Inquests (PFDs)

10/12/2024

2024-0679

Peter McCarthy

Surrey

[REDACTED], Registered Manager Care4U- Surrey and Director of Care4U Healthcare

An Investigation was commenced on the Eleventh December 2023, and an Inquest opened on the Fourteenth December 2023, into the death of Peter McCarthy. The� Inquest concluded on the Ninth October 2024.�� Peter McCarthy died on the 30th November 2023 from heart failure and pneumonia. The conclusion was that he died by Accident.

Peter McCarthy fell from his wheelchair at home on the evening of the 25th November� 2023 when his wheelchair flipped over a slight ridge between the bathroom and corridor.� He was not found until the following morning by his carer. She called an ambulance. She left the premises. Shortly thereafter a district nurse attended and made a further call to the ambulance which resulted in a quicker categorisation of the response. He was taken by� ambulance to East Surrey Hospital and found to have sustained rib fractures and a� subdural hematoma. He was given appropriate care, but he deteriorated and died on the� 30th November 2023 from heart failure and pneumonia.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� [REDACTED] The Care Quality Commission I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� I may also send a copy of your response to any other person who I believe may find it useful or of interest.� The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Community health care and emergency services related deaths

Care4U Healthcare

06/02/2024

2024-0361

Paula Elsley

Berkshire

[REDACTED], Ringmead Medical Practice

On 11 April 2022 I commenced an investigation into the death of Paula Elizabeth ELSLEY aged 54. The investigation concluded at the end of the inquest on 06 February 2024. The conclusion of the inquest was that: � On the 28th March 2022 Paula Elizabeth Elsley died at her home address in Birch Hill, Bracknell. She was suffering from undiagnosed lung cancer with a metastatic tumour in her brain. This secondary tumour itself lead to the formation of an abscess which caused her death.

On the 9th December 2021 Paula spoke to a GP on the phone reporting an ongoing cough. She had previously reported a shortness of breath in November 2021 which improved with antibiotics. She had also reported left leg pain and her leg giving way in the same month. Paula was not assesed further on this occasion and given worsening advice. � On the 5th January 2022 Paula spoke to a GP reporting a new chest pain. She was not assessed further and given worsening advice. On the 17th February 2022 she spoke to another GP reporting back and leg pains. She was offered an assessment at the musculoskeletal clinic but declined. Paula had visited an osteopath on the 8th February and did so again on the 21st February. � On the 25th February 2022 she reported to a GP that she had almost collapsed and that her legs had felt like jelly. The GP was concerned by these symptoms and booked her for a face to face assessment on the 1st March 2022. � On the 4th March 2022 Paula attended the emergency department with left leg weakness, new left arm weakness and intermittent headaches. She was admitted for further investigations but decided to leave prior to these being completed. An outpatient MRI was arranged. � On the 16th March 2022 she returned to the emergency department due to the severity of her headaches which were causing her to black out. She was not admitted on this occasion and was due to attend her MRI on the 27th March 2022. She did not make this scan due to circumstances beyond her control. � Paula was found unresponsive at home on the 28th March 2022 and declared deceased. A post-mortem examination revealed a primary lung tumour with abscess formation and a brain abscess. The brain abscess was likely the result of a secondary brain tumour.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] [REDACTED] �[REDACTED] Frimley Health NHS Foundation Trust � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Ringmead Medical Group

15/05/2024

2024-0228

Gary Ash

East London

[REDACTED], Royal Colleges of Anaesthesia [REDACTED], Clinical Quality Department of Health and Social Care

On 28/09/2019 I commenced an investigation into the death of Gary David Ash (aged 62 years). The investigation concluded at the end of the inquest on the 22nd April 2024. The conclusion of the inquest was a narrative conclusion: � Mr Ash�s death was contributed to by an adverse drug reaction following a general anaesthetic that he was not correctly consented for, and by an over administration of fluid whilst in the critical care department.

Mr. Gary Ash suffered from long standing ulcerative colitis. In May 2019 he was referred to the two-week-wait surgical clinic, for anaemia and rectal bleeding. He was seen by a surgeon on 31 May 2019 who advised Mr. Ash that the necessary investigations could be carried out under a general anaesthetic. The Trust policy on seeking consent for a general anaesthetic was not followed. On the balance of probability, had Mr. Ash been carefully consented by an anaesthetist, he would have accepted deep sedation as an effective and safer form of anaesthesia. On the 24 June 2019, Mr. Ash underwent the necessary investigations and, in the absence of a valid consent, received a general anaesthetic. Very shortly after the procedure, he developed signs and symptoms of serotonin syndrome. Serotonin syndrome was not recognised by the treating clinicians and the diagnosis has now been made with the benefit of hindsight and the benefit of expert opinion. The primary differential diagnosis of neuroleptic malignant syndrome was made on 24 June 2019. Mr Ash was admitted to critical care on the evening of 24 June 2019. Due to excessive sweating, Mr. Ash was prescribed a large amount of intravenous fluids. These fluids were not carefully monitored and reviewed. The fluids were not reduced when the sweating decreased and the urine output was noted to be low. Additional boluses of fluids were administered by nursing staff, with no clear rationale. By 1230pm on the 25 June 2019, Mr. Ash had a positive fluid balance of 4.9L. This was recorded, but not acted upon as a red flag. The oxygen level in Mr Ash�s blood was decreasing and need for oxygen increasing on the morning of 25 June 2019. Dantrolene was administered to him as an intravenous infusion. This involved additional fluid administration and during the course of the Dantrolene infusion, Mr Ash suffered a cardiac arrest. It is likely that the cardiac arrest was caused by pulmonary oedema and resultant hypoxaemia. Mr. Ash passed away at Queen�s Hospital on the 25 June 2019

I have sent a copy of my report to the Chief Coroner and to the family of Gary David Ash, the Care Quality Commission, Barking, Havering and Redbridge University Hospitals Trust, MHRA and the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Royal Colleges of Anaesthetists | Department of Health and Social Care

29/07/2024

2024-0425

Lamarah Scarlett

Gloucestershire

[REDACTED], Secretary of State for Education, Sanctuary Buildings, Great Smith Street, London, SW1P 3BT [REDACTED], Director of Policy and Deputy Chief Executive at Local Government Association, 18 Smith Square, Westminster, London SW1P 3HZ [REDACTED], Traffic Commissioner for West of England, Jubilee House, Croydon Street, Bristol, BS5 0GB

On the 28 November 2022 I commenced an investigation into the death of Lamarah Grace Scarlett. The investigation concluded at the end of the inquest on the 5 June 2024. The conclusion of the inquest was a narrative conclusion. The medical cause of death was 1A Unascertained.

Lamarah Grace Scarlett �Lamarah� was a 12 year old girl who suffered with alternating hemiplegia of childhood (AHC) which is characterised by repeated episodes of weakness or paralysis. On the 24th September 2021 she had attended school. Lamarah had appeared happy and well during the day. At the end of the day Lamarah appeared to be tired. Staff did not feel she was presenting with any signs of a seizure or paralysis. At approximately 1500 hours she is secured in her wheelchair by staff and placed on a minibus to be transported to her home address. She is accompanied by a driver and a passenger assistant. During the journey Lamarah appears to be in distress, and is experiencing breathing difficulties. It is probable that Lamarah was suffering from a significant and profound episode of muscle weakness which made her unable to reposition her head to an upright position. Her head was in a hyper extended position, which caused her airway to become obstructed and led to her becoming acutely hypoxic. Neither the passenger assistant or the driver on the bus is aware of this. They do not raise the alarm or seek further assistance. If Lamarah�s head had been supported in an upright position and/ or if she had been placed in recovery position, it is likely that her airway would have opened up. However it remains unclear whether this would have enabled sufficient airflow to her lungs as she had significant truncal weakness. At approximately 15.45 hours Lamarah arrives at her home address in an unresponsive state. Her mother commences resuscitation efforts, and emergency services soon thereafter arrive. Despite extensive resuscitation efforts, Lamarah is pronounced deceased at 16.45 hours.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (1) [REDACTED], Senior Associate, HCC Solicitors, New London House, 6 London Street, London, EC3R 7AD (2) [REDACTED], DAC Beachcroft, Portwall Place, Portwall Lane, Bristol, BS1 9HS (3) [REDACTED], [REDACTED] (4) [REDACTED], SENT team, Gloucestershire County Council, Block 5, 6th Floor, Shire Hall, Westgate Street, Gloucester, GL1 2TG (5) [REDACTED], HCR Legal LLP, 62 Cornhill, London, EC3V 3NH I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015)� � This report is being sent to: Department for Education | Local Government Association | Traffic Commissioner for West of England

03/10/2024

2024-0525

John Turner

Manchester South

[REDACTED], Secretary of State for Health and Social Care

On 7th June 2024, I opened an inquest into the death of John Turner who died on 23rd August 2023 at Tameside General Hospital, Ashton-under-Lyne, aged 73 years. The investigation concluded with the inquest which I heard on 27th September 2024.� A post mortem examination determined Mr Turner died as a consequence of:� 1) a) Pulmonary Embolism;� 1) b) Deep Vein Thrombosis.� At the end of the inquest, I recorded a conclusion of Natural Causes contributed to by Neglect

Mr Turner died on 23rd August 2023 at Tameside General Hospital as a consequence of a Pulmonary� Embolism due to a Deep Vein Thrombosis, neither of which had been identified when he previously� presented at the hospital�s Emergency Department on 20th August 2023.�� Mr Turner first became unwell whilst on holiday in Greece and experienced a cough and following� his return home, progressive breathlessness. A course of oral antibiotics prescribed by a staff� member at the GP surgery did nothing to improve his symptoms, leading Mr Turner to attend the� Emergency Department where he was assessed and sent home without any further treatment in� circumstances where a D-Dimer test requested by the triage nurse was not undertaken

I have sent a copy of my report to the Chief Coroner and�[REDACTED] of Leigh Day & Co. on behalf of Mr Turner�s family, together with [REDACTED] of Weightmans LLP on behalf of the Trust.� I have also sent a copy to the Care Quality Commission, Tameside Metropolitan Borough Council,�NHS Greater Manchester Integrated Care Partnership and [REDACTED], Member of�Parliament for Ashton-under-Lyne, who may find it useful or of interest.�� I am also under a duty to send the Chief Coroner a copy of your response.��� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may� send a copy of this report to any person who he believes may find it useful or of interest. You may� make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care

07/10/2024

2024-0534

John Eyre

Mid Kent and Medway

[REDACTED], Secretary of State for Health and Social Care

On 30 November 2022 I commenced an investigation into the death of John Raymond EYRE. The investigation concluded at the end of the inquest . The conclusion of the inquest was� Natural causes� 1a Pneumonia 1b Liver Disease 1c 1d II

The deceased was a serving prisoner at HMP Swaleside and had been experiencing a� deterioration in his health in the latter part of his life. �� It was described at the inquest that there was a sudden deterioration in Mr Eyre�s presentation� in spring 2022 and mention of a possible lymphoma. It was clear from all of the medical� evidence that the clinicians who were treating Mr Eyre thought that lymphoma was the most� likely cause of the deterioration in his health. It appears that potential diagnosis was only� excluded shortly before his death.� �� During Mr Eyre�s deterioration it is apparent that tests were missed. It is also apparent that he� had neutropenic sepsis on more than one occasion. The inquest was not able to come to a� conclusion as to what was causing the neutropenic sepsis. �� �� As a result of Mr Eyre�s condition, he spent time as an inpatient at Medway Maritime Hospital. �� �� In October 2022, Mr Eyre was due to be discharged from hospital again to return to a custodial setting. The prison healthcare provider was adamant that his needs could not be met in the� custodial setting and was concerned that there were outstanding investigations to be� completed. A healthcare professional from the prison shared her concerns with staff in the� acute hospital. A junior doctor indicated that the concerns would be escalated to a Consultant� prior to discharge. That did not happen, instead, there was a telephone conference in which� the prison healthcare staff were challenged as to their approach. The responsible Consultant� gave evidence at the inquest that she had not been made aware of the concerns of the prison� healthcare provider. �� �� Mr Eyre was returned to prison. Shortly thereafter, he was readmitted to hospital by� ambulance having been found on the floor. �� �� In hospital, Mr Eyre�s health deteriorated and despite efforts at treatment, he died there on 20� November 2022.� �� The record of inquest states:� �� John Eyre was serving a custodial sentence at the time of his death, his health deteriorated in� 2022 and he was treated for recurrent sepsis. The root cause of the sepsis was not identified.� On 31 October 2022, John was readmitted back to Medway Maritime Hospital as his health� had deteriorated. Despite efforts as to ongoing investigations and treatment, John died at� Medway Maritime Hospital of pneumonia on 20 November 2022. At the time of John�s death� he had liver disease which had not been identified. �� �� The conclusion was a death by natural causes.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons in the� inquest. I have also sent it to the Prison and Probation Ombudsman who may find it useful or� of interest.� I am also under a duty to send the Chief Coroner a copy of your response.� The Chief Coroner may publish either or both in a complete or redacted or summary form. He� may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me, the coroner, at the time of your response, about the� release or the publication of your response by the Chief Coroner.

State Custody related deaths | Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care

10/12/2024

2024-0680

Charles Devos

Cornwall & the Isles of Scilly

[REDACTED], Secretary of State for Health and Social Care

On 20 July 2023 an investigation was commenced into the death of 54-year-old Charles George Edward Devos.� The investigation concluded at the end of the inquest on 2 December 2024. �� The medical cause of death was found as follows: 1a) Small bowel infarction The four statutory questions � who, when, where and how � were answered as follows: Charles George Edward Devos died on 9 January 2021 at [REDACTED] Cornwall from an acute bowel condition.�� Charles� death followed 999 calls by Charles� family at 22:55 hours and 23:47 hours on 8� January 2021 requesting an ambulance.� There was a delay in South West Ambulance�Service (SWAST) conducting a necessary clinical assessment to determine categorisation of priority.� This delay denied Charles an opportunity to obtain potentially lifesaving treatment at hospital.� Charles died at home on 9 January 2021 shortly after the arrival of paramedics.� This missed opportunity is attributable to the extreme operational pressures exerted upon� SWAST which was a direct result of the failure of the whole system of health and social� care which adversely influenced or delayed decisions made by SWAST.� � The conclusion of the inquest was as follows: Charles died from a treatable bowel condition following a missed opportunity to obtain� potentially lifesaving treatment.� This opportunity was missed due to extreme operational pressure on ambulance services following the failure of the system of health and social� care which was possibly causative of Charles� death.

1. Charles� family called 999 on 8th January 2021 at 22:55 hours requesting an emergency� ambulance.� Charles was reported to have vomited and was sweating in a hot and cold�fever, and in dreadful abdominal pain. The call was referred for clinical assessment in order� to determine categorisation of priority.� �� 2. There was a further 999 call at 23:47 from Charles� family due to the severity of his� symptoms.� 3. There was a conversation between call handler and a clinical adviser about whether to� upgrade the call for an emergency ambulance.� The clinical advisor was informed that�Charles was reported to have vomited and to be rolling around in pain and that Charles�could be heard by the call handler to be screaming in agony.� 4. The clinician decided the appropriate course of action was for clinical triage. Due to severe� operational pressure the clinician did not have time to conduct clinical assessment herself at that time. The 999 call was again referred for clinical assessment in order to determine� categorisation of priority.� 5. Clinical assessment was further delayed until a call back by a clinician at 03:15 hours on 9�January 2021.� 6. The court found that the reported symptoms at 23:47 likely necessitated the prioritization�of Charles� clinical triage which should have taken place at 23:47 or shortly thereafter.� 7. If triage had taken place at 23:47 or shortly thereafter it is possible that triage would have�led to an emergency ambulance being arranged.� This is because triage would have been� taking place at a time when Charles was still suffering the initial symptoms of acute bowel�ischemia.� 8. If an emergency ambulance had collected Charles in the early hours of 9 January, it is� probable that he would have received lifesaving treatment.� The sooner that he could have� been taken to hospital for surgery the likelier it is that he would have survived.� 9. The court found that the delay in clinical assessment amounted to a missed opportunity to� provide potentially curative surgery.� 10. By the time of the clinician call back at 0315, Charles� condition had worsened but the� presentation had altered so that it appeared to have improved. On the false belief of� improvement Charles agreed to self-convey to hospital but did not do so.�� 11. By the time Charles� family called again for an ambulance on the afternoon of 9 January it� was too late. His condition had deteriorated to such an extent that it was not survivable.� 12. Charles died at home shortly after the arrival of paramedics.� SYSTEMIC FAILURE IN 2021 13. The court heard that on 8th January 2021 the ambulance service lost 109 hours of� ambulance availability to handover delays at Royal Cornwall Hospital (RCHT). This excludes the 15-minute allowance for each handover. That is the equivalent to losing ten, 12-hour�ambulance shifts.� This led to significant delays in ambulance response times due to the� numbers of ambulances detained at hospital.� 14. As a consequence of handover delays there was a significant volume of unallocated� emergency calls to the ambulance service, awaiting ambulances, triage or assessments. �� 15. The court found that severe and extreme operational pressure on SWAST influenced or� delayed necessary decisions.�� 16. Reports from SWAST and the Health Services Safety Investigation Body (HSSIB) found a� strong correlation between handover delays and ambulance response delays.�� 17. The SWAST report stated:� �The investigation found that there is a direct link between patients waiting in the hospital for discharge to social care and patients being cared for inside� ambulances and Emergency Departments.� 18. The reports indicated a direct connection between ambulance delays and inadequate social and community care. This is because inadequacies in those services lead to delayed� discharges from hospital which lead to shortages of acute beds, impeded patient flow,� crowding in emergency departments (ED) and the inability of ambulances to handover� patients to ED.�� 19. There was no culpability on the part of SWAST call handlers or clinicians who were doing� their best to mitigate the risks created by the systemic failure.� 20. The organisations immediately required to deal with ambulance delays are ambulance� trusts and acute hospitals, In Cornwall that is SWAST and RCHT. These organisations do not� have control over the services primarily responsible for ambulance delays, namely social�and community care provision. They are unable to influence the whole-system and� therefore carry risks that they cannot wholly mitigate or manage.�� 21. The court noted the HSSIB report which states that delayed discharges (and consequent� ambulance delays) are a national issue which is attributed to a whole system failure of� health and social care. The court noted the HSSIB investigation�s first safety� recommendation is an urgent �whole system� response to reduce patient harm.� 22. The court found that the extreme and severe pressure on SWAST can be attributed to by a� systemic failure of the entire system of health and social care.� SYSTEMIC FAILURES IN 2024 23. Significant average handover delays at RCHT were recorded for every month of 2024 up the date of Inquest.� 24. SWAST witnesses stated that the average handover delays conceal spikes which exert�severe operational pressure. Such long delays increase the risk of mortality.� 25. The court heard evidence of extreme mitigating measures being deployed by SWAST and� other ambulance services across England and Wales seeking to reduce risks following� ambulance delays. The court discussed the hypothetical example of a patient with a� suspected heart attack facing a long ambulance delay.� The court heard that due to the risks associated with ambulance delays a number of mitigating measures would be pursued in� circumstances where ordinarily an emergency ambulance would be provided. These �included:� � Self-conveyance: recommending that the patient arrange for family or friends to�convey them to hospital with safety netting advice if the condition worsens� (namely pull over and call 999).� � Taxis: Arranging taxis to collect said patients if family or friends cannot assist.� � Unattended drop offs: Ambulance paramedics wheeling patients into emergency�departments on spare ambulance beds notwithstanding there being no available� bed for that patient in ED, and leaving the patient unattended by ambulance crews, in order to release ambulances to attend to other calls.

I have sent a copy of my report to the Chief Coroner and to Charles� family and SWAST. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may� make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards)

Department of Health and Social Care

03/10/2024

2024-0531

Kevin Woods

Cornwall and Isles of Scilly

[REDACTED], Secretary of State for Health and Social Care

On 19 January 2024 I commenced an investigation into the death of 64-year-old Kevin Woods. The investigation concluded at the end of the inquest on 30 September 2024.� The medical cause of death was found as follows: 1a. Hypertensive heart disease The four questions � who, when, where and how � were answered as follows: Kevin George WOODS died on 17 January 2024 at�[REDACTED] from complications of an undiagnosed heart condition following an�ambulance delay which denied Kevin the opportunity of potentially lifesaving� treatment. �� Kevin�s family made a 999-call requesting an ambulance at 22:24 hours on 16� January 2024, at which time Kevin was exhibiting clear symptoms of a heart�attack.� The ambulance service allocated Kevin a category 2 priority but there�were no ambulances available on that category.� Kevin went into cardiac arrest at 02:33 hours on 17 January 2024 and�subsequently became unresponsive.� The ambulance service re-categorised the call as category 1 and despatched an ambulance. �� A Paramedic Support Vehicle arrived at 02:44 hrs on 17 January 2024 whilst the� family were giving Kevin CPR.� The paramedics continued CPR but were unable to save Kevin�s life.� Kevin was pronounced deceased at the scene at 03:31 hrs that� day.� There was a response delay of 4 hours and 16 minutes from the original category�2 priority decision to the arrival of the paramedic support vehicle.� Kevin�s heart condition was possibly treatable, and the ambulance delay denied� him the opportunity of potentially lifesaving treatment. The ambulance delay was attributable to a systemic failure related to the whole system of health and social� care.� The narrative conclusion of the Inquest was as follows: � Kevin died from an undiagnosed and possibly treatable heart condition, following� an ambulance delay attributable to a systemic failure related to the whole system� of health and social care. The ambulance delay was possibly causative of death in that it denied Kevin potentially lifesaving treatment.

1. The findings of fact on how Kevin died are set out above in the answers to the four statutory questions.� � Systemic failure and Kevin�s death 2. The court made findings of fact upon the wider circumstances, namely the�systemic failure that was possibly causative of Kevin�s death.� 3. On the day the ambulance call was made there were considerable ambulance� delays. Whilst Kevin�s priority remained category 2, during the period from the� original 999 call to the onset of cardiac arrest (over four hours) there were no� ambulances available for Kevin.� 4. The national target set by the Department of Health is to attend Category 2� incidents within 40 minutes on at least 90% of occasions, with an average� response of 18 minutes.� Kevin waited over four hours and the reason the� ambulance then attended was because Kevin�s case was re-prioritised to Category 1 following the cardiac arrest.� 5. Data provided to the court suggested that on the 16th January 2024 some Category 2 calls were having to wait 6 hours for an ambulance.� 6. At approximately the time the ambulance call was made, 23:00 hours, there were�33 incidents awaiting allocation in Cornwall, including 20 that were Category 2. At� this time South West Ambulance Service Trust (SWAST) reported that all� ambulance resources were either responding to calls or delayed at hospitals (in the patient handover process). At the two main receiving hospitals for Cornwall, there� were 12 ambulances delayed at Plymouth hospital and 22 ambulances delayed at� Truro Royal Cornwall Hospital (RCHT).� At this time SWAST was 123% resourced� for anticipated demand in Cornwall, with a total of 45 ambulances available. This� means approximately half of the allocated ambulances for Cornwall were delayed�at RCHT.� 7. The court found that the hospital has regularly failed to meet the 4-hour target for� moving patients out of the Emergency Department (ED) during 2024. It was noted� that there is a recent major study which shows that the standardised mortality rate� starts to rise from 5 hours after the patient�s time of arrival at the ED and they� concluded that after 6�8 hours, there is one extra death for every 82 patients� delayed.� 8. The court found insufficient bed availability on acute wards was attributable to�an increase in patients with no reason to reside (NCTR), these being patients who�� are medically optimised but cannot be discharged due to lack of onward care�support.� 9. Approximately 80% of NCTR patients at RCHT are of that status for external� reasons beyond the control of RCHT. The main causes of external NCTR numbers� were found to be as follows:� a) Social care provision (whether commissioned by social services or NHS)� namely packages of care in the community, beds in nursing homes or� residential care homes� b) NHS primary healthcare support for discharge (in the home)� c) NHS community hospital provision� 10. The court found significant correlation between delayed discharges, handover� delays and delays in ambulance response times. On this basis, the court found�there was a direct connection between the ambulance delay and inadequate social care provision, community hospital provision and primary healthcare support.� 11. The connection between delayed discharges and ambulance delays and the�associated risks has been referred to in reports from Southwest Ambulance� Service Trust (SWAST) and the Health Services Safety Investigations Body� (HSSIB). The court found that the state knew or ought to know of the risks.� Current circumstances of systemic failure 12. The findings of fact upon current circumstances in relation to the systemic failure�were as follows.�� 13. There was found to be a direct connection between current ambulance delays and�inadequate social care provision, community hospital provision and primary� healthcare support on discharge. This is because inadequacies in those services� lead to delayed discharges from hospital which lead to shortages of acute beds,� impeded patient flow, crowding in ED and the inability of ambulances to handover� patients to ED.�� 14. Significant average handover delays at RCHT were recorded for every month of�2024. This is a picture reflected across the SW and indeed nationally.�� 15. The average handover delays conceal spikes such as that which led to the long�delay in this case. Such long delays increase the risk of mortality.�� 16. There are continuing delays of patients from ED which is evidenced by the ongoing failure to regularly meet the 4-hour standard. These delays increase the risk of� mortality. �� 17. Over the last year up to 16% of patients in RCHT have been of external NCTR� status, patients who meet the criteria for discharge but cannot be discharged for�reasons external to RCHT. �� 18. The court found that if the external NCTR numbers could be reduced, this would�significantly address current issues of ambulance delays, ED crowding, and the� shortage of acute beds. �� 19. The main drivers of external NCTR patients are inadequate social care provision,�community hospital provision and primary healthcare support on discharge.� 20.� The court noted the SWAST systems report which found�� ���.there is a direct link between patients waiting in the hospital for� discharge to social care and patients being cared for inside ambulances� and Emergency Departments.��� 21.� Approximately 10% of social care posts in Cornwall are currently vacant� notwithstanding Cornwall Council securing the agreement of social care providers�to pay the living wage. This reflects the national picture of 165,000 vacant social� care posts. �� 22. The extent of the obligation on local authorities is set out in the Care Act s5 �� A local authority must promote the efficient and effective operation of a�market in services for meeting care and support needs with a view to� ensuring [inter alia] �. a variety of high quality services to choose from��� 23. The NHS does not carry responsibility for the recruitment and retention of social�care staff or any broad obligation to promote the social care market.�� 24. The organisations immediately required to deal with ambulance delays are�ambulance trusts and acute hospitals, In Cornwall that is SWAST and RCHT.� These organisations do not have control over the services primarily responsible for� ambulance delays, namely social care provision, primary healthcare provision and� community hospital provision. They are unable to influence the whole-system and� therefore carry risks that they cannot wholly mitigate or manage.�� 25. The court noted the HSSIB report which states that delayed discharges (and� consequent ambulance delays) are a national issue which is attributed to a whole�system failure of health and social care. The court noted the HSSIB investigation�s� first safety recommendation is an urgent �whole system� response to reduce patient harm.

I have sent a copy of my report to the Chief Coroner and to the following Interested� Persons: Kevin�s family and SWAST. I have also sent it to other bereaved families who have experienced ambulance delays who may find it useful or of interest.� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of� interest. You may make representations to me, the coroner, at the time of your response,� about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards)

Department of Health and Social Care

29/07/2024

2024-0415

John Codd

Cornwall and the Isles of Scilly

[REDACTED], Secretary of State for Health and Social Care

On 29/7/24, I concluded the inquest into the death of Colonel John Frederick Codd (Bill) who died on 16/1/24 at the age of 88.� I recorded the cause of death as:� 1a) Massive rectus sheath haematoma and severe coronary artery atherosclerosis;� II) Essential hypertension.� I recorded a Narrative conclusion that Colonel Codd died from an� Accident. There was a delay in the arrival of an ambulance and a further� delay in admitting Colonel Codd from the ambulance into the Emergency Department. It is probable that an earlier admission into ED would have� resulted in an earlier CT scan that would have revealed the haematoma� that developed. It is possible that a blood transfusion could have been� arranged that may have avoided the outcome.

On 16/1/24, Colonel Codd fell over while exiting a taxi that had collected� him after an appointment with his GP. An ambulance was called at 12:31� and the initial disposition was for a Category 3 response requiring 90% of attendances within 2 hours and an average of 60 minutes. The� ambulance arrived at 14:49, left the scene at 15:46 and arrived at Royal� Cornwall Hospital at 16:30. Although there was a delay in ambulance� attendance, I felt this was relatively modest and unlikely to have been a� contributory factor in the death.� National guidance requires a handover to hospital staff within 15 minutes.� Unfortunately, the hospital was full and Colonel Codd remained in an� ambulance outside the hospital until he was brought into a bed in the� Majors 2 part of the ED at 21:11, approximately 4 hours and 40 minutes� after arrival. At 22:10, Colonel Codd was found collapsed in cardiac� arrest. He could not be resuscitated.� At inquest, I heard from [REDACTED], one of the ED consultants at the� hospital. I accepted his evidence that had there been a timely admission;� � An x-ray to confirm/exclude a hip fracture would have been� conducted earlier;� � A CT scan ordered to elucidate the findings of the x-ray would then have been ordered earlier (the CT was not conducted);� � It was probable the CT scan would have revealed the haematoma� from which Colonel Codd died;� � It was possible that a blood transfusion could have been organised that would have avoided the death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� [REDACTED] [REDACTED} Royal Cornwall Hospital (via its solicitors) I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make�representations to me, the coroner, at the time of your response, about� the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: Department of Health and Social Care

15/11/2024

2024-0628

Aviva Otte, Oscar Barker and Yousef Al-Kharboush

London Inner (South)

[REDACTED], Secretary of State for Health and Social Care, House of Commons, London SW1A 0AA [REDACTED], NHS Regional Director for London, NHS England London, 133-135 Wellington Road, London, SE1 8UG [REDACTED], Interim Chief Executive, Care Quality Commission, 2 Redman Place London E20 1JQ [REDACTED], Chief Executive, Medicines, and Healthcare Products Regulatory Agency (MHRA), 10 South Colonnade, Canary Wharf, London E14 4PU

In 2014 an investigation was commenced into the death of Yousef Al-Kharboush (born 23rd May 2014, died 1st June 2014, aged 8 days), Oscar Barker (born 27 May 2014, died 29 June 2014, aged 1 Month) and Aviva Otte (born 10 October 2013, died 2 January 2014, aged 2 months). The investigation concluded at the end of the inquest on 23 October 2023. The conclusions of all 3 inquests were a narrative with each of the causes of death being: � Aviva Otte: Narrative Conclusion Aviva was the second twin, her twin sister surviving to this day, born extremely preterm at 24+2 as a result of spontaneous onset of preterm labour at 02.03 hrs on 10.10.2013. She was described as being born in moderate condition with HR >60 and good colour, but with no spontaneous breathing, that initially being assisted by positive pressure breaths and then intubation by 22 minutes of age. She was treated with surfactant and anti-biotics. Conditions for which she received treatment from then until 31.12.2013 included: Patent ductus ateriosis, high glucose levels, a large (right sided) intraventricular haemorrhage (which in the opinion of the expert, would not have caused/ contributed to death), intestinal distension and perforation, (resulting in a laparotomy 30.10.2013 showing ileal perforation secondary to necrotising enterocolitis) with resultant stoma formation. Parenteral nutrition restarted on 6.12.2013. Remaining stable until the day of planned surgery for closure of stomas � 31.12.2013 (day 83 of life) At that operation, the surgeons found multiple adhesions, which were carefully divided and succeeded in re-aligning the two segments of bowel despite the size and operational difficulties. The plan, as far as ant-biotic cover was concerned, was to continue with iv anti-biotics for 2 days post-operatively. She was settled in/around 08.45 on the morning of 1.1.2014. By approximately 10 am, she had developed irritability, which was initially interpreted as pain, but Aviva did not settle. Further investigations revealing a developing metabolic acidosis and acute anaemia raising the possibility of blood loss from somewhere. In additional the previous irritability was considered to be increasing with the development and signs of an abnormal brain function; bedside ultrasound revealed a catastrophic intra-cranial haemorrhage or series of haemorrhages. Despite medical supportive efforts she continued to deteriorate and sadly died the following day, 2.1.2014. � Cause of death: I (a) Intracranial Haemorrhage (b) Bacillus cereus (Bc.38) (c) Extreme prematurity at 24+2 weeks gestation and extreme low birth weight II Necrotising Enterocolitis Conclusion � Oscar Barker: Narrative Conclusion � Oscar was born at the Rosie Hospital, Addenbrooke�s, Cambridge on 27 May 2014 at 28 weeks gestation by C-section. He was one of twins, his antenatal period being complicated by Intra uterine growth retardation and poor foetal doppler measures, suggesting that he was compromised as a foetus chronically and was noted to have a VSD antenatally. Intubated at birth, given surfactant, treated for low glucose and had a long line inserted, but by 13 hours was extubated and receiving CPAP together with empirical anti-biotics given his earlier breathing problems. At day 3 of life, he developed a slightly raised CRP which increased the concern about possible infection. Blood tests taken earlier on had also shown low platelet and white cell counts which, although common and as a result of prematurity, could also have been linked to the signs of developing infection; as such he received additional anti-biotic treatment. Echocardiography also revealing than in addition to his VSD, Oscar was also suffering from congenital malformation of the great vessels which would have required surgery at some point in the future but treated at the time by medical infusion to maintain foetal circulation. On day 7 (3.6.2014) he developed increasing amounts of desaturation and apnoeas and was found to have developed a spontaneous perforation of his bowel and taken to theatre for its repair and stoma formation. Post-operatively, he was critically ill receiving medications through his long line to support his circulation, platelet and red blood cell transfusions. On day 8 he developed pulmonary haemorrhage, received a further transfusion and an additional anti-biotic, then renal impairment (ultrasound scan was unable to locate a left sided kidney at this stage but it was not known whether it had ever been present). By day 20 (16 June), following the ceasing of anti-biotics 2 days earlier there was a progressive deterioration with increased oxygen requirements, bradycardias and abdominal distension, he was re-intubated. He was very sick at this stage with multi-organ failure. Given the septic diagnosis, his long line in-situ was removed and replaced the following day. Oscar had blood cultures taken on 16 and 18 June, together with the tip of the long line being sent off on 16 June. The former were negative, the latter was confirmed as having Bacillus, later identified as Bc.44. Upon commencement of the septic screen, he was also started on anti-biotics and an anti-fungal agent. Despite this and additional medical management, Oscar continued to deteriorate with excess fluid and deteriorating renal function. By day 33 he was really unwell: unstable, acidotic and with severe reduction in urine output with a resultant metabolic acidosis from, not only the infection but also the renal failure. The medical team feared Oscar would not survive and he sadly died on that day � 29 June 2014. � Cause of death: I (a) Multi Organ Failure (b) Bacillus cereus (Bc.44) sepsis � Yousef Al-Kharboush: Narrative Conclusion Yousef was described as being born moderately premature at 32 weeks (with his twin) on 23 May 2014 but with very low birth weight, an extra factor mitigating against health, respiratory distress syndrome, patent ductus arteriosus and jaundice. He spent most of the first week being fairly unremarkable until the morning of 30 May when he started to show signs of infection (unstable temp, blood sugars were high, CRP was high) with an ultrasound showing the presence of quite severe abnormalities � indicative of brain abscesses. He had been given total parenteral nutrition on 27th and 28th. At the time of his hand over on 30th, he had an infection of unknown cause for which investigations had been commenced and for which he had been started on empirical anti-biotics. Over the night he required increasing levels of support (transfusion and platelets). The following morning, the microbiology team confirmed the positive growth of Bacillus (24-hrs after being taken) and his anti-biotics were changed accordingly. By this time, he was showing signs of multi-organ derangement; he was a very sick and unstable, small baby. His downward trend continued with a re-addressing of care aims on the Sunday: he subsequently died at 18.00 that Sunday evening, 1 June 2014. Cause of death: I (a) Sepsis � Bacillus cereus (Bc.44) � (b) IUGR � II Twin Pregnancy

Aviva�s death (January 2014) was in hospital where she had received TPN provided and compounded by the NHS establishment under a section 10 exemption. That TPN had,�on balance, been contaminated by Bacillus cereus (subsequently identified as type� BC.38). The Trust undertook a root cause analysis together with involving the UKHSA� and its own infection and microbiological teams, but no definitive source for the outbreak was found.�� In June 2014 Oscar Barker and Yousef Al-Kharboush received TPN, compounded by a� commercial provider, which it turned out was also contaminated by Bacillus cereus� (subsequently typed as Bc.44). The compounder having positive finger dab testing for�the Bacillus within its laboratory/environmental testing. This outbreak also affected other babies in other Trusts.� Bacillus cereus is resistant (because it is spore forming) to the spray and wipe cleaning methods used (with alcohol) and sporocides are required to decontaminate the outside� of, for example, ampoules containing one of the constituents.� This was information and a conclusion that the Trust had reached in early 2014 and� therefore prior to the outbreak in May/June 2014.� It had not passed on those findings either within other section 10 units compounding TPN or the wider market.� Subsequently, the MHRA brought in further advice for the use of sporocides in 2015.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � � Yousef Al-Kharboush family Oscar Barker�s mother: [REDACTED] Aviva Otte: [REDACTED] ITH Pharma: [REDACTED] Hickman & Rose and [REDACTED] of Hickman & Rose GSTT: [REDACTED] of DAC Beachcroft Cambridge University Hospital; [REDACTED] of Kennedy�s Law MHRA; [REDACTED] of Government Legal UKHSA/ PHE: [REDACTED] of Kennedy�s Law �� Fresenius Kabi: [REDACTED] of DWF Law � [and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. I have also sent it to who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Alcohol, drug and medication related deaths

Department of Health and Social Care | NHS England | Care Quality Commission | Medicines, and Healthcare Products Regulatory Agency

07/10/2024

2024-0533

Helen Davey

Durham and Darlington

[REDACTED], Secretary of State for Trade and Business Office for Product Safety and Standards� Department for Business and Trade

On 10-Jun-24, I commenced an investigation into the death of Helen DAVEY, 39. The investigation concluded at the end of the inquest on 04-Oct-24. The conclusion of the� inquest was that the death was accidental.

The deceased was leaning over the storage area of an Ottoman-styled �gas-lift bed� when the mattress platform descended unexpectedly, trapping her neck against the upper�surface of the side panel of the bed�s base. Unable to free herself, she died of positional�asphyxia. One of the two gas-lift pistons was defective.

I have sent a copy of my report to the Chief Coroner and to the family. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of� interest. You may make representations to me, the coroner, at the time of your response,� about the release or the publication of your response by the Chief Coroner.

Product related deaths

Office for Product Safety and Standards�| Department for Business and Trade

15/05/2024

2024-0439

Benjamin Sulzbacher

Manchester North

[REDACTED], Secretary of State for the Department of Health and Social Care [REDACTED], Chief Executive Officer, Priory Head Office [REDACTED], Chief Executive, NHS Greater Manchester Integrated Care Board

On the 9th October 2023, I commenced an investigation into the death of Mr Benjamin Sulzbacher who died on the 27th September 2023.� The investigation concluded on the 2nd May 2024. The medical cause of death was confirmed as 1a) Hanging. A conclusion of suicide was recorded.

CIRCUMSTANCES OF DEATH Mr Sulzbacher had suffered from a deterioration in his mental health for a number of years.� This became more acute during 2023.� Throughout this time he had accessed assistance from professionals within his community and this was done on a private basis. � On the 24th August 2023 having tried to tie a ligature at home, he was taken to the Accident and Emergency Department at North Manchester General Hospital.� He was assessed and it was recognised he required an inpatient admission which he agreed to as a voluntary patient. Due to the only available acute inpatient bed being in the South, his family funded a private admission at the Priory hospital in Altrincham. He was an inpatient from the 26th August until the 18th September 2023. On his discharge from the Priory part of the discharge plan was for a follow up phone call within 48 hours.� This occurred on the 21st September 2023. Learning from how this call was conducted has already been recognised by the Priory. The court heard evidence that no referral was made to the NHS mental Health trust for follow up via the Home Based Treatment Team. In this case due to where Mr Sulzbacher lived, a referral would have been to Pennine Care NHS Trust Foundation Trust. �This would have occurred automatically if he had been an NHS inpatient.� The court heard if a referral had been made to the Home Based Treatment Team they would have conducted a face to face follow up within 72 hours and if necessary, would have remained engaged with Mr Sulzbacher for up to 4 weeks. The court also heard evidence that the NHS Trust would have accepted such a referral even though Mr Sulzbacher had been a private paying inpatient. The evidence from the family was that Mr Sulzbacher�s mental health declined on his return home and he died having tied a ligature on the 27th September 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- Family of Mr Sulzbacher Pennine Care NHS Foundation Trust � � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) � � This report is being sent to: Department of Health and Social Care | Priory Group

21/10/2024

2024-0569

Henry Willems

Worcestershire

[REDACTED], Secretary of State of Health and Social Care, 39 Victoria Street, London SW1H 0EU.

On 11 March 2024 I commenced an investigation and opened an inquest into the death of Henry Michael Patrick WILLEMS. The investigation concluded at the end of the inquest on 21 October 2024. The conclusion of the inquest was that Mr. Willems �died from natural causes, to which the lack of a timely ambulance response contributed.�

In answer to the questions �when, where and how did Mr. Willems come by his death?�, I recorded as follows: �In the early hours of 12.10.23 Mr. Willems, who had been unwell with gastritis over the preceding 48 hours, collapsed at his home in Malvern. His family called the emergency services, and paramedics attended him at home, but he was confirmed deceased a short time later. Paramedics had been unable to attend Mr. Willems� address within the mean target response time for a Category 2 case because ambulances were experiencing significant delays in handing their patients over to staff at hospital emergency departments across the region. Had that mean target response time been met, it is likely that Mr. Willems would have survived.� A post mortem examination confirmed the medical cause of death for Mr. Willems was: 1a ischaemic heart disease.

I have sent a copy of my report to the Chief Coroner and to the following: (a) [REDACTED], Mr. Willems� daughter; (b) West Midlands Ambulance Service University NHS Foundation Trust; (c) Worcestershire Acute Hospitals NHS Trust. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards)

Department of Health and Social Care

14/10/2024

2024-0543

Locket Williams

Surrey

[REDACTED], The Chief Executive Officer of Surrey and Borders Partnership NHS Foundation Trust

I commenced an investigation into the death of Locket Ure Williams. The inquest concluded on the 31st May 2024 when I found that the medical cause of death� was:��� Ia Multiple Injuries and my conclusion as to the death was that: Locket Ure Williams died as a result of Suicide.�� Their death was more than minimally contributed to by Surrey and Borders� Partnership NHS Foundation Trust�s Children and Adolescent Mental Health Service�s:� (i) delay in assessing Locket�s condition and needs, (ii) underestimation of Locket�s risk of suicide, and (iii) failure to deliver necessary therapeutic treatment to Locket in a timely manner. � I subsequently held a hearing to receive evidence relating to the prevention of future deaths and this was concluded on the 26th September 2024.

