence that Mr Amesbury needed to be referred from secondary to tertiary services within Greater Manchester. The inquest heard evidence that the speed and quality of that referral was impacted by the way in which information was shared between clinicians in different trusts within Greater Manchester. The use of different systems and reliance on postal services and lack of a clear, effective electronic system of referrals including transfer of images /notes meant there were delays in assessing patients which led to a delay in formulating a treatment plan in tertiary services; 2. The evidence also indicated that there were delays in patients who had been identified as requiring cardiology input being seen in cardiology clinics due to availability of clinicians/appointment slots inquest. This was exacerbated where there was a need for trans- oesophageal echocardiogram due to resource issues. The inquest heard that this type of echocardiogram could be key in understanding the cardiac issues of a patient. | On 6th December 2022 I commenced an investigation into the death of Michael Kevin Amesbury. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 19/07/2023 | 2023-0258 | Sylvia Pollitt | Ms Alison Patricia Mutch OBE | Greater Manchester South | Other related deaths | Prevention of Future Deaths | L&Q Group Housing | https://www.judiciary.uk/prevention-of-future-death-reports/sylvia-pollitt-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Sylvia-Pollitt-Prevention-of-future-deaths-report-2023-0258_Published.pdf | Sylvia Pollitt was an elderly resident of a property owned by L&Q. She called them to highlight a concern with her boiler. The call was passed to Liberty who were subcontracted to provide gas services. They were unable to contact her and closed the call down, They should have escalated the situation. On 1st December 2022 Sylvia Pollitt was found in her home address 1 Seamons Walk. Post mortem examination found she had died from complications of hypothermia. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 2nd December 2022 I commenced an investigation into the death of Sylvia Pollitt. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 19/07/2023 | 2023-0257 | Bernhard Marek | Ms Alison Patricia Mutch OBE | Greater Manchester South | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/bernhard-marek-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Bernhard-Marek-Prevention-of-future-deaths-report-2023-0257_Published.pdf | Bernhard John Marek (date of birth 2nd October 1946) had an accidental fall whilst walking from his car to a coffee shop. He could not weight bear following the fall. An ambulance was called. There was a 16 hour wait for an ambulance at that point. He was outside in the street in December. He was moved with assistance from members of the public to his car and driven home where an ambulance was again called for. He remained in his car whilst waiting for an ambulance as he could not mobilise from the car. The ambulance took him to Stepping Hill Hospital. He was diagnosed with a fracture to the neck of femur and admitted after a 9 hour wait in the emergency department. He was operated on. Post operatively his kidney function deteriorated further from his baseline. He required oxygen and his early warning score fluctuated. On 6th January 2023 he deteriorated rapidly having developed pneumonia. He died in Stepping Hill Hospital on 6th January 2023. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 11th January 2023 I commenced an investigation into the death of Bernhard John Marek .The investigation concluded on the 31st May 2023 and the conclusion was one of Accidental Death. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | ||
| 19/07/2023 | 2023-0256 | Thelma Radmore | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/thelma-radmore-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Thelma-Radmore-Prevention-of-future-deaths-report-2023-0256_Published.pdf | Thelma Mary Radmore had a complex medical history. She was taken to Stepping Hill Hospital on 11th December 2022 at 18:20 via ambulance following a prolonged delay waiting for an ambulance to become available. Due to the volume of patients at the Emergency Department Mrs Radmore waited for over an hour with the ambulance crew in a corridor on an ambulance trolley. She was then moved to a hospital trolley in a cubicle. She was in the Emergency Department for in excess 26 hours before being transferred to a ward this was due to demand for and availability of beds. On the balance of probabilities the prolonged wait for a hospital bed and delayed transfer to hospital contributed to a significant deterioration in her skin integrity. Her sacral pressure ulcer was found to be unstageable on assessment by the tissue viability nurse on 16th December 2022. On 20th December 2022 she was swabbed for Covid-19 and Influenza A. Both on balance of probabilities contracted in hospital. She was initially stable. On 22nd December 2022 she began to deteriorate rapidly with Covid Pneumonitis and Influenza A. She died at Stepping Hill Hospital on 23rd December 2022. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 30th December 2022 I commenced an investigation into the death of Thelma Mary Radmore. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | ||
| 18/07/2023 | 2023-0255 | Christine Dickinson | Mr Chris Morris | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Stockport NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/christine-dickinson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Christine-Dickinson-Prevention-of-future-deaths-report-2023-0255_Published.pdf | Mrs Dickinson had been diagnosed with Grade II Follicular Lymphoma and had been receiving treatment at the Laurel Unit with Rituximab. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 30th November 2022, I opened an inquest into the death of Christine Mary Dickinson who died on 15th November 2022 at Stepping Hill Hospital, Stockport, aged 76 years. The investigation concluded with an inquest which I heard on 16th June 2023. The inquest determined that Mrs Dickinson died as a consequence of:- 1) a) Pneumocystis Jirovecii Pneumonia; b) Interstitial Lung Disease and Immunosuppression II) Lymphoma | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 12th September 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 19/07/2023 | 2023-0254 | Evelyn Dutton | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/evelyn-dutton-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Evelyn-Dutton-Prevention-of-future-deaths-report-2023-0254_Published.pdf | Evelyn Mary Dutton had severe Systemic Sclerosis. She was admitted to Stepping Hill Hospital following an accidental fall at her home address. It was identified that she had fractured her neck of femur. She was operated on. Post-operatively her weight was found to be low and she was referred to the dietetics team. Her nutritional status remained compromised and an Nasojejunal (NJ) tube was sited on 21st July 2022. There was a delay in utilising the NJ Tube until 29th July. The NJ feeding was subsequently stopped due to concerns of aspiration and fluid overload. It was restarted on the night of 4th August. There was a significant electrolyte imbalance, probably due to refeeding syndrome due to the issues with nutrition. On 5th August the feeding via the NJ Tube was stopped due to episodes of vomiting of blood from her gastro intestinal issues including duodenal ulcers, identified in a series of gastroscopies, probably caused by steroid treatment. She continued to become increasingly frail. She deteriorated further and died at Stepping Hill Hospital on 13th August 2022. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 19th August 2022 I commenced an investigation into the death of Evelyn Mary Dutton. The investigation concluded on the 4th May 2023 and the conclusion was one of Narrative: Died from natural causes contributed to by complications of an accidental fall, poor nutritional status and complications of necessary medication. The medical cause of death was 1a) Multi-organ failure; 1b) Frailty; II) Multiple Duodenal Ulcers, Fracture left hip with Hemiarthroplasty, Poor Nutritional Status, Systemic Sclerosis | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 19/07/2023 | 2023-0253 | Carole McQuinn | Ms Catherine Cundy | North Yorkshire and York | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Leeds Teaching hospitals and York Hospital Legal trust | https://www.judiciary.uk/prevention-of-future-death-reports/carole-mcquinn-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Carole-McQuinn-Prevention-of-future-deaths-report-2023-0253_Published.pdf | On the 21st of February 2022 the deceased underwent a distal pancreatectomy and splenectomy at St James’s University Hospital, Leeds to treat a malignant pseudo papillary tumour. She subsequently developed leaking of fluid from the remnant pancreas which is a recognised complication of this surgery and for which an abdominal drain was sited. She had a prolonged in-patient admission, during which she required periods of intravenous antibiotic therapy to treat abdominal collections, drainage of a pleural effusion and nutritional support via naso-gastric feeding and total parenteral nutrition. Her abdominal drain was removed on the 11th of April 2022. She was discharged home on the evening of the 20th of April 2022 without a discharge note or medication, which were not supplied until the following day. No follow up appointment was booked for the deceased. On the 21st of April 2022 the site of her previous abdominal drain was leaking pus. A swab was taken of the site and booked in to St James’s Hospital for testing on the 22nd of April 2022. The results of the swab were reported on the 26th of April 2022 but not reviewed by a member of the clinical team until the 3rd of May 2022 when oral antibiotics were commenced. On the evening of the 4th of May 2022 the deceased was found collapsed at home and was admitted to York Hospital by ambulance. She was treated for intra-abdominal sepsis and her observations stabilised, but she was found unresponsive in her hospital bed on the morning of the 7th of May 2022. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 16 May 2022 an investigation was commenced into the death of Carole MCQUINN aged 66. The investigation concluded at the end of the inquest on 11 July 2023. The conclusion of the inquest was that the deceased died as a consequence of a recognised complication of necessary surgery to treat pancreatic cancer, namely a pulmonary embolism which was likely to have developed as a result of post-operative infection, inflammation and immobility. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by September 07, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 18/07/2023 | 2023-0252 | Colin Greenway | Ms Yvonne Kathleen Blake | Norfolk | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Queen Elizabeth Hospital | https://www.judiciary.uk/prevention-of-future-death-reports/colin-greenway-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Colin-Greenway-Prevention-of-future-deaths-report-2023-0252_Published.pdf | Mr Greenway went to Cyprus with his family [REDACTED] all became ill with a gastroenteritis. Mr Greenway returned home to the U.K. on 18 October, he remained unwell with diarrhoea and nausea. He spoke to his GP on 19 October who advised rest and fluids and went with [REDACTED] to a walk in centre on 21 October who advised him to attend hospital. He was taken to the Queen Elizabeth Hospital in King’s Lynn and admitted. He was unwell with acute kidney injury and febrile. He was given IV fluids and antibiotics and urine and stool samples sent. The junior doctor clerking him did not use the clerking booklet when performing a VTE assessment which would have guided [REDACTED] to prescribe 40mg of enoxaparin an anti- coagulant, instead [REDACTED ]used the VTE assessment on the electronic prescribing system which is not as detailed as the paper clerking booklet. To prescribe anticoagulants the electronic VTE assessment has to be filled in. Despite Mr Greenway’s known risk factors of age, obesity, recent infection and loss of mobility she prescribed a “renal dose” of 20mg of enoxaparin, half the usual dose. Mr Greenway’s eGFR (measurement of renal function) was 58 and the dose of anticoagulant is only supposed to be reduced if this measurement is below 30. When spoken to after Mr Greenway’s death [REDACTED] explanation was that [REDACTED] did this in a excess of caution despite clear guidelines. Mr Greenway remained on this dose for his entire hospital stay. No senior clinician checked this prescription, the consultant who gave evidence assumed the pharmacists would have done a reconciliation. Mr Greenway was discharged and died several days later from a pulmonary embolism. The pharmacy service at weekends at this hospital had been suspended for some time, this consultant was even aware of this. [REDACTED] said [REDACTED]was too busy to check individual patients’ new prescriptions on [REDACTED] ward rounds. The pharmacy reconciliation is meant to operate as a fail safe or safety net, it is the Consultant Doctor’s responsibility to check what their junior unsupervised doctors do at the weekend when a patient is admitted. This consultant didn’t ever speak to this junior doctor about this mis-prescribing or know what action if any had been taken about it. I was informed by a senior nurse that other such drug errors have occurred since Mr Greenway died. Documentation was poor and the TRAINED NURSES are undertaking courses to show them how to complete fluid balance charts which is something I would expect them to already know how to do. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: · Junior doctors incorrect prescribing despite clear guidelines. · VTE assessments not being completed on clerking a patient just on the electronic medicines prescription which is much less detailed. · Consultants stating it is the pharmacists’ job to check for errors when there is only a 3 day service by pharmacists to do this and it is intended as a safety net procedure only. · Consultants not accepting that it is their responsibility to monitor what their junior doctors are doing when prescribing new medications for patients. · 3 different consultants seeing the same patient over 3 days, no continuity of care. · Patients at higher risk of an embolus not being monitored correctly or at all after initial clerking. | On 3 November 2022 I commenced an investigation into the death of Colin Vincent GREENWAY aged 63. The investigation concluded at the end of the inquest on 17 July 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by September 12, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 17/07/2023 | 2023-0251 | Jane Wadsworth | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Tameside & Glossop Integrated Care NHS Foundation Trust | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/jane-wadsworth-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Jane-Wadsworth-Prevention-of-future-deaths-report-2023-0251_Published-1.pdf | Jane Elizabeth Wadsworth had elective hip surgery. She returned to Tameside General Hospital with concerns over her wound. She subsequently developed a deep vein thrombosis and cellulitis. On 22nd November 2022 she became very unwell and was admitted to Intensive Care Unit with sepsis, acute kidney injury and liver failure. She was treated on the Intensive Care Unit until 26th November when she returned to the ward. She continued to be treated for her cellulitis and an ulcer of the left foot that had developed. She was stepped down to the Stamford Unit on 16th December 2022. On 22nd December 2022 she returned to Tameside General Hospital due to concerns about her raised NEWS 2 score, raised probably as a consequence of cellulitis. She was started on intravenous antibiotics. Her liver function was deranged and she had acute kidney injury. She had a catheter but her urine output was difficult to assess due to issues regarding possible catheter bypass. On 24th December, one dose of antibiotics was missed. On 25th December, two doses of antibiotics were missed. She continued to be unwell and on 27th December further antibiotics were prescribed. She was referred to the Critical Care Outreach Team who assessed and determined that Intensive Care Unit referral was not necessary. On 29th December the antibiotics were changed. There was a further referral to Critical Care Outreach that was unsuccessful as there were no staff available. There was no doctor to doctor assessment and no consultant review and no liver specialist advice sought or provided. She continued to deteriorate on 30th December with poor liver function and poor kidney function. On the morning of 31st December she deteriorated rapidly and was accepted by the Intensive Care Unit where despite aggressive treatment she deteriorated rapidly and died on 31st December 2022. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. Mrs Wadsworth missed three doses of antibiotics prescribed to treat her infection according to the evidence given to the inquest. This did not appear to have been escalated and there was no clear explanation regarding this occurring other than that her cannula may not have been in place and there was a delay in a doctor being available to reinsert one; 2. The evidence before the inquest was that on her admission over Christmas/New Year there was no effective consultant input into her care; 3. The junior doctor involved in her care felt that ICU involvement/input would be beneficial. The evidence was that there did not seem to be any doctor to doctor discussion of this. The inquest heard evidence that this was one way a patient could be transferred to ICU. It was unclear why there had not been such a discussion and whether in periods such as Christmas/ New Year where there were fewer consultants available the system worked effectively. This was not a situation where there had been a ward based ceiling of care put in place and ultimately Mrs Wadsworth was treated by ICU but was extremely unwell at that point and did not respond to that intervention at that point; 4. The alternative support available to ward based staff and possible route into ICU according to the evidence given at inquest was via the Critical Care Outreach team. That team is staffed primarily by nurses and its key focus is on presentation linked to NEWS2 scores according to the evidence given to the inquest. Mrs Wadsworth’s case was a complex one involving issues relating to her liver function and kidney function rather than just her NEWS2 scores and it was unclear if the Critical Care Outreach Team were best placed to assess her need for ICU support; 5. The inquest heard that on the date of one referral that team was not in any event available to the ward and the nurse who should have undertaken the role had been redeployed elsewhere in the trust and there was no capacity to fill that role; 6. Following her first admission to ICU there was a note that Mrs Wadsworth’s case should be discussed with a specialist Liver team. There was no evidence available to the inquest that such a discussion had taken place. It was not entirely clear on the evidence precisely which clinician was to take ownership of the action. | On 3rd January 2023 I commenced an investigation into the death of Jane Elizabeth Wadsworth .The investigation concluded on the 12th June 2023 and the conclusion was one of | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 14/07/2023 | 2023-0250 | Sean Heeny | Mr Jonathan Dixey | Northamptonshire | Alcohol, drug and medication related deaths | Prevention of Future Deaths | State Custody related deaths | HM Prison | Probation Service | https://www.judiciary.uk/prevention-of-future-death-reports/sean-heeny-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Sean-Heeny-Prevention-of-future-deaths-report-2023-0250_Published.pdf | At the time of his death, Mr Heeney was a resident at Bridgewood House Approved Premises in Northampton. He had been released from prison on licence on 9th September 2019. Mr Heeney had a history of drug and alcohol misuse. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 2nd October 2019 an investigation was commenced into the death of Sean Anthony Heeney, aged 34. The investigation concluded at the end of the inquest on 13th July 2023. The conclusion of the inquest was a narrative conclusion: | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 8th September 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 18/07/2023 | 2023-0249 | Ronald Ashdown | Mr Sean Kevan Horstead | Essex | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Mid and South Essex NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/ronald-ashdown-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Ronald-Ashdown-Prevention-of-future-deaths-report-2023-0249_Published.pdf | Ronald Scott Ashdown (RA) died on the 15th August 2021 at Basildon University Hospital, Nethermayne, Basildon, Essex from complications arising from the severe disability sustained following a cardiac arrest and subsequent significant hypoxic brain injury in 2013. | Notwithstanding the finding of a natural cause of death, inquest evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. Upon RA’s arrival back at the Nursing Home on 2nd August, staff immediately raised a Safeguarding concern in respect of, inter alia, his genitals being covered in a white “cheese” like substance with, additionally, faecal matter in his pubic hair; extensive areas of flaking skin including behind his ears was also identified. Colour photographs were taken and provided to the Trust along with the Safeguarding documentation. Objectively, the photographs clearly documented the flaking skin and white “cheese” like material covering RA’s penis. 2. Evidence confirmed that the Mid and South Essex NHS Foundation Trust, responsible for Basildon Hospital, carried out a significantly flawed RCA investigation which effectively rejected any suggestions of shortcoming in care, management and treatment. The Ward Matron (responsible for the ward concerned) was the co-author responsible for the RCA Report. [REDACTED] gave evidence to the inquest that she had not been provided with the photographs provided by the Nursing Home and RA’s daughter until just two weeks prior to the inquest hearing. (It was noted and accepted that even when [REDACTED] had seen the photographs neither nor the Trust had seen fit to draw this to HMC’s attention or to provide either an addendum statement or a revised RCA). 3. The Trust’s responsible Adult Safeguarding Lead provided a statement in which [REDACTED] confirmed that, notwithstanding the photos having been expressly noted in the original Safeguarding referral and raised in subsequent correspondence and meetings with the Thurrock Local Authority Safeguarding Team, [REDACTED] had not made the photos available for the purposes of the RCA. [REDACTED] was unable to provide any explanation at all for this failure. This lack of professionalism was and remains a grave cause for concern resulting as it did in a seriously flawed Trust investigation, which itself fed into the Thurrock Adult Safeguarding investigation and, further still, a wider section 42 systemic investigation involving RA’s case and two others to which a range of stakeholders contributed. It was accepted by the Trust witnesses that but for the coronial investigation, the denials of any Trust failings would have remained unchallenged perpetuating a false record of the basic nursing care provided (or not provided) to the highly vulnerable and dependent RA. 4. The evidence heard at the inquest undermined the following erroneous findings of the RCA: · In response to the concern that RA had extensive flakes of fungal growth behind his ears the RCA concluded that “no flakes noted in hospital, documentation supports regular personal care was provided throughout admission.” · In respect to the concern that RA’s foreskin/genitals were covered in flakes and what appeared to be “cheese / paste” the RCA asserted that there were “no flakes noted in hospital, documentation support regular personal care was provided throughout admission.” | On 3rd September 2021 I commenced an investigation into the death of Ronald Scott Ashdown, aged 55 years. The investigation concluded at the end of the inquest on the 1st June 2023. The conclusion of the inquest was one of natural causes in the context of an expanded narrative conclusion. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 12th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 18/07/2023 | 2023-0248 | Philip Hawkins | Mr David Pojur | North Wales (East & Central) | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Betsi Cadwaladr University Health Board BCUHB | Welsh Ambulance Service Trust WAST | https://www.judiciary.uk/prevention-of-future-death-reports/philip-hawkins-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Philip-Hawkins-Prevention-of-future-deaths-report-2023-0248_Published.pdf | The circumstances of the death are as follows :- On 18.3.23 Mr Hawkins, aged 97, suffered a fall at home and was transferred by ambulance to hospital where he subsequently died. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 29.03.23 an investigation was commenced into the death of Philip Hawkins (DOB 09.07.1925) who died on 23.03.23. The investigation concluded at the end of the inquest on 18.07.23. The conclusion of the inquest was Accident. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 12.09.23. I, David Pojur, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 14/07/2023 | 2023-0247 | Emily Corfield | Ms Kate Robertson | North Wales (East & Central) | Alcohol, drug and medication related deaths | Prevention of Future Deaths | Adferiad Recovery | Betsi Cadwaladr University Health Board BCUHB | https://www.judiciary.uk/prevention-of-future-death-reports/emily-corfield-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Emily-Corfield-Prevention-of-future-deaths-report-2023-0247_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/07/Emily-Corfield-Prevention-of-future-deaths-report-2023-0247-b_Published.pdf | The circumstances of the death are as follows : | During the course of the inquest, the evidence revealed matters giving rise to concern. | On 27 September 2021 an investigation was commenced into the death of Emily Corfield (DOB 30/12/79) who died on 19 September 2011. The investigation concluded at the end of the inquest on 11 July 2023. The conclusion of the inquest was an alcohol related death. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 8 September 2023. I, Kate Sutherland, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 14/07/2023 | 2023-0246 | Phoenix Chapman | Ms Mary Hassell | London Inner North | Child Death (from 2015) | Prevention of Future Deaths | Homerton Healthcare NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/phoenix-chapman-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Phoenix-Chapman-Prevention-of-future-deaths-report-2023-0246_Published.pdf | Phoenix was born unexpectedly at home and died as a consequence of a cord compression during the second stage of labour. His mother was attended by paramedics, but really what she needed was early hospital obstetric care. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. That Phoenix’ death was and remains utterly devastating for his parents is unsurprising. However, it was clear at inquest that it was also deeply shocking for those trying to care for him and his mum. Events were outside the experience of several of the healthcare professionals involved. I heard at inquest that new national maternity guidance is to be published at the end of the month. This will include within it revised advice for paramedics faced with an unplanned home delivery such as this one to transport to hospital even if birth is imminent. I was assured at inquest that the advice will quickly be disseminated. Had I not been given this information, I would have made a prevention of future deaths report to the ambulance service. It is of course of the utmost importance that hospital clinicians and ambulance clinicians have the same understanding of how a patient in any given situation should be treated, and I have copied this report to the London Ambulance Service (LAS). The reason I make a report to the Homerton, is because it seemed to me at inquest that there were two matters that had not yet been resolved. i) At inquest, there was not a shared understanding among the clinicians within the trust about how such a situation should be approached. The obstetricians were clear that, given her very high risk status, Phoenix’ mum needed to come in to hospital as soon as she showed the first signs of labour. And even if she had started to deliver, she could still only be treated effectively and Phoenix given the best chance of a good outcome in hospital. | On 3 August 2022, I commenced an investigation into the death of Phoenix Chapman, a baby who died less than six weeks after he was born. The investigation concluded at the end of the inquest on 7 July 2023. I made a determination at inquest of death by natural causes. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. | |
| 17/07/2023 | 2023-0245 | Ross Ballatine, Carl McGrath, Alan Minard | Mr David Lewis | North Wales (East & Central) | Other related deaths | Prevention of Future Deaths | Maritime & Coastguard Agency | https://www.judiciary.uk/prevention-of-future-death-reports/ross-ballatin-carl-mcgrath-and-alan-minard-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Ross-Ballatin-Carl-McGrath-and-Alan-Minard-Prevention-of-future-deaths-report-2023-0245_Published.pdf | The vessel set sail on the morning of 27 January 2021 with its skipper and two other fishermen (the three deceased) on board. Their intention was to collect whelks for sale. The vessel capsized at around 18:00. The bodies of the three men were washed ashore at various points around the coast of North West England around 7 weeks later. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Although I was somewhat reassured to learn that the relevant Regulations have been revised and strengthened since these events, I am concerned that in this case (and, therefore, possibly in other cases) the Agency did not establish or apply a clear threshold in determining the need for a full stability assessment to be performed following significant modifications to the vessel. Too much reliance was placed on: (1) reassurances offered by the skipper of the vessel in relation to his appreciation of risk and/or his operational intentions (notably about the size and distribution of the load); and (2) informal visual assessments of the impact of the modifications which were undertaken whilst the vessel was in dock and was not under loaded conditions. In addition, insufficient concern arose from the issues identified on the two occasions when Holyhead Coastguard advised the Agency of the need to rescue the vessel following breakdowns at sea. I am concerned that other vessels (whether or a similar size or otherwise) may be operating, which have been modified since the issue of the original safety certificate and which require a full stability assessment before their operational safety can be properly evaluated. | On 14 July 2023, sitting with a jury, I heard simultaneously the inquests into the deaths of three men (Ross Stephen Ballatine, Carl Stephen McGrath, Alan Wallace Minard), each of whom died from immersion/drowning after the fishing vessel on which they were working (Nicola Faith) capsized off the coast of North Wales on 27 January 2021. In each case the jury returned a narrative conclusion in the same terms: | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th of September 2023 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 14/07/2023 | 2023-0244 | Peter Fleming | Mr James Bennett | Birmingham and Solihull | Other related deaths | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/peter-fleming-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Peter-Fleming-Prevention-of-future-deaths-report-2023-0244_Published.pdf | Peter had a long history of depression, anxiety, and reported suicide attempts. He had acknowledged his reluctance to always engage fully with the treatment offered. On 3/08/22 he was referred to the home treatment team for crisis intervention. After poor engagement he was transferred back to the community mental health team. On 14/10 he was detained by police under section 136 mental health act after expressing suicidal ideation. He told a psychiatric liaison service nurse he had no ongoing suicidal ideation and was referred to the community mental health team and his GP. He contacted the crisis team on 30/10. He was telephoned by a mental health nurse on 31/10, and Peter reported upset about personal issues but no suicidal ideation. On 31/10 he also contacted RELATE and had a telephone consultation with his GP, reporting worsening mental health in part because of a delay in his medication being prescribed, but reported no suicidal ideation. On 8/11 he called the crisis team reporting upset but no suicidal ideation. This prompted a community mental health team nurse on the 9/11 to try without success contacting Peter on the telephone. On 10/11/22 Peter was found deceased in his flat having taken a deliberate overdose of his prescribed medication. At the time of his death he was on the waiting list to be allocated a mental health care co-ordinator and there had been no multi-disciplinary meeting with all teams involved to agree how best to work with Peter. | During the course of the inquest the evidence revealed matters giving rise to concern. | On 3 January 2023 I commenced an investigation into the death of PETER MARTIN AARON FLEMING. The investigation concluded at the end of the inquest on 4 July 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 14/07/2023 | 2023-0243 | Terence Burns | Mr Andrew David Cousins | Blackpool and Fylde | Care Home Health related deaths | Prevention of Future Deaths | Highgrove Rest Home | https://www.judiciary.uk/prevention-of-future-death-reports/terence-burns-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Terence-Burns-Prevention-of-future-deaths-report-2023-0243_Published.pdf | I returned the following in box 3 of the Record of Inquest recorded: Mr Terence Burns was resident at the Highgrove Rest Home, Blackpool. The care plan that was put in place for Mr Burns included that he required a blended food diet. On 28 October 2022, Mr Burns’ physical condition deteriorated and an ambulance was called to the Highgrove Rest Home. When Mr Burns was transferred to Blackpool Victoria Hospital, his dietary requirements were not notified to North West Ambulance Services. Consequently, during his course of treatment, the dietary requirements for Mr Burns were not known by Blackpool Victoria Hospital. During the evening of 28 October 2022, Mr Burns was given a sandwich to eat at Blackpool Victoria Hospital. At approximately 22.52hrs on 28 October 2022, Mr Burns was found unresponsive in the hospital cubicle with food reside in his throat. Mr Burns displayed no breathing effort and died at approximately 23.00hrs. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. | On 10 July 2023, at an inquest held at Blackpool Town Hall, I returned a short form conclusion that Mr Terence Burns died as a result of misadventure. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 8 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 11/07/2023 | 2023-0242 | John James | Ms Nadia Persaud | London East | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Barts Health NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/john-james-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/John-James-Prevention-of-future-deaths-report-2023-0242_Published.pdf | Mr. James was admitted to Whipps Cross Hospital on the 13 October 2022 and was found to be suffering from malnutrition and a bowel obstruction (later discovered to be due to an adenocarcinoma). He underwent surgery on 18 October 2022 to remove the tumour. This was surgically uneventful. Post-operatively, he required a lengthy period of intensive care. On the 19 December 2022 he was stepped down from intensive care to a ward. He was at a very high risk of developing a thromboembolism due to his cancer diagnosis, recent surgery, lengthy period in hospital and immobility. During the period of 9 to 15 January 2023 he refused his anti- coagulation medication on three occasions. The reason for refusal is unclear and there is no documented evidence that the risk of non-compliance with the medication was explained to him or escalated to the medical team. On the 20 January 2023, Mr. James suffered from an acute deterioration in his health, culminating in a cardiac arrest. He passed away at Whipps Cross Hospital on the 21 January 2023 from a pulmonary embolism. The missing doses of anticoagulation during the two weeks leading up to his death is likely to have contributed to a degree, to the development of the pulmonary embolism. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: The refusal of anti-coagulation medication was not brought to the attention of medical staff. The administration of anti-coagulation medication to patients like Mr James, is vital for reducing the risk of a venous thrombo-embolism, a potentially life-threatening condition. There is no electronic prompt/alert to highlight to the medical team when prescribed anticoagulation medication is not administered. The Trust’s internal investigator recognised that a fail-safe should be put in place within the electronic records, to ensure escalation to the medical team where doses of prescribed anti- coagulation are not administered. Such a measure could prevent similar deaths from occurring. It was considered that this measure could assist in preventing future deaths not just locally, but at a wider level. | On 16 February 2023 I commenced an investigation into the death of Mr John Michael James. The investigation concluded at the end of the inquest on the 6 July 2023. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 6 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 12/07/2023 | 2023-0241 | Mohammed Hussain | Mrs Louise Hunt | Birmingham and Solihull | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/mohammed-hussain-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Mohammed-Hussain-Prevention-of-future-deaths-report-2023-0241_Published.pdf | At around 01.30 on 28/11/22 Mr Hussain was found collapsed on the bathroom floor at his home address. An ambulance was called by his sister when she arrived at the property but sadly he was confirmed deceased at 02.09. He had been seen by his sister the day before when he was noted to be well. He had been diagnosed with treatment resistant schizophrenia and depression and had been under the care of Mental health team since 1997. He was established on clozapine in 2004 which requires monthly monitoring due to its potential toxic effects. His clozapine level was 904 ug/L on 03/05/22. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. Monitoring clozapine levels: The inquest heard evidence that there was a clear system to monitor monthly blood test results looking for low white cell count, however there was no clear system for monitoring the actual clozapine and nor clozapine levels. In addition the inquest heard how there was no safe system to communicate high levels of clozapine. 2. Medication changes: After a review on 14/10/22, when a high level of clozapine was noted from a blood test on 03/05/22, the consultant indicated that medication should reduce on the next prescription. This was communicated by email to the care coordinator however this was not read or acted upon. The inquest heard how there was no safe system to effect medication changes. 3. How to record high clozapine levels: The clozapine and nor clozapine levels are recorded in the pharmacy section of the records. There was no system for highlighting high clozapine results in the rio notes which are routinely used by all clinicians. 4. Understanding of clozapine: I heard evidence that there was a lack of understanding of when to measure clozapine levels, how to interpret high clozapine levels and then how to respond to a high level. 5. August 2020 Regulation 28 report: I sent a Regulation 28 report in August 2020 (case of Ian Allen) which identified that there was no system in place to ensure abnormal clozapine levels were escalated and acted upon and that there was a lack of understanding of the importance of clozapine monitoring and how frequently levels should be monitored. Given this report there is a concern that the Trust has not learnt from the previous Regulation 28 report. 6. Quality of the internal investigation process: The initial investigation report did not raise significant issues regarding the monitoring of clozapine and importantly whether Mr Hussain did in fact have toxicity. It was only when [REDACTED] wrote a report on 26/03/23 (7months after the death) that this issue was highlighted and addressed. This raises a concern about the quality of the internal investigation process and whether it is able to identify central issues in a particular case. 7. Pharmacy resourcing: The inquest heard evidence that processes within the pharmacy were | On 5 January 2023 I commenced an investigation into the death of Mohammed Khalid HUSSAIN. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Natural causes | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 15/05/2023 | 2023-0240 | Roy Walklet | Mr Duncan James Ritchie | Stoke on Trent and North Staffordshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Royal Stoke University Hospital | https://www.judiciary.uk/prevention-of-future-death-reports/roy-walklet-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Roy-Walklet-Prevention-of-future-deaths-report-2023-0240_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/07/2023-0240-University-Hospitals-of-North-Midlands-.pdf | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 20 April 2022 I commenced an investigation into the death of Roy WALKLET aged 62. The investigation concluded at the end of the inquest on 03 April 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by June 21, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 10/07/2023 | 2023-0239 | Christian Tuvi | Mr Andrew Harris | London Inner South | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/chrisitian-tuvi-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Chrisitian-Tuvi-Prevention-of-future-deaths-report-2023-0239_Published.pdf | The public cannot be assured that the lessons have been learnt from this tragedy unless the redesigned improved system of work for cleaners is implemented with appropriate training and leadership in a permanent sustainable contracting system. These matters remain in dispute and may need political and regulatory enforcement. | You are under a duty to respond to this report within 56 days of the date of this report, namely by September 4th, 2023. I, the coroner, may extend the period. | ||||||