Locket Williams was 15 years of age when they died. They had a history of self- harm, suicidal ideation, and suicide attempts. This history included a referral to� Surrey and Borders Partnership NHS Foundation Trust�s Children and Adolescent Mental Health Service, with a report of self-harm and suicidal ideation, in October 2020, and three subsequent suicide attempts, in February, June and July 2021.� Locket was suffering a Depressive Disorder and Emotional Dysregulation and, in� April 2021, they were placed on the waiting list for Cognitive Behaviour Therapy, which was expected to be effective in treating their conditions and controlling�their suicidal ideation. Although Locket was prescribed medication and received� some monitoring and support from the Children and Adolescent Mental Health� Service, the Cognitive Behaviour Therapy did not commence until very shortly� before their death, and no effective treatment had been provided prior to their� death.� On the night of the 27th September 2021, Locket left their home and walked to [REDACTED], from where they jumped to the road below. Locket�s death, from consequential injuries, was recognised at 00:01 hours on the 28th� September 2021.�� Full details of the events and failings which lead to Locket Ure Williams� death� are set out in my �Findings and Conclusions� document, a copy of which is sent with this report.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� (i)�[REDACTED], (ii) [REDACTED], � (iii) [REDACTED] and (iv) Surrey County Council I am also under a duty to send a copy of your response to the Chief Coroner.�� I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or� summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the� coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Suicide (from 2015)

Surrey and Borders Partnership NHS Foundation Trust

15/03/2024

2024-0145

Sydney Piper

East London

[REDACTED], The Commissioner of Police of the Metropolis, Metropolitan Police Service � � Corporate Director Adult Social Care and Quality Standards London Borough of Waltham Forest Principal Adults Lawyer Director for Care and Support, Outlook Care Ltd The Care Quality Commission

On 24th March 2023, this court commenced an investigation into the death of Sydney Piper, aged 69 years. The investigation concluded at the end of the inquest on 14th March 2024. The court returned a narrative conclusion. � �Sydney Alex Piper was discovered deceased in a tent on 24th March 2023 in Epping Forest near to Sky Peals Road, IG8. His death was caused by morphine toxicity. Mr Piper was a vulnerable adult who was diagnosed with schizophrenic illness and a cognitive deficit. Mr Piper was cared for in supported accommodation where lawful restrictions were placed on his liberty. Mr Piper was to receive constant 1:1 supervision from a support worker when he left his home. � On 23rd February 2023 he left home to attend a medical appointment accompanied by a support worker. Due to a significant and sustained lapse in supervision Mr Piper left his medical appointment unaccompanied. Mr Piper travelled to a nearby park and then to a nearby residential street, after that there was no trace of the deceased until the discovery of his death a month later. � It has not been possible to determine how Mr Piper came to have been administered morphine or how he came to be at the site he was located.� Mr Smith�s medical cause of death was determined as; 1a Morphine Toxicity

Sydney Piper was a 69 yr. old man who had spent much of his life in supported accommodation due to mental health problems. � On 23rd February he was escorted by support staff to an appointment at a mental health clinic to receive a depot medication injection. � In all excursions outside of his home Mr Piper was to be always subject to supervision by a support worker. � Upon arrival at the clinic, Mr Piper was ignored by his carer who sat in an area away from Mr Piper and looked at her phone. For much of this period, Mr Piper was out of the direct line of sight of his carer. � Mr Piper left the clinic on three occasions, the final time (11.14) he did not return. Mr Piper�s absence was not noticed until 11.51. Procedures indicated by Mr Piper�s care provider were not effectively followed and a delay of 1 hour and 23 minutes was recorded between the discovery of his disappearance and a call being made to 999. � A missing persons investigation was commenced but it was not until 24th March 2023 that Mr Piper was discovered in a tent on the outskirts of Epping Forest. Mr Piper had been dead for some time. � Although no drug paraphernalia was found near to the deceased his death was later determined to have been caused by morphine toxicity.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Piper and to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Alcohol, drug and medication related deaths This report is being sent to: Metropolitan Police Service | London Borough of Waltham Forest | Outlook Care Ltd | Care Quality Commission

20/07/2023

2023-0269

Stephen Weatherley

Inner South London

[REDACTED], The Director at HMP Thameside, Griffin Manor Way, London, SW28 0FJ. � [REDACTED], Director General Chief Executive HM Prison and Probation Service (HMPPS), 102 Petty France, London, SW1H 9AJ. � Mr Alex Chalk KC MP, Lord Chancellor and Secretary of State for Justice, Ministry of Justice, 102 Petty France, London SW1H 9AJ.1 � [REDACTED], HM Chief Inspector of Prisons, HM Inspectorate of Prisons, 3rd Floor, 10 South Colonnade, Canary Wharf, London, E14 4PU.

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.

1.�SW died from the toxic effects of cocaine and methadone whilst detained at HMP Thameside. 2.�He was a known drug dependant individual receiving methadone therapy. 3.�On 7th October 2017, [REDACTED] SW was searched and no item was found. He was moved to the care and separation unit (�CSU�) for monitoring and his visitor was banned for 3 months from all visits. An adjudication hearing was held and there was no finding against him due to lack of evidence. 4.�SW was then held on closed visits until a new decision was made on 31st January 2018 to change his status to open visits. The same visitor who attended on 7th October 2017 was allowed on open visits, contrary to local guidance. 5. On 23rd February 2018, staff monitored SW�s visit and reacted to a call over the radio (by the CCTV operator), for a suspected pass, restraining SW and taking him away to a room to be searched. His visitors were taken to separate rooms to be questioned and not searched. 6.�The CCTV footage was reviewed at this point and no pass was seen by staff. SW was searched and nothing was found by officers. SW was returned to his wing. The nurse was informed and given no indication that SW had received any contraband. 7.�Various calls were made by SW that evening. At the time they were not listened to by prison officers. Later review of the calls confirmed reference to [REDACTED]. � 8. On the morning of 24th February 2018, the cellmate found SW on the floor with blood coming from his mouth and activated the cell bell at 0705. It was answered but not responded to in person. A second cell bell call was made at 0723. It was answered by staff and another member of staff was sent to the call where SW was seen lying on the floor experiencing a seizure. 9. A nurse attended the cell at 0726, and an ambulance was called. After a delay in entering the prison, the ambulance reached SW at 0741. CPR was administered and SW was confirmed dead at approximately 0847. 10. The jury found that the conveyance by SW�s visitor of a list A article into the prison and passing it to SW was a material contribution to his death. 11.�The decision to allow this visitor (who had been banned on 7th October 2017) an open visit on the 23rd February 2018 was a material contribution to SW�s death. The decision was inappropriate due to various factors including insufficient record keeping and information sharing, inadequate scrutiny of the decision made and failure to follow policy. 12. The decision by prison staff to not to monitor SW possibly made a material contribution to his death. There was insufficient investigation after the visit and a lack of implementation of precautionary measures. The omission of searching the visitors post-visit and a defective decision-making pathway possibly made a material contribution to SW�s death.

I have sent a copy of my report to � [REDACTED] (TV Edwards) for the family [REDACTED] (DWF) for Serco [REDACTED] (Capsticks) for Oxleas [REDACTED] (Womble Bond Dickinson) for We are With you. [REDACTED] Chair Independent Advisory Panel on Deaths in Custody � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related deaths | State Custody related deaths This report is being sent to: HMP Thameside | HM Prison and Probation Service | Ministry of Justice | HM Inspectorate of Prisons

25/10/2024

2024-0587

Natasha Johnston

Surrey

[REDACTED], The Secretary of State for the Home Department [REDACTED], The Chief Executive Officer of Surrey County Council

The inquest into the death of Natasha Johnston was heard and concluded on the 21st October 2024. � The medical cause of Ms Johnston�s death was: � 1a: Shock and Haemorrhage including Perforation of the Left Jugular Vein 1b: Multiple Penetrating Dog Bites to Neck, Arms and Torso

In the early afternoon of the 12th January 2023, Ms Johnston was walking some eight dogs in the area of the �Viewpoint�, Gravelly Hill, Caterham, Surrey. The dogs ranged dramatically both in size and weight, from small to very large. She was in the habit of acting as a dog walker and had walked these same dogs on previous occasions without difficulty. Between approximately 14:00 hours and 15:00 hours she was seen in the area, by a number of different people. Initially, she appeared to be in control of the dogs, but as time went by, the dogs became increasingly excited and out of her control. At one point she was seen by another dog walker with a large group of dogs. He had seen her before with a lot of dogs and, as before, on seeing him she immediately turned around called the dogs and went in the opposite direction with the dogs following. Another person, who was out exercising, saw her with a large number of dogs. He stood to one side to allow her to pass and one of the larger dogs jumped up at him and put its paws on his chest, albeit causing him no harm. At another point, two riders came across her, at that time she was sat on the floor surrounded by a group of dogs, their leads were all tangled up. She shouted, �go back, go back�. The dogs were not attacking her, but they were out of control. Two of them ran towards the horses frightening them and causing one of them to bolt with the result that its rider was thrown to the ground. After this, one of the larger dogs, began worrying a smaller dog that was being walked by its owner. On picking up her dog, the owner was then bitten in her left buttock, by this dog, causing her severe pain and injury. By the time of the last two encounters, the dogs were no longer in Ms Johnston�s control. A short while later, another walker�s attention was drawn, by a fellow walker, to a large number of dogs that were all off their leads and causing a commotion. On going to investigate he saw an object at the bottom of a nearby very steep slope. He descended the slope to see two of the dogs with blood on their muzzles in the vicinity of the object, which, as he approached, he recognised to be the body of a woman, this was Ms Johnson. Despite the aggressive stance of the dogs, he approached Ms Johnston, who was covered in blood and had suffered a large number of puncture wounds. He could not find any signs of life, but called the ambulance service and, under their instruction, began CPR on Ms Johnston. Despite his attempts and those of two police officers and a paramedic, Ms Johnston remained unresponsive. Ms Johnston�s death was recognised at 15:29 that same day; she had died from her wounds. It was clear that she had been the subject of a vicious dog attack by an unknown number of dogs, which had formed part of the group of eight dogs that she had been walking that day. The post mortem examination revealed that she had sustained multiple injuries consistent with dog bites and claw marks. The concentration of bite marks was particularly severe around the neck. They had led to the penetration of the jugular vein, which in itself would have been fatal. However, the remaining bite marks would also have led to catastrophic haemorrhage which would also have resulted in her death. There were no other injuries that could have caused or contributed to death. Whilst, when she was first seen, Ms Johnston appeared to have some control over the dogs, it was readily apparent that as time went by that any such control was lost, eventually with a tragic result.� Bearing in mind the sheer number and size of the dogs involved, her inability to control and to hold them was not surprising. I heard evidence that, whilst there maybe guidance available as to the maximum number of dogs a person should walk on their own in a public place, there is no actual restriction on the number or size of dogs that a person can walk on their own in a public place, either locally or nationally.

COPIES � I have sent a copy of this report to the following Interested Persons in the Inquest and to the Chief Coroner. 1. [REDACTED]

Accident at Work and Health and Safety related deaths | Other related deaths

Home Office | Surrey County Council

19/01/2024

2024-0033

Matthew Wickes

Hampshire, Portsmouth and Southampton

[REDACTED], Vice-President of Education, University of Southampton������������������ [REDACTED], Associate Director, Student Support, Student and Education Services, University of Southampton

On 30 June 2022 I commenced an investigation into the death of Matthew George WICKES aged 21. The investigation concluded at the end of the inquest on 4 August 2023. The conclusion of the inquest was that the Deceased impulsively took his own life (by jumping from a bridge) whilst suffering an acute anxiety crisis.

The Deceased died in hospital care at 06.35 on the morning of 30 June 2022 after falling from a road bridge across Thomas Lewis Way in Southampton at approximately 05.30 that morning. Despite emergency medical attention he was unable to be resuscitated and died as a result of his injuries. No drugs or alcohol were involved in the death. The Deceased was a third-year student at university and was neurodiverse. He had been struggling with the pressures of his third year of study, following irregularities created and imposed on his otherwise established study routine and rhythm of daily living as a result of successive lockdowns. He had also fallen ill with Covid-19 in March 2022 and was believed to have been suffering long covid symptoms in the subsequent months. His illness had impacted on his concentration and his ability to perform, as well as causing chronic fatigue and insomnia. As a result, he had fallen behind in his third-year project and, it is believed, had determined that he was going to be unable to successfully pass his year of study, thereby preventing his ability to proceed at university and halting his ambition to pursue his academic career. It is believed that these factors had had an overwhelming effect on him, leading, on 30 June 2022 � the day of the publication of his exam results � to an acute anxiety crisis out of which he was unable to see a path. Although he had left no clear explanation of his feelings or reason for his actions, the evidence established that it was more likely than not that he had jumped from the bridge in a moment of acute distress in the early hours of the morning. There was no evidence to suggest that he had accidentally fallen to his death and no evidence of any third-party involvement. It was found that his actions were impulsive yet deliberate in their intent to take his own life, whilst suffering an acute anxiety crisis.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED], Head of Electronics and Computer Science, Chair of ECS Exam Boards, University of Southampton. � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: University of Southampton

08/05/2024

2024-0264

Donna Smith

Worcestershire

[REDACTED], West Mercia Police, Hindlip Hall, Worcester WR3 8SP � [REDACTED], Chief Executive, Wychavon District Council, Civic Centre, Queen Elizabeth Drive, Pershore, Worcestershire WR10 1PT

On 5 April 2023 I commenced an investigation� and opened an inquest into the death� of Donna Louise SMITH ( dob 06.02.1975 ). The investigation concluded at the end of the inquest on 7 May 2024. � The conclusion of the inquest was that Ms. Smith�s death was alcohol-related.

In answer to the questions �when, where and how did Ms. Smith come by her death?�,� I recorded as follows: � �On the morning of 4.3.23 Donna Smith was found unresponsive in Worcester City Centre. She was taken to Worcestershire Royal Hospital where, a short time later, she was confirmed deceased. She died as the result of acute alcohol intoxication.� � Ms. Smith had first been spotted on a Worcester city centre CCTV camera ( operated by an employee of Wychavon District Council ) at 0654hrs on the morning of 4.3.23, lying in a flower bed outside the Maggs Day Centre, Deansway. She remained there for the next two hours or so, at which point the CCTV operator became concerned for her wellbeing and contacted the West Mercia Police control room. In that call over Airwaves radio, the CCTV operator stated that Ms. Smith had not moved at all for several minutes and �might be subject to hypothermia�. The communications officer to whom he spoke replied �that would need to go to the ambulance service�, at which point the call ended. In fact, neither party made a call to the ambulance service, as each had assumed that the other would be making the call. The communications officer stated in evidence to the inquest that although she felt she was being clear at the time, she appreciated that the words she used �could have been ambiguous�. In the end, a concerned member of the public found Ms. Smith, and made a call to the ambulance service some 20 minutes later. Paramedics attended, provided Advanced Life Support, and took Ms. Smith to Worcestershire Royal Hospital, where she died later that morning. The cause of death established at inquest was: 1a acute alcohol (ethanol) intoxication; 2 hepatic steatosis, left ventricular hypertrophy. � Given the evidence which I heard at the inquest, I could not conclude, on the balance of probabilities, that a timely phone call to the ambulance service by either the CCTV operator or the police communications officer would in fact have led to a different outcome in this case.

I have sent a copy of my report to the Chief Coroner and to [REDACTED], Ms.�Smith�s father. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drug and medication related deaths This report is being sent to: West Mercia Police | Wychavon District Council

21/04/2023

2023-0130

Peter Lawrence

Berkshire

[REDACTED], consultant trauma and orthopaedics surgeon via his legal representative at DWF.

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. � � His cause of death was: � � 1a Septic Shock 1b Gluteal and Hamstring Abscess 1c Spinal Decompression 2 Type 2 Diabetes Mellitus, Ischaemic Heart Disease, Cerebrovascular Disease

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. Adequate medical records are fundamental to patient safety, particularly when patients are receiving treatment from numerous clinicians and organisations both in the private sector and in the NHS. � I did not find that the record-keeping approach in this case contributed to Mr Lawrence�s death, but I remain concerned of a risk to other patients, in adopting this approach.

I have sent a copy of my report to the Chief Coroner and to Mr Lawrence�s family. I have also sent a copy to the Spire Hospital in Portsmouth, and to the senior coroner in Hampshire, given the location of these events. � To be clear, I have included the Spire Hospital in this regulation 28 report, not because I had concerns about record-keeping within the hospital setting. However, they are involved in recruiting and relying on private consultants to carry out operations for patients under their care. I do not require a formal response from Spire Hospital.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Spire Hospital

02/12/2024

2024-0659

Junior Powell

Inner West London

[REDACTED],� Secretary of State for Health and Social Care, Department of Health and Social Care,� 39, Victoria Street,� London.� SW1H 0EU.

On the 26th and 27th November 2024, evidence was heard touching the death of Mr�Junior George Powell, who died on 6th September 2021 at St George�s Hospital aged 57 years.� Medical Cause of Death 1 a. Intestinal Ischaemia b. Aortic Dissection with arterial branch occlusion How, when, where the deceased came by his death: Mr Powell presented at approximately 22:00 to St George�s Hospital on 3rd September of 2021 with acute onset of abdominal pain and vomiting. Initial CT scanning did not find� nay surgical cause for his symptoms. He was reviewed at 05:15 on the 4th September� 2021 by the medical registrar who was concerned about his pain and worsening clinical� condition. She discussed the CT scan results with the radiologist and surgical team.� In retrospective analysis of the CT scan images subtle changes were noted that� prompted further imaging if his vascular system. This showed an abdominal aortic� dissection, reduced blow flow to the coeliac axis, the superior mesenteric artery and renal arteries and evidence of intestinal ischaemia.� He was reviewed by the general surgeons, vascular surgeons and interventional radiologists, by which time he deteriorated further.� He underwent resection of his bowel midmorning on 4th September 2021 but received no surgical treatment to restore blood flow to the abdominal arteries or treat the dissection�in the aorta. He was heparinised only.� As a result, his condition continued to deteriorate and he developed increasing ischaemic damage to his abdominal organs.� Despite further resection of his by now necrotic gall bladder and damaged bowel on 5th September 2021, he died at 15:49 on 6th September 2021 on GITU.� If mechanical restoration of blood flow to the abdominal arteries had occurred on the morning of 4th September 2021 or by late afternoon of 4th September 2021, on the� balance of probabilities he would not have died at this time.� As such the lack of treatment to reduced flow to the arteries via mechanical means contributed to his death.� Conclusion of the Coroner as to the death: Natural Causes contributed to by lack of definitive treatment of the aortic dissection.

Evidence relevant to the matters of concern Extensive evidence was taken and exhibited and some potential Regulation 28 matters explored. Of relevance to this report:� They was a more than five hour delay before Mr Powell was reviewed by the� medical registrar and he should have been in a bed in the medical ward by� 01:15. This delay was caused by shortage of staff during that night and he was eventually seen by the medical registrar who should have been based on the� ward, not seeing patients in accident and emergency.� Evidence was taken that confirmed that such delays are usual, not just in St� George�s Hospital, and delays in admission to the wards are caused largely by� the inability to discharge patients who are fit for discharge due to lack of suitable social support in the community.� In this case, treatment for Mr Powell was time critical and as such this delay probably contributed to his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� Wife of Mr Powell: [REDACTED] � [REDACTED],Chief Executive Officer, St George�s Hospital,� Blackshaw Road,� London.� SW17 OQT.� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your� response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care

30/12/2024

2024-0712

Michael Jervis

Cornwall and Isles of Scilly

[REDACTED]. Chief Executive, Royal Cornwall Hospital Trust

On 21 July 2024 I commenced an investigation into the death of 69-year-old� Michael Ramon Jervis. The investigation concluded at the end of the inquest on 24 October 2024.� The medical cause of death was found to be 1a Neutropenic Sepsis� 1b Chemotherapy� II Germ Cell Testicular Cancer The four questions � who, when, where and how � were answered as follows � Michael Ramon JERVIS died on 16 July 2023 at Royal Cornwall Hospital� Truro from Neutropenic Sepsis, a recognized complication of chemotherapy treatment for Testicular Cancer.� There was a 20-hour delay in the� administration of antibiotics from the point at which clinical observations�repeatedly indicated that antibiotics were clearly required.� This delay in�the administration of antibiotics more than minimally contributed to his�death.� The conclusion as to the death is � Michael Ramon JERVIS died from a recognized complication of necessary medical treatment contributed to by neglect.

1.� Mike was diagnosed with testicular cancer in May 2023 at Royal Cornwall Hospital Truro (RCHT). The cancer was treatable. The treatment plan was four cycles of chemotherapy. The aim of treatment was curative. Prior�to the cancer diagnosis Mike was an independent, fit, and active man.� 2.� Mike underwent three cycles of chemotherapy. The cancer responded� well to chemotherapy with the tumour markers falling from 18,000 to 18�by 5 July 2023.� 3.� Mike was discharged home on 9 July 2023 with a plan to admit him for�the fourth round of chemotherapy. �� 4.� However, Mike was re-admitted on 13 July 2023 to RCHT after becoming�unwell. Bloods were taken on admission which revealed neutropenia.�� This is a condition which involves a significant weakening of the immune� system and indicated a high risk of sepsis.� 5.� At 1600 hours 13 July 2023, an acute oncology nurse specialist recorded�on Mike�s notes that antibiotics should be administered should Mike�s� temperature fall below 36 or rise above 37.5. This note is consistent� with hospital policy and guidance.�� 6.� The court found that infections and sepsis are a recognized complication�of chemotherapy because the treatment leaves patients immuno- compromised.� 7.� The court heard that a bundle of six measures are required when clinical�indicators of sepsis are present, known as the �Sepsis Six� bundle. The� indicators for implementation of sepsis six, particularly for those� immuno-compromised, include temperature above 37.5, below 36.�� 8.� The six measures include administering fluids and administering� antibiotics. The court found that of the six measures, antibiotics is the�most important and should be administered within 60 minutes.� 9.� The court heard that the Sepsis Six bundle has been policy since 2006 at�RCHT and nursing staff and doctors are expected to be aware of and� implement sepsis six when indicated.� 10. The first indication that sepsis six should be implemented was at 1710�hours on 13 July 2023 when observations gave a NEWS score of 4 in�which low temperature (temp 35.6) and low blood pressure (78/42)� should have resulted in a medical review and met the low threshold for� IV antibiotics.� 11. Thereafter numerous observations were taken over the following hours indicating that Mike met the low threshold for IV antibiotics. �� 12. In total, there was a 20-hour delay in the administration of antibiotics�from 1710 hours on 13 July 2023 until 14:30 hours the following day.� 13. The court found that this delay in the administration of antibiotics more than minimally contributed to his death and amounted to neglect.

I have sent a copy of my report to the Chief Coroner and to the family. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or� summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the�coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Royal Cornwall Hospital Trust

06/03/2020

2020-0061

REDACTED

Inner North London Category: Alcohol, drugs medication related deaths This report is being sent to: Department of Health and Social Care | NHS England

[REDACTED]: Director, Alcohol, Drugs & Tobacco, Health and Wellbeing� Directorate, Public Health England � Wellington House, 133-155 Waterloo Road, London. SE1 8UG� [REDACTED], National Medical Director, NHS England � Skipton House, 80 London Road, London SE1 6LH Department of Health and Social Care | NHS England

[REDACTED]�died on 13 June 2019, aged 30 years, from the consequences of� cocaine use, which resulted in a posterior stroke. I heard the inquest into his death on 22 November 2019 and recorded a narrative conclusion, as set out below:� [REDACTED]�died from the consequences of cocaine use, which resulted in a posterior� stroke. There were intervals to the treatment of this, although it is not possible to conclude that this contributed to his death.

[REDACTED]�was admitted to Queen�s Hospital, Romford on 9 June 2019. The previous�evening he had ingested cocaine and, in the early hours of 9th, he collapsed, unable to speak or move his left side. He was diagnosed with a basilar artery occlusion and underwent� thrombolysis at 14.40 later that day. He was transferred to The National Hospital for� Neurology and Neurosurgery shortly thereafter.�� A thrombectomy procedure was successfully carried out, also on 9 June. However, he suffered a further deterioration and was declared brainstem dead on 13 June 2019.

I have sent a copy of my report to the Chief Coroner, [REDACTED], Barking, Havering and Redbridge University Hospitals NHS Trust and University College London�Hospitals NHS Foundation Trust.�� I am also under a duty to send the Chief Coroner a copy of your responses. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of� interest. You may make representations to me, the coroner, at the time of your response,� about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related deaths

22/09/2023

2023-0346

Sebastian Daniels

Hampshire, Portsmouth and Southampton

[REDACTED]; CEO Hampshire Hospitals NHS Foundation Trust [REDACTED]; CEO Southern Health NHS Foundation Trust

On 08 July 2021 I commenced an investigation into the death of Sebastian Harry DANIELS aged 26. The investigation concluded at the end of the inquest on 01 September 2023. The conclusion of the inquest was that: � On the 4th July 2021 Sebastian Harry Daniels died at the Royal Hampshire County Hospital in Winchester. He died as a result of a hypertriglyceridemia caused by his diabetes, obesity and medication that he required to control his enduring mental health condition. This condition was identified during a blood test on the 30th April 2021 but the result was passed on in a manner which did not trigger a medical review.

Mr Daniels suffered from paranoid schizophrenia and was prescribed clozapine in early 2019. This was effective in controlling his mental health difficulties. Patients taking clozapine require close monitoring of their physical health due to the risks associated with the medication and attend a 4-weekly clinic. Blood samples are taken at these clinics to monitor white blood cell counts. � In addition to the regular clozapine clinic Mr Daniels underwent a periodic physical health check in accordance with the relevant guidelines and Southern Health policy. At the check on the 1/4/21 a blood lipid profile (including triglycerides) was not requested as it should have been. The multi-agency Root Cause Analysis (RCA) report identified this as a missed opportunity to monitor Mr Daniel�s blood lipid levels. � On the 30/4/21 Mr Daniels attended Basingstoke & North Hampshire Hospital ED due to abdominal pain. Blood tests were requested but Mr Daniel�s self-discharged prior to the results becoming available. Owing to the appearance of the blood sample the testing technician added triglyceride levels to the test results. These were abnormal and significantly raised. The ED doctor preparing the discharge summary included the blood test results but did not flag the triglyceride levels as abnormal or requiring attention by Mr Daniel�s GP. As a consequence, the GP surgery administrative staff filed the discharge note without bringing it to the GP�s attention. � Subsequent blood tests reported on the 29/6/21 revealed even higher levels of triglycerides. The GP was concerned about the levels given this leads to a risk of pancreatitis and took steps to commence treatment. � On the 3/7/21 Mr Daniels was taken to hospital by ambulance with abdominal pain. Despite treatment his health deteriorated quickly and he sadly died on the 4/7/21. � The medical cause of death was recorded as: 1a Multiple Organ Failure 1b Severe necrotising pancreatitis 1c Severe hypertriglyceridemia due to clozapine therapy, diabetes mellitus and obesity II Hypertensive Heart Disease and paranoid schizophrenia

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] � I have also sent it to � Royal College of Pathologists � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related death This report is being sent to: Hampshire Hospitals NHS Foundation Trust | Southern Health NHS Foundation Trust

15/01/2025

2025-0027

Tammy Milward

Surrey

[REDACTED} Chief Executive�� Surrey and Borders Partnership NHS Foundation Trust 18 Mole Business Park �� Leatherhead �� Surrey KT22 7AD �� [REDACTED] Esher Green Surgery Esher Green Drive� Esher� Surrey� KT10 8BX

INQUEST An inquest into Ms Milward�s death was opened on 14 March 2024.� The inquest was resumed on 13 December 2024 and concluded on 20� December 2024.��� � The medical cause of Ms Milward�s death was: 1a. Mixed Drug Toxicity With respect to where, when and how Ms Milward came by her death it was recorded at Box 3 of the Record of Inquest as follows:� Tammy Denise MILWARD was found unresponsive by police� following concerns for her welfare at her home in Esher Surrey on�1 January 2024. Her death was formally recorded by paramedics at� 21:34 hours the same day. She had been prescribed [REDACTED] and�toxicology revealed a potentially fatal concentration of [REDACTED], in� excess of prescribed levels, in her blood sample and that she had� also used cocaine shortly before her death. As a result, Ms Milward died of the effects of mixed drug toxicity.�� The inquest concluded with a short form conclusion of �Drug Related�:

Ms Milward had a history of mental health problems including severe�obsessive compulsive disorder. She was prescribed�[REDACTED] and�diazepam by her GP to help her deal with pain following a road traffic� collision in approximately 2012. She had become dependent on her� medication. On the advice of her GP, she wanted to reduce prescription� levels, but she found this difficult to achieve and on occasions Ms� Milward used her prescribed medication too quickly and had to request� more through her GP. This caused her distress, and she would self-harm, or threaten self-harm. Towards the latter part of 2023, the GP practice� referred Ms Milward to Surrey and Borders NHS Foundation Trust on� several occasions for mental health support. As a result advice was� provided by I-Access and she was referred to GP Integrated Mental� Health Service (GPimhs).�� On 28 December 2023, Ms Milward sent an email message asking to be� discharged from the GPimhs. In that email she accused her GPs of leaving her without medication and that �they are the reason for everything that� happens next�.� GPimhs did not contact Ms Milward about her message� and she was discharged from their service the next day. Separately on the� 28 December 2023 Ms Milward�s pharmacy contacted her GP practice and told them she wanted her prescription and had threatened self-harm. The� practice spoke to Ms Milward and then the GP left a message for Ms� Milward confirming the prescription had been authorised and providing� her with crisis numbers.� The GP was unaware that GPimhs had received�a message from Ms Milward and GPimhs was not aware of the welfare� concern raised by the pharmacy.��� Ms Milward phoned her mother in the early morning of 1 January 2024� and talked about going shopping. But later that day concerns were raised� about her wellbeing and police conducted a welfare check and found her� unresponsive. Toxicology revealed that she had used a significant amount of�[REDACTED] as well as cocaine shortly before her death.

COPIES� I have sent a copy of this report to the following: 1.� Chief Coroner�� 2.� Ms Milward�s family�� 3.� Surrey Adult Social Care�� 4.� NHS Surrey Heartlands Integrated Care Board and Integrated Care System

Alcohol, drug and medication related deaths | Suicide (from 2015)

Surrey and Borders Partnership NHS Foundation Trust | Esher Green Surgery

08/08/2023

2023-0288

Reginald Bourn

Surrey

[REDACTED}, Chief Executive, Health Education England����������������������������� [REDACTED], Chief Executive, National Institute for Health and Care Excellence

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. The cause of death was: I a Aspiration of Gastrointestinal Content I b Small Bowel Obstruction caused by either a Peritoneal Adhesion or Incarceration of an Inguinal Hernia (Resolved) � The narrative conclusion was: � Reginald Bourn was admitted to Frimley Park Hospital with acute abdominal pain and a distended stomach. Investigations revealed prominent small bowel loops but no transition point. He began to vomit. He was treated conservatively and a nasogastric tube was used to decompress his stomach. On the 24th February 2022 the tube had fallen out by 4.30 by which time he no longer felt nauseous. He began to vomit again, and staff were advised to reinsert the nasogastric tube at 7.02. He was seen at a surgical ward round at 9.45 by which time the tube had not been reinserted. The plan remained for conservative treatment and decompression with a nasogastric tube. He was admitted to a surgical ward with a NEWS score of 3 at 10.20. Insertion of the nasogastric tube was effected by 11.40. The tube was misplaced into his left lung. Prior to 12.00 he suffered an acute event resulting in the aspiration of one and a half litres of stomach content into his lungs. His condition significantly worsened, his NEWS score was 10 and his blood oxygen level deteriorated to 88%. He died from the aspiration of gastrointestinal content. The misplacement of the nasogastric tube more than minimally contributed to the death. Misplacement of nasogastric tubes into the lungs is a known complication of a necessary medical procedure.

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Mr Bourn�s Family Frimley Park Hospital � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Health Education England | National Institute for Health and Care Excellence

04/01/2024

2024-0007

Bobby Lee

Inner North London

[REDCATED] Chief Executive Officer Office for Product Safety & Standards Cannon House 18 The Priory Queensway Birmingham B4 6BS

On 31 July 2023, an investigation was commenced into the death of BOBBY LEE, then aged 74 years. The investigation concluded at the end of an inquest, heard by me, on 19 December 2023. � The conclusion of the inquest was accidental death, the medical cause of death being: � 1a smoke inhalation, severe burn injuries 2 frailty, severe coronary artery stenosis and atherosclerosis, hypertension, severe chronic kidney disease, type 2 diabetes mellitus.

Mr Lee died at home on 6 July 2023 from the effects of smoke inhalation and severe burn injuries, resulting from a house fire that commenced at approximately 06:56 that morning. The fire was found to have been caused by the over-charging of a lithium-ion e-bike battery that had no battery management system in situ. The e-bike from which the battery came, was owned by another member of the household. The bicycle had started off as a regular mountain bike, but was subsequently fitted with a �conversion kit� which converted the bicycle into an e-bike. The e-bike was purchased second-hand, without a charger. A charger was subsequently purchased from an online marketplace. � I found on the evidence, which included that of a London Fire Brigade Fire Investigation Officer (whose evidence included input from the Chief Scientific Adviser at the Fire Science Department, who had examined the remains of the converted e-bike, the lithium-ion battery and the charger) that the fire was started by the over-charging of the lithium-ion battery, using a charger which was not suitable for the battery in that the charger had a substantially different voltage rating to the battery. In addition, the battery was not fitted with a battery management system aimed at reducing the risk of over- charging. This set of circumstances led to thermal runaway and a catastrophic failure of the lithium-ion battery. � Despite attempts from family members to assist Mr Lee�s evacuation from his ground floor bedroom, it was not possible to secure his safe evacuation from the premises. Mr Lee suffered severe burn injuries and the effects of the inhalation of toxic smoke and died as a result.

I have sent a copy of my report to the Chief Coroner and to the following Interested Person: � [REDACTED] (family member). [REDACTED] (London Fire Brigade) � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: Product Safety and Standards

16/12/2024

2024-0690

Matthew Sheldrick

West Sussex, Brighton and Hove

Secretary of State for Health NHS England

On 23rd November 2022 I commenced an investigation into the death of Matthew Zak Sheldrick (Matty). Matty identified as non-binary and preferred the use of the pronouns they and them.The investigation concluded with the Inquest being held over a two-week period which concluded on Friday 13th December 2024.At the end of the Inquest, I concluded that:On 3rd November 2022 at around 02.21 Matty had attended Accident & Emergency at the Royal Sussex County Hospital in crisis following a further deterioration in their mental health. This was the second admission in no less than 5 weeks. During this second admission they were experiencing intense suicidal thoughts.Later on 4th November 2022 they were formally assessed under the Mental Health Act and the decision taken was not to detain them. Provision was however made for Matty to be able to stay in the hospital that night if they wished.However, Matty left shortly afterwards and tied a ligature around their neck and suspended themself from [REDACTED]. �Their intentions at the time of carrying out this act remain unclear.The following issues contributed to their death:-1. The fact that Matty�s private housing accommodation, which had been arranged following their move to Brighton, was not suitable due to their� ongoing sensory issues.2. The fact that there had been no psychiatric bed available to Matty� during their first admission to Accident and Emergency Department in� September. They stayed in the Accident and Emergency department for 26 days during their admission between 5th and 30th September 2022. This� meant that there was no meaningful therapeutic input at that time.3. The fact that Accident and Emergency Department was not a suitable environment for a neurodivergent individual and the 26-day period of theirstay contributed to the deterioration of their mental health difficulties.4. The fact that there was a general lack of inpatient bed provision for�informal patients and in particular for those who are autistic and non- binary who require to be on a mixed ward.5. The fact that Matty was discharged from the Crisis Resolution Home Treatment Team on 18th October 2022 before being picked up by� Assessment and Treatment Service. This left a gap in service provision for� Matty.6. The rigidity of the referral process to Transforming Care in Autism� team (TCAT) meant that Matty was unable to access specialist advice and�resources whilst in A&E or in the community.7. The fact that the mental health assessment carried out during thissecond admission did not take into account the following:- � The views and observations of the nearest relative, Matty�s mother. � Matty�s preferred communication aids and in particular Matty�s communication book. � The need for Matty to have an advocate present during the assessment and give consideration to the use of idiosyncratic language. � The extent of Matty�s deteriorating mental state and their increasing risks in the context of their neurodivergence. � The fact that Matty�s change of behaviour during the assessment may be due to:- a) the fact that Matty had been given diazepam b) the fact that Matty may have been able to mask their distress. � Too much emphasis was placed on Matty�s presentation within the assessment itself.8. There was a lack of discharge care planning documented after the assessment on 4th November 2022 particularly if Matty decided to leave before the morning. This led to confusion within the A&E department when Matty decided to leave the hospital.

BRIEF Matty had struggled with their mental health throughout their adult life, but it wasn�t until 2019 that Matty was finally diagnosed with Autism, ADHD and Autistic Spectrum Disorder.� However, they had never been sectioned under the Mental Health Act or had spent time as a voluntary patient in a mental health hospital. Matty had moved to Brighton from Surrey in November 2021 having wanted to live independently.� He was drawn to Brighton as they wished to be involved in the trans/non-binary community. Matty�s mental health deteriorated during the summer of 2022 due to accommodation issues that they had been facing and issues with an online relationship.� By 3rd September they were in crisis. On 5th September 2022 Matty was admitted to A&E at the Royal County Hospital, Brighton. They remained within A&E, short stay ward, for 26 days awaiting a psychiatric bed. During this time no bed was found, and they were eventually discharged back home with support from the Crisis Home Treatment Team. Matty�s mental health had been affected by the unsuitability of the environment within A&E for someone awaiting an inpatient mental health bed. Less than 5 weeks later Matty was again admitted to the A&E department at the Royal Sussex County Hospital on 3rd November 2022 in crisis. Their presentation fluctuated and this led to them being assessed under the Mental Health Act.� However, they were not found to be detainable.� They left the hospital shortly after the assessment and were sadly found hanging in the grounds of the hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- a) The family of Matty Sheldrick b) Sussex Partnership Foundation Trust c) Brighton and Hove City Council d) University Hospital Sussex Trust e) GP Practice � WellBn f) The Clare Project g) [REDACTED] h) Integrated Care Board. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form.� He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths | Suicide (from 2015) | Mental Health related deaths

Department of Health and Social Care | NHS England

26/11/2024

2024-0648

Jon-Paul Prigent

Derby and Derbyshire

1. The Secretary of State for Transport 2. Driving Standards Agency (DVSA) 3. The National Farmers Union 4. The Agricultural Engineers Association 5. The British Agricultural and Garden Machinery Association 6. The Health and Safety Executive

On 31 July 2020 I commenced an investigation into the death of Mr Jon-Paul PRIGENT aged 47. The investigation concluded at the end of the inquest on 15 November 2024. The conclusion of the inquest was that: � Jon�s death was due to the decoupling of a laden trailer from its towing tractor. It is unlikely that his death would have occurred if the hitch and coupling components had been checked to a reasonable standard.

Jon died on 30 July 2020 at Station Lane Old Whittington near Chesterfield, due to a trailer containing soil overturning on to the car he was in. Jon was sitting in the passenger seat preparing to give a driving lesson to his daughter. The trailer had decoupled from the tractor it was hitched to, and the trailer descended down the hill hitting a wall which caused it to overturn. The weight of the trailer put Jon into a compressed position and led to asphyxiation. The tractor and trailer belonged to and was used by a skip hire company. On 30 July they were being used to transport soil from the business premises and yard to the family home for use on land surrounding the property. The journey was along Station Lane, a public highway. The trailer decoupled from the tractor as the tractor went over a speed bump. That section of Station Lane is also on a hill. On the evidence the decoupling probably occurred due to a combination of factors: � � Wear of the coupling components: the towing hook, the hitch ring was warm to below its minimum thickness, and there was a gap between the location of the tip of the towing hook and the keeper plate. � The trailer was overloaded. It was manufactured for a maximum load of ten tonnes but the soil it was loaded with weighed thirteen point eight tonnes. � The soil was unevenly distributed and weighted more to the rear of the trailer adversely affecting the trailer�s centre of gravity. � As the hitch coupling passed over the speed bump a bigger gap opened up for the hitch ring to pass between the tow hook and keeper plate. � On inspection after the incident it was noted that the tip of the tow hook was missing. Whether it had been missing before the decoupling or was sheared-off during the decoupling cannot be established. � The owner and user of the tractor and trailer was required to check their roadworthiness including the hitch and coupling components before each day of use. It is unlikely that a check that day, or recent checks, had been adequate because had those checks been good enough, the degree of component wear would have been noted, and appropriate corrective measures should have been taken. Independent professional vehicle testing is not legally required for tractors and trailers used for agricultural purposes. The driver of the tractor stated that had he seen the degree of wear on the components he would not have taken the tractor trailer on to the road on 30 July. � The tractor and trailer did not have safety features to prevent decoupling because legislation does not require these for tractors which are driven at below twenty-five miles per hour.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- � [REDACTED] � [REDACTED] � [REDACTED] � [REDACTED] I have also sent it to: � � Derbyshire police road traffic team, and � The National Police Chiefs� Council lead for Roads Policing, Chief Constable [REDACTED] of Sussex Police, who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Road (Highways Safety) related deaths

Department for Transport | Driving Standards Agency | The National Farmers Union | The Agricultural Engineers Association | The British Agricultural and Garden Machinery Association | The Health and Safety Executive

25/11/2024

2024-0644

Margaret Feeney

Derby and Derbyshire

Macklin Street Surgery, 90 Macklin Street, Derby DE1 1JX Daynight Pharmacy, 93 Macklin Street, Derby DE1 1JX The Secretary of State for Health and Social Care NHS Derby and Derbyshire Integrated Care Board

On 11 April 2024 I commenced an investigation into the death of Margaret Mary Feeney aged 78. The investigation concluded at the end of the inquest on 11 November 2024.� The conclusion of the inquest was that: � � Margaret died due to taking excess prescribed medication which she had become dependent on and addicted to. She had access to excess medication because of medical prescribing decisions and arrangements leading up to a bank holiday period.

Margaret was found deceased at her home address on 1 April 2024 by her friend and cleaner. She had last been spoken to in a telephone call on 30 March 2024. Post-mortem examination with toxicology identified the medical cause of Margaret�s death as the combined toxic effects of prescribed medication which she had taken in excess. She was also identified to have pneumonia which contributed to her death. A high total morphine level suggests the potential additional taking of a morphine-based substance. Margaret had a long history of being prescribed benzodiazepines and codeine, the latter medication for pain for diagnosed conditions. Unfortunately Margaret had become dependent on those medications and was recognised to overuse them. As a consequence, she was given seven-day prescriptions. On 26 March Margaret�s friend was concerned that Margaret was confused, and the friend and Margaret attended a GP appointment that afternoon. The GP wanted to reduce Margaret�s diazepam and issued a prescription for a lower dose in a daily dose blister pack. The codeine prescription was not altered. The new diazepam prescription was with Margaret on 27 March. This was the week prior to the Easter holiday period. Margaret had received her usual Monday prescription (25 March) including diazepam and codeine. With the new diazepam prescription received on 27 March Margaret had an excess of five days of that drug. Because of the pending bank holiday Margaret received an early prescription of codeine on 28th March, which meant she had four days excess codeine. Clearly, given her recognised dependence and overuse, there was a real and foreseeable risk that Margaret would take excess diazepam and codeine that was available to her between 27 March and her death. In addition to the toxicological evidence, when she was found deceased there were empty or near empty blister packs from the excess medication prescribed to her. On the evidence there is no reason to consider that Margaret had deliberately taken the excess medication to cause her own death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] (daughter) [REDACTED] (son) [REDACTED] (son) Macklin Street Surgery�� � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form.� He may send a copy of this report to any person who he believes may find it useful or of interest.� � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Alcohol, drug and medication related deaths

Macklin Street Surgery | Daynight Pharmacy | Department of Health and Social Care | NHS Derby and Derbyshire Integrated Care Board

13/02/2023

2023-0054

Steven Easdale

Herefordshire

[REDACTED] Chief Executive of Hertfordshire County Council [REDACTED] Chief Executive of National Highways [REDACTED] UK Power Networks Holdings Ltd

On the 12th December 2021 Steven Easdale died at Addenbrookes Hospital from injuries sustained in a road traffic collision. His death was reported to the Coroner and an investigation commenced. A post- mortem examination performed by Dr Martin Goddard on 21st December 2021 provided the following cause of death: 1a Purulent Bronchitis and Bronchopneumonia 1b Multiple Traumatic Injuries An inquest was opened on 9th March 2022 and the investigation concluded at the end of that inquest on the 8th February 2023, which found: Circumstances: � On the 5th November 2021 Steven Easdale was struck by a car whilst crossing the B197 Digswell Hill. He sustained multiple injuries and was taken by ambulance to Addenbrookes Hospital. Despite treatment, Mr Easdale died on the 12th December 2021. There was a central pedestrian island near to where Mr Easdale crossed the road but he did not use it. It was dark at the time Mr Easdale crossed, he was wearing dark clothing and the driver did not have time to react to his presence in the road and avoid the collision. The central pedestrian island near to where Mr Easdale crossed the road should have been illuminated. It was not in working order, however, and was therefore unlit. A nearby streetlamp was also not working and was unlit. Had the pedestrian island and streetlamp been illuminated it may have helped the driver to see Mr Easdale earlier and avoid the collision. Conclusion of the Coroner as to the death: Road Traffic Collision

At the inquest I heard evidence from two police officers�[REDACTED] of the Bedfordshire, Cambridgeshire and Hertfordshire (BCH) Serious Collision Investigation Unit. They outlined that approximately 15 metres from where Mr Easdale crossed the road, there was a traffic island (or pedestrian refuge) with a bollard and streetlamp in place. The bollard on the island is made out of opaque white plastic and is designed to be illuminated from within. The time of the collision was around 5pm on a December afternoon meaning that this stretch of road was in deep darkness. � When the collision occurred on the 5th November 2021, neither the illuminated bollard nor the streetlamp were in working order and were therefore unlit. Both officers from the collision unit gave evidence that this situation presented a danger to road users and pedestrians. � A Traffic Management Officer has brought this situation to the attention of Hertfordshire County Council, Highways England (now National Highways) and National Power Networks (now UK Power Networks). � Despite this, I heard evidence at the inquest that both the bollard and the streetlamp have still not been repaired and remain unlit even in the hours of darkness. � I was not able to say on the balance of probabilities that the lack of lighting on the pedestrian island contributed to Mr Easdale�s death as he was not using the crossing itself when he was struck. He crossed nearby, however, and it is possible that had there been illumination at that island the driver of the car would have seen him earlier and potentially avoided the collision. � I am satisfied that the lack of working lights at this location on the B197 Digswell Hill poses a danger to road users and pedestrians. The location of the island is near to the Red Lion Public House and may be used by people going to and from the pub.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mr Steven Easdale. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Road (Highways Safety) related deaths

Hertfordshire County Council, National Highways | UK Power Networks Holdings Ltd

16/12/2024

2024-0689

Matthew Sheldrick

West Sussex, Brighton and Hove

? �������� Chief Executive Integrated Care Board

On 23rd November 2022 I commenced an investigation into the death of� Matthew Zak Sheldrick (Matty). Matty identified as non-binary and preferred the use of the pronouns they and them.�� The investigation concluded with the Inquest being held over a two-week period which concluded on Friday 13th December 2024.�� At the end of the Inquest, I concluded that: On 3rd November 2022 at around 02.21 Matty had attended Accident &� Emergency at the Royal Sussex County Hospital in crisis following a further deterioration in their mental health. This was the second admission in no� less than 5 weeks. During this second admission they were experiencing� intense suicidal thoughts.�� Later on 4th November 2022 they were formally assessed under the Mental Health Act and the decision taken was not to detain them. Provision was however made for Matty to be able to stay in the hospital that night if they�wished.� However, Matty left shortly afterwards and tied a ligature around their neck and suspended themself from�[REDACTED]. �Their intentions at the time of carrying out this act remain unclear. The following issues contributed to their death:-�� �� 1. The fact that Matty�s private housing accommodation, which had been�arranged following their move to Brighton, was not suitable due to their� ongoing sensory issues.� � �� 2. The fact that there had been no psychiatric bed available to Matty�during their first admission to Accident and Emergency Department in� September. They stayed in the Accident and Emergency department for 26� days during their admission between 5th and 30th September 2022. This� meant that there was no meaningful therapeutic input at that time.�� �� 3. The fact that Accident and Emergency Department was not a suitable� environment for a neurodivergent individual and the 26-day period of their�stay contributed to the deterioration of their mental health difficulties.�� � 4. The fact that there was a general lack of inpatient bed provision for�informal patients and in particular for those who are autistic and non-binary� who require to be on a mixed ward.�� � 5. The fact that Matty was discharged from the Crisis Resolution Home� Treatment Team on 18th October 2022 before being picked up by� Assessment and Treatment Service. This left a gap in service provision for� Matty.�� � 6. The rigidity of the referral process to Transforming Care in Autism team� (TCAT) meant that Matty was unable to access specialist advice and� resources whist in A&E or in the community.�� � 7. The fact that the mental health assessment carried out during this� second admission did not take into account the following:-�� � The views and observations of the nearest relative, Matty�s mother. �� � Matty�s preferred communication aids and in particular Matty�s� communication book.�� � The need for Matty to have an advocate present during the� assessment and give consideration to the use of idiosyncratic�language.� � The extent of Matty�s deteriorating mental state and their increasing�risks in the context of their neurodivergence.� � The fact that Matty�s change of behaviour during the assessment may be due to:-�� ������������������� a) the fact that Matty had been given diazepam� ������������������� b) the fact that Matty may have been able to mask their distress.� � Too much emphasis was placed on Matty�s presentation within the�assessment itself.�� 8. There was a lack of discharge care planning documented after the�assessment on 4th November 2022 particularly if Matty decided to leave� before the morning. This led to confusion within the A&E department when� Matty decided to leave the hospital.

BRIEF Matty had struggled with their mental health throughout their adult life, but� it wasn�t until 2019 that Matty was finally diagnosed with Autism. ADHD and Autistic Spectrum Disorder.� However, they had never been sectioned under the Mental Health Act or had spent time as a voluntary patient in a mental�health hospital.�� Matty had moved to Brighton from Surrey in November 2021 having wanted to live independently.�They were drawn to Brighton as they wished to be� involved in the trans/non-binary community.�� Matty�s mental health deteriorated during the summer of 2022 due to� accommodation issues that they had been facing and issues with an online relationship.� By 3rd September they were in crisis.� On 5th September 2022 Matty was admitted to A&E at the Royal County� Hospital, Brighton. They remained within A&E, short stay ward, for 26 days awaiting a psychiatric bed. During this time no bed was found, and they� were eventually discharged back home with support from the Crisis Home� Treatment Team. Matty�s mental health had been affected by the� unsuitability of the environment within A&E for someone awaiting an� inpatient mental health bed.�� Less than 5 weeks later Matty was again admitted to the A&E department at the Royal Sussex County Hospital on 3rd November 2022 in crisis. Their� presentation fluctuated and this led to them being assessed under the�Mental Health Act.� However, they were not found to be detainable.� They� left the hospital shortly after the assessment and were sadly found hanging� in the grounds of the hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:-� a) The family of Matty Sheldrick� b) Sussex Partnership Foundation Trust c) Brighton and Hove City Council� d) University Hospital Sussex Trust� e) GP Practice � WellBn� f)� The Clare Project� g) [REDACTED] ������������ ��������������������������� �� I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� I may also send a copy of your response to any person who I believe may find it useful or of interest.� The Chief Coroner may publish either or both in a complete or redacted or summary form.� He may send a copy of this report to any person who he� believes may find it useful or of interest.��� You may make representations to me, the coroner, at the time of your� response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths | Suicide (from 2015) | Mental Health related deaths

Sussex ICB

18/07/2023

2023-0255

Christine Dickinson Coroner name: Chris Morris Coroner Area: Manchester South Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Stockport NHS Foundation Trust

[REDACTED], Chief Executive, Stockport NHS Foundation Trust

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 The conclusion of the inquest was a Narrative Conclusion to the effect that Mrs Dickinson died as a consequence of recognised complications of prescribed medication in conjunction with the effects of interstitial lung disease and lymphoma.

Mrs Dickinson had been diagnosed with Grade II Follicular Lymphoma and had been receiving treatment at the Laurel Unit with Rituximab. In August 2022, Mrs Dickinson was admitted to hospital with respiratory difficulties, and provisionally diagnosed with Hypersensitivity Pneumonitis which initially responded to treatment with steroids. Following her discharge, Mrs Dickinson was administered with Rituximab on the Laurel Unit once more. In October 2022, Mrs Dickinson was admitted to hospital for the final time and became gravely ill, dying on 15th November 2022.

I have sent a copy of my report to the Chief Coroner, Harvey Roberts Solicitors on behalf of Mrs Dickinson�s family, and Browne Jacobson LLP on behalf of Stockport NHS Foundation Trust. I have also sent a copy to the Care Quality Commission and NHS Greater Manchester Integrated Care who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

19/09/2024

2024-0502

Suzanne Eccles

Greater Manchester South

[REDACTED], Chief Executive, Tameside and Glossop Integrated Care NHS Foundation Trust

On 10th April 2024, Alison Mutch, Senior Coroner for Greater Manchester (South), opened an inquest into the death of Suzanne Rose Eccles who died on 3rd March 2024 at Tameside General Hospital,� Ashton-under-Lyne, aged 72 years. The investigation concluded with an inquest which I heard on� 13th September 2024.� The inquest determined that Mrs Eccles died as a consequence of:-� 1) a) Pneumonia and Empyema;�� b) Lung Cancer (operated 16th February 2024) II Ischaemic Heart Disease The conclusion of the inquest was a Narrative Conclusion, to the effect that Mrs Eccles died as a� consequence of complications arising from necessary surgery which had not been identified in the� course of previous hospital attendances.

Mrs Eccles died on 3rd March 2024 at Tameside General Hospital having developed Pneumonia and� Empyema against a background of recent surgery for lung cancer. Her death was contributed to by� Ischaemic Heart Disease. In the days leading up to her death, Mrs Eccles had been seen in the Same Day Emergency Care Unit and Emergency Department, and also been a patient on the Virtual Ward.

I have sent a copy of my report to the Chief Coroner, Mrs Eccles�s daughter and son-in-law, and the� Trust�s legal team.�� I have also sent a copy to the Care Quality Commission and NHS Greater Manchester Integrated Care who may find it useful or of interest. �� I am also under a duty to send the Chief Coroner a copy of your response.��� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may� send a copy of this report to any person who he believes may find it useful or of interest. You may� make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Tameside and Glossop Integrated Care NHS Foundation Trust

15/06/2023

2023-0300

Nicholas Stout

County Durham and Darlington

[REDACTED], Chief Executive, Tees Esk and Wear Valleys, NHS Foundation Trust

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.

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED]� [REDACTED], Chief Executive, North East Ambulance Service, NHS Foundation Trust [REDACTED], Chief Constable, Durham Constabulary � I have also sent it to � Care Quality Commission � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related deaths This report is being sent to: Tees Esk and Wear Valleys NHS Foundation Trust

13/08/2024

2024-0456

Matthew Gale

County Durham and Darlington

[REDACTED], Chief Executive, Tees Esk and Wear Valleys, NHS Foundation Trust

On 24/03/2023 18:22an investigation was commenced into the death of Matthew Clive GALE 11/10/1985 00:00:00. The investigation concluded at the end of the inquest on 23/05/2024 14:17.� The conclusion of the inquest was that Matthew�s death occurred on 19th March 2023 at�[REDACTED]. Matthew had a history of mental ill-health dating back to June 2017 including periods as a patient in West Park Hospital. Matthew had a schizoaffective episode in February 2023 and was admitted to Maple Ward of West Park Hospital. Treatment plans were put in place but Matthew�s condition deteriorated from 6th March 2023 and he was formally detained under the Mental Health Act on that day. He was granted Section 17 leave on the 8th March but there are no records to support this. The conditions of his leave were widened and incorrect forms were used and the conditions were not conveyed to Matthew�s family. The salient condition was that Matthew should not be left alone and the failure to communicate contributed..

Matthew�s death occurred on 19th March 2023 at�[REDACTED]. Matthew had a history of mental ill-health dating back to June 2017 including periods as a patient in West Park Hospital. Matthew had a schizoaffective episode in February 2023 and was admitted to Maple Ward of West Park Hospital. Treatment plans were put in place but Matthew�s condition deteriorated from 6th March 2023 and he was formally detained under the Mental Health Act on that day. He was granted Section 17 leave on the 8th March but there are no records to support this. The conditions of his leave were widened and incorrect forms were used and the conditions were not conveyed to Matthew�s family. The salient condition was that Matthew should not be left alone and the failure to communicate contributed.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] Watson & Woodhouse Solicitors I have also sent it to who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015)

Tees Esk and Wear Valleys NHS Foundation Trust

27/11/2023

2023-0480

Benn Curran-Nicholls

Manchester City

[REDACTED], Chief Executive, UK Health Security Agency in respect of Matter One. � ��������������������� [REDACTED], Chief Executive, Manchester City Council in respect of Matter Two.

On 23.09.22 an investigation was opened into the death of Benn Curran-Nicholls who died on 19.09.22, aged 14 years. The investigation concluded on 13.11.23. The medical cause of death was 1a Refractory cardiogenic shock due to taxane alkaloid poisoning following ingestion of yew tree berries and leaves. 2 � The conclusion was Misadventure.

Benn Curran-Nicholls moved to Didsbury, with his family ([REDACTED]) from Australia in June 2022. Benn suffered severe autism with intellectual impairment, and daily walks in the local parks became a part of his daily routine. On the morning of 18.09.22 Benn and his father went for a walk in Fletcher Moss Park where, among other things, there was a yew tree that Benn liked to climb. Benn ate some yew tree berries and also some of the leaves. Benn�s father was not aware of the poisonous nature of yew tree berries/leaves, and so took no action. Interestingly neither was, in his evidence to me, Manchester City Council�s Neighbourhood Manager for Environmental Health aware that yew trees were poisonous. � Later that day at about 6pm Benn suddenly collapsed. He was admitted to Royal Manchester Children�s Hospital by emergency ambulance where he died in the early hours of 19 September 2022. � Toxicological evidence was that yew tree poisoning in humans was rare, but that a number of cases had been reported.

I have sent a copy of my report to the Chief Coroner. I have sent a copy to Benn�s mother and father. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: UK Health Security Agency | Manchester City Council

12/11/2024

2024-0636

Erin Tillsley

Suffolk

[REDACTED], Chief Executive, West Suffolk NHS Foundation Trust [REDACTED], Chief Executive, Suffolk and North East Essex Integrated Care Board

On 20th July 2023 I commenced an investigation touching the death of Erin Louise TILLSLEY aged 14. The Investigation concluded at the end of the Inquest on 31st May 2024. The medical cause of death was confirmed as: 1a Ligature around the neck The Conclusion of the Inquest was that: Narrative Conclusion � Erin Louise Tillsley was described by her family as a bubbly, bright and loving young person who exuded warmth and charisma. A person whose company was uplifting and who had a desire to see the lives of those around her enhanced. Erin initially adjusted well to secondary schooling, however following the restrictions imposed during the COVID pandemic being lifted, she struggled with her attendance although an explanation why this was the case could not be established.� Following a difficult period with a friend at the end of 2022, on the 31st December 2022 Erin consumed some of her mother�s prescribed medication which Erin described as an overdose.� She attended hospital where she was assessed for her physical symptoms.� These were not considered serious and she was discharged on the 1st January 2023.� Emergency Department staff at the West Suffolk Hospital did not consider a referral to psychiatric liaison services to be appropriate during the admission; however advice was given for a referral by Erin�s GP to mental health services. This occurred on the 4th January 2023 with a referral being received by the Norfolk and Suffolk NHS Foundation Trust Wellbeing Hub. The referral was screened and triaged and sent to Child and Family and Young Peoples mental health team (CFYP) for further action. Erin was contacted by the CFYP team on the 3rd May 2023 and arrangements were agreed for her to be referred to a counselling service.� Safety netting advice was provided at this time.� It has not been possible to establish whether such a referral was made to counselling services and at the time of Erin�s death no further contact with mental health services had occurred. Following her return to school in January 2023, Erin�s attendance suffered further and in April 2023 it was agreed that she would transfer to another school which it was hoped would improve her attendance levels.� This was not the case and her attendance levels slipped further and she attended her new school for only 4 days between the end of the May half term break and her death on the 14th July 2023. On the 13th July 2023 Erin attended a meeting at her school with her father where arrangements were discussed to both improve her attendance and resolve a disagreement she had with another pupil in her tutor group.� Although initially upset at the commencement of the meeting, Erin was observed to be smiling and cheerful when leaving the meeting.� She had agreed to return to school the following day. During the evening of the 13th July Erin was observed at home to be happy and preparing to attend school the next day. On 14th July 2023 Erin was seen by her family during the early morning and showed no signs of being distressed or upset.� During telephone calls with her father mid-morning, Erin stated that she would not be attending school and refused, despite attempts to persuade her otherwise by her father, to change her mind.� Around 1030am her father became concerned that Erin had stopped responding to text messages or answering her phone and returned home to find Erin suspended by a ligature in her room.� Emergency services attended and despite attempts at resuscitation Erin was pronounced deceased at the scene. Police enquiries revealed no suspicious circumstances or third-party involvement in the death. Erin Louise TILLSLEY took her own life.

The circumstances of the death are recorded in the Narrative Conclusion.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of Erin Louise TILLSLEY Norfolk and Suffolk NHS Foundation Trust Thomas Gainsborough Academy Ormiston Academy I may also send a copy of your response to any other person who I believe may find it useful or of interest I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Suicide (from 2015) | Mental Health related deaths

West Suffolk NHS Foundation Trust | Suffolk and North East Essex Integrated Care Board

15/12/2023

2024-0013

Terence Hines

Worcestershire

[REDACTED], Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD

On 24 July 2023 I commenced an investigation and opened an inquest into the death of Terence Edward Hines. The investigation concluded at the end of the inquest on 14 December 2023. � The conclusion of the inquest was that Mr. Hines �died as the result of a bacterial infection of a recent surgical wound. His death was contributed to by neglect.�

In answer to the questions �when, where and how did Mr. Hines come by his death?�, I recorded as follows: � �On 30.6.23 Mr. Hines, who had recently sustained a fractured right neck of femur following a fall whilst an inpatient in the Alexandra Hospital, Redditch, was admitted to Worcestershire Royal Hospital and underwent surgery there to fix the fracture the following day. A few days later his surgical wound became infected with the bacteria methicillin-resistant staphylococcus aureus ( MRSA ). Despite treatment, including surgical debridement and washout of the infected wound, his condition continued to deteriorate, and he died in hospital on 15.7.23. Investigations confirmed that he had picked up the MRSA bacteria because his room at the Alexandra Hospital, which had previously been occupied by another patient with MRSA, had not been cleaned in accordance with hospital policy.�

I have sent a copy of my report to the Chief Coroner and to the following: � [REDACTED], ( Mr. Hines� brother ). �� I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Worcestershire Acute Hospitals NHS Trust

04/06/2024

2024-0303

Susan Edwards

Worcestershire

[REDACTED], Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD;

On 17 October 2023 I commenced an investigation and opened an inquest into the death of Susan Lynne EDWARDS. The investigation concluded at the end of the inquest on 28 May 2024 � The conclusion of the inquest was that Mrs. Edwards �Died as the result of a recognized complication of an accidental fall�.

In answer to the questions �when, where and how did Mrs. Edwards come by her death?�, I recorded as follows: � �On 7.10.23 Susan Edwards, who had fractured her left neck of femur in a fall in hospital in August 2023, and who had been admitted to Worcestershire Royal Hospital on 10.9.23 and treated for a likely urinary tract infection, suffered a sudden deterioration in her condition. Despite treatment, she declined and died in hospital later the same day. Post mortem examination has established that she died as the result of developing a large pulmonary embolus.�

I have sent a copy of my report to the Chief Coroner and to the following: � [REDACTED], Mrs. Edwards� daughter. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Worcestershire Acute Hospitals NHS Trust

24/09/2024

2024-0512

Kelly Stevens

Worcestershire

[REDACTED], Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD;

On 21 February 2024 I commenced an investigation and opened an inquest into the death of Kelly Marie STEVENS. The investigation concluded at the end of the inquest on 24 September 2024 � The conclusion of the inquest was that Ms. Stevens �Died from complications associated with an excessively low, and unrecognized, sodium level while in hospital. Her death was contributed to by neglect.�

In answer to the questions �when, where and how did Ms. Stevens come by her death?�, I recorded as follows: � �On 28.12.23 Kelly Stevens, who lived with profound learning and physical disabilities, and received all nutrition, hydration and medication via a percutaneous endoscopic gastrostomy ( PEG ) tube, was admitted to Worcestershire Royal Hospital with abdominal distension and concern about her PEG tube. She was diagnosed with a likely pseudo-bowel obstruction and a plan was made for her to undergo endoscopic investigation. In the meantime, she was prescribed intravenous fluids but her intake of these was not properly recorded, and her electrolyte levels were not monitored. On the morning of 3.1.24 she suffered a seizure during which she aspirated some vomit. This seizure was caused by an excessively low sodium level which had not been recognized. She went on to develop aspiration pneumonia and, despite treatment, declined and died in hospital later that night.�

I have sent a copy of my report to the Chief Coroner and to the following: � [REDACTED], Ms. Stevens� mother; Dimensions UK, who run the supported living accommodation where Ms. Stevens� lived; The Care Quality Commission. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Worcestershire Acute Hospitals NHS Trust

17/01/2025

2025-0033

Vauna Leeming

Worcestershire

[REDACTED], Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD;

On 3 April 2024 I commenced an investigation and opened an inquest into the death of Vauna LEEMING. The investigation concluded at the end of the inquest on 15� January 2025.� The conclusion of the inquest was that Mrs. Leeming �died from natural causes, to which a recent fractured neck of femur and surgical repair thereof contributed�.

In answer to the questions �when, where and how did Mrs. Leeming come by her death?�, I recorded as follows:� �On 6.2.24 Vauna Leeming was admitted to Worcestershire Royal Hospital after� suffering an accidental fall at home, and was found to have sustained a fractured right neck of femur. She underwent surgery to repair the fracture on 8.2.24, from which she initially made a satisfactory recovery. However, on 23.3.24 her condition deteriorated,� and she tested positive for Covid-19. She went on to suffer a pulmonary embolism� and, despite treatment, declined and died in hospital on 25.3.24.�

I have sent a copy of my report to the Chief Coroner and to the following: (a)�[REDACTED] ( Mrs. Leeming�s husband and next of kin ); (b)�[REDACTED], National Medical Director, NHS England. � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief� Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Worcestershire Acute Hospitals NHS Trust

14/11/2024

2024-0633

Teresa Auriemma

Worcestershire

[REDACTED], Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD;

On 25 March 2024 I commenced an investigation and opened an inquest into the� death of Teresa AURIEMMA. The investigation concluded at the end of the inquest on 14 November 2024� The conclusion of the inquest was that Mrs. Auriemma �Died as the result of an over- prescription of supplementary potassium, due to a failure properly to monitor� potassium levels in her blood. Mrs. Auriemma�s death was contributed to by neglect.�

In answer to the questions �when, where and how did Mrs. Auriemma come by her death?�, I recorded as follows:� �On 18.2.24 Teresa Auriemma was admitted to the Alexandra Hospital, Redditch after� becoming unwell at home, and treated for aspiration pneumonia, dehydration and� acute kidney injury, and deranged electrolytes. When reviewed in hospital on 15.3.24� she was given further intravenous potassium, a decision which was based on an out- of-date and inaccurate blood test. After the provision of that intravenous potassium, a� blood test should have been carried out to check Mrs. Auriemma�s potassium levels,� but was not, and she was given further intravenous potassium on 16.3.24. She then� collapsed suddenly on the ward on 17.3.24, and was confirmed deceased a short time later. A blood test which had been taken very shortly before she died confirmed a� fatally high level of potassium. Had Mrs. Auriemma�s potassium level been checked�on 14 or 15.3.24 and again on 16.3.24, it is likely that her death would have been� prevented.�

I have sent a copy of my report to the Chief Coroner and to the following: (a) [REDACTED] and�[REDACTED]�( Mrs. Auriemma�s daughters ); I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Worcestershire Acute Hospitals NHS Trust

20/09/2024

2024-0509

Margaret Maycroft

Worcestershire

[REDACTED], Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD;

On 31 January 2024 I commenced an investigation and opened an inquest into the� death of Margaret Rose MAYCROFT. The investigation concluded at the end of the inquest on 12 September 2024.� The conclusion of the inquest was that Ms. Maycroft �Died from natural causes, to which injuries sustained in a number of recent accidental falls contributed.�

In answer to the questions �when, where and how did Ms. Maycroft come by her death?�, I recorded as follows:� �On 18.12.23 Margaret Maycroft, who had recently suffered a number of falls at home, which had caused an intracranial bleed, and on a hospital ward during a previous� admission, was readmitted to Worcestershire Royal Hospital and found to have� suffered an ischaemic stroke. During this admission, she suffered two further falls and� was found to have sustained a displaced fractured neck of femur. She underwent� surgery to repair this fracture, but thereafter continued to decline. She was transferred� to the Princess of Wales Community Hospital, Bromsgrove for palliative care, and� declined and died there on 27.1.24.�

I have sent a copy of my report to the Chief Coroner and to the following: (a) [REDACTED], Ms. Maycroft�s nephew. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief� Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Worcestershire Acute Hospitals NHS Trust

26/01/2018

2023-0414

Vanessa Ferkova

Inner North London

[REDACTED], Chief Inspector of General Practice, Care Quality Commission [REDACTED], National Clinical Director for Urgent Care for NHS England, NHS England, PO Box 16738, Redditch, B97 9PT

Vanessa Ferkova died, aged 2, on 16 January 2017 from meningococcus septicaemia. The inquest into her death concluded on 26 January 2018; I recorded a narrative conclusion (see attached).

Miss Ferkova had a non-significant medical history. She presented to Coventry GP Walk-in Centre at 2pm on 16 January 2017 with her parents, having suffered from fever and vomiting that morning. A receptionist took down details of her illness and recorded that Vanessa looked �pale�. The information recorded did not meet the �red or yellow flag� conditions which would have prompted prioritisation of her care. � Her parents stated that Vanessa vomited in the waiting room which would have prompted prioritisation but they were not aware of this �flag� and did not report this incident. Vanessa also developed a rash whilst waiting to be seen which, if �non-blanching� would have also prioritised Vanessa assessment. Her parents� evidence was that the development of a rash was raised to the receptionist, although this was not her recollection of events. As such, there was no clinical assessment until Vanessa was seen by a nurse shortly after 4pm. � At that time she was recognised to be very unwell and likely suffering from meningococcal septicaemia. She was given antibiotics and and an ambulance was called. In the ambulance, at shortly after 4.30pm, Vanessa went into cardiac arrest. Unsuccessful resuscitation attempts were made, including on arrival at hospital shortly after her arrest, and she died at 5.11pm. � I heard evidence from the treating hospital paediatrician that it was likely Vanessa was suffering from compensated shock on her arrival at the walk-in centre and that, had observations been undertaken at this stage, this would have been recognised, treated and Vanessa would have survived. The paediatrician set out that recording clinical observations was a �vital patient safety tool� in the secondary care setting. I heard from commissioned to undertake clinical triage and that nor is there a timeframe within which patients are required to be initially assessed.

I have sent a copy of my report to the Chief Coroner, Miss Ferkova�s family, NHS England and Virgin Care Limited. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) This report is being sent to: Care Quality Commission | Urgent Care NHS England | Coventry and Rugby Clinical Commissioning Group | Virgin care Coventry LLP

18/04/2024

2024-0209

Alexander Reid

West Yorkshire (Eastern)

[REDACTED], Chief Medical Officer EMIS [REDACTED], Chief Medical Officer TPP [REDACTED], Chief Clinical Information Officer, Vision & Cegedim committee, BMA and RCGP [REDACTED], Medical Director for Primary Care [REDACTED], Chief Information Officer, NHS England [REDACTED], National Chief Clinical Information Officer, NHS England The Digital Safety Team at NHS England

On 14th July 2021 I commenced an investigation into the death of Alexander (Alex) Lee Reid, 22/12/1992. The investigation concluded at the end of the Inquest on 10/11/2023. The conclusion of the Inquest was a narrative conclusion reflecting Alex�s death being linked to his having received the Oxford AstraZeneca vaccination against Covid-19, the medical cause of death being 1a) Cerebral Venous Sinus Thrombosis 1b) Covid-19 Vaccine-Induced Immune Thrombotic Thrombocytopenia.

Alex was invited to receive his Covid vaccination earlier than his age alone would have entitled him to do so. Alex received his first dose of the Oxford AstraZeneca vaccine on 21/03/2021. On 07/04/2021, official advice was given that persons aged under 30 should not receive the Oxford Astra Zeneca vaccination as their first vaccination. Those who had by that date received it as their first vaccination were advised to receive it as their second. Alex did so on 18/05/2021. He died on 29/06/2021. He was 28.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;. I have also sent it to [REDACTED] � who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of our response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: EMIS | TPP | Vision and Cegedim | BMA and RCGP | NHS England

09/05/2024

2024-0254

Brandon Turner

Cornwall and the Isles of Scilly

[REDACTED], Chief Medical Officer, CIOS ICB The Rt Hon Victoria Atkins MP, Secretary of State for Health and Social Care

On 9 May 2024, I concluded the inquest into the death of Brandon William Turner, also known as Amelia Turner, who died on 21/6/23 at the age of 21. In accordance with the wishes of his mother who attended inquest, I shall refer to him hereafter as Brandon. � I recorded the cause of death as 1a) Asphyxia 1b) Fatal pressure on the neck; II) PTSD; Autism � I concluded Brandon died from suicide.

Brandon had suffered adverse childhood experiences including neglect and emotional abuse that led to his adoption along with his brother. As he grew into adolescence and then early adulthood mental health difficulties emerged that led to a diagnosis of complex PTSD/emotionally unstable personality disorder. Additionally, he had a diagnosis of autistic spectrum disorder. In total, Brandon had five Mental Health Act assessments between May 2021 and May 2023, to include two on consecutive days on 14 and 15 May 2023, the latter following detention under s136. I heard at inquest that it is contrary to national guidance and local policy to admit someone with PTSD/EUPD into hospital and, absent any other therapeutic option, the consultant psychiatrist referred Brandon to the local CMHT. He was discussed at MDT on 23/5/23 and a duty worker spoke to him on 16/6/23 when a decision was made to put him on the CMHT therapy pathway. He was found deceased five days later before any treatment had commenced. On reflection, it was noted that referrals would aim to be actioned within five days but took 16 here. The inquest heard that the CMHT was short- staffed at the time and the Manager concerned was fulfilling two roles.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� [REDACTED] � mother � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: CIOS ICB | Department of Health and Social Care

14/05/2024

2024-0267

Sally Poynton

Cornwall and the Isles of Scilly

[REDACTED], Chief Medical Officer, CIOS ICBRt Hon V Atkins MP, Secretary of State for Health & Social Care

On 8 May, I concluded the inquest into the death of Sally Poynton who was stabbed to death by her son on 22 June 2021. � I recorded the cause of death as 1a) Knife wounds to neck and abdomen � I returned the following narrative conclusion. Sally Poynton was unlawfully killed. Had referrals for medical re-assessment of her assailant been accepted or a needs assessment conducted, on the evidence, it is more likely than not that the assailant�s deteriorating mental health would have been identified, a treatment plan instituted, and Sally would not have died when she did.

This was a long and complex inquest involving multiple State agencies. I enclose a copy of my written judgment. In summary, my overview of the background to the case was as follows: � 1) Sally was just 44 years of age when she was fatally stabbed on 22 June 2021. What compounds this tragedy is that it was her son [REDACTED] who was her assailant when Sally had known he was unwell for some considerable time and had been trying to obtain help for him. At [REDACTED] subsequent criminal trial, he was diagnosed by two psychiatrists with schizophrenia. He wascharged with murder but, given his diagnosis, the Crown accepted a plea of guilty to manslaughter on the grounds of diminished responsibility. [REDACTED] has been made the subject of a hospital order pursuant to s37 MHA with a s41 restriction. He did not attend the inquest. 2. [REDACTED] mental health difficulties were known. Indeed, as we shall hear, in June 2020, a year before Sally�s death, he had been detained under s2 of the MHA and spent 10 days or so as an in-patient at Longreach Hospital. After his discharge, [REDACTED] was recognised by various members of his family, particularly Sally, to deteriorate still further. She tried repeatedly to persuade State agencies to help her son. The NHS England report (the Niche report) documents 23 specific requests to four different agencies from Sally for�[REDACTED] to be seen and have his mental health assessed and ten occasions when other family members requested help. Yet, at the time of her death, as a matter of fact, [REDACTED]�was not under the care of CPFT and had not been assessed by a doctor from the Trust for a year. Additionally, there had been four alerts to safeguarding but in the 13 months where [REDACTED] was known to Adult Social Care, no one had actually seen him, face-to-face. 3. This inquest has been concerned to understand how Sally could have died in these circumstances. In addition to my written judgment, you may wish also to consider the independent NHS mental health review (the Niche report) and the forthcoming DHR, a final draft of which was made available to the Interested Persons.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Sally�s family; ��� [REDACTED]; ��� [REDACTED]; Penryn Surgery; Cornwall Council � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: Cornwall & Isles of Scilly Integrated Care Board | Cornwall Council | Department of Health and Social Care | CIOS ICB

29/12/2023

2023-0549

Andrew Guillaume

Coventry and Warwickshire

[REDACTED], Chief Medical Officer, South Warwickshire University NHS Foundation Trust����������������������� [REDACTED], Chief Executive of South Warwickshire University NHS Foundation Trust Secretary of State for Health, Department of Health NHS

On 6 July 2023 I commenced an investigation into the death of Andrew Douglas Guillaume, aged 51. The investigation concluded at the end of the inquest on 29 December 2023. The conclusion of the inquest was a narrative verdict.

1. Mr Guillaume was admitted to Warwick Hospital on 5 June 2023, having presented himself to his GP with shortness of breath and a cough. 2. Following a review on 7 June 2023, it was agreed that the likely diagnosis was severe aortic stenosis requiring an urgent Consultant to Consultant referral to University Hospitals Coventry and Warwickshire (UHCW) cardiology team, to be followed by a multi-disciplinary meeting with UHCW. 3. No Consultant to Consultant referral was made as the Consultant was unable to get through to the switchboard at UHCW. 4. Mr Guillaume remained at Warwick Hospital. 5. Mr Guillaume�s condition worsened and on 16 June 2023 a plan was made to update the cardiothoracic surgery team at UHCW to expedite the surgery required but the Consultant was unable to get through to the switchboard at UHCW. 6. Mr Guillaume was admitted to the Cardiothoracic Critical Care unit at UHCW on 19 June 2023, but sadly died on 20 June 2023 due to a further sudden deterioration in his condition.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED]� brother and sister-in-law of the deceased I have also sent it to Chief Executive, University Hospital Coventry and Warwickshire, who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: South Warwickshire University NHS Foundation Trust | University Hospitals Coventry and Warwickshire NHS Trust | Department of Health and Social Care | NHS England

14/10/2024

2024-0545

Mia Gauci-Lamport

Surrey

[REDACTED], Chief executive, NHS England [REDACTED], Health Secretary, Department of Health [REDACTED], Chief Executive, Children�s Trust, Tadworth [REDACTED], Medical Director, Children�s Trust, Tadworth Care Quality Commission

On 30th July 2024 I recommenced an investigation into the death of Mia Louise Gauci-Lamport.� On 6th August 2024 I concluded the Investigation. The medical cause of death given was: 1a. STXBP1 related Encephalopathy with Epilepsy I concluded in the record of Inquest that Mia had died by way of: Natural causes

Mia had Ohtahara syndrome due to an STXBP1 gene mutation. This� causes treatment resistant refractory epilepsy and progressive global� developmental delay. She required assistance for all her activities of daily living requiring full-time residential care which had been provided by� Tadworth Children�s Trust, (TCT), Tadworth from July 2020.� �� On 10th September Mia was well prior to going to bed and during the� early hours of the 11th September 2023. She was last known to be alive at� 06.10 hours. A carer entered her room at or around 06.15 but did not� undertake any visual checks. Mia was found cyanotic and unresponsive� 17 minutes later at or around 06.32 hours. Resuscitation was undertaken� but was not successful and she was recorded to have died at the Trust� shortly thereafter.

COPIES� I have sent a copy of this report to the following: 1.�[REDACTED] and [REDACTED] 2.�[REDACTED] In addition to this report, I am under a duty to send the Chief Coroner a� copy of your response.�� The Chief Coroner may publish either or both in a complete or redacted� or summary form. He may send a copy of this report to any person who, he believes, may find it useful or of interest. You may make� representations to me at the time of your response, about the release or� the publication of your response by the Chief Coroner.

Child Death (from 2015) | Care Home Health related deaths

NHS England | Department of Health and Social Care | Tadworth Children�s Trust | Care Quality Commission

24/10/2022

2023-0001

Terri Malone

Herefordshire

[REDACTED], Clinical Lead, Herefordshire and Worcestershire Healthy Minds

On 9 February 2022 I commenced an investigation into the death of Terri Ann Malone. The investigation concluded at the end of the inquest on 10 October 2022. The conclusion of the inquest was �Alcohol Related.

The deceased was drinking excessively and probably died from ketoacidosis as a consequence of excessive alcohol consumption, however at the time of her death she was also known and had received assistance from Adult Safeguarding, Hereford Recovery Service, The Mental Health Crisis Team, the Police and others.

Alcohol, drug and medication related deaths

Herefordshire and Worcestershire Healthy Minds

03/10/2024

2024-0526

Gabrielle Steel

East London

[REDACTED], Commissioner, London Fire Brigade Sent via email:�[REDACTED] [REDACED], Chief Executive Officer, London Borough of Newham. Sent via email:�[REDACTED]

On the 6 November 2023 I commenced an investigation into the death of Mrs Gabrielle Sarah Anne Steel (aged 76 years). The investigation concluded at the end of the�inquest on the 2 October 2024. The conclusion of the inquest was that Mrs Steel died�as a result of an accident.

Gabrielle Steel suffered a decline in her overall health from January 2023, following the death of her husband. She was admitted to hospital in March 2023 with weakness,� malnutrition, and deranged electrolytes. She required admission to hospital for around� 3 weeks, following which she was deconditioned, and her mobility was much reduced.� On discharge from hospital in April 2023 she was bed bound. Mrs. Steel was known by� the multi-agencies supporting her, to be bed bound; to smoke in her bed and to drink� alcohol. The risk of fire was recognised, and the local authority occupational therapist� requested a fire home safety visit from the London Fire Brigade. A fire home safety visit took place by the London Fire Brigade at her home address on the 3 August 2023. The� London Fire Brigade assessor recommended flame retardant bedding. They also� recommended to Mrs. Steel that her non-flame-retardant bedding should be disposed� of. The flame-retardant bedding was provided promptly, but there was poor� communication of the wider fire risk management plan. The outcome of the fire� assessment was not shared with Mrs. Steel�s daughter, the care agency or the referring� occupational therapist. A copy of the fire risk assessment document and management� plan was not left within the premises to inform those caring for Mrs. Steel. The local� authority care and support plan was updated by a social worker on the 29 September� 2023. The fire risk was again recognised, but there is no evidence that any attempt was� made to seek the outcome of the fire safety visit or to devise a fire risk management� plan. On the late evening of 17 October 2023 the emergency services were called, due� to a fire in Mrs. Steel�s home address. The fire service attended promptly. A fire was� discovered on Mrs. Steel�s bed. Mrs. Steel was removed from the address and� resuscitation was provided. Sadly, she did not respond to resuscitation and her life was� pronounced extinct on scene. A fire investigation determined that the likely cause of� the fire was the unsafe disposal of smoking materials on the bed area. The flame- retardant duvet cover was not on the bed at the time of the fire.

I have sent a copy of my report to the Chief Coroner and to the family of Gabrielle�Steel, to Highland Care UK Ltd and to the local Director of Public Health who may find it useful or of interest.� I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� �� I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it� useful or of interest.�� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Product related deaths | Other related deaths | Emergency services related deaths (2019 onwards)

London Fire Brigade | London Borough of Newham

16/08/2024

2024-0457

Anthony Nixon

County Durham and Darlington

[REDACTED], Community Pharmacist and Director, York Road Pharmacy, Peterlee. The General Pharmaceutical Council (GPhC).

On the 4th of September 2023 an investigation was commenced into the death of Anthony Paul Nixon. The investigation concluded at the end of the inquest on the 15th of August 2024 . I gave a conclusion that the death was drug related and that the actions of the Pharmacy contributed more than minimally in supplying additional methadone on multiple occasions, not in accordance with the prescription for such. The medical cause of death was :- 1a) The combined toxic effect of [REDACTED], [REDACTED] and [REDACTED].

Anthony Paul Nixon, aged 45 years, was found deceased on the 12th June 2023 at his home address. He died as a result of an a drug overdose, having taken a combination of [REDACTED], [REDACTED] and [REDACTED], which in combination led to a fatal toxicity. � Despite a prescription for supervised consumption of [REDACTED] on specific days, including a home office approved form of wording on the prescription in relation to such, on a number of occasions in the period leading to his death, the deceased was given his [REDACTED] in advance for days when the pharmacy was open, which was not in accordance with the prescription which was issued for him, which was designed to reduce the obvious risks of the deceased taking additional [REDACTED].

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; the Family of the deceased and �My space� supported housing provider. I have also sent a copy to CGL (Change Grow Live) and Humankind � drug and alcohol treatment agencies, and to the Care Quality Commission (CQC)� who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

�Alcohol, drug and medication related deaths

York Road Pharmacy | General Pharmaceutical Council

31/07/2024

2024-0416

Susan Pollitt

Manchester North

[REDACTED], Department of Health And Social Care, 39 Victoria Street, London, SW1H 0EU [REDACTED], Chief Executive, General Medical Council, Regent�s Place, 350 Euston Road, London NW1 3JN President of the Faculty of Physician Associates, Royal College of Physicians, 11 St Andrews Place, Regents Park, London NW1 4LE

On the 17th July 2023, I commenced an investigation into the death of Susan Pollitt. Mrs Pollitt died on the 16th July 2023. The investigation concluded on the 29th July 2024. The medical cause of death was confirmed as 1a) Spontaneous Bacterial Peritonitis 1b) Prolonged Insertion of Ascitic Drain 1c) Non Alcoholic Liver Cirrhosis 2) Type 2 Diabetes Mellitus, Osteoarthritis and Fracture of the Humerus. The Inquest concluded that Mrs Pollitt died as a result of an unnecessary medical procedure contributed to by neglect.

CIRCUMSTANCES OF DEATH On the 3rd July 2023 Mrs Pollitt was admitted to the Royal Oldham Hospital (the Hospital) following a collapse at her home address. She was treated for a number of medical issues including acute kidney injury. During her admission, she developed ascites. The Consultants involved in her care decided an ascitic drain was not required at that time. On the 11th July, a junior doctor reviewed Mrs Pollitt and decided that an ascitic drain should be placed. The Court found that this procedure was not clinically indicated at that time. The Physician Associate who undertook the procedure was not aware of the local Hospital Guidance on the insertion of ascitic drains or that the drain should remain in place for no longer than six hours. Mrs Pollitt�s drain remained in place for 21 hours before being removed. The Physician Associate had also directed that the drain be clamped due to a concern that the loss of fluid could cause a drop in blood pressure. This was unwarranted given the moderate level of fluid which had been drained and the Court heard that the Physician Associate did not appreciate that clamping a drain increased the risk of infection. Mrs Pollitt developed bacterial peritonitis and died on 16th July 2023. The situation was compounded by Mrs Pollitt�s placement on a respiratory ward rather than a gastroenterology ward since there was a lack of understanding and awareness across all the staff on the respiratory ward including the medical team as to the management of ascitic drains.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- Family of Mrs Susan Pollitt Northern Care Alliance � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: Department of Health and Social Care | General Medical Council | Faculty of Physician Associates

06/06/2024

2024-0309

Dominic Chapman

Worcestershire

[REDACTED], Director and sole proprietor, Ultra Events Ltd, Unit 15b Sawley Park, Nottingham Road, Derby, England, DE21 6AS;

On 28 April 2022 I commenced an investigation and opened an inquest into the death of Dominic Mark Chapman. The investigation concluded at the end of the inquest on 23 May 2024 � The conclusion of the inquest was that Mr. Chapman �died as the result of an accident.�

In answer to the questions �when, where and how did Mr. Chapman come by his death?�, I recorded as follows: � �On 9.4.22 Dominic Chapman sustained a fatal head injury in the course of a charity boxing match organised by Ultra Events Ltd at Tramps nightclub in Worcester. He was taken by ambulance to the Queen Elizabeth Hospital, Birmingham where he succumbed to that injury and died on 11.4.22.�

I have sent a copy of my report to the Chief Coroner and to the following: � [REDACTED], Mr. Chapman�s parents; Tramps Nightclub, Worcester; Worcestershire Regulatory Services. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: Department for Digital Culture, Media and Sport | Ultra Events Ltd

07/03/2024

2024-0174

David Siirak

West London

[REDACTED], Director of Safety Central and North West London NHS Foundation Trust 350 Euston Road Regent�s Place London NW1 3AX

INQUEST I conducted an Inquest into the death of David Louis SIIRAK between 4 and 7 March 2024. 3 Mr Siirak was a detained inpatient in Frays Ward in the Riverside Centre. On 1 March 2020, he was the victim of a serious assault at the hands of another patient in his room on the Ward, as a result of which he suffered unsurvivable injuries which caused his death on 4 March 2020.

CORONER�S CONCERNS 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. Mr Siirak was discovered in his room, having been assaulted, at 1647 hours on 1 March 2020. The crash team, led by�[REDACTED], arrived at 1703 hours. The evidence was that between those times (until�[REDACTED] took charge at 1703) the response of ward staff to the incident was �chaotic� and �panicking� (as was acknowledged by the staff). � The evidence was that various members of your staff had never previously been involved in a real or simulated emergency. By �simulated emergency�, I mean an unexpected dummy run on the ward, as opposed to training in the calm confines of a planned day. � One member of staff told the court that she had never been involved in an unexpected simulated emergency in the 14 years of working on the ward prior to 1 March 2020, nor in the 4 years since. � The jury found that �there was a clear failure to provide the adequate training in simulation exercises to effectively manage situations like the one that occurred on 1st March 2020.� � It was equally clear on the evidence that members of staff have still not undergone unexpected simulation training.

Richard Furniss, Assistant Coroner for West London

Other related deaths This report is being sent to: Central and North West London NHS Foundation Trust

18/09/2023

2023-0336

Anthony Friend

Worcestershire

[REDACTED], Director, Bluebird Care, 3 Millenium Court, Buntsford Park Road, Bromsgrove, Worcestershire B60 3DX [REDACTED] Chief Executive, Herefordshire and Worcestershire Health and Care NHS Trust, Kings Court, 2, Charles Hastings Way, Worcester WR5 1JR ( �HWHCT� ). [REDACTED] Director, Divine Health Services Ltd.,Unit59, Basepoint Business Centre,Isidore Road,Bromsgrove,WorcestershireB60 3ET.