| 12/07/2023 | 2023-0238 | Luke Ashton | Mr Ivan Cartwright | Leicester City and South Leicestershire | Other related deaths | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/luke-ashton-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Luke-Ashton-Prevention-of-future-deaths-report-2023-0238_Published.pdf | Luke Ashton was a 40-year-old man who was discovered deceased by attending police officers and paramedics at Carnegie House, Swinton, near Rotherham, South Yorkshire on 22 April 2021, [REDACTED]. His death was confirmed at the scene by one of the attending paramedics. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) Preamble During the course of the inquest, evidence was heard about Mr. Ashton’s gambling activities, both prior to and, in greater detail, after July 2019. The evidence showed that Mr. Ashton had, at times, used a number of ways to protect himself from the potential of excessive losses from, and excessive deposits into, his online account, in order to gamble. Those methods included self-exclusion, temporary or permanent, from certain products and/or activities and placing limits on the value of his deposits and/or losses, during a specific, pre-determined period of time. During the ‘relevant period’ examined closely during the investigation and inquest, between July 2019 and the date of Mr. Ashton’s death on 22 April 2021, although Mr. Ashton utilised a number of what are known as ‘player protection tools’, as outlined above, the operator he was gambling with during the relevant period, Betfair, did not take any measures, save for sending a number of e-mails to Mr. Ashton, to tell him about the existence of a number of protection tools that players could potentially access. During the relevant period, the evidence showed that Mr. Ashton was a problem gambler and, in the last 10-12 weeks of his life, his problem gambling became more acute, intrusive and, on balance, distressing to him. Concerns 1) I remain concerned that the player protection tools, as mentioned above, were and are inadequate to protect a person such as Mr. Ashton, who was a problem gambler with a worsening problem, specifically that such tools do not amount to any or any meaningful interaction with the gambler, or any intervention into the practices of the gambler. 2) I remain concerned that the algorithm devised and operated by Betfair, to assist its staff in, amongst other things, observing and monitoring the gambling patterns and practices of its customers, failed to flag up Mr. Ashton as a problem gambler, despite the increases in his time online (gambling) the value of his deposits and the size of his losses, in part because his gambling practices, even in the last 10-12 weeks of his life, were deemed not to be exceptional, when averaged among gambling customers, generally. 3) I remain concerned that, as was apparent through the evidence of a senior employee witness during the course of the inquest, the operator Betfair appears to judge the extent of its responsibilities to gambling customers solely with regard to industry (regulatory) standards, rather than current good or best practice in order to prevent further harming problem gamblers, or those who, as a result of their changing practices and patterns are likely to become problem gamblers. | On 06 May 2021 I commenced an investigation into the death of Luke Anthony Ashton aged 40. The investigation concluded at the end of the inquest on 29 June 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 5th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 11/07/2023 | 2023-0237 | Mustafa Nadeem | Mr James Bennett | Birmingham and Solihull | Child Death (from 2015) | Prevention of Future Deaths | Road (Highways Safety) related deaths | https://www.judiciary.uk/prevention-of-future-death-reports/mustafa-nadeem-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Mustafa-Nadeem-Prevention-of-future-deaths-report-2023-0237_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/07/2023-0237-Response-from-West-Midlands.pdf | On 6/12/22 Mustafa was riding an e-scooter to school on the pavement on the B4128, approaching the traffic island with Belchers Lane, Bordesley Green when at 7:58am he inadvertently collided with a pedestrian and fell into the path of a bus that was travelling at slow speed. He suffered fatal injuries and was confirmed deceased at the scene. The e-scooter was authorised for use in Birmingham as part of a national pilot scheme and users were required to have a valid motor-vehicle driving licence and be aged over 18. The e-scooter being used by Mustafa had been unlocked by a 14-year-old friend via an ‘app’ on his mobile phone. | During the inquest the evidence revealed matters giving rise to concern. The | On 12 December 2022 I commenced an investigation into the death of MUSTAFA NADEEM. The investigation concluded at the end of the inquest. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 5 September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 10/07/2023 | 2023-0236 | Mary Jones | Ms Kate Robertson | North West Wales | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | Wales prevention of future deaths reports (2019 onwards) | https://www.judiciary.uk/prevention-of-future-death-reports/mary-jones-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Mary-Jones-Prevention-of-future-deaths-report-2023-0236_Published.pdf | The circumstances of the death are as follows : | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows This is a further Report, of several by me, as both Senior Coroner for North West Wales and Assistant Coroner for North Wales East & Central relating to matters of ambulance delays and inability to offload patients in a timely manner into Emergency Departments across North Wales. Evidence was heard at the Inquest that the initial delays experienced by Mary Elizabeth Jones whilst awaiting an ambulance and waiting in the rear of the ambulance possibly contributed indirectly to her existing frailty. Whilst not in themselves causative of Mrs Jones’ death it remains a significant concern that despite evidence of improvements by the Health Board and WAST upon which I have previously been provided, that even as recently as December 2022, unacceptably lengthy delays remain such as in the case of Mary Elizabeth Jones. I have still not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. | On 19 January 2023 an investigation was commenced into the death of Mary Elizabeth Jones (DOB 30/12/36) who died on 14 January 2023. The investigation concluded at the end of the inquest on 7 July 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 4 September 2023. I, Kate Robertson, the Coroner, may extend the period. I am willing to accept a joint response from all to whom this Report is made. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 10/07/2023 | 2023-0235 | Harold Wilberforce | Mr Edward Steele | East Riding of Yorkshire and Kingston-upon-Hull | Other related deaths | Prevention of Future Deaths | Orchard 2000 Pharmacy and General Pharmaceutical Council | https://www.judiciary.uk/prevention-of-future-death-reports/harold-wilberforce-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Harold-Wilberforce-Prevention-of-future-deaths-report-2023-0235_Published.pdf | Mr Wilberforce had a fall at his home address on 16 January 2023. An employee from a pharmacy delivery centre located him and assisted him to a chair. He was complaining of a leg injury and resisted her efforts to call an ambulance. The emergency services were not called. A note was left by the pharmacy delivery agent to say that Mr Wilberforce had had a fall. She left the premises. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) The pharmacy delivery agent attended upon Mr Wilberforce at his home address to deliver his prescription. He had fallen inside the home address and support was provided to him by her. Mr Wilberforce had resisted her attempts to contact the emergency services. Mr Wilberforce was also moved, with the assistance of the prescription delivery agent, from the floor without having been subjected to a medical examination. The prescription delivery agent was, further, unaware of the status of Mr Wilberforce in respect of his dementia. (2) Evidence was provided on behalf of the pharmacy that there was no training provided to staff members in respect of how to deal with and what actions should be taken when a service user is found to have had a fall at their home address by a pharmacy delivery agent. Evidence was also heard that the majority of service users were elderly persons. (3) I am concerned that a lack of clarity exists in respect of the roles and responsibilities of persons attending upon the home addresses of elderly service users, particularly in the context of what action should be taken when someone is found to have fallen. | On 10 February 2023, I commenced an investigation into the death of Harold Wilberforce, aged 87 years. The investigation concluded at the end of the inquest on 7 July 2023. The conclusion of the inquest was Accidental Death. | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 4th September 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 05/07/2023 | 2023-0234 | [REDACTED] | Ms Mary Hassell | London Inner North | Alcohol, drug and medication related deaths | Prevention of Future Deaths | Metropolitan Police Service | https://www.judiciary.uk/prevention-of-future-death-reports/inner-north-london-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Inner-North-London-Prevention-of-future-deaths-report-2023-0234_Published.pdf | On the afternoon of 18 March 2021, [REDACTED] took cocaine and went to a friend’s home. He demonstrated features of acute behavioural disturbance (ABD) and police were called. They recognised this as a medical emergency and sought an ambulance, but [REDACTED] arrested before the ambulance arrived. With police assistance paramedics achieved a return of spontaneous circulation, but [REDACTED] died in hospital the following day. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. | On 25 March 2021, I commenced an investigation into the death of [REDACTED], aged 44 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest that death was drug related. I recorded the medical cause of death as: 1a complications arising from cocaine intoxication. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 4 September 2023. I, the coroner, may extend the period. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. | |
| 07/07/2023 | 2023-0233 | David Lyth | Mrs Charlotte Keighley | Cheshire | Accident at Work and Health and Safety related deaths | Prevention of Future Deaths | 3D Trans, Health and Safety Executive | https://www.judiciary.uk/prevention-of-future-death-reports/david-lyth-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/David-Lyth-Prevention-of-future-deaths-report-2023-0233_Published.pdf | On the 30th November 2021 David Lyth had been working for 3D Trans Limited through a driving agency. That day he had complained of an issue with the air cables on his trailer and had been advised to collect a new trailer from the 3D Trans Limited yard. As he coupled up to a new trailer, the trailer started to roll back and he put his arms out to stop it and became trapped between two HGV trailers. When he was found, he was unresponsive and was taken to Whiston Hospital where his death was confirmed. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 10 December 2021 I commenced an investigation into the death of David Alan LYTH aged 45. The investigation concluded at the end of the inquest on 27 June 2023. The conclusion of the inquest was that: On 30 November 2021 at 3D Trans Shell Green Industrial Estate, Widnes, David Alan Lyth became trapped between two trailers resulting in asphyxia. From the evidence presented the rollaway could only have occurred from neither the unit and the trailer brake not being applied. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by September 01, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 06/07/2023 | 2023-0232 | Elizabeth Agbejimi | Mr Paul Stanford Cooper | Lincolnshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | United Lincolnshire Hospital Trust | https://www.judiciary.uk/prevention-of-future-death-reports/elizabeth-agbejimi-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Elizabeth-Agbejimi-Prevention-of-future-deaths-report-2023-0232_Published.pdf | On 06 July 2021 I commenced an investigation into the death of Elizabeth Oluwatofunmi AGBEJIMI aged 22. The investigation concluded at the end of the inquest on 13 June 2023. The conclusion of the inquest was that: | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |||||
| 06/07/2023 | 2023-0231 | Oleg Khala | Dr Fiona Jane Wilcox | London Inner West | Prevention of Future Deaths | Suicide (from 2015) | West London NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/oleg-khala-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Oleg-Khala-Prevention-of-future-deaths-report-2023-0231_Published.pdf | On the 4th July 2023 evidence was heard touching the death of Mr Oleg Khala. He had been found deceased on the 151 January 2022, aged 56 years. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them. | You are under a duty to respond to this report within 56 days of the date of this report. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013. | |||
| 06/07/2023 | 2023-0230 | Gordon Renfrew | Dr Elizabeth Didcock | Nottinghamshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Homerton Healthcare NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/gordon-renfrew-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Gordon-Renfrew-Prevention-of-future-deaths-report-2023-0230_Published.pdf | Gordon died on the 14th June 2022, at Queens Medical Centre (QMC), Nottingham, after a short admission. He had been transferred to QMC, from the Royal Derby Hospital for further management of a severe and extensive stroke. Detailed findings as to how he came by his death are described within a written Determination dated 28.6.23, appended to this report | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows – · There is limited evidence to date of improved communication, and a stronger working relationship, between the stroke team and the neurosurgical team at the Trust · There is limited evidence to date of the Stroke team having a clear understanding of the NICE guidance regarding Decompression Craniectomy, specifically the importance of detailed careful monitoring post stroke, with clarity about referral criteria to Neurosurgery. The planned Standard Operating Procedure, which may set out this clarity is not yet finalised. · There are currently limited opportunities for joint case discussion and learning between the Stroke and Neurosurgical teams. The Interventional Neuroradiologists could of course also usefully participate in such Educational opportunities – I note it was [REDACTED], (Consultant in Interventional Neuroradiology) rather than the Stroke team, who asked that Gordon was reviewed by the Neurosurgical team on the early evening of the 7th June 2022 I am not reassured that necessary actions to address these serious issues identified are in place. | On the 14th June 2022, I commenced an investigation into the death of Gordon Harry Renfrew. The investigation concluded at the end of the inquest on the 28th June 2023 | In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by the 31st August 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 06/07/2023 | 2023-0229 | Emlyn Roberts | Mr John Gittins | North Wales (East & Central) | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | Wales prevention of future deaths reports (2019 onwards) | https://www.judiciary.uk/prevention-of-future-death-reports/emlyn-roberts-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Emlyn-Roberts-Prevention-of-future-deaths-report-2023-0229_Published.pdf | The circumstances of the death are that at 20.01 on the 13th of March 2022, the deceased called an ambulance complaining of a sudden onset of pain and trouble breathing. He made a further call at 00.20 but due to an absence of available resources, an ambulance was unable to attend for a further seven hours at 07.27 on the morning of the following day, when he was found deceased at his home. In total there was a delay of almost eleven and a half hours from the initial call for help. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On the 17th March 2022 an investigation was commenced into the death of Emlyn Victor Roberts (DOB 09/05/48) who died at his home on the 14th March 2022. The investigation concluded at the end of the inquest on 5th of July 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 31st August 2023. I, John Gittins, the Coroner, may extend the period. I would be prepared to accept a joint response from all organisations. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 30/06/2023 | 2023-0228 | Sinon Masha | Miss Emma Brown | Birmingham and Solihull | Child Death (from 2015) | Prevention of Future Deaths | University Hospitals of Birmingham NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/sinon-masha-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Sinon-Masha-Prevention-of-future-deaths-report-2023-0228_Published.pdf | Sinon Masha was born following a home birth at 13:41 on the 17th December 2021. For a variety of reasons, a home birth was against medical advice, this had been explained on a number of occasions throughout the pregnancy. On the 17th December 2021 advice to transfer to hospital had been given by midwives during early labour due to concerns that Sinon’s mother was showing signs of pre-eclampsia and due to findings of light meconium staining on rupture of membranes which could indicate fetal distress. This advice was not accepted. At 12:47 it was identified that Sinon maybe an undiagnosed breech presentation, transfer to hospital was recommended and declined. Up to that time presentation based on abdominal palpitation and vaginal examinations had been assessed as cephalic. A frank breech presentation was confirmed during a 999 call commencing at 13:00. Paramedics arrived at scene at 13:07 and transfer to hospital was again advised and not accepted. The presenting part delivered at 13:14, there was then a 27 minute period before delivery of Sinon’s head causing a catastrophic hypoxic brain injury. He received resuscitation and was transferred to Birmingham Heartlands Hospital arriving at 49 minutes of age. At 57 minutes Sinon was found to have a heartbeat, he was ventilated and cooled but remained comatose and subsequently developed signs of encephalopathy and multi organ failure, a decision was made to provide palliative care on the 20th December and Sinon died at 05:15 on the 21st December 2021. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows 1. The University Hospitals of Birmingham NHS Foundations Trust (‘UHB’) has specific guidance covering home birth against medical advice in the form of ‘Birth Choices Guidance, CG1200, June 2021’ and ‘Homebirth Including Risk Assessment, CG1143, August 2021’. 2. Specifically, Section 5 of the Birth Choices Guidance includes: “5.1 All women requesting birth outside of guidance must be referred for discussion to the consultant midwife via BadgerNet for decision-making regarding their birth choices. …. 5.7. Where there are complexities that require the input of other professionals and if the woman remains undecided or voices a decisive choice to pursue a plan outside of Trust guidance a joint multiprofessional appointment must be arranged. 5.8. This appointment should include the consultant midwife; the woman’s named obstetric consultant and other relevant professionals/clinicians as needed. The consultant midwife will convene the multiprofessional team meeting with the purpose of ensuring that a comprehensive multiprofessional pregnancy and birth plan is formulated. 5.9. There may be occasions when the multiprofessional team cannot meet. In these circumstances it is acceptable for the multiprofessional team to see the woman separately. However, the team members must still agree a plan together and document this on the woman’s records.” 3. Evidence given at the inquest pertaining to the current situation was that the system outlined in section 5.8 of the Birth Choices Guidance is not in operation at all. Evidence was given by UHB’s Community Matron that without the input of a Consultant Obstetrician at the multiprofessional appointment, things might be missed in the birth plan, and the information given by the Consultant Midwife and Community Midwives may not carry the same weight with the patient as hearing the opinion of the Consultant Obstetrician. It was stated in evidence by the Community Matron that this could put the lives of Mums and babies at risk. | On 30 December 2021 I commenced an investigation into the death of Sinon MASHA. The investigation concluded at the end of the inquest. The conclusion of the inquest was: Natural causes. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 03/07/2023 | 2023-0227 | Liam Bentley | Ms Patricia Harding | Kent Mid and Medway | Prevention of Future Deaths | State Custody related deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/liam-bentley-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Liam-Bentley-Prevention-of-future-deaths-report-2023-0227_Published.pdf | Liam Bentley was transferred to HMP Swaleside on 25th March 2022. He was a serving prisoner with a sentence expiry in 2024. He had ADHD and ASD for which he was medicated with mirtazapine administered by healthcare and at the time of his death atomoxetine, held in possession. He had 19 previous ACCTs for self harm and an attempt at suspension whilst serving his sentence at other establishments. Following his transfer he informed prison staff that he was in fear of other prisoners and wanted a move to another wing. He caused a superficial cut to his hand and said that he wanted to kill himself before anyone else did. An ACCT was not opened, the evidence being that officers after further speaking to him did not regard this as a self harm issue, the focus being to engineer a wing move. He was moved to a different wing but continued to express concerns about prisoners on the new wing. A self seclusion document was opened, a local policy closely aligned to the ACCT process aimed at reintegrating the prisoner to the regime was started but was not managed in accordance with the policy with assessments and reviews being done weeks after they should have been and no management plan were not put in place. Required daily interactions were sometimes done, sometimes not, referrals to psychology and SOS were either not made having been identified as necessary through the self seclusion, CSIP and SIM processes or made and not actioned | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) There was evidence from prison staff from which it was concluded by the jury that the safety of deceased was compromised as a result in staff shortages (2)The current complement of Band 2 Operational Support Group staff is 71% this is predicted to further reduce to 54%, the current complement of Band 3 Prison Officers is 68% this is predicted to further reduce to 46%. | On 13th June 2022 I commenced an investigation into the death of Liam Ryan Wayne Bentley. The investigation concluded at the end of the inquest on 29th June 2023. The conclusion of the inquest was Liam Bentley took his own life ([REDACTED]) but his intention in doing so was unclear. The failure to provide adequate physiological support through SOS and/or a psychologist possibly contributed to the death. Other issues which were deemed to be relevant to the circumstances of the death but could not possibly contribute to the death were as follows. 1. Failure to open an ACCT on or after 16th April. 2. Failure to instigate a care plan 3. Inadequate response to missed medication from 16th April onwards. 4. The Management of the self seclusion plan was inadequate, and failures to implement agreed actions from CSIP and SIM meetings. 5. Ineffective communication between the prison and the health care provider. 6. Staff shortages and gaps in training. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 29th August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 03/07/2023 | 2023-0226 | Arezou Tirgari | Ms Alison Brydie Hewitt | London City | Prevention of Future Deaths | Suicide (from 2015) | Landsec | https://www.judiciary.uk/prevention-of-future-death-reports/arezou-tirgari-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Arezou-Tirgari-Prevention-of-future-deaths-report-2023-0226_Published.pdf | On the evidence currently available to me, I understand that Arezou Tirgari died on the 1st June 2023 after jumping from the roof [REDACTED], a building which is operated by Landsec. | The evidence I have gathered to date reveals matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | I have commenced an investigation into the death of Arezou Tirgari. The investigation has not yet been concluded. | In my opinion action should be taken to prevent future deaths by addressing the concerns set out above and I believe your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by the 28th August 2023. I, as coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 30/06/2023 | 2023-0224 | Sam Taylor | Mr HG Mark Bricknell | Herefordshire | Prevention of Future Deaths | Suicide (from 2015) | Herefordshire Council | https://www.judiciary.uk/prevention-of-future-death-reports/sam-taylor-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Sam-Taylor-Prevention-of-future-deaths-report-2023-0224_Published.pdf | The deceased SAM MALCOLM TAYLOR suffered mental health issues and had on previous occasions attempted suicide. Paperwork found on the deceased suggested the deceased had recently been admitted into hospital due to a suicide attempt which had left him in a coma for 3 days. Updates on the note stated the deceased would feel suicidal if he returned to the tent he seemed to be staying in. The deceased was found in his tent alone next to the RIVER WYE located by members of the public. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken . In the circumstances it is my statutory duty to report to you . The MATTERS OF CONCERN are as follows. (1) A prevention duty was owed to the decease d and due to Herefordshire Council communication process failure, contact was not made with him or those with whom he had approved contact prior to his death. (2) Evidence suggests that in reality Mr Taylor would have met the threshold for vulnerability set out in the Housing Act 1996 but the failure to progress the application resulted in this never being established. | On 9 November 2022 I commenced an investigation into the death of Sam Malcolm TAYLOR. The investigation concluded at the end of the inquest on 21June 2022. The conclusion of the inquest was narrative. | In my opinion action should be taken to prevent future deaths and I believe you, [REDACTED] have the power to take such action. | You are under a duty to respond to this report within 56 day s of the date of this report, namely by 21 August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timet ab le for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Invest igations) Regulations 2013. http:/ / www.legislati on.gov.uk/ukpga/ 2009/ 25/ sche dule/5/ para graph/ 7 http:/ / www.legislati on.gov.uk/u ksi/2013/1629/part/7/made | |
| 28/06/2023 | 2023-0223 | George Griffiths | Mr HG Mark Bricknell | Herefordshire | Mental Health related deaths | Prevention of Future Deaths | Suicide (from 2015) | Wye Valley NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/george-griffiths-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/George-Griffiths-Prevention-of-future-deaths-report-2023-0223_Published-1.pdf | On 01.2.22, Mr Griffiths went from home by ambulance to A&E, County Hospital, Hereford. He was admitted to the hospital for treatment as it was diagnosed he had an acute kidney injury, gastritis, poorly controlled diabetes and infected toes. Profound metabolic acidosis was noted on a VBG test. He developed worsening hypernatraemia and sepsis. He was also treated for Hyperosmolar Hyperglycaemic State and he was investigated for Fournier’s Gangrene. Mr Griffiths was then transferred to ICU for further care and treatment. He had long treatment in ICU and following stepdown back to ward developed delirium . Mr Griffiths developed COVID during his hospital stay and treatment for this was given. He was transferred to a ward for elderly care after his long and complicated admission by which time he had developed a significant pressure sore and C diff diarrhoea. Doctors believe the pressure sore has contributed to death and this occurred during hospital admission. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 9 May 2022 I commenced an investigation into the death of George Edward GRIFFITHS. The investigation concluded at the end of the inquest on 14 June 2023. The conclusion of the inquest was narrative. | In my opinion action should be taken to prevent future deaths and I believe you, [REDACTED] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 August 2023 I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. htt p:// www .legislation.gov.uk/ukpga/2009/25/scheduIe/5/paragraph/7 http:/ / www .legislation.gov.uk/uksi/2013/16 29/part/7/ made | |
| 30/06/2023 | 2023-0222 | Victoria Storey | Mrs Anna Loxton | Surrey | Alcohol, drug and medication related deaths | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/victoria-storey-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Victoria-Storey-Prevention-of-future-deaths-report-2023-0222_Published.pdf | Victoria was found deceased in her bedroom on the evening of 3rd September 2022. Toxicology found she had low therapeutic levels of prescribed drugs; a higher level of Venlafaxine consistent with chronic (not acute) dosage and [REDACTED] of Metonitazene in her post mortem blood; which the Toxicologist stated “contributed more than minimally, and possibly substantially, to the cause of Ms Storey’s death”. [REDACTED] containing Metonitazene were found in Victoria’s bedroom. | The MATTERS OF CONCERN are: Victoria had a history of opioid dependency to assist with her mental health struggles. She had previously admitted to healthcare professionals purchasing illicit opioids from the internet and there was evidence of this from 2019 and 2020 on her electronic devices. | The inquest into the death of Victoria STOREY was opened on 24th January 2023. Evidence was heard and the inquest was concluded on 26th June 2023. | In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one above have the power to take such action. | You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. | ||
| 30/06/2023 | 2023-0221 | Kaye McCoy | Ms Caroline Saunders | Gwent | Mental Health related deaths | Prevention of Future Deaths | Suicide (from 2015) | Aneurin Bevan University Health Board | https://www.judiciary.uk/prevention-of-future-death-reports/kaye-mccoy-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Kaye-McCoy-Prevention-of-future-deaths-report-2023-0221_Published.pdf | Kaye McCoy suffered from depression and anxiety and was diagnosed with Unstable Affective disorder. Kaye had been under the care of the Older Adults Mental Health Team since 2017 and prior to that under the care of the Adult Psychiatric Services. On 1/9/2022, Kaye had an outpatient appointment with her consultant psychiatrist who advised admission to hospital, but Kaye declined. On 5/9/2022, Kaye took an overdose of prescribed medication with an intention to end her life, she was assessed in hospital and discharged back to the care of her care co-ordinator. | The MATTERS OF CONCERN are as follows: At the inquest I was referred to the National Confidential Enquiry into Suicides. I was informed that the Enquiry identified key factors that should be adopted by Health Organisations to reduce the incidence of suicides, including: • That there should be a strategy for engagement with the family. • That every patient should have access to 24-hour Crisis Support Neither of these key components of care were available to Kaye. Whilst I was informed that there were steps being taken to address these I was not persuaded that these guidelines had been fully inculcated into policy and practice at Aneurin Bevan University Health Board. | On 3/10/2022, an investigation was opened into the death of Kaye McCoy. The investigation concluded at the end of the inquest on 27/6/2023. The conclusion of the inquest was recorded as: | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. I should be grateful if the following information be provided to me: 1. Confirm the processes that are in place to ensure that all patients who are in receipt of care by the mental health teams have a strategy for the engagement with the family and how this will be audited. It should be noted that Kaye had been under the care of the Older Adults Mental Health Services since 2017. 2. Confirm the plans for ensuring that all patients in crisis can be followed up, out of hours and at weekends by a Crisis Team or similar. | You are under a duty to respond to this report within 56 days of the date of this report, namely 25/8/2023. I, the Coroner, may extend this period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is necessary | I make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 | |
| 09/02/2022 | 2023-0220 | Michelle Jennings | Ms Alison Patricia Mutch OBE | Greater Manchester South | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/michelle-jennings-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Michelle-Jennings-Prevention-of-future-deaths-report-2023-0220_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/07/2023-0220-Response-from-Department-of-Health-and-Social-Care.pdf | Michelle Louise Jennings had a history of contact with mental health services and had a history of indicating suicidal ideation to a number of agencies. She was assessed as being suitable for step 4 therapy. However at the time of the assessment of her need there was a 2 year waiting list to access therapy. On the balance of probabilities this delay possibly contributed to her death. On 11th April 2019, 17th July 2019, 28th July 2019, 17th January 2020 and 8th May 2020 she was dealt with by British Transport Police (BTP) and indicated suicidal thoughts. Following the incident on 8th May 2020 BTP prosecuted her for obstructing the railways when she had indicated she had suicidal ideation at the time she was on the railway. She was subsequently arrested on a warrant and held in custody before being sentenced. On the balance of probabilities this decision to prosecute possibly contributed to the deterioration in her mental health and her subsequent death. On 1st August 2020 following calls to the mental health crisis line she was referred for a mental health assessment by the Primary Care Mental Health Team (PCMHT) part of Cheshire & Wirral partnership NHS Trust (CWP). On 3rd September 2020 she was assessed by telephone by the PCMHT and then the case was referred to the PCMHT MDT. On 6th September she rang Cheshire Police from Delamere Forrest with suicidal thoughts. She was taken to Hospital and discharged the following day. On 9th September 2020 her case was considered by the PCMHT MDT. They determined her needs were too complex for the PCMHT and she was to be referred to the Community Mental Health Team (CMHT) part of CWP. The referral was not made until 16th September 2020. At the point of referral she was discharged from the PCMHT caseload. On 17th September 2020 she presented at Stepping Hill Hospital with suicidal thoughts. She was assessed by mental health services and discharged. On 23rd September 2020 she was discussed at the CMHT MDT where the referral was rejected and she was to be referred back to the PCMHT. She was discharged from the CMHT caseload at that point. She was no longer on the caseload of either the PCMHT or the CMHT. Despite the complexity of her needs and her deteriorating mental health there was no discussion between the PCMHT and the CMHT in relation as to how to manage or mitigate the risk at this point although it was documented that she felt rejected by mental health services. On the balance of probabilities the poor communication between the PCMHT and the CMHT, the failure to assess risk effectively to ensure she remained on the caseload of either the PCMHT or the CMHT probably contributed to the further decline in her mental health and her death. On 3rd October 2020 she made her way [REDACTED] and hanged herself [REDACTED] She was found on 5th October 2020. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. | On 6th October 2020 I commenced an investigation into the death of Michelle Louise Jennings. The investigation concluded on the 24th November 2021 and the conclusion was one of suicide. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 6th April 2022. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 29/06/2023 | 2023-0219 | Matthew Phipps | Ms Nadia Persaud | London East | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/matthew-phipps-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Matthew-Phipps-Prevention-of-future-deaths-report-2023-0219_Published.pdf | On the 10 July 2022, Matthew Phipps was admitted to Queens Hospital with a severe, acute kidney injury and a 5 day history of fever, chills, diarrhoea and vomiting. On the 10 July 2022 he also presented with lower abdominal pain, lower back pain and pain in the top of his right leg. He was recognised as being critically unwell and the emergency department requested transfer to the intensive care unit. There was a delay in transferring Matthew to intensive care. He should have been transferred by 2230 on the 10 July 2022, but was not transferred until 0930 on the 11 July 2023. Matthew’s family observed that only one of two bottles of antibiotics prescribed to Matthew in A&E were administered to him. Matthew was not observed as closely as he should have been, given his very concerning clinical condition and there were delays in carrying out necessary blood tests and in commencing renal replacement therapy. The inquest has found however that Matthew presented to hospital on the 10 July 2022 with a likely acute kidney injury, associated with sepsis. As such, his prognosis was very poor, even with optimal treatment. There is no evidence that the failings in the care provided to him contributed to his death. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: A concern arose at the Inquest hearing in relation to the lack of a contingency plan in place to ensure that intensive care is provided to all patients who require it, but where the intensive care unit itself is full. The Inquest heard evidence from an independent consultant anaesthetist who stated: I do not understand why one or two of the 8 ICU patients who were deemed to be wardable, could not have been moved elsewhere (e.g. to a post anaesthetic care unit in an operating suite), to enable a sick patient such as Mr Phipps to be admitted to the ICU. It is my understanding that most ICUs have such contingency plans in place, in the form of agreed standard operating procedures. The Trust were aware of this concern, but did not provide any evidence to address this. | On 4 October 2022 I commenced an investigation into the death of Mr Matthew John Phipps, aged 56 years. The investigation concluded at the end of the inquest on the 26 June 2023. The conclusion of the inquest was that Mr Phipps died from natural causes. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | ||
| 27/06/2023 | 2023-0218 | Rachel Garrett | Ms Penelope Schofield | West Sussex, Brighton and Hove | Mental Health related deaths | Prevention of Future Deaths | Suicide (from 2015) | NHS England | Integrated Health Board NHS Sussex | https://www.judiciary.uk/prevention-of-future-death-reports/rachel-garrett-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Rachel-Garrett-Prevention-of-future-deaths-report-2023-0218_Published.pdf | Rachel had been struggling with her mental health for some time, but there had been a marked deterioration in July 2020. | During the investigation, my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Patients who attend a Hospital Accident and Emergency Department with mental health difficulties are in most hospitals seen by a Mental Health Liaison team (made up of Consultant Psychiatrists and Mental Health nurses) These staff are not employed by the Acute Hospital Trust but are employed by a local Mental Health Trust (in this particular case it was the Sussex Partnership Foundation Trust). As a result of their employment status the Mental Health Liaison team (who have the best knowledge of the patient having been caring for them) cannot invoke the Doctors or Nurses holding powers under Section 5(2) Mental Health Act (Section 5(4) for nurses). If a patient decides to abscond from the Acute Trust Hospital the Mental Health staff cannot detain/hold the patient. They would have to ask a Doctor within the Acute Hospital to do so. This Doctor may not have any knowledge of the patient and would be unlikely to act immediately in a busy A&E. By that time the patient would have been long gone. Due to this technical issue around the employment status of the Mental Health Team, those suffering with a deteriorating mental health in an acute setting are at risk in these circumstances. | On 30th July 2020 Ms Hamilton-Deeley, the former Senior Coroner, commenced an investigation into the death of Rachel Kathleen Garrett aged 22 years. The investigation was concluded at the end of the Inquest on 2nd June 2023. The conclusion given was a narrative conclusion namely: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd August 2023 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 29/06/2023 | 2023-0217 | Peter Walker | Mr Nigel Parsley | Suffolk | Other related deaths | Prevention of Future Deaths | Department for Transport | https://www.judiciary.uk/prevention-of-future-death-reports/peter-walker-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Peter-Walker-Prevention-of-future-deaths-report-2023-0217_Published.pdf | Peter Walker came by his death at Beccles Aerodrome, Ellough Airfield, near Beccles in Suffolk on Thursday 24th March 2022. | During the course of the investigation my inquiries revealed matters giving rise to concern. | On 04 April 2022 I commenced an investigation into the death of Peter John WALKER aged 87. The investigation concluded at the end of the inquest on 21 June 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by August 24, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 28/06/2023 | 2023-0216 | Hilary Thomas | Mrs Louise Hunt | Birmingham and Solihull | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/hilary-thomas-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Hilary-Thomas-Prevention-of-future-deaths-report-2023-0216_Published.pdf | The deceased attended Birmingham Heartlands Hospital emergency department on 28/10/22 with intermittent abdominal pain for 24 hrs. She was known to suffer from constipation and diverticulitis, hypertension, arthritis and had a previous hysterectomy. All tests were normal and she was reviewed by the OPAL team at 12.15 when she was noted to be pain free so she was discharged home at 15.15. She reattended the emergency department on 29/10/22 and was referred to the surgical team who reviewed her at 11.30. She complained of colicky abdominal pain and was passing wind but had not had bowels open for 4 days. She was complaining of severe pain but had normal observations and the initial diagnosis was acute diverticulitis. However the doctor was contemplating CT scan but incorrectly decided to wait for blood test results before proceeding. Due to workload the doctor came to review blood tests results at 20.00 but which time she had self discharged. These showed a slightly raised white cell count however the clinical decision at time was that she did not need to be recalled. During this attendance no clear plan was set out in the records about how to proceed with her care and the extent of her pain coupled with reattendance was not identified as indicating she was a high risk patient and her case was not escalated for consultant review. On balance a CT scan should have been arranged at this time which would have identified the condition and provided an opportunity for earlier surgery. She represented on 30/10/22 shocked and profoundly unwell with suspicion of an ischaemic bowel which was confirmed on CT scan and found to be due to adhesions constricting the bowel from previous hysterectomy surgery. She was rushed to theatre where the ischaemic bowel was resected; however, she failed to recover and sadly passed away on 31/10/22. Had her condition been identified as it should have been on 29/10/22 she would have likely survived emergency surgery. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Department of Health and Social care 1. Witnesses explained at the inquest that the volume of patients attending hospital is at a level the like of which has never been seen and current resources are unable to deal with that volume. This had a direct impact on Mrs Thomas’s death as the doctor treating her was unable to review her blood tests results until the evening handover, 6 and a half hours after the results were available by which time Mrs Thomas had left the department. | On 10 November 2022 I commenced an investigation into the death of Hilary THOMAS. The investigation concluded at the end of the inquest . The conclusion of the inquest was: | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 28/06/2023 | 2023-0215 | Carol Hatch | Mr Kevin McLoughlin | Yorkshire West Eastern | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Spire Healthcare Limited | https://www.judiciary.uk/prevention-of-future-death-reports/carol-hatch-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/07/Carol-Hatch-Prevention-of-future-deaths-report-2023-0215_Published-1.pdf | Carol Ann Hatch aged 73 underwent a surgical procedure in 2015 known as a 360 degree Nissen Fundoplication to repair a hiatus hernia and reduce the risk of reflux. On 31 August 2022 she underwent an identical procedure as a further hiatus hernia had developed, causing a recurrence of symptoms. The surgery was performed at the Spire Private Hospital in Leeds. Mrs Hatch became unwell during the night following the surgery. It was only the following morning when the surgeon returned to the hospital that the extent of her deterioration was appreciated. She was transferred to an NHS hospital in Leeds, underwent emergency surgery within a few hours and was admitted to an intensive care unit. Over the following six weeks she was treated on the intensive care unit for septic shock and organ failure. She died on 18 October 2022 at St James University Hospital in Leeds. | During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 20 October 2023 I commenced an investigation into the death of Carol Ann Hatch aged 73. The investigation concluded at the end of the Inquest on 26 June 2023. The conclusion of the Inquest was a Narrative which recorded the medical cause of death as (1a) Sepsis, (1b) Gastric perforation (1c) revision Nissen Fundoplication. | In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 August (to make allowance for the holiday season). I, the Coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 27/06/2023 | 2023-0214 | Richard Littlewood | Miss Lorraine Harris | East Riding of Yorkshire and Kingston-upon-Hull | Prevention of Future Deaths | Road (Highways Safety) related deaths | Highways Department | https://www.judiciary.uk/prevention-of-future-death-reports/richard-littlewood-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Richard-Littlewood-Prevention-of-future-deaths-report-2023-0214_Published.pdf | Mr Littlewood was travelling on his motorcycle with a friend in convoy, he has braked when taking a bend in the road causing his motorcycle to travel in a straight line and into the path of an oncoming vehicle. He was conveyed to Hull Royal Infirmary with traumatic injuries. He died 3 weeks later 29th July 2022. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) Evidence was heard that, on this particular stretch/bend of the A1033, there have been 3 incidents that have occurred within a short space of time. · A fatality leading to the death of Mr Littlewood in July 2022. · A fatality leading to the death of another male in November 2022. · An incident involving a farm vehicle which shed its load in late June/early July 2022 (very little details are known of this, suffice that it occurred near the location of the bend in the road where Mr Littlewood died, albeit on the opposite side). I do acknowledge that each of these incidents are completely different scenarios. It may be worthwhile to note that it is local road users that have been involved in all the incidents. (2) During evidence it was heard that signage and road markings have been discussed between the police and Highways that may make the road safer. Some signage had been put in place but an assessment needs to be completed for additional road markings and the timings for this were unclear. I am aware that after every fatality in this area the police and the Highways liaise with each other over signage/road markings as a matter of course. I have concerns only regarding the fact that no timescale had been set for the assessment to take place. | On 2nd August 20222 I commenced an investigation into the death of Richard Stephen LITTLEWOOD, aged 40 years. The investigation concluded at the end of the inquest on 26th June 2023. The conclusion of the inquest was Road Traffic Incident. | In my opinion action should be taken to prevent future deaths and I believe your department/organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 26/06/2023 | 2023-0213 | Matthew Power | Ms Susan Ridge | Surrey | Alcohol, drug and medication related deaths | Prevention of Future Deaths | EMIS Health | https://www.judiciary.uk/prevention-of-future-death-reports/matthew-power-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Matthew-Power-Prevention-of-future-deaths-report-2023-0213_Published.pdf | Mr Power was a 33 year old man living in supported accommodation. He had a history of mental health issues and had been diagnosed with Dissocial Personality Disorder. He also had a history of drug and alcohol abuse dating back to his teenage years. He had been known to take impulsive overdoses of drugs including prescription drugs ([REDACTED]). | During the course of the inquest the evidence revealed matters giving rise to concern. Inmy opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. The GP practice uses EMIS for patient records and prescribing. From the evidence it appears that when one doctor ends a repeat prescription on EMIS, it remains in the ‘pending’ Medication Management box of the doctor to whom it was originally sent. Creating the risk, as in this case, that as a pending prescription it is actioned and issued instead of cancelled. 2. I heard evidence that the EMIS system appears to group prescriptions into the amount prescribed rather than simply recording when a prescription is issued. In this case there were different entries grouped as 100 tablets, 50 tablets, 30 tablets, and 24 tablets. Consequently, it was not clear to the duty doctor that the most recent prescriptions for co-codamol had been for a shorter course of only [REDACTED] tablets and as a result [REDACTED] tablets of co-codamol were prescribed and issued. 3. Evidence was given by the GP practice that to interrogate the EMIS system in order to ascertain what had actually been prescribed, issued and when, was a challenging task; it had taken 3 GPs and the in-house pharmacist to conduct the review. | An inquest into the death of Matthew William Thomas Power was opened on 29 September 2022 and resumed and concluded on 14 June 2023. | In my opinion action should be taken to prevent future deaths and I believe youhave the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 21 August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7(1) of Schedule 5, to The Coroners and Justice Act 2009. | |
| 26/06/2023 | 2023-0212 | Ginger Wright | Miss Anna Crawford | Surrey | Alcohol, drug and medication related deaths | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/ginger-wright-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Ginger-Wright-Prevention-of-future-deaths-report-2023-0212_Published.pdf | ||||||||
| 26/06/2023 | 2023-0211 | Keith Nielsen | Miss Anna Crawford | Surrey | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/keith-nielsen-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Keith-Nielsen-Prevention-of-future-deaths-report-2023-0211_Published.pdf | ||||||||
| 23/06/2023 | 2023-0210 | Stephen Beadman | Mr Kevin McLoughlin | Yorkshire West Eastern | Mental Health related deaths | Prevention of Future Deaths | State Custody related deaths | https://www.judiciary.uk/prevention-of-future-death-reports/stephen-beadman-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Stephen-Beadman-Prevention-of-future-deaths-report-2023-0210-b_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/07/Stephen-Beadman-Prevention-of-future-deaths-report-2023-0210_Published.pdf | On 20th April 2021 I commenced an investigation into the death of Stephen Kurt Beadman, aged 34. The investigation concluded at the end of the Inquest on 21st June 2023. The conclusion of the Inquest was a Narrative which included a finding that Mr Beadman committed suicide having been bullied by other prisoners. | In my opinion action should be taken to prevent future deaths and I believe you and the Prison Service have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd September 2023 (to take account of the impending holiday season). I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |||
| 22/06/2023 | 2023-0209 | Stephen Richardson | Mr André Rebello OBE | Liverpool and the Wirral | Mental Health related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/stephen-richardson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Stephen-Richardson-Prevention-of-future-deaths-report-2023-0209_Published.pdf | i. The Jury found, | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) It was clear from the investigation that at the time of Stephen ligaturing in May 2019 there was an national shortage of acute pyschiatric beds to treat patients in the community suffering with mental disorder of a nature or degree which necessitated immediate assessment treatment and care as an inpatient. The evidence heard has confirmed that that parlous situation has not improved. | On 04 October 2019 I commenced an investigation into the death of Stephen Norman RICHARDSON aged 47. The investigation concluded at the end of the inquest on 22 June 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by August 17, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 22/06/2023 | 2023-0208 | Mason French | Mr Derek Winter DL | Sunderland | Child Death (from 2015) | Prevention of Future Deaths | Road (Highways Safety) related deaths | South Tyneside Council | https://www.judiciary.uk/prevention-of-future-death-reports/mason-french-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Mason-French-Prevention-of-future-deaths-report-2023-0208_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0208-Response-from-South-Tyneside-Council.pdf | Mason French died on 25th October 2022 at a concealed junction on Lizard Lane, Whitburn., when his bicycle collided with a passenger bus. | The MATTERS OF CONCERN are, as follows: Despite the safety improvements at the location of the road traffic collision, I continue to be concerned that without further measures cyclists in particular remain at risk in that area. | On 31st October 2022 I commenced an Investigation into the death of Master Mason French, who was born on 2nd January 2011 and who died at Lizard Lane, Whitburn, Sunderland on 25th October 2022 aged 11 years. The Investigation concluded at the end of an Inquest on 22nd June 2023. The conclusion of the Inquest was ‘Road traffic collision’. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st August 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 06/06/2023 | 2023-0207 | Alexander Blewitt | Dr Séan Cummings | Milton Keynes | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/alexander-blewitt-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Alexander-Blewitt-Prevention-of-future-deaths-report-2023-0207_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0207-Response-from-Milton-Keynes-University-Hospitals.pdf | Alexander Shone Blewitt died at the Milton Keynes University Hospital on the 11th July 2022. He had attended on the 9th July 2022 after visiting the nearby Urgent Care Centre (UCC) and being referred to ED by the GP there. He was provided with a printout of his consultation with her. She was worried about him. That communication detailed his complaint of loose stools and abdominal pain. The triage nurse did not record the content of the UCC letter accurately and took that letter from Mr Blewitt. He later saw the ED doctor who did not see or read the UCC letter or attempt to source it. The ED doctor did not record any questions relating to bowel habit on his contemporaneous note, but sometime subsequent to Mr Blewitt’s death wrote a statement in which he identified that he had and that there were no bowel complaints. This was despite several days of being faecally incontinent at home and highlighting this to the UCC doctor. The ED doctor sent him home with a diagnosis of a possible resistant or recurrent urinary tract infection even though the MSU taken by his GP a few days earlier and available to the UCC doctor showed no growth. Mr Blewitt, even though he was sent home with a diagnosis of a possible resistant urinary tract infection on the 9th July 2022, was told to continue the original antibiotics his GP had started him on and then to start the new ones the next day. Mr Blewitt spent a difficult two days with faecal incontinence and abdominal pain before returning on the 11th July 2022 to the ED. At this visit a possible acute abdomen was diagnosed and CT scanning confirmed this. He was taken to theatre and suffered a cardiac arrest before surgery and died the next day on ITU. It emerged in evidence that there were no reliable records of any fluid resuscitation in the ED available for examination. This is because the computerised system records the prescription of IV fluids but unless the prescription is signed, that prescribed item is erased. The best information I received was that he had received two litres of an unknown fluid at some point during his time in the ED. It seems that doctors were not as a routine signing the prescriptions and so no reliable record was retained. I was told that doctors had been reminded on the need to sign prescriptions but no audit of this had been carried out since Mr Blewitt’s death. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) [1] At the time of Mr Blewitt’s death there was no effective, reliable recording of intravenous fluids administered to patients in the emergency department. That in my view has potential to represent a threat to the safety and lives of patients suffering with a wide variety of different conditions. The author of the SI report who attended to give evidence did not, at the time of Inquest 8 months later, was unable to demonstrate that the Trust had remedied that. [2] Despite the 8 month interval between Mr Blewitt’s death and the Inquest the issues of concern had not been brought to the attention of hospital authorities. [3] On arrival at the ED a triage nurse summarised the communication from the urgent care centre. The triage nurse missed important points during the transcription. The attending doctor did not concern himself to look at the communication himself. [4] I was concerned that the treating doctor made a contemporaneous note on the 9th July 2022 at Mr Blewitt’s first presentation which failed to record the major presenting symptom, diarrhoea with faecal incontinence, which Mr Blewitt had communicated to the urgent care doctor who in turn had included that in her notes and letter to the ED. The treating doctor did record a flatly contradictory note to the effect there was no change in bowel habit. [5] The Incident Investigation Report which is in part designed to assist with learning from adverse events was of a generally poor standard. There was a failure to consider issues in detail; there was a failure to challenge the statements of clinicians where there were obvious contradictions between statements made and the medical record; there was a failure to put in place measures to correct and monitor prescribing clinicians failure to sign off on IV fluid prescriptions so that the contemporaneous record would be available for clinicians coming after them and they could see whether a patient had satisfactory or unsatisfactory fluid management. The only record in the case was a typed note by a junior doctor to the effect that it was thought Mr Blewitt had received 2 litres of fluid since arrival. | On 20 July 2022 I commenced an investigation into the death of Alexander Shone BLEWITT aged 48. The investigation concluded at the end of the inquest on 21 March 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by July 24, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 22/06/2023 | 2023-0206 | Lucy Walles | Mrs Heidi Julia Connor | Berkshire | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/lucy-walles-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Lucy-Walles-Prevention-of-future-deaths-report-2023-0206_Published.pdf | Lucy was born on 17th November 1997. She was 24 at the time of her death. Her death in hospital on 23 February 2022 happened after she jumped [REDACTED] on 16 February 2022. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The concerns arising out of this investigation and inquest relate to the following key areas, a) Safeguarding b) Mental health provision c) Inter-agency communication – particularly where there is some doubt over who should provide additional support needed by a person. We heard in evidence that in the months after Lucy’s death, a Safeguarding Adults Board considered the case, but did not consider that a Safeguarding Adults Review (‘SAR’) should be undertaken. Evidence from Wokingham Borough Council was that they were not at that time aware of the number of safeguarding referrals that had been made. A decision was made (some six days before the inquest) that a SAR will now be conducted. The evidence of the Assistant Director of Adult Social Care was that this is likely to be completed within 1-3 months after the inquest. I have set out the issues / concerns that I have for each of the two recipients of this report, below. Reading Borough Council 1) Time scales for review and triage of safeguarding referrals. 2) Requirements to speak to the individual about whom safeguarding concerns have been raised. 3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry. 4) Systems for making other involved agencies aware of safeguarding referrals and concerns. 5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training. 6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ? 7) Whether they consider that the resourcing of this service is adequate and safe. 8) Systems for auditing, and what will happen if the auditing reveals ongoing issues. Berkshire Health Care 1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically: a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February? b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February? 2) Do they consider that resourcing of these services is adequate and safe? | I conducted an inquest into the death of Lucy Anne Walles, which concluded on 16th June 2023. I recorded a conclusion of suicide. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | A response to a regulation 28 report is usually required within 56 days of the date of the report. Given the forth coming SAR, and in order to maximise the benefit of both of these investigations, I indicated at the inquest that I would allow a 4 month time period for this response, namely by 22/10/2023. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 21/04/2023 | 2023-0205 | Maria Shafighian | Ms Caroline Saunders | Gwent | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Aneurin Bevan University Health Board | https://www.judiciary.uk/prevention-of-future-death-reports/maria-shafighian-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Maria-Shafighian-Prevention-of-future-deaths-report-2023-0205_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0205-Response-from-Aneurin-Bevan-University-Health-Board.pdf | Maria Shafighian was a 59-year-old woman who was referred to the ENT department at Aneurin Bevan University Health Board by her GP on 27/1/2020 with symptoms of persistent hoarseness. Ms Shafighian was assessed by a specialist ENT trainee on 3/2/2020 who ordered a CT scan, which found no evidence of laryngeal cancer. Maria was diagnosed with vocal cord palsy and referred to the Speech and Language Therapists (SALT). | The MATTERS OF CONCERN are as follows: During the inquest I heard that the process by which the SALT team notified the ENT department of the change in Maria’s presentation and the development of dysphagia was through an internal postal system. Following assessment by SALT on 4/5/2020, a letter was written to the ENT team which was printed and left in a pigeon hole. No evidence was forthcoming to describe a system whereby urgent matters would be brought immediately to the attention of the referring team and there was no process for ensuring that the post was dealt with in a timely manner. In Maria’s case there appears to have been a delay of a month between the letter being sent and being noticed by the ENT team. | On 10/12/2020 an investigation was opened into the death of Maria Christine Shafighian. The investigation concluded at the end of the inquest on: 6/4/2023 | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 16 June 2023. I, the Coroner, may extend this period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is necessary | I make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 |
| 22/06/2023 | 2023-0204 | Christopher Stevens | Mr Andrew Cox | Cornwall and the Isles of Scilly | Prevention of Future Deaths | Suicide (from 2015) | Cornwall Partnership Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/christopher-stevens-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Christopher-Stevens-Prevention-of-future-deaths-report-2023-0204_Published.pdf | Chris had enjoyed a long period of relative stability with his mental health until 2020/21. In the period that followed there were two serious attempts at overdose both of which resulted in lengthy admissions into ICU. He was admitted to Longreach and was known to the in-patient team. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The Trust has conducted a PSIR the contents of which were reviewed at inquest. The report reached conclusions I found entirely reasonable. I also heard from [REDACTED] about the steps that are being taken to implement the changes felt to be appropriate. This includes a change to the consultant model with one consultant now responsible for the individual wards. There is also an initiative to standardise documentation, for example, at handover, and later MDT (when risks are reviewed), to ensure this is incorporated into RiO, together with an express intention to involve the family in decision-making. It was accepted that risk should be assessed by a nurse prior to granting leave to an informal patient particularly where unescorted leave is being considered for the first time. Although Chris’s death occurred in February 2022, it also became clear that the process had not been completed. It was hoped this could be achieved by the end of July this year but the inquest was told there would need to be consideration of the proposals by the different consultants now involved. I was concerned to ensure that the process was completed without undue delay and it is with this in mind that I now write to you. | On 21/6/23, I concluded an inquest into the death of Christopher Stevens, aged 58, who was found deceased on 11/2/22. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 August. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 21/06/2023 | 2023-0203 | Jean Frickel | Katie Sutherland | North Wales (East & Central) | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | Wales prevention of future deaths reports (2019 onwards) | https://www.judiciary.uk/prevention-of-future-death-reports/jean-frickel-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Jean-Frickel-Prevention-of-future-deaths-report-2023-0203_Published.pdf | The circumstances of the death are as follows : Jean Frickel had required an ambulance on 19 December 2022 due to symptoms of shortness of breath and confusion following a GP home visit. She was in reasonably poor health. A call was made by her husband to WAST at 17:09 hours. At 08.07 hours the following morning a further call was made informing WAST that Jean Frickel was unresponsive and not breathing. Paramedics arrived at 08:12 and confirmed that she had died. It took 13 hours and 3 minutes from the initial call for paramedics to arrive. Cardiology evidence indicated that had Mrs Frickel received timely medical treatment then her life may have been prolonged by several weeks. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – There was evidence from WAST and BCUHB that improvements had been made internally within their organisations. It seems that patient flow i.e. those patients who are ready to be discharged from hospital but are unable to be discharged due to insufficiencies in social care means that ambulances are unable to offload patients into the Emergency Department which then causes the community delays as ambulances are not readily available. I have not been presented with any meaningful evidence on the involvement of Local Authorities in the considerations by WAST and BCUHB of lack of patient flow due to social care deficiencies. I have previously issued Prevention of Future Death Reports to BCUHB and WAST pertaining to the length of time it is taking for ambulances to arrive to patients (as well as handover at hospitals). I remain significantly concerned that delays are continuing and that deaths will continue to occur into the future. Specifically, I require responses to the following: 1. Extent of working relationship between WAST, BCU and North Wales Local Authorities to address the above issues; and 2. Extent of progress between WAST, BCU and North Wales Local Authorities in addressing the above issues; and Extent of Strategic plan of action / improvement plan to address the above issues. | On 30 December 2022 an investigation was commenced into the death of Jean Frickel (DOB 4/2/43) who died on 20 December 2022. The investigation concluded at the end of the inquest on 20 June 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 16 August 2023. I, Kate Sutherland, the Coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 20/06/2023 | 2023-0202 | Leonard Harmsworth | Katie Sutherland | North Wales (East & Central) | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | Wales prevention of future deaths reports (2019 onwards) | https://www.judiciary.uk/prevention-of-future-death-reports/leonard-harmsworth-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Leonard-Harmsworth-Prevention-of-future-deaths-report-2023-0202_Published.pdf | The circumstances of the death are as follows : Leonard Charles Harmsworth died on 18 June 2022 at Ysbyty Glan Clwyd from cardiac related issues contributed to by a fractured ankle and immobility due to a fall. He had been admitted on 7 June following a fall at home. He remained under conservative management before undergoing manipulation. He suffered a sudden deterioration following a manipulation of his ankle and died on 18 June 2022. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 29 June 2022 an investigation was commenced into the death of Leonard Charles Harmsworth (DOB 29/3/33) who died on 18 June 2022. The investigation concluded at the end of the inquest on 19 June 2023. The conclusion of the inquest was a narrative conclusion. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 15 August 2023. I, Kate Sutherland, the Coroner, may extend the period. I would be prepared to accept a joint response from all organisations. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 20/06/2023 | 2023-0201 | Anita Graves | Mr Adrian John Farrow | Greater Manchester South | Alcohol, drug and medication related deaths | Prevention of Future Deaths | Medicines & Healthcare products Regulatory Agency | https://www.judiciary.uk/prevention-of-future-death-reports/anita-graves-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Anita-Graves-Prevention-of-future-deaths-report-2023-0201_Published.pdf | Mrs Graves was diagnosed with hyperthyroidism in 2019. Her condition was monitored by specialists from the Endocrinology Team at the local hospital and regulated by carbimazole and propranolol. The regular dose of carbimazole in particular, was adjusted periodically by Mrs Graves’ GP in light of regular reviews of blood test results under the supervision and guidance of the Endocrinology Team. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) That the visual similarity of tablets of differing strengths of carbimazole to each other and to aspirin presents a risk of inadvertent overdose; and That the dispensing process in the community for carbimazole appears to contribute to rather than mitigating the risk | On 27th January 2023, an investigation was commenced into the death of Anita Graves, aged 92 years. The investigation concluded at the end of the inquest on 30th May 2023. The outcome of the inquest was that the medical cause of the death of Mrs Graves was: 1a. Urinary Tract Infection 1b. E.Coli 2 Hyperthyroidism | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 20/06/2023 | 2023-0200 | Michael Sullivan | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Stockport Integrated Care Partnership | https://www.judiciary.uk/prevention-of-future-death-reports/michael-sullivan-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Michael-Sullivan-Prevention-of-future-deaths-report-2023-0200_Published.pdf | Michael Brian Sullivan had schizophrenia and was bipolar. He took lithium medication. He deteriorated at his home address and was admitted to Stepping Hill Hospital after concerns were raised by his family. He was found to have pneumonia and lithium toxicity, a complication of his bronchopneumonia and related to his dehydration. He deteriorated despite treatment and died at Stepping Hill Hospital on 17th December 2022. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 22nd December 2022 I commenced an investigation into the death of Michael Brian Sullivan. The investigation concluded on the 16th May 2023 and the conclusion was one of Narrative: | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 20/10/2021 | 2023-0199 | Freeda Glausiusz | Ms Mary Hassell | London Inner North | Prevention of Future Deaths | Suicide (from 2015) | East London NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/freeda-glausiusz-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Freeda-Glausiusz-Prevention-of-future-deaths-report-2023-0199_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0199-Response-from-East-London-NHS-Foundation-Trust.pdf | Freeda Glausiusz jumped from her [REDACTED] home on 15 May 2021. Her father had called the crisis line in desperation the day before. His call was not treated with the seriousness it deserved. It is unclear whether any alternative action by the crisis team would have changed the outcome. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. I was shocked when I listened to the recording of the call that [REDACTED] made to the crisis line the day before his daughter died. The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation; did not listen to [REDACTED] ; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis. In reaching my conclusion at inquest that the call was not treated with the seriousness it deserved, I agreed with all of those observations. [REDACTED] was not taken seriously, he was not treated respectfully and he was not treated kindly. He was clearly desperate about his daughter’s mental health and, as we now know, he was right to be desperate. He rang the crisis line and he was belittled. The clinician then made no note of the call in the medical records, even retrospectively. I note the many recommendations of the thoughtful SI report, but I remain concerned on three counts. · This is not the first time that I have made a PFD report to ELFT about its crisis line. · Not only did the clinician in question not make a note of the call in the medical record, he told me in court that, after Freeda Glausiusz’s death his manager had told him not to make an appropriately dated retrospective note in the record. He said that he had made a note on a piece of paper, but he did not now have that piece of paper. When I asked the lead SI reviewer if the trust is confident that it has taken all appropriate actions in respect of that clinician, she was not able to give me that assurance. | On 25 May 2021 I commenced an investigation into the death of Freeda Glausiusz, aged 32 years. The investigation concluded at the end of the inquest yesterday. I made a determination at inquest of death by suicide whilst suffering a psychotic episode. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 December 2021. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. |
| 08/06/2023 | 2023-0198 | Hilary Guedalla | Mr Edwin Buckett | London Inner North | Prevention of Future Deaths | Suicide (from 2015) | East London NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/hilary-guedalla-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Hilary-Guedalla-Prevention-of-future-deaths-report-2023-0198_Published.pdf | The circumstances surrounding the death are set out in Box 3 above. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. Evidence was given by staff members of the East London Foundation NHS Trust that: 1. The deceased was allowed to leave Gardener Ward (“the unit”) which was part of a secure facility of the hospital, alone, when a clinical decision had been taken that they should not be allowed to leave the unit unaccompanied by staff, because they posed a serious risk of suicide. 2. The decision that the deceased should not be allowed unescorted leave was not communicated to all members of staff working in the unit such that the person who allowed the deceased to leave was unaware that the decision had been made. 3. The relevant information gathered during the Ward Round on the 28th October 2021, which included the fact that the deceased had attempted to take their own life, the night before, was not adequately communicated to all staff on the unit. 4. The “Sign in/Sign out” book which was supposed to record the movements of service users in the unit was frequently not completed, particularly when service users went out for short periods. 5. There was no proper system for identifying whether a service user should be permitted to leave the unit. 6. The member of staff who allowed the deceased to leave the unit made a brief risk assessment of them before deciding whether they should be allowed to leave. That person did not consult any medical notes or records about the deceased when making that assessment. Had that member of staff consulted the deceased’s medical notes and records, the serious suicide risk which they posed would have been evident. 7. Once the deceased was found to be missing from the unit, there was an unexplained delay in informing the police and ambulance service, a failure to inform either of the serious suicide risk which the deceased posed to themselves and a lack of appreciation of the urgency of the situation by staff generally. 8. The hospital policy which applied to missing patients was not properly adhered to by staff and there was confusion about who should be contacted and in what manner, once a patient was found to be missing. 9. No proper efforts were made to contact members of the deceased’s family once the deceased was found to be missing. 10. The unit was short-staffed and this affected the care provided to the deceased, the assessment of the deceased whilst in the unit and record keeping generally. The summary of the evidence given, as set out above, sets out the matters of concern. | On the 11th November 2021 I commenced an investigation into the death of Hilary Clare (Billy) Guedalla who died aged 46 on the 30th October 2021 [REDACTED]. The investigation resulted in an inquest, which was conducted by myself over a period of 5 days and concluded on 19th May 2023. I made a determination at inquest that the deceased died as a result of suicide and returned a narrative conclusion as follows: 1. The deceased suffered from long standing psychiatric conditions of a Recurrent Depressive Disorder and complex Post Traumatic Stress Disorder. 2. On occasions, the deceased’s psychiatric conditions led to psychiatric in-patient admission to hospital, usually as a voluntary patient, on a number of occasions between 2013 and 2021. Those admissions were associated with the deceased exhibiting suicidal ideation and sometimes involved attempts to take their own life. 3. On the 26th October 2021, the deceased was admitted to Gardener Ward, Homerton Hospital, London E9 as a voluntary patient suffering a worsening of their psychiatric condition. 4. At a ward round at that hospital on the 28th October 2021, at around 11am, the deceased indicated to staff that they had tried to take her own life the night before in hospital and that they had equipment at home for the purposes of ending their life. 5. The deceased’s condition worsened thereafter and staff at the hospital considered that the deceased should not be allowed out of the ward alone, for her own safety because, in effect they were a high risk of suicide. That decision was made in the morning of the 29th October 2021 but not communicated to all staff on the ward. 6. The deceased asked a member of the clinical staff to leave the ward, at around 6pm on the 29th October 2021. That member of staff was unaware of the decision that had been made that the deceased should not be allowed out alone. The member of staff carried out a brief assessment of the deceased, largely based on their appearance, but did not refer to any medical notes and records. The deceased was then allowed to leave the ward. 7. Sometime between leaving the ward and around 3pm on the 30th October 2021, the deceased took their own life by hanging themselves [REDACTED]. No-one else was involved. The deceased was found by members of the London Fire Brigade between 3 and 4pm, on that day. 8. After the deceased had left the ward, night staff found the deceased to be missing at around 8pm on the 29th October 2021. Staff first contacted the police 2.10am and again at 2.46am on the 30th October, 2021 and requested that the police carry out a welfare check. They did not inform the police that the deceased was a serious suicide risk. They were advised to contact the London Ambulance Service but did not do this until 3pm on the 30th October 2021 and in any event, that request did not generate attendance at the deceased’s home address. 9. At around 2pm on the 30th October 2021, the deceased’s mother attended the ward having made a pre-arranged booking to visit the deceased. She was shocked to be informed that the deceased had left the ward. She enlisted support from family and friends which led to the attendance of emergency services at the deceased’s home address, between 3-4pm on the 30th October 2021. | In my opinion, action should be taken to prevent future deaths and I believe that your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by the 4th August 2023. I, the coroner, may extend the period in appropriate circumstances. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. | |
| 20/06/2023 | 2023-0197 | Joan Corcoran | Ms Alison Patricia Mutch OBE | Greater Manchester South | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/joan-corcoran-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Joan-Corcoran-Prevention-of-future-deaths-report-2023-0197_Published.pdf | Joan Mary Corcoran had an accidental fall. She was operated on for a fracture to the neck of femur. Post-operatively she developed pneumonia. Subsequently the wound became infected, and a wound wash and debridement took place. She became increasingly frail. She was discharged home with support from the discharge to assess team. She felt unwell on 13th December 2022 and called for an ambulance with chest pains. Her initial call was dealt with as a category 5 call, and she contacted her GP. Her GP visited her and was concerned about her presentation. A further call to the ambulance service resulted in her being classified as a category 2 call. The blood tests taken indicated she was in severe heart failure and at a risk of a myocardial infarction. The ambulance arrived significantly outside the target Department of Health response times. The ambulance crew identified she needed urgent cardiac treatment and she was for transfer to hospital. Enroute to hospital she deteriorated further and died in the ambulance from complications of heart failure. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The inquest heard evidence that under the Department of Health’s Ambulance Response time criteria, a category 2 call should have an average response time of 18 minutes and be within 40 minutes in 9 out of 10 cases. The evidence before the inquest was that in her case the response time on the category 2 call was 1 hour and 5 minutes – significantly outside the target time. A response within the target time would have meant that she would not have deteriorated and died in the ambulance. She would have been in a hospital with access to treatment available in such a setting. The evidence before the inquest was that her case was not a one off and delays of this nature had been occurring throughout the day. The mean time for Category 2 response times that day was 1 hour and 22 minutes and the 90th percentile was just over 3 hours. At 17.58 that day there were 142 emergencies waiting in Greater Manchester alone and 430 across the North West. The average response time at that point for Category 2 patients was 2 hours and 33 minutes. The inquest heard that the cause of these significant delays in patients receiving care in a timely manner was multifactorial and included the demand for ambulances across Greater Manchester and the North West and the long ambulance delays at A and E departments due to the demand on A and E services. | On 19th December 2022 I commenced an investigation into the death of Joan Mary Corcoran. The investigation concluded on the 15th May 2023 and the conclusion was one of Narrative: | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | ||
| 16/06/2023 | 2023-0196 | Christine Cumbers | Dr Jeane Rosa Mellani | Essex | Other related deaths | Prevention of Future Deaths | Clacton Community Practices | https://www.judiciary.uk/prevention-of-future-death-reports/christine-cumbers-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Christine-Cumbers-Prevention-of-future-deaths-report-2023-0196_Published.pdf | Christine Margaret CUMBERS was born on 3 September 1948 and at the time of her death on 22 April 2022 she lived in Clacton-on-Sea, Essex. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The Practice, despite identifying shortcomings in their practice, took no action to implement the learnings identified in the Significant Event Analysis report and, as at the date of the inquest, no details of plans or timescales for implementation were available. | On 10 May 2022 I commenced an investigation into the death of Christine Margaret Cumbers. The investigation concluded at the end of the inquest on 19 May 2023. The conclusion of the inquest was a narrative conclusion: | In my opinion, action should be taken to prevent future deaths and I believe that your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29 | |
| 16/06/2023 | 2023-0195 | Girmaye Guyo | Mr Zak Golombeck | Manchester City | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/girmaye-guyo-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Girmaye-Guyo-Prevention-of-future-deaths-report-2023-0195_Published.pdf | The Deceased had a long history of mental health illness and substance abuse. Between 4th June 2020 and 15th September 2020 he was detained pursuant to the provisions of Mental Health Act 1983 at Eagleton Ward, Meadowbrook Unit. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there 1s a risk that future deaths will occur unless action is taken In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows: The Nearest Relative Power may (as it did in this case) present an opportunity for a patient and/or their Nearest Relative to apply to the Responsible Clinician for discharge in circumstances when the patient remains liable for their continued detention There does not appear to be a thorough procedure or legal test for clinicians to apply, and thus there is a risk that Responsible Clinicians may be faced with circumstances whereby a patient will be discharged from hospital despite them continuing to meet the criteria for detention. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday 11th August 2023, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |||
| 04/05/2023 | 2023-0194 | Helen Coogan | Ms Mary Hassell | London Inner North | Other related deaths | Prevention of Future Deaths | Ritchie Street Group Practice | https://www.judiciary.uk/prevention-of-future-death-reports/helen-coogan-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Helen-Coogan-Prevention-of-future-deaths-report-2023-0194_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0194-Response-from-Ritchie-Street-Group-Practice.pdf | The medical cause of death was: 1a sudden cardiac death 1b metastatic neuroendocrine carcinoma of the ileocaecal valve and coronary artery atheroma 2 chronic obstructive pulmonary disease, hypertension and atrial fibrillation | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. You provided a statement regarding the care given to Ms Coogan by you and your colleagues at the Ritchie Street Group Practice. In it, you said that she reported to Dr [REDACTED] in July 2022 that she had had abdominal cramps present for months, with alternating loose stool and constipation. You said that a qFIT tool test for blood was requested but there was no subsequent result. You said the same about the qFIT requested on 13 September 2022. It was not clear to me why there were no qFIT results but, given the cause of Ms Coogan’s death, that seems to me to be a matter worthy of your investigation, particularly in case there is some system issue. | On 27 October 2022, I commenced an investigation into the death of Helen Coogan aged 77 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest as follows. “Helen Coogan died in October 2022 from a natural cause, being cancer. She first sought advice from her general practitioner regarding related symptoms in July 2022, but there was no result from the qFIT (faecal immunochemical test) ordered.” | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. |