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 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.�

I have sent a copy of my report to the Chief Coroner and to the following: (a)� [REDACTED], Mr. Friend�s daughter; (b)� [REDACTED], Director, Divine Health Services Ltd.; (c)��[REDACTED], Chief Executive, Herefordshire and Worcestershire Health and Care NHS Trust. � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths This report is being sent to: Bluebird Care | Herefordshire and Worcestershire Health and Care NHS Trust | Divine Health Services

27/06/2024

2024-0346

Norman Leadbeater

Manchester North

[REDACTED], Director, Evolve Services, Bury Business Centre, Unit 23, Kay Street, Bury, BL9 6BU

On 24 January 2024 an investigation into the death of Norman Leadbeater was commenced. The investigation concluded at the end of the inquest on 27 June 2024. I recorded a conclusion of Natural Causes. The medical cause of death was 1a) Aspiration Pneumonia 1b) Parkinsons Disease 2) Liver Cancer

CIRCUMSTANCES OF DEATH Norman Leadbeater had a past medical history of advanced Parkinsons disease, vascular dementia and presumed liver cancer. Following a swallowing assessment on 10 November 2023, he was advised to have thickened fluids to prevent chest aspiration. He was admitted to Fairfield General Hospital on 27 November and diagnosed with aspiration pneumonia secondary to Parkinsons disease. His medications were altered to liquid and dispersible forms. He was readmitted to hospital on 7 January and diagnosed with a further aspiration pneumonia. Despite treatment, he deteriorated and died on 14 January 2024.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- The family of the Deceased Bury Adult Social Care The Care Quality Commission Bury Integrated Care Partnership � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Evolve Services

12/05/2023

2023-0172

Angela Craddock

Cheshire

[REDACTED], Director, HMP Altcourse Ministry of Justice HM Prisons & Probation Service

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.

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Cheshire Constabulary National Probation Service Representatives of the former Cheshire Rehabilitation Company Family � I have also sent it to [REDACTED], Chair, Domestic Homicide Review who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: HMP Altcourse, Ministry of Justice and HM Prison and Probation Service

14/08/2023

2023-0294

Leonard King

Milton Keynes

[REDACTED], Executive Officer � Association of Ambulance Chief Executives [REDACTED], Chief Executive Officer � Royal College of Emergency Medicine� [REDACTED], Chief Executive Officer � Royal College of General Practitioners [REDACTED], Chief Executive Officer � Urgent Health UK

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.

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons ������ Family of Mr King ������ Milton Keynes Urgent Care Centre ������ South Central Ambulance Service � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Association of Ambulance Chief Executives | Royal College of Emergency Medicine | Royal College of General Practitioners | Urgent Health UK

11/07/2023

2023-0242

John James

East London

[REDACTED], Group Chief Executive of Barts Health NHS Trust

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. The conclusion of the inquest was a narrative conclusion: � Mr. James died as a result of a pulmonary embolism during the course of a lengthy hospital admission. He was at very high risk of developing a venous thromboembolism. There were three missed doses of anti-coagulation medication in the two weeks leading up to his death.

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.

I have sent a copy of my report to the Chief Coroner and to the family of Mr James. I have also sent a copy to the local Director of Public Health who may find it useful or of interest and to the CQC. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Barts Health NHS Foundation Trust

17/04/2024

2024-0206

Timothy Clayton

Surrey

[REDACTED], Group Chief Executive, St George�s. Epsom and St Helier Hospital Group. [REDACTED], Chief Executive Officer of NHS England.

An inquest into the death of Mr Timothy Charles Clayton was opened on the 29th December 2022 and resumed on the 16th January 2024. The inquest was concluded on the 12th March 2024 when evidence in respect of matters pertaining to this report was heard. � It was concluded that Mr Clayton died on the 12th December 2022 at Epsom General Hospital and the medical cause of his death was: � 1a Hypothermia 1b Self Neglect and Chronic Alcohol Excess A narrative conclusion found that: Timothy Clayton was suffering from alcohol related brain damage and malnutrition as result of chronic alcohol use. His mobility was impacted and he had fluctuating confusion. He was found hypothermic at home on the 27th October 2022, taken to hospital and discharged. On the 20th November 2022 he was again hypothermic and was admitted to hospital. He was discharged on the 24th November 2022 to be cared for by a family member. On the 29th November 2022 he was admitted to hospital and transferred to Epsom General Hospital suffering with reduced mobility, slurred speech and confusion. The underlying cause of his condition was not diagnosed. He was found to be medically fit for discharge. The discharge planning was not undertaken in accordance with the hospital policy. No heed was paid to his family�s concerns that he was not well enough to care for himself. He was discharged on the 5th December 2022 to live at his own flat. The heating was inadequate and he self neglected in relation to eating. He was found profoundly hypothermic on the 11th December 2022 and admitted to Epsom General Hospital. He died from the effects of hypothermia on the 12th December 2022. Pressure on staff to vacate hospital bed spaces led to inadequate discharge planning and more than minimally contributed to the death.

Mr Clayton�s health had declined in the summer of 2022 and he had lost a significant amount of weight. He was suffering from alcohol related brain damage and continued to abuse alcohol. His mobility was impacted and he had fluctuating confusion. He was self neglecting and his ability to live alone was reduced. He developed hypothermia in an inadequately heated flat. There was a lack of information sharing and investigation in relation to the discharge planning for Mr Clayton. Contrary to the Trust�s policy he was not identified as a vulnerable patient. His family was not involved in the discharge planning. On a number of occasions, they raised their concerns as to his ability to live independently and were ignored. Staff were unaware of the discharge planning policy. The underlying cause for his presentation was not diagnosed. Discharge decisions were taken in a vacuum without understanding the recent history of frequent admissions, his diagnosis and without sufficient investigation of his home circumstances. An assumption that Mr Clayton had capacity was made and used to justify his discharge without considering whether he could make informed decisions about his ability to live alone without knowing what underlay his deterioration and how his ability to self-care was impacted. It was accepted that pressure to vacate hospital bed spaces played a part in the inadequacy of discharge planning. The imperative to free up a bed space led to a rushed discharge on the 5th December 2022 without an adequate care plan being in place.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Mr Clayton�s family Epsom General Hospital Surrey County Council The Care Quality Commission � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Alcohol, drug and medication related deaths This report is being sent to: St George�s Epsom and St Helier Group | NHS England

26/11/2024

2024-0655

Elan Adams

East London

[REDACTED], Group Operations Director, Abbey Healthcare, Sutherland House, 70-78 West Hendon Broadway, London, NW9 7BT� Sent via email: [REDACTED]

On 20 February 2024 I commenced an investigation into the death of Elan Gransford� Adams (aged 69 years old). The investigation concluded at the end of the inquest on the 18 November 2024. The conclusion was that Mr Adams died as a result of an� accident (choking on food in care home setting).

Mr. Adams resided in a nursing home. He was not at known risk of choking and there� was no evidence of dysphagia. He was able to eat a level seven (normal), diet. He� required staff to provide meals to him. On the 5 February 2024, Mr. Adams was� provided with a burger at around 630pm. When staff attended to collect his plate, at� around 7pm, he was found with the burger scattered over his lap and he was not fully� responsive. The care assistant called for a nearby nurse. The nurse attended and a set� of observations were taken, which were concerning and included an oxygen saturation of 87%. At 7.14pm a call was made to the London Ambulance Service. A poor history� was provided by the nurse; the call sound quality was poor and there was a lack of� clarity around Mr. Adams� respiratory status. During the call, Mr. Adams stopped� breathing and the staff carried out chest compressions under the guidance of the LAS� call handler. Paramedics arrived at 7.41pm and took over resuscitation efforts. On� inspection of the lower airway, utilising specialist equipment, a food obstruction was� seen, and attempts were made to clear this. After removing the visual obstruction,� ventilations became effective, and a return of spontaneous circulation was achieved.� Mr. Adams was taken to Newham University Hospital. Emergency care continued, but� sadly there was no further response. Mr. Adams passed away at Newham University� Hospital at 853pm on 5 February 2024. A post-mortem examination confirmed the� cause of death to be choking on a food bolus.

I have sent a copy of my report to the Chief Coroner, to the family of Mr Adams, to the London Ambulance Service, the Care Quality Commission, and the local Director of� Public Health who may find it useful or of interest.� I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� �� I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it� useful or of interest.�� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Care Home Health related deaths

Abbey Healthcare

04/03/2024

2024-0125

Vanessa Ford

Inner North London

[REDACTED], Group Safety & Engineering Director, Network Rail ������������������������������������������ [REDACTED], Interim Chief Executive, London Borough of Hackney, 1 Hillman Street, London, E8 1DY

On 2 October 2023, an investigation was commenced into the death of VANESSA FORD, then aged 47 years. The investigation concluded at the end of an inquest, heard by me, on Monday 26 February 2024. � The conclusion of the inquest was a short narrative conclusion, the medical cause of death being: � 1a multiple traumatic injuries

On 23 September 2023, Vanessa Ford consumed a significant amount of alcohol while undergoing an acute mental health crisis. She accessed [REDACTED] and allowed herself to drop onto the railway tracks below, where she was later struck by a train. There is insufficient evidence to suggest that she intended to take her own life.

COPIES and RESPONSE I have sent a copy of my report to the Chief Coroner and to the following Interested Person: � [REDACTED] �(Vanessa Ford�s husband) � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Railway related deaths This report is being sent to: Network Rail | London Borough of Hackney

20/12/2024

2024-0702

Haydar Jefferies

Surrey

[REDACTED], HMP Coldingley� [REDACTED], Minister of State for Prisons, Parole and Probation.�� [REDACTED], CEO NHS England [REDACTED], CEO Parole Board

An inquest into the death of Mr Haydar Jefferies was opened on the 4th April 2023 and resumed with a jury on the 11th November 2024. The� inquest was concluded on the 29th November 2024.�� The jury concluded that Mr Jefferies died on the 5th March 2023 at Frimley Park Hospital, Frimley and the medical cause of his death was:� 1a. Hypoxic Brain Injury and Bilateral Pneumonia 1b. Suspension�� They concluded with a narrative conclusion and found that: MATERIAL CAUSES Haydar died as a result of tying a ligature around his neck. It is not possible to determine his intention.�� The following are facts that, on the balance of probabilities, have been� found to have happened and have made a material contribution to Haydar Jefferies� death:� Between the 18th February 2023 and the 1st of March 2023, Haydar was� suffering from psychosis as referenced by the expert psychiatrist. The fact� that Haydar was an IPP prisoner and that his parole hearing was delayed� more than minimally contributed to the development of this psychosis, due to the psychological stress.� �� In February 2023, during Haydar�s detainment at HMP Coldingley, there� was a serious failure by the custodial staff to record risk relevant� information in regard to his presentation. Specifically, concerns raised by� his family through numerous telephone calls and concerning comments� made by Haydar to custodial staff. There was an additional failure to�ensure that risk relevant information was shared with prison officers and clinical staff.�� Between the 18th and 27th February 2023, there was a serious failure to� refer Haydar to the Mental Health team. This was despite evidence� showing acknowledgement and intent to make a mental health referral on more than one occasion. By 17.30 on the 28th of February 2023, Haydar� was floridly psychotic as evidenced by the expert psychiatrist. The proper response would have been to ensure his immediate safety by putting him� on constant supervision and taken him to an external place of safety due� to Coldingley�s unsuitable provision of safer cells. That none of this was� done represents a serious failure by HMP Coldingley custodial staff.�� There was a failure to undertake a substantive mental health assessment� on the 28th February 2023 following the morning referral from custodial� staff and the subsequent CSU review. A mental health review was booked in for the following day which was inadequate.�� POSSIBLE CAUSATIVE MATTERS�� The following are matters which we have found possibly occurred and more than merely speculatively made a material contribution towards� Haydar�s death but we have not found on the balance of probabilities:� Such records as were made were across multiple systems with different� levels of access, no set expectation of cross referencing and reliant on� individual initiative and curiosity to be found. The clinical staff at HMP� Coldingley were lacking this initiative and curiosity and thereby missed a pattern of behaviour that they could have identified and used to drive� better-informed clinical decisions at point such as the brief CSU rounds� and reviews.� When the allegation that led to Haydar�s recall was no longer being� pursued, there was an opportunity for the Secretary of State to consider an executive release, which was not taken. The IPP parole decision could� have been made on �on papers� without the need for a meeting, and this� too was declined.�� The training for custodial staff at HMP Coldingley is inconsistent and� inadequate with regard to mental health presentation. The ACCT� document and process is unsuitable for a mental health crisis of this kind. NEGLECT�� The death was contributed to by Neglect.�� This is in relation to a failure to share risk relevant information with clinical staff and procure mental health intervention for Haydar between the 18th� and the 27th February 2023 and a failure to procure medical attention for� Haydar after he suffered acute mental health deterioration on the evening of the 28th February 2023.�� SYSTEM FAILURE�� The death was caused or more than minimally contributed to by the failure on the part of the Ministry of Justice to ensure there was a system in place for the recording of the family concerns raised in telephone calls to the� prison.� ADMITTED FAILURES�� It is admitted that HMP Coldingley ought to have automatically conducted� five observations per hour because an ACCT was opened for Mr Jefferies whilst he was on the CSU. It is accepted that only two observations were� conducted per hour.

Haydar Jefferies was sentenced to imprisonment for public protection (�IPP�) in 2006. He was released in 2013. Haydar then integrated into� the community, married and was working as a publican. Following the death of his spouse and his father in 2021 Haydar attempted suicide.�� In January 2022 allegations were made against him and he was� recalled to prison under the terms of the IPP.� By April 2022 the� allegations were not being pursued. An Executive Release order� request was made and declined. ln order to be released from prison� Haydar had to attend a parole board hearing. The parole board�decided that a hearing in person was required.�� In May 2022 Haydar disclosed he had made a ligature. A parole board� hearing was fixed on the 13th October 2022.The parole board hearing� was vacated owing to the unavailability of the chair person. The next�parole hearing was listed for the 2nd March 2023. The extended period of detention was detrimental to Haydar�s health and he stated to� clinical staff he felt hopeless and helpless after his cancelled parole hearing.�� On the 28th December 2022 Haydar was transferred to HMP�Coldingley from HPM Bullingdon. Haydar travelled with prisoners who were aware Haydar had come from the vulnerable prisoners wing and� made inaccurate assumptions about reasons for being on the wing.� �� On arrival at HMP Coldingley Haydar�s mental health was reviewed� and appeared stable.�� On 10th February 2023 the Government rejected IPP resentencing. On the 12th February 2023 Haydar asked to be segregated for his own safety in the care and separation unit (CSU). This move was�supported by a call from Haydar�s mother concerned about his safety. On the 14th February Haydar reported low mood and was unwilling to� restart previously prescribed medication for depression.�� The Independent Monitoring Board (lMB) visited Haydar on February 15th 2023 following the Government rejection of the proposed IPP� resentencing. Haydar reported that he had lost hope�.�� From the 18th February 2023 Haydar developed severe depression� with psychosis. Haydar�s family made several calls to the prison from 18th February 2023 onwards raising concerns about his safety and� deteriorating mental health. These calls were not recorded in any� prison records.�� Haydar made various statements to individual prison staff from 18th February 2023 onwards, which were symptomatic of deteriorating� mental health and development of psychosis, including many which were not recorded in any prison records.�� A number of statements about Haydar�s presentation were recorded� across a disparate landscape of on and offline recording systems. On the 19th February custodial staff acknowledged the need to refer� Haydar to mental health. This referral was never made despite being� recorded as having been completed in prison records.�� On the 26th February 2023 custodial staff identified the need to� request a mental health review following Haydar�s delusional� allegations towards staff. Haydar then experienced auditory and� visual hallucinations and reported them to his family and custodial staff. This further evidence of psychosis was not recorded. At this�time, Haydar was also not taking part in the CSU regime, remaining in his cell at all times.�� Prior to the 28th February 2023 neither the information in the family� calls nor the concerning statements made to individual prison officers were shared with clinical staff or other prison staff and no referrals� were made to the mental health team in relation to Haydar.� On the morning of the 28th February 2023, Haydar told custodial staff� he had made peace and was ready for staff to kill him. An email� referral, followed up by a phone call, was made to the mental health� team for Haydar to be seen as soon as possible on the morning of the� 28th February 2023. No mental health assessment was conducted that day.�� ln the afternoon of the 28th February 2023 Haydar attended a CSU� review. During the review Haydar requested a mental health� assessment. As part of the review documentation, the CSU algorithm was completed as �no psychosis�. Evidence provided by an expert� witness determined that in fact Haydar was psychotic from 18th� February 2023, and on the morning of the 28th had demonstrated red flag behaviour. The CSU review document was not fully completed.� The box relating to mental health concerns was left blank.�� At around 16.30 on the 28th February 2023 Haydar was observed in�his cell, flushing his head down the toilet, naked, on all fours, barking� like a dog and he said a female officer had told him to behave like this. At this stage Haydar was floridly psychotic.�� An ACCT was opened at 17.30. The ACCT was not fully completed� with a justification for Haydar to remain in CSU. No Defensible� Decision log was completed. No medical advice was sought and no� medical treatment obtained for Haydar on the evening of the 28th� February 2023. The medical team were still on site at the time the� ACCT was opened. Observations were incorrectly set at 2 per hour� and only constant observations would have been sufficient to ensure safety.�� Haydar remained on the CSU. This was not appropriate, outside� provision should have been sought. During CSU observation, Haydar was found to be slumped over the toilet in his cell. At 2.40 on the 1st� March 2023 Haydar was found in cardiac arrest having self -ligatured� in his cell. Paramedics attended within minutes and resuscitated� Haydar and transported him to Frimley Park Hospital where he was� admitted at 04.45 on 1st March 2023.�� Haydar had sustained a hypoxic brain injury. Haydar was pronounced dead at 15.11 on the 5th March 2023 at Frimley Park Hospital. His� death was caused by hypoxic brain injury and pneumonia.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� Mr Jefferies Family�� Central North West London NHS Foundation Trust (�CNWL�) I am also under a duty to send a copy of your response to the Chief� Coroner and all interested persons who in my opinion should receive it.� I may also send a copy of your response to any other person who I believe may find it useful or of interest.� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

State Custody related deaths | Mental Health related deaths

HMPPS | Ministry of Justice | NHS England | HMP Coldingley

24/07/2023

2023-0271

John Coles

West London

[REDACTED], Head of Airside Operations, Heathrow Airport Ltd, The Compass Centre, Nelson Road, Hounslow, Middx

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.

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.

I have sent a copy of this report to the Chief Coroner and to the Solicitors acting for the Family of the Deceased, John David Coles. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: Heathrow Airport

27/02/2018

2024-0095

Kevan Funnell

West Sussex, Brighton and Hove

[REDACTED], Head of Legal Service, South East Coast Ambulance � [REDACTED], Emergency Operations Centre Manager, South East�Service, Chief Executive, South East Coast Ambulance Service

On 10th November 2017 I commenced an investigation into the death of Kevan FUNNELL. The investigation concluded at the end of the inquest on 14th February 2018. The conclusion of the inquest was ACCIDENT

See Record of Inquest

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. [REDACTED] Brighton and Hove Clinical Commissioning Group, Care Quality Commission, Secretary of State for Health, Department of Health [REDACTED], Chief Executive, NHS England � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards) This report is being sent to: South East Coast Ambulance Service

19/07/2024

2024-0388

Rita Howells

Herefordshire

[REDACTED], Hereford County Hospital

On 10th May 2023 I commenced an investigation into the death of Rita HOWELLS. The investigation concluded at the end of the inquest on 10th July 2024. The conclusion of the inquest was Accidental Death.

Rita Howells was transferred to Bromyard Hospital on 6th March 2023 for rehab and discharge planning.� She became confused and agitated around 17th March 2023.� She was found to have a low grade fever and a raised CRP.� She was treated with antibiotics to cover for a possible chest or urine infection.� A CT head was requested as she had a fall from bed whilst on the ward.� Rita Howells generally used a call bell but on the day she fell it was found not to be working.� Staff were aware.� She had the CT scan on 23rd March 2023 which showed �acute cerebral haemorrhagic contusions at the right frontal lobe and also at the base of the frontal lobes on either side of the midline� She was transferred to A&E that day and after discussion with the neurosurgical team it was deemed that this was to be treated conservatively. She deteriorated and following discussion with the family a palliative approach was implemented.� � Cause of death: � 1a. Intracerebral Haemorrhage

I have sent a copy of my report to the Chief Coroner. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths | Product related deaths � This report is being sent to: Hereford County Hospital

22/03/2024

2024-0161

Regina Ademiluyi

East London

[REDACTED], Interim Chief Executive Officer, The East London Foundation NHS Trust (ELFT) � [REDACTED], Chief Executive Officer and Jason Strelitz Director of Social Care, The London Borough of Newham

On 17th April 2023 this court commenced an investigation into the death of Regina Olufunmilola Ademiluyi, aged 83 years. The investigation concluded at the end of the inquest on 21st March 2024. The conclusion of the inquest was a short-form conclusion of �Natural causes� � Mrs Ademiluyi�s medical cause of death was determined as; 1a Aspiration Pneumonia II Malnutrition, fractured left femur (previously operated on}, sacral pressure sore

Regina Olufunmilola Ademiluyi was a frail 83 yr old woman who had a number of co� morbidities including; osteoarthritis, vascular dementia, hypertension and a previous post-surgical CVA. � In the months leading to Mrs Ademiluyi�s death she was bed-bound due to complications arising from the surgical repair of a broken hip. From the time of that surgery the local authority had assessed Regina as requiring double-handed domiciliary care 4 times per day. � From October 2023 state-funded domiciliary care was not provided to Regina as her daughter (Regina �s primary carer) was dissatisfied with the quality of care being provided and asked for it to cease. Regina�s daughter was thereafter given control of the state-allocated care budget to deploy as she saw fit. � At the time of Regina�s death in March 2024, no carers had been engaged by the family using the state-allocated care budget. To be clear, Regina�s daughter did not take any state funding for herself, she simply did not deploy it to instruct domiciliary carers. � From October 2023 until her death Regina�s cognition and physical health declined. Regina�s dysphagia and loss of appetite led to malnutrition and a corresponding decrease in physical reserve evidenced at autopsy by atrophy of the liver and virtually no abdominal fat. Regina developed a grade 4 pressure ulcer on her sacrum and suffered an aspiration incident that led to her fatal illness.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mrs Ademiluyi and to the Care Quality Commission. I have also sent it to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time rt/;�your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: East London Foundation NHS Trust | Newham Social Care

26/03/2024

2024-0168

Mark Kinzley

East London

[REDACTED], Managing Director, The Cambridge Nursing Home Ltd � [REDACTED] Interim Chief Executive, London Borough of Redbridge � � ������������������������ [REDACTED], Chief Executive Officer, The Integrated Care Board (ICB) for North-East London � The Evergreen Surgery, Wanstead

On 9th November 2023 this court commenced an investigation into the death of Mark Wolfe Kinzley aged 61 years. The investigation concluded at the end of the inquest on 26th March 2024. The court returned a narrative conclusion. �Mark Wolfe Kinzley died in hospital on 1st November 2023 due to complications of injuries sustained on 30th October 2023 in his nursing home when he suspended himself from a ligature [REDACTED]. It has not been possible to determine his intentions at the time of the suspension.� Mr Kinzley�s medical cause of death was determined as; 1a Hypoxic-ischaemic brain damage 1b Asphyxia

Mark Wolfe Kinzley was a frail 61 yr old man who suffered from a neurological disorder, Dandy-Walker Syndrome. This congenital disorder presented itself in symptoms of cerebellar ataxia which limited his mobility, speech and continence. Mr Kinzley had recently developed seizure activity. � Mr Kinzley had a history of mental health problems having been diagnosed with anxiety and depression. On at least two previous occasions Mr Kinzley had attempted self-harm by overdose, on one of those occasions he was admitted for inpatient mental health treatment. � Mr Kinzley was known to have periodic episodes of aggressive and irritable behaviour, marked by utterances of frustration and accidental self-harm due to high-risk behaviours. � In January of 2023 following a hospital admission due to physical symptoms of self-neglect, Mr Kinzley was discharged to a nursing home funded by the local authority. The nursing home was typically occupied by elderly persons receiving end of life care. � Concerns lay as to the extent of Mr Kinzley�s capacity and a DOLS (deprivation of liberty standards) order had been applied for, but not finalised with the local authority. � Mr Kinzley was socially isolated, during his 10-month residence at the nursing home he received neither a visit nor a telephone call from a relative or friend. � In the months leading to Mr Kinzley�s death he was noted by carers at the nursing home to have experienced episodes of agitation at an increased level of frequency and acuity. Mark was observed on multiple occasions to be �sad�,� agitated�,� angry� & �trying to hit/injure self�. These episodes accelerated in the week prior to his death. � On the morning of 30th October 2023 he was found unresponsive in his bedroom, suspended by a coat hanger around his neck, attached to his door handle. Despite the best efforts of carers and the emergency services he later died in hospital from his injuries.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Kinzley and the Care Quality Commission. I have also sent it to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Mental Health related deaths This report is being sent to: The Cambridge Nursing Home Ltd | London Borough of Redbridge | The Integrated Care Board (ICB) for North-East London | The Evergreen Surgery

04/10/2023

2023-0371

Ronald Harris

Herefordshire

[REDACTED], Managing Partner, Hereford Medical Group

On 14 June 2023 I commenced an investigation into the death of Ronald Leslie HARRIS. The investigation concluded at the end of the Inquest on 27 September 2023. The conclusion of the Inquest was suicide.

a)������ On the 24th April 2023 the Patients� wife contacted the practice indicating her husband had mental health difficulties. The symptoms were said to be getting worse. b)������ The Patients� family requested further help from the surgery on the 27th April 2023. The family were very concerned, indicating behaviour out of character and requesting GP in put. Were told to expect a call the following week. c)������� A routine appointment was offered which the Inquest was advised would be 4-6 weeks. No call was made. d)������ The Patient received correspondence (copy to GP) in connection with cancerous lesions dated 23rd May 2023. No apparent reference on documents supplied to Inquest showing mental health position and no connection made between mental health position and correspondence. e)������ The Patient committed suicide on the 5th June 2023

I have sent a copy of my report to the Chief Coroner and Local Mental Health who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form . He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: Hereford Medical Group

11/03/2024

2024-0132

Isaac Onyeka

East London

[REDACTED], National Medical Director, NHS England

On 14 June 2023 I commenced an investigation into the death of Isaac Onyeka (age 3 years old). The investigation concluded at the end of the inquest, on the 5 March 2024. The conclusion of the inquest was that Isaac died as a result of natural causes. The inquest heard that there were non-causal concerns in relation to the treatment provided to Isaac in the days leading up to his death.

Isaac Onyeka was a 3-year-old boy, diagnosed with Down�s Syndrome. On the 26 May 2023 Isaac showed the first signs of chicken pox. On the evening of 30 May 2023, Isaac�s mother noted that Isaac had a painful swelling under his arm. She called NHS111 and spoke to a health adviser. On the basis of the information elicited through the use of the NHS 111 Pathways algorithm, an appropriate disposition was reached, for Isaac to be assessed by his general practitioner within 24 hours. The following morning, Isaac�s mother was asked to provide a photograph of Isaac�s swelling to the GP practice. She immediately uploaded a photograph of the swelling under the arm and also a swelling in the groin area. In addition, she provided important clinical detail with the photographs. An ST3 GP registrar viewed the photographs, but did not view the additional clinical information. The same GP registrar then spoke with Isaac�s mother at around 1030am. Red and amber flags of sepsis were described to the GP registrar, but the clinical significance of these were missed. In assessing Isaac�s risk of a serious infection, the GP registrar did not consider two applicable risk factors, namely the immune deficiency associated with Down�s Syndrome and the raised risk of Group A streptococcal infection associated with chicken pox. Isaac should have been directed to hospital following the consultation. Instead, his mother was advised that the lymphadenopathy would likely self-resolve. During the afternoon of the 31 May 2023, Isaac became unresponsive in his home address. Resuscitation efforts were made by his mother, the ambulance service and the helicopter emergency medical service. Isaac was taken to Whipps Cross Hospital where sadly his life was pronounced extinct on 31 May 2023. Due to the fulminant nature of Group A streptococcal infection, had Isaac attended hospital during the morning of 31 May 2023, it is unlikely that his death would have been avoided. Hospital care would have been required during the evening of the 30 May 2023 for Isaac�s death to have been avoided. Application of the current NHS 111 Pathways assessment did not capture all of the necessary background clinical detail, which could have resulted in the necessary hospital disposition on 30 May 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons to the Inquest, family of Isaac Onyeka, Forest Practice, Hertfordshire Urgent Care, to the Care Quality Commission and to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Child Deaths (from 2015) This report is being sent to: NHS England

02/04/2024

2024-0175

Andrew Ewin-Ripp

East London

[REDACTED], National Medical Director, NHS England � [REDACTED], President of Royal College of Physicians � [REDACTED], Chief Executive Officer, Royal College of GP�s

On 30 January 2023 I commenced an investigation into the death of Andrew Ewin-Ripp (aged 27). The investigation concluded at the end of the inquest on the 25 March 2024. The conclusion was that Andrew died as a result of natural causes (SUDEP). Whilst there was no evidence that the care provided to Andrew contributed to his death, there were concerns that aspects of the care, if left unchanged, could result in further, similar deaths occurring.

Andrew Ewin-Ripp suffered from epilepsy. He had been under secondary care neurology services until May 2020, when he was deemed to be well and had been seizure free for 14 months. No clear written advice was provided to Andrew to inform him that he was being discharged, or that he should notify his GP or neurology team if his seizures returned. No information was provided to Andrew on discharge, about how to contact the epilepsy nurses in the event of seizure recurrence. In August 2022 Andrew contacted his GP with a report of having suffered 4 seizures that year, the last having occurred the previous week. On the 9 August 2022 the GP sent an advice and guidance request to a neurology team unknown to Andrew. There was no response to this advice and guidance request by the 4 September 2022. The GP therefore sent an urgent request for an outpatient appointment and for urgent advice relating to medication, to Andrew�s secondary care team. This urgent request had not even been triaged by the 1 November 2022. Whilst still awaiting a response from the secondary care team, Andrew suffered a fit in his home address on the 1 November 2022. Andrew was on the phone to his partner at this time. Andrew�s partner called the emergency services and through the information that he provided; an emergency Category 1 response was generated. A paramedic arrived at Andrew�s home within 5 minutes of the call. The paramedic checked the property and found that it was secure. The London Fire Brigade had to attend to force entry. The emergency team were at Andrew�s side 23 minutes after the emergency call. Andrew was found to be in cardiac arrest. Advanced life support commenced rapidly, and a return of spontaneous circulation was gained. Andrew was taken to Queen�s Hospital where intensive care was provided. Sadly, despite all efforts by the hospital team, Andrew did not recover. He passed away at Queens Hospital on the 4 November 2022. The unanimous view in relation to his cause of death is sudden unexpected death in epilepsy.

I have sent a copy of my report to the Chief Coroner, to the family of Andrew Ewin-Ripp, to the other interested persons to the inquest, to the Care Quality Commission, and the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Other related deaths This report is being sent to: NHS England | Royal College of Physicians | Royal College of General Practitioners

23/02/2023

2023-0071

Anthony Ingram

Suffolk

[REDACTED], National Police Chiefs� Council 1st Floor, 10 Victoria Street London SW1H 0NN

On 7th April 2022 I commenced an investigation into the tragic death of Anthony John Raymond INGRAM. The investigation concluded at the end of the inquest on 26th January 2023. The conclusion of the inquest was that: Anthony Ingram, died as the result of suicide � The medical cause of death was confirmed as: � 1a Hanging

Anthony Ingram was found deceased at his second home in Westleton, Suffolk, on the 29th March 2022. � When found, Anthony was inside the property, suspended by a rope around his neck. � Anthony lived in London, and his mental health had been deteriorating over a period of time. � On 29th March 2022, at approximately 13:30 Anthony left London and headed towards his second home in Suffolk. � Anthony was known to be in possession of rope and a �collapsible� bicycle when he left. � The information regarding the rope and the bicycle was not passed to Suffolk police at the time the case was reported to them. � At 17:50 a Suffolk officer attended Anthony�s second home but did not enter although keys were available from a neighbour. Anthony�s vehicle was not present, and the officer formed the opinion that he had insufficient information to enter the premises under Section 17, Police and Criminal Evidence Act at that time. Shortly after this time, Anthony�s vehicle was found in a car park more than two miles from his second home, and police search activity was focussed there. At approximately 20:00, once Suffolk officers became aware that Anthony had a rope, and the search of the car park area had failed to locate him, they returned to the second home and entered, finding Anthony deceased. The collapsible bicycle was found in the hallway. Poor communication between the Metropolitan Police and Suffolk Constabulary meant that the officers on the ground were missing information which would have informed their decision making regarding the search for Anthony and informed their use of police powers. This resulted in a missed opportunity to find Anthony earlier than he was found.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1.���������� Anthony�s next of kin. 2.���������� Chief Constable for Suffolk 3.���������� The Commissioner Metropolitan Police � I am also under a duty to send a copy of your response to the Chief Coroner, and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015)

National Police Chiefs� Council

09/01/2025

2025-0012

John Liddle

Newcastle and North Tyneside

[REDACTED], Network Manager, Gateshead Council [REDACTED], Strategy Director, Gateshead Council

On 25th May 2023 I commenced an investigation into the death of John Michael Liddle, aged 44. The investigation concluded at the end of the inquest on 10th January 2025. The conclusion of the inquest was Road Traffic Collision. The medical cause of Mr Liddle�s death was 1a) Blunt head injury.

On the night of 3rd May 2023 John Michael Liddle was riding his pedal cycle southwards along the A694 Lockhaugh Road, Rowlands Gill, Gateshead. His cycle lights were illuminated and he was wearing a yellow cycling jacket. As he moved out towards the centre of the road to take the turn into Sherburn Park Drive he was hit by a minibus travelling behind him who was overtaking. Mr Liddle suffered unsurvivable head injuries and died at the Royal Victoria Infirmary Hospital in Newcastle upon Tyne on 21st May 2023.

I have sent a copy of my report to the Chief Coroner and to the interested persons, namely Mr Liddle�s family and the driver of the minibus involved in the collision. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Road (Highways Safety) related deaths

Gateshead Council

30/03/2023

2023-0111

Carol Robinson

East London

[REDACTED], North East London Foundation Trust

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. The conclusion of the inquest a narrative conclusion: �Mrs Robinson died as a result of an overdose of medication. The evidence does not reveal her intention at the time of taking the overdose.�

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Carol Robinson, Care Quality Commission. I have also sent it to the Local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Alcohol, drug and medication related deaths

North East London Foundation Trust

11/09/2023

2023-0328

Amanda Kramer

East London

[REDACTED], North East London Foundation Trust (NELFT), CEME Centre, March Way, Rainham, Essex, RM13 8GQ [REDACTED] � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care, 39 Victoria St, Westminster, London SW1H 0EU � � [REDACTED], Wood Street Medical Centre, 6 Linford Road, Walthamstow, London, E17 3LA

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; � �Mrs Amanda Jane Kramer died at her home address on 31st December 2022, she had taken an accidental, fatal overdose of Zoplicone. Mrs Kramer had been prescribed that medication for approximately 18 years, when guidance indicates it should be prescribed for the short-term treatment of insomnia. Those treating Mrs Kramer had not monitored; whether there was an ongoing need for her to receive this drug, the risks associated with the medication, or whether Mrs Kramer was compliant with dosage instructions.� � Mrs Kramer�s medical cause of death was determined as; � 1.a. Zopiclone Toxicity 2. Fatty Liver Disease

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] Mrs Kramer was found unresponsive at home on 31st December 2022. Her death was caused by an overdose of prescribed hypnotic, zoplicone.

I have sent a copy of my report to the Chief Coroner and the following, the family of Mrs Kramer. I have also sent it to local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at he time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: North East London Foundation Trust | Department of Health and Social Care | Wood Street Medical Centre

22/11/2023

2023-0463

David Lewsey

Cornwall and the Isles of Scilly

[REDACTED], Old Bridge Surgery National Institute for Clinical Excellence (NICE)

On 21/11/23, I concluded an inquest into the death of David John Lewsey who died on 15/12/22 at the age of 68. The medical cause of death was recorded as: 1a) Pulmonary thromboembolism 1b) Deep vein thrombosis of left calf 1c) Knee replacement operation � I recorded a Narrative Conclusion that Mr Lewsey died from a known complication of an elective surgical procedure.

Mr Lewsey was a 68-year-old man who underwent a left knee replacement on 29/11/22. Upon discharge, he was prescribed with two weeks of aspirin to reduce the risk of developing a clot and codeine for pain relief. The codeine caused Mr Lewsey to become constipated. � On 15/12/22, he rang the surgery for treatment to relieve his constipation. In the first call with reception staff, he reported a �terrible, terrible pain in his side.� This information was not passed on to the Advanced Nurse Practitioner (ANP) who returned Mr Lewsey�s call. � In his first call with the ANP, Mr Lewsey said that his left side hurt like he had a stitch and that he felt pain when he breathed in. I found as fact that it was more likely than not that this was caused by a developing pulmonary embolus. � No consideration was given to excluding a PE as a possible cause of the pain. It is more likely than not that the PE was caused by a DVT in his leg that developed following Mr Lewsey�s immobility after his knee operation. Mr Lewsey collapsed later that evening at his home address and could not be resuscitated. Mr Lewsey was a 68-year-old man who underwent an elective left knee replacement on 29/11/22. [REDACTED], the consultant orthopaedic surgeon who performed the procedure, confirmed that his default position was to prescribe low molecular weight heparin for the initial period in hospital and then to prescribe a fortnight�s worth of aspirin. It was established in evidence that the NICE guidance (NICE 89 � VTE in over 16s � reducing the risk of hospital acquired DVT or PE) suggested at paragraph 1.11.8 that LMWH should be used with TED stockings until discharge. It was [REDACTED] view that the foot pumps provided in hospital, Flowtrons, were superior to TED stockings and, in this regard, the consultant felt the NICE guidance needed to be updated. It is understood that there may be other compression systems or VTE prevention pumps that it may also be appropriate to consider. Mr Lewsey collapsed on the evening of 15/12/22 at his home address and could not be resuscitated.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mr Lewsey; [REDACTED] legal representaitves; [REDACTED] legal representatives. � I am also under a duty to send the Chief Coroner and above IPs a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Old Bridge Surgery | National Institute for Health and Care Excellence

06/11/2024

2024-0611

Sarah McGreevy

Inner North London

[REDACTED], Operations Director, Tenancy and Homeowner Services, London Borough of Hackney

On 2 July 2024, HM Senior Coroner Mary Hassell commenced an investigation� into the death of Sarah McGreevy aged 37 years. The investigation concluded at the end of the inquest on 6 November 2024. The conclusion of the inquest was� that Ms McGreevy had died from injuries sustained when she fell from her�balcony on 16 June 2024. I returned a conclusion of accident. The medical cause of Ms McGreevy�s death was: 1a multiple injuries, 1b trauma, 1c fall from�height.

Ms McGreevy was the assured shorthold tenant of [REDACTED]. The property is a 2-bedroom flat on the 6th floor. The� freeholder of the premises is London Borough of Hackney. Around 9.40 am on�16 June 2024, Ms McGreevy fell to the ground from her balcony and sustained� fatal injuries. Police officers attended the scene and noted that there was a� wooden box on the balcony and Ms McGreevy�s mobile phone was on a window ledge next to the balcony. The phone was close to a downwards drainpipe�which came from the floor of the 7th floor balcony above Ms McGreevy�s flat� before diverting down the exterior wall to the block. The pipe had previously� been repaired using heavy duty tape. Residents made police officers aware of�problems with the guttering and drainpipes in the block. Police were told of� residents on the 5th and 6th floors climbing onto their balconies to manually�unblock pipes, particularly following heavy rainfall. The Police investigation did� not reveal any evidence to suggest that anyone else was involved in Ms�McGreevy�s death or that she had any suicidal intent. Photographs taken of Ms� McGreevy�s hands following her death show dirt around her fingernails� consistent with undertaking a cleaning task. I found that it was more likely than not that Ms McGreevy had climbed onto the wooden box to clear the pipe and�had accidentally fallen over the balcony.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:�� [REDACTED], (parents of Sarah McGreevy) [REDACTED], (leaseholder of [REDACTED]) � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or� summary form. She may send a copy of this report to any person who he� believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths

London Borough of Hackney

26/07/2023

2023-0277

Finley May

East Riding and Hull

[REDACTED], President, Royal College of Obstetricians & Gynaecologists [REDACTED], Chief Executive of NHS England

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. The medical cause of death was determined as follows: 1(a): High Spinal Cord Injury due to Keilland�s Forceps Delivery 1(b): Malposition and Prolonged Labour II: Hypoxic Ischaemic Encephalopathy

These are set out in my summary and findings of facts which are attached.

I have sent a copy of my report to the following Interested Persons: � ���[REDACTED] , Family Counsel ���[REDACTED] , Capsticks, Counsel for Humber NHS Trust � I have also sent it to the local child safeguarding officer, [REDACTED]. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Royal College of Obstetricians and Gynaecologists and NHS England

17/09/2023

2023-0338

Kimberley Sampson and Samantha Mulcahy

Central and South East Kent

[REDACTED], President, Royal College of Obstetricians &Gynaecologists [REDACTED], Chief Executive NHS England

INVESTIGATIONS and INQUESTS An investigation into the deaths of Kimberley Sampson who died on 22 May 2018 and Samantha Mulcahy who died on 4 July 2019 both from herpes simplex infections initially led to a discontinuation of both investigations on 2 October 2019. The investigations were reopened on 4 January 2022 as concerns were raised about a possible common source of infection. The investigations concluded at the end of the inquests which were held jointly and final conclusions handed down on 26 July 2023. The cause of death for both young women determined at the inquests was: 1a) Multi- Organ Failure 1b) Disseminated Herpes Simplex type I infection 1c) Herpes Simplex virus acquired before or around the time of delivery 2. Third trimester pregnancy A narrative conclusion was reached in both inquests and both narratives are set out below: �Kimberly Sampson died as a consequence of disseminated Herpes Simplex 1 infection with the initial infection having been acquired before or around the time of the delivery of her baby. There was a delay in instituting antiviral therapy, the known treatment for her illness, due in part to the presence of a concurrent bacterial infection but also due to a delay in recognising and linking the cause of her deteriorating liver function as being a symptom of a viral infection.� �Samantha Mulcahy died as a consequence of disseminated Herpes Simplex 1 infection with the initial infection having been acquired before or around the time of the delivery of her baby. Antiviral therapy, the known treatment for her illness, was not instituted as her symptoms were unclear and her previous obstetric cholestasis had complicated the picture.�

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. The circumstances in relation to Samantha Mulcahy�s death occurred very shortly after the death of Kimberley Sampson and clinicians in common were involved in looking after both mothers. I found that their index of suspicion should have been raised and indeed a viral cause and possible treatment was suggested by one Obstetrician but following a discussion with a Microbiologist was not instituted. Samantha Mulcahy had a past medical history of oesophageal hernia, polycystic ovaries, gallstones and underactive thyroid when she became pregnant in 2017. She developed obstetric cholestasis in the latter stages of her pregnancy and required a caesarean section for failure to progress on 26 June 2018 which was complicated by a tear to the broad ligament. On 28 June she developed signs of sepsis and was commenced on broad spectrum intravenous antibiotics. She did not improve and her respiratory function deteriorated and investigations including a CTPA on undertaken to rule out a pulmonary embolism as a cause of her symptoms. Antiviral medication was discussed by the obstetrician and microbiologist on 30 June 2018 but a decision made that it should not be commenced. She was transferred to Intensive care unit on the morning of the 30 June and she was considered to be suffering from respiratory failure secondary to abdominal distension with a possible pneumonia and she improved slightly over the course of the day with treatment. A CTPA was undertaken on 2 July 2018 to rule out a pulmonary embolism as a cause of her symptoms which showed no PE but some patchy shadowing in her lungs and bilateral pleural effusions. She deteriorated significantly overnight between the 2 and 3 July 2018 with a decrease in urine output and her liver function tests the next morning showed fulminant liver failure and she had also developed ascites. There was a delay in recognising a viral cause of her illness as it was thought that she may be suffering from steatosis plus sepsis and discussions with the liver unit at Kings College hospital led to recommendations to commence antifungal not antiviral medication. She continued to deteriorate and discussions were held about ECMO with the team arriving around 2am on 4 July 2018. She was transferred to theatres to set up ECMO and operate if necessary. Despite all attempts to improve her situation she continued to deteriorate and died around 07.15 that morning.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the families, and East Kent Hospitals University NHS Foundation Trust. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Royal College of Obstetricians and Gynaecologists | NHS England

09/11/2023

2023-0437

Luca Yates

Manchester South

[REDACTED], President, Royal College of Paediatrics and Child Health

On 14th July 2022, an inquest was opened into the death of Luca Yates who died at Tameside General Hospital, Ashton-under-Lyne on 24th January 2022 aged 1 day. A post mortem examination determined Baby Luca died as a consequence of: 1) a) Hypoxic ischaemic encephalopathy due to; 1)� b) Asphyxia around the time of birth. The investigation concluded with an inquest which I heard between 18th � 22nd September 2023 following which I recorded a Narrative Conclusion as follows: �Luca Yates died as a consequence of complications arising from asphyxia around the time of birth. When his mother was assessed the evening before Luca was born, it was not recognised that she was either in, or transitioning towards established labour.� This led to an absence of monitoring in hospital which contributed to death. Luca�s death was also contributed to by a period of 14 minutes in the resuscitation phase where 100% oxygen was not utilised as required by protocol. Luca Yates�s death was contributed to by neglect�.