| 12/06/2023 | 2023-0193 | Heather Findlay | Ms Mary Hassell | London Inner North | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/heather-findlay-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Heather-Findlay-Prevention-of-future-deaths-report-2023-0193_Published.pdf | At the time of her death, Heather Findlay was in the care of the East London Foundation Trust (ELFT), detained under section 2 of the Mental Health Act at Mile End Hospital. At approximately 3pm on 11 June 2020, she was on s17 escorted leave, standing with a healthcare assistant (HCA) at the front gates of the hospital having a cigarette, when she turned to the HCA, said “I’m sorry I have to do this to you” and ran away. ELFT contacted the Metropolitan Police Service (MPS) at 3.17pm, but by 3.58pm, Ms Findlay had been found by a member of the public in a nearby park. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. When Ms Findlay ran off, the HCA escorting her was so panicked that she did not even think of following. Ms Findlay had run across a road and so chasing her at speed did present safety considerations. However, the ELFT policy, training, culture and expectation was such, that there the HCA did not at any point consider attempting to walk after her to keep her in sight. Clinical staff must be adequately prepared for such an eventuality. That means more than simply a change in policy wording. | On 16 June 2020, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Heather Findlay, aged 28 years. The investigation concluded at the end of the inquest earlier today. At inquest, the jury came to a conclusion of death by suicide, making a narrative determination that I now attach, and giving a medical cause of death of: 1a hypoxic ischaemic encephalopathy 1b sodium nitrate toxicity | In my opinion, action should be taken to prevent future deaths and I believe that you and have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. | ||
| 13/06/2023 | 2023-0192 | Raquel Harper | Ms Nadia Persaud | London East | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Barts Health NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/raquel-harper-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Raquel-Harper-Prevention-of-future-deaths-report-2023-0192_Published.pdf | Raquel Harper attended Whipps Cross Hospital on the 23 June 2021. She complained of a 5-day history of shortness of breath and difficulty breathing. Raquel had a low oxygen saturation, a high respiratory rate and a tachycardia. The assessing doctor used the pulmonary embolism rule out criteria (PERC), to rule out the likelihood of a pulmonary embolism causing her symptoms. The PERC test was positive, and a D Dimer should have been carried out. This was not done. A diagnosis of iron deficiency anaemia was made, based upon a low haemoglobin and low MCV level. Raquel was admitted to hospital and suffered from periods of desaturation requiring medical review and assessment. The diagnosis of iron deficiency anaemia was not re-visited and further investigations, such as arterial blood gases were not carried out. In the very early hours of 25 June 2021, Raquel became critically unwell. She required escalation of her care, but this was not provided until she was in a peri-arrest state at around 0330 on 25 June 2021. Raquel suffered a cardiac arrest at around 0400 and received resuscitation and thrombolysis. Sadly, there was no response to the emergency efforts and Raquel passed away at Whipps Cross Hospital on 25 June 2021. Had Raquel received the D Dimer test on the 23 June 2021, in accordance with the Trust’s policy, this is likely to have triggered further investigations which would have resulted in a diagnosis of pulmonary embolism and a treatment dose of lower molecular weight heparin. On the balance of probabilities this would have prevented Raquel’s death on the 25 June 2021. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. There was a lack of thorough history taking and a number of assumptions were made on the basis of Raquel’s high BMI. There was an assumed chronic low oxygen saturation with no evidence that the doctors had checked the records available or asked the patient about her baseline. The oxygen saturations recorded in the Barts sleep apnoea clinic in 2015 and 2016 were noted to be 99% and 100%. 2. There was a lack of escalation of monitoring following the NEWS score of 10. It is of concern that the NEWS policy was not complied with by the nursing staff. There was disagreement between senior clinicians as to how the Trust’s PE policy should have been applied. The policy is often not used in accordance with the specific wording. For example, the requirement for pleuritic chest pain is often ignored in practice. A senior clinician within the Trust considered that the caveat for pleuritic chest pain in the policy should be reviewed. In addition, the senior clinician described some of the wording in the policy as “clumsy”. In light of this, the Trust may wish to review the policy. | On the 26th July 2021 I commenced an investigation into the death of Raquel Mellonie Harper, aged 33 years. The investigation concluded at the end of the inquest on 2nd May 2023. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 07/06/2023 | 2023-0191 | Brenda Shields | Dr Nicholas Alastair Shaw | Cumbria | Alcohol, drug and medication related deaths | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/brenda-shield-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Brenda-Shields-Prevention-of-future-deaths-report-2023-0191_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0191-Response-from-Cumbria-Northumberland-Tyne-and-Wear-NHS-Foundation-Trust.pdf | The record of inquest read as follows: “Brenda Shields died in her home , [REDACTED], Carlisle on 8th December 2022. She took her life by ligature suspension while under the influence of a very high blood alcohol level”. A narrative conclusion was given. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 15 December 2022 I commenced an investigation into the death of Brenda SHIELDS age The investigation concluded at the end of the inquest on 6th June 2023 . The conclusion of the inquest was: | In my opinion action should be taken to prevent future deaths and I believe you and the wider trust have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd August 2022. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 11/06/2023 | 2023-0190 | Marlene McCabe | Mr Tim Holloway | Blackpool and Fylde | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/marlene-mccabe-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Marlene-McCabe-Prevention-of-future-deaths-report-2023-0190_Published.pdf | Box 3 of the Record of Inquest recorded as follows: On 4th September 2019, between around 5.10pm and 5.50pm, Marlene McCabe was killed unlawfully in her own home. She died as a consequence of being struck a multiplicity of times to the head and face with a blunt object, namely, a doorstop, which occasioned catastrophic head and facial injuries. The actions of her assailant were more than minimally contributed to by the assailant’s undiagnosed and untreated schizophrenia coupled with alcohol intoxication. There were accepted prior failures in the collation and consideration of information, including from the available records and family, and in the mental health assessment of and progression of treatment for the assailant, in particular from early July 2019, which did not more than minimally contribute to Marlene McCabe’s death. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: A. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust 1) There remains the potential for a lack of understanding amongst clinicians as to how urgent referrals into the PIMHT should be made. B. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust (iv) North West Ambulance Service 2) There is inconsistent availability of access to mental health records across the service providers and information sharing between service providers using different data bases is difficult. C. To: (i) Blackpool Teaching Hospitals NHS Foundation Trust (ii) Lancashire and South Cumbria NHS Foundation Trust 3) There is a residual risk that reference to drug and/or alcohol misuse in mental health referrals and/or assessments may lead to the missing of a mental health diagnosis and that circumstances may arise in which assumptions are made concerning substance misuse. D. To: (i) Bloomfield Medical Centre (ii) Blackpool Teaching Hospitals NHS Foundation Trust (iii) Lancashire and South Cumbria NHS Foundation Trust 4) There is a residual risk of non-communication of material information pertaining to patients’ mental health between healthcare providers. E. To: (i) Blackpool Teaching Hospitals NHS Foundation Trust (ii) Lancashire and South Cumbria NHS Foundation Trust 5) There is a risk that delayed assessment of patients who may appear to be or are reported to be intoxicated will give rise to a loss of opportunity to identify signs of psychosis. | On 5 September 2019 an investigation was commenced into the death of Marlene McCabe. An inquest was opened on 10 September 2019. The investigation concluded at the end of the inquest held at Blackpool Town Hall on 6 March 2023 – 23 March 2023 and 3 May 2023. Conclusion of Investigation (Section 4) Unlawful killing. On 4th September 2019, between around 5.10pm and 5.50pm, Marlene McCabe was killed unlawfully in her own home. She died as a consequence of being struck a multiplicity of times to the head and face with a blunt object, namely, a doorstop, which occasioned catastrophic head and facial injuries. The actions of her assailant were more than minimally contributed to by the assailant’s undiagnosed and untreated schizophrenia coupled with alcohol intoxication. | In my opinion action should be taken to prevent future deaths and I believe your organisations have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 7th August 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 09/06/2023 | 2023-0189 | Elsie Murphy | Dr Nicholas Alastair Shaw | Cumbria | Other related deaths | Prevention of Future Deaths | Cumberland Council | https://www.judiciary.uk/prevention-of-future-death-reports/elsie-murphy-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Elsie-Murphy-Prevention-of-future-deaths-report-2023-0189_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0189-Response-from-Cumberland-Council.pdf | On 27th September 2022 Elsie was walking along the footpath from that leads from Windermere Road to Ewanrigg Road in Maryport to reach a bus stop. immediately below the steps leading up to Ewanrigg road the path turns 90 degrees right, Elsie slipped in a puddle that had formed here and fell, sustaining her fatal injury. She died in Cumberland Infirmary the following day. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 30 September 2022 I commenced an investigation into the death of Elsie Mary MURPHY, aged 86. The investigation concluded at the end of the inquest . The conclusion of the inquest was | In my opinion action should be taken to prevent future deaths and I believe your council have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, 7 namely by 14th July 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 09/06/2023 | 2023-0188 | Alice Fox | Mr Peter Nieto | Derby and Derbyshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/alice-fox-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Alice-Fox-Prevention-of-future-deaths-report-2023-0188_Published.pdf | Jean was admitted to Royal Derby Hospital on 7 June 2021 following her fall, and surgery was performed on 9 June. There were no complications during the surgery nor in her post- operative care leading to discharge to Ripley Rehabilitation Hospital where she arrived at about 23:00 on 22 June. Because she arrived so late and out of core hours, she did not have the benefit of the full and usual assessments and she had also been waiting for the transfer for some significant time at the general hospital in its discharge lounge. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: – 1. Jean had spent a lengthy period in the general hospital discharge lounge, during which time which she would not have had close checks and observations as compared to ward- based care. She did not arrive at the rehabilitation hospital until late at night and so did not have the usual core admission assessments. Such situations appear to me to have the potential to place patients such as Jean at significant risk. Given that there would usually be three parties involved in the transfer (the discharging hospital, the transporting ambulance service, and the discharge destination) there is opportunity for consideration of protocols to ensure such discharge arrangements are safe and appropriate. 2. Jean had signs of infection to the surgical site on arrival at the rehabilitation hospital and should have had more robust clinical review but confirmation of infection and referral back to the general hospital did not occur until her blood results were reviewed 3 days later. There had been opportunity to expedite the blood results. On the evidence at inquest there is reason to think that the rehabilitation staff were falsely reassured by a low NEWS score whereas there was suspected infection that could have been confirmed earlier. | On 05 July 2021 I commenced an investigation into the death of Alice Jean FOX aged 90. The investigation concluded at the end of the inquest on 26 May 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by August 04, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 07/06/2023 | 2023-0187 | Anthony Smith | Mr Nicholas Leslie Rheinberg | Lancashire and Blackburn with Darwen | Prevention of Future Deaths | State Custody related deaths | HM Prison | Probation Service | https://www.judiciary.uk/prevention-of-future-death-reports/anthony-smith-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Anthony-Smith-Prevention-of-future-deaths-report-2023-0187_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0187-Response-from-HM-Prison-and-Probation-Service.pdf | Mr Smith at the time of his death at HMP Preston was suffering an acute relapse in respect of his schizophrenia. He was delusional, hallucinating and hearing voices. On 4th May 2022 he was found hanging in his cell. He was cut down and officers commenced cardio-pulmonary resuscitation | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | An investigation into the death of Anthony George Smith aged 34 was commenced on 16th May 2022. The investigation concluded at the end of the inquest on 7th June 2023. The conclusion of the inquest was that Mr Smith died as a result of self-suspension but his intention in doing so could not be determined | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 05/06/2023 | 2023-0186 | Jonathan Cole | Miss Sophie Cartwright KC | Derby and Derbyshire | Other related deaths | Prevention of Future Deaths | Ministry of Defence | Homerton Healthcare NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/jonathan-cole-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Jonathan-Cole-Prevention-of-future-deaths-report-2023-0186_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0186-Response-from-Ministry-of-Defence.pdf | On the 9th August 2018 at a location of Old Stone Bridge, Butterley Park, Codnor Park, Ironville, Derbyshire Jonny Cole was found hanging [REDACTED] having acted with the intention to end his life. Jonny had PTSD, anxiety, suicidal ideation and was under the care of his local mental health trust. Jonny had not been seen since leaving his home on the afternoon of 7th August 2018 and was due in court on 8th August 2018 to face charges of criminal damage but did not attend. | During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | In 2018 an investigation was commenced into the death of Jonathan “Jonny” Philip Cole [JC], aged 39. The investigation concluded at the end of the Inquest on 25 April 2023. The conclusion of the Inquest was a Narrative Conclusion namely: | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 31st July 2023. I, the Coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 08/06/2023 | 2023-0185 | Eifion Huws | Katie Sutherland | North West Wales | Prevention of Future Deaths | Suicide (from 2015) | Betsi Cadwaladr University Local Health Board | https://www.judiciary.uk/prevention-of-future-death-reports/eifion-huws-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Eifion-Huws-Prevention-of-future-deaths-report-2023-0185_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0185-Response-from-Betsi-Cadwaladr-University-Local-Health-Board.pdf | The circumstances of the death are as follows : Eifion Wyn Huws was aged 63 at the time of his death on 10 June 2022. He had a past medical history of non-Hodgkin’s lymphoma having had the diagnosis on 12 January 2022 and poorer mental health as a result. Other than the lymphoma he had no other significant past medical history. The anticipation of awaiting scans and treatment impacted severely upon his mental health but he had significant family support. Eifion was regularly reviewed by a GP and medicated accordingly. He had previous attempts at self-harm by way of medication overdose or self-inflicted injury. He had been under the care of the Community Mental Health Team including Home Treatment Team and primary care since early 2022 up to his death. His acts of self-harm were impulsive but serious. On 10 June 2022 Eifion had left his home address to attend his daughter’s home across the road to let the cat out. There was a concern for Eifion when he did not reply to a text message from his wife around 15 mins later who then attended at their daughter’s home and on opening the front door found Eifion suspended by a ligature [REDACTED]. Eifion was confirmed as having passed away at the property on 10 June 2022 at 10.37 by an attending paramedic. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. a. During the Inquest evidence was heard that Eifion’s GP had made a ‘very urgent’ referral to the Single Point of Access and Allocation within BCUHB on 13 May 2022 indicating that on the background of attempts at ending his life, he was extremely concerned that Eifion was experiencing deterioration in his mental state. This document was contained within the hard copy set of notes held by the Psychiatric Liaison Team. When Eifion attended at the Emergency Department the following day, on 14 May 2022, the Emergency department staff were not aware of this ‘very urgent’ referral as they only had access to the electronic notes and not the hard copy notes. Had they been aware it is likely to have further informed their decision making. It is concerning that the process of ensuring electronic notes to allow for fully informed decisions around treatment and care based on all available records, is not available to staff. It was not clear at Inquest whether the transition from paper-based notes to electronic notes was a Health Board initiative or a nationally followed initiative. Either way, any delay in ensuring all notes are available electronically is potentially harmful to patients. b. During the evidence it was accepted that ‘a’ above was not a consideration for improvement as part of the Health Board’s investigation and so was not an action within the Action Plan upon which it could make improvements or plan to make improvements. It is surprising that the Health Board did not consider this as an issue which required further consideration and improvements in its learning and improvement. An investigation was commenced by the Health Board into Eifion’s death which appears to have been concluded in July 2022 but did not appear to be finalised and ready for sharing / disseminating until March 2023. I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations, specifically in relation to investigations from deaths in 2020 and 2021. Whilst I have previously been advised of improvements into investigation processes in respect of more recent deaths the issue of timeliness remains. Eifion died in 2022 and yet the time it took for the investigation to be completed and shared, with actions undertaken has been too long. I am concerned that deaths will occur when the actions arising are not acted upon in a timely manner. | On 21 June 2022 an investigation was commenced into the death of Eifion Wyn Huws (DOB 25/4/59) who died on 10 June 2022. The investigation concluded at the end of the inquest on 7 June 2023. The conclusion of the inquest was suicide. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 3 August 2023. I, Kate Sutherland, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 08/06/2023 | 2023-0184 | David Wilson | Mr Kevin McLoughlin | Yorkshire West Eastern | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Mid Yorkshire Hospitals NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/david-wilson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/David-Wilson-Prevention-of-future-deaths-report-2023-0184_Published.pdf | Mr D B Wilson was admitted to hospital on 27 December 2022. A CT scan indicated an inflammation in the distal section of his colon. The established diagnostic procedure to identify the cause of the suspected colitis was a flexible sigmoidoscopy. A recognised complication of this procedure was a colonic perforation. This happened in this case and resulted in his death the following day, 31 December 2022, at Pinderfields Hospital, Wakefield. | During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The Consent form signed by Mr Wilson was a standard pre-printed form. It did not attempt to provide any statistical rating for the risks identified, which would have enabled Mr Wilson to evaluate the risks. (2) No attempt was made to interpret or tailor the risks inherent in the procedure in the light of his extensive medical history and co-morbidities. (3) The Consent Form did not refer to the risks of death, which befell him. He was thus not in a position to make a truly informed consent to undergo the sigmoidoscopy. (4) The Consent Form did not identify those clinicians involved in discussing the decision with him, save for who obtained his signature at a time when he was under the influence of morphine sedation. The objective of the Consent process should be to demonstrate a patient has made a truly informed decision at a time when he is able to evaluate the risks clear! . | On 18 January 2023 I commenced an investigation into the death of David Barnet WILSON, aged 67. The investigation concluded at the end of the Inquest on Tuesday 6 June 2023. The conclusion of the Inquest was a Narrative based upon the following medical cause of death; 1a Sepsis 1b Bowel Perforation (Sigmoidoscopy Procedure Undertaken on 30.12.22) 1c lschaemic Colitis, II End Stage Renal Failure, Abdominal Aortic Aneurysm (operated), lschaemic Heart Disease. | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Tuesday 1 August 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 09/05/2023 | 2023-0183 | Sandra Finch | Miss Emma Serrano | Stoke on Trent and North Staffordshire | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | NHS England | West Midlands Ambulance Service | https://www.judiciary.uk/prevention-of-future-death-reports/sandra-finch-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Sandra-Finch-Prevention-of-future-deaths-report-2023-0183_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0183-Response-from-West-Midlands-Ambulance-Service.pdf | i) Sandra Diane Finch was 44 year old woman who had a history of Type 1 diabetes mellitus. She used an insulin pump to administer insulin and had done so since 2005. ii) She had recently had a dental procedure and was also recently prescribed antibiotics for an infection. It was accepted by clinicians that this can cause a Type 1 diabetic to need more insulin than they would normally need. iii) On the 3 December 2021, Sandra Diane Finches glucose levels start to rise. This is picked up by the pump that she used and this sounded regular alarms and gave correctional doses of insulin. iv) On the 4 December 2021 Sandra Diane Finch called the West Midlands Ambulance Service and told them she was feeling more sleepy, her glucose was high and she had been vomiting. The categorisation of this call was category 3. This meant she was a medical emergency and required an ambulance. However, before an ambulance could be dispatched a clinical review Was required by the CV team. v) The team was under staffed and had no time limit attached for an assessment. As such, an attempt for an assessment did not take place until 10 hours later. At 7:22 a call was made to Miss Finch. This was unanswered. The options available, at this stage, would have been to dispatch an ambulance, or to place the call back, back into the CV Teams work load. This was what happened. vi) At 12:47 on the 5 December 2023 the decision was made by the team to categorise the ambulance request as a category 2 and dispatch an ambulance. This arrived at Sandra Diane Finches address at 13:08 and she was found to have passed away as a result of ketoacidosis. vii) Clinical opinion disagreed that category three was the correct categorisation. It should be have been a category 2. Evidence was heard that the pathway had to be followed rigidly so a computer could decide the category, but accepted that a clinician listening to the answers may well have made a different decision and given the call a category 2 marking. The view of clinicians was that had the ambulance been despatched within the accepted time limit for a category 3 ambulance, Sandra Diane Finch would not have died when she did. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path. This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly. That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays. | On the 9th October 2021, I commenced an investigation into the death of Ms Sandra Diane Finch. The investigation concluded at the end of the inquest on 3 May 2023. The conclusion of the inquest was a narrative conclusion of ketoacidosis due to insulin depravation contributed to by neglect. The cause of death was: 1a) Ketoacidosis 1b) Uncontrolled Type 1 Diabetes Mellitus 1c) Insulin depravation | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 June 2023. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | |
| 08/06/2023 | 2023-0182 | Ivan Ignatov | Mrs Rachael Clare Griffin | Dorset | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/ivan-ignatov-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Ivan-Ignatov-Prevention-of-future-deaths-report-2023-0182_Published.pdf | At around 21.15 hours on the 19th July 2020 Ivan Rumenov Ignatov was seen to enter the driver’s seat of a motor vehicle parked on Easton Square, Portland attempting to take the vehicle. There was a tussle where Ivan received injuries and he fled on foot, knocking on the doors of residents nearby asking for help, displaying agitated behaviour. At approximately 22.00 hours he was seen by police officers, and he ran off from them on foot into a nearby quarry. At approximately 22.13 hours he was seen to enter and exit the water at Church Ope Cove, Portland fully clothed, displaying odd behaviour. At around 22.21 hours he was located walking on the cliffs and coastline of Portland, Dorset. He was acting erratically and seen stumbling along the rocky terrain. He was followed by the national police helicopter and police officers on the ground in an attempt to safeguard him. At 22.48 hours he entered the waters of the English Channel, north of Durdle pier and swam away from shore a distance of approximately 20 to 50 meters. At approximately 23.03 hours he went underneath the water and did not resurface. He was found deceased in the water south of Durdle Pier, Portland on the 31st July 2020. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On the 11th August 2020, an investigation was commenced into the death of Ivan Rumenov Ignatov, born on the 10th February 1996. The investigation concluded at the end of the Inquest on the 26th May 2023. | In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, 3rd August 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 07/06/2023 | 2023-0181 | David Wood | Mr Tom Osborne | Milton Keynes | Mental Health related deaths | Prevention of Future Deaths | Suicide (from 2015) | John Radcliffe Hospital | MK together Partnership | https://www.judiciary.uk/prevention-of-future-death-reports/david-wood-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/David-Wood-Prevention-of-future-deaths-report-2023-0181_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0181-Response-from-Oxford-University-Hospitals-NHS-Foundation-Trust.pdf | Mr. Wood had been suffering from depression and difficulty sleeping following his release from hospital after the surgery. He had been to see his doctor about this. On Wednesday the 22nd of June 2022 Mr. Wood was at home with his wife. During the afternoon Mrs. Wood went out leaving him sat in a downstairs chair. On her return he was no longer in the chair and she thought that he had gone upstairs to try and sleep. Later that evening at 8pm she went to wake him up. Mrs Wood found him suspended by the neck. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 29 June 2022 I commenced an investigation into the death of David WOOD aged 56. The investigation concluded at the end of the inquest on 06 December 2022. The conclusion of the inquest was that: The deceased having recently undergone open heart surgery in Oxford developed a severe depression. He was found on 22nd June 2022 hanging at his home [REDACTED] Milton Keynes. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by August 01, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 07/06/2023 | 2023-0180 | Robert Stevenson | Mr Martin Dominic Fleming | Yorkshire West Western | Alcohol, drug and medication related deaths | Prevention of Future Deaths | Suicide (from 2015) | Medicines & Healthcare products Regulatory Agency | https://www.judiciary.uk/prevention-of-future-death-reports/robert-stevenson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Robert-Stevenson-Prevention-of-future-deaths-report-2023-0180_Published.pdf | Mr Stevenson was a 63 year old gentleman who was a very respected and experienced Consultant Cardiologist and General Physician at Huddersfield Royal Infirmary, who resigned his post in May 2022 to enter full retirement. On 6/5/22 he was referred to the urology department for the investigation of possible prostate cancer, when a decision was also made to consult a private Consultant Urologist. In order to relieve his symptoms of prostatitis and to make him ready for an investigative biopsy, he was prescribed Ciprofloxacin on 19/5/22 at a dose of [REDACTED]. He had no previous history of depression or mental health problems. | During the inquest I was referred by Mr Stevenson’s treating urologist to published literature relating to Ciprofloxacin and Quinolone antibiotics and a potential rare link to suicide behaviour in patients, although I found on the balance of probabilities that it remained unclear that he was suffering from this side effect, it remained possible for this to be the case. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) • I heard evidence to suggest that the prescribing doctor did not reference this side effect at the time of issuing the prescription to Mr Stevenson, since it was not in accord with current advice. • I also heard evidence to suggest that prescribing doctors may not be fully aware of this rare side effect, and that patient’s suffering from depression may be more vulnerable to it. I am therefore concerned that this potential risk has not been given sufficient emphasis and I would ask you to consider the appropriateness of reviewing the current guidelines as to the dispensation of the drug to patients by clinicians and increasing the awareness of the side effect in order to monitor and mitigate the risks. | On 22/06/22 I opened an inquest into the death of Robert Newton Stevenson who, at the date of his death was aged 63 years old. The inquest was resumed and concluded on 25/5/23. I found that the cause of death to be: 1a. asphyxia (hanging) I arrived at a narrative conclusion: Robert Newton Stevenson intended to take his own life when the balance of his mind was disturbed. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by August 01, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 02/06/2023 | 2023-0179 | Nigel Harper | Mr David Donald William REID | Worcestershire | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/nigel-harper-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Nigel-Harper-Prevention-of-future-deaths-report-2023-0179_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0179-Response-from-Herefordshire-and-Worcestershire-Health-and-Care-NHS-Trust.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0179-Response-from-Gloucestershire-Health-and-Care-NHS-Foundation-Trust.pdf | In answer to the questions “when, where and how did Mr. Harper come by his death?”, I recorded as follows: | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty t report to you. The MATTERS OF CONCERN are as follows. | [the details below are fictional] On 27 July 2022 I commenced an investigation and opened an inquest into the death of Nigel Harper. The investigation concluded at the end of the inquest on 15 May 2023. | In my opinion action should be taken to prevent future deaths and I believe you, as the Chief Executives of HWHCT and GHCT have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 02/06/2023 | 2023-0178 | Andrew Dean | Michael Spencer | East Sussex | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/andrew-dean-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Andrew-Dean-Prevention-of-future-deaths-report-2023-0178_Published.pdf | On 26th March 2021 at approximately 10.11am in cell A3-10 at HMP Lewes, Andrew Dean was found with a ligature around his neck [REDACTED]. He was treated at the scene by prison staff, healthcare staff and paramedics. Andrew Dean was declared dead at 11.27am at HMP Lewes. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 29 March 2021 I commenced an investigation into the death of Andrew DEAN aged 50. The investigation concluded at the end of the inquest on 31 March 2023. The jury recorded a conclusion of SUICIDE. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 31 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 31/05/2023 | 2023-0177 | Andrew Shambrook | Mr John Gittins | North Wales (East & Central) | Prevention of Future Deaths | Suicide (from 2015) | Wales prevention of future deaths reports (2019 onwards) | Betsi Cadwaladr University Health Board BCUHB | https://www.judiciary.uk/prevention-of-future-death-reports/andrew-shambrook-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Andrew-Shambrook-Prevention-of-future-deaths-report-2023-0177_Published.pdf | The circumstances of the death are that Mr Shambrook took his own life by hanging [REDACTED] on the 27th of March 2022. | During the course of the inquest the evidence revealed the following matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. The health board (by their own admission through counsel) acknowledge that there is no documented or robust policy in relation to decision making/meeting criteria and thereafter future treatment and care pathways when a patient is referred to the Home Treatment Team | On the 28th of March 2022 I commenced an investigation into the death of Andrew John Shambrook (DOB 17.2.77 DOD 27.3.22). The investigation concluded at the end of the inquest on the 28th of April 2023. The cause of death was recorded as being due to 1(a) Hanging and the conclusion of the inquest was that of suicide. The evidence indicated that Mr Shambrook was under the care of the mental health services and that there had been a referral to the Home Treatment Team, however he did not meet their criteria for treatment. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th of July 2023 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 25/05/2023 | 2023-0176 | Jean Hardy | Mrs Karen Dilks | Newcastle and North Tyneside | Prevention of Future Deaths | Road (Highways Safety) related deaths | Sunderland City Council | https://www.judiciary.uk/prevention-of-future-death-reports/jean-hardy-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Jean-Hardy-Prevention-of-future-deaths-report-2023-0176_Published.pdf | On 4th February 2020 Jean Hardy (JH), a 71-year-old lady (generally fit and well), crossed the B1286 Doxford Parkway Sunderland from the Southside to the Westbound carriageway. She did so, at a point where there was no designated pedestrian crossing, when it was dark and when the carriageway was illuminated by street lighting. JH was struck by a motor vehicle and sustained multiple Injuries that led to her death within RVI Newcastle Upon Tyne on 8th February 2020. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) The B1286 Doxford Parkway is bordered by Multiple housing estates and the evidence confirmed that local practice of crossing at non designated crossing points which are more easily accessible and convenient is common and well known. (2) Access to the carriageway is not restricted by fencing (save for limited fencing at designated crossing points) and there is no signage prohibiting crossing at non designated crossing points or warning of the risks to the public of doing so. (3) There is a risk of further deaths occurring in this location and in similar circumstances. To prevent future deaths there should be a comprehensive review of current pedestrian crossing provision on B1286 Doxford Parkway. | On 14 February 2020 I commenced an investigation into the death of Jean HARDY. The investigation concluded at the end of the inquest on 24th April 2023. The conclusion of the inquest was Road Traffic Collision | In my opinion action should be taken to prevent future deaths and I believe you Dave Smith CEO Sunderland City Council have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 30/05/2023 | 2023-0175 | Carol Clements | Mrs Rebecca Ollivere | Birmingham and Solihull | Care Home Health related deaths | Prevention of Future Deaths | Birmingham Community Healthcare NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/carol-clements-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Carol-Clements-Prevention-of-future-deaths-report-2023-0175_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0175-Response-from-Birmingham-Community-Healthcare-NHS-Foundation-Trust-.pdf | The deceased was a resident at Perry Trees Centre following discharge from hospital after surgery to repair a hip fracture. Whilst at the centre, she was incorrectly assessed as being a medium risk of falls, when in fact, she should have been categorised as a high risk. She therefore did not have the correct level of supervision. On 2nd October 2022, Carol was found on the floor of her room, having been previously sat in her chair by staff. The fall was unwitnessed. Carol sustained a further hip fracture as a result of this fall. She was returned to hospital where further surgical fixation was carried out successfully. Initially, she recovered well post operatively, however, Carol developed Pneumonia. She had a RESPECT form in place from her earlier admission and therefore her care was comfort care only. Her Pneumonia progressed to Sepsis, and she died on 23rd October 2022 in hospital. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. | On 8 November 2022, I commenced an investigation into the death of Carol Ann CLEMENTS. The investigation concluded at the end of the inquest. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action – otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 26/05/2023 | 2023-0174 | Jessica Hodgkinson | Mr Matthew Kewley | Derby and Derbyshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Chesterfield Royal Hospital NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/jessica-hodgkinson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Jessica-Hodgkinson-Prevention-of-future-deaths-report-2023-0174_Published.pdf | Jess was born on 9 August 1994. Jess died on 14 May 2021 at the Chesterfield Royal Hospital shortly after giving birth to her daughter. Jess had a high risk pregnancy. This was primarily due to Jess’ severe hypertension. Jess also had a rare condition known as Klippel-Trenaunay Syndrome (“KTS”) which created an increased risk of Jess developing a deep vein thrombosis/pulmonary embolism. The main challenge during Jess’ pregnancy was her hypertension. The inquest found, however, that Jess’ hypertension was managed appropriately by her consultant in Chesterfield with input from a specialist renal physician. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 5 October 2021 I commenced an investigation into the death of Jessica Hodgkinson (“Jess”). The investigation concluded at the end of the inquest on 27 January 2023. The narrative conclusion of the inquest was: ‘Jess died on 14 May 2021 due to a pulmonary embolism that arose from a deep vein thrombosis (the risk of this was increased by the KTS) as well as acute anaphylaxis of unknown cause. There was a failure to ensure that Jess received anticoagulant medication that a clinician had intended should be taken until birth. This failure made a more than minimal, negligible or trivial contribution to Jess’ death on 14 May 2021.’ | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 21 July 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 26/05/2023 | 2023-0173 | Conrad Colson | Ms Nadia Persaud | London East | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/conrad-colson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Conrad-Colson-Prevention-of-future-deaths-report-2023-0173_Published.pdf | Conrad Colson suffered from severe body dysmorphic disorder (BDD). The symptoms from this condition had led to a serious suicide attempt in February 2020. In 2021, following several months on the waiting list, Conrad received highly specialised therapy from the Centre for Anxiety Disorders and Trauma (CADAT). He made significant progress in managing his BDD symptoms during this therapy, however there was a known risk of relapse. He completed the sessions with his CADAT therapist in November 2021. Before and during this therapy, he had also received support from his local mental health trust’s Peer Open Dialogue Team. As he had made such good progress with CADAT and as he had requested discharge from the Peer Open Dialogue Team, he was also discharged from this team in November 2021. There was no joint multi-disciplinary risk assessment and risk management plan on discharge from the teams. The practitioners were aware that Conrad was not taking a therapeutic dose of medication at the time of discharge, but no medical review was arranged for him. At the time of discharge from services, Conrad was also accessing treatment from an aesthetic dermatology clinic. This was not taken into account in his discharge risk assessment. Conrad had raised concerns with the skin clinic about his skin and the treatment, in December 2020; January 2021; March and April 2021. On the 27 and 28 February 2022, Conrad again raised concerns about the appearance of his skin, following treatment at the aesthetic dermatology clinic. His friends became concerned for his welfare when they could not reach him on the 2 March 2022. Emergency services attended and sadly Conrad was found deceased within his home address. The evidence at the inquest revealed that Conrad took his own life. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 11 March 2022 I commenced an investigation into the death of Conrad Richard James Colson, aged 34 years. The investigation concluded at the end of the inquest on the 18 May 2023. The conclusion of the inquest was a narrative conclusion: | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 July 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | ||
| 12/05/2023 | 2023-0172 | Angela Craddock | Ms Jacqueline P Devonish | Cheshire | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/angela-craddock-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Angela-Craddock-Prevention-of-future-deaths-report-2023-0172_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0172-Response-from-Sodexo-Government.pdf | On 3 April 2018 the offender was released from HMC Altcourse on a licence. The offender was subject to a licence condition to attend at the local community rehabilitation team upon release. There was also in place a Restraining Oder for the protection of Angela Craddock. When the offender failed to present himself the local rehabilitation team issued a recall to prison for breach of the licence condition. On 6 April 2018 a recall notice was authorised by the National Offender Management Service and sent to the police to enforce. Police resources were such, at that time, that no patrol was effectively deployed to locate him. The offender attended the address of Angela Craddock where he inflicted upon her survivable injuries. She died on 11 April 2018. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 03 May 2018 I commenced an investigation into the death of Angela Vanessa CRADDOCK aged 40. The investigation concluded at the end of the inquest on 12 May 2023. The conclusion of the inquest was that: Angela Craddock was unlawfully killed when the offender remained unlawfully at large. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by July 07, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 24/05/2023 | 2023-0171 | Peter Camp | Mr Jason Pegg | Hampshire, Portsmouth and Southampton | Other related deaths | Prevention of Future Deaths | Churchers Solicitors | https://www.judiciary.uk/prevention-of-future-death-reports/peter-camp-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Peter-Camp-Prevention-of-future-deaths-report-2023-0171_Published.pdf | Police officers attended the address of 2, The Haven, Gosport, Hampshire, PO12 2BD following a concern for welfare raised by the deceased’s friend. The deceased had complained of feeling unwell the previous morning. Police entered the property and noted the heating in the property was on. They found the deceased (Peter John CAMP) in his bedroom. There were no signs of forced entry, and the death was reported to the coroner as a non-suspicious category 3 death. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by July 18, 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 23/05/2023 | 2023-0170 | Daniel Lyle | Mr Paul John Rogers | London Inner West | Mental Health related deaths | Prevention of Future Deaths | Metropolitan Police Service | College of Policing | https://www.judiciary.uk/prevention-of-future-death-reports/daniel-lyle-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/Daniel-Lyle-Prevention-of-future-deaths-report-2023-0170_Published.pdf | : Extensive evidence was heard by the court in the form of written and oral evidence, and I was able to view the body worn video evidence of police officers who attended a call to police about Daniel’s behaviour that day. | On the 21st March, 22nd March and 23rd March 2023 evidence was heard touching the death of Daniel LYLE. He died on 20th March 2020 aged 46 years. | In my opinion action should be taken to prevent future deaths and l believe your organisation has the power to take such action. It is for each addressee to respond to matters relevant to them. | You are under a duty to respond to this report within 56 days of the date of this report. 1, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 22/05/2023 | 2023-0169 | Kaius Tutt | Guy Davies | Cornwall and the Isles of Scilly | Prevention of Future Deaths | Road (Highways Safety) related deaths | Connectivity and Environment | https://www.judiciary.uk/prevention-of-future-death-reports/kaiustutt-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/06/KaiusTutt-Prevention-of-future-deaths-report-2023-0169_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/06/2023-0169-Response-from-Cornwall-Council.pdf | Kaius died from injuries sustained after the motorcycle he was riding collided with a car coming in the opposite direction. At the point of the collision the motorcycle that Kaius was riding was in contravention of solid double white lines. The collision occurred at approximately 19:05 hours on Friday 14th October 2022, on the A391, St Austell, Cornwall. Kaius was approaching the Carclaze roundabout, riding his Honda 125cc motorcycle towards St Austell having come from the direction of the Scredda roundabout. The court found that rider error on the part of Kaius was the cause of the collision, contributed to by the faded road markings and a visibility issue at the collision location. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) The deflection arrows on this stretch of road were found to have faded and to have almost entirely disappeared in places. | On 25 October 2022 I commenced an investigation into the death of Kaius. The investigation concluded at the end of the inquest on 27 April 2023. | In my opinion action should be taken to prevent future deaths and I believe you, Cornwall Council, have the power to take such action. | — You are under a duty to respond to this report within 56 days of the date of this report, namely by 18 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 22/05/2023 | 2023-0168 | Karl Mitchell | Dr Peter Harrowing | Avon | Accident at Work and Health and Safety related deaths | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/61812-2/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Karl-Mitchell-Prevention-of-future-deaths-report-2023-0168_Published.pdf | The Deceased was a lorry driver with Titan Containers Limited a company who provided shipping type containers to various sites which were then used for storage and as temporary site facilities. The containers were loaded and off loaded using a lorry mounted crane. The lorry used by the Deceased was fitted with a hydraulic stabiliser beam and swing-up (rotating) hydraulic stabilising leg at each corner. These were deployed during the loading and off loading procedure so as to stabilise the vehicle whilst the crane was in use. | During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 29th September 2021 I commenced an investigation into the death of Mr. Karl Mitchell age 50 years. The investigation concluded at the end of the inquest on 23rd March 2023. The conclusion was that the medical cause of death was l( a) Cerebral oedema; 1(b) Hypoxic brain injury; 1(c) Traumatic crush injury to chest, and the conclusion of the jury as to the death was ‘Accident’ | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th July 2023. I, the coroner, may extend the period. | I make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 19/05/2023 | 2023-0167 | Amelia Barbosa | Mrs Samantha Goward | Cambridgeshire and Peterborough | Child Death (from 2015) | Prevention of Future Deaths | North West Anglia NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/amelia-barbosa-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Amelia-Barbosa-Prevention-of-future-deaths-report-2023-0167_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0127-Response-from-Product-Safety-Standards-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0167-Response-from-North-West-Anglia-NHS-Foundation-Trust.pdf | 1. In summary, Amelia’s mother had a routine pregnancy and was given a due date of 01 December 2020. She attended Peterborough City Hospital at around 1030 hours on 5 December 2020. 2. From very early on, the CTG trace was classified as suspicious on a number of occasions and on some occasions as pathological. Evidence and a report from HSIB confirms that assessment and decision making during this period was appropriate. 3. Due to a failure to progress in the second stage of labour and suspected fetal compromise at around 0240 hours, a decision was made for a Category 2 Caesarean section delivery. The CTG trace was stopped at 0404 hours to enable the Caesarean to take place. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN ARE: 1. While I heard evidence that there has been training for Midwives on how to take cord blood, and I was provided with a copy of a poster that was said to have been in use at the Trust for some time, in April 2023, over 2 years after this delivery, the Midwife gave evidence that she and her colleagues were of the opinion that it was appropriate to take a sample from anywhere in the cord, not just in the clamped area. The expert and the Trust’s own Head of Midwifery advised that this was not appropriate. It therefore does not appear that the learning has been passed on to all Trust Midwives and there is a risk that in future cases those treating the baby will be falsely reassured by normal cord pH results which may not be accurate. While I read evidence of some training that had been provided in response to HSIB recommendations for further training on auscultation in addition to saturation monitoring and ECG monitoring during resuscitation, the independent expert also recommended training on UVC and IO access. I am also concerned that there does not appear to have been training in relation to the provision of blood transfusions in such cases to ensure that all potential reversible causes are treated before resuscitation stops. The Head of Midwifery who attended the inquest to advise on issues relating to the recommendations was not in a position to provide evidence on the neonatal position and I have been provided with no evidence by the Trust that these issues have been considered. I am concerned that they require further action. | On 14 October 2021 an investigation in to the death of Amelia Barbosa was commenced. Amelia died on 13 December 2020, aged 7 days. The investigation concluded at the end of the inquest on 17 May 2023. The conclusion of the inquest was: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Coroners and Justice Act 2009 (legislation.gov.uk) The Coroners (Investigations) Regulations 2013 (legislation.gov.uk) |
| 19/05/2023 | 2023-0166 | Emilia Watson | Dr Richard Ian Brittain | Warwickshire | Child Death (from 2015) | Prevention of Future Deaths | Nursing and Midwifery Council | https://www.judiciary.uk/prevention-of-future-death-reports/emilia-watson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Emilia-Watson-Prevention-of-future-deaths-report-2023-0166_Published.pdf | Emilia was born at Warwick Hospital after her mother had been admitted from home for what had been planned to be a homebirth. Concerns were raised about fetal wellbeing, which prompted admission to hospital. | During the course of this inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |||
| 19/05/2023 | 2023-0165 | Norma Bruton | Ms Vanessa McKinlay | Birmingham and Solihull | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | University Hospitals of Birmingham NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/norma-bruton-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Norma-Bruton-Prevention-of-future-deaths-report-2023-0165_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0165-Response-from-University-Hospitals-Birmingham-NHS-Foundation-Trust-.pdf | The deceased was admitted to Birmingham Heartlands Hospital on 13 October 2022 for treatment of a pneumothorax with a background of pulmonary mycobacterium infection and chronic obstructive lung disease. An assessment of her risk of falling did not take into account the presence of a chest drain and an intravenous drip and Mrs Bruton was assessed as being able to mobilise independently. She had an unwitnessed fall on the morning of 15 October 2022 when trying to walk the short distance to her bathroom and sustained a right fractured neck of femur for which she underwent surgery on 20 October 2022. Mrs Bruton’s condition deteriorated after the surgery and she died in hospital on 22 October 2022. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 3 November 2022 I commenced an investigation into the death of Norma Winifred BRUTON. The investigation concluded at the end of the inquest . | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 18/05/2023 | 2023-0164 | Akash Bhudia | Ms Nadia Persaud | London East | Hospital Death (Clinical Procedures and medical management) related deaths | Other related deaths | Medica Reporting Service | https://www.judiciary.uk/prevention-of-future-death-reports/akash-bhudia-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Akash-Bhudia-Prevention-of-future-deaths-report-2023-0164_Published.pdf | Akash Bhudia suffered from a persistent cough from December 2021. On the 17 January 2022 he attended A&E where he underwent blood tests, chest Xray and medical reviews. The impression at this time was that he was suffering from community acquired pneumonia. He received a dose of intravenous antibiotics and intravenous fluids and was discharged from hospital with a course of oral antibiotics. Akash attended for a follow-up chest Xray on the 28 February 2022. This Xray showed progression in his left lung consolidation and showed a new consolidation in his right lung. The inquest heard that the primary diagnosis based on this Xray should have been tuberculosis. On the 4 March 2022, an emergency ambulance was called when Akash was found to be coughing and vomiting blood. Paramedics attended and provided emergency assistance. They could not however resuscitate Akash and his life was pronounced extinct by a paramedic. A post-mortem examination revealed a pulmonary abscess which was most likely to have been caused by tuberculosis. There is no evidence that any acts or omissions in the care provided to him, contributed to his death. The chest radiograph was not sent for analysis until 8 March 2022. The lack of an alert did not therefore contribute to Akash’s death. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The Xray on the 28 February 2022, which was carried out following treatment for pneumonia, showed an obvious progression in lung consolidation and was highly suggestive of tuberculosis (a new clinical diagnosis). Akash was not an in-patient in hospital at the time of the follow-up Xray. He had been discharged and was therefore not under the active management of a clinical team. The inquest heard that such significant, unexpected, and important changes should have been highlighted to the referring clinician. This was not done. There does not appear to be a process in place for an alert to be added to the normal communication method to ensure that such significant, unexpected, and important findings are acted upon in a timely manner. The inquest also heard that the incidence of TB is rising in certain areas of the UK and that it is important that radiologists recognise TB changes and that these are duly highlighted to the referrer. | On the 30 May 2022, I commenced an investigation into the death of Akash Dinesh Bhudia, age 28 years. The investigation concluded at the end of the inquest on 16 May 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 18/05/2023 | 2023-0163 | Samuel Morgan | Mrs kirsten heaven | Swansea and Neath Port Talbot | Prevention of Future Deaths | Suicide (from 2015) | Swansea Bay University Health Board | https://www.judiciary.uk/prevention-of-future-death-reports/samuel-morgan-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Samuel-Morgan-Prevention-of-future-deaths-report-2023-0163_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0163-Response-from-Swansea-Bay-University-Health-Board-.pdf | The deceased was Samuel Alexander Morgan. At the time of his death Samuel was suffering from alcohol addiction and had a diagnosis of ADHD and social anxiety. Prior to his death Samuel had received treatment from the Community Drug and Alcohol Treatment (‘CDAT’) team and primary mental health services. Samuel was discharged from CDAT fifteen months prior to his death. CDAT had information on their system (including from their own risk assessment) to indicate that Samuel had been assessed as a significant risk of suicide. There was other valuable information about Samuel’s risk factors on the CDAT system. At the time when Samuel was under CDAT the GP had also referred Samuel to the community mental health team raising his concerns about Samuel’s risk of suicide. It is not clear is CDAT had access to this letter. When the primary mental health services consultant began treating Samuel for his ADHD – which continued up to Samuel’s death – he received a referral from CDAT but he did not have access to the detailed information on the CDAT electronic system. The consultant could not and did not see the CDAT risk assessment, the outcome and assessment from the individual CDAT sessions and other vital historical information of potential relevance to Samuel’s risk factors and triggers for suicide. | During the inquest the evidence revealed matters giving rise to a concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to make a report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 The first MATTERS OF CONCERN is as follows: I am concerned that in cases where an individual is receiving treatment from alcohol and drug addiction services and treatment from the primary community mental health team that neither team is able to access the other teams records electronically. The lack of integrated electronic records between treating team means that important information regarding patient safety is not easily accessible between treating teams. Treating teams are reliant on referral letters which are necessarily limited and not always sufficient to capture all the detailed information available to a referring team. This is particularly concerning where there is dual diagnosis – such as substance misuse and mental health – given these are often complex cases. This is particularly the case where complex cases have not been referred into secondary mental health services and so do not have access to a care-coordinator who can oversee and understand the views of the various professionals treating and assisting an individual. I am concerned that the lack of such an integrated electronic system of medical and treatment records inhibits the effective sharing of information regarding patient safety and so increases the risk that information of significance regarding a risk to life will be lost between agencies and not sufficiently understood between all those managing. | On 13th May 2019 an investigation was commenced into the death of Samuel Alexander Morgan who was found deceased in his parents’ house on the 9th May 2019 after having tied a ligature around his neck. He was 29 years of age at the time of his death. The investigation concluded at the end of the inquest on 6th March 2023. | In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 July 2023. I, as the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 11/05/2023 | 2023-0162 | Julie Nolan | Mr Andrew Philip Hetherington | Northumberland North | Care Home Health related deaths | Prevention of Future Deaths | Maria Mallaband Care Group | Countrywide Care Homes | https://www.judiciary.uk/prevention-of-future-death-reports/julie-nolan-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Julie-Nolan-Prevention-of-future-deaths-report-2023-0162_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0162-Response-from-Maria-Mallaband.pdf | The deceased had underlying natural disease including diabetes mellitus, hypertension, chronic kidney disease and peripheral vascular disease which placed her at risk of the development of pressure damage and ulceration. On 18 March 2021 the deceased underwent an amputation of her left fourth toe and on 7 July 2021 underwent a left femoro-anterior tibial bypass. On 5 November 2021 the deceased suffered a total anterior cerebral infarction leaving her unable to swallow and requiring feeding through a PEG tub. The deceased was admitted to a care home on 24 December 2021. Upon admission a body map was completed with three areas of pressure damage noted to areas of the left foot described as scabbed and blistered. The deceased was identified as very high risk of developing pressure damage. There was limited documentation of wound management and pressure care and it is unclear the extent to which wound management and repositioning was provided in line with the care plans. There was no referral to tissue viability specialists. On 24 January 2022 the deceased was conveyed by ambulance to Northumbria Specialist Emergency Care Hospital, Cramlington unwell with raised inflammatory markers indicating infection and further significant pressure damage to her left foot. It was reported she had also vomited in her PEG tube whilst which may have led to aspiration. The deceased was found to have acute osteomyelitis and received active treatment including intravenous antibiotics. On 26 January 2022 the deceased was transferred from Northumbria Specialist Emergency Care Hospital, Cramlington to Wansbeck General Hospital. Whilst awaiting transfer to the Freeman Hospital for specialist vascular review the deceased deteriorated with a temperature, low oxygen levels and a high heart rate likely as the progression of infection in her chest, foot or both. On 30 January 2022 the deceased suddenly deteriorated with difficulty breathing, low oxygen saturations and died within Wansbeck General Hospital. | 1. The deceased was a resident in Astor Lodge Care Home. I am concerned there was limited documentation of wound management and pressure care and it is unclear the extent to which wound management and repositioning was provided in line with the care plans. 2. I am concerned that the Manager and Registered Nurse was the designated nurse for the Care Home for two consecutive days. | On 4 February 2022 I commenced an investigation into the death of Julie Elizabeth Nolan Deceased . The investigation concluded at the end of the inquest on 25 April 2023. The conclusion of the inquest was a narrative conclusion: Died as a result of significant progression of wound damage to the left foot leading to the development osteomyelitis whilst a nursing resident in a care home from 24 December 2021 to 24 January 2022 contributed to by underlying natural disease | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by I, the coroner, may extend the period. | I make this report under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://legislation.gov.uk/ukpga/2009/25/schedule/5/paragra ph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 16/05/2023 | 2023-0161 | Stuart Robinson | Ms Katy Ainge | Liverpool and the Wirral | Prevention of Future Deaths | Suicide (from 2015) | Ministry of Justice Coroners | https://www.judiciary.uk/prevention-of-future-death-reports/stuart-robinson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Stuart-Robinson-Prevention-of-future-deaths-report-2023-0161_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0161-Response-from-HM-Prison-Probation-Service.pdf | See above. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) This inquest highlighted the significant numbers of prisoners who enter the prison system with known or undiagnosed mental health issues. Whilst ACCT 6 requires multidisciplinary attendance at review meetings, this case highlighted the need for specific attendance of an RMN or other mental health expert at any review, (Mr Robinson had repeatedly self harmed prior to committing suicide but had presented without concern at each review which had been carried out without any input from the mental health team). The prison in question now operates a local policy to ensure someone from the mental health team attends all ACCT reviews irrespective of other disciplines attending. This has enabled the prison to identify issues which may not be picked up by other professionals involved, to enable support to be put in place by way of separate care plans which has had a notable impact upon SASH in the prison. | On 05 May 2021 I commenced an investigation into the death of Stuart Michael ROBINSON aged 20. The investigation concluded at the end of the inquest on 15 May 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by July 11, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 12/05/2023 | 2023-0160 | Tamsin Dolamore | Mr Andrew Cox | Cornwall and the Isles of Scilly | Other related deaths | Prevention of Future Deaths | Devon and Cornwall Police | Police and Crime Commissioner | Network Rail | https://www.judiciary.uk/prevention-of-future-death-reports/tamsin-dolamore-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Tamsin-Dolamore-Prevention-of-future-deaths-report-2023-0160_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/Tamsin-Dolamore-Prevention-of-future-deaths-report-2023-0160b_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/Tamsin-Dolamore-Prevention-of-future-deaths-report-2023-0160c_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0160-Response-from-Dorset-Police.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0160-Response-from-Cornwall-Council.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0160-Response-from-Ministry-of-Justice-.pdf | Tamsin was raped as a schoolchild. In October 2017, she made a complaint to police that she had been raped again. (Of note, her adoptive parents, to whom a copy of this letter is being sent, were not aware of either incident until after her death.) Her GP reported her life having been turned upside down. It was intended that a SOLO would be appointed after the initial report but, in evidence, it was established that did not happen until the end of October, a delay of approximately a month. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. I was informed by [REDACTED] that as of January this year, there were 600 open cases of rape or serious sexual assault. I was told additionally that there are over 20 vacancies for DCs to progress these complaints. One consequence was that it was taking over a month to achieve best evidence through video interview or otherwise. [REDACTED] agreed that the lack of available DCs meant that both the quality and amount of work that could be done were affected. | On 12.5.23, I concluded an inquest into the death of Tamsin Ann Dolamore who died at the age of 24 on 9.1.18. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 15/05/2023 | 2023-0159 | Julie Hancock | Mr Andrew Cox | Cornwall and the Isles of Scilly | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Royal Cornwall Hospital | https://www.judiciary.uk/prevention-of-future-death-reports/julie-hancock-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Julie-Hancock-Prevention-of-future-deaths-report-2023-0159_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0159-Response-from-Royal-Cornwall-Hospitals-NHS-Trust.pdf | Julie had a past medical history that included rheumatoid arthritis and hypertension. In December 2021, she was offered staged bilateral knee replacements. She was assessed by [REDACTED] as being at high risk of developing a DVT. She had a nurse-led pre-op assessment on 26/1/22 when, I am told, a further risk assessment was not done, in accordance with policy at the time. | During the course of the investigation, my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – I enclose the bundle of evidence. At pp A32-A54, you will find what I am told is the Trust’s Guideline Summary for Thrombosis Prevention and Anticoagulation. At p42, following elective knee replacement, it is suggested clinicians may choose any one of Aspirin [REDACTED] for 14 days LMWH for 14 days and anti-embolism stockings Rivaroxaban [REDACTED] once daily for 14 days As matters of fact, I am told Mrs Hancock was prescribed 14 days of aspirin and, in apparent error, one unidentified doctor also prescribed Dalteparin which was stopped after a single dose. It is of concern that the doctor cannot be identified and I have no record of the decision-making. At C32, you will find the Trust’s full guidance for drug prophylaxis following elective knee replacement which is taken from its Thrombosis Prevention and Anticoagulation Policy v9.0 dated Feb 2022. It provides: Low risk – Aspirin [REDACTED] daily for 14 days High Risk – Rivaroxaban [REDACTED] daily for 14 days or Dalteparin or Enoxaparin for 28 days plus stockings (until discharge.) [REDACTED] had not seen the full guidance previously despite it having been published for over a year which, as a consultant orthopaedic surgeon, is of concern in itself. [REDACTED] further said that Mrs Hancock was high risk yet she appears to have been given prophylaxis for a low risk patient because the summary guidelines appear not to reflect accurately the full guidance. [REDACTED], as I understood [REDACTED], said that it had been [REDACTED] practice to prescribe aspirin to all high-risk patients since (at least) February 2022. This raises the question of whether other patients have died from a PE or DVT because of wrongly prescribed prophylaxis that have not been reported to this Office. You will need to consider the position. I have only considered the situation as it came before me, namely, for an elective knee replacement. As I understand the anticoagulation policy will have a much wider reach than that there is an obvious need to consider the implications across all the Trust’s services. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13/7/23. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 16/05/2023 | 2023-0158 | Roger Southwick | Mr Christopher Briggs | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Tameside & Glossop Integrated Care NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/roger-southwick-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Roger-Southwick-Prevention-of-future-deaths-report-2023-0158_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0158-Response-from-Tameside-and-Glossop-Integrated-Care-NHS-Foundation-Trust-.pdf | Roger Southwick had a stent inserted in his chest following a heart attack in October 2022. On 5th November 2022 he was feeling breathless and admitted to Tameside General Hospital where a chest infection was diagnosed and low sodium levels detected secondary to his heart failure and he was admitted for treatment. A falls risk assessment was inaccurately completed and concerns raised about his mobility were not actioned. On 7th November Roger was found outside his cubicle having fallen and hit his head. CT scanning revealed a significant subdural haemorrhage which was not amenable to surgical intervention and he died at Tameside General Hospital on 9th November 2022. | On 10th November 2022 an investigation was commenced into the death of Roger Southwick. The investigation concluded at the end of the inquest on 10th March 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th July 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 16/05/2023 | 2023-0157 | Carl Thompson | Ms Anna Morris | Greater Manchester South | Alcohol, drug and medication related deaths | Mental Health related deaths | Prevention of Future Deaths | Pennine Care NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/carl-thompson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Carl-Thompson-Prevention-of-future-deaths-report-2023-0157_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0157-Response-from-Pennine-Care-NHS-Foundation-Trust.pdf | At the time of his death on the 9th March 2022, Carl was on s.17 Mental Health Act (MHA) leave from the Arden Ward, Stepping Hill Hospital where he was detained under s.3 MHA. Carl had been granted leave by his Responsible Clinician on the 4th March and his leave commenced on the 7th March. He was granted 5 days overnight leave and should have returned to the ward on the 11t March. | On 11th March 2022 an investigation was commenced into the death of Carl Garry Thompson. The investigation concluded on the 17th February 2023 and the conclusion was one of Drug-Related Death. The medical cause of death was 1a) Drug Toxicity; 2) Hypertensive Heart Disease | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th July 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 16/05/2023 | 2023-0156 | Benedict Peters | Mr Chris Morris | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Manchester University NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/benedict-peters-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Benedict-Peters-Prevention-of-future-deaths-report-2023-0156_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0156-Response-from-Manchester-University-NHS-Foundation-Trust.pdf | Mr Peters was found dead at his parents’ home on 12th November 2022 having been staying there following his discharge from the Manchester Royal Infirmary Ambulatory Care Unit the previous day. | On 27th January 2023, Lauren Costello, Assistant Coroner opened an inquest into the death of Benedict Peters who was found dead on 12th November 2022 whilst staying at his parents’ home, aged 25 years. The investigation concluded with an inquest which I heard on 4th May 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th July 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 15/05/2023 | 2023-0155 | Drew Howe | Mr Chris Morris | Greater Manchester South | Mental Health related deaths | Prevention of Future Deaths | Suicide (from 2015) | Pennine Care NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/drew-howe-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Drew-Howe-Prevention-of-future-deaths-report-2023-0155_Pulished.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0155-Response-from-Pennine-Care-NHS-Foundation-Trust.pdf | Mr Howe was found dead on 19th October 2022 on the A18 in Lincolnshire having suspended himself by the neck with a ligature in the back of his lorry. | On 3rd February 2023, an inquest was opened into the death of Drew Howe who was found dead on 19th October 2022 in a Heavy Goods Vehicle parked on the A18 in Lincolnshire, aged 25 years. The investigation concluded with an inquest which I heard on 25th April 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th July 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 15/05/2023 | 2023-0154 | Rebecca Fisher | Ms Alison Patricia Mutch OBE | Greater Manchester South | Prevention of Future Deaths | Suicide (from 2015) | Greater Manchester Police | https://www.judiciary.uk/prevention-of-future-death-reports/rebecca-fisher-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Rebecca-Fisher-Prevention-of-future-deaths-report-2023-0154_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0154-Response-from-Greater-Manchester-Police-.pdf | On 15th April 2022, Rebecca Alice fisher was found deceased by her family in a secluded area of Reddish Vale. Post-mortem examination included toxicology. She had a fatal dose of drugs in her system including pregabalin. [REDACTED] Rebecca had been reported by the Norbury Ward to Greater Manchester Police (GMP) as a high-risk missing person on the 11th April at about 6pm after she failed to return from 30 minutes of unescorted leave. Rebecca had a complex mental health history [REDACTED]. She had been admitted to the Norbury ward as a crisis patient. [REDACTED]. She had been allowed to leave for 30 minutes of unescorted leave. It was recognised that this presented a risk. Her failure to return was correctly assessed by hospital staff as creating an escalated risk and a high-risk situation. Greater Manchester Police failed to correctly assess her as a high-risk missing person. As a consequence, this meant that mobile telephone enquiries were not immediately undertaken, and the investigation did not have specialised input in the hours immediately following her being reported missing. It is probable that if these enquiries had taken place Greater Manchester Police would have known she was in the area of her home address and Reddish Vale. It is possible that Rebecca would have been found before she died had she been treated as a high-risk missing person. | On 19th April 2022 I commenced an investigation into the death of Rebecca Alice Fisher. The investigation concluded on the 18th April 2023 and the conclusion was one of Suicide. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th July 2023. I, the coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 12/05/2023 | 2023-0153 | Barbara Mitchell | Dr Peter Henry Straker | London North | Care Home Health related deaths | Prevention of Future Deaths | Bluebird Care (Kent) | https://www.judiciary.uk/prevention-of-future-death-reports/barbara-mitchell-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Barbara-Mitchell-Prevention-of-future-deaths-report-2023-0153_Published.pdf | On the 9th July 2022 Barbara Mitchell died at Northwick Park Hospital having fallen at home despite being assisted at the time by a carer. | The MATTERS OF CONCERN are as follows. 1. Consideration of specialist training of staff in connection with the moving and handling of individuals, especially after a fall. | On the 13th July 2022 I opened an investigation touching the death of Barbara Mitchell , aged 94 years old. I opened and heard an inquest on the 7th December 2022. The conclusion of the inquest was “ Barbara Mitchell died as the result of an accident ”, the medical case of death was 1a Pneumonia, 1b Fracture of Sternum and under paragraph 2 Atrial Fibrillation. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Friday the Seventh of July 2023 I, the assistant coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 15/05/2023 | 2023-0152 | Rebekah Mills | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | NHS England | National Institute for Health & Care Excellence | https://www.judiciary.uk/prevention-of-future-death-reports/rebekah-mills-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Rebekah-Mills-Prevention-of-future-deaths-report-2023-0152_Published.pdf | Rebekah Juliet Mills had an accidental fall when skiing and she hurt her knee. She went to Stepping Hill Hospital and was seen in the Emergency Department. An examination identified no obvious injury. The notes did not capture her being on oral contraceptive or the degree of her lack of mobility. The virtual fracture clinic review on 13th June 2022 referred her to the physiotherapy team for an appointment. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 3rd August 2022 I commenced an investigation into the death of Rebekah Juliet Mills. The investigation concluded on the 6th February 2023 and the conclusion was one of Narrative: Died from post-operative complications of surgery following an accidental fall resulting in injury. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 15/05/2023 | 2023-0151 | Raymond Lee | Ms Alison Patricia Mutch OBE | Greater Manchester South | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | NHS England | National Institute for Health & Care Excellence | https://www.judiciary.uk/prevention-of-future-death-reports/raymond-lee-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Raymond-Lee-Prevention-of-future-deaths-report-2023-0151_Published.pdf | Raymond Douglas Lee had oesophageal cancer. Due to his underlying health, he was treated with radiotherapy- other treatments were not felt to be suitable. He developed an oesophageal stricture as a consequence of the radiotherapy treatment. Dilatation procedure did not lead to an improvement. A biodegradable stent was inserted to try to improve the position. He was in significant pain as a consequence of the stent. Pain is a recognised complication of stenting in these circumstances. He was admitted to Stepping Hill Hospital on 13th September 2021 following episodes of bleeding. A gastroscopy on 14th September 2021 confirmed that the bleeding was from the oesophagus – from an aorta/oesophageal fistula. On the balance of probabilities, the stent had contributed to the development of the fistula. Raymond Douglas Lee continued to deteriorate and died at Stepping Hill Hospital on 14th September 2021. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. The inquest heard evidence that oesophageal strictures are a recognised complication of radiotherapy for oesophageal cancers. The implications of them are significant for patients as they can lead to aspiration and as well as significantly impact quality of life. At this time there is only very limited national guidance on how to best treat patients with strictures and limited evidence on which to develop best practice. The evidence given was that careful dilatation by an experienced practitioner was the best approach initially. However, dilatation particularly repeated dilatation carried risk of perforation and needed to be seen as something that could not be continued indefinitely. However, there was limited evidence on what the optimum number of dilatations were and/or when to stop and move to consider stenting. The inquest heard that stenting of patients in these circumstances has a limited body of evidence regarding the risk. The inquest highlighted that perforation may be a risk in some cases where a stent is used and that needed to be factored into any decision to use a stent. | On 16th September 2021 I commenced an investigation into the death of Raymond Lee. The investigation concluded on the 19th January 2023 and the conclusion was one of Narrative: Died from complications of treatment for oesophageal cancer and a subsequent oesophageal stricture. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 10th July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | |
| 12/05/2023 | 2023-0150 | Odessa Carey | Mr Andrew Philip Hetherington | Northumberland North | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/odessa-carey-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Odessa-Carey-Prevention-of-future-deaths-report-2023-0150_Published.pdf | Odessa Carey was last seen alive on the evening of Thursday 4th April 2019 within her home address [REDACTED], Ashington. She was attacked by the perpetrator. On 7th April 2019 the police have attended [REDACTED], Ashington and found the body of the deceased covered with bedding sheets. The body was without the head. Police officers have then attended another address and following a systematic search of that property, the perpetrator was found and arrested in connection with the murder of the deceased. | During the course of the inquest evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless ‘action is taken. In the circumstances it is my statutory duty to report to you. | On 10 April 2019 HM Senior Coroner Tony Brown commenced an Investigation into the death of Odessa Carey who was born on 20 May 1945 and who died within [REDACTED] on 8 April 2019. He adjourned and suspended the investigation under Schedule 1 of the CJA as he was informed on 15 April 2019 that an individual had been charged with a homicide offence of murder. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by | I make this report under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/201 3/1629/part/7 /made | ||