Baby Luca was his parents� first child. After an uncomplicated pregnancy, his mother was booked for induction of labour at 41 weeks. On 22nd January 2022 following symptoms suggestive of the onset of labour, Baby Luca�s mother contacted her local maternity unit on a number of occasions and was assessed in the unit twice, before being sent home. When Baby Luca�s mother re-presented the following day, it was recognised that she was in established labour, and it was considered birth may be imminent. Following transfer to the delivery suite, the CTG was connected which detected a fetal-bradycardia. Urgent assistance was summoned and the Obstetric Registrar on duty decided to deliver Luca by emergency caesarean section. Following administration of general anaesthetic, Baby Luca was born at 16:19 on 23rd January 2022 in very poor condition with repeated Apgar scores of 0. Attempts to resuscitate Luca proved difficult and it was not until 16:42 that the second paediatric registrar called to assist the multi-disciplinary team successfully passed an ET Tube. A heart rate was finally detected when Luca was around 38 minutes� of age. Once stabilised, Baby Luca was transferred to the Neonatal Unit where he sadly died the following day.

I have sent a copy of my report to the Chief Coroner and to Linda Reynolds of Hugh James Solicitors on behalf of the family. I have also sent a copy to Weightmans LLP on behalf of Tameside and Glossop Integrated Care NHS Foundation Trust I have sent a copy of my report to the Healthcare Safety Investigation Branch, and the Care Quality Commission, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Royal College of Paediatrics and Child Health

06/03/2023

2023-0083

Maureen Dick

East London

[REDACTED], CEO, Barking, Havering & Redbridge NHS Trust

On 26th January 2022 I commenced an investigation into the death of Maureen Edna Dick. The investigation concluded at the end of the inquest on 27th February 2023. The conclusion of the inquest was a narrative conclusion: � Mrs Dick died as a result of a hospital acquired pressure ulcer. Her death was contributed to by neglect.

Mrs Dick was admitted to Queens Hospital on the 4 September 2021. She was very unwell on admission to hospital with likely sepsis from a respiratory source. She had recovered from the respiratory point of view by mid-September 2021. On admission to hospital, she was at very high risk of developing a pressure ulcer, yet she did not receive early, careful risk assessment and care planning to prevent the development of a pressure ulcer. Mrs Dick was not re-positioned in accordance with hospital policy and a pressure ulcer developed shortly after her admission to hospital. The sacral pressure ulcer slowly deteriorated over the course of the admission to Queens hospital. By the 24 October 2021 the pressure ulcer had deteriorated to a Grade 3. By the 24 October 2021 the pressure ulcer is likely to have been infected but no medical attention was given to it. There was no wound swab or liaison with microbiology; a lumbar MRI scan was not carried out and no antibiotics were administered. Mrs Dick was transferred to Broomfield Hospital from Queens Hospital with a likely Grade 4 pressure ulcer and osteomyelitis. She received a very good standard of care at Broomfield Hospital, but sadly optimal treatment at this time could not address the severity of her condition. She died on the 8 January 2022 at Broomfield Hospital from her infected hospital acquired pressure ulcer.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: family of Mrs Dick, Care Quality Commission (CQC). I have also sent it to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths

Barking, Havering & Redbridge NHS Trust

27/02/2023

2023-0074

Doris Smith

Essex

[REDACTED], CEO, Essex Partnership NHS Foundation Trust

On 23 October 2020 an investigation was commenced into the death of Doris Joyce SMITH, aged 74 years. Doris Joyce Smith died on the 14 October 2020. The investigation concluded at the end of the 5-day inquest on 27 January 2023. The conclusion of the inquest was Narrative with a medical cause of death of Ia Head Injury Ib Fall, II Dementia, Frailty, Coronary Atherosclerosis�.

Doris Joyce Smith had a fall on Ruby Ward on 9 October 2020. As a consequence she suffered a head injury and was taken to Broomfield General Hospital. Subsequently she was diagnosed with a subarachnoid haemorrhage and after consultation with Addenbrookes, it was confirmed that her injury was not operable and not survivable. Doris Smith was placed on an end-of-life care pathway care plan and passed away on 14 October 2020. The falls risk assessment was only completed 12 days after Doris�s admission onto Ruby Ward. Under policy guidelines and procedures it should have been completed within 24 hours after admission by the nurse. It was finally completed by a� senior healthcare assistant instead but had an incomplete medical history. Subsequent errors and omissions with regard to the updates of the falls risk assessment � No evidence of the physiotherapist�s advice of close monitoring during mobilsation being implemented by staff. � Confusion regarding observation levels e.g 1,2 or 3 and inadequate frequency of both neurological and ward observations. Doris Joyce Smith died as a direct result of the fall on Ruby Ward on the 9th October 2020. Had Mrs Smith been observed and monitored as she should have been, the fall on 9th October 2020 would either have been avoided or there would have been a staff member present to break her fall. Had the fall been broken, it is likely that Mrs Smith would have avoided injury, or her injuries would have been less severe. The fall suffered by Mrs Smith on 9 th October 2020 caused her to suffer a traumatic subarachnoid haemorrhage, which led to her death on 14th October 2020. In addition, the falls risk assessment and the level of observations were inadequate. There is no evidence of effective communication between the different professionals as to the correct care Doris Smith should be receiving. As well as the lack of implementation of correct and accurate record keeping. Evidence heard as to inconsistencies between staff on Ruby Ward as to which were the correct levels of observations, especially following the falls on the 1 st , 8th and 9th October 2020. All of these factors led to the incorrect observation of Doris Smith which contributed to the circumstances leading to her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ���[REDACTED], (Son) ���Care Quality Commission � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Essex Partnership NHS Foundation Trust

27/02/2023

2023-0075

Sharon Langley

Essex

[REDACTED], CEO, Essex Partnership NHS Foundation Trust

On 2 September 2019 an investigation was commenced into the death of Sharon Elizabeth LANGLEY, aged 62 years. Sharon Elizabeth Langley died on the 10 August 2019. The investigation concluded at the end of the 10-day inquest on 21 February 2023. The conclusion of the inquest was Suicide with narrative with a medical cause of death of 1a Immersion in Water (Drowning) 1b Severe Depressive Disorder with Psychosis.

On 10 August 2019 at the Princess Alexandra Hospital, Hamstel Road, Essex, Sharon Elizabeth Langley an inpatient with Severe Depressive Disorder and Psychosis died by Immersion in Water unsupervised in an assisted bathroom on Chelmer Ward. Following several documented suicide attempts the latest on 7 July 2019� Sharon Elizabeth Langley took the actions to immerse herself in the water in the bath and did so with the intention to end her life. Therefore, we return a conclusion of Suicide with the following additional narrative. Sharon was taken for a supervised bath and access was granted by staff to the bathroom at 09:33:57. The evidence shows staff who should have been assisting Sharon were in other places on the ward at the time of her bath, suggesting she was left alone and unsupervised. Although not formally documented evidence was heard Sharon should be assisted whilst having a bath. Sharon was found face down and unclothes in a bath with water at around 10am by the healthcare assistants who pulled her out of the bath and laid her on the floor next to the bath. Initial staff response was inadequate and insufficient causing a delay in triggering the pinpoint alarm and ambulance being called. However, when nurses arrived emergency treatment was adequate with evidence showing the AED was used correctly. Paramedics arrived on the scene within 3 minutes to take over emergency aid. The paramedics lacked information about the incident from staff and Sharon was taken to the Accident and Emergency department at 10:39 where she was declared dead.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ���[REDACTED] (Mother) ���Care Quality Commission � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths

Essex Partnership NHS Foundation Trust

05/02/2024

2024-0059

Georgia Dehaney-Perkins

Essex

[REDACTED], CEO, Essex Partnership NHS Foundation Trust

On 13 September 2022 an investigation was commenced into the death of Georgia Gypsy Catherine Dehaney-Perkins aged 36 years. Georgia Dehaney- Perkins died on the 6 September 2022. The investigation concluded at the end of the inquest on 6 December 2023. The conclusion of the inquest was Narrative �Ms Dehaney-Perkins consumed prescription medication and alcohol and had been previously found at the same location when she went missing. It is not possible to determine if Ms Dehaney-Perkins intended the outcome to be fatal� with a medical cause of death of �1a a Combined Alcohol and Drug Toxicity [REDACTED]�

Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow by her family who had reported her missing that morning and gave this as the last known location of Georgia. Police did not attend Georgia�s home address and downgraded her from a missing person to a concern and did not inform the family of the decision. Ms Dehaney-Perkins sought medical assistance when she began to struggle with her mental health and following a misdiagnosis of cancer. Ms Dehaney-Perkins had a known history of self-harm, suicidal ideation and being found as an at-risk missing person with inpatient admissions for care and treatment due to her deteriorating mental health. Ms Dehaney-Perkins� recent overdose of medication required admission to �hospital as she could not keep herself safe. Ms Dehaney-Perkins attempted to hang herself on 28 August whilst in her bathroom on the ward. Ms Dehaney-Perkins was discharged on 2 September 2022 with 14 days� supply of her medication. A 24-hour follow-up call had not been made by mental health services. The Home First Treatment Team assessed Ms Dehaney-Perkins on 4 September at home and transferred her care back to her care co-ordinator. Ms Dehaney-Perkins was suffering from mental health disorder with features of self-harm that elevated when she consumed alcohol. Ms Dehaney-Perkins� father contacted the Home First Treatment Team on the evening of 4 September asking if they had attended that day and informed the nurse that he understood that Ms Dehaney-Perkins had consumed alcohol, police had attended, and she left home with her medication. The Home First Treatment Team nurse did not attempt to contact Ms Dehaney Perkins, her partner or the police. Ms Dehaney- Perkins died due to Combined Alcohol and Drug Toxicity ([REDACTED]) that interacted to increase sedation and cardiac arrhythmia causing death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Ms Dehaney-Perkins Hertfordshire Partnership University NHS Trust � I am also under a duty to send the Chief Coroner a copy of your response. � I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drug and medication related deaths This report is being sent to: Essex Partnership NHS Trust

19/02/2023

2023-0078

Molly-Ann Sergeant

Essex

[REDACTED], CEO, Essex Partnership NHS Foundation Trust [REDACTED], Essex County Council

On 27 October 2020 an investigation was commenced into the death of Molly Ann SERGEANT, aged 17 years. Molly Ann Sergeant died on the 16 October 2020. The investigation concluded at the end of the 5-day inquest on 7 December 2022. The conclusion of the inquest was Narrative with a medical cause of death of �1a Hanging

Molly-Ann Sergeant was found deceased on 16 October 2020 hanged [REDACTED] in Woodlands [REDACTED] with the intention of ending her life and left a note. Molly was treated for depression and had a history of chronic self-harm that had required a prolonged hospital admission at St Aubyn�s under the Mental Health Act and did not accept her diagnosis with Autistic Spectrum Disorder. Molly was discharged on 17 August 2020 following phased community leave with a plan in place for her mental health. Confusion between different statutory provisions led to her case being closed to social care and, significant delays in this �case being reopened. Molly was allocated a social worker five weeks after her discharge for an assessment that was ongoing. Molly attended her Care Programme Approach meeting on 9th October 2020 and left distressed. Suicide � Social care failed to carry out appropriate requested assessments during Molly�s prolonged hospital admission and there was not a coherent co- ordinated approach to meeting Molly�s social aftercare needs. Molly�s right to aftercare services was recorded but the functions were not discharged as they should have been during her admission, and this contributed to her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ���[REDACTED]�(Parents) ���[REDACTED]�(Grandmother) ����Care Quality Commission I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form.� He� may� send� a� copy� of� this� report� to� any� person� who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Child Death (from 2015)

Essex Partnership NHS Foundation Trust and Essex County Council

28/07/2023

2023-0507

Kirsty Taylor

Hampshire, Portsmouth and Southampton

[REDACTED], CEO, Southern Health Foundation Trust.�������������� [REDACTED], Mental Health, Learning Disabilities & Autism and Childrens Care Director and Deputy Chief Delivery Officer, Hampshire and Isle of Wight Integrated Care Board. NHS England

On 04 July 2022 I commenced an investigation into the death of Kirsty Clare TAYLOR aged 33. The investigation concluded at the end of the inquest on 09 June 2023. The conclusion of the inquest was that the Deceased impulsively took her own life (by hanging) whilst suffering increased emotional dysregulation against a background of Emotionally Unstable Personality Disorder.

The Deceased was found in a lifeless state in the garage at her family home at approximately 09.15 on the morning of 25 June 2022 by her partner, who had last seen her alive when the couple went to bed at approximately midnight on the evening of 24 June 2022. She was found suspended [REDACTED]. The evidence indicted that she had secured the ligature herself before lowering herself into it. The evidence established that she had died at some point in the early hours of the morning � it was known that she was not sleeping. There were no suspicious circumstances concerning the death. The Deceased was diagnosed with EUPD and ADHD and was receiving therapy and support from the community mental health team and from her GP in respect of physical pain. She had been struggling in the months prior to her death with emotional dysregulation, reflective of her EUPD but influenced in part by a programme of gradual reduction in her medications, which she had requested. The evidence was not able to establish that the change in her medication had chemically caused an instability in her emotions (and it was recognised that both the long term and concomitant use of her various prescription medications were clinically indicated and without contra-indications). However, the psychological impact of reduction, coupled with increasing social stressors and an increasingly subjective feeling of isolation, abandonment and lack of being heard in the last few weeks of her life are believed to have all contributed to an increasing internal narrative which led, on the evening of 24 June 2022, and without warning, to a spontaneous and impulsive act against an increasing background of emotional dysregulation. There was no evidence to indicate that her death had been an accident or a cry of help (given the timing and nature of the act). In the context of her complex diagnosed conditions however, the risk of dangerous and impulsive acts with impulsive intent was recognised, but not in all the circumstances expected.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED], Southern Health Foundation Trust [REDACTED], [REDACTED], [REDACTED], � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: Southern Health Foundation Trust | Hampshire and Isle of Wight Integrated Care Board | NHS England

06/03/2024

2024-0129

John MacGregor

Herefordshire

[REDACTED], Care Home Manager, Credenhill Court Rest Home , Hereford.

On 28 April 2023 I commenced an investigation into the death of John Patrick MacGREGOR . The investigation concluded at the end of the inquest on 28 February 2024. The conclusion of the inquest was �Narrative� � Mr MacGregor fell at Credenhill Court Rest Home on the 2nd April 2023. Substantive medical intervention did not take place until the 13th April 2023 when he was profoundly unwell.

Patient admitted with chest pain and shortness of breath after a fall in a care home. He was found to have a left sided hydropneumothorax, fractured right proximal humerus and Ll end plate compression fracture . A chest drain was inserted and drained well on the ward and he was receiving IV antibiotics. He was reviewed by geriatricians and respiratory physicians, who assisted in optimising his management. He was also reviewed by T&O for his fracture. However, his infection markers did not improve after 7 days of IV antibiotics and IV antifungals. � He became significantly more unwell with fluctuations in blood pressure and increasing oxygen requirements. A chest x-ray showed a right sided-HAP. He was already receiving the antibiotic of choice for this with no improvement and a decision� was made to� start him on the end of life pathway.� There� was concern regarding the lapse chime from the fall to hospital admission.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; [REDACTED]. I have also sent it to Herefordshire Council and the CQC who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner .

Care Home Health related deaths This report is being sent to: Credenhill Court Rest Home

06/06/2023

2023-0305

Jennifer Rackley

Berkshire

[REDACTED], Care UK, Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex C04 9QB

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. � The family asked me to refer to Mrs Rackley as Jennifer during the inquest, and I have respected that request in this report. � Jennifer died at Wexham Park Hospital on 15th January 2022 after a fall in her nursing home on 17th December 2021. Her cause of death was: � 1 a Multi-organ Failure 1 b Sepsis from infected Hip c Fractured Neck of Femur (Operated)Atrial Fibrillation, Frailty, Dementia, Hypertension, Colorectal cancer, Covid 19 Infection � The conclusion of the inquest was that Jennifer Evelyn Rackley died as a result of an accident.

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. � Evidence was given under oath by the manager of the care home. Her evidence was that: � 1. Staff were alerted to Jennifer�s fall by the sensor mat sounding. 2. Jennifer�s bed was against the wall and therefore only required 1 sensor mat. 3. The home had carried out an investigation into the circumstances of the fall. � It was clear from the evidence that staff were alerted to Jennifer�s plight by her shouting and not by a sensor mat sounding. In documents provided for the first time in court, it was clear that the first trigger of the sensor mat was at 0632 on the 17th of December, some 7 minutes after the computer generated record of the fall in Jennifer�s notes (with the time automatically generated). Jennifer was already on the floor at that time. It is likely that the sensor mat was triggered by somebody else in the room who went to assist her and not by Jennifer herself. I was concerned about evidence given under oath that the bed was against the wall with the need only for one sensor mat. The evidence from two separate family members was very different on this point. They both said that the bed was in the centre of the room with a sensor mat on one side only. Their evidence was consistent and convincing. The manager, despite earlier giving clear evidence about the bed position, then accepted that she could not remember this, and she had assumed the bed was against the wall. � I was told that the care home had conducted an investigation after Jennifer�s fall and subsequent death. I was told that there is no report / written record of this. The care home manager who attended the inquest (with the benefit of legal representation), could not even tell me the names of the carers who were involved on the 17th of December. She accepted in her evidence that she assumed the bed was against the wall because that was usual. She did not have a specific memory of this. She also later accepted that it is likely that the sensor mat was triggered by someone else in the room after the fall, and not by Jennifer herself. � It is fair to note that these events were some time ago, and that memories fade. But it is an entirely different matter to give positive evidence rather than simply saying that one cannot remember something.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Family Legal representative of Wexham Park Hospital � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths This report is being sent to: Care UK

25/10/2023

2023-0408

Carl Fullalove

Cheshire

[REDACTED], Chair of National Police Chiefs Council [REDACTED], CEO College of Policing

On 04 January 2016 I commenced an investigation into the death of Carl FULLALOVE aged 29. The investigation concluded at the end of the inquest on 11 October 2023. The conclusion of the inquest was that: � Narrative Conclusion � On the night of 13 December 2015 at 00:12, Carl Fullalove was witnessed jumping on cars by residents of Melverley Drive. Officers arrived to find Carl leaning against a wall with a calm demeanour although his conversations led officers to believe he was under the influence of a substance. Signs of ABD were not present to officers for them to have considered Carl a medical emergency as he could walk and talk and did not otherwise appear unwell. � All available information to the officers was passed to control and subsequently custody suite so an FME was not requested on standby. � Carl was adequately assessed by all within the custody suite and within cell 9. Prone restraint in cell was necessary and justified however it is felt that it did contribute to the death of Carl negligibly on the balance of probabilities.

On the night of 13 December 2015 at 00:12 Carl Fullalove came to his death: � He was observed jumping on cars in Melverley Drive at 00:12. This caused local residents to call the police. � Carl was shouting about dogs and behaving bizarrely. � Carl was under the influence of a substance. � Carl was handcuffed, arrested and taken into police custody where he was placed in cell 9 in Blacon Custody Suite. � Carl was placed in prone restraint onto a mattress to enable disrobing and a search to be carried out. During this, he was found to be non-responsive and suffering from cardiac arrest by the FME. � The ambulance arrived and took Carl to the Countess of Chester Hospital having secured a return of spontaneous circulation. � vii. He subsequently died on 14 December 2015 at 14:13 hours.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Carl Fullalove�s parents Cheshire Constabulary � I have also sent it to The Rt Hon Chris Philp MP, Minister for Policing, UK Parliament � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: National Police Chiefs Council | College of Policing

25/04/2024

2024-0223

Jonathan Shaw

Manchester North

[REDACTED], Chair of the National Police Chiefs Council The Rt Hon James Cleverly MP, Secretary of State for the Home Office (Border Force)

On 6 December 2023 an investigation into the death of Dr Jonathan Harvey Shaw was commenced. The investigation concluded at the end of the inquest on 24 April 2024. I recorded a conclusion of Suicide. The medical cause of death was 1a) fatal nitrite/nitrate toxicity.

CIRCUMSTANCES OF DEATH Dr Jonathan Shaw took his own life through the intentional ingestion [REDACTED] which he had procured through an online purchase from a company that operates in Malaysia. Before the package [REDACTED] was delivered to Dr Shaw, it had been stopped by UK Border Force at the request of the National Fast Parcel Targeting Team who received intelligence about the Malaysian company and information about concerns for Dr Shaw�s welfare and the risk to life. Officers from Greater Manchester Police (GMP) made contact with Dr Shaw and informed him that the parcel had been stopped by UK Border Force. There is no evidence that the officers were informed by UK Border Force of the timescales before release and the officers would most likely not have been aware that UK Border Force could only lawfully keep hold of the package for 30 days. UK Border Force released the package 9 days after its arrival in the UK and without examining its contents or consulting with GMP. The lack of consultation with GMP represented a significant missed opportunity as the evidence was that Dr Shaw would most likely have agreed to the safe destruction of the package if he had been asked at a point before he took physical possession of it. In the event, Dr Shaw concealed the package and informed his family, the police and mental health professionals that he had disposed of it. He subsequently used the contents of the package to end his life.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- The family of Dr Shaw � I have also sent a copy of my report to the following organisations who may find its contents of interest:- Greater Manchester Police National Suicide Prevention Strategy Advisory Group � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: National Police Chiefs Council | Home Office

25/06/2018

2023-0415

Sylvia Davies

Inner North London

[REDACTED], Chair � Coventry and Rugby Clinical Commissioning Group (CCG), Parkside House, Quinton Road, Coventry CV1 2NJ � ��������������������� [REDACTED], Service Manager � Virgin Care Coventry LLP (Virgin Care), Stoney Stanton Road, Coventry CV1 4FS

INVESTIGATIONS and INQUESTS � Vanessa Ferkova died, aged 2, on 16 January 2017 from meningococcus septicaemia. The inquest into her death concluded on 26 January 2018; I recorded a narrative conclusion (see attached). � Sylvia Daniel died, aged 73, on 2 January 2018 from acute meningitis. The inquest into her death concluded on 16 May 2018. I recorded a narrative conclusion (see attached).

Miss Ferkova Miss Ferkova had a non-significant medical history. She presented to Coventry GP Walk-in Centre (operated by Virgin Care) at 2pm on 16 January 2017 with her parents, having suffered from fever and vomiting that morning. A receptionist took down details of her illness and recorded that Vanessa looked �pale�. The information recorded did not meet the �red or yellow flag� conditions which would have prompted prioritisation of her care. � Her parents stated that Vanessa vomited in the waiting room, which would have prompted prioritisation but they were not aware of this �flag� and did not report this incident. Vanessa also developed a rash whilst waiting to be seen which, if �non-blanching� would have also prioritised Vanessa�s assessment. Her parents� evidence was that the development of a rash was raised to the receptionist, although this was not her recollection of events. As such, there was no clinical assessment until Vanessa was seen by a nurse shortly after 4pm. � At that time she was recognised to be very unwell and likely suffering from meningococcal septicaemia. She was given antibiotics and and an ambulance was called. In the ambulance, shortly after 4.30pm, Vanessa went into cardiac arrest. Unsuccessful resuscitation attempts were made, including on arrival at hospital shortly after her arrest, and she died at 5.11pm. � I heard evidence from the treating hospital paediatrician that it was likely Vanessa was suffering from compensated shock on her arrival to the walk-in centre and that, had observations been undertaken at this stage, this would have been recognised, treated and Vanessa would have survived. The paediatrician set out that recording clinical observations was a �vital patient safety tool� in the secondary care setting. I heard from Virgin Care that, unlike in the secondary care setting, they are not commissioned to undertake clinical triage and that nor is there a timeframe within which patients are required to be initially assessed. � Mrs Daniel Mrs Daniel presented to Coventry Walk-in Centre on 1 January 2018 with symptoms reported by her family to include, amongst others, a stiff neck/neck pain. Her daughter stated in evidence that she completed a handwritten registration form at reception which included this detail. However, electronic documentation recorded by the receptionist did not include reference to Mrs Daniel�s neck. Virgin Care have subsequently confirmed that the handwritten forms are not retained at the walk-in centre and this form would have been destroyed. � Mrs Daniel was seen by a doctor after a wait of approximately 90 minutes. Her family set out that they had raised concerns she had deteriorated and needed to be seen prior to this but that this was not acted upon by reception staff. � The doctor who consulted with Mrs Daniel diagnosed her with an ear infection and prescribed antibiotics. There was differing recollection between the family and the doctor as to whether neck symptoms were specifically referred to in the consultation. The doctor set out that, had they been part of the history provided, he would have undertaken a specific examination to assess the cause. He was clear that the information provided by reception made no reference to neck symptoms and demonstrated this by reference to the electronic documentation. � Mrs Daniel�s family stated that on the way home she became more confused and unsteady. On arriving at her home Mrs Daniel went to sleep but was found deceased the following morning, after contact could not be made by her family.

I have sent a copy of my report to the Chief Coroner, Miss Ferkova�s family, Mrs Daniel�s family, the CQC and NHS England. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Coventry and Rugby Clinical Commissioning Group | Virgin care Coventry LLP

27/02/2023

2023-0077

Kyron Hibbert

Bedfordshire and Luton

[REDACTED], Chairman of Trustees, The Forest of Marston Vale Trust

On 05 August 2022 I commenced an investigation into the death of Kyron Marcus HIBBERT aged 13. The investigation concluded at the end of the inquest on 26 January 2023. The conclusion of the inquest was that Kyron died as result of Misadventure.

During a heatwave whilst spending time with friends at Stewartby Lakes near Marston Moretaine on 29 July 2022, the Deceased, who was unable to swim, at around 18.30 hours, decided to have a turn on the rope swing that was attached to a tree at the lakeside and which the others had been using to enter the water. He took off his shoes, socks and t-shirt and pushed his jogging trousers down to his ankles and, after being swung over the water for a second time, he released hold of the rope and entered the water. He immediately struggled to find his footing or tread water owing to a combination of the depth and coldness of the water as well as the restriction of his trousers. His friends were unable to take hold of him and he quickly became submerged. Emergency services were alerted and after extensive searches he was recovered from the water; his death was confirmed by paramedics at 02.25 hours on 30 July 2022.

I have sent a copy of my report to the Chief Coroner. I have also sent it to Royal Life Saving Society (RLSS) Red Hill House, 227 London Rd, Worcester. WR5 2JG Central Bedford Safeguarding Children Board (CBSCB) [REDACTED] who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Other related deaths | Child Death (from 2015)

The Forest of Marston Vale Trust

21/06/2023

2023-0299

Matthew Harris

Worcestershire

[REDACTED], Chief Constable, Dyfed-Powys Police.

[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. � The conclusion of the inquest was that Mr. Harris died as the result of suicide.

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.� � Mr. Harris had been arrested on 13.5.22 by Dyfed-Powys Police on suspicion of murder, and was subsequently charged and remanded into custody at HMP Swansea on 16.5.22.

I have sent a copy of my report to the Chief Coroner and to the following: � (a)��� Deighton Pierce Glynn solicitors ( acting for Mr. Harris� family ); (b)��� Government Legal Department ( acting for HM Prison & Probation Service ); (c)���� Practice Plus Group; (d)��� Midlands Partnership NHS Foundation Trust; (e)��� Swansea Bay University Health Board; (f)����� HM Chief Inspector of Prisons; (g)��� Independent Advisory Panel on Deaths in Custody. � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | State Custody related deaths This report is being sent to: Dyfed-Powys Police

06/12/2024

2024-0677

Champagauri and Dipak Bhatt

North London

[REDACTED], Chief Executive Office of Product Safety Standards 4th Floor Cannon House 18 The Priory Queensway Birmingham B4 6BS C/O: [REDACTED] � [REDACTED], Chief Executive British Standards Institute 389 Chiswick High Road London W4 4AL C/O [REDACTED] & [REDACTED] & [REDACTED] � The Home Office Fire Policy Team Direct Communications Unit 2 Marsham Street London SW1P 4DF C/O: [REDACTED] � National Fire Chief�s Council 71-75 Shelton Street Covent Garden London WC2H 9JQ C/O: [REDACTED]� [REDACTED], Chief Executive Association of Manufacturers of Domestic Electrical Appliances Vintage House 36-37 Albert Embankment London SE1 7TL Email: [REDACTED] C/O: [REDACTED] [REDACTED], Chief Executive Chartered Trading Standards Institute 1 Sylvan Court Sylvan Way Southfields Business Park Basildon Essex SS15 6TH C/O: [REDACTED] & [REDACTED] � [REDACTED], Managing Director Hotpoint UK Appliances Limited Morley Way Peterborough PE2 9JB C/O: [REDACTED] [REDACTED], Chief Executive North Yorkshire Council County Hall Northallerton DL7 8AD C/O: [REDACTED]

On the 17th of May 2023 I commenced investigations into the deaths of Champagauri and Dipak Bhatt. The investigations concluded on the 15th of November 2024 after inquests held over the 6th, 7th and 8th of November 2024. The inquests had the following short narrative conclusions: (a) Following a fire caused by an electrical fault in the tumble dryer, Champagauri Bhatt died from the resulting inhalation injury. (b) Following a fire caused by an electrical fault in the tumble dryer, Dipak Bhatt died from the resulting inhalation injury.

On the evening of 29th of March 2023 a fire caused by an electrical fault in the tumble dryer at [REDACTED] Edgware caused Champagauri and Dipak Bhatt to die from inhalation injuries. There was a 10% chance the EMI filter caused the fire and a 90% chance the condensate pump caused the fire.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; � � 1. The family of Ms Champaguri and Mr Dipak Bhatt 2. London Fire Brigade 3. Hotpoint

Product related deaths

Office of Product Safety Standards | British Standards Institute | The Home Office | National Fire Chief�s Council | Association of Manufacturers of Domestic Electrical Appliances | Chartered Trading Standards Institute | Hotpoint UK Appliances Limited | North Yorkshire Council

23/03/2023

2023-0103

Benjamin Nelson-Roux

North Yorkshire and York

[REDACTED], Chief Executive Harrogate Borough Council, [REDACTED], Chief Executive North Yorkshire County Council Rt Hon Steve BARCLAY MP, Secretary of State for Health and Social Care

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: � On 8 April 2020 Benjamin Nelson Roux, aged 16 and a Child in Need, was found unresponsive at 23 Robert Street, Harrogate, a hostel for homeless adults in which he had been temporarily placed due to there being no more suitable accommodation available. His death was confirmed there at 16.50 hours that day. The cause of his death is unascertained. He had taken multiple drugs of abuse prior to death, the impact of which cannot be determined with any degree of confidence. It cannot be concluded that his accommodation has contributed to his death.

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] North Yorkshire Police Tees Esk and Wear Valley NHS Trust Harrogate and District NHS foundation trust � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Other related deaths | Child Death (from 2015)

Harrogate Borough council | North Yorkshire County Council | Department for Health and Social Care

02/08/2024

2024-0426

Thomas McAuley

Dorset

[REDACTED], Chief Executive Health and Safety Executive

On the 13th July 2022, an investigation was commenced into the death of Thomas Joseph McAuley, born on the 1st April 1968.� The investigation concluded at the end of the Inquest on the 19th July 2024. The Medical Cause of Death was: 1a Multiple Injuries 1b 1c 2 The conclusion of the Inquest recorded that Thomas Joseph McAuley died as a consequence of an accident.

Thomas Joseph McAuley was employed by Kiely Brothers Limited (�KBL�) as part of a crew of men undertaking road resurfacing works. On 5th July 2022, Mr McAuley, together with a crew of 6 others, was undertaking resurfacing work in Redwood Drive, Ferndown. At approximately 11 am Mr McAuley placed himself within the area between the third and fourth axles of a four axle, 32 tonne grab lorry that was on site. This was likely so that he could urinate. The driver of the grab lorry was unaware of Mr McAuley�s presence within this area and moved the grab lorry forward a short distance and at low speed, causing Mr McAuley catastrophic injuries that caused his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� (1) [REDACTED] (2) [REDACTED] (3)�[REDACTED] (4)�[REDACTED] (5) DWF Law, representing KBL;� (6) Dolmans Solicitors, representing Dorset Council. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

�Accident at Work and Health and Safety related deaths � This report is being sent to: Health and Safety Executive

26/09/2023

2024-0026

Benjamin Hazelden

North East Kent

[REDACTED], Chief Executive NHS Kent and Medway Clinical Commissioning Group [REDACTED], Chief Executive NHS England

ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

Suicide (from 2015) | Railway related deaths This report is being sent to: NHS Kent and Medway Clinical Commissioning Group | NHS England

28/03/2024

2024-0184

Ellen Woolnough

Suffolk

[REDACTED], Chief Executive Norfolk and Suffolk NHS Foundation Trust [REDACTED], CHIEF EXECUTIVE NHS ENGLAND

On 03 August 2022 I commenced an investigation into the death of Ellen Ocean WOOLNOUGH aged 27. The investigation concluded at the end of the inquest on 13 February 2024. The conclusion of the inquest was that: � Narrative Conclusion Ellen Ocean WOOLNOUGH was described by her family and friends as a caring, compassionate, thoughtful, kind and generous person who exuded warmth and charisma. A person whose company was uplifting and who had a genuine desire to see the lives of those around her enhanced. � Ellie had a history of mental health issues which started when she was around six years of age. Ellie had contact with mental health services between 2001 to 2011 following which her contact was sporadic up until 2022. Her mental health continued to suffer through her adolescence and into her young adult years. She was diagnosed with Emotionally Unstable Personality Disorder in April 2020. � From 2019 Ellie�s mental health problems became more acute when she suffered periods of physical illness, with particularly serious events identified in 2019 when she suffered from food poisoning and in May 2022 when she suffered from COVID. Although in May 2022 her physical symptoms were not severe, her mental health deteriorated significantly and she reported to her family that she attempted suicide by using a ligature on the 11th May 2022. She was seen the following day by the Crisis Resolution and Home Treatment Team (CRHTT) and following assessment referred to the Integrated Delivery Team (IDT). � On the 20th May 2022 Ellie met with IDT staff for the purposes of an assessment, however this was curtailed when Ellie left the meeting abruptly. A further meeting was not attempted and Ellie was discharged from the IDT a few days later. � On the 19th July 2022 Ellie had been suffering from a gastrointestinal illness for several days. Her family were concerned both in relation to her physical wellbeing but also her mental health which had deteriorated due to her physical health condition. Ellie�s father contacted her GP who referred Ellie to the CRHTT as an urgent referral. � Ellie was spoken to by the CRHTT on two occasions around 17:30 hours following which arrangements were made for Ellie to be seen the following day (20th July 2022) by the CRHTT at her home. Concerned about her physical condition, her family called an ambulance who attended late on the evening of 19th July 2022 and treated Ellie at home for dehydration. Following a period of time spent at her parents that evening, Ellie returned to her home in the early hours of the 20th July 2022 and went to bed. � From around 06:41 am until 09:21 am Ellie exchanged a series of text messages and phone calls with her father and partner which caused increasing concern for her welfare and resulted in her father and partner attending her residence. On gaining entrance they discovered Ellie suspended by a ligature [REDACTED]. � Ambulance attended and following attempts at resuscitation, a return of spontaneous circulation was achieved and Ellie was transported to hospital. Sadly she had suffered an irreversible hypoxic brain injury and despite treatment Ellie died on the 28th July 2022. � Ellen Ocean WOOLNOUGH took her own life whilst suffering from the diagnosed mental health condition of emotionally unstable personality disorder. The medical cause of death was confirmed as: 1a Hypoxic Brain Injury 1b Hanging

Narrative Conclusion see Box 4.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons �[REDACTED] �[REDACTED] I have also sent it to � who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Mental Health related deaths | Suicide (from 2015) This report is being sent to: NHS England | Norfolk and Suffolk NHS Foundation Trust

12/07/2023

2023-0238

Luke Ashton

Leicester City and South Leicestershire

[REDACTED], Chief Executive Officer (�CEO�) of Flutter UK & Ireland, the parent company of �Betfair� (through its legal representatives) [REDACTED], Chief Executive Officer (�CEO�) of the Gambling Commission The Rt. Hon. Lucy Frazer KC, MP, Secretary of State for Culture, Media and Sport

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. The conclusion of the inquest was that: � Narrative Conclusion: � Luke Ashton died as a result of his own actions, intending those actions to cause his death. At the time of his death, Luke was suffering from a gambling disorder, which was longstanding, at least from 2019 and which contributed to his decision to take his own life. In the months prior to his death, the evidence showed that Luke had been assessed as a low-risk gambler by the operator with whom he was gambling, although Luke�s gambling activity, deposits made and losses suffered were most intensive in the 10 weeks prior to his death. The same operator did not intervene or interact with Luke, in any meaningful way, between 2019 and the date of Luke�s death, when more efforts to intervene or interact should have been made. Opportunities were missed which may possibly have changed the outcome for Luke. � The cause of death was established as: � I a ([REDACTED]) � I b Gambling Disorder

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1.��[REDACTED] , wife of the Deceased (via her legal representatives, Leigh Day & Company). 2.�Flutter Entertainment UK & Ireland (via its legal representatives). � I have also sent it to 1.������ Gamble Aware (Charity, Registered in England No. 4384279) � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may� send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Other related deaths This report is being sent to: Betfair | Gambling Commission | Department for Culture, Media and Sport

05/09/2024

2024-0493

Carol Guest

South Yorkshire East

[REDACTED], Chief Executive Officer and [REDACTED], Acting Medical Director, Rotherham Doncaster and South Humber NHS Foundation�Trust

On 9 April 2024 I commenced an investigation into the death of Carol Ann Guest. The investigation� concluded at the end of the inquest. The conclusion of the inquest was� Suicide.� 1a Hanging �� 1b�� � 1c� �� �II

Carol Ann Guest resided at home with her partner and did not have a history of mental health� problems until 2024. These appear to have been triggered by her mother (for whom she had been� caring for for a considerable period of time) being admitted to a care home. There were references� in the GP notes to Ms Guest and her family seeking help and support in relation to mental health� difficulties, which the family felt were escalating. On the 8th March 2024 a family member contacted the GP expressing concerns regarding escalation of symptoms and Ms Guest having taken excess� medication the previous week. The GP did not feel a telephone call that day was indicated but did� feel that urgent referral was necessary but regrettably the urgent referral was not sent until a week� later. Once received by yourselves on Friday the 15th March, Mrs Guest�s referral was placed on� the SPA meeting list for the following Thursday (the 20th March) where it was discussed and� determined that she would not follow the usual pathway and wait for a routine appointment but that� a consultant would visit her the following week. Before that visit could be arranged Ms Guest� hanged herself�[REDACTED] at her home address on the 24th March 2024.

I have sent a copy of my report to the Chief Coroner and to�[REDACTED]. I am also under a duty to send the Chief Coroner a copy of your response.� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may� send a copy of this report to any person who he believes may find it useful or of interest. You may� make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Suicide (from 2015) | Mental Health related deaths | Community health care and emergency services related deaths

Rotherham Doncaster and South Humber NHS Foundation�Trust

04/07/2024

2024-0360

David Morris

East London

[REDACTED], Chief Executive Officer, Barking, Havering & Redbridge University Trust � Secretary of State for Health & Social Care � ����������������������������������� [REDACTED], Medicines & Healthcare products Regulatory Agency

On 17/05/2022, this Court commenced an investigation into the death of David John Morris aged 78 years. The investigation concluded at the end of the inquest on 3rd July 2024. The Court returned a narrative conclusion; � �David John Morris died in hospital on 16th May 2022 due to complications of necessary surgery to treat the effects of oesophageal cancer. Mr Morris fell into septic shock due to peritonitis caused by a leak of enteral feed into his abdomen from a gastrostomy apparatus. It has not been possible to determine how the leak arose.� � Mr Morris�s medical cause of death was determined as; � Intra-Abdominal Sepsis Laparoscopic Gastrostomy Oesophageal Cancer II Chronic Obstructive Pulmonary Disease, Ischaemic Heart Disease

David Morris was a 78-year-old man who developed symptoms of abdominal pain and blood-stained vomiting in October 2021. Mr Morris was assessed by his GP who made a number of referrals to specialists under the two week wait pathway. Delays occurred in undertaking diagnostic tests of the deceased, which resulted in a finalised diagnosis of oesophageal cancer only being arrived at in late February 2022. � The onset of cancer resulted in a stricture of the oesophagus which impeded oral intake of nutrition. On 2nd May 2022 Mr Morris underwent a surgical gastrostomy to facilitate enteral feeding through a tube directly into his stomach. � On 3rd May 2022 Mr Morris began to deteriorate whilst treated on a surgical ward, he experienced difficulty in breathing and pain in his left upper quadrant. A leak was detected from his gastroscopy on two occasions during the day but enteral feeding was allowed to continue. Shortly before midnight, the leak re-occurred, Mr Morris was reviewed by a registrar and again, the enteral feed was allowed to continue. � At approximately 07.00 hrs on 4th May 2022, the leak from the gastrostomy was observed to have increased and again a doctor was called for. Mr Morris�s clinical observations were taken and it was noted that he had deteriorated, a mottled rash was observed on his abdomen. � Despite these concerning signs, no clinical action was taken until after 10.30hr, over three hours later, when a surgical registrar reviewed Mr Morris. The surgeon identified septic shock with a likely abdominal cause and Mr Morris was prepared for emergency surgery. � A laparotomy determined that the gastrostomy device had failed, Mr Morris had a gangrenous bowel, caused by peritonitis due to the spillage of stomach content and enteral feed into the abdomen. The ischaemic bowel was removed and re-look surgery was arranged for the following day. � The gastrostomy device was removed and tested for 7 days thereafter, it appeared to be functional. The device was subsequently lost, negating the possibility of further investigation when it was returned to a manufacturer. Human error in the handling of the gastric ballon inflation port on the device remains a potential cause for the deflation and failure of the device. � On the 8th May a final surgery was undertaken to repair the bowel and insert a feeding tube into the small intestine. � Mr Morris declined post-operatively, passing away in hospital on 16th May 2022. � Some time after the death of Mr Morris, the nurse in charge of the ward where the deceased was cared for on 3rd May 2022 was found collapsed and unresponsive at work. The nurse volunteered that they were under the effects of stolen controlled medication that belonged to the hospital. The nurse offered that they had been stealing and self-administering controlled medications during every shift they worked for approximately three years. At inquest, the nurse declined to answer questions on whether their drug misuse could have had a contributary effect of the failure of Mr Morris�s gastrostomy.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Morris and the Care Quality Commission. I have also sent it to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Barking, Havering and Redbridge University Trust | Department of Health and Social Care | Medicine and Healthcare products Regulatory Agency

19/09/2024

2024-0503

Gordon Long

East London

[REDACTED], Chief Executive Officer, Barking, Havering & Redbridge University Trust� Sent via email:�[REDACTED]

On 11th July 2023, this court commenced an investigation into the death of Gordon Long aged 73 years. The investigation concluded at the end of the inquest on 18th� September 2024. The court returned a narrative conclusion,�� �George Richard Long died in hospital on 8th July 2023 the day after necessary surgery to amputate his left leg. Mr Long died due to complications of surgery along with the� effects of multiple, pre-existing, serious medical conditions.�� Mr Gordon�s medical cause of death was determined as; 1a: Infective Exacerbation Of Chronic Obstructive Pulmonary Disease And Congestive Cardiac Failure� 1b: Septic/Gangrenous Left Foot Treated With Left Above Knee Amputation,�Ischaemic Heart Disease And Extensive Metastatic Carcinoma To The Liver� 1c.Peripheral Vascular Disease� II. Type 2 Diabetes Mellitus, Atherosclerosis, Dyslipidaemia, Cirrhosis Of The Liver, Depression And Previous Left Sided Cerebrovascular Accident

Mr Long was admitted to hospital by ambulance on 1/7/23. A preliminary diagnosis of� dry gangrene of the left foot was arrived at in the ED. A care plan was arrived at that� involved amongst other things, admission onto a ward and referral to the vascular team for assessment.� Mr Long was not assessed by a vascular specialist until 6th July 2023, by which time he had suffered a significant clinical decline. Surgery to amputate the effected limb was� undertaken on 7th July 2023, he died on 8th July 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested� Persons the family of Mr Long and the Care Quality Commission. I have also sent it to the local Director of Public Health who may find it useful or of interest.� I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� �� I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest.�� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths

Barking, Havering & Redbridge University Trust

29/06/2023

2023-0219

Matthew Phipps

East London

[REDACTED], Chief Executive Officer, Barking, Havering and Redbridge University Hospital NHS Foundation Trust

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.

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.