| 11/05/2023 | 2023-0149 | Nicholas Pennicott | Ms Penelope Schofield | West Sussex, Brighton and Hove | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | NHS England | NHS Improvement | https://www.judiciary.uk/prevention-of-future-death-reports/nicholas-pennicott-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Nicholas-Pennicott-Prevention-of-future-deaths-report-2023-0149_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0149-Response-from-Universityt-Hospitals-Sussex-NHS-Foundation-Trust.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0149-Response-from-NHS-England.pdf | Mr PENNICOTT’s health had been deteriorating since March 2021 and this resulted in an admission to A&E at St Richards Hospital on 23rd June 2021. Following this admission Mr PENNICOTT was referred to see a Neurologist , as an urgent referral, as an outpatient. At the time he was suffering from Guillain Barre Syndrome. Despite his GP and family chasing up this appointment he was not offered an appointment until 19th August 2021. Sadly he suffered a cardiac arrest in the early hours of the very day that his appointment was due to take place. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 24 August 2021 I commenced an investigation into the death of Nicholas John PENNICOTT aged 61. The investigation concluded at the end of the inquest on 19 April 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by July 04, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 07/05/2023 | 2023-0148 | Bency Joseph | Ms Sonia Marie Hayes | Essex | Mental Health related deaths | Prevention of Future Deaths | Essex Partnership NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/bency-joseph-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Bency-Joseph-Prevention-of-future-deaths-report-2023-0148_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0148-Response-from-Essex-Partnership-University-NHS-Foundation-Trust.pdf | Bency Joseph died instantly on 27 May 2022 from Traumatic Head Injury following a head first fall from an upstairs window at home, she did not have the capacity to formulate an intention to take her own life. Bency Joseph had been suffering with recent mental health issues and attended Broomfield Accident & Emergency Department on 24 May with acute psychotic presentation and assessed as not having capacity. Bency Joseph underwent Mental Health Act assessment on 25 May and referred to the Home Treatment Team and the First Episode Psychosis Team. Bency Joseph was reviewed on 26 May and prescribed urgent medication by the community psychiatrist for a severe psychotic episode and was responding to unseen stimuli and was assessed as not having capacity. Bency Joseph’s mental health deteriorated further at home. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 9 June 2022 an investigation was commenced into the death of Bency JOSEPH, aged 43 years. Bency Joseph died on the 27 May 2022. The investigation concluded at the inquest on 4 April 2023. The conclusion of the inquest was a Narrative: There was delay in the provision of antipsychotic and anxiolytic medications to Bency Joseph during a four-day period in 24-27 May 2022 and this contributed to her death during a severe psychotic episode with a medical cause of death of ‘1a Traumatic head injury, 1b Fall from height. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 7 July 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 05/05/2023 | 2023-0147 | Joshua Asprey | Ms Sonia Marie Hayes | Essex | Mental Health related deaths | Prevention of Future Deaths | Essex Partnership NHS Trust | https://www.judiciary.uk/prevention-of-future-death-reports/joshua-asprey-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Joshua-Asprey-Prevention-of-future-deaths-report-2023-0147_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0147-Response-from-British-National-Formulary-Publications.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0147-Response-from-NICE-.pdf | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1. The evidence heard during the course of the inquest highlighted an inconsistency between the literature provided by the manufacturer of sertraline (the patient information leaflet (‘PIL’)) and the British National Formulary (‘BNF’) produced by the Royal Pharmaceutical Society (latest version: BNF 85, March 2023). 2. The PIL contains a list of “uncommon” side effect of suicidal behaviour, which includes the following in bold: “Cases of suicidal ideation and suicidal behaviours have been reported during sertraline therapy or early after treatment discontinuation (see section 2).” 3. The BNF relating to Depression (3.4, p395) and the use of Antidepressant Drugs states under the heading “Suicidal depression and antidepressant therapy” (p397): “The use of antidepressants has been linked with suicidal thoughts and behaviour; children young adults and patients with a history of suicidal behaviour and particularly suicidal behaviour are particularly at risk. Where necessary patients should be monitored for suicidal behaviour, self-harm or hostility, particularly at the beginning of treatment or if the dose is changed.” 4. The section of the BNF relating to SSRIs (p401) also identifies “suicidal behaviours” as a potential uncommon side-effect. 5. However, the section with respect to sertraline does not specifically identify suicidal tendencies at all, although it does identify “thinking abnormal” as an uncommon side effect (p.405). 6. I am concerned that there is a risk that a medical practitioner consulting the BNF with a view to determining dosage and treatment with Sertraline will be unaware of the potential risk of the onset of suicidal behaviour and/or would not consider it necessary to discuss that risk with the patient. The evidence heard at the inquest suggested that it would not be appropriate or practical for GPs to consider PILs before prescribing. On the other hand, the PIL and BNF are intended for different purposes. It may be that the evidence of risk of suicidal ideation associated with Sertraline specifically (as opposed to SSRIs) is so low that it need not be referred to in the BNF, notwithstanding its inclusion in the PIL. Nevertheless, this is a matter of concern that would in my view benefit from further consideration. | On 18 June 2021 I commenced an investigation into the death of Joshua Fynn ASPREY aged 19. The investigation concluded at the end of the inquest on 15 March 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 30 June, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 05/05/2023 | 2023-0146 | Callum Wong | Dr Peter Henry Straker | London North | Child Death (from 2015) | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/callum-wong-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Callum-Wong-Prevention-of-future-deaths-report-2023-0146_Published.pdf | On the 27th August 2022 Callum Wong was found having hanged himself Mr Wong had had suicidal thoughts in the past but having been supported by his family, overcame them. When Mr Wong had suicidal thoughts again, patient confidentiality issues resulted in those from whom he sought help, not informing his family. | The MATTERS OF CONCERN are as follows. 1. Consideration for exceptions to patient confidentiality in cases of mental illhealth, where informing third parties of a patient’s condition may result in crucial non-medical support. | On the 31st August 2022 I opened an investigation touching the death of Callum Wong who was 17 years old when he died. I opened an inquest on the 23rd September 2022. The inquest concluded on the 27th February 2023. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by Wednesday the Twenty-Eighth of June 2023 I, the assistant coroner, may extend the period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 13/02/2023 | 2023-0145 | Minaal Salam | Miss Emma Serrano | Stoke on Trent and North Staffordshire | Child Death (from 2015) | Prevention of Future Deaths | Road (Highways Safety) related deaths | Stoke on Trent City Council | https://www.judiciary.uk/prevention-of-future-death-reports/minaal-salam-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Minaal-Salam-Prevention-of-future-deaths-report-2023-0145_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0145-Response-from-Stoke-on-Trent-City-Council.pdf | Minaal Salam was being collected, by her father, from her school. This is Newstead Primary Academy Blurton Stoke-on-Trent. The incident occurred outside the pedestrian school gate on Waterside Drive. When leaving the school with her father, they were standing on the side of the road, waiting to cross. She was hit by a motor vehicle, which caused survivable injuries. She passed away at the sight of the incident. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 19/04/2022 I commenced an investigation into the death of Minaal Salam, aged 5. The investigation concluded at the end of the inquest on 17th January 2023. The conclusion of the inquest was Minaal Salam passed away on the 1 April 2022 outside her primary school Newstead Primary Academy, Blurton, Stoke-on-Trent, on Waterside Drive, after she was struck by a Volkswagen Touran. This caused poly trauma that led to a traumatic cardiac arrest. | In my opinion action should be taken to prevent future deaths and I believe you Stoke on Trent City Council have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 April 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 27/04/2023 | 2023-0144 | Caroline Forte | Ms Penelope Schofield | West Sussex, Brighton and Hove | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/caroline-forte-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Caroline-Forte-Prevention-of-future-deaths-report-2023-0144_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/Caroline-Forte-Prevention-of-future-deaths-report-2023-0144.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0144-Response-from-NHS-England.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0144-Response-from-Sussex-Partnership-Foundation-Trust.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0144-Response-from-Sussex-Partnership-Foundation-Trust-2.pdf | Caroline had been struggling with her mental health for some time following the breakdown of a relationship. Since 27th January 2022 she had been receiving treatment as an inpatient (under Section 2 Mental Health Act 1983) on the Amberley Ward at the Department of Psychiatry, Eastbourne Hospital. [REDACTED] On 18th February 2022 she was granted Section 17 weekend to take place at her parents address. Sadly on 20th February she was found hanging [REDACTED]. | During the investigation, my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- Ms Forte had for a number of years been seeing a private psychiatrist. Details of her consultations and treatments were not made readily available to those working in the NHS Trusts. It appears that there is no clear pathway for details of any private psychiatrist consultations to be shared with those in either the acute or mental health inpatient settings. The concerns are that any relevant history may be lost and details of any regular medication being prescribed may not, in a time of crisis, be immediately known. | On 21st February 2022 I commenced an investigation into the death of Caroline Victoria Forte aged 35 years. The investigation was concluded at the end of the Inquest on 14th March 2023. The Inquest was held with Jury. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 23rd June 2023 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 28/04/2023 | 2023-0143 | Winbourne Charles | Mr graeme Irvine | London East | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/winbourne-charles-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Winbourne-Charles-Prevention-of-future-deaths-report-2023-0143_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0143-Response-from-North-East-London-Foundation-Trust-.pdf | Winbourne Gregory Charles was a admitted into hospital under section 2 of the Mental Health Act 1983 in November 2020 following an attempt to take his own life. In December 2020 on a diagnosis of depressive illness incorporating psychotic symptoms, Mr Charles was made subject to an order under section 3 of the Mental Health Act 1983. On 10th April 2021 Mr Charles was found unresponsive, suspended [REDACTED] on the mental health ward. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. A failure to adequately assess risk of harm – Poor record keeping and a failure to read electronic records meant that important information was not considered at a Multi-Disciplinary Team (“MD T”) ward round on 6th April 2021. The MDT arrived at a conclusion that Mr Charles’ risk of self-harm was “no risk”. A psychologist’s assessment on the clinical record that assessed Mr Charles risk of self-harm as high on 31/3/21 was neither read nor incorporated into the MDT discussion. 2. A decision to reduce observation frequency made by the MDT on 6/4/21 was not supported by the Trust Policy guidance which indicated that enhanced observations were appropriate. 3. A failure to ensure that a treatment plan was followed – observations between 16.00 and 17.00 on the day of Mr Charles’ death were suspended by the ward shift co-ordinator. The decision meant all patients subject to general observation on the ward were ignored. 4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked ” and did not follow policy, specific issues include; a. A ward emergency bell was not sounded, b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles . c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination, d. Duty doctors were not called promptly, e. Oxygen administration was delayed, f. An on-site defibrillator was not used by staff g. Staff could or would not provide a clear and relevant history to paramedics. 5. The credibility of evidence provided by Trust staff. a. Two Trust witnesses declined to answer questions put to them regarding whether their observation records were truthful. b. Observation records appeared to have been created utilising a “cut and paste” function. c. Records often inaccurately recorded the prescribed frequency of observation. d. Factually inaccurate entries were made in the record following Mr Charles’ death. On 11th April 2021 an entry stated that Mr Charles was, “Awake in his bedroom sitting on his bede (sic)” at 07.21. On 12th April two entries made at 9.48 and 11.40 recorded that Mr Charles’ was alive and well. Senior Trust witnesses characterised these entries as dishonest. 6. Governance process failings. a. A datix incident report created on the evening of 10th April 2021 by a senior nurse and Modern Matron contained misleading information that suggested that emergency response policies were followed when in fact they were not. b. The Datix failed to mention that observations had been suspended by the shift coordinator, a fact that was understood at that time. This obvious and significant piece of information that should have been escalated through the Trust governance team for action. C. The Trust 72 hour report was written by the Modern Matron and was signed-off by an integrated care director on 15th April 2021. This document also failed to identify or escalate the significant issue of the suspension of observation at 16.00 on 10th April 2021. d. The Trust SI report presented to the inquest failed to address the poor risk assessment or inadequate datix & 72 hr reports. | On 11th April 2021 this Court commenced an investigation into the death of Winbourne Gregory Charles, aged 58. The investigation concluded at the end of the inquest held before a jury between the 17th and 21st April 2023. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 23/06/2023 . I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http:// www.legislation.gov.uk/ukpga/ 2009/ 25/sch edule/ 5/ paragraph/7 http://www.legislation .gov.uk/ uksi/ 2013/ 1629/ part /7 /made | |
| 27/04/2023 | 2023-0142 | Milan Hamza | Mr Simon Milburn | Cambridgeshire and Peterborough | Child Death (from 2015) | Prevention of Future Deaths | Road (Highways Safety) related deaths | Cambridgeshire County Council | https://www.judiciary.uk/prevention-of-future-death-reports/milan-hamza-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Milan-Hamza-Prevention-of-future-deaths-report-2023-0142_Published-1.pdf | Milan was the front seat passenger in a vehicle travelling west along Old Oundle Road, Wittering at about 1035hrs on 03.09.22. The vehicle failed to negotiate a sharp left hand bend, left the carriageway to the offside before it entered a pond and became submerged upside down in water. Milan was unable to escape from the submerged vehicle which was not discovered until around 1730hrs that day. Emergency Services attended the scene and Fire Officers then extracted Milan from the submerged vehicle. He was rushed to Peterborough City Hospital but sadly his death was confirmed at 1944hrs. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 03.09.22 I commenced an investigation into the death of Milan Peter HAMZA (Otherwise known as Milan Peter RADOCZ), aged 8 years. The investigation concluded at the end of the inquest on 07.03.23. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by June 22, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. The Coroners (Investigations) Regulations 2013 (legislation.gov.uk) | |
| 27/04/2023 | 2023-0141 | Vivien Radocz | Mr Simon Milburn | Cambridgeshire and Peterborough | Prevention of Future Deaths | Road (Highways Safety) related deaths | Road Highways Safety related deaths | https://www.judiciary.uk/prevention-of-future-death-reports/vivien-radocz-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Vivien-Radocz-Prevention-of-future-deaths-report-2023-0141_Published.pdf | Vivien was the driver of a Ford Focus motor vehicle travelling west along Old Oundle Road, Wittering at about 1035hrs on 03.09.22. The vehicle failed to negotiate a sharp left hand bend, left the carriageway to the offside before it entered a pond and became submerged upside down in water. Vivien was unable to escape from the submerged vehicle which was not discovered until around 1730hrs that day. Emergency services attended the scene and Fire Officers then extricated Vivien from the vehicle. Sadly her death was confirmed at the scene by a paramedic at 1942hrs | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 03.09.22 I commenced an investigation into the death of Vivien RADÓCZ, aged 28 years. The investigation concluded at the end of the inquest on 07.03.23. | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by June 22, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. The Coroners (Investigations) Regulations 2013 (legislation.gov.uk) | |
| 27/04/2023 | 2023-0140 | Ben Shipley | Mr Ian Geoffrey Pears | Yorkshire West Western | Mental Health related deaths | Prevention of Future Deaths | Railway related deaths | NHS England | NHS Improvement | https://www.judiciary.uk/prevention-of-future-death-reports/ben-shipley-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Ben-Shipley-Prevention-of-future-deaths-report-2023-0140_Published.pdf | Ben is a 22yr old single man who lived with his family in Lepton, Huddersfield. On the 28th of August Ben was seen by his GP who referred Ben to the ‘Single Point of Access’ service. On the 29th of August Ben was at the hospital with is parents, waiting to be sectioned under the mental health act when he ran away. His parents reported him as a missing person. That afternoon Ben was struck by a train in a rural area of Huddersfield. His life was pronounced extinct at 14:14hrs. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 03 September 2019 I commenced an investigation into the death of Ben Alan SHIPLEY aged 22. The investigation concluded at the end of the inquest on 23 February 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by April 28, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 26/04/2023 | 2023-0139 | Elsie Leaver | Dr Fiona Jane Wilcox | London Inner West | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/elsie-leaver-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Elsie-Leaver-Prevention-of-future-deaths-report-2023-0139_Published.pdf | On the 24th, 25th and 26th April 2023 evidence was heard touching the death of Mrs Elsie Leaver. She had died on 23rd August 2020, aged 89 years. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them. | You are under a duty to respond to this report within 56 days of the date of this report. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013. | ||||
| 26/04/2023 | 2023-0138 | Colin Gumm | Mr Paul Stanford Cooper | Lincolnshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Lincolnshire County Council | https://www.judiciary.uk/prevention-of-future-death-reports/colin-gumm-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Colin-Gumm-Prevention-of-future-deaths-report-2023-0138_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0138-Response-from-Lincolnshire-County-Council.pdf | Please refer to above and below | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 14 December 2021 I commenced an investigation into the death of Colin Robert GUMM aged 65. The investigation concluded at the end of the inquest on 25 April 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by June 20, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 26/04/2023 | 2023-0137 | Nancy Price | Katie Sutherland | North Wales (East & Central) | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Wales prevention of future deaths reports (2019 onwards) | Betsi Cadwaladr University Local Health Board | https://www.judiciary.uk/prevention-of-future-death-reports/nancy-price-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Nancy-Price-Prevention-of-future-deaths-report-2023-0137_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0137-Response-from-Betsi-Cadwaladr-University-Local-Health-Board.pdf | The circumstances of the death are as follows : Nancy Carolyn Price, aged 62 at the time of her death, presented to the Emergency Department of Wrexham Maelor Hospital on 30 December 2020 via ambulance which had arrived at her home at 16:37. She had sudden onset of movement and sensation in both lower limbs since midday. She was eventually seen by a medic, at approximately 9.45pm, when limb ischaemia was diagnosed. In consultation with the on call vascular consultant at Ysbyty Glan Clwyd, where vascular services are centralised for the Health Board, urgent CT angiogram was advised, IV heparin and pain relief, and also urgent ambulance transfer to Ysbyty Glan Clwyd. Nancy Price arrived many hours later, at approximately 3am and required rehydrating prior to the surgery. The surgery was commenced at approximately 05:55. Following surgery she developed multi organ failure and died on 1 January 2021. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. An investigation was commenced by the Health Board into the death of Nancy Carolyn Price, a significant time after her death and was completed only on 9 June 2022, some 17 months after her death. At Inquest it was identified that not all actions arising have been fully completed and the dates by when actions ought to have been completed (according to the investigation report) not adhered to. For example, the investigation report was due to be shared with vascular services to share learning by June 2022 (once approved) and yet the Report was only shared with vascular services in January 2023. The actions arising from the investigation report are not always realistic. For example, one action was to identify any gaps in knowledge with regards to assessment and management of vascular emergencies, including recording of limb colour, sensation and movement, by the end of June 2022, approximately 3-4 weeks after the final report. I have previously issued Prevention of Future Death Reports to the Health Board pertaining to the lack of timeliness of their investigations. I remain significantly concerned that the strategic management of internal Health Board investigations is lacking leading to investigations that are too slow, actions are not always realistic and, as a result, identification of areas for learning and training are not understood quickly enough, such that deaths will occur or will continue to occur into the future unless rapid action is taken. | On 11 January 2021 an investigation was commenced into the death of Carolyn Nancy Price (DOB 3/6/1958) who died on 1 January 2021. The investigation concluded at the end of the inquest on 25 April 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 21 June 2023. I, Kate Sutherland, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 26/04/2023 | 2023-0136 | Janet Smith | Mrs Catherine Mason | Leicester City and South Leicestershire | Care Home Health related deaths | Prevention of Future Deaths | Silver Birches Care Home | https://www.judiciary.uk/prevention-of-future-death-reports/janet-smith-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Janet-Smith-Prevention-of-future-deaths-report-2023-0136_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0136-Response-from-Pine-View-Care-Homes-LTD.pdf | Janet Smith was an 81-year-old woman with a history of advanced dementia and ischaemic heart disease, who was found by carers on the floor following an unwitnessed fall in an unsafe environment at around 20.00 hours on 15 March 2022, at the Silver Birches care home, Leicester, where she was a resident. Although Mrs. Smith sustained no obvious physical injury, she complained of head pain the same evening and was taken by ambulance to the Leicester Royal Infirmary in the early hours of 16 March 2022, where she was diagnosed with spinal fractures. On a balance of probabilities, the injuries were caused by a high energy fall and in keeping with having fallen down the stairs. At the hospital Mrs. Smith was treated conservatively due to her age and dementia; she deteriorated over the following days and, after discussions with family members on 21 March 2022, she was placed on palliative care and died the following day. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) At the time of Mrs. Smith’s fall, there were 17 residents and 2 carers. One carer was attending a resident upstairs and the other carer was outside the care home accompanying another resident who wished to have a cigarette. This meant that no carer was in the lounge area monitoring the residents. Accordingly, when Mrs. Smith left the lounge area she was not monitored as required. If she had been monitored, it is understood that she would have been offered assistance and, on a balance of probabilities, the fall that led to her death would not have occurred. It was understood that at the care home there were, and still is, a number of residents with challenging behaviour and care needs, and that for some activities of daily living 2 carers may be required. With only 2 carers on a shift, it is foreseeable that residents can and will be left unattended. It is also foreseeable that competing needs of the residents will mean that residents will be left unmonitored, and an unsafe environment created as occurred with Mrs. Smith. Accordingly, there remains a concern that the provider has not done everything possible to mitigate the risk of actual or potential harm including death. | On 31 March 2022 I commenced an investigation into the death of Janet SMITH aged 81. The investigation concluded at the end of the inquest on 24 April 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by June 21, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 25/04/2023 | 2023-0135 | John Roberts | Guy Davies | Cornwall and the Isles of Scilly | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/john-roberts-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/John-Roberts-Prevention-of-future-deaths-report-2023-0135_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0135-Response-from-Royal-Cronwall-Hospitals-NHS-Trust.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0135-Response-from-BNF-Publications.pdf | John was a 78-years-old gentleman with a past medical history of • diabetes (type 2) diagnosed 1999 • chronic kidney disease, from 2012 • diverticular disease from 2012 • raised BMI, at times over 30, • myasthenia gravis (MG), symptoms identified from around April 2020, John was prescribed steroids from December 2020 for MG, escalating to the highest recommended dose of 100mg prednisolone, taken every other day. John received this high dose from 21 February 2021 until his death on 26 June 2021. That is with the exception of a period between 7 and 13 June 2021 following an inadvertent reduction in dosage to 25mg whilst an in-patient at RCHT. John was discharged on 15 June 2021 after this dosage error. I found that John was medically fit at the time of discharge and that the dosage error did not contribute to his cause of death. John was re-admitted on 22 June with a history of vomiting and retching for 2 days before admission; I found on the evidence that this was the likely period when John suffered his perforated sigmoid colon. This was deemed inoperable. John did not respond to antibiotics and was discharged home on 25 June 2021 for palliative care. John died peacefully at home on 26 June 2021. I found on the evidence of the histopathologist [REDACTED], that steroid therapy was contributory to John’s cause of death, alongside John’s other conditions. I found on the evidence that it was not possible to distinguish between the multiple conditions contributing to, and causative of, the perforated bowel. [REDACTED] stated in evidence as follows: …steroid therapy increases the risks of gastrointestinal complications including ulceration and perforation of the stomach, duodenum and the colon and these are recognised complications documented in the literature. The mechanism is unclear but steroids are thought to impair the mucosal barrier which enables bacteria to penetrate. Steroid induced colonic perforation is more likely to occur in patients with diverticular disease and the deceased was noted at autopsy to suffer from diverticular disease. It is speculated that in diverticular disease there is a localised concentration of bacteria. Also, if the patient is treated by high dose steroids, the signs and symptoms of gastrointestinal and colonic complications may be masked by the anti-inflammatory effects of the drugs. This may potentially lead to delays in identification of the drug induced complications, so potentially resulting in the patient presenting with advanced complications such as viscus perforation. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 22 July 2021 I commenced an investigation into the death of John Alfred Roberts. The investigation concluded at the end of the inquest on 14 April 2023. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 June 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] | |
| 12/05/2017 | 2023-0134 | Nasar Ahmed | Ms Mary Hassell | London Inner North | Child Death (from 2015) | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/nasar-ahmed-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Nasar-Ahmed-Prevention-of-future-deaths-report-2023-0134_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0134-Response-from-Department-of-Health-and-Social-Care-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0134-Response-from-Compass-Wellbeing-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0134-Response-from-British-Society-for-Allergy-and-Clinical-Immunology.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0134-Response-from-Bow-School.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0134-Response-from-Barts-Health-NHS-Trust-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0134-Response-from-St-Andrews-Health-Centre.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0134-Response-from-London-Ambulance-Service-NHS-Trust.pdf | Nasar died following an anaphylactic reaction contributed to by his asthma, when he was in the internal exclusion room at school. | During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. The MATTER OF CONCERN – 1. Chief Medical Officer for England Department of Health The respiratory paediatrician who gave evidence at inquest was firmly of the view that generic adrenaline auto-injectors should be available, in much the same way as defibrillators, in public spaces. Is this a suggestion that could be given wider consideration? | On 17 November 2016 I commenced an investigation into the death of Nasar Ahmed, aged 14 years. The investigation concluded at the end of the inquest today. I made a narrative determination, which I attach. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 14 July 2017. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. | |
| 24/04/2023 | 2023-0133 | Samuel Howes | Mr John C Taylor | London South | Child Death (from 2015) | Prevention of Future Deaths | Railway related deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/samuel-howes-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/05/Samuel-Howes-Prevention-of-future-deaths-report-2023-0133_Published.pdf | A jury found: Suicide Samuel’s mental health and his use of drugs and/or alcohol probably contributed to his death. We believe that the following matters also possibly made more than minimal, trivial or negligible contributions to his death a) The inadequate response of mental health and social care services in relation to Samuel’s dependency on alcohol and the possibility of a rehabilitative placement. There were inadequate provisions for Samuel’s complex needs. In particular, it was noted that no alternative treatments were proactively pursued. The agencies identified Covid as an obstacle to justify their inadequate responses. b) The failure to inadequately share risk information by Social Services and/or Mental Health Services with each other, and with the police. A number of factors were noted in this regard: • Missing risk assessments were not completed consistently • The Grab Pack was not completed • iii) Samuel’s vulnerabilities and suicide notes were not adequately communicated to the police by Social Services | During the course of the investigation, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN (some of which overlap) are as follows: (1) Samuel’s case should be a stimulus for some level of Child & Adolescent Mental Health Service reflection on how different Child and Adolescent Mental Health Service teams are organised and work together. (2) The delayed response of the Adult Complex Additions Service to referral and issues related to provision of care to adolescents presenting with mental health vulnerabilities and substance use difficulties. (3) The lack of a complex service providing, to adolescents, treatment for both substance misuse and mental health issues models, in terms of willingness to engage, being problematic for some young people. (4) The inadequate response of mental health and social care services in relation to Samuel’s dependency on alcohol and the provision of a rehabilitative placement. Samuel’s mental health and his use of drugs and/or alcohol probably contributed to his death. | : Samuel Thomas Howes On 17th September 2020, the Senior Coroner commenced an investigation into the death of Samuel Thomas Howes. The investigation concluded at the end of the inquest on 30th March 2023. | In my opinion action should be taken to prevent future deaths and I believe you, the Department of Health and Social care and NHS England, have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 19 June 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action, otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 24/04/2023 | 2023-0132 | Christopher Evans | Dr Peter Harrowing | Avon | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/christopher-evans-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Christopher-Evans-Prevention-of-future-deaths-report-2023-0132_Published.pdf | The Deceased had a long history of alcohol misuse, although he had a very low level of alcohol in his blood at the time of his death, and poorly controlled diabetes mellitus. As a result he was vulnerable and his physical health was deteriorating. Following a Care Act assessment on 7th September 2020 social services determined that the Deceased required placement with 24-hour care appropriate to meet his care and support needs. A referral was made to the Extra Care Housing team in order that a suitable placement be found. In the meantime the Deceased was placed in supported accommodation provided by Supported Independence Limited. The services provided Supported Independence Limited were registered with the Care Quality Commission (CQC). However, the Deceased’s accommodation was a small flat within a single building comprising a number of similar fiats. The building was licensed with the local authority as a house in multiple occupation (HMO) and therefore was not within the remit of the CQC. | During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 9th December 2020 I commenced an investigation into the death of Mr. Christopher Evans age 56 years. The investigation concluded at the end of the inquest on 1st March 2023. The conclusion was that the medical cause of death was l(a) Acute myocardial ischaemia; 1(b) Coronary Artery Atheroma and immersion in hot water and the conclusion as to the death was that ‘The Deceased died of an acute cardiac event following immersion in very hot water’ | In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 19th June 2023. I, the coroner, may extend the period. | I make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 20/04/2023 | 2023-0131 | Jodie McCann | Dr Elizabeth Didcock | Nottinghamshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Derby and Burton NHS Foundation Trust | | https://www.judiciary.uk/prevention-of-future-death-reports/jodie-mccann-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Jodie-McCann-Prevention-of-future-deaths-report-2023-0131_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0131-Response-from-University-Hospitals-of-Derby-and-Burton-NHS-Foundation-Trust-.pdf | Jodie was a previously fit and well young woman aged twenty two. She developed gallstone pancreatitis requiring admission to Kings Mill Hospital on 16.3.22. She had a cardiac arrest on the ward at KMH on 18.3.22, and as a consequence developed multi organ failure, requiring Critical Care treatment. She had a period of care at KMH CCU, but had to be transferred to Burton Hospital on 22.3.22 as KMH CCU was at operational capacity. She continued to make good progress on the CCU at Burton Hospital, but there were continuing issues of difficult airway management. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows · There is limited evidence to date for the introduction and continuing use of comprehensive airway strategies, with structured planning and preparation, when a difficult airway is anticipated. There should be airway plans A, B, and C recorded, shared, and the equipment and skills to carry them out must be available · There is limited evidence to date for the universal use of the NAP4 algorithms and checklists, which should be available on the difficult airway trolley, and be familiar to all ICU nursing and medical staff, and to the wider anaesthetic team · There is limited evidence to date, for the robust daily checking of all necessary equipment on the difficult airway trolley, to ensure immediate replacement of all key equipment if it is broken or misplaced · The Mortality Review policy was not followed, leading to a significant delay in completing the serious incident review, delaying Trust learning, and delaying the family’s understanding of the circumstances of Jodie’s death. There is limited evidence of progress in implementing the national Patient Safety Incident Response Framework at the Trust I am not reassured that necessary actions to address these serious issues identified are in place. | On the 2nd April 2022, I commenced an investigation into the death of Jodie Catherine McCann. The investigation concluded at the end of the inquest on the 19th April 2023 | In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by the 16th June 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 21/04/2023 | 2023-0130 | Peter Lawrence | Mrs Heidi Julia Connor | Berkshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Trauma and Orthopaedics Surgeon | https://www.judiciary.uk/prevention-of-future-death-reports/peter-lawrence-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Peter-Lawrence-Prevention-of-future-deaths-report-2023-0130_Published.pdf | In brief terms, Mr Peter Lawrence underwent spinal surgery at Spire Hospital in Portsmouth on the 11th January 2022. He had had several other spinal operations before then. He developed infection and abscesses, and the evidence showed that the most likely origin of that infection was the surgery that he had in January. He died at the Royal Berkshire Hospital on the 3rd March 2022. As part of the investigation, I reviewed the medical records. These included medical records from the time of his surgery at Spire Hospital in Portsmouth, but also included outpatient appointments (as a private patient) with [REDACTED] on (inter alia) 29th December 2021 (by telephone), 26th January 2022, and 23rd February 2022. My investigation revealed that [REDACTED] made no formal medical records of the outpatient appointments. It is right to point out that [REDACTED] letters dictated and typed up by his secretary (to the patient and his GP), and some of this correspondence is relatively detailed. It was advanced on his behalf that this correspondence effectively represents a medical record and it is entirely appropriate to make ‘records’ in this way. I did not accept that this correspondence is as full as a medical record would be. Much of the correspondence relates predominantly to plans and proposed courses of action, rather than a record of the patient’s condition at that time. In questioning, [REDACTED] accepted that much of the further information which he gave at the inquest (and referred to in a witness statement) is not recorded anywhere other than his own personal memory. Even leaving aside GMC requirements in relation to record-keeping, it is plainly the case that records are important for patient safety, and storing information about a patient in an individual doctor’s memory is clearly unacceptable. Leaving aside the issue of protection for the clinician, this approach carries a risk for patients. I was clear at the inquest that I had no reason to disbelieve the additional evidence which [REDACTED] brought to the inquest – both in his oral evidence in court and in his witness statement – but I am concerned about the risks of this continued approach for other patients. In questioning, [REDACTED] clarified that his intention is to continue practising in this way. | The issue about which I have concern is clear. [REDACTED] should review his record-keeping approach, perhaps with the benefit of legal advice and reference to GMC guidance. An approach of ‘storing’ information in an individual clinician’s memory carries a risk (including a risk of death) for future patients. | I conducted an inquest into the death of Peter William Frederick Lawrence, which concluded on 15th March 2023. Mr Lawrence was 79 at the time of his death. I recorded a short narrative conclusion : complication of necessary surgery. | In my opinion, action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th June 2023. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 21/04/2023 | 2023-0129 | Amy Henderson | Miss Caroline Topping | Surrey | Prevention of Future Deaths | Suicide (from 2015) | The Priority Group | NHS England | https://www.judiciary.uk/prevention-of-future-death-reports/amy-henderson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Amy-Henderson-Prevention-of-future-deaths-report-2023-0129_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0129-Response-from-NHS-England.pdf | Miss Henderson had a baby in 2021. When her baby was 11 months old she returned to work, but was signed off sick suffering from anxiety and depression. On the evening of the 14th March 2022 she was taken by her family to Kingston Hospital and assessed by the liaison psychiatric team. She expressed suicidal thoughts and plans [REDACTED]. She was diagnosed with postpartum depression. She was advised to become an informal patient in the NHS but there was no bed available so she would have had to wait in the hospital until a bed could be found. She decided to seek a private admission the following day. On the 15th March 2022 she sought treatment at the Priory Hospital, Woking. She had a preadmission assessment with [REDACTED] a consultant psychiatrist who accepted her as a patient. She told him that she had a suicide plan but did not provide details of what it was. He assessed her as a high risk of suicide and set observations at four times an hour. She was allocated a Key Worker who was not due to be in the hospital until 22nd March 2022, and a Co-worker, who had a one-to-one with her on 19th March 2022. Her overall mental health appeared to have improved when she was reviewed by [REDACTED] on March 18th 2022. The observation level was reduced to twice an hour on the 16th March 2022, and then further to once an hour on the morning of March 21st 2022, on each occasion without a risk assessment being performed as specified in the Priory policy. Later on the morning of the 21st March 2022 Miss Henderson made comments during a therapy session which indicated that her mental health was deteriorating. The therapists recorded what she had said in her notes, but the concerns were not considered to be serious enough to be escalated to the nursing team. Evidence presented to the inquest suggests that Amy’s observations should have been increased at this stage. Amy was not reviewed by the nursing team when the therapists’ notes were uploaded onto the system at 16.06 on 21st March 2022. The information was not reviewed and therefore not acted upon. Miss Henderson was last seen in person at 18.02 in the dining room. At 18.12. she entered the downstairs disabled toilet. The disabled toilet had been identified in risk assessments as a high-risk area but it was not locked. She wrote a farewell note to her parents at 18.14. She was found in the disabled toilet on the ground floor at 20.01. She had taken her own life by suspension, [REDACTED]. | During the course of the inquest the evidence revealed matters giving rise to concern. Inmy opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. The information that Miss Henderson had practised tying a ligature was divulged by her at Kingston Hospital but not repeated on admission to the Priory Woking. The evidence given at the inquest was that there is no quick method to obtain NHS records on admission to a private hospital. A request could have been made but the records would have taken over a week to be released. The records were not sought. An ability to obtain the NHS records quickly would have been of assistance to the Priory clinicians. The Priory Woking has a policy in relation to the removal of banned and restricted items but there was a lack of clarity and confusion among the clinicians as to who was responsible for ensuring that such items are identified and removed from the patient at admission. | An inquest into the death of Miss Amy Henderson was opened on the 26th April 2022 and resumed with a jury on the 6th February 2023. The inquest was concluded on the 23rd February 2023. Evidence in respect of matters pertaining to this report was heard on the 20th March 2023. | In my opinion action should be taken to prevent future deaths and I believe you[AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 16th June 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 20/04/2023 | 2023-0128 | Joseph Maunick | Mr Peter Taheri | Suffolk | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/joseph-maunick-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Joseph-Maunick-Prevention-of-future-deaths-report-2023-0128_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0128-Response-from-NHS-England.pdf | Joseph Willy Maunick (Will) was an intelligent man, gifted with communication skills, who worked as a teacher and spoke multiple languages. In his later years he developed cognitive impairment, which in turn led to him being at very high risk of falls. This risk, in relation to which he needed constant supervision, was known to those caring for him and to those responsible for looking after him when he was admitted to the Emergency Department of the West Suffolk Hospital on 4th March 2022. He was admitted to the hospital Emergency Department not because he himself was experiencing a medical emergency, but as a last resort after exhaustive efforts to explore all options before Will was admitted to hospital: it proved not to be possible to find suitable alternative care for him in residential care placements while his wife, and main carer, underwent unplanned emergency major surgery. The inquest heard evidence that, prior to his admission to hospital, at least eight social care providers were contacted plus further residential homes, but none of them could provide emergency care for Will. The inquest heard undisputed evidence that this was an instance of a national care shortage. The inquest heard evidence that in an Emergency Department where many patients are suffering medical emergencies constant one-to-one supervision will not always be possible. I found as a fact that it was not possible on this occasion and that Will’s fall in the Emergency Department took place when the nursing assistant who was trying to maintain constant one-to-one supervision of Will insofar as possible had their attention momentarily diverted to another patient experiencing a medical emergency. I judged that it would not be just to describe this as a failure on the part of the nursing assistant or the Emergency Department staff. The reason why it was not an individual failure included that the inquest heard evidence that the hospital, and in particular the Emergency Department, was experiencing significant pressures associated with high demand and an internal critical incident had been declared. There was a high demand for beds within the hospital without the availability of beds to meet the demand. This included the facts that there were, at the time of Will’s arrival in the Emergency Department, 50 patients in the Emergency Department, of whom 32 were waiting for bed placement. Moreover, staffing was at a ‘black status’ (the worst level) across the hospital, with a deficiency of staff of around 60 nurses and nursing assistants. I found as a fact that those severe pressures – the high demand levels and the deficiency of staff and scarcity of resource – contributed to the death. Firstly, if it had been possible to care for and supervise Will on a constant basis as he needed, then on the balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged. Secondly, on the balance of probabilities, the scarcity of resource relative to demand contributed to Will not being transferred to a ward – or other more appropriate environment – sooner. Apart from the inherent particular difficulties in providing constant supervision in an Emergency Department referred to above, the inquest also received undisputed evidence that the environment of a busy, noisy Emergency Department, with lights on at all hours of the day and night would be overly stimulating and not the most suitable environment for someone with cognitive impairment who was experiencing confusion and agitation. I found that such an environment probably contributed to Will’s inclination to wander and so to his fall. If it had been possible to transfer Will to a more suitable environment sooner, then on the balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged. I found as a fact that, on the balance of probabilities, the lack of availability of more appropriate care contributed to the death. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) 1) A national care shortage contributed to a situation where a gentleman who was not experiencing a medical emergency, but who required constant supervision for his own safety in view of his cognitive impairment and very high falls risk, could not be cared for anywhere other than in a hospital Emergency Department. If there is not sufficient provision of care, including residential care placements, such that those in similar need do not receive suitable care, then circumstances creating a risk of future deaths will occur or continue to exist in the future, when they are placed in an environment that is not realistically able to provide the constant supervision needed, as occurred in this case. The severe pressures on the hospital, including the Emergency Department, were such that they were experiencing scarcity of resource relative to demand and a severe deficiency of staff. In these circumstances, it was both not possible to provide the care and supervision that Will needed in the Emergency Department, and the scarcity of resource contributed to Will not being transferred sooner to a ward or other more appropriate environment, where Will could receive the constant supervision that would probably have prevented the fall that led to his death. The evidence was that the scarcity of resource experienced was a challenge on the national level, rather than just a particular local issue. If hospitals, including Emergency Departments, do not receive sufficient resource, then circumstances creating a risk of future deaths, due to an inability to provide the required care and / or prompt transfer to an available ward bed or appropriate alternative place, will occur or continue to exist in the future. | On 18th March 2022 an investigation was commenced into the death of Joseph Willy Maunick. The investigation concluded at the end of the inquest on 18th April 2023. The narrative conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe each of you and / or your organisations have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 15 June 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 20/04/2023 | 2023-0127 | Chester Mossop | Miss Kirsty Gomersal | Cumbria | Child Death (from 2015) | Prevention of Future Deaths | National Health Service | Product Safety and Standards | https://www.judiciary.uk/prevention-of-future-death-reports/chester-mossop-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Chester-Mossop-Prevention-of-future-deaths-report-2023-0127_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0127-Response-from-NHS-England.pdf | Chester was a healthy and well looked after 9 months’ old baby. He was usually fit and well. However, on 29 May 2022, he had a mild viral infection (which was confirmed at post-mortem). Chester was placed in a bath seat and given a bath in suitably warm water. The water level was higher than advised – so that Chester did not get chilled. After about 20 minutes of bath time, Chester was left alone in his bath seat whilst a plug- in diffuser (to help his cold) was prepared in his bedroom. It was believed that the bath seat was safe and secure to hold him in place. After a few minutes, Chester was found face down in the bath. The bath seat had become unfixed. There were no sounds that Chester was in distress or difficulty. He was immediately removed from the bath and given immediate CPR by a trained adult. Emergency services were quickly on scene and CPR was continued by police, paramedics and clinicians. Return of spontaneous circulation was achieved. Chester was flown by air ambulance to the Great North Children’s Hospital at the Royal Victoria Infirmary in Newcastle. However, an MRI scan undertaken on 2 June 2022 showed that Chester had an extensive severe brain injury consistent with severe global hypoxic ischaemia caused by drowning. It was considered that Chester was unlikely to survive and further intensive care treatment was not in his best interest. Intensive care support was withdrawn on 3 June 2022 and Chester died peacefully in his mother’s arms at 18:05. I received a statement from RoSPA (the Royal Society for the Prevention of Accidents) setting out that: · Baby bath seats are unstable and prone to toppling over leaving the baby trapped in the water. · Bath seats may give parents and carers a false sense of security that baby is safer in a bath seat and can be left alone (despite warnings that this should not happen). · There can be a misconception that a baby bath seat is a safety product – this is not the case. · Under no circumstances should parents regard bath seats as a safety aid and leave a child out of arms reach. · RoSPA is aware of incidents where parents have been in the room, but away from the baby, with tragic results. · RoSPA is aware of a number of drownings of young children in the bath where a baby bath seat has been used. · There may be some bath seats that are less stable than others or that have inadequate methods to hold them in place. | The evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: I am aware of similar tragic deaths to Chester’s and inquests held by my fellow Coroners. RoSPA is also aware of fatal and non-fatal incidents. The use of bath seats is of concern to RoSPA. Whilst I am aware of the regional Bath Safety Advice (set out above), I am not aware that similar advice has been distributed on a national level to healthcare professionals and to parents / carers. I am not aware whether parents / carers are provided with advice about the safe use of bath seats as part of e.g. health visits. I am concerned that bath seats may given parents a false sense of security that their child is safe. Bath seats are not safety devices. | Chester Alan Stanley MOSSOP died on 3 June 2022 following an incident at his home address on 29 May 2022. Baby Chester’s death was reported to HM Coroner for Cumbria on 6 June 2022 and his death formally transferred from HM Coroner Newcastle. An investigation into his death (in accordance with Section 1 Coroners and Justice Act) was commenced on the same day. | In my opinion action should be taken to prevent future deaths and I believe the NATIONAL HEALTH SERVICE OFFICE OF PRODUCT SAFETY AND STANDARDS has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 June 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013: https://www.legislation.gov.uk/ukpga/2009/25/contents http://www.legislation.gov.uk/uksi/2013/1629/contents |
| 19/04/2023 | 2023-0126 | Elizabeth Hutchins | Mrs Maria Eileen Voisin | Avon | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Royal United Hospitals | https://www.judiciary.uk/prevention-of-future-death-reports/elizabeth-hutchins-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Elizabeth-Hutchins-Prevention-of-future-deaths-report-2023-0126_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/05/2023-0126-Response-from-Royal-United-Hosiptals-Bath-NHS-Foundation-Trust.pdf | The deceased Elizabeth Mavis HUTCHINS died on 23 January 2022 at Royal United Hospital, Bath. She had been admitted unwell on 11th January 2022 after falling and breaking her arm. She suffered myocardial ischaemia and injury on the night of 13th /14th January which was not treated or managed in any way at all. She was not seen by a doctor again until she suffered a cardiac arrest on 18th January 2022. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. On 13th January, at 23.15hrs a doctor reviewed Mrs Hutchins because she was complaining of being short of breath. She was alert but appeared to be very breathless, she was speaking with some difficulty. Mrs.Hutchins reported a one-day history of being short of breath with a productive cough and intermittent chest tightness. She was also nauseous. He sought advice from an SHO and documented the plan that she was for an ECG, blood test including a troponin, CRP and oxygen. The ward cover SHO for Medicine, said that he was called initially for advice on the blood tests he said in evidence that he considered a heart attack and pulmonary embolism so said Troponin and D-Dimer. He sought advice from the Registrar who said that the ECG trace was not normal. The Registrar said that at the time she had raised CPR and that she had a productive cough and he considered that this was a pneumonia. He said that he considered Troponin but thought that it would not be a useful test in the circumstances. His plan at this time was to give antibiotics, IV fluids, to repeat her heart trace in half an hour and to increase her observations to 1 hourly. It is known that the Troponin result was returned at 01.35hrs on 14th January and that it was raised at 358. The SHO saw Mrs Hutchins at 04.57 that morning, he had noted the raised Troponin, he made a plan for the day team to review her and for bloods to be done to include a serial Troponin level. He also recalls that he gave a handover and spoke to the nurses. He said he expected her to be reviewed. Mrs Hutchins did not have a medical review on 14th or 15th or 16th or 17th. | On 28 January 2022 I commenced an investigation into the death of Elizabeth Mavis HUTCHINS. The investigation concluded at the end of the inquest . The conclusion of the inquest was Natural causes contributed to by neglect. The medical cause of death was recorded as: 1a Cardiac arrest 1b Acute coronary syndrome, myocardial infarction 1c Coronary artery atherosclerosis II Type 2 diabetes, hypertension, aortic stenosis | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 14th June 2023. I, the coroner, may extend the period. | I make this report under Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 19/04/2023 | 2023-0125 | David Mason | Mr Nicholas H Lane | Worcestershire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/david-mason-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/David-Mason-Prevention-of-future-deaths-report-2023-0125_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0125-Response-from-NHS-England.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0125-Response-from-NICE.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0125-Response-from-Worcestershire-Acute-Hospitals.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0125-Response-from-West-Midlands-Ambulance-Service.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0125-Response-from-Association-of-Ambulance.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0125-Response-from-Society-for-Endocrinology.pdf | David Mason was an 82-year-old gentleman with significant medical co-morbidities, including a known diagnosis of Addison’s disease. By March 2022, Mr Mason was becoming more frail and, owing to mobility issues, was suffering from recurrent falls. Mr Mason fell in his bedroom on the evening of 5 March 2022. An ambulance was called but it took a number of hours until paramedics arrived and transported Mr Mason to hospital. Once there, Mr Mason was diagnosed with a fractured hip, as a result of the trauma suffered when he fell. | During the course of the investigation and inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows (numbered separately in respect of each organisation, who are required to respond to each of the numbered paragraphs relating to them): Worcestershire Acute Hospitals NHS Trust (WAHT) 1) Evidence heard at the inquest demonstrated that no clinician involved in providing care to Mr Mason (in both the emergency department and the surgical trauma department) appreciated that, as someone who had Addison’s disease and who had suffered the trauma of a fall, long lie and a fractured hip, Mr Mason required additional replacement steroid therapy, to prevent the development of an acute adrenal crisis. 2) The relevant internal Trust guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure-based/perioperative situations, and (save for a small section containing ‘sick day’ rules, which are on the same page as advice to patients and families for long-term condition management) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress. 3) Evidence heard at the inquest (relating to the trauma/surgical department at WAHT) suggested that it is likely that many clinicians (including at consultant level) do not have a well-developed understanding of adrenal insufficiency and the crucial importance of administering replacement steroid therapy to patients who, although not presenting as acutely unwell, are at risk of suffering an adrenal crisis. 4) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency. Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included. West Midlands Ambulance Service University NHS Foundation Trust (WMAS) 1) Evidence heard at the inquest demonstrated that no clinician involved in providing pre-hospital care to Mr Mason appreciated that, as someone who had Addison’s disease and who had suffered the trauma of a fall, long lie and a fractured hip, Mr Mason required additional replacement steroid therapy, to prevent the development of an acute adrenal crisis. 2) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately. This appears to be potentially relevant both in respect of whether time-critical steroid treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety- netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. Currently there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not being considered by call-handlers at WMAS. 3) The Serious Incident investigation report disclosed by WMAS did not make any recommendations in respect of improving clinicians’ knowledge of adrenal insufficiency and the importance of considering administering replacement steroid therapy. 4) Evidence heard at the inquest confirmed that the investigation lead at WMAS had not been shown the inquest disclosure bundle, which had been disclosed to the legal department at WMAS a number of months prior to the inquest. This bundle contained relevant evidence from a different internal investigation (by WAHT), suggesting that the likely cause of Mr Mason’s deterioration and death was an acute adrenal crisis and not, as had been considered when a coronial referral had initially been made, hyperkalaemia and rhabdomyolysis (following a fall and long lie). This lack of internal co-ordination within WMAS prevented full internal investigation and learning in respect of the care given to Mr Mason by WMAS. The legal department of WMAS did not attend the inquest (it was their right not to) nor were WMAS legally represented by an external solicitor or barrister (it was their right not to be). Greater engagement and participation in the coronial investigation and inquest process would improve the Trust’s ability to learn from patient-safety incidents and enable the legal, governance and safety departments to better co-ordinate such investigations. Association of Ambulance Chief Executives (AACE) 1) The relevant JRCALC (Joint Royal Colleges Ambulance Liaison Committee) guideline for steroid dependent patients (which was disclosed by WMAS as part of inquest proceedings) places very little emphasis on the importance of administering steroid replacement therapy to patients who, although not presenting as acutely unwell, are at risk of developing an acute adrenal crisis, owing to them suffering from trauma or physiological stress. The relevant section (contained in bullet point 2 of the ‘administer hydrocortisone’ box) is itself a sub-section of an ‘emergencies in adults and children’ box and therefore is not able to be easily differentiated from treatment required for patients who are already established as being in an emergency situation. Further, it is stated that patients who are ‘unwell’ require hydrocortisone to prevent an adrenal crisis – it is not sufficiently clear that patients who may have suffered trauma or physiological stress also require steroid treatment, to prevent an adrenal crisis. To lend weight to this latter concern, evidence heard at the inquest suggested that the clinicians involved in treating Mr Mason considered ‘unwell’ in this context to mean obviously medically unwell, such as having signs of infection or sepsis, or gastro- intestinal symptoms, such as diarrhoea. There was no evidence of any understanding that this definition encompasses patients who have suffered trauma or physiological stress. 2) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately. This appears to be potentially relevant both in respect of whether time-critical medical treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety- netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. The pathway and programmed- logarithm should be looked at, as currently there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not able to be considered by ambulance service control centres. National Institute for Health and Care Excellence (NICE) 1) The relevant treatment guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure- based/perioperative situations, and (save for a small section containing ‘sick day’ rules) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress. Evidence heard at the inquest suggested that this internal Trust guideline (and, one assumes, other such guidelines in other acute trusts in the country) is based upon various pieces of national guidance. It is my understanding that a new guideline in respect of managing the treatment of adrenal insufficiency is currently being developed by NICE. Consideration of these matters should be included as part of guideline development. Society for Endocrinology (Clinical Committee) 1) The relevant treatment guideline disclosed by WAHT (‘Guideline for the management of adrenal insufficiency in adults’) very much focuses on presentations of acute adrenal crisis and procedure- based/perioperative situations, and (save for a small section containing ‘sick day’ rules) does not emphasise that replacement steroid therapy must be given to patients with adrenal insufficiency who have suffered trauma or physiological stress. Evidence heard at the inquest suggested that this internal Trust guideline (and, one assumes, other such guidelines in other acute trusts in the country) is based upon various pieces of national guidance. The clinical committee of the Society for Endocrinology has previously been involved in providing guidance in respect of managing patients with adrenal insufficiency. The Society’s input going forward is important in respect of considering any future NICE or JRCALC guidelines regarding the management of adrenal insufficiency. 2) The relevant JRCALC (Joint Royal Colleges Ambulance Liaison Committee) guideline for steroid dependent patients (which was disclosed by WMAS as part of inquest proceedings) place very little emphasis on the importance of administering steroid replacement therapy to patients who, although not presenting as acutely unwell, are at risk of developing an acute adrenal crisis owing to them suffering from trauma or physiological stress. The relevant section (contained in bullet point 2 of the ‘administer hydrocortisone’ box) is itself a sub-section of an ‘emergencies in adults and children’ box and therefore is not able to be easily differentiated from treatment required for patients who are already established as being in an emergency situation. Further, it is stated that patients who are ‘unwell’ require hydrocortisone to prevent an adrenal crisis – it is not sufficiently clear that patients who may have suffered trauma or physiological stress also require steroid treatment, to prevent an adrenal crisis. To lend weight to this latter concern, evidence heard at the inquest suggested that some of the clinicians involved in treating Mr Mason considered ‘unwell’ in this context to mean obviously medically unwell, such as having signs of infection or sepsis, or gastro-intestinal symptoms, such as diarrhoea. There was no evidence of any understanding that this definition encompasses patients who have suffered trauma or physiological stress. The Society’s input going forward is important in respect of considering any future NICE or JRCALC guidelines regarding the management of adrenal insufficiency. NHS England 1) Evidence heard at the inquest demonstrated that when information is given to an EOC (emergency operations centre) call-handler at WMAS that a patient has a diagnosis of Addison’s disease and has suffered trauma, the call-handler question pathway (which, the inquest heard, is based on a computer-programmed logarithm (designed by NHS Digital, now part of NHS England)) does not go on to consider the risk of adrenal insufficiency and the requirement for replacement steroid therapy to commence immediately. This appears to be potentially relevant both in respect of whether time-critical medical treatment may be required (and thus for a holistic consideration of call categorisation) and safety-netting advice that should be given (for additional doses of steroid medication to be taken by the patient, prior to any ambulance arrival). Safety- netting advice takes on even greater significance in the current climate, where healthcare demand and pressures on capacity are often causing severe delays in ambulance attendance. Evidence heard at the inquest confirmed that the position is different if information is given that the patient is medically unwell, particularly if concerns of a cardiac nature are present or adrenal insufficiency may be the direct cause of current illness, with the call-handler question pathway then going on to consider the risk of adrenal insufficiency. The pathway and programmed- logarithm should be looked at, as currently it appears that there is a cohort of patients (which included Mr Mason) whose risk of developing an adrenal crisis is not able to be considered by ambulance service control centres. 2) Evidence heard at the inquest confirmed that no prompts exist on emergency department/clerking documentation at WAHT for clinicians to check whether a patient suffers from adrenal insufficiency. Although the inquest was informed that changes have been made in this regard by WAHT to some peri-operative patient documentation, the National Patient Safety Alert (NatPSA/2020/005/NHSPS) requires acute trusts to review admission/assessment/clerking documentation to ensure such prompts are included. It is not clear what follow-up action is taken by NHS England in relation to monitoring of compliance by NHS Trusts following National Patient Safety Alerts being issued. | On 13 March 2022 an investigation was commenced into the death of David Ernest Mason. The investigation concluded at the end of the inquest hearing on 12 April 2023 at Stourport Coroner’s Court, in the Worcestershire Coroner Area. The conclusion (a ‘narrative’ conclusion in Box 4 of the Record of Inquest) was determined as follows: | In my opinion action should be taken to prevent future deaths and I believe your organisations have the power to take such action. | Your organisation is under a duty to respond to this report within 56 days of the date of this report, namely by 14 June 2023. I, the coroner, may extend the period. If any request is to be made for this period to be extended, please ensure this is made in writing at least 7 days prior to the above required response date. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | |
| 18/04/2023 | 2023-0124 | Patrick Soames | Mr Edmund Gritt | London South | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/patrick-soames-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Patrick-Soames-Prevention-of-future-deaths-report-2023-0124_Published.pdf | Patrick lived at home with his parents and was employed. However, in the final month of his life, Patrick experienced a severe emotional deterioration. He engaged in repeated episodes of serious self-harm including cutting his arms, medication overdose and uncharacteristic excessive alcohol misuse. At one point, he briefly went missing when he travelled to Yorkshire – where he also self-harmed. On 9 occasions during that final month, Patrick attended various hospital accident and emergency departments (in different NHS Trust areas), following incidents of self-harm. Some incidents also involved police contact. Patrick, however, declined to engage with psychiatric liaison services on these occasions and abruptly terminated a brief engagement with psychiatric assessment services following referral. Patrick had mental capacity to refuse treatment. | On 6th July 2021 an investigation was commenced into the death of Patrick Soames, who was 24 years old when he died on 21st June 2021. I assumed conduct of that investigation on about 18th February 2022 and I concluded that investigation at the end of Patrick’s inquest on 21st February 2023. | In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13th June 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |||
| 15/02/2023 | 2023-0123 | Natalie Young | Mrs Samantha Marsh | Somerset | Other related deaths | Prevention of Future Deaths | Department for Transport | https://www.judiciary.uk/prevention-of-future-death-reports/natalie-young-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Natalie-Young-Prevention-of-future-deaths-report-2023-0123_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0123-Response-from-Department-for-Transport.pdf | Natalie was an independent (and somewhat spritely) 92 year old lady who had full mobility. On the 9th March 2022, Natalie was shopping on her own in a supermarket and was queued at the tills to pay for her groceries. Whilst she was waiting to be served, another shopper on a mobility scooter has joined the queue and was waiting, stationary. Without warning the mobility scooter accelerated forward, ploughing into Natalie with some force and knocking her over. The forward propulsion of the mobility scooter was a conscious act of the driver/rider rather than an unforeseen mechanical or electrical fault. On becoming aware of the injury caused to Natalie, the mobility scooter driver flees the scene and has not been identified or heard from since. An ambulance was called but declined to attend and so staff from the supermarket transport Natalie to Musgrove Park Hospital where, on admission, it is discovered that she has sustained a fractured hummerus. Whilst she was medically fit for discharge throughout the duration of her stay in hospital, she required physiotherapy and occupational therapy assessments as part of her discharge planning. Natalie was ultimately discharged from hospital on the 9th April 2022 with a package of care in place. Natalie suffered from immobility as a result of the injury, as well as severe pain. She was re-admitted back into hospital on the 13th April 2022 when she was diagnosed with severe sepsis and an acute kidney injury due to a lower respiratory tract infection which had arisen solely as a consequence of the injuries she had sustained, and the resultant immobility, following a fall. Natalie died on the same day. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – During the course of the Inquest the evidence revealed that in relation to mobility scooters there are: 1. No restrictions on those who are able to operate them; i.e. there are no requirements on the drivers to have vision to a certain standard; to evidence cognitive ability and competence to a standard to be able to understand the controls of the vehicle and how to operate them safely; to be within the acceptable drink drive limit of 80mg/100ml and/or not under the influence of any other substance. | On the 16th April 2022 the then-Senior Coroner, Mr Tony Williams, commenced an investigation into the death of Natalie Ann Young, aged 92 (“Natalie”). | In my opinion action should be taken to prevent future deaths and I believe you your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 05th April 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 24/04/2020 | 2023-0122 | Russell Curwen | Mr James Newman | Lancashire and Blackburn with Darwen | Other related deaths | Prevention of Future Deaths | Road (Highways Safety) related deaths | Department for Transport | https://www.judiciary.uk/prevention-of-future-death-reports/russell-curwen-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Russell-Curwen-Prevention-of-future-deaths-report-2023-0122_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0122-Response-from-Department-for-Transport.pdf | During the course of the investigation information has come to my attention, giving rise to concerns. In my opinion there is a risk that future deaths will occur unless action is taken_ In the circumstances it is my statutory duty to report to you. Firstly I must at this time indicate that this is not, nor should be considered as, criticism of the invaluable service that volunteers within the blood bike community provide to the National Health Service. | On the 15th May 20181 commenced an investigation into the death of Russell Curwen aged 49. An inquest has yet to be concluded. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. It is not my place to seek to inform you of what your actions should be. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd June 2020. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www. legislation. gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/162 9/part/7/made | |
| 18/04/2023 | 2023-0121 | David Levett | Mrs Anne Pember | Northamptonshire | Prevention of Future Deaths | Road (Highways Safety) related deaths | National Highways | https://www.judiciary.uk/prevention-of-future-death-reports/david-levett-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/David-Levett-Prevention-of-future-deaths-report-2023-0121_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0121-Response-from-National-Highways.pdf | On the evening of 28th January 2018, a car broke down on a stretch of the M1 south-bound motorway near Daventry known as a “Smart Motorway”. A second vehicle came to the rescue of the first and parked behind the first vehicle in lane 1. A lorry collided with the rear of the second vehicle, pushing it into the rear of the first vehicle. Mr David Levett was a rear seat passenger in the second vehicle. He received severe head and chest injuries and was conveyed to Hospital. He succumbed to his injuries and was confirmed deceased on 24th February 2018. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 18th April 2018, I commenced an investigation into the death of David Levett aged 53 years. The investigation concluded at the end of the Inquest on 13th April 2023. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by June 12, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 18/04/2023 | 2023-0120 | John Stiff | Ms Nadia Persaud | London East | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/john-stiff-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/John-Stiff-Prevention-of-future-deaths-report-2023-0120_Published.pdf | On the 10 November 2022, Mr. Stiff was admitted to Queen’s Hospital having suffered a believed unwitnessed fall. In Queen’s Hospital, he was diagnosed as suffering from an undisplaced fracture of the pelvis. A decision was taken to treat Mr. Stiff conservatively. Even though there was no surgical intervention, he was admitted under the care of the orthopaedic team. The orthopaedic team are not specialists in controlling medical problems associated with fractures. During the course of the admission, Mr. Stiff’s appetite was much reduced. He was not offered any nutritional supplements. On the 15 November 2022 he had reduced oxygen saturations and the medical team became involved in his care. He was diagnosed as suffering from a chest infection. He was treated with supplemental oxygen; intravenous fluids and intravenous antibiotics. Sadly, Mr. Stiff did not recover and he passed away at Queen’s Hospital on the 16 November 2022. It is likely that the fall and fractured pelvis on the 10 November 2022 caused a decline in health and mobility which would have contributed to the development of the fatal pneumonia. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: The Inquest heard evidence from an orthopaedic surgeon that patients such as Mr Stiff, who suffer hip and pelvic fractures and who have a number of additional age-related co-morbidities, would be best cared for by ortho- geriatricians. The inquest heard that this matter has been raised by the orthopaedic team on multiple occasions, but the orthogeriatric provision has not been increased. The Inquest also heard that the lack of orthogeriatric provision is a national issue of concern within the NHS. Orthopaedic trauma in elderly patients often exacerbates underlying medical conditions. Orthogeriatric trained staff would be better trained to recognise and treat medical co-morbidities. It is therefore considered that improved access to orthogeriatric care for this patient cohort could prevent future untimely deaths. | On 1 December 2022 I commenced an investigation into the death of John Edward Stiff. The investigation concluded at the end of the inquest on the 5 April 2023. The conclusion of the inquest was that Mr Stiff died as a result of an accident (following a fall). | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 June 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | ||
| 18/04/2023 | 2023-0119 | Keith Hodson | Mr HG Mark Bricknell | Herefordshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | Hereford County Hospital | https://www.judiciary.uk/prevention-of-future-death-reports/keith-hodson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Keith-Hodson-Prevention-of-future-deaths-report-2023-0119_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0119-Response-from-Wye-Valley-NHS-Trust-.pdf | Mr Hodson had a complex medical history. There were delays prior to an ambulance being called, in connection with the attendance of the ambulance, on admission to hospital and subsequently in connection with appropriate treatment. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken . In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) I am advised that an appropriate Triage System is not always adopted in practice at Accident and Emergency. (2) Without the adoption of a Triage System taking place escalation of care cannot meaningfully take place. (3) I am advised that on occasion appropriate senior oversight does not occur, this is required to identify when a patient has not been appropriately assessed . (4) 5.1. reports are not signed off in a timely fashion by a responsible individual. | On 20 July 2022, I commenced an investigation into the death of Keith Hodson, aged 68 years . The investigation concluded at the end of the Inquest on 5 April 2023. The conclusion of the Inquest was narrative (see 4 below). | In my opinion action should be taken to prevent future deaths and I believe you, [REDACTED] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 13 June 2023 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. ht tp:/ / www .legislatio n.gov.uk/ukpga/ 2009/ 25/schedule/ S/ para graph/7 htt p:/ / www .legislation.gov.uk/ uksi/ 2013/1629/ part/7 /made |
| 15/04/2023 | 2023-0118 | Sara Jones | Mr Duncan James Ritchie | Stoke on Trent and North Staffordshire | Prevention of Future Deaths | Road (Highways Safety) related deaths | Royal Stoke University Hospital | Betsi Cadwaladr University Health Board BCUHB | https://www.judiciary.uk/prevention-of-future-death-reports/sara-jones-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Sara-Jones-Prevention-of-future-deaths-report-2023-0118_Published-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/Sara-Jones-Prevention-of-future-deaths-report-2023-0118-2_Published-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0118-Response-from-Betsi-Cadwaladr-University-Health-Board-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0118-Response-from-University-Hospitals-of-North-Midlands.pdf | Road traffic collision contributed to by neglect | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 10 March 2022 I commenced an investigation into the death of Sara Anest JONES aged 25. The investigation concluded at the end of the inquest on 07 March 2023. The conclusion of the inquest was that: Sara Anest Jones died at the Royal Stoke University Hospital, Stoke-on-Trent on 2nd April 2021 of complications of a bowel injury sustained in a road traffic collision on 30th March 2021. Miss Jones was treated for her injuries at the Royal Stoke University Hospital, Stoke- on-Trent. Those responsible for Miss Jones’ care at the Royal Stoke University Hospital did not identify that she had sustained a bowel injury and consequently it remained untreated. Miss Jones developed peritonitis because of the untreated bowel injury, from which she later died. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by May 09, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 06/04/2023 | 2023-0117 | Alexandra Briess | Mrs Heidi Julia Connor | Berkshire | Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/alexandra-briess-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Alexandra-Briess-Prevention-of-future-deaths-report-2023-0117_Published.pdf | Alexandra was born on 3rd January 2004. She was 17 at the time of her death. The key facts in this case are as follows: · Alexandra had no significant past medical history. · She underwent an uneventful tonsillectomy on 22nd May 2021. · After returning home, she suffered post-operative bleeding and required further surgery. · The second operation was carried out on 30th May. · When the anaesthetic was administered on 30th May, Alexandra deteriorated suddenly and suffered a cardiac arrest. · A large number of clinicians were involved in trying to assist Alexandra, but tragically, she died at the Royal Berkshire Hospital in Reading on 31st May 2021. · There are no concerns about her clinical management. The most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium, a drug which she had not had before. | Background This is not new territory. Several coroners have raised concerns similar to mine. Those listed below are simply the cases where coroners have sent Regulation 28 reports. There may well be others. Previous cases include : 1. In the case of Shante Turay-Thomas (who I believe was 18 at the time of her death), the Senior Coroner for Inner North London stated: “The issues within this Prevention of Future Deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England, or the Department of Health as a whole.” | I conducted an inquest into the death of Alexandra Briess, which concluded on 15th December 2022. I recorded a Narrative Conclusion as follows: Alexandra Briess underwent an uneventful tonsillectomy on 22nd May 2021. She suffered post-operative bleeding, and required further surgery. This was carried out on 30th May. During anaesthesia, Alexandra suffered a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, she died at Royal Berkshire Hospital, London Road, Reading on 31st May 2021. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium. This was a drug she had not had before, and her reaction to it was unpredictable. Alexandra was a bright and well loved young woman, who had planned to study medicine herself. Her cause of death was: I a Anaphylaxis due to Rocuronium used during anaesthesia I b Surgery to repair post operative bleeding 30th May 2021 I c Tonsillectomy 22nd May 2021 This Regulation 28 Report has been deliberately delayed, to allow for careful consideration of guidance to pathologists, police and coroners, and in order to ensure the report is addressed to the correct recipients. Alexandra’s family has been kept updated in this respect. | In my opinion action should be taken to prevent future deaths, and I believe your organisation has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 2 June 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I am Mrs Heidi J Connor, Senior Coroner for Berkshire. I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 04/04/2023 | 2023-0116 | Thomas Jayamaha | Dr Elizabeth Didcock | Nottinghamshire | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/thomas-jayamaha-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Thomas-Jayamaha-Prevention-of-future-deaths-report-2023-0116_Published-2.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0116-Response-from-Nottinghamshire-Healthcare-NHS-Foundation-Trust.pdf | Tom took his own life on by taking Pentobarbitol, that he had ordered from a website abroad. He had Autism Spectrum Disorder (ASD), and a long history of suicidal ideation, with previous self harm/suicide attempts. He was aged twenty three when he died. | On the 1st March 2022, I commenced an investigation into the death of Thomas Jayamaha. The investigation concluded at the end of the inquest on the 15th March 2023 The conclusion of the inquest was Suicide | In my opinion, action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by the 2nd June 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. For the avoidance of doubt, I will require a response from the Chief Executive of the Nottinghamshire Healthcare NHS Foundation Trust, to all three matters of concern, with collaboration with the Nottinghamshire Integrated Care Board to ensure a full response to the first matter. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 03/04/2023 | 2023-0115 | REDACTED | Mr Alan Wilson | Blackpool and Fylde | Child Death (from 2015) | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/blackpool-fylde-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Blackpool-and-Fylde-Prevention-of-future-deaths-report-2023-0115_Published.pdf | In addition to the contents of section 3 above, the following is of note: | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to send the report: | The death of [REDACTED] on 24th September 2022 at his home address was reported to me and I opened an investigation which concluded by way of an inquest held on 29th March 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report. Given the approaching holiday period I have extended this period to Tuesday, 23rd May 2023. I, the coroner, may extend the period further. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 07/02/2023 | 2023-0114 | Bridget Gormley | Mr David Donald William REID | Worcestershire | Care Home Health related deaths | Prevention of Future Deaths | Barchester Healthcare | Weightmans LLP | https://www.judiciary.uk/prevention-of-future-death-reports/bridget-gormley-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Bridget-Gormley-Prevention-of-future-deaths-report-2023-0114_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0114-Response-from-Barchester-Healthcare-.pdf | In answer to the questions “when, where and how did Mrs. Gormley come by her death?”, I recorded as follows: “On 20.7.22 Bridget Gormley, who had had an increasing number of falls since the end of March 2022, fell again at the care home in Worcester where she lived. She was taken by ambulance to the Alexandra Hospital, Redditch, where she was found to have sustained significant traumatic intracranial bleeding. She was transferred to Worcestershire Royal Hospital where, despite treatment, she continued to decline and died on 31.7.22.” | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | [the details below are fictional] On 3 August 2022 I commenced an investigation and opened an inquest into the death of Bridget GORMLEY. The investigation concluded at the end of the inquest on 8 February 2023. The conclusion of the inquest was that Mrs. Gormley died as the result of an accident. | In my opinion action should be taken to prevent future deaths and I believe you, as CEO of Barchester Healthcare, have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 6 April 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 31/03/2023 | 2023-0113 | Benjamin Hart | Ms Patricia Harding | Kent Central and South East | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/benjamin-hart-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Benjamin-Hart-Prevention-of-future-deaths-report-2023-0113_Published.pdf | Benjamin Hart, 25 had a medical diagnosis of post-traumatic stress disorder, enduring personality change after a catastrophic experience, emotionally unstable personality disorder borderline type and generalised anxiety disorder. He likely had Asperger’s syndrome. At the time of his death was under the care of the community mental health team following a suicide attempt by hanging in December 2021 following which he was formally sectioned. After his release he was allocated a care coordinator who between May 2022 and his death in October 2022 saw him on only three occasions (his care plan envisaging weekly involvement). The Trust was aware that the relationship between Ben and his care coordinator had broken down but a new care coordinator was not appointed and Ben had no contact from the community mental health team for 5 weeks before his death on 12th October 2023 when he hanged himself at his mother’s home address. He had telephoned the Crisis team three times in the two days before his death, calls which included complaints of having been abandoned by the mental health team, expressions of hopelessness about his future and indications that he felt suicidal. He was informed that the community mental health team would contact him. Although the community mental health team and the care coordinator were notified of Ben’s calls the day before his death, no one attempted contact until after this death had occurred. Kent & Medway NHS partnership Trust accepted at the inquest that the care provided to Ben fell below the standard he could have expected to receive and there were missed opportunities to treat him. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 17th October 2022 an investigation was commenced into the death of Benjamin James HART. The investigation concluded at the end of the inquest 28th March 2023. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 26th May 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made | ||
| 31/03/2023 | 2023-0112 | Veronica Jenkins | Miss Anna Crawford | Surrey | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/veronica-jenkins-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/04/Veronica-Jenkins-Prevention-of-future-deaths-report-2023-0112_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/04/2023-0112-Response-from-South-East-Coast-Ambulance-Service.pdf | |||||||
| 30/03/2023 | 2023-0111 | Carol Robinson | Ms Nadia Persaud | London East | Alcohol, drug and medication related deaths | Prevention of Future Deaths | North East London Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/carol-robinson-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Carol-Robinson-Prevention-of-future-deaths-report-2023-0111_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0111-Response-from-North-East-London-Foundation-Trust.pdf | On the 7 May 2022, Carol Robinson called a family member to report that she had taken an overdose of medication (quantity and identity of medication unknown). The family member called the emergency services and ambulance service personnel attended. The first response paramedic tried to elicit the history, but was unable to determine from Mrs Robinson what medication had been taken. There was a delay in conveying Mrs Robinson to hospital, in the order of around 50 minutes, but there is no evidence that this delay contributed to her death. Mrs Robinson was taken to Queen’s Hospital where a diagnosis of mixed drug toxicity, on the background of severe co-morbidities, was made. She was provided with intensive care. Sadly she did not recover and she passed away at Queen’s Hospital on the 8 May 2022. By way of background, Mrs Robinson had taken an overdose in March 2022 and had received care from the mental health home treatment team. On the 25 April 2022 she was discharged back to the care of the general practitioner. She was not assessed by a doctor in the home treatment team before her discharge and she did not receive a comprehensive risk assessment in the days leading up to her discharge. Whilst such assessments and reviews should have taken place, it is not possible to conclude that they would have prevented her death. It is noted that there were no documented concerns about her mental health between the 26 April and the 6 May 2022. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. Mrs Robinson did not receive a medical review by a doctor within the Home Treatment Team prior to her discharge back to the care of her GP on the 25th April 2022. 2. Mrs Robinson did not receive a comprehensive risk assessment prior to her discharge from the Home Treatment Team on the 25th April 2022. 3. There was no multi-disciplinary team discussion to ensure a safe community plan following discharge from the Home Treatment Team. There was no communication with regard to the withdrawal of the Home Treatment Team’s input, with the domiciliary care agency or family of Mrs Robinson. | On the 19th May 2022 I commenced an investigation into the death of Carol Ann Robinson age 70 years. The investigation concluded at the end of the inquest on 22nd March 2023. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 May 2023 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 29/03/2023 | 2023-0110 | Rebecca Kirby | Miss Lorraine Harris | East Riding of Yorkshire and Kingston-upon-Hull | Prevention of Future Deaths | Road (Highways Safety) related deaths | https://www.judiciary.uk/prevention-of-future-death-reports/rebecca-kirby-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Rebecca-Kirby-Prevention-of-future-deaths-report-2023-0110_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0110-Response-from-Hackney-Carriage-Association.pdf | Miss Kirby was out socialising with friends. She had consumed alcohol and was in an area of Hull known for its night time economy. She became separated from her friends and after looking in one location crossed a road. She misjudged the crossing and despite seeing the vehicle still attempted to cross the road. When struck by the car she landed on her head causing catastrophic injuries. Police witnessed the incident and were immediately on scene. Throughout the advanced life support she remained in cardiac arrest, without a pulse or signs of breathing. She was conveyed to Hull Royal Infirmary where CPR was ceased and she was declared dead. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1) On a Friday and Saturday night the Lowgate area of Hull city is exceptionally busy with people enjoying the night time economy. As such many are in drink. The area of Lowgate is open to traffic, it is also the location of a taxi rank. There is only one crossing facility (aside from at either end of the road), the road narrows significantly at one end. (2) Police raised concerns as follows: – The road remaining open during a Friday and Saturday night. – The number of pedestrians using the area. – Many people in drink in the area having to cross the road. – The road is a 30 mph. – Lights of vehicles are distracting – The location of the taxi rank, pedestrians having to navigate around the parked taxis, some with lights on, to enter the road. Taxis do 3 point turns in the road and any vehicle doing this is a danger to pedestrians. (3) Evidence was heard one doorman working in the area who stated “Having worked at the same location for some time, the area where the bars are on Lowgate is an accident waiting to happen. Members of the public are leaving the bars in a drunken state and they just wander into the road to cross, many of them not even looking for traffic on the road. Some vehicles travel down Lowgate far too fast given the evening activity” and another doorman stated “the road and both the footpaths at the location of the collision occurred on Lowgate are both very narrow. There is also a taxi rank outside O’Leary’s which doesn’t help as taxis were parked there at the time of the collision. I have seen numerous near misses over the years I have worked in the area. It is no exaggeration to say that there are between six to twelve incidents each night between cars and pedestrians, one thing which does not help and is also dangerous are taxis which do U turns in the road once they have collected their fare”. (4) The police had previously made recommendations and further felt that closing Lowgate to all through traffic on a Friday and Saturday evening, making Lowgate a total no stopping zone on an evening between certain hours, moving the location of a taxi rank onto nearby Alfred Gelder Street. (5) I note the statement from the local authority listed – They have erected 2 speed signs since the incident. Bearing in mind that this incident occurred with a vehicle travelling well within the limits, traffic is the concern not limited to the speed of vehicles. – The council was looking at developing a document that reviewed speed limits for the whole of the city centre. Lowgate has a special reason for being an area of concern and should be looked at as a priority and not in conjunction with all other city centre streets. – That engagement with the councils public transport department has commenced with the intention to relocate the taxi rank to Alfred Gelder street “but this requires consultation with the Hackney Carriage Association”. No indication was given regarding what was being done to facilitate this. – The council say that there are no resources to manage the road closure, despite acknowledging it is their responsibility. The fact the road is open at this time is a danger and I am concerned given the comments of the doormen that the danger is being underestimated. – Crossing facilities had been looked at but could not be positioned within a suitable distance. (6) I am concerned that inappropriate weight has been given to the danger arising in this area and that without appropriate action further incidents will occur. | On 2nd September 2021 I commenced an investigation into the death of Rebecca Lisa KIRBY, aged 31 years. The investigation concluded at the end of the inquest on 29th March 2023. The conclusion of the inquest was Road Traffic Incident. Box 3 of the record of inquest read: On the evening of 27th August 2021 Rebecca Lisa KIRBY was out socialising. She misjudged the traffic on Lowgate, Hull and ran in to the path of an oncoming vehicle. The vehicle was travelling at 23 miles per hour however the way Ms Kirby landed resulted in significant head injuries, causing her to become immediate unresponsive. Despite many people coming to her aid to offer advanced life support, she remained in cardiac arrest. She was transported to Hull Royal Infirmary where she was declared deceased. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th May 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 29/03/2023 | 2023-0109 | Angela Kearn | Miss Caroline Topping | Surrey | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/angela-kearn-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Angela-Kearn-Prevention-of-future-deaths-report-2023-0109_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0109-Response-from-General-Medical-Council-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0109-Response-from-National-Trading-Standards.pdf | i.) Angela Kearn was aged 63 when she died. She had recently been diagnosed with hypertension which was being treated with atenolol. She was also taking hormone replacement therapy. ii.) For the previous 5 years she had been using a Decathlon Easybreath full face snorkel mask when on holiday. iii.) On the 13th January 2020 she was snorkelling using the full face mask when she expressed concerns and was accompanied back to the beach. She collapsed and died. iv.) Expert evidence at the inquest identified immersion pulmonary oedema as the cause of the death. This is caused by the build-up of fluid in the lungs as a result of an increase in pulmonary capillary pressure caused by water pressure when the chest is submerged. This is exacerbated by hypertension and hormone replacement therapy. Negative pressure in the lungs causes fluid from the blood vessels to be drawn into the lungs. v.) The use of a full face snorkel mask contributed to the death in two ways: a.) because negative pressure in the lungs is increased as a result of the increased effort of breathing caused by inhalation through the snorkel tube and mask, and b.) because respiratory effort is increased by the inhalation of elevated carbon dioxide levels caused by inhaling air drawn through a dead space in the mask. Both exacerbate the negative pressure in the lungs and increase the effects of immersion pulmonary oedema. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Awareness of Immersion Pulmonary Oedema in the medical profession: i.) Concerns were raised by the medical witnesses that there is very little awareness of Immersion Pulmonary Oedema in the medical profession and that it is not addressed in medical training, as a consequence, it can be missed by those treating the condition and is often mistaken for drowning. The Full Face Mask ii.) At the time that the Easybreath full face snorkel mask was developed by Decathlon there were no United Kingdom or European Standards which were applicable to a full face snorkelling mask. iii.) In the course of its development, Decathlon commissioned a number of tests to be undertaken on it, but it was accepted in evidence that the tests undertaken did not replicate the conditions of the use of the mask by the general public. iv.) Decathlon have sold over 16 million of the masks. Other such masks are also on the market. v.) The Decathlon usage instructions for the full face mask, contained in small print, have been amended over time. From the 17th August 2015 the instructions included a warning that you must make sure that you are in good physical condition before snorkelling and that the mask is not suitable for swimming. vi.) Further tests were undertaken and an Ergomedical report considered the issue of whether use of the mask and inhalation through the mask’s dead space gave rise to excess carbon dioxide inhalation. The report concluded “we strongly recommend to advise against wearing Easybreath masks to people who suffer from underlying cardio-respiratory conditions.” vii.) As a result, Decathlon amended their instructions for use to include that the mask should not be used if the user has unstable cardio-respiratory pathologies, that the mask is to be used under conditions of submaximal exercise (mild to moderate) and that it is not suitable for active swimming. viii.) Development of a United Kingdom standard in relation to this type of mask is now being put in train but has not yet begun and is likely to take some time. ix.) Decathlon have recently updated their website in the United Kingdom to include the following, “It is not recommended to use this product if you have any ongoing respiratory or cardiovascular issues including but not limited to chest infection, asthma, high/raised blood pressure (hypertension), heart disease or angina etc. If you have any doubts or questions relating to this please check with your medical practitioner.” The same additional wording is being translated and added to all websites of the company. x.) The packaging of the mask has been revised to show a pictogram to warn against use of the mask by those with heart or other cardiovascular conditions. xi.) The concern is that many million of the full face masks have been sold and the safety concerns about their use by those with ongoing cardiovascular and respiratory issues has not been widely publicised or brought to the attention of those who already own the masks. Those purchased before 2017 had no warning is relation to these matters and the warning included in the instructions from 2017 inwards was not prominent nor sufficient to alert prospective purchasers to the hazards of use which have now been identified. | Following an investigation opened on the 2nd March 2020 and an inquest opened on the 5th March 2020 the inquest was concluded on the 20th December 2022. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 9th May 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 28/03/2023 | 2023-0108 | Louis Rogers | Dr Karen Henderson | Surrey | Child Death (from 2015) | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/louis-rogers-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Louis-Rogers-Prevention-of-future-deaths-report-2023-0108_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0108-Response-from-Emergency-Care-Committee.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0108-Response-from-Association-of-Ambulance-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0108-Response-from-NICE.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0108-Response-from-NHS-England.pdf | 1. Louis was born fit and well on 1st August 2019. On the 20th September 2020 he had a short self-limiting seizure whilst having a mild cold like illness. He was admitted to St Peters Hospital, Chertsey (SPH) for further assessment and discharged later that day having fully recovered. 2. Louis remained well until the morning of 11th February 2021 when he had a second self-limiting seizure. He was again taken to St Peters Hospital, Chertsey for observation and discharged later that day after being reviewed by a consultant paediatrician. 3. However, shortly after discharge, Louis had a further seizure in the early evening 17.00 hours of 11th February 2021. The emergency services attended and after a period of observation, Louis remained at home. 4. On 1st May 2021 Louis attended the Emergency Department at St Peters Hospital accompanied by his father over concerns of a 1 day history of being lethargic, clingy and wobbly on his feet following a minor head injury 5 days prior. Louis was discharged after observations were normal and no abnormalities, including neurological deficits, were found. | 1. Management and investigation of Febrile Seizures Evidence was heard that a number of children who have ‘febrile’ seizures subsequently die from ‘sudden unexpected death in childhood’. Evidence was provided that there should be greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures. Further evidence was heard that referrals for assessment and investigation of febrile seizures should be undertaken earlier to exclude a more severe underlying illness. 2. Information provided to parents/guardians after their child had a Febrile Seizure Evidence was heard that the NHS website and pamphlet provided to parents/guardians following a child’s febrile seizure is insufficiently informative to provide parents with sufficiently detailed information to assist them in picking up potential early indicators of a more severe illness e.g. issues with gait, co-ordination, definition of complex seizures, developmental regression etc. 3. Improvement to and highlighting of the JRCALC guidelines for paramedic management of seizures in children JRCALC guidelines indicated paramedics should have conveyed Louis to hospital or contacted the GP and/or Out of Hours GP service following Louis’s second seizure on 11th February 2020, as the close proximity of two seizures indicated it was a ‘complex febrile seizure’ rather than a febrile seizure. This led to a lost opportunity to expeditiously trigger further investigation and/or a referral to either the ‘first seizure’ service or to a specialist paediatrician for further assessment and management. Evidence was heard that improving and highlighting JRCALC guidelines with additional teaching would prevent this happening again. | On 8th February 2022 I recommenced an investigation into the death of Louis James Rogers. On 2nd February 2023 I concluded the Investigation. | In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one have the power to take such action. | You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. | |
| 27/03/2023 | 2023-0107 | Aoife McAdam | Mr Oliver Robert Longstaff | Yorkshire West Eastern | Alcohol, drug and medication related deaths | Prevention of Future Deaths | Burton Croft Surgery | https://www.judiciary.uk/prevention-of-future-death-reports/aoife-mcadam-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Aoife-McAdam-Prevention-of-future-deaths-report-2023-0107_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0107-Response-from-Burton-Croft-Surgery.pdf | Aoife died on 4th September 2021 in Leeds General Infirmary where she had been brought at 0823 hours having taken a significant overdose of propranolol at about 0430 hours. She rang the Crisis Team and NHS 111 within 30 minutes of taking the overdose. There were two opportunities missed to send her an ambulance sooner which would on the balance of probabilities have meant her reaching hospital at least two hours earlier than she eventually did. | During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 13th September 2021 I commenced an investigation into the death of Aoife Rose McAdam, aged 19. The investigation concluded at the end of the Inquest on 24th March 2023. The conclusion of the Inquest was that Aoife’s death was a misadventure. | In my opinion action should be taken to prevent future deaths and I believe Burton Croft Surgery (“your organisation” for the purposes of this report) has the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 24th May 2023. I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] |
| 27/03/2023 | 2023-0106 | Kayleigh Burns | Mr S. McGovern | Warwickshire | Alcohol, drug and medication related deaths | Child Death (from 2015) | Prevention of Future Deaths | Ministry for Justice | https://www.judiciary.uk/prevention-of-future-death-reports/kayleigh-burns-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Kayleigh-Burns-Prevention-of-future-deaths-report-2023-0106_Published.pdf | Miss Burns was 16 years old and suffered from asthma. On the 3rd June 2022, Kayleigh visited a friend’s flat in Stratford upon Avon. Whilst there she ingested the contents of a number of nitrous oxide cannisters. She started to wheeze and used her blue inhaler. She declined an ambulance and collapsed as she was going outside to get air. An ambulance was called and her friend performed CPR. She was resuscitated but died the next day at University Hospital Coventry & Warwickshire. The medical cause of death was inhalation of Nitrous Oxide compounding Asthma. I concluded that her death was drug related (ie inhalation of Nitrous Oxide) in the context of Asthma. | During the inquest, the evidence and information revealed matters giving rise to concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In the circumstances, it is my statutory duty to report to you. | On 17 June 2022, I commenced an investigation into the death of Miss Kayleigh Burns. The investigation concluded at the end of the inquest on 24th March 2023 at Warwick Coroners Court. The medical cause of death was confirmed as 1a inhalation of Nitrous Oxide compounding Asthma. | In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 22nd May 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. [HYPERLINKS] | |
| 24/07/2017 | 2023-0105 | Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi | Mr Alan R Craze | East Sussex | Other related deaths | Prevention of Future Deaths | Various | https://www.judiciary.uk/prevention-of-future-death-reports/gustavo-da-cruz-mohit-dupar-inthushan-sriskantharasa-gurushanth-srithavarajah-kenugen-saththiyanathan-kobikanthan-saththiyanathan-and-nitharsan-ravi-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/East-Sussex-Prevention-of-future-deaths-report-2023-0105_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0105-Response-from-Rother-District-Council-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0105-Response-from-Department-for-Transport-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0105-Response-from-Royal-National-Lifeboat-Institution-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0105-Response-from-RoSPA.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0105-Response-from-National-Water-Safety-Forum-.pdf | On 24th of June 2016 Mr. Da Cruz and Mr. Dupar went into the sea at Camber Sands, Rye. Mr. Da Cruz was seen to be in difficulties and his body was later washed up on the shore. Mr. Dupar was seen to be in difficulties and was brought to the beach unconscious. He had suffered from hypoxic brain damage and died at Ashford Hospital, Kent on the 28th of July. The other five deceased were all part of a party of five young Sri Lankan men who travelled together to Camber to enjoy a day at the beach on 24t of August 2016. They all went into the sea at a time when the tide had started to come in. It is not known how well any of them could swim. It is thought that they were all on a sand bar when they were overtaken and cut off by the incoming tide. All five bodies were recovered to the shore that day, or found after the tide had receded. The RNLI had recommended deploying lifeguards at the beach in 2013 but Rother District Council had not implemented that recommendation. It was accepted quite quickly after these deaths and lifeguards are now deployed. There was considerable evidence at the inquest on the question of whether that step, and others recommended, would have prevented any of the deaths. It should be noted that the length of the beach from which people can swim is about three miles and the distance between high water mark and low water mark is as much as a kilometre in some tides. | During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 24th of July 2016 I commenced an investigation into the death of GUSTAVO SILVA DA CRUZ. On 29th of July 2016 I opened an investigation into the death of MOHIT DUPAR. On 25th of August 2016 I opened investigations into the deaths of INTHUSHAN SRISKANTHARASA, GURUSHANTH SRITHAVARAJAH, KENUGEN SATHTHIYANATHAN, KOBIKANTHAN SATHTHIYANATHAN and NITHARSAN RAVI. | In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by the 18 September 2017. I, the Coroner, may extend this period. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 26/03/2023 | 2023-0104 | Jordan Clare | Mr Adrian John Farrow | Greater Manchester South | Alcohol, drug and medication related deaths | Other related deaths | Prevention of Future Deaths | Suicide (from 2015) | https://www.judiciary.uk/prevention-of-future-death-reports/jordan-clare-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Jordan-Clare-Prevention-of-future-deaths-report-2023-0104_Published-.pdf | Mr Clare had diagnoses of ADHD, attachment and conduct disorder and suffered from anxiety and depression. He had historically been addicted to Class A drugs and this led him into conflict with the criminal law and with his family which had resulted in a restraining order which restricted contact with his family and periods in custody. He had significant support from a number of sources: he was supervised by the probation service and the police “Spotlight” team; he was working with Mosaic – an organisation who assist with drug misuse; the local authority Leaving Care team provided assistance on a voluntary basis as he was over 21 years old. The local authority housing organisation provided him with the tenancy of a flat in Marple and as part of that tenancy, he had an Offender Support Worker who assisted him. He had regular contact with his General Practitioner. | During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 1st September 2020, an investigation was commenced into the death of Jordan Peter Clare, aged 22 years. The investigation concluded at the end of the Inquest on 14th October 2022. The conclusion of the inquest was misadventure in that that he died of hypoxic brain injury as a result of suspension by a ligature in a state of distress at an unresolved housing issue. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st May 2023, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | ||
| 23/03/2023 | 2023-0103 | Benjamin Nelson-Roux | Mr Jonathan Richard Heath | North Yorkshire and York | Child Death (from 2015) | Other related deaths | Prevention of Future Deaths | https://www.judiciary.uk/prevention-of-future-death-reports/benjamin-nelson-roux-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Benjamin-Nelson-Roux-Prevention-of-future-deaths-report-2023-0103_Published-.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0103-Response-from-North-Yorkshire-Council.pdf | Ben Nelson Roux was 16 years of age and a Child in Need. He was a regular user of alcohol and drugs of abuse which impacted on his relationship with his family, his offending behaviour (he was a victim of child criminal exploitation) and his physical and mental health. He became homeless and was placed in an adult hostel as there was no other suitable accommodation in the County he lived in at the time. He was found deceased on the 8 April 2020. He had taken multiple drugs of abuse prior to his death the impact of which could not be determined with any degree of confidence. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 14 April 2020 I commenced an investigation into the death of Benjamin NELSON-ROUX aged 16. The investigation concluded at the end of the inquest on 13 March 2023. The conclusion of the inquest was a narrative: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by May 18, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 24/03/2023 | 2023-0102 | Richard Hill | Mr Peter Nieto | Derby and Derbyshire | Alcohol, drug and medication related deaths | Prevention of Future Deaths | Rugby Football Union | https://www.judiciary.uk/prevention-of-future-death-reports/richard-hill-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Richard-Hill-Prevention-of-future-deaths-report-2023-0102_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0102-Response-from-Rugby-Football-Union.pdf | Richard died on 30 April 2022 at a sports and recreation club where his rugby club was holding its annual awards ceremony. Richard had been drinking alcohol all day and at the event and by 21:23 when he collected his trophy he was clearly showing the effects of alcohol inebriation and this was apparent to people at the event, including club members. About thirty minutes later he was unable to walk and had reduced responsiveness and he had to be carried to an outside bench. When it was realised that he was possibly critically unwell an ambulance was called, although medically trained attendees at the club event had started to provide resuscitative interventions, including use of a defibrillator which identified there was no shockable rhythm. Paramedics attended but intensive resuscitation was sadly unable to revive Richard and he was pronounced dead at the scene. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 10 May 2022 I commenced an investigation into the death of Richard James HILL, referred to as Richard for the purposes of the inquest, aged 24. The investigation concluded at the end of the inquest on 13 March 2023. The conclusion of the inquest was that Richard’s death was alcohol related. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by May 19, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 23/03/2023 | 2023-0101 | Jade Revell | Sarah Huntbach | Derby and Derbyshire | Other related deaths | Prevention of Future Deaths | TPP LTD | https://www.judiciary.uk/prevention-of-future-death-reports/jade-revell-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Jade-Revell-Prevention-of-future-deaths-report-2023-0101_Published.pdf | Jade Revell died from a sudden cardiac event. A missed opportunity to treat hypokalaemia shown in blood results on 27 October 2021 has more than minimally contributed to the cause of the sudden cardiac event. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 05 January 2022 I commenced an investigation into the death of Jade Paula REVELL aged 30. The investigation concluded at the end of the inquest on 22 March 2023. The conclusion of the inquest was that: | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by May 17, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 22/03/2023 | 2023-0100 | Kenneth Adams | Mr Brendan Joseph Allen | Dorset | Emergency services related deaths (2019 onwards) | Prevention of Future Deaths | International Academics of Emergency Dispatch | https://www.judiciary.uk/prevention-of-future-death-reports/kenneth-adams-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Kenneth-Adams-Prevention-of-future-deaths-report-2023-0100_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0110-Response-from-Hull-City-Council.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0100-Response-from-International-Academics-of-Emergency-Dispatch.pdf | At approximately 3.30am on 19th October 2021, Kenneth Michael Adams, who was prescribed clopidogrel and who lived alone at 60 Vernons Court in Bridport, which is supported housing provided by a housing association, suffered an accidental fall from a standing height, which resulted in a laceration to his scalp. At 4.06 am Mr Adams contacted the ambulance service to explain that he had fallen, injured his scalp and that he could not stop the bleeding. Mr Adams’ call was triaged using the Medical Priority Despatch System, which resulted in a disposition of 17-b-01: fall possible dangerous area. This translated to a category 3 ambulance response. The national target set by the Department of Health is to attend category 3 incidents within 120 minutes on at least 90% of occasions (so by 6.13 am), with an average response time of 60 minutes (by 5.13am). At the time of this call, Mr Adams appeared well with no additional symptoms. Mr Adams had also activated his careline, which is an element of the support provided by the housing association. At 7.53 an operator from the careline contacted Mr Adams to check on his welfare. Mr Adams reported that he was now feeling sick, that he was wobbly when stood up and that his bleeding was continuing. The careline operator contacted the ambulance service and advised of the new symptoms. A further triage was conducted, with the same disposition of fall, possibly dangerous area being reached, as the algorithm being used failed to account for the persistent nature of the bleeding being experienced and that Mr Adams was prescribed clopidogrel. At 10.25 Mr Adams again spoke to a careline operator. He was by now slurring his words and his speech was noticeably slow. It is likely he was experiencing symptoms associated with hypovolaemic shock. If Mr Adams had received treatment by 10.25, he would have survived the injury he had sustained. The first ambulance resource arrived at Mr Adams’ property at 11.56, by which time a neighbour had found Mr Adams when Mr Adams had called for his help. Mr Adams was conveyed to Dorset County Hospital, where despite treatment he died on 19th October 2021. | The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. A patient, prescribed either antiplatelet or anticoagulant medication, falling and sustaining a scalp laceration that is not “spurting or pouring blood” (the MPDS definition of “uncontrolled bleeding”), will never reach an MPDS disposition that results in a prioritisation higher than category 3, regardless of how long the bleeding has been persisting, unless the patient becomes unconscious or stops breathing. I heard evidence that the scalp is an area of high venous blood flow, such that a laceration to the scalp is capable of bleeding significantly. However, because of the nature of the blood supply in this area, the wound will not “spurt or pour” blood, so with the current iteration of MPDS a wound in this area of the body can never be considered as “serious haemorrhage”. Despite this, when assessing the seriousness of a bleed that does not meet the criteria for a “serious haemorrhage”, the MPDS algorithm does not allow for consideration of any delay in treatment or for the consideration of medications that may either exacerbate the extent of a bleed or prevent the blood from clotting to stop the bleed. For a patient such as Mr Adams, prescribed antiplatelet medication, there is a considerable risk that the bleeding will persist until the wound is closed, such that a delay in receiving treatment, where the wound continues to bleed, leaves the patient at risk of developing hypovolaemic shock. | On the 5th November 2021, an investigation was commenced into the death of Kenneth Michael Adams, born on the 2l5t August 1951. The investigation concluded at the end of the Inquest on the 9th March 2023. | In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, 17th May 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 22/03/2023 | 2023-0099 | Ben Harrison | Katie Sutherland | North Wales (East & Central) | Prevention of Future Deaths | Suicide (from 2015) | Wales prevention of future deaths reports (2019 onwards) | Betsi Cadwaladr University Health Board BCUHB | https://www.judiciary.uk/prevention-of-future-death-reports/ben-harrison-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Ben-Harrison-Prevention-of-future-deaths-report-2023-0099_Published.pdf | The circumstances of the death are as follows : Ben was aged 37 at the time of his death on 18 December 2020. He had known psychiatric issues. On 15 December 2020 and whilst a voluntary inpatient at the Ablett Psychiatric Unit, Glan Clwyd Hospital he was found in cardiac arrest with a ligature around his neck, [REDACTED]. He was resuscitated and oxygen cylinder utilised. The cylinder has two valves, both of which have to be opened before the cylinder will function. The valve on the side of the cylinder was not opened and so Ben was ventilated only on room air. Ben was transferred to Intensive Care Unit and died 3 days later. | During the course of the Pre-Inquest hearing , the evidence revealed matters giving rise to concerns. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 21 December 2020 an investigation was commenced into the death of Ben Christopher Harrison following his death on 18 December 2020. | In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely 10 May 2023. I, Kate Sutherland, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. | |
| 30/08/2022 | 2023-0098 | Jennifer Davies | Ms Penelope Schofield | West Sussex, Brighton and Hove | Prevention of Future Deaths | Road (Highways Safety) related deaths | Department for Transport | https://www.judiciary.uk/prevention-of-future-death-reports/jennifer-davies-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Jennifer-Davies-Prevention-of-future-deaths-report-2023-0099_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0099-Response-from-Department-for-Transport-.pdf | On 21st May 2020 Mrs Davies was struck by a parcel delivery service vehicle when crossing the road in front of the junction with Dyke Road at the Seven Dials Roundabout in Brighton. She was knocked to the ground and sustained a serious head injury. She was taken to Hospital but despite treatment she did not recover from her injuries, and she sadly died on 23rd May 2020. | During the investigation, my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 26th May 2020, the then Senior Coroner Veronica HAMILTON-DEELEY commenced an investigation into the death of Jennifer Lilian Davies aged sixty-nine. | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by 30th October 2022 I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 14/03/2023 | 2023-0097 | Nicola Norman | Dr Fiona Jane Wilcox | London Inner West | Prevention of Future Deaths | Suicide (from 2015) | Central & North West London NHS Foundation Trust | https://www.judiciary.uk/prevention-of-future-death-reports/nicola-norman-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Nicola-Norman-Prevention-of-future-deaths-report-2023-0097_Published.pdf | On the 27th April 2021, 22nd and 23rd November 2022, evidence was heard touching the death of Nicola Norman. She had died on 20th January 2020, aged 42 years. | In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. It is for each addressee to respond to matters relevant to them. | You are under a duty to respond to this report within 56 days of the date of this report. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013. | |||
| 17/03/2023 | 2023-0096 | Benjamin Teague | Mrs Anne Pember | Northamptonshire | Prevention of Future Deaths | Road (Highways Safety) related deaths | The Chief Executive of National Highways | https://www.judiciary.uk/prevention-of-future-death-reports/benjamin-teague-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Benjamin-Teague-Prevention-of-future-deaths-report-2023-0096_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0096-Response-from-National-Highways.pdf | On the evening of 2nd August 2021, Benjamin Teague drove his BMW car on the A5 between Potterspury and Paulerspury. He overtook a vehicle, crossed to his incorrect side of the road where he collided head on with an approaching car. He was confirmed deceased at the scene. My conclusion was Road Traffic Collision | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. | On 11 August 2021 I commenced an investigation into the death of Benjamin James TEAGUE aged 26. The investigation concluded at the end of the inquest on 08 March 2023. The conclusion of the inquest was: 1a Head Injury | In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. | You are under a duty to respond to this report within 56 days of the date of this report, namely by May 11, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. | I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 16/03/2023 | 2023-0095 | Rachael Walker | Mr Peter Nieto | Derby and Derbyshire | Hospital Death (Clinical Procedures and medical management) related deaths | Prevention of Future Deaths | The University Hospitals of Derby and Burton NHS FT | https://www.judiciary.uk/prevention-of-future-death-reports/rachael-walker-prevention-of-future-deaths-report/ | https://www.judiciary.uk/wp-content/uploads/2023/03/Rachael-Walker-Prevention-of-future-deaths-report-2023-0095_Published.pdf | https://www.judiciary.uk/wp-content/uploads/2023/03/2023-0095-Response-from-Royal-Derby-Hospital.pdf | Rachael Walker, known as Chloe, died in hospital on 19 June 2021 due to experiencing a placental haemorrhage and amniotic fluid embolism at the thirty seventh week of her pregnancy. Chloe had been diagnosed with placenta previa during her antenatal care. | During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: My principal concern is that having heard evidence from the Trust as to ‘lessons learnt’ and its current processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, I remain unclear that the Trust now has sufficiently robust processes in place to prevent similarly avoidable deaths to that of Chloe. Indeed, I am unclear that the processes are substantively different to those that existed at the time of Chloe’s death. It was of very particular concern to hear that clinicians at the time were aware of revised national pregnancy guidance issued in September 2018 but this had not been incorporated into Trust policy and guidance. I was told that introducing revised guidance was necessarily complex and lengthy and yet the Trust did incorporate the revised guidance just several weeks following Chloe’s death and it appears because of her death. It was also very concerning to hear that the Trust had established a regional pregnancy service using out of date guidance. Certain changes relating to the circumstances of Chloe’s death have only very recently been addressed or are in process; for example, the procedure to call and respond to a major maternal haemorrhage was to be tested a week or two after the inquest. I therefore consider that the Trust should review its processes for identifying when Trust clinical policies and guidance needs updating, and where essential equipment needs to be obtained and located, in the inte |