I have sent a copy of my report to the Chief Coroner and to the family of Mr Phipps. I have also sent a copy to the local Director of Public Health who may find it useful or of interest and to the CQC. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Barking, Havering and Redbridge University Hospital NHS Foundation Trust

24/07/2023

2023-0270

Christine Nakafeero

East London

[REDACTED], Chief Executive Officer, Barts Health NHS Foundation Trust � [REDACTED], National Medical Director, NHS England � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

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. � �Christine Goodfriday Nakafeero died at home on 21st June 2022 due to a pulmonary embolism caused by a deep vein thrombosis (�DVT�). The DVT was made more likely by: a medical condition, uterine fibroids and the treatment for that condition, tranexamic acid. In 2019 Ms Nakafeero was referred to the gynaecology clinic with a recommendation that she underwent a hysterectomy to effectively treat her uterine fibroids. Due to a breakdown of communication between Ms Nakafeero and the Trust, the surgery was not undertaken. Had the surgery taken place, Ms Nakafeero would probably not have developed a pulmonary embolism in June 2022.� � Ms Nakafeero�s medical cause of death was determined as:� 1a Pulmonary Emboli; 1b Deep Vein Thrombosis; II Uterine Fibroids

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Ms Nakafeero. I have also sent it to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Barts Health NHS Foundation Trust | NHS England | Department of Health and Social Care

16/10/2023

2023-0386

Claire Twinn

East London

[REDACTED], Chief Executive Officer, Barts Health NHS Foundation Trust � � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

On 16 December 2022 this Court commenced an investigation into the death of Claire Twin aged 47. The investigation concluded at the end of the inquest on 13th October 2023. The conclusion of the inquest was a short-form conclusion of a death by natural causes: � a. BronchopneumoniaVentricular Septa! Defect And Pulmonary Hypertension (Down�s Syndrome)

Claire Twinn was a 47 year old woman who was born with the chromosomal condition, Down�s syndrome. Ms Twinn had a congenital heart defect which resulted in a further condition, Eisenmenger syndrome which adversely affected her respiratory output. Ms Twinn was also assessed to be affected by a severe learning disability. � On 15th December Ms Twinn became unwell with symptoms of; a productive cough with yellow sputum, sickness and diarrhoea. Her family took Ms Twinn to the emergency department of Newham General Hospital. � An initial rapid assessment identified low oxygen saturations at 61% she was treated with oxygen. � Clinical observations were taken and the patient was monitored, blood tests could not be taken as Ms Twinn had a significant phobia of needles. Her learning disability meant that she could not be persuaded to voluntarily provide a blood sample. Similarly, any assessment of potential confusion was made more difficult due to her non-verbal status. � It was decided that a blood sample or 1/V therapy could only be administered if the patient was sedated. Ms Twinn�s complex lung and heart problems meant sedation would carry high risk and was therefore discounted. � Ms Twinn had continuous monitoring of oxygen levels, blood pressure and heart rate. A chest x-ray was undertaken that was interpreted by the emergency team as inconclusive of infection despite that, based on history, chest auscultation and a raised temperature, a working diagnosis of bilateral pneumonia was arrived at. � A senior doctor took over care of the patient. Oxygen requirement was titrated down from high flow oxygen mask to low flow nasal cannula. Achieving saturations 75% at rest without oxygen, this was patients baseline level from medical notes. � Ms Twinn was discharged late in the evening on oral antibiotics, she was found deceased the following morning when her family tried to rouse her from sleep. � The Trust now accepts that the more appropriate course would have been to admit Ms Twinn for observation, monitoring of oxygen levels and providing remedial oxygen therapy if a de-saturation occurred. � The inquest took expert evidence into account in determining that an admission into hospital would not have, on the balance of probability, resulted in Ms Twinn�s death being avoided.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Ms Twinn. I have also sent it to the Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me,� the coroner, at the �time of your response , about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Bart Health NHS Foundation Trust | Department of Health and Social Care

13/06/2023

2023-0192

Raquel Harper

East London

[REDACTED], Chief Executive Officer, Barts Health NHS Foundation Trust, Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB

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. The conclusion of the inquest was a narrative conclusion: � Raquel Harper died as a result of natural causes. Her death was however contributed to by an omission of hospital staff to carry out appropriate investigations and to instigate timely treatment for her pulmonary embolism.

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Ms Harper, CQC and to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Barts Health NHS Foundation Trust

20/12/2024

2024-0706

Edith Pye

Worcestershire

[REDACTED], Chief Executive Officer, Care UK Ltd, Connaught House, 850 The Crescent, Colchester, Essex, CO4 9QB.

On 1 May 2024 I commenced an investigation and opened an inquest into the death of Edith Theresa PYE. The investigation concluded at the end of the inquest on 16� December 2024.� The conclusion of the inquest was that Mrs. Pye �died as the result of an accidental fall in a care home. Her death was contributed to by neglect�.

In answer to the questions �when, where and how did Mrs. Pye come by her death?�, I recorded as follows:� �On 29.3.24 Edith Pye sustained a periprosthetic fracture to her left knee after rolling off her bed at Chandler Court Care Home, Bromsgrove, where she lived. At the time� of the fall she had briefly been left unattended while receiving personal care which� should have been provided by at least two carers, but at the time was only being� provided by one. As a result of her injury, she underwent an above knee amputation, and went on to develop a chest infection and pulmonary emboli. Despite treatment,� she continued to decline and was discharged back to the care home for end of life� care, where she died on 28.4.24.�

I have sent a copy of my report to the Chief Coroner and to the following: (a) [REDACTED], Mrs. Pye�s son; (b)� DAC Beachcroft solicitors, who represented Care UK Ltd. at the inquest hearing.� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief� Coroner.

Care Home Health related deaths

Care UK Ltd

08/11/2023

2024-0109

Lee Bowman

South Yorkshire East

[REDACTED], Chief Executive Officer, College of Policing

On 12th January 2022 I commenced an investigation into the death of Lee Bowman born on 10th January 1977. The investigation concluded at the end of the inquest which commenced on the 8th November 2023. The conclusion of the inquest was: � An open conclusion � In box three it was recorded � On 2 November 2021 Lee Bowman was reported missing to police by his family. The last sighting of him was on 31 October 2021. His body was found at 62 Green Arbour Road, between two fence panels in the garden on 3 January 2022 The medical cause of death was: 1a: Unascertained

Lee Bowman was last seen by his family on 29 October 2021 going to his girlfriend�s home address in South Yorkshire. His family did not hear from him after this and that was out of character for Lee who would ordinarily be in touch with his family hourly during the day. � Lee did not possess his own phone and therefore family had to rely on Lee contacting them rather than being able to ring him themselves. � Lee had a number of underlying health conditions including mental health conditions and history of self harm. He also had recently had a diagnosis of liver cirrhosis which was causing him concern. On top of that his father had recently been diagnosed with cancer and that had upset him. � On 31 October 2021 Lee was reported as being seen in the vicinity of his girlfriend�s home address with injuries consistent with being assaulted. This is the last unquestioned sighting of Lee before his body is found. � On 2 November 2021 Lee was reported missing to Nottinghamshire Police by his brother. His brother reports that they haven�t heard from him and that this was out of character for Lee. He also makes reference to mental health problems and that he has not taken it well that his father has been diagnosed with cancer. Nottinghamshire Police determined that this is not a true missing person enquiry at this stage as it is not clear that he is actually missing, and they asked South Yorkshire Police to make enquiries at th.e last known address that Lee was going too. � The log that Nottinghamshire police hold is updated before the addition of information �from South Yorkshire police confirming that they had attended at his girlfriends address and she said she had kicked him out two days previously. � The matter then returned to Nottinghamshire Police who closed the incident down as a deliberately absent individual. � On 4 November 2021 Lee�s father also reported Lee missing as they had still not heard from him. This commenced the missing person investigation from Nottinghamshire Police. � There were a number of sightings reported of Lee when media appeals were issued. These were both in South Yorkshire and Nottinghamshire. These were not necessarily thoroughly checked for accurateness although they were followed up by officers in Nottinghamshire. These sightings gave false assurance that Lee was well and was not contacting family for unknown reasons. � The sightings included a sighting by a police officer and this check was assessed as being particularly reliable however there was insufficient scrutiny applied to that veracity of that sighting. In any event, that sighting was in early November still leaving days unaccounted for. � There was no referral to detectives from Nottinghamshire Police and instead the investigation was transferred to South Yorkshire Police on 28 November 2021. This was closed by South Yorkshire Police as a result of an incorrectly confirmed sighting by a PCSO of Lee. � The case was reopened by South Yorkshire Police on 7 December 2021 following a call from Lee�s family confirmed that he had still not been seen. � When the case was reopened on the 7 December 2021 and then reviewed on the 9 December with the grading being low risk. This was revisited on the 10 December and despite no particular change to the circumstances it was revised to be Medium risk. � On 14 December 2021 the missing person report was regraded as high as it was apparent that the sightings were unconfirmed sightings. This resulted in detectives being asked to lead the investigation who undertook a number of enquiries including CCTV, door to door enquiries and financial and phone enquiries. � It appears that it was not until 31 December 2021 that the police in South Yorkshire became aware of the jacket which Lee was wearing in the last known sighting, being found and that narrowing the search scene to near where Lee was ultimately found. � Between Lee�s reported disappearance on 2 November 2021 right up until his body was found on 3 January 2022 there had been no activity in Lee�s bank account and no contact with his family despite his usual levels of contact with them. � [REDACTED], gave evidence that there were four possible medical explanations for Lee�s death:- Liver disease � Hyperthermia � Drug or alcohol use � Positional asphyxia � However, he also explained that there was not enough pathological evidence to be persuaded by to give a preference and for that reason he had to return unascertained and rely upon the inquest to try and ascertain the circumstances. � There was no evidence heard during the inquest that assists with the circumstances beyond Lee having been seen with injuries in the vicinity of where his body was found on 31 October 2021. � [REDACTED], �was clear that Lee had been where he was found for some time but could not be precise as to when he had died. � The following findings were made during the inquest: � � The decision making around the closure of the Log created when Lee was first reported missing on 2 November 2021 was lacking in clarity and has been largely based on presumption. The log appears to have been closed before the clarity has been received from South Yorkshire Police about whether or not Lee was at his partners address and seems to be based upon intelligence information held by the police rather than risk assessment of the current situation which Lee was in at the time that he went missing. � That said, even if the log had remained open and a missing persons case been commenced it is apparent that a key factor for Nottinghamshire police�s risk assessment when Lee was reported again on 4 November was the fact that his money had gone into his account on 3 November but that it had not been touched. This would not have been the case on the 2 November and therefore it cannot be confirmed whether that would have made a difference to the searches that were conducted for Lee on that date. � On the basis of �[REDACTED], evidence, it cannot be said whether Lee was already dead on 2 November 2021. � The checks conducted by South Yorkshire Police on 2 November 2021 lacked professional curiosity. When it was confirmed that Lee had been kicked out of the house and not seen since there was no sense that this might require any additional follow up or any further enquiries made of his then partner about whether he was ok when he left the address. Whilst this is unlikely to have made a difference to the overall outcome it was a missed opportunity to gather information and intelligence about Lee�s condition at the time he was a missing person. � There was evidence of unconscious bias influencing the decision making and judgments of officer�s risk assessing. For example, there were assumptions that Lee led a chaotic lifestyle and therefore was not missing but choosing not to be found as he was drunk somewhere. This was never triangulated with the fact that he had not touched his bank account and even within the confines of his addiction, he ordinarily maintained contact with his family which he did not do here. Police also relied upon sightings from those who lead similarly �chaotic� lives to demonstrate that Lee was well and just had not been located. Again, this was not weighed against the body of evidence from the family that he was unwell and was not in contact with them which was out of character. � Once detectives took over the inquiry on the 14 December 2021 matters picked up in PACE and enquiries were undertaken with greater clarity and order however in reality nothing had substantially changed in Lee�s position in that time. What was discovered in December 2021 was that the sightings relied upon in fact could not be relied upon and had not been adequately scrutinised. � Unfortunately, the evidence from the pathologist was such that it cannot be said when Lee died and therefore the point at which he could still have been found alive cannot be identified. The decisions in respect of the searches therefore cannot be said, even on the balance of probabilities, to have made a difference to the outcome for Lee.

l have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of Lee Bowman, Deputy Chief Constable of West Yorkshire Police as the National Police Chief Council Lead for Missing Persons, Home Office, Chief Constable of South Yorkshire and Chief Constable of Nottinghamshire Police. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Other related deaths This report is being sent to: College of Policing

19/09/2023

2023-0466

Lauren Bridges

Manchester South

[REDACTED], Chief Executive Officer, Dorset Healthcare University NHS Foundation Trust, Sentinel House, Nuffield Industrial Estate, Nuffield Road, Poole BH17 0RB

On 01.03.22 an investigation commenced into the death of Lauren Elizabeth Bridges who died on 26.02.22, aged 20 years. � The inquest concluded on 01.09.23. � The medical cause of death was 1a) Hypoxic brain injury 1b) Cardiac arrest 1c) Hanging injury � The conclusion of the jury was Lauren Elizabeth Bridges ended her life by ligature. This was misadventure with Lauren not intending to commit suicide. � Missed opportunities for moving Lauren closer to home with acute and PICU beds available during significant periods between July 2021 and February 2022 at St. Ann�s, Seaview and Haven wards, contributed to increased incidents and her death. � The prolonged stay in a PICU placement in Priory Cheadle led to iatrogenic deterioration. This was prolonged by a delayed discharge. There was inadequate communication about Lauren from Dorset Healthcare NHS Trust to relevant parties, and there was insufficient communication about Lauren from Priory Cheadle to relevant parties. � Dorset Healthcare NHS Trust did not recognise the exceptional circumstances of the effects on Lauren being in an out-of-area placement over 260 miles away from home.

Lauren lived in Bournemouth. From March 2020 Lauren had been an in-patient, detained under section 3 of the Mental Health Act 1983. In January 21 Lauren was admitted to a Rehabilitation Unit, at The Priory, Dorking, as an Out-of Area patient. This placement was commissioned by Dorset CCG (as it was then � now Dorset ICB). Dorking is just over 100 miles from Bournemouth. In about mid-June 2021 Lauren�s mental health deteriorated and it was determined on 01.07.21 that Lauren needed to be transferred to a Psychiatric Intensive Care Unit to keep her safe. On 23.07.21 Lauren was transferred to Pankhurst Ward PICU, The Priory, Cheadle. Again, Lauren was an Out-of-Area patient at a distance, now, of some 260 miles from home. This placement was commissioned by Dorset Healthcare NHS Trust. Lauren was ready for step-down from the PICU by 02.09.21. The plan being to seek an acute bed, at or closer to home, while a suitable Rehabilitation Unit was found. Lauren remained in the PICU, at The Priory, Cheadle for the next 5 months, until her death on 26.02.22 following a ligaturing incident on 24.02.22. Over that time Lauren�s mental health deteriorated, with an increasing number of incidents of self-harm. A major factor in Lauren�s deterioration was the distance from her home and family.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, who may find it useful or of interest. Lauren�s family The Priory Dorset ICB Bournemouth, Christchurch & Poole Council � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Dorset Healthcare University NHS Foundation Trust

25/09/2024

2024-0513

Jyoti Rao

Manchester South

[REDACTED], Chief Executive Officer, Manchester University NHS Foundation Trust

On 19th June 2024, Alison Mutch, Senior Coroner for Greater Manchester (South), opened an inquest into the death of Jyoti Rao, who died on 20th February 2024 at Tameside General Hospital, Ashton- under-Lyne, aged 56 years. The investigation concluded with an inquest which I heard on 16th� September 2024.� The inquest determined that Miss Rao died as a consequence of:-� 1) a) Hypoxic-ischaemic brain injury;�� b) Sepsis on background of end-stage renal failure with failure of transplanted kidney. II Traumatic nasogastric tube insertion The conclusion of the inquest was a Narrative Conclusion, to the effect that Miss Rao died as a� consequence of complications arising from renal transplantation.

Miss Rao died on the 20th February 2024 at Tameside General Hospital, Ashton-under-Lyne as a� consequence of Hypoxic-ischaemic brain injury due to sepsis on the background of end-stage renal failure with failure of a transplanted kidney. Miss Rao�s death was contributed to by traumatic� nasogastric tube insertion.

I have sent a copy of my report to the Chief Coroner, Miss Rao�s brother and sister-in-law, and the�Trust�s legal team.�� I have also sent a copy to Tameside and Glossop Integrated Care NHS Foundation Trust, the Care� Quality Commission and NHS Greater Manchester Integrated Care who may find it useful or of� interest.�� I am also under a duty to send the Chief Coroner a copy of your response.��� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may� make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Manchester University Hospitals NHS Foundation Trust

23/12/2024

2024-0711

Nigel Sweet

Cornwall and Isles of Scilly

[REDACTED], Chief Executive Officer, National Highways

On 18 March 2024 I commenced an investigation into the death of 63 year old� Nigel William Sweet. The investigation concluded at the end of the inquest on 19 December 2024.�� The medical cause of death was found as follows: 1a Multiple Injuries� 1b Road Traffic Collision The four questions � who, when, where and how � were answered as follows: Nigel William SWEET died on 7 March 2024 on the A38 between� Trerulefoot and Tideford Cornwall from injuries sustained after he lost� control of his motorcycle due to rider error whilst attempting to complete� an overtake of another vehicle in wet conditions.� The motorcycle fell onto its side as Nigel lost control.� Nigel was separated from his motorcycle and he slid across the carriageway into the path of an oncoming vehicle which� was unable to avoid him despite emergency braking and steering input. That oncoming vehicle drove over Nigel who suffered unsurvivable injuries as a consequence.� The conclusion of the inquest was as follows: Road Traffic Collision

The reason for the collision was found to be rider error by Nigel, in wet road conditions whilst attempting an overtake in a creeper lane.� A creeper lane is an additional lane, added to a single carriageway for a short� stretch to allow for overtaking.� There are a number on this stretch of the A38 which present road users with brief opportunities to overtake slower moving� vehicles, before the road reverts to single carriageway on both sides.� Nigel had overtaken at least one vehicle and was attempting to overtake a second vehicle by using the additional lane of the creeper lane. There was steady and� oncoming traffic on the other carriageway. Nigel had insufficient space in the� creeper lane to safely complete the overtaking manoeuvre of the second vehicle.� Nigel lost control of his motorcycle whilst under braking at which time he was� likely trying to get back into the single carriageway at the end of the creeper lane. In that sense the creeper lane contributed to the collision. �� The court found that there was nothing that the driver of the oncoming vehicle could have done to avoid Nigel.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, namely Nigel�s family.� I have also sent it to MPC [REDACTED] who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or� summary form. He may send a copy of this report to any person who he believes� may find it useful or of interest. You may make representations to me, the�coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Road (Highways Safety) related deaths

National Highways

12/08/2024

2024-0443

David Thompson

Manchester North

[REDACTED], Chief Executive Officer, Priory Head Office, Floor 5, 80 Hammersmith Road, London W14 8UD [REDACTED], Chief Executive, NHS Greater Manchester Integrated Care Board Chief Executive Pennine Care NHS Foundation Trust

On the 25th April 2024 I commenced an investigation into the death of Mr David Thompson who died on the 3rd March 2024.� The investigation concluded on the 31st July 2024. The medical cause of death was confirmed as 1a) Hypovovalmic Shock 1b) Deep cuts to left wrist 2) Fatty liver disease (alcohol related), Affective disorder, Acute alcohol intoxication. � A narrative conclusion was recorded; �On a background of a longstanding diagnosis of Affective disorder of which emotional dysregulation was a feature, the deceased died as a result of self-inflicted stab wounds. His diagnosis together with acute alcohol intoxication suggested on the balance of probabilities that his actions were impulsive and he did not intend to end his life.�

CIRCUMSTANCES OF DEATH Mr Thompson had a longstanding diagnosis of bi-polar disorder. �Over the years he had also used alcohol and illicit drugs, albeit at the time of his death he had not used drugs for years and had been abstinent from alcohol for several years. He was under the care of Pennine Care NHS Foundation Trust for his mental health. In June 2023 David had self-harmed by cutting himself and had been admitted to Tameside hospital where he remained as an inpatient until 29th August 2023.� He also underwent Transcranial Magnetic Stimulation therapy at Royal Oldham hospital until the 23rd September 2023. At the time David had health insurance via his employment so he took the opportunity to undergo further inpatient treatment at the Priory hospital in Altrincham.� He was admitted under the care of [REDACTED] on the 23rd September 2023. He remained an inpatient until the 19th October 2023.� On his discharge Mr Thompson relapsed and was then admitted to the Priory Hospital in Dorking from the 28th October until the 8th November 2023. This was as an NHS patient and the location was due to bed availability. Throughout this time Mr Thompson remained under the care of his NHS Psychiatrist [REDACTED] who reviewed him as an outpatient in December 2023. At this time Mr Thompson was stable and a plan was to review him in March 2024. In January 2024 he was reviewed by [REDACTED].� This was the outpatient appointment which had been made following his discharge on the 19th October. It is acknowledged that Mr Thompson was stable at this appointment.� The plan following this appointment included: �to continue to get input from the local NHS Mental health services.� On the 29th February 2024 Mr Thompson was in Budapest accessing dental treatment when he was advised he may require a biopsy due to a possible abnormality on his gums.� He returned home on the 2nd March 2024.� He had intimated some level of distress at this news.� It is also likely that he relapsed and used alcohol. On his return home he did not wish relatives to stay with him. He then consumed alcohol and cut his wrists.� He had attempted to make contact with some family in the middle of the night but due to the time of day his messages were not accessed until the morning.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- � Family of Mr Thompson � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.

Mental Health related deaths

Priory Group | NHS Greater Manchester Integrated Care Board | Pennine Care NHS Foundation Trust

26/05/2023

2023-0173

Conrad Colson

East London

[REDACTED], Chief Executive Officer, South London & Maudsley NHS Foundation Trust (SLAM), Michael Rutter Centre, London SE5 8AZ ��������������������������������������������� [REDACTED] Acting Chief Executive Officer, North East London Foundation Trust [REDACTED] President, Royal College of Psychiatrists, London Office, 21 Prescot Street, London, E1 8BB [REDACTED] National Medical Director, NHS England � � Rt Hon Steve Barclay MP, Ministerial Correspondence and Public Enquiries Unit, Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU

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: Conrad Colson took his own life whilst suffering from severe body dysmorphic disorder. At the time of his death, he was accessing aesthetic dermatology treatments; he was not receiving a therapeutic level of medication and he was not in receipt of any professional mental health support for his body dysmorphic disorder. He had been discharged from mental health services without any robust risk assessment and without the safety net of a fully considered risk management/relapse plan.

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested persons; Family of Mr Colson and the Aesthetic Dermatology Clinic. I have also sent a copy to the local Director of Public Health who may find it useful or of interest and to the CQC. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Suicide (from 2015) This report is being sent to: South London & Maudsley NHS Foundation Trust | North East London Foundation Trust | Royal College of Psychiatrists | Department of Health and Social Care | NHS England and Tatiana Aesthetic Dermatology Clinic

18/11/2024

2024-0641

Kevin Ince

Lancashire and Blackburn with Darwen

[REDACTED], Chief Executive Officer, The Priory Group

On 2 November 2023 I commenced an investigation into the death of Kevin Anthony Ince, age 55 years. The investigation concluded at the end of the inquest on15 November 2024. The conclusion of the inquest was natural causes.

Mr Ince was detained under the Mental health Act 1983 at Kemple View Hospital, Langho, Blackburn in Lancashire. On 24 October 2023 he pressed his call bell as he was unwell. It was noted that he was short of breath and panting. Oxygen was administered due to low oxygen saturation levels, whilst waiting for an ambulance. Mr Ince was taken to Royal Blackburn Hospital where his requirement for support with oxygen continued. Whilst in hospital he underwent a series of diagnostic tests whilst treatment continued over the following days. Unfortunately, his condition deteriorated, and he did not recover. He died on 25 October 2023. He died as a result of right ventricular failure caused by acute Interstitial pneumonitis as a result of vaping associated lung injury.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family and Sadben and Whalley Medical Group. I have also sent it the Care Quality Commission who may find it useful or of interest � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths | Mental Health related deaths

The Priory Group

07/11/2023

2023-0432

Michael Vincent

Bedfordshire and Luton

[REDACTED], Chief Executive of East of England Ambulance Service [REDACTED], Chief Executive Officer, Royal College of Emergency Medicine��������������������� [REDACTED], Managing Director, Association of Ambulance Chief Executives [REDACTED], National Medical Director, NHS England

On 09 January 2023 I commenced an investigation into the death of Michael John VINCENT aged 79. The investigation concluded at the end of the inquest on 25 May 2023. The conclusion of the inquest was that: � Mr Michael John Vincent died at the Luton and Dunstable Hospital on the 20th December 2022. He was 79 years old. He had fallen the morning before, at home, and had remained on the floor until admittance to the ED at approximately 05:32 on the 20th December 2022. He had made a first call to the East of England Ambulance Service at around 7:29 pm on the 19th December 2022. The call was allocated a C2 category which aims to have an urgent response within an 18 minute time frame. The EEAS was extremely busy that night with previously unseen levels of C2 allocations of ambulances. In addition, the hospitals in the area were queuing ambulances outside ED�s because they were unable to offload patients and then proceed to other calls. That combination meant that despite being allocated an urgent response time Mr Vincent was effectively left on the floor for a very prolonged time. Ultimately he had a cardiac arrest at home and an ambulance attended promptly. He was resuscitated but the �down time� was prolonged. He died as a result of a combination of an undiagnosed bronchopneumonia complicated by severe coronary artery disease and a long lie. On the balance of probabilities it is likely that had he been admitted at the time of the first call he would not have died at the time he did.

Mr Michael John Vincent died at the Luton and Dunstable Hospital on the 20th December 2022. He was 79 years old. He had fallen the morning before, at home, and had remained on the floor until admittance to the ED at approximately 05:32 on the 20th December 2022. He had made a first call to the East of England Ambulance Service at around 7:29 pm on the 19th December 2022. The call was allocated a C2 category which aims to have an urgent response within an 18 minute time frame. The EEAS was extremely busy that night with previously unseen levels of C2 allocations of ambulances. In addition, the hospitals in the area were queuing ambulances outside ED�s because they were unable to offload patients and then proceed to other calls. That combination meant that despite being allocated an urgent response time Mr Vincent was effectively left on the floor for a very prolonged time. Ultimately he had a cardiac arrest at home and an ambulance attended promptly. He was resuscitated but the �down time� was prolonged. He died as a result of a combination of an undiagnosed bronchopneumonia complicated by severe coronary artery disease and a long lie. On the balance of probabilities it is likely that had he been admitted at the time of the first call he would not have died at the time he did.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � I have also sent it to [REDACTED] who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards) This report is being sent to: East of England Ambulance Service NHS Trust | Royal College of Emergency Medicine | Association of Ambulance Chief Executives | NHS England

16/06/2023

2023-0366

Vaughan Whalley

Manchester North

[REDACTED], Chief Executive of Midlands Partnership NHS Foundation Trust

On 23 February 2023 an investigation into the death of Vaughan Lee WHALLEY (the Deceased) was commenced. The investigation concluded at the end of the inquest on 13 June 2023. I recorded a conclusion of Suicide

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 9 August 2023. I, the Area 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.

Suicide (from 2015) This report is being sent to: Midlands Partnership NHS Foundation Trust

28/08/2024

2024-0472

Moira Farnell

Milton Keynes

[REDACTED], Chief Executive of Milton Keynes City Council

On 09 May 2024 I commenced an investigation into the death of Moira FARNELL aged 79. The investigation concluded at the end of the inquest on 17 July 2024. The conclusion of the inquest was that: Accident

The deceased fell on the pavement outside her house, [REDACTED], Bletchley, Milton Keynes on the 18th April 2024. She hit her head on the pavement. She was taken to Milton Keynes University hospital and following a CT scan was diagnosed with a traumatic subdural haematoma. Her condition deteriorated and she died on 6th May 2024 at Milton Keynes University Hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED]. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Other related deaths

Milton Keynes City Council

19/12/2023

2023-0533

Linda Banks

County Durham and Darlington

[REDACTED], Chief Executive of Tees Esk and Wear Valley Acute NHS Trust

On the 19th of April 2022 an investigation was commenced into the death of Linda Louise Banks, aged 48 years. The investigation concluded at the end of the inquest on the 18th of December 2023. The medical cause of death was 1a) Paracetamol overdose with alcohol misuse. I gave a narrative conclusion as follows:- � Linda Louise Banks died on the 10th of April 2022 at the University Hospital of North Durham. Linda had a history of alcohol misuse and mental health difficulties, including self harm and suicidal ideation. Linda also had learning difficulties which may have increased her vulnerability, which were not identified by vast majority of the mental health professionals, and there is no evidence that consideration was given to any reasonable adjustments that might be necessary, or as to any impact such may have had on her presentation, communication and understanding. � Linda herself, her family and her friends, made multiple contacts with mental health services between February 2022 and her death, as her mental health deteriorated and concerns were expressed as to her safety. Referrals were also made by two external agencies, namely her GP and a home support agency, both expressing concerns about Linda�s presentation. On each occasion risks were considered to be minimal and no further treatment or care was provided by mental health services. � There were a multiplicity of difficulties revealed by a serious incident review which was extensively delayed and not received until the end of January 2023, some 9 months after Linda�s death. It concludes that Linda did not receive the right care at the right time and her needs were not fully met, and included concerns, in summary, in relation to the quality of assessments and triage, quality of safety planning, poor record keeping, and further considers that there was an underestimation of risk and a lack of a trauma informed approach. I also find that these difficulties culminated in advice being given to a friend attempting to support Linda and communicated to her family, from an unknown mental health worker, that they should consider �tough love� and to effectively step back from their intensive support of Linda, thus removing an essential safety net in the absence of any ongoing mental health treatment or support. The identified failings cumulatively contributed to the death more than minimally. � An earlier thematic review which had been completed in November 2021 identified many similar serious issues in the provision of mental health services, to those identified in this case, and it is clear that many of these issues were continuing at the time of Linda�s death in April of 2022 and had not been addressed effectively by the Trust. � On the 9th April 2022 Police forced entry to Linda�s home, as a result of concerns raised by her family and friends and was taken to hospital by ambulance. She was hyperthermic and had low blood sugar and had taken an overdose of medication. Despite attempts to treat her she died in hospital on the 10th April 2022 as a result of the acute complications of paracetamol overdose on a background of alcohol related liver disease

Linda Louise Banks died on the 10th of April 2022 at the University Hospital of North Durham as a result of an overdose of paracetamol against a background of alcohol misuse and subsequent to a deterioration in her mental health.

I have sent a copy of my report to the Chief Coroner and to the family of the deceased. I have also sent it to the Care Quality Commission who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related deaths This report is being sent to: Tees Esk and Wear Valley Acute NHS Trust

31/03/2023

2023-0113

Benjamin Hart

Central and South East Kent

[REDACTED], Chief Executive of the NHS Kent and Medway Integrated Care Board Kent & Medway NHS & Social Care Partnership Trust

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. The conclusion of the inquest was a short form conclusion of Suicide 1a�Suspension by the neck

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED], (mother). I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: NHS Kent and Medway Integrated Care Board | Kent & Medway NHS & Social Care Partnership Trust

2/8/2024

2024-0430

Peter Gregory

Worcestershire

[REDACTED], Chief Executive, Civil Aviation Authority, Aviation House, Beehive Ring Road, Crawley, West Sussex, RH6 0YR.

On 30 June 2023 I commenced an investigation and opened an inquest into the death of Peter GREGORY. The investigation concluded at the end of the inquest on 1 August 2024 � The conclusion of the inquest was that Mr. Gregory �died as the result of an accident�.

In answer to the questions �when, where and how did Mr. Gregory come by his death?�, I recorded as follows: � �On the morning of 25.6.23 a hot air balloon being flown by Peter Gregory, an experienced balloon pilot, suffered a sudden parachute stall in the course of a rapid ascent during a competition race. The parachute stall caused the envelope of Mr. Gregory�s balloon to collapse, and the balloon to descend rapidly to the ground in a field at Ombersley Court, Ombersley. Mr. Gregory suffered fatal injuries in the resulting impact, and was confirmed deceased at the scene a short time later that day.�

I have sent a copy of my report to the Chief Coroner and to the following: � [REDACTED] Mr. Gregory�s parents; The Air Accidents Investigation Branch. � � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths�| Product related deaths � This report is being sent to: Civil Aviation Authority

03/06/2024

2024-0296

Tcherno Bari

Birmingham and Solihull

[REDACTED], Chief Executive, Birmingham and Solihull Mental Health NHS Foundation Trust (�BSMHFT) [REDACTED], Chief Constable, West Midlands Police (�WMP�) Parties to the National Partnership Agreement: Right Care, Right Person: � Department for Health Home Office College of Policing:�[REDACTED], Chief Executive Officer NHS England: [REDACTED], Chair National Police Chiefs� Council: [REDACTED], Chief Constable Association of Police and Crime Commissioners: [REDACTED], Chief Executive

CORONER�S LEGAL POWERS � 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.

INVESTIGATION and INQUEST � On 05/10/23 I commenced an investigation into the death of Tcherno Bari. The investigation concluded at the end of the inquest on 21/05/24.

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 July 2024. 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.

Suicide (from 2015) This report is being sent to: Birmingham and Solihull Mental Health Foundation Trust | West Midlands Police | Department of Health and Social Care | Home Office | College of Policing | NHS England | National Police Chiefs� Council | Association of Police and Crime Commissioners

07/03/2024

2024-0128

Adrian James

Inner West London

[REDACTED], Chief Executive, Central and North West London NHS Foundation Trust- via email � [REDACTED], Chief Executive, NHS England- via email

Between 5th and 6th March 2024, evidence was heard before the Coroner touching the death of Mr Adrian Michael James. He had died on the 21st June 2021, aged 39 years at St Mary�s Hospital, Praed Street, London, following dropping from height. � Medical Cause of Death � 1 a Head Injury � b Fall from height � � How, when, where and the deceased came by his death: � On 25th June 2021 at approximately 15:30, Adrian dropped from the 4th floor of the block of flats in which he lived. He sustained a serious head injury which rendered him immediately unconscious and caused his death, despite extensive resuscitation at St Mary�s Hospital at 16:39 hours. � Adrian suffered with Antisocial and Emotionally Unstable Personality Disorders, complicated by depression and substance misuse. He had attempted to take his own life on multiple occasions. He had been more settled in recent years, but his suicidal risk remained high. � In the last months of his life, he was under the care of community mental health services, primary care network (PCN) and was being treated with structured psychological support. From April 2021, building works at his residence exacerbated his paranoia and from 8th June 2021 this manifested as repeated crisis contact with emergency and psychiatric services- more than 25 occasions up to his death from 8th June 2021. � Twice during this time, he was detained on section 136 and then discharged following Mental Health Act Assessment to his usual community care. � His care was reviewed daily from 9th June 2021 in PCN meetings, and he was supported by crisis contact, including a home visit when he failed to respond to welfare check calls. � On 25th June 2021 he was engaging in a structured psychological support session with a psychiatrist, when police attended to check on him following concerns raised about suicidality from a member of the public. � Shortly after police left, he was heard to be screaming and then seen to be hanging off the balcony on the 4th floor of his block of flats. He was seen to let go and fall to his death. � At all assessments in the last weeks of his life he had presented with paranoid ideation and with a background risk of suicide, but no increased intent to take his own life. � It is likely that his death was due to an impulsive act on his part whilst suffering distress due to paranoia as part of his illness. � Conclusion of the Coroner as to the death: He took his own life whilst suffering severe and enduring mental illness

Extensive evidence was taken during the inquest from multiple live witnesses, written statements, and exhibited reports. Of relevance to this report in addition to the findings above, which I do not repeat: � Adrian�s death as an impulsive act, was not easily predicable and preventable and the emotional variability with which he presented made it difficult for him to be assessed, as he could switch quickly from an agitated state to one in which he was relatively calm. At all times he retained capacity. � At no point was he sectionable under the Mental Health Act in the last 2 weeks of his life, although he had been detained by Police twice under section 136. � He accepted treatment through community health services and used crisis interventions for support which are likely to have been roughly equivalent to services that he would have received had he been supported by the Home Treatment Team or equivalent during the material time, as this would likely have been by phone call as this was during Covid lockdown. � However, despite the sheer number of contacts no pro-active treatment past his usual care and response to crisis calls was offered. Note that in the last 14 days of his life he had received 2 Mental Health Act Assessments after s136 detention, been seen by Liaison Psychiatry at Chelsea and Westminster Hospital and made countless calls for support. Despite him continually denying an active suicidal intent, I remain concerned that whilst albeit there were multiple reviews at MDTs insufficient consideration was given to his risk of impulsive suicide and the possibility of mitigating this risk by a pro- active rather than reactive care package. The evidence of distress caused by paranoia was there. It may be that a more structured support plan would have helped to contain his distress between his fortnightly sessions of structured psychological therapy. Despite the obvious deterioration in his paranoia there was no evidence heard that medication was actively considered to help alleviate, this except in hindsight. � Home Treatment Team Care (First Response Team) had been considered on 15th June 2021 as part of his assessment by the AMHP, but there is no evidence in his notes from CNWL, that this was considered after this time, despite further crisis contact. � Adrian was undoubtedly a complex patient to treat, but when he deteriorated, his treatment sessions were left with the specialist doctor in training and he did not receive assessment by the psychiatric consultant in the community, who in fact never met him, either before he started the structured psychological treatment or when he deteriorated. � When the police interrupted his last treatment session, the psychiatrist did not try and call Adrian back to ask how he was and to re- assess his risk, despite the number of crisis contacts, his paranoia with associated distress, his known high background risk of suicide, his risk of impulsivity, emotional instability, and his very recent s136 detentions etc. The doctor discussed what had happened with the team and it was decided to wait and see if police contacted psychiatric services rather than re contact the patient, taking reassurance from police presence, despite police officers wishing to talk to doctor and requesting telephone contact numbers but being unable to secure these before the signal on the call between police and psychiatrist failed. Adrian�s phone number was available to the doctor and the PCN team. Police officers are not mental health clinicians. � The court found that the lack of re contact with Adrian by the psychiatrist after the treatment session was interrupted, was a failure in care. � Police did try and call SPA but hung up after being told that they were 4th in the queue as they expected a wait of hours before being answered at that time. � Police did arrange a follow up visit for Adrian by the police night shift. Adrian had declined LAS attendance and refused a lift from the officers to St Thomas�s Hospital. � However, Adrian had come from the balcony about an hour after the police left. � Police systems have now changed, and Adrian would now be checked by health care rather than police. SPA answer times have also improved. � It was not until the final witness, who was from the PCN, did the level of consideration and care being given by the PCN become apparent. Both the treating consultant and the PCN Service Lead noted the lack of formal regular input from the treating consultant�s team to the PCN MDT. � Whilst it could not be said that the matters outlined above contributed to the death on the facts of this case, concerns remain. � This report has also been sent to NHS England, so that the lessons learned from this death may be applied to mental health care services.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Sister of Mr James : � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Mental Health related deaths | Suicide (from 2015) This report is being sent to: Central and North West London NHS Foundation Trust | NHS England

25/09/2023

2023-0464

Robert Leigh

Manchester West

[REDACTED], Chief Executive, Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, M25 3BL.

INVESTIGATION AND INQUEST � On the 17th of February 2023 I commenced an Investigation into the death of Robert Leigh, 75 years, born 15th of July 1947. � The Investigation concluded at the end of the Inquest on the 26th of July 2023. � The Medical Cause of Death was: la Hanging The Conclusion of the Investigation was Suicide.

1. Robert Leigh (hereinafter referred to as the �Deceased� [REDACTED]�dead at his home address [REDACTED] on the 7th of February 2022, having suspended himself by a ligature attached to a loft beam in the roof space at the premises. � 2. The Deceased was first referred to the Mental Health Services in in October 2020 with a further referral on the 5th of January 2022, following a deliberate self-harm attempt. He was detained under Section 2 of the Mental Health Act 1983 on the 7th of January 2022, and he was discharged on the 16th of June 2022. He had been treated for depressed mood. 3. Following his discharge, the Deceased was visited regularly by his Community Psychiatric Nurse (hereinafter referred to as the �YL�1, and he was able to build a therapeutic relationship with YL, who had been appointed his Care Coordinator. The Deceased and his Partner were able to share their concerns with YL and be supported by the Community Mental Health Team. � 4. On the 25th of October 2022 the Deceased was visited by YL, who found the Deceased to be calm and pleasant in mood. The Deceased reported that he was settled in mood and denied any suicidal thoughts or plans. YL arranged to see the Deceased again on the 15th of November 2022. � 5. At the time YL was visiting the Deceased every 2 weeks but YL was absent from work between the 10th of November 2022 and the 6th of February 2023 and YL had no contact with the Deceased after the 25th of October 2022. � 6. The Deceased lacked a Care Coordinator from the 10th of November 2022 and had no contact with a Care Coordinator after the 25th of October 2022 until a new Care Coordinator was appointed in January 2023 leading to a visit on the 4th of January 2023. � 7. During the period from the 25th of October 2022 to the 4th of January 2023 the Deceased had no visits from a care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed. � 8. Following the absence of YL, a Care Coordinator was not appointed for 2 months and there was no appointment of a Community Psychiatric Nurse to cover the planned 2 weekly visits to the Deceased, which the Deceased and his Partner had found beneficial to his settled mood. � 9. Following the 4th of January 2023, the Deceased only had one further visit from a Community Psychiatric Nurse/Care Coordinator prior to his death and there had been no continuity of care after the 25th of October 2022. � 10. The Deceased was found dead at his home address [REDACTED] on the 7th of February 2022, having suspended himself by a ligature [REDACTED]. His death was verified by Paramedic from the North West Ambulance Service a short time after he was found.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � � 1. �[REDACTED], Son I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both In a complete or redacted or summary form. � He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: Greater Manchester mental Health NHS Foundation Trust

30/06/2023

2023-0224

Sam Taylor

Herefordshire

[REDACTED], Chief Executive, Herefordshire Council

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.

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED]Hereford and Worcestershire Health & Care NHS Trust . � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: Herefordshire Council

25/10/2024

2024-0579

Mark Eccles

Herefordshire

[REDACTED], Chief Executive, Herefordshire Council

On 7th July 2022 I commenced an investigation into the death of Mark Francis ECCLES. The investigation concluded at the end of the inquest on 18th October 2024. The conclusion of the inquest was Road Traffic Collision.

The deceased was an advanced motorcyclist.� Whilst on the B4361, Mr Eccles has been approaching the junction with the 92620 on his near side.� A vehicle has been at this junction looking to go straight ahead, and as a result has then pulled out in front of the motorcycle of Mr Eccles.� His death was confirmed at 18:06 on the 30th June 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED], [REDACTED] and Orleton Parish Council. �I have also sent it to [REDACTED] who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Road (Highways Safety) related deaths

Herefordshire Council

14/10/2024

2024-0548

Caroline Staite

Herefordshire

[REDACTED], Chief Executive, Herefordshire and Worcestershire Health and Care NHS Trust.

On 18 March 2024 I commenced an investigation into the death of Caroline Ann STAITE. The investigation concluded at the end of the inquest on 30 September 2024. The conclusion of the inquest was Suicide.

A member of public on his way home from work, called at 2339 hrs on 8/3/24 stating he was on the Old Bridge Hereford. �They described a body with a backpack, dark clothes, and white trainers in the river and stated the river was flowing fast, that the body had now moved into darkness but was heading towards Victoria foot bridge. Officers were deployed to speak with the informant and additional officers were dispatched to numerous locations along the River Wye.� A female body was recovered near the Canary Bridge, Hereford and Paramedic [REDACTED] pronounced the female deceased at 0241 hours on 9/3/24. The deceased was fully clothed. �The deceased had no obvious injuries.� A [REDACTED] contacted the Police saying his sister had not been seen for 24 hours.� Her name was Caroline Anne STAITE born 2/6/72. The description matched that of the deceased and subsequent formal identification provided confirmation.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED], CEO Herefordshire Mind. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015)�| Mental Health related deaths

Herefordshire and Worcestershire Health and Care NHS Trust

11/10/2024

2024-0541

Oliver Davies

Worcestershire

[REDACTED], Chief Executive, Midlands Partnership NHS Foundation Trust, St. George�s Hospital, Corporation Street, Stafford ST16 3SR.

On 16 January 2023 I commenced an investigation and opened an inquest into the death of Oliver Peter DAVIES. The investigation concluded at the end of the inquest on 11 October 2024 The conclusion of the inquest was as follows: Oliver Davies died as a result of suicide. [ Questionnaire ]: 1.�� (a) During Oliver�s time at HMP Hewell, were sufficient steps taken to ensure a proper and timely review by a GP of Oliver�s mental health needs, and whether mental health medication should be re-prescribed to him? NO (b) If your answer to 1(a) above is YES or CANNOT SAY, go to Question 2; (c) If your answer to 1(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES (d) If your answer to 1(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY (e) If your answer to 1(d) above is NO or CANNOT SAY, please include the following words at the end of Section 3 of the Record of Inquest: �It is admitted that the fact that Oliver was not seen by a GP in the prison before his death represents a failing in the healthcare system provided there. It cannot be concluded that this failing possibly caused or contributed to Oliver�s death on 31 December 2022. 2.� (a) Was information relevant to Oliver�s recent and current mental state shared sufficiently between prison staff, healthcare staff and mental healthcare staff at HMP Hewell, such that Oliver�s ongoing risk of self-harm of suicide could be properly assessed? ���� NO (b) If your answer to 2(a) above is YES or CANNOT SAY, go to Question 3; (c) If your answer to 2(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES (d) If your answer to 2(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY 3. (a) Did the mental health assessment on 6.12.22 consider sufficiently all information relevant to Oliver�s ongoing risk of self-harm or suicide? YES (b) If your answer to 3(a) above is YES or CANNOT SAY, go to Question 4; (c) If your answer to 3(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY (d) If your answer to 3(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY 4. (a) Did the ACCT case review of 30.12.22 consider sufficiently all information relevant to Oliver�s ongoing risk of self-harm or suicide? NO (b) If your answer to 4(a) above is YES or CANNOT SAY, go to Question 5; (c) If your answer to 4(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? NO (d) If your answer to 4(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES 5. (a) Was Oliver kept sufficiently informed of progress regarding his applications for a doctor to review his mental health needs and to consider whether mental health medication should be re-prescribed to him? NO (b) If your answer to 5(a) above is YES or CANNOT SAY, go to Question 6; (c) If your answer to 5(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES (d) If your answer to 5(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY 6. (a) Was Oliver kept sufficiently informed of his allocation to, and forthcoming appointments with, a mental health care-coordinator? NO (b) If your answer to 6(a) above is YES or CANNOT SAY, go to Question 7; (c) If your answer to 6(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES (d) If your answer to 6(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY 7. Was Oliver�s death contributed to by neglect? YES

In answer to the questions �when, where and how did Oliver come by his death?�, the jury recorded as follows: �Oliver Davies committed suicide in his cell at HMP Hewell by hanging. He died on the 31.12.22.�

I have sent a copy of my report to the Chief Coroner and to the following Interested Parties at the inquest: (a) [REDACTED], Oliver�s mother; (b) HM Prison and Probation Service; (c) Practice Plus Group; (d) West Mercia Police; (e) GEOAmey. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Mental Health related deaths | State Custody related deaths | Suicide (from 2015)

Midlands Partnership NHS Foundation Trust

13/08/2024

2024-0450

Jeffrey Marshall

Surrey

[REDACTED], Chief Executive, NHS England [REDACTED], Chief Executive, National Institute for Health and Care Excellence

The inquest into the death of Jeffrey MARSHALL was opened on 4th January 2024.� Evidence was heard and the inquest was concluded on 13th June 2024.�� Mr Marshall died at St Peter�s Hospital in Chertsey on 13th December 2023, aged 72 years.� � I found the medical cause of death to be: ���� 1a. Ischaemic Stroke� ���� 1b. Thrombosis of Basilar Artery� ���� 1c. Atherosclerosis of Basilar Artery� ���� 2.�� Previous Subdural Haematoma; Hypertension; Diabetes Mellitus;� ���������� Atrial Fibrillation; Cessation of Anticoagulation Therapy� �� I found that whilst the cause of death was natural, it was contributed to by the withholding of anticoagulation therapy over the previous 47 days prior to death. Mr Marshall had sustained a subdural haematoma in a fall on 21st October 2023, following which his anticoagulation therapy was withheld pending further CT scan to check that this had resolved before recommencing anticoagulation.�� Whilst a further CT scan took place on 8th November 2023, this was not reported until 3rd December 2023, and Mr Marshall�s GP was informed by the� Hospital� that� his� anticoagulation� should� be� recommenced� on� 6th December� 2023.� Mr� Marshall� suffered� an� ischaemic� stroke� on� 7th December 2023 as a result of thrombosis of the basilar artery, of which he was at increased risk due to the withholding of anticoagulation therapy. He deteriorated until his death.�� I heard evidence from a Stroke Consultant at Ashford and St Peter�s Hospitals� NHS� Foundation� Trust� that� the� half-life� of� Direct� Oral anticoagulants is short and therefore the benefit of its risk reduction for thrombus is lost within a short period of time, placing the patient at high risk of stroke. She detailed that whilst it is standard protocol to withhold anticoagulation following a head injury, there is no national guidance (e.g. from the National Institute for Health and Care Excellence) to assist in determining when anticoagulation should be recommenced. There is also�� no�� guidance�� for�� clinicians�� to�� discuss�� the�� withholding�� of anticoagulation� and� the� risks/benefits� of� this� with� patients,� to� enable them� to� make�� an� informed� decision�� as� to� when� to� recommence anticoagulation in this scenario.�� I recorded a narrative conclusion of Natural Causes contributed to by withholding�� of�� anticoagulation�� over�� 47�� days�� following�� subdural haematoma.

Mr Marshall died from an ischaemic stroke at St Peter�s Hospital in Chertsey on 13th December 2023.�� He had suffered a fall whilst exiting a car on 21st October 2023, in which he sustained� an� acute� subdural� haematoma.� His� anticoagulation� therapy� of Edoxaban,� prescribed� for� atrial� fibrillation� and� permanent� pacemaker,� was withheld in accordance with NICE guidance.�� Neurosurgeons at St George�s Hospital in Tooting gave advice and reiterated the need to withhold anticoagulation and to monitor the bleed via further CT scan the following day, and again two weeks thereafter.�� The last scan on 8th November 2023 revealed that the haematoma had resolved, but this was requested on a routine basis with a reporting time of 28 days. It was therefore reported on Sunday 3rd December, and Mr Marshall�s GP was advised that anticoagulation could be restarted on 6th December 2023.� �� Mr Marshall suffered a sudden loss of consciousness at home on the evening of 7th December 2023 and was admitted to St Peter�s Hospital, where he was found to have suffered a Basilar Artery Thrombosis and Basilar Territory Infarction. His anticoagulation had been withheld for 47 days on a background of atrial fibrillation�� and�� permanent�� pacemaker,�� increasing�� his�� risk�� of�� thrombus development.�� Mr Marshall�s stroke was not survivable and he died on 13th December 2023.

COPIES� I have sent a copy of this report to the following: 1.� See names in paragraph 1 above� 2. [REDACTED] 3. Ashford & St Peter�s Hospitals NHS Foundation Trust 4. The Chief Coroner� � In addition to this report, I am under a duty to send the Chief Coroner a� copy of your response.�� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who, he�� believes,�� may�� find�� it�� useful�� or�� of�� interest.�� You�� may�� make representations to me at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

NHS England | National Institute for Health and Care Excellence

13/03/2024

2024-0139

Terence Sullivan

Worcestershire

[REDACTED], Chief Executive, National Institute for Health and Care Excellence; [REDACTED], Chief Executive Officer, British Society of Gastroenterology [REDACTED], National Medical Director, NHS England;

On 16 August 2023 I commenced an investigation and opened an inquest into the death of Terence William SULLIVAN. The investigation concluded at the end of the inquest on 28 February 2024. � The conclusion of the inquest was that Mr. Sullivan �Died as the result of complications of necessary surgery, to which the temporary cessation of anticoagulation medication contributed.�

In answer to the questions �when, where and how did Mr. Sullivan come by his death?�, I recorded as follows: � �On 8.8.23 Terence Sullivan underwent a surgical procedure at Worcestershire Royal Hospital to remove a polyp from his sigmoid colon. Mr. Sullivan had been on anticoagulant medication following a previous diagnosis of atrial fibrillation and the insertion of coronary artery stents, and this medication was temporarily suspended so that the procedure on 8.8.23 could go ahead. Following the procedure, Mr. Sullivan suffered an acute myocardial infarction caused by a blockage in a coronary artery stent. Despite treatment, he continued to decline and died in hospital on 10.8.23.�

I have sent a copy of my report to the Chief Coroner and to the following: � [REDACTED], Mr. Sullivan�s daughter. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: National Institute for Health and Care Excellence | British Society of Gastroenterology | NHS England

17/05/2024

2024-0269

Jada Monoja

Inner North London

[REDACTED], Chief Executive, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ Hon Victoria Atkins MP, Secretary of State for Health and Social Care, The Department for Health and Social Care, 39 Victoria Street, London SW1H 0EU NHS England

On 27/11/2020 an investigation commenced into the death of Jada Monoja, a 33 year old man who died from a self-inflicted knife wound. His inquest was concluded on 23 April 2024. The conclusion of the inquest was that Mr Monoja died by suicide, likely while experiencing delusional and paranoid thoughts.

Mr Monoja had a history of chronic paranoid and delusional thinking. On 15 November 2020 his mother contacted 111 after he disclosed suicidal thinking to her. This was rapidly escalated to mental health services and that evening a member of the Crisis Assessment Team (CAT) assessed Mr Monoja. He denied remaining suicidal, agreed to treatment and was assessed to have capacity. He was referred to the Home Treatment Team (HTT). On 16 November 2020 Mr Monoja was assessed and accepted by the HTT and a care plan agreed. In the early hours of 17 November 2020, his mother woke and found Mr Monoja had left their home. She found him nearby on Cleaver Square, unresponsive. Emergency Services attended but he could not be resuscitated. At home he had left notes of farewell.

I have sent a copy of my report to the Chief Coroner and to the family, as the other Interested Person in this inquest. I have also sent it to Oxleas who may find it useful or of interest, as the other major provider of mental health services in this jurisdictional area. � [REDACTED] for Family(Next of Kin) [REDACTED] Chief Executive, Oxleas NHS Trust Chief Coroner @ Regulation28reports@judiciary.uk � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response.

Suicide (from 2015) This report is being sent to: South London and Maudsley NHS | NHS England | Department of Health and Social Care

15/05/2023

2023-0155

Drew Howe

Manchester South

[REDACTED] Chief Executive, Pennine Care NHS Foundation Trust

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. A post mortem examination confirmed that Mr Howe died as a consequence of: 1)a) Suspension by a Ligature around the Neck. The conclusion of the inquest was one of Suicide.

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. Mr Howe had experienced a dramatic deterioration in his mental health and had sought specialist help on numerous occasions. At the time of his death, Mr Howe was awaiting a further assessment by the Military Veterans Service having been discharged by the Access Team without any diagnosis or treatment plan being in place.

I have sent a copy of my report to the Chief Coroner and to Mr Howe�s next of kin. I have also sent a copy to the Care Quality Commission and Stockport Metropolitan Borough Council who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Mental Health related deaths This report is being sent to: Pennine Care NHS Foundation Trust

02/04/2024

2024-0178

Anne Hawkes

South Yorkshire East

[REDACTED] Chief Executive, Rotherham NHS Foundation Trust

On 3 August 2023 I commenced an investigation into the death of Anne HAWKES. The investigation concluded at the end of the inquest . The conclusion of the inquest was � Narrative conclusion. � Mrs Hawkes died in Rotherham District General Hospital on the 15th July 2023 as a consequences of multi organ dysfunction due to an infected hip joint. The infection occurred due to surgical wound breakdown because of pressure caused by fluid overload as a result of poorly managed cardiac failure.

Mrs Hawkes was admitted to Rotherham Hospital on the 3rd of May 2023 following a fall at home. She had sustained a fracture neck of femur and underwent surgical fixation the following day. Mrs Hawkes initially recovered well and was medically fit for discharge by the 11th of May 2023. Mrs Hawkes remained on the orthopaedic ward whilst awaiting social care input prior to discharge. Whilst on the orthopaedic ward, her cardiac failure was not monitored by way of fluid balance charts or daily weights. Her weight on admission had been estimated at 72 kilogrammes, by the 22nd May 2023, her weight had increased to 104.5 kilogrammes. � This increase in weight was not acted upon until the 17th of May 2023 when a referral to cardiology was made, by this time she was very unwell with fluid retention, hyponatremia and deteriorating renal function. Mrs Hawkes was seen by specialist Cardiac failure nurses on the the 22nd May and immediately commenced on intravenous medication to deal with this fluid excess. Mrs Hawkes was transferred to the cardiology ward on the 25th of May 2023. � Whilst on the cardiology ward her weight gradually reduced to 83 kilogrammes. On the 26th June 2023, she was considered stable in relation to her cardiac failure. On the 3rd of June 2023 the surgical wound started to break down. All witnesses at the inquest agreed that the wound breakdown was most likely due to this fluid overload putting pressure on the wound causing it to breakdown. There was no evidence of infection in or around the wound out this time. � Despite the wound starting to break down on the 3rd of June, the referral to tissue viability was not made until the 29th of June 2023. By this time, tissue viability were unable to assist due to the advanced state of dehiscence and they made a referral to the orthopaedic surgeons. A surgical washout was declined by Mrs Hawkes, therefore the wound was managed with dressings and antibiotics. She deteriorated and died on the 15th of July 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me1�� the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Rotherham NHS Foundation Trust

25/03/2024

2024-0163

Jacqueline Cobain

London Inner (South)

[REDACTED] Chief Executive, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ

On the 16 September 2021 an investigation into the death of Jacqueline Anne Cobain commenced, aged 60 years. The investigation concluded at the end of the ?nal day of the inquest on 15 March 2024. The conclusion of the inquest was a short form conclusion of suicide.

Jacqueline Anne Cobain had a past medical history of anxiety and depression, as well as alcohol dependence. She was consulting with her P in relation to these issues and was taking antidepressants. She had also contacted mental health services, although she had cancelled the scheduled appointment and the rescheduled appointment was not until 16 September 2021, however she had submitted her responses to a questionnaire shortly after cancelling her appointment which had included some concerning responses. This questionnaire was not reviewed upon receipt. She had taken an overdose some years before at a time of great stress in her working life and her family believed this was not an attempt to take her life, but rather a consequence of stress, desperation of her work situation and insomnia. During the afternoon of 11 September 2021, she deliberately jumped in front of moving train at Vauxhall London Underground station, London. Her family indicated that she seemed stable, and they were less concerned about her than they had been for some time. She su?ered multiple injuries and died at the scene.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of Mrs Cobain, I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may ?nd it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may ?nd it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Railway related deaths | Suicide (from 2015) This report is being sent to: South London and Maudsley NHS Foundation Trust

26/04/2023

2023-0139

Elsie Leaver

Inner West London

[REDACTED] Chief Executive, St George�s University Hospital NHS Foundation Trust, St George�s Hospital, Blackshaw Road, London. SW17 OQT � The Roehampton Surgery, 191 Roehampton Lane, London, SW15 4HN. � [REDACTED] Chief Executive, NHS South West London Integrated Care Board, First Floor 73-75 Upper Richmond Road, London. SW15 2SR

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. � Medical Cause of Death � 1 (a) Multiple organ failure (b) Mixed drug overdose � 11 Depressive illness, chronic obstructive pulmonary disease, Ischaemic heart disease, Hypertension, Frailty. How, when, where the deceased came by her death: Mrs Leaver was admitted to St George�s Hospital, (SGH) on 15th August 2020 suffering with phenytoin toxicity. She had an extensive psychiatric history recently complicated by overdose and suicidality. This was not recognised by the clinical team despite evidence available in the electronic records, concerns raised by the family and intermittent agitation. She was deemed to have reduced mental capacity between 16th August 2020 and her discharge for rehabilitation to Queen Mary�s Hospital (QMH) on 18th August 2020, but her bag was not searched. [REDACTED] On transfer to QMH, she was found to have capacity and again refused a bag search. Overnight on 19th August 2020, she expressed suicidality to her family who notified nursing staff at QMH. On 20th August 2020, this suicidality was explored by the SHO who found her not to be actively suicidal and sought no advice from the psychiatric liaison service. On 22nd August 2020, whilst collateral psychiatric history was being sought after she threatened self-discharge, at approximately 15:00 she took an overdose [REDACTED] Mrs Leaver was readmitted to SGH and died there on ITU at 16:37 23rd August 2020 as a result of the overdose. The failures in care and communication together constitute a �total picture� that amounts to neglect. Conclusion of the Coroner as to the death: Mrs Leaver took her own life whilst suffering from depressive illness. Her death was contributed to by neglect.

CIRCUMSTANCE OF DEATH Extensive evidence was taken and accepted by the court. In summary, of relevance to this report: � On 14th August 2020 Mrs Leaver attended SGH with 3 odd episodes though to be due to a TIA and discharged on aspirin. � She re-attended with a history of a fit with a past history of epilepsy on phenytoin on 15th August 2020 and was admitted to SGH under the medical team. The neurologist thought it likely that her phenytoin would be low and when it was found to be in the toxic range ascribed the fit to phenytoin toxicity and she was admitted for monitoring, stopping phenytoin, and restarting once levels back to normal. � No active consideration was given as to the possible cause of this toxicity, which could have been due to overdose, given her psychiatric history as outlined below. � Despite being under active psychiatric care from the CMHT for older persons, being on psychiatric medication, taking a call from the CMHT whilst an inpatient at SGH, having taken an overdose in November 2019, having multiple hospital attendances, including 17th July 2020 with suicidal ideation to Kingston, suffering agitation, concerns being raised about her mental health by her family, a safeguarding concern being raised against her partner/friend, and intermittent agitation requiring diazepam, 1:1 nursing, the attendance of her son and hospital security and presenting with drug toxicity, psychiatric illness was never considered. She was seen by multiple clinicians at SGH, none of whom undertook any psychiatric history, or made any proper inquiry with her relatives, nor of her electronic notes. � This deprived her of a holistic assessment. There was no referral to psychiatric liaison services, nor advice sought from them at either site. � Mrs Leaver therefore did not have a self-harm risk assessment despite her presentation and past history, which would have likely prompted more active searching of her belongings for medication which could be potentially used in an overdose. This could have been undertaken even against her permission when she had reduced capacity in her best interests. � Mrs Leaver had declined a bag search on admission to the ward at SGH which was apparently passed on verbally to the day team. This did not appear to have been acted upon and was not recorded, such that a search never occurred. � This was compounded by the fact that when psychiatric illness was finally being considered at QMH from 20th August 2020, there was only an informal telephone advice available, the quality of which varied with the person who took the call, and anything further required the transfer of Mrs Leaver back to SGH by LAS to A&E. � I understand that the NHS South West London Integrated Care Board declined to provide formal psychiatric cover to QMH, neither formal telephone advise nor staff on site to see patients. � In evidence this was identified as a lacuna in the service provision at QMH, by all the clinicians with whom it was discussed, such that for the last 10 years psychiatric liaison has been providing informal telephone advice without the need for the patient to be transferred back to A&E at SGH. � The Health Information Exchange viewer, ( HIE) available to doctors with in St Georges Hospital Trust at the time, contained a GP summary which did not contain the recent overdose or CMHT treatment as part of the active problem summary, nor even depression as a diagnosis despite a relapsing and remitting history of depression and anxiety going back to 2006. � HIE did contain sections of her RIO notes (psychiatric records) which appear to have been missed and details of attendance with suicidal ideation at Kingston 19th July 2020, which also appears to have been missed or disregarded by the clinicians. � Senior doctors in evidence were not aware of the information on the HIE. � Instead the incomplete past medical history which listed anxiety and dementia appears to have taken at face value. � As above, severe agitation at SGH did not prompt a reconsideration, neither did tearfulness and low mood at QMH. � Concerned phone calls from family were not logged nor passed to clinicians until she expressed active suicidality, and no doctor returned a call to the family until the daughter insisted on the 22?d August 2020 that if no doctor called her back to discuss her concerns about her mother she would attend the hospital despite the pandemic. By then it was all too late. � The lack of psychiatric history taking deprived Mrs Leaver of the opportunity for psychiatric liaison opinion and risk assessment that would have been likely to have discovered medication she had secreted in her bag that she subsequently consumed to lethal effect. � This was despite the fact that for at least 2 out of the three days that she was at SGH from 15th to 18th�August 2020, she was found by nursing staff ta lack full mental capacitay. I understand that considerable training has now been given on this issue so that patients who lack capacity may have their belongings searched to identify and secure dangerous items such as medication. � There were also concerns that her suicidality may have been exacerbated by drug interactions between phenytoin and diazepam. These matters have been addressed by SGH in the training of its clinicians.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons : [REDACTED] Clinical Director, Springfield Hospital, 61, Glenburnie Road, London [REDACTED], children of the Mrs Leaver, by email. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: St Georges University Hospital NHS Foundation Trust, The Roehampton Surgery and NHS South West London Integrated Care Board

11/10/2023

2023-0383

Sarah Holmes

County Durham and Darlington

[REDACTED] Chief Executive, Tees, Esk and Wear Valleys NHS Foundation Trust, West Park Hospital, Edward Pease Way, Darlington, DL2 2TSCare Quality Commission [REDACTED]

INVESTIGATION � On 25th of July 2022 an investigation was commenced into the death of Sarah Elizabeth Holmes, aged 32. The investigation has not yet concluded and the Inquest has not been heard, and is currently listed to commence on the 16th of November 2023.

The deceased had a history of mental health difficulties and self harm and was found dead after a discharge home, subsequent to a mental health assessment, [REDACTED] . The medical cause of death is [REDACTED] Asphyxia

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, [REDACTED] , Sarah�s parents. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: Tees, Esk and Wear Valleys NHS | Care Quality Commission

17/02/2023

2023-0061

Jamie Wood

Dorset

[REDACTED] Chief Executive, The Health and Safety Executive

On the 5th February 2021, an investigation was commenced into the death of Jamie Paul Woods, born on the 12th August 1980. The investigation concluded at the end of the Inquest on the 7th December 2022. � The Medical Cause of Death was: 1a Multiple Injuries � The conclusion of the Inquest recorded that Jamie Paul Woods died as a consequence of an accident.

Jamie Paul Woods was a farm worker at Hawkins Farm in Dorset. Hawkins Farm is a family-owned dairy farm. As part of the fabric of some of the buildings on the farm, pre-cast concrete panels were used extensively, predominately as external walls for barns or similar. Typically, the concrete panels, which weigh approximately 800kg, are placed between vertical reinforced steel joists (RSJs), secured to the RSJ by means of a metal bracket bolted to the concrete panel. On Hawkins Farm two concrete panels had been repurposed from another building to form a divide between a �collecting yard� (an area where cattle are held prior to be being encouraged into the milking parlour) and an adjacent barn where straw was stored, with one panel placed on top of the other, to form a wall that was approximately 6 feet in height. The concrete panels did not stretch between the two RSJs present. As a consequence, one side was secured using the above-described method, with the other side being secured using sections of steel �box� (hollow steel tubing) welded to the RSJ and �clipped� against the rear of the concrete panel using a metal bracket. On 30th January 2021, Mr Woods was in the collecting yard when the upper concrete panel that divided the collecting yard from the straw storage came away from its fixing, causing multiple injuries to Mr Woods, who was sadly confirmed deceased at the scene.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1)� Trethowans Solicitors (solicitors for Mr Woods� family); (2)� DAC Beachcroft (solicitors for Hawkins Farm Partnership). � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths

The Health and Safety Executive

20/01/2023

2023-0020

Dorothy Jones

Gwent

[REDACTED] Chief Executive, Welsh Ambulance Service NHS Trust (WAST) Minister for Health and Social Services

INVESTIGATION AND INQUEST � On 11/04/2022 an investigation was opened into the death of Dorothy Anne Jones The investigation concluded at the end of the inquest on: 17/01/2023. The conclusion of the inquest was recorded as: � A narrative conclusion in the following terms: � Dorothy Anne Jones died at home on 29/03/22 from the effects of bronchopneumonia. Her death was contributed to by the failure of Welsh Ambulance Services NHS Trust to convey Mrs Jones to hospital within a reasonable timescale as dictated by her poor clinical condition. The medical cause of death was: 1a Bronchopneumonia 2. Advanced multiple Sclerosis

On 22/03/22, Dorothy Anne Jones developed a chest infection. After failing to respond to antibiotics, she was seen at home by [REDACTED] her GP on 29/03/22. [REDACTED] considered that Mrs Jones needed to be admitted immediately to hospital. Mrs Jones had low oxygen levels and was drowsy and [REDACTED]�requested that an ambulance attends within 2 to 3 hours. Following discussion with the ambulance service they informed�[REDACTED]�that there was a 2- 4 hour wait but that they would attempt to send an ambulance quicker. � Unfortunately, the pressure on the ambulance service and a failure to identify an earlier available resource meant that paramedics did not attend until 20:28, over 9 hours later. On arrival, paramedics confirmed that Mrs Jones had died and could not be revived. On hearing the evidence, I determined that a failure to send an ambulance within a timescale required by the severity of Mrs Jones�s illness, contributed to her death.

COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Dorothy Anne Jones Health Inspectorate Wales. I am also under a duty to send the Chief Coroner a copy of your response. The Chief coroner may publish either or both in a complete or redacted summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief coroner.

Emergency services related deaths (2019 onwards) | Wales prevention of future deaths reports (2019 onwards)

Welsh Ambulance Service NHS Trust and Department of Health and Social Care

12/7/2024

2024-0372

Sandra Phillpott

Blackpool & Fylde� � Category: Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: Blackpool Teaching Hospitals NHS Foundation Trust

[REDACTED] Chief Executive,� Blackpool Teaching Hospitals NHS Foundation Trust Blackpool Teaching Hospitals NHS Foundation Trust

The death of Sandra Phillpott on 31st October 2023 was reported to me and I opened an investigation, which concluded by way of an inquest on 5th July 2024.�� I determined that the medical cause of Sandra�s death was: 1a Multi � organ failure�� 1b Sepsis with Disseminated Vascular Coagulation [D.I.C]�� 1c Streptococcus Pneumoniae�� II E.coli 0157 infection; left ventricular hypertrophy; coronary artery atheroma In box 3 of the Record of Inquest I recorded as follows: Sandra Phillpott was aged 57 years. She was regarded as active and previously healthy. At� around 5pm on Friday, 27th October 2023 she returned home after a holiday in Egypt with� her twin Sister. By the time she arrived home she was experiencing some cold-like� symptoms due to a bacterial infection � later identified as E.coli 0157 � contracted whilst in� Egypt from an unidentified source. The situation was complicated after she then developed a pneumococcal infection which left her feeling cold and shivering. Over the course of that� weekend, Sandra remained unwell but did not deteriorate noticeably until the morning of� Monday 30th October 2023. She had largely preferred not to seek medical attention,� expecting her symptoms to improve. After her condition became more concerning she� attended a walk � in � centre from where she was appropriately transferred to the hospital� emergency department. She had to remain in an ambulance for around forty minutes� before she could enter the department. Initial investigations suggested she had a�suspected pulmonary embolism, but she was also showing signs of infection and by 12�noon antibiotics and intravenous fluids had been prescribed. These were not administered� in a timely fashion. Her presentation had not indicated she had a specific pneumococcal� infection until later that afternoon when following a delayed transfer to the intensive� treatment unit a consultant noted a florid rash indicative of pneumococcal sepsis. The�results of bloodtests would later confirm the infection to be Streptoccocus Pneumonaie.� Over subsequent hours, Sandra�s condition deteriorated and her death confirmed at 05.50 hours on 31st October 2023. The likelihood Sandra had sepsis had been under appreciated, and there was a missed opportunity to provide timely antibiotic therapy and fluids, but from the available evidence this would not have altered the fatal outcome because from� around the time antibiotics were prescribed Sandra�s condition was non � survivable. She�died from complications arising from a pneumococcal infection. She had been more� susceptible to dying from such infection due to the effects of heart disease identified at�post mortem examination, and reduced physiological reserves caused by the separate� infection which had been contracted in Egypt.� In box 4 of the Record of Inquest I determined that: Natural causes.

In addition to the contents of section 3 above, the following is of note: As mentioned above, despite showing signs of infection, the necessary treatment was not provided in a timely manner, notably antibiotic therapy and the administration of� intravenous fluids.� Sandra�s shortness of breath, some reported calf pain, and recent flights contributed to a� feeling amongst some of the clinical / nursing staff that she had a likely pulmonary embolism [later ruled out] and this in part contributed to a lack of focus on the possibility she had� developed a potentially fatal infection.� A helpful Patient Safety Incident Investigation [PSII] Report, provided to the court in advance of the inquest by Blackpool Teaching Hospitals NHS Foundation Trust, found that:� There had been delays in sepsis management� The initial treatment had focused upon ruling out a pulmonary embolism and deep vein thrombosis, delaying sepsis management. Sandra had multiple sepsis triggers, but the main focus remain a pulmonary embolism. Having considered all of the above, I have determined that I have a duty to write this report.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� The family of Sandra Phillpott. � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief� Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths� �

11/03/2024

2024-0131

Keith Smith

East London

[REDACTED] Church Elm,�Lane Medical Practice, Dagenham

On 6th July 2023, this court commenced an investigation into the death of Keith Smith aged 75 years. The investigation concluded at the end of the inquest on 8th March 2024. The conclusion of the inquest was a short-form conclusion of natural causes. Mr Smith�s medical cause of death was determined as; 1a Acute Myocardial Infarction 1b Severe Stenosis of the Coronary Arteries 1c Atherosclerosis II Hypertension, 2 Diabetes Mellitus

Kevin Smith was diagnosed through MRI as suffering from degeneration of his lumbar spine which caused impingement of his lower sciatic nerve resulting in chronic pain. � Mr Smith experienced a development in his pain in early July 2023 with symptoms of back and chest pain, radiating into his neck. Mr Smith sought medical treatment from his GP in telephone calls with the surgery reception on 3rd, 4th and 5th July 2023. � The response from the surgery was chaotic and at times the behaviour of those taking telephone calls was unprofessional and inappropriate. � On 4th and 5th July 2023 Mr Smith was informed that he would receive a GP call-back, on both days that did not occur. � On the evening of 5th July 2023 Mr Smith�s family, frustrated with the lack of contact called 111 who diverted the call to the 999 service. An ambulance attended upon Mr Smith who, utilising an ECG diagnosed that Mr Smith was suffering a myocardial infarction. Moments later, Mr Smith lapsed into cardiac arrest, despite prompt and effective CPR his death was declare just after midnight on 6th July 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons to the family of Mr Smith. I have also sent it to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representation to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Church Elm Lane Medical Practice

07/02/2023

2023-0049

Richard Kew

Leicester City and South Leicestershire

[REDACTED] Department of Health and Social Care

On 15 September 2022 I commenced an investigation into the death of Richard Nigel KEW aged 70. The investigation concluded at the end of the inquest on. The conclusion of the inquest was that: � Mr Kew was admitted to the Glenfield Hospital Leicester and underwent a resection of small bowel endocrine tumour with extensive lymphadenectomy and resection of multiple liver metastases on the 21 July 2022. Immediately post-operatively he was admitted to the adult Intensive Care Unit. During mobilisation of Mr Kew on the 22 July there was an inadvertent omission to secure one of the central venous catheter lines with a bung. This omission allowed air entrainment into Mr Kew�s circulation. His condition deteriorated rapidly and whilst he received immediate senior medical attention, he never regained consciousness and died as a direct result of the consequences of the omission on the 05 September 2022.

As above with a cause of death as 1a) Diffuse Hypoxic Brain Injury 1b) Air entrainment via a central venous catheter 1c) Peri-operative requirement for physiological support 1d) Ileocolic anastomosis and resection of liver metastases to treat small bowel neuroendocrine tumour and multiple liver metastases

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] Wife University Hospitals of Leicester � I have also sent it to the Heath and Safety Investigation Board (HSIB) who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care

19/09/2023

2023-0337

Stephen Cassidy

Avon

[REDACTED] Deputy Director of Patient Safety, Digital at the NHS � [REDACTED], North Bristol NHS Trust.

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. The conclusion of the inquest was � � �Mr Cassidy died from a known drug allergy because its existence was not obtained by hospital medical staff from his Summary Care Record.�

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. � On 4th March 2023 Mr Cassidy fractured his hip and clinical staff from South Western Ambulance Service NHS Foundation Trust (SWAS) conveyed him by ambulance to Southmead Hospital, Bristol (SMH). SWAS staff were able to access the Summary Care Record, obtain the history of Ceftriaxone allergy and record this in their clinical record. � On admission to SMH a copy of the SWAS clinical record was scanned into the SMH records and a member of SMH emergency department nursing staff noted the Ceftriaxone allergy, but it was not acted upon further. Mr Cassidy was listed for surgical repair of his fractured hip the following day. None of the doctors who assessed Mr Cassidy in the emergency department, the trauma and orthopaedics team or the anaesthetist at his operation were able to access the Summary Care Record to obtain the history of Ceftriaxone allergy and none of them were aware of it. � On 5th March 2023 Mr Cassidy was administered intravenous Ceftriaxone as part of routine induction of anaesthesia for his hip surgery. He immediately suffered a severe anaphylactic reaction to the Ceftriaxone from which he died shortly afterwards despite appropriate and extensive attempts to resuscitate him. � Despite the Ceftriaxone allergy being recorded on his Summary Care Record in 2018 and the potential fatal outcome of such a history being disregarded, the evidence at the Inquest demonstrated that � � a)������ There was no provision for clinical staff at SMH to access patients� Summary Care Record routinely or easily; b)������ This was despite provision existing for SWAS clinical staff to do so before a patient arrived at hospital; c)������� There was 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 (EMIS � Egton Medical Information System) � such that the Ceftriaxone allergy automatically appeared in SMH�s electronic patient record; d)������ As a result none of the emergency department doctors, the trauma and orthopaedics team or the anaesthetist who administered the antibiotic with induction were able to ascertain Mr Cassidy�s Ceftriaxone allergy; e)������ This led to an avoidable fatal anaphylactic reaction.

I have sent a copy of my report to the chief coroner and to the family. � I am also under a duty to send the chief coroner a copy of your response. � The chief coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the chief coroner.

Alcohol, drugs medication related deaths, Care Home Health related deaths This report is being sent to: Digital | North Bristol NHS Trust

21/12/2023

2023-0545

Nicholas Dymond

Exeter and Greater Devon

[REDACTED] Devon Partnership NHS Trust Wonford House Dryden Road Exeter EX2 5AF

On 13 November 2018 an investigation was commenced into the death of Nicholas James Glavind Dymond. The investigation concluded at the end of the inquest on 19 June 2023. The conclusion of the inquest was suicide. The cause of death was recorded as: 1a) Fatal injuries of head, neck, chest, right leg 1b) Railway accident

Nicholas Dymond had been an intermittent drug user for much of his adult life. In 2018 he began to suffer from paranoia and by October that year he had started to express thoughts of suicide � specifically of jumping in front of a train. His GP referred him to the Mental Health Crisis Team. � Following Nicholas� arrest on 31st October 2018, a Mental Health Act Assessment was carried out. He was discharged and a taxi was arranged to take him home. On arrival of the taxi, Nicholas ran away. He was seen less than 3 hours later to step in front of a train at a local train station. He was pronounced deceased at the scene.

I have sent a copy of my report to the Chief Coroner and to Nicholas Dymond�s Family. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Railway related deaths This report is being sent to: Devon Partnership NHS Trust

02/02/2023

2023-0039

Jason Williams

Dorset

[REDACTED] Director General Operations His Majesty�s Prison and Probation Service (HMPPS), [REDACTED] Chief Executive of NHS England, [REDACTED] Governor at HMP Guys Marsh, Shaftesbury, Dorset

On the 13th August 2020 an investigation was commenced into the death of Jason Anthony Williams, born on the 7th January 1981. � The investigation concluded at the end of the Inquest on the 30th January 2023. The Medical Cause of Death was: 1a Synthetic cannabinoid intoxication � The jury reached a narrative conclusion that �Jason deliberately took drugs but did not intend the consequences to be fatal i.e he had no intention to end his life�

As recorded by the jury in Section 3 on the Record of Inquest: At 15.15 hours on the 31st July 2020 Jason Anthony Williams was found unresponsive in his cell, cell 42, Gwent wing, HMP Guys Marsh, Shaftesbury, by prison officers carrying out accommodation fabric check. His death was confirmed a short time later by attending paramedics. Prior to his death he had used psychoactive substances. On 30th July 2020 prison staff on the wing opened a welfare log following suspicion that Jason was under the influence of illicit substances, however the process set out in the Illicit Substances Welfare Document was not fully followed. It cannot be established that this had any causative or contributory bearing on Jason�s death the following day. On 31st July 2020 Jason�s cell door was unlocked by prison staff at 14.14 hours however a welfare check was not conducted upon unlock. It cannot be established that this had any causative or contributory bearing on Jason�s death. i� JASON�S HISTORY OF MISUSE OF DRUGS � Jason�s history of misuse of drugs probably caused or contributed more than minimally to his death. Jason had a habitual drug habit that was documented on assessment on entering HMP Guys Marsh and throughout his custodial sentence. � ii� JASON�S VULNERABILITY We are satisfied that Jason�s vulnerability possibly contributed to his death more than minimally. Jason�s drug dependency in Prison contributed to his vulnerability due to his apparent willingness to take illicit substances. iii� THE DRUG PREVENTION STRATEGIES IN THE PRISON IN JULY 2020 The restrictions imposed in July 2020 due to Covid, impacted the execution of the drug prevention strategy. This possibly contributed more than minimally to Jason�s death. iv. THE MEASURES TAKEN BY THE PRISON FOLLOWING THE SUSPECTED THROWOVER ON 25TH JULY 2020 v THE STEPS TAKEN BY THE PRISON, AND/OR ISMS TO SAFEGUARD JASON FOLLOWING THE SUSPECTED THROWOVER ON 25TH JULY 2020 AND ONCE HE WAS FOUND TO BE UNDER THE INFLUENCE OF PS ON 30TH JULY 2020 No specific instruction was given to staff relating to Jason following the suspected throwover of illicit items and the increase of psychoactive substance incidents around this time. Nor were there any additional briefings to prison officers or notices distributed to prisoners. This possibly contributed more than minimally to Jason�s death. This could be constituted as a safeguarding failure towards Jason from the steps taken by the Prison.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1)� GT Stewart Solicitors on behalf of Jason�s family (2)� Government Legal Department on behalf of the Ministry of Justice (3)� Hill Dickinson LLP on behalf of Practice Plus Group (4)� EDP I am also under a duty to send the Chief Coroner a copy of your response. I have also provided copies to the following who I believe this report will be of interest to: (1)� Hill Dickinson LLP on behalf of Oxleas NHS Foundation Trust (2)� Hill Dickinson LLP on behalf of Change Life Grow �� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related deaths | State Custody related deaths

HM Prison and Probation Service, NHS England and HMP Guys Marsh

09/10/2023

2023-0379

Kirandip Bharaj

Blackpool & Fylde

[REDACTED] Director of Adult Services Blackpool Council Bickerstaffe House 1 Bickerstaffe Square Talbot Road Blackpool FY1 3AH

The death of Kirandip Bharaj [known to her family as Kiran] on 14th September 2019 was reported to me and I opened an investigation, which concluded by way of an inquest on 30th September 2023. � I determined that the medical cause of Kiran�s death was: 1 a Fire fumes inhalation and burns � In box 3 of the Record of Inquest I recorded as follows: � Kiran Bharaj was aged 45 years. She had a history of mental health� issues, having�� been diagnosed with transient psychotic episodes. She also had a known eating disorder, and had maintained a chronic low weight for some time. She was also��� known to be frail, with limited vision and hearing. In May 2019, it was felt there had been a deterioration in her mental health and a mental health assessment was performed but Kiran was not� felt to be� detainable and she� remained in the community with support initially provided to her by a care company, and then with�� the aid of a support worker from adult social care. At shortly before 12.30pm on 14th September 2019, a neighbour� became aware of� a fire in Kiran�s flat and alerted the� fire service. When the emergency services entered her� flat,� they� found� Kiran deceased in the kitchen area. A subsequent fire investigation determined that the fire had been caused by the unintentional ignition of a cotton tea towel by turning on the wrong control on an electrical cooking ring hob. Once a fire had taken hold, and Kiran has become aware of the fire, she approached the location and her clothing caught� fire, and she suffered significant burns. She died quickly from the combined effects of the burns and from inhaling some fumes. In recent weeks, her weight had become more concerning and was being monitored by her GP. Kiran was referred to an eating disorder clinic on 23/07/19, but was not willing to give her consent to this. On 30/08/19, some 15 days before Kiran died, a support worker had raised a concern� when Kiran appeared confused and had been unable to recognise her. In due course, she was the subject of a further metal health assessment on 6th September 2019. By that date, her weight was declining. The assessment was inadequate. There was a failure to sufficiently assess the status of her eating disorder at that time. Her presentation justified a period of detention in a hospital setting where her declining weight could have been stabilised, and the decision not to detain her was a missed opportunity. When social care professionals attended her home on 10th September 2019 and weighed Kiran, her weight� had reduced further.� A� decision was taken to seek an inpatient eating disorder bed. Professionals could have convened an� immediate mental health assessment, which may have led to admission to a general acute or medical bed rather than waiting for a specialist eating disorder bed to materialise. Discussions were held with a hospital on 12th September 2019, but there was no eating disorder unit bed� free at� that time.� One would most likely� have become available within the next seven days but not by the date of Kiran�s death on 14th September 2019. There was some confusion amongst professionals about when a necessary mental health assessment would take place prior to Kiran being able to access the eating disorder bed, and who would be responsible for monitoring her in�� the community prior to hospital admission, but this did not contribute to her death. From the available evidence, it cannot be established that the circumstances surrounding the fatal house fire were more than minimally, trivially or negligibly contributed to by her mental disorder, nor by her eating disorder and how it was managed and responded to. � � In box 4 of the Record of Inquest I determined that Kiran died as a result of: � Accidental death

In addition to the contents of section 3 above, the following is of note: � ������ Notwithstanding that I determined that it could not be established this fatal house fire was contributed to by Kiran�s eating disorder and how it was managed and responded to, I was satisfied that I have a duty to write this report. � ������ At the time of her death, Kiran lived alone her flat with support from adult social care. A support worker assisted her with tasks such as ordering prescriptions, booking taxis, medical appointments, for example. ������ Although Kiran was said to have maintained a chronic low weight for some time, evidence before the inquest suggested that in the weeks prior to her death she lost significant weight, and could take steps to avoid accurate recording of her weight, such as on two occasions when she refused to remove her boots prior to being weighed. Her BMI was 14, and would reduce further. She was said to have been �presenting as not eating, and with an increased level of confusion� and no longer willing to have prescribed ensure drinks, something she had previously agreed to. � ������ The quality of assistance she received from professionals varied. A support worker was proactive in seeking to provide Kiran with the help she needed, By contrast, during an inadequate mental health assessment the extent of her eating disorder and a declining weight was not considered to the degree clearly required. � ������ This inquest was held some time after Kiran�s death, the inquest having been necessarily adjourned on previous occasions for a range of reasons. � ������ The court heard how, at the time Kiran died, in terms of managing and treating an eating disorder the relevant guidance was what is often referred to as the MARSIPAN guidance. Some time later, from around May 2022, the Royal�� College of Psychiatrists replaced that guidance with their up-dated Guidance on�Recognising and Managing Medical Emergencies in Eating Disorders, sometimes known as the MEED guidance. � ������ The court received evidence from a witness who� at the time of Kiran�s death� had been Deputy Head of Adult Social Care and in her witness statement, she explained how it was part of her role to provide some level of oversight, and to identify any gap in services and address these. However, no significant internal investigation into Kiran�s death had taken place since, and no changes have� been made in response to her death. � ������ She confirmed that at the time of Kiran�s death, Adult Social Care staff had not received training on how to recognise indicators of concern in relation to eating disorders. � ������ A support worker explained how what knowledge he had about eating disorders he had accumulated from his experience of dealing with service users allocated� to him previously. � ������ Two approved mental health practitioners [AHMPs] employed by Blackpool Council confirmed this also applied to AMHPs, with training on eating disorders limited to whether they happened to choose an eating disorder module as part of their annual refresher training. � ������ There had been little if any awareness of the MARSIPAN guidance therefore around the time of Kiran�s death. ������ In addition, adult social care witnesses were largely unaware of the more recent MEED guidance, and the court was told no steps had been taken to bring the� new MEED guidance to the attention of staff, nor to provide specific training on eating disorders. � ������ Although the court was told that workers in adult social care do have access to colleagues working in an eating disorder service with who they can discuss their service users, they are only likely to do so upon having recognised that there� may be a potential problem relating to an eating disorder. � Having considered all of the above, I have determined that I have a duty to write this report.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � ��� [REDACTED] [Kiran�s Sister] ����[REDACTED][GP] St Paul�s Medical Centre Dickson Road North Shore Blackpool � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete, redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: Blackpool Council

04/11/2024

2024-0594

Polly Friedhoff

Oxfordshire

[REDACTED] Director of Highways and Operations Oxfordshire County Council

On 24 October 2024 at Oxfordshire Coroner�s Court I conducted the inquest into the sad death of Polly Friedhoff, aged 81, who died at the John Radcliffe Hospital on 2� December 2022 from injuries sustained in a collision with a pedal cyclist on 20� November 2022. It occurred on the path beside the River Thames at Iffley Lock, Oxford.� I returned a conclusion of Accident and I attach a copy of the Record of Inquest for your� information.�� I heard oral evidence from the cyclist, investigating police officers�, and, helpfully, from [REDACTED], Operations Manager, Countryside Access and Tree Service,�Oxfordshire County Council (OCC). I was grateful to [REDACTED]/OCC for providing a� witness statement at relatively short notice. I note the towpath is recorded as a public� footpath and it forms part of the Thames Path National Trail. I understand OCC are� responsible for managing the footpath although Iffley Lock itself, through which it� passes, is owned by the Environment Agency.

The brief circumstances are set out in the Record of Inquest but I also attach the�investigating police officer�s report, that of [REDACTED], and also the�aforementioned statement of�[REDACTED] for your information. It will be seen that�raises some safety issues about the path at the end of his report and�[REDACTED] outlines at paragraphs 2.6 and 2.7 that OCC and local Councillors have given�considerable thought to the issue of safety. Mrs Friedhoff�s two son�s have also raised significant concerns which I share (see below).

I have sent a copy of my report to: The Chief Coroner� The Family of Mrs Polly Friedhoff [REDACTED]�Solicitors� I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest.�� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Other related deaths

Oxfordshire County Council

16/05/2023

2023-0156

Benedict Peters

Manchester South

[REDACTED] Group Chief Executive, Manchester University NHS Foundation Trust.

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. A post mortem examination confirmed that Mr Peters died as a consequence of: 1a) Haemopericardium; b. Acute aortic dissection. The conclusion of the inquest was a narrative conclusion to the effect that Mr Peters died as a consequence of complications arising from an underlying heart defect which had not been diagnosed during his life.

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. Mr Peters had attended hospital in the early hours of 11th November 2022 having become acutely unwell with chest pain, shortness of breath, a sore throat and an aching arm. In the Emergency Department, an ECG was undertaken which was reported as showing Normal Sinus Rhythm and his recorded observations were essentially normal. Whilst awaiting review, Mr Peters experienced a severe episode of vomiting. Blood tests were taken and Mr Peters� Prothrombin time was noted to be abnormal. Troponin and D-Dimer levels were within normal limits. Mr Peters was reviewed on the Ambulatory Care Unit by a Physician Associate. A Chest X-Ray was performed which was reported as being normal and following discussion with the duty Consultant, Mr Peters was discharged with a diagnosis of panic attack / gastric inflammation and a prescription of Propranolol and Omeprazole.

I have sent a copy of my report to the Chief Coroner and to Mr Peters� parents and the Trust�s legal services department. I have also sent a copy to the Care Quality Commission and the Greater Manchester Integrated Care Partnership who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Manchester University NHS Foundation Trust

16/03/2023

2023-0093

John Ibboston

North Yorkshire and York

[REDACTED] Health & Safety Executive [REDACTED] Road Transport Industry Training Board [REDACTED] COVEY TIMCOM, The Timber Packaging and Pallet Confederation The Director � The Associate of Pallet Networks

On 23 September 2020 I commenced an investigation into the death of John Anthony IBBOTSON aged 57. The investigation concluded at the end of the inquest on 07 February 2023. The conclusion of the inquest was that: � Mr John Anthony Ibbotson was 57 years of age who, at the time of his death worked as a warehouse operative at Systagenix Wound Management Ltd, Airebank Mills, Gargrave, Skipton BD23 3RX. He arrived at work at around 06:30 am on Monday 21st September 2020. Sometime thereafter his colleagues went looking for him as he had not been seen for a while. He was found in the raw materials storage, bulk storage area (RMGJ05), this was an area in which he was authorised to work. He was a trained warehouse operative with up-to-date forklift truck training. He was known to be safety conscious and not a risk taker. Mr Ibbotson was found in a sitting position, leaning forward with a pallet on top of his back. The incident was reported to the police at 08:38. The paramedics pronounced lift extinct at 08:53. On balance of probability, it is more likely than not that the pallets were double stacked and not in the pyramid/brick formation, but likely that one pallet was stacked directly on top of the other. It is unclear what caused the pallet to fall.

As above

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] I have also sent it to British Standards Institute who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Accident at Work and health and Safety related deaths

Health & Safety Executives | Road Transport Industry Training Board | The Timber Packaging and Pallet Confederation | The Associate of Pallet Networks

29/07/2024

2024-0410

Wendy Hammon

Surrey

[REDACTED] Interim Chief Executive Ashford and St. Peter�s Hospitals NHS Foundation Trust

INQUEST An inquest into Mrs Hammon�s death was opened on 27 October 2022. The inquest was resumed on 24-25 June 2024 and concluded on 12 July 2024.� The medical cause of Mrs Hammon�s death was: 1a. Multi-Organ Failure 1b. Non-Occlusive Mesenteric Ischaemia 1c. Small Bowel Obstruction due to Adhesions from Previous Surgery (2011)� 2.� Chronic Kidney Disease�� The inquest concluded with a narrative conclusion as follows: Mrs Hammon had a past medical history which included chronic kidney� disease.�� In 2011 she had developed ischaemic bowel, due to Streptococci A, and�had undergone surgery to remove a portion of her bowel and to create an� ileostomy.�������� As a result of the procedure in 2011 she developed scar tissue� known as adhesions, which are a recognised complication of the� procedure.�� On 30 August 2022 Mrs Hammon was admitted to St. Peter�s Hospital� with abdominal pain, vomiting and a non-functioning stoma.� She was� diagnosed with, and treated non-operatively for, a small bowel�obstruction caused by the adhesions from her surgery in 2011. �� At approximately 15:30 on 5 September 2022 Mrs Hammon began to� complain of severe abdominal pain and at 17:52 a CT scan was requested� to investigate the cause of the pain.� Thereafter, the plan was for the� oncoming night shift to arrange for a senior clinical review of Mrs� Hammon and to chase the CT scan. However, the plan was not� implemented and Mrs Hammon was not seen by the oncoming night shift until 01:00 on 6 September 2022 when she was found to have blood and� pus coming out of an old surgical scar, for which she was commenced on� intravenous antibiotics.�� At 02:41 on 6 September 2022 the CT scan was reported as being strongly� suggestive of mesenteric iscahaemia with infarction complicating a�known small bowel obstruction and thereafter at 10:50 on 6 September�2022 Mrs Hammon underwent an emergency laparotomy, during which� the surgical team found widespread ischaemic bowel, and resected a� significant amount of her small bowel.��� On 7 September 2022 a further relook laparotomy was carried out after� which Mrs Hammon was cared for on the Intensive Care Unit, however,� her condition deteriorated and she died at St. Peter�s Hospital on 9� September 2022.�� Her death was due to Multi-Organ Failure due to Non Occlusive� Mesenteric Ischaemia.� The ischaemia was caused by the small bowel� obstruction which in turn was caused by adhesions from her surgery in� 2011.�� The small bowel obstruction caused the ischaemia firstly by impairing the� blood flow within the lining of the bowel and secondly by causing Mrs� Hammon to become dehydrated, due to vomiting and reduced fluid� absorption from the bowel, which in turn led to her developing� hypovolaemia, acute kidney injury and low blood pressure, which� prompted her body to reduce the blood supply to the bowel in order to� protect other major organs.�� � Mrs Hammon�s death was contributed to by her Chronic Kidney Disease� which made her more susceptible to developing acute kidney failure.�� During the period from 1 September 2022 onwards there was a failure to� accurately monitor Mrs Hammon�s fluid input and output which led to a� failure to provide her with adequate fluid replacement, which contributed to her developing dehydration and related bowel ischaemia.���� �������������������������������������������������������������������������������������� � During the same period there was a failure to identify that Mrs�Hammon�s blood tests showed high CRP levels, which is a non-specific� inflammatory marker and can be consistent with bowel ischaemia. By 4 September 2022 the clinical team caring for Mrs Hammon ought to� have recognised that she had ongoing unexplained high CRP levels, in the context of an ongoing small bowel obstruction, with ongoing vomiting, a� return of abdominal discomfort and a deteriorating kidney function.�� Those matters ought to have prompted a senior clinical review and a CT� scan which would have diagnosed bowel ischaemia and resulted in� emergency surgery on 4 September 2022.� Had Mrs Hammon been taken� for surgery on 4 September 2022 she would have survived.�� On the afternoon of 5 September, when Mrs Hammon developed severe� abdominal pain, she ought to have received a senior clinical review which� would have prompted an expedited CT scan which would have�diagnosed ischaemia and would have resulted in emergency surgery on� the night of 5 September 2022.� Had Mrs Hammon been taken for surgery� on 5 September 2022 she would have survived.� Mrs Hammon�s death was contributed to by neglect.

The circumstances of Mrs Hammon�s death are set out in the narrative conclusion above.

COPIES� I have sent a copy of this report to the following: 1. [REDACTED] Interim Chief Executive, Ashford and St. Peter�s Hospitals NHS Foundation Trust� 2. Chief Coroner�� 3. Mrs Hammon�s family

Hospital Death (Clinical Procedures and medical management) related deaths�� � This report is being sent to: Ashford and St. Peter�s Hospitals NHS Foundation Trust

22/04/2024

2024-0213

David Carpenter

Coventry and Warwickshire

[REDACTED] Managing Director, Dennis Eagle Ltd [REDACTED] Engineering Director, Dennis Eagle Ltd

On 19th January 2023 I commenced an investigation into the death of David John CARPENTER (aged 60 years). The investigation concluded at the end the inquest on 22nd April 2024 at Coventry Coroners Court. The conclusion of the death of Mr Carpenter was that death was �accident� a copy of which I attach to this report.

Mr Carpenter was employed by Coventry City Council as a Refuse Collector. He was based at Whitley Depot, Coventry. His job involved collecting bins from the side of the road and taking them to a bin lorry/Rear Compaction Vehicle (RCV) to empty them. He worked as part of a team with another collector and a driver. The bin lorry involved in the incident was a Dennis Eagle lorry equipped with a Terberg �Omnideka� automatic bin lift system. The Terberg bin lift system comprises two �lifting chairs� which enable two household-sized waste bins to be emptied side by side. Each lifting chair has its own control panel located on the rear of the vehicle. The controls are used by bin crew to switch between different modes of use. The bin lift system can be operated in two modes (manual and/ or automatic) the two lifting chairs capable of operating independently of each other. CCTV cameras are fitted to these vehicles. Mr Carpenter was lifted into the rear hopper of this bin lorry when he activated the proximity start sensor and his coat became caught on the lifting chair comb tooth associated with the bin security switch. The machine through the automatic compaction cycle tragically causing Mr Carpenter fatal injuries.

I have sent a copy of my report to the following: HHJ Thomas Teague KC the Chief Coroner of England & Wales Chief Coroner�s Office, 11th Floor Thomas More, Royal Courts of Justice, Strand, London, WC2A 2LL. chiefcoronersoffice@judiciary.gsi.gov.uk David Carpenters family. Coventry City Council. Heath and Safety Executive Waste Industry Safety and Health Forum I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Accident at Work and Health and Safety related deaths This report is being sent to: Dennis Eagle Ltd

30/01/2023

2023-0032

Felice Banfield

Cornwall and the Isles of Scilly

[REDACTED] Medical Director, Royal Cornwall Hospital

On 25/1/23, I concluded an inquest into the death of Felice Eileen Grace Banfield who died in RCHT on 22/10/21. The medical cause of death was recorded as: 1a) Chronic Obstructive Pulmonary Disease and Sarcoidosis I recorded a Conclusion of Natural Causes. I considered adding a rider of neglect but did not do so on the basis that the shortcomings identified � and accepted � were not gross in the sense they were not total and complete. Nevertheless, I felt the circumstances gave rise to a concern and engaged my statutory duty to make this PFD report.

Ms Banfield had a past medical history that included COPD ([REDACTED] felt this was actually Obesity Hypoventilation Syndrome) chronic kidney disease (stage 3) and type 2 diabetes. She used non-invasive ventilation (NIV) at home and brought her machine into RCHT with her when admitted. Her presenting complaint was a painful knee, and the initial differential diagnoses were gout, septic arthritis or a flare of osteo arthritis. Her need for NIV was recognised but following her admission to MAU at 22:20 on 17/10/22, there was a lack of clarity about if and where NIV could be undertaken. As respiratory consultants do not provide an on- call service, it appears to have been decided to leave the issue until the following day when the evidence suggested the matter was simply forgotten. Although presenting with a respiratory element to her condition, her admission was not brought to the attention of respiratory clinicians. On 21/10/21, a respiratory nurse became aware of her presence and took bloods that revealed a mixed respiratory and metabolic acidosis that had caused an AKI. Despite treatment, Ms Banfield deteriorated and died. It was accepted in evidence that this was an avoidable death. The structured judgment review conducted found a poor level of care. There was discussion about the cause for the AKI. While the failure to provide NIV was accepted, it was felt in evidence that the more likely significant driver was a failure to provide adequate fluid and food. Charts to evidence this were not completed.[REDACTED], accepted this had been a problem in MAU for years where there is a rapid turnover of patients and a lack of continuity in medical and nursing care.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] (daughters.) I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Royal Cornwall Hospital

09/7/2024

2024-0366

Nancy Rogers

Cumbria� � Category: Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: University Hospitals Morecambe Bay Trust

[REDACTED] Medical Director, University Hospitals Morecambe Bay Trust University Hospitals Morecambe Bay Trust

On 22 November 2023 I commenced an investigation into the death of Nancy ROGERS. The investigation concluded at the end of the inquest . The conclusion of the inquest on 9th July 2024 was Death from natural causes. The medical cause of death being: 1a Bilateral Haemothorax 1b Ruptured Dissecting Aortic Aneurysm 1c II I also refer to an inquest opened on 10th August 2023 and concluded on 23/11/23 touching on the death on 12th February 2023 of [REDACTED], the medical cause of death being 1a Haemopericardium due to 1b Ruptured Dissecting Aortic�Aneurysm.

18/11/2023 � Nancy collapsed outside on Storey Square, Barrow when she was walking with her sister�[REDACTED] into town. This occurred around 1300hrs. An ambulance was called and Nancy attended A&E. She had tests done however the results were not back and they are due to come back on Monday 20/11/2023. Hospital discharged Nancy back to her home address. They stated she possibly had fluid on her lung which would need a referral. On 19/11/2023 at around 0530hrs [REDACTED] helped Nancy to the toilet; she left the bathroom to give Nancy some privacy and immediately heard her fall.�[REDACTED] went into the bathroom and Nancy was not breathing. CPR was started and the neighbour�[REDACTED] came over as she heard the shouting through the wall. No response to CPR from family attempts and paramedics arrived to continue. Nancy is in the process of selling her home to return to the ��Philippines and this has been causing her some stress.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� [REDACTED], [REDACTED]. I have also sent it to�[REDACTED] �who may find it useful or of interest.� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your� response, about the release or the publication of your response by the Chief Coroner.� 9 July 2024

Hospital Death (Clinical Procedures and medical management) related deaths� �

11/12/2023

2023-0518

Amarnih Lewis-Daniel

East London

[REDACTED] NHS England

On 1 April 20211 commenced an investigation into the death of Amarnih Louis Lewis� Daniel, aged 24 years. The investigation concluded at the end of the inquest on the 30 November 2023. The conclusion of the inquest was a narrative conclusion delivered by a jury: � Amarnih took the action that led to her falling from [REDACTED] floor window. The evidence does not fully disclose whether she intended the outcome to be fatal.

Amarnih Lewis-Daniel suffered from traits of emotionally unstable personality disorder, mixed anxiety and depression, anger management difficulties and gender dysphoria. She was under assessment for autism spectrum disorder. Amarnih had been referred to the gender identity clinic in August 2018. The inquest heard evidence that Amarnih had suffered bullying and abuse, causing her a great deal of distress . She reported to professionals that she was keen to be accepted by and to receive treatment from the Gender Identity Clinic. Amarnih had sourced hormone medication [REDACTED] The hormone medication was not� supervised by any healthcare professional.� In the months leading up to her death, Amarnih�s mental state declined, and she came into contact with the police, criminal justice system and mental health professionals. �On the 17 March 2021 she jumped [REDACTED] and sustained fatal injuries in the fall. Amarnih was still awaiting care from the Gender Identity Clinic when she passed away.

I have sent a copy of my report to the Chief Coroner and to the following Interested persons: Family of Amarnih Lewis-Daniel , North-East London Foundation Trust and the Tavistock and Portman Clinic. I have also sent a copy to the local Director of Public Health who may find it useful or of interest and to the CQC. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form . He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Other related deaths This report is being sent to: NHS England

17/04/2024

2024-0202

Thomas Wakefield

Cheshire

[REDACTED] NHS England 7 and 8 Wellington Place Leeds LS1 4AP

On 02 January 2024 I commenced an investigation into the death of Thomas Geoffrey WAKEFIELD aged 79. The investigation concluded at the end of the inquest on 10 April 2024. The conclusion of the inquest was that: � Thomas Wakefield died from natural causes. It is not possible to say on balance of probabilities whether Mr Wakefield would have survived if the correct diagnosis had been made on admission.

On 22 September 2023, 79 year old Thomas Wakefield was admitted to Countess of Chester Hospital at 22:22 hours with a three day history of severe stomach pain and sudden collapse at home in the early afternoon. The clinicians were not made aware of the collapse at home. � He was promptly assessed in A&E for concerns with acute kidney injury. The plan was to prescribe intravenous fluids due to hypotension. There was a delay in medical assessment. A CT scan was considered at 05:59 but not ordered or completed. This was a missed opportunity to review the diagnosis of pancreatitis on admission and provide a 50% chance of survival. � He was sadly found deceased in bed at 16:10 hours on 23 September 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Mr Thomas Wakefield�s family Countess of Chester Hospital � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS England

15/12/2023

2023-0525

John Taylor

Teesside and Hartlepool

[REDACTED] North East Ambulance Service NHS Foundation Trust Bernicia House Goldcrest Way Newburn Riverside Newcastle upon Tyne NE15 8NY

On 29 July 2022 I commenced an investigation into the death of John Robert TAYLOR aged 35. The investigation concluded at the end of the inquest on 07 December 2023. The conclusion of the inquest was that: � John Robert Taylor took a deliberate overdose of insulin, probably on 18.07.2022, with the intention of ending his life. He contacted the emergency services for help. The ambulance arrived the following morning. There was a delay of over 13 hours in the arrival of the ambulance. John was transported to the University Hospital of North Tees. He died at the University Hospital of North Tees on 27.07.2022. Johns� death was contributed to by the delay in the arrival of the ambulance � The Medical Cause of his death is: 1a. Aspiration Pneumonia 1b. Hypoglycaemic Brain injury 1c. Insulin Overdose II Morbid Obesity, Asthma, Ischaemic Heart Disease

Mr Taylor contacted the fire brigades befriend service on 18.07.22 expressing suicidal intent and plans. The fire brigade contacted Cleveland police who is turn contacted NEAS at 1557 on that day. After 3 unsuccessful attempts to speak with Mr Taylor, contact was made at 1610 by a call handler. The matter was assessed as requiring a Category 3 response. The ambulance arrived at Mr Taylor�s home at 0523 on 19.07.22, occasioning a delay of over 13 hours. The paramedic tried the door, but access could not be gained. At 0543 a request was to the police to gain entry. The police arrived on scene at 0558. When the police arrived, they noted that the door was unlocked and that the ambulances hadn�t tried the handle. They gained access to the property within one minute. Care and attention were provided to Mr Taylor, and he was transported to UHNT. He died on 27.07.22. I instructed an independent expert who determined that the delay in the ambulance arrival contributed to Mr Taylor�s death. NEAS undertook an SI report. Oral evidence was provided by a Team Leader and a Clinical Section Manager, the latter having authored the SI Report. It was clear that a comprehensive investigation had been undertaken and learning implemented. The author of the SI report was not aware that the door to the property was unlocked, and that access could have been gained over thirty minutes earlier. My concern is that this information has not been offered or elicited nor has it been reported to the SI author. This issue has therefore not been considered within the SI. A further concern is that the Family gave evidence about NEAS previously using a taxi to transport Mr Taylor to hospital on several occasions. The Clinical Section Manager said there was no policy on this and that it is in the operator�s �gift�. She told me there is no evidence that this option was considered on 18-19 July 2022 to transport him to hospital sooner.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to John Robert Taylor�s family who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards) This report is being sent to: North East Ambulance Service NHS Foundation Trust

31/08/2023

2023-0315

Donna Levy

East London

[REDACTED] North East London Foundation Trust (NELFT), CEMEEssex, RM13 8GQ [REDACTED] Chief Executive, London Borough of Redbridge Council, , 0 erational Director of Assurance, � � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care, 39 Victoria St, Westminster, London SW1H 0EU

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; �Donna Rose Lydia Levy died in hospital on 14th December� 2022� due to complications of a pressure sore she developed in the community. The pressure� sore developed� due to self-neglect despite support from community health organisations.� � Ms Levy�s medical cause of death was determined as; � 1a Sepsis secondary to pressure sore II Frailty secondary to self-neglect

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mrs Levy, the Care Quality Commission. I have also sent it to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete r� redacted or summary form. He may send a copy of this report to any person who e believes may find it useful or of interest.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: North East London Foundation Trust | London Borough of Redbridge Council | Department for Health and Social Care

15/06/2018

2024-0094

Darren Carrington

West Sussex, Brighton and Hove

[REDACTED] North Laine Medical Centre, 12-14 Gloucester Street, Brighton [REDACTED], Practice Manager, North Laine Medical Centre, 12-14 Gloucester Street, Brighton [REDACTED] Clinical Commissioning Group, Hove Town Hall, Norton Road, Hove

On 18 th April 2018 I commenced an investigation into the death of Darren James CARRINGTON The investigation concluded at the end of the inquest on 6th June 2018. The conclusion of the inquest was MISADVENTURE BEING IMPULSIVE OVERDOSE WHILST UNDER THE INFLUENCE OF ALCOHOL (DRUG RELATED DEATH)

I am enclosing a copy of the Record of Inquest and also the letter (without it�s annexures) from the Controlled Drug Liaison Officer for the City of Brighton and Hove, [REDACTED] which is self-explanatory

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � South East Coast Ambulance Service, [REDACTED] , Sussex Partnership NHS Foundation Trust 3. [REDACTED] Secretary of State for Health, Department of Health [REDACTED], Chief Executive, NHS England [REDACTED], NHS England South (South East) [REDACTED], Gordons Solicitors [REDACTED], Boots UK Limited � I have also sent it to:- [REDACTED], General Pharmaceutical Council [REDACTED],CQC [REDACTED], Sussex Police � Who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drug and medication related deaths This report is being sent to: North Laine Medical Centre | Brighton and Hove Clinical Commissioning Group

18/12/2023

2023-0529

David Hemmings

Inner West London

[REDACTED] Regional Operations Manager, Choice Support, Ground Floor, 100 Westminster Bridge London. SEI 7XA.

On the 12th and 13th December 2023 evidence was heard touching the death of Mr David Hemmings. He had died on the 4th June 2021, aged 73 years. � Medical Cause of Death � 1 a. Peritonitis Wound InfectionComplex right hemipelvic fractures (operated 13/01/2021, 20/02/2021 and 20/5/2021 � � � How, when, where the deceased came by his death: � David suffered with severe learning disability, dementia and poor mobility. He was resident in Concorde House. At approximately 0800 on 12th January 2023, he was found to have fallen within his flat. He was unable to get up without significant assistance. At approximately 11:00, the London Ambulance Service was called as he was distressed and unable to walk. He was taken to St George�s Hospital and found to have sustained severe pelvic fractures and a fractured and displaced right femur. These were surgically treated on 13th January 2021 with pins and plates to the pelvis and reduction of the femur. This was unsuccessful due to osteopenia and some plates were removed on 20th February 2021. He was discharged immobile to Mc Crae Lane on 25th February 2021. From mid-March he developed a wound infection. This was treated in the community by district nurses, GPs and paramedics. The GP advised referral back to the surgeons on 5th May 2021. He was admitted from outpatients back to St George�s Hospital on 13th May 2021 and underwent washout and removal of metal work on 20th May 2021. During this procedure, the peritoneum was breached and despite treatment, he died of peritonitis on 4th June 2021. � Conclusion of the Coroner as to the death: Complications of surgical treatment of injuries sustained in an accidental fall.

Extensive evidence was taken during the inquest from multiple live witnesses, written statements, and exhibited reports. Of relevance to this report: � David was living in a flat within a complex. There was a communal area. Due to pandemic restrictions no communal activities were taking place and he became increasingly socially isolated, exacerbated further by reduced staff availability. He was able to get up unaided and walk but had coordination difficulties worsened by visual impairment and dementia, such that he required the assistance of 2 persons to move around. � On 12th January 2021, there were severe staff shortages such that the manager of the home had worked more than 36 hours without a break and there was only a skeleton crew on duty. � This meant that David was not receiving the 1O hours per day of contact time during the days that he had allocated to him and instead was subject to 30 min checks in the day and hourly checks at night. � Records suggest that he was checked and found asleep at 0750 hours. � At approximately 0800 on 12th Jan 2021, a support worker entered the complex and heard David calling out in a distressed manner. This worker attended David�s flat and found David sat on the floor in hall behind his front door. The worker called for assistance from the manager and together they lifted and supported him to walk backwards to the chair in his bedroom. He was latter assisted to his bed. It was only when he refused at about 10:30 to stand off his bed and was distressed that another manager was consulted and medical assistance sought. � David was unable to communicate verbally due to his learning disability and had not indicated any particular area of pain on his body. � However the injuries that he had sustained in the fall were severe with multiple pelvic fractures and an impaction fracture of the right head of femur. The pelvic fractures involved the hip joint such that the femur was displaced through the pelvic bones into the pelvic cavity. The evidence of the surgeon was that David would have unable to weight bare on the right and could not have been moved without being lifted and with considerable assistance. � Those staff that had moved David would have had to have provided this assistance. � To move an injured person in this way when they were unable to weight bare was unsafe, could have exacerbated any injuries, and was against the training in moving and handling following a fall that those two staff would have received. � Following evidence from the surgeon, I was satisfied that in this particular case, the actions of moving David did not contribute to his death, however I remain concerned. The support worker in evidence could hardly remember what training he had received in relation to moving and handling following a fall. At the time, during the pandemic, the training would have apparently been eLearning and video watching for the support worker. The manager was said to be experienced and committed to his work; however both these staff acted outside their training and moved a severely injured man in a way which could have exacerbated his injuries and would have caused him severe pain. � It was only when a second manager became involved that clinical care was sought.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Sister of Mr Hemmings: [REDACTED] �� St George�s Hospital Legal Department, St George�s Hospital, Blackshaw Road, London. Sw17 OQT � Director Integrated Learning Disability Team, Social Services, 4th Floor Merton Civic Centre, London Road, Morden SM4 5DX. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths This report is being sent to: Choice Support

30/08/2023

2023-0313

Allison Aules

East London

[REDACTED] Royal College of Paediatrics & Child Health, NHS England � ����������������������� [REDACTED] President, Royal College of Psychiatrists, London Office, 21 Prescot Street, London, E1 8BB � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

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.

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.

I have sent a copy of my report to the Chief Coroner, to the family of Allison Aules and to the other Interested Persons involved in the Inquest. The report will also be sent to the Care Quality Commission, to the Child Death Overview Panel and to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Child Death (from 2015) | Suicide (from 2015) This report is being sent to: NHS England | Royal College of Psychiatrists | Department for Health & Social Care

22/05/2023

2023-0169

Kaius Tutt

Cornwall and the Isles of Scilly

[REDACTED] Service Director � Connectivity and Environment

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. � The conclusion of the inquest was as follows � Road Traffic Collision � The four questions � who, when, where and how � were answered as follows � Kaius John Paul TUTT died on 14 October 2022 on the A391 Between the SCREDDA and CARCLAZE roundabouts near St Austell Cornwall from trauma after Kaius attempted an overtaking manoeuvre whilst riding his motorcycle and collided with a car being driven on the opposite carriageway. � The medical cause of death was found as follows � 1a) Multiple injuries Comment: There were head, aortic and pelvic injuries that were not compatible with life. Toxicology was negative.

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.

I have sent a copy of my report to the Chief Coroner and to Kaius� family. � I have also sent a copy to�[REDACTED] of Cormac who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Road (Highways Safety) related deaths This report is being sent to: Connectivity and Environment

14/06/2024

2024-0321

Michael Harrison

Cheshire

[REDACTED] Technical manager of ALLMI

On 04 March 2021 I commenced an investigation into the death of Michael HARRISON aged 42. The investigation concluded at the end of the inquest on 10 June 2024. The conclusion of the inquest was that: � Misadventure

Michael Harrison was a driver for a scaffolding firm. On 26 February 2021 he was working at Victoria Mills, Macclesfield Road, Holmes Chapel. Whilst unloading scaffolding from a Hiab truck the Hiab arm (a crane-like device) came down on him, causing crushing injuries which proved fatal. The jury found that he was wearing the remote control over his head and across his chest causing the inadvertent movement of the crane arm. The remote control had not been isolated during the unloading activity

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] [REDACTED] [REDACTED] HSE [REDACTED] Cheshire [REDACTED] Constabulary [REDACTED] Representing 3D Scaffolding � I have also sent it to � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Accident at Work and Health and Safety related deaths This report is being sent to: ALLMI

10/7/2024

2024-0379

Mahamoud Ali

Inner North London

[REDACTED] The Chief Executive Officer� East London NHS Foundation Trust Trust Headquarters� 9 Alie Street� London�� E1 8DE

On 1 September 2020, an investigation was commenced into the death of Mahamoud Hussain Ali, aged 40 years old.�� The investigation concluded at the end of the inquest on 26 April 2024. The medical cause of death was: 1a. Bronchopneumonia� 1b. Ischaemic encephalopathy 1c. Subdural haematoma� The conclusion of the jury was accident.

On 19� August� 2020,� Mahamoud� Hussain� Ali� fell� in� the� street.� He was� taken� by ambulance to Homerton University Hospital where he was treated in the Emergency Department. A CT scan of his brain showed no intracranial bleeding and no skull fracture. He discharged himself.� �� The same morning, he fell again in the street and was taken back to the same hospital by� ambulance.� A second CT brain� scan� showed� no� change.� Concerns about his behaviour and mental health led to him being admitted overnight.�� Following a mental health assessment conducted by a psychiatrist on 20 August 2020, Mr Ali was detained under section 2 of the Mental Health Act 1983 and transferred to Lea Ward, Mile End Mental Health Hospital, arriving just before 7pm on 20 August 2020. He� was� placed� in� isolation� pending� a� covid� test� and� was� assigned� to� be� under observation every 15 minutes.�� The next day 21 August 2020 at around 1800 he was found unresponsive on the floor of his room. LAS were called and he was taken to Royal London Hospital where a CT scan showed evidence of unsurvivable early brain death and where surgery was considered futile.�� Mahamoud Hussain Ali died on 26 August 2020 at the Royal London Hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� The family of Mahamoud Hussain Ali� [REDACTED] Chief Executive of the Homerton Healthcare NHS Foundation Trust I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. She may send a copy of this report to any person who she believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief� Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: East London NHS Foundation Trust

29/04/2024

2024-0265

William Stockil

West Sussex, Brighton and Hove

[REDACTED] Vice President of Oracle Corporation UK Limited National Medical Director, NHS England & NHS Improvement

On 23 September 2022 I commenced an investigation into the death of William Richard STOCKIL aged 74. The investigation concluded at the end of the inquest on 25 April 2024. The conclusion of the inquest was that: � William Richard Stockil died on 6 September 2022 at Royal Surrey County Hospital, Egerton Road, Guildford, Surrey from a pneumonia. This developed following his admission for treatment of conditions caused by a long lie at his home where he had been on the floor for more than 8 hours on 31 August 2022.

On 31 August 2022 Mr Stockil was admitted to hospital having been found on the floor at home that day by his family. He was reportedly walking when his legs gave way and he was unable to get himself up. He had evidence of rhabdomyolysis and dehydration on admission. � I heard evidence that there was a suspicion Mr Stockil may have an infection due to infection markers, but I also heard that this could have been a result of inflammation following being on the floor. In any event he was prescribed broad spectrum antibiotics to cover an infection having been seen by a Dr at 1am on 1 September 2022. � Mr Stockil�s prescription was completed using the Trust�s electronic prescription system. It was intended by the Dr that he would receive IV 1.2mg of Co-amoxiclav once every 8 hours. When inputting the prescription, the Dr inadvertently selected 18 rather than 8 hourly administration using the drop down menu. The Dr prescribed the medication for 72 hours on the basis that Mr Stockil was awaiting blood results and that once those were received, likely within 72 hours, there would be a review of his medications. � On 3 September 2022 Mr Stockil received the last dose of the prescription made on 1 September 2022. It had not been extended. The electronic prescription system sent out alerts to any member of staff who accessed his medical records on the system to make them aware that his prescription was due to end. It is not clear who received these but I heard evidence that they may have been received by a number of staff who would not consider that this was relevant to their role in the care of Mr Stockil and as such �clicked� off the alerts to them on the system. It was not the case that the alerts were only sent to prescribers but instead anyone who accessed his medical records for whatever reason. � The alerts were not picked up or actioned by any clinician. The system sent out the pre-agreed number of alerts and then stopped sending the alerts. � Mr Stockil received no further antibiotics until 5 September 2022 when he developed signs of infection and clinicians prescribed further antibiotics. The Court found that the cessation of medication was not on the balance of probabilities causative or contributory to Mr Stockil�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] [REDACTED] Royal Surrey NHS Foundation Trust � I have also sent it to N/A who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Oracle UK Limited | NHS England and NHS Improvement

15/08/2023

2023-0291

Ian Darwin

County Durham and Darlington

[REDACTED] ����������������������������������� , Chief Executive Tees Esk and Wear Valleys NHS Foundation Trust West Park Hospital Edward Pease Way Darlington DL2 2TS [REDACTED] National Director of Patient Safety NHS England Wellington House, 133-135 Waterloo Road, London, SE1 8UG CQC

INVESTIGATION � On 7th March 2023 I commenced an investigation into the death of Ian Darwin, 42. The investigation has not yet concluded and the inquest has not yet been heard.

Death was caused by multiple injuries, Ian Darwin being found below , [REDACTED] Durham.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons. I have also sent it to NHS England and the CQC, who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Tees Esk and Wear Valleys NHS Foundation Trust

17/04/2024

2024-0201

Jade Griffiths-Jones

Birmingham and Solihull

[REDACTED] � CEO Birmingham Integrated Care Board [REDACTED] � NHS England, Midlands Regional Director The Rt Hon Victoria Atkins MP � Secretary of State for Health and Social Care

On 4 December 2023 I commenced an investigation into the death of Jade Marie GRIFFITHS-JONES. The investigation concluded at the end of the inquest. The conclusion of the inquest was; �Death was due to natural causes in combination with a delay in ambulance attendance arising from increased demand for ambulances and significant hospital delays.�

Mrs Griffiths-Jones died at the Queen Elizabeth Hospital on the 4th June 2023 as a result of severe and fatal hypoxic brain injury sustained during a cardiac arrest at around 15:00 hours on the 31st May 2023 caused by coronary artery disease. An ambulance had initially been called when Mrs Griffith-Jones started to suffer chest pain at 13:33 but an ambulance was not available to attend due to increased demand and delays handing over patients at hospitals. If an ambulance could have attended within national target times Mrs Griffith- Jones would have arrived at hospital before suffering a cardiac arrest and would have been likely to survive. � Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a Hypoxic-ischaemic brain damage 1b Cardiac arrest 1c Coronary artery disease � percutaneous coronary intervention � II Diabetes mellitus

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons : [REDACTED] (the deceased�s cousin), [REDACTED] (the deceased�s brother), West � Midlands Ambulance Service. � I have also sent it to the CQC, who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards) This report is being sent to: Birmingham Integrated Care Board | NHS England | Department of Health and Social Care

07/12/2023

2023-0510

Katharine Fox

Essex

[REDACTED] � CEO Essex Partnership University Trust The Lodge, Lodge Approach Wickford, Essex, SS11 7XX

On 26 October 2022 I commenced an investigation into the death of KATHARINE ANNE FOX, aged 51. The investigation concluded at the end of the inquest on 1st December 2023. The conclusion of the inquest was that the deceased had died from hanging, and the conclusion was suicide.

Katharine Fox was being treated at home following a stay as an in-patient in Broomfield Hospital. Some of that stay had involved the deceased being detained under section 2 Mental Health Act 1983. While being treated in hospital, the deceased obtained psychology treatment in the form of a series of sessions with a trainee psychologist with whom she built a good clinical relationship and from which she reported benefiting significantly. Following her discharge from hospital, this psychology treatment effectively came to an end, since the procedures for receiving this treatment in the community were passed to an entirely separate set of clinicians. There was an entirely separate procedure for referral and provision of psychology sessions, with a very significant wait, and the deceased never in fact secured access to those services in the months between being discharged (in May 2022) and her death in October 2022. I was also told by the witness conducting EPUT�s own investigation that the teams use separate notes, and it may not always be possible for those notes to be accessed by other teams. This included evidence that a different computer system is used in the north of the county from in the south.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) [REDACTED] (2)� EPUT � The Lodge, Lodge Approach, Wickford, Essex, SS11 7XX I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: Essex Partnership University Trust

09/01/2024

2024-0016

Karena Wicking

Cumbria

[REDACTED] � CEO of North Cumbria Integrated Care

On 16 February 2023 I commenced an investigation into the death of Karena WICKINGS. The investigation concluded at the end of the inquest . The conclusion of the inquest was � Death from complications arising from an essential surgical procedure. 1a Pulmonary Embolism

Karena Wickings � aged 58 died in her home in Brampton, Cumbria on 5th February 2023. She had been admitted to hospital two months previously for laparoscopic surgery to remove a screening detected colonic cancer. She had a prolonged admission due to multiple postoperative complications requiring further surgeries. Throughout her admission she was given anticoagulant prophylaxis in the form of enoxaparin. Her clinical condition was improving and it seemed as if the cancer had been fully removed but at the time of discharge her mobility remained significantly restricted. Anticoagulant prophylaxis stopped when she left the hospital and it is unclear if ongoing indication was considered. It is more likely than not that the lack of ongoing prophylaxis led to the formation of thrombosis in her left leg and her death due to pulmonary embolism.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [NAMES] � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: North Cumbria Integrated Care

16/12/2024

2024-0696

Anne Leake

Staffordshire and Stoke-on-Trent

[REDACTED] � Chairman of University Hospitals of North Midlands NHS Trust

On 13th June 2024 I commenced an investigation into the death of Anne Patricia Leake, aged 67. The investigation concluded at the end of the inquest on 9th December 2024. � The medical cause of death was: � 1a Hypoxic brain injury 1b Cardiac arrest 1c Ventricular arrhythmia � The narrative conclusion was: � Natural causes contributed to by neglect.

Mrs Leake suffered arrhythmia and cardiac arrest on 17th April 2024.� She was admitted to the Royal Stoke University Hospital and a multi-disciplinary team (MDT) of doctors decided that she was to have heart valve surgery and have an Implantable Cardioverter Defibrillator (ICD) fitted before she was released from hospital.� The purpose of the ICD was to prevent Mrs Leake from suffering future cardiac arrhythmia and cardiac arrest. � A few days later, Mrs Leake underwent heart valve surgery as planned, but she was then mistakenly released from hospital without having fitted the ICD which she needed. � Three days after she was released from hospital Mrs Leake suffered a cardiac arrhythmia of the type which an ICD is designed to address, and she died as a result. � I found that the failure to fit the ICD was causative of Mrs Leake�s death and it amounted to neglect. � The decision of the MDT to fit the ICD was overlooked by the doctors who released Mrs Leake from hospital because the note of the MDT meeting which made this decision was not recorded on the medical notes which they were working from.

I have sent a copy of my report to the Chief Coroner and to the following Interested Person: � [REDACTED] (Mrs Leake�s husband) � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

University Hospitals of North Midlands NHS Trust

28/11/2023

2023-0484

Ann Pearce

West Sussex, Brighton and Hove

[REDACTED] � Chief Executive University Hospitals Sussex NHS Foundation Trust

On 13 April 2022 I commenced an investigation into the death of Ann Dorothy PEARCE aged 61. The investigation concluded at the end of the inquest on 27 November 2023. The conclusion of the inquest was a narrative which stated: � Ann Dorothy Pearce sustained a fracture of her tibial spine on 26 March 2022 having fallen from her bicycle in Burgess Hill that day. She was taken to the Princess Royal Hospital for treatment and discharged on 28 March 2022. On 1 April 2022 she became unwell at home and an ambulance attended and took her to the Princess Royal Hospital for treatment where she was diagnosed with a massive pulmonary embolism. She was treated but sadly died on 1 April 2022.

Ann Dorothy Pearce was taken to the Princess Royal Hospital for treatment and was discharged on 28 March 2022. During her admission she was immobilised in a brace and on discharge was only partially weight bearing. The Venous Thromboembolism Prevention Policy of University Hospitals Sussex NHS Foundation Trust version 1.4 required that this should be undertaken on admission and reviewed on the daily ward round. No Venous Thromboembolism assessment was undertaken during her admission or on discharge. She became unwell at home on 1 April 2022 and was taken to hospital for treatment but sadly died from a massive pulmonary embolism that day.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] [REDACTED] � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: University Hospitals Sussex NHS Foundation Trust

01/02/2024

2024-0058

Lucas Pollard

Bedfordshire and Luton

[REDACTED] � Chief Executive, East of England Ambulance Service

On 08 June 2023 I commenced an investigation into the death of Lucas Tyler POLLARD aged 14. The investigation concluded at the end of the inquest on 18 January 2024. The conclusion of the inquest was that: � Lucas Tyler Pollard was aged 14 at the time of his death on the 1st June 2023. He had been given a new electric moped the day before. He had no prior experience of riding the moped. It was in sound mechanical order although the tyres were significantly underinflated. It was not designed to carry pillion passengers. He went out to ride it with a friend in the early hours of the 1st June 2023 in Leighton Buzzard. It was dry and there was very little other traffic. He was driving east along Leighton Road and his friend was riding pillion when the bike tilted to the right (offside) and then struck a sign post at approximately 20 miles per hour. He sustained very severe injuries to his chest, liver, spleen and pelvis and suffered catastrophic internal haemorrhage. A category 1 ambulance with a target response time of 7 minutes was dispatched from Luton Ambulance Station. It was known that the journey time would be in excess of 20 minutes. A critical care clinician considered the deployment of an air ambulance. That had an estimated journey time of greater than 40 minutes and was not dispatched. There was a rapid response vehicle based at the Leighton Buzzard Ambulance station with an estimated response of 3 minutes. That was dispatched by the computer aided dispatch system but then cancelled by a dispatcher as it would contravene East of England Ambulance Service End of Shift Policy. Deployment of the rapid response vehicle would have enabled aid to be given to Lucas much before the arrival of the ambulance from Luton. There was no discussion between the critical care clinician and the dispatcher. However, I found that the multiple injuries suffered by Lucas during the collision were catastrophic and mean�t that he would not survive the collision whatever aid had been provided.

Lucas Tyler Pollard was aged 14 when he died at the Luton and Dunstable University Hospital. He had been driving his new electric moped at about 1.30 am on the 1st June 2023 when he collided with street furniture and sustained catastrophic unsurvivable injuries. He had no prior experience of riding the moped. A nearby resident heard the collision and went to his aid and called emergency services. The call recording illustrates the first-aider�s increasing concern as Lucas deteriorated. Lucas can be heard in the background very clearly to be deteriorating rapidly and significantly. A Category 1 (C1) ambulance was dispatched followed by another as there were two casualties. C1 reflects an emergency response travelling with blue lights and sirens. The EEAST uses a computer aided dispatch (CAD) system which also automatically dispatched a solo paramedic in a rapid response vehicle (RRV). Fire co-responders were also deployed. A General Broadcast (GB) was not made. A GB is an alert to any other nearby resources who might possibly assist. EEAST policy requires a GB where there are no nearby resources. The first ambulance sent was based at the Luton ambulance station meaning it was greater than 20 minutes away. The second ambulance was also greater than 20 minutes away. The target response time for a C1 ambulance is an average of 7 minutes and 15 minutes for 90% of calls. It was known at the time of dispatch that it would greatly exceed the target time. A Critical Care Dispatcher was aware of the call and nature and considered deploying a Critical Care Team (CCT) but opted to let the crew from the first ambulance to assess and report. This was despite the crew being at least 20 minutes away. The nearest CCT was 42 minutes away by air. It was night which presents difficulties in safe landing etc. It was accepted on reflection that the CCT should have been sent. The RRV was 3 minutes from the scene. The proximity of the RRV was not revealed in the EEAS Serious Incident Investigation Report but emerged during questioning. The RRV was dispatched by the CAD but then immediately cancelled by a dispatcher due to the Trust�s End of Shift Policy seemingly without regard to the actuality of the situation, that the two dispatched ambulances were more than 20 minutes away, a CCT was not dispatched and that a RRV 3 minutes away could have rendered essential aid. The End of Shift Policy limits the calls crews can be dispatched to within the last one hour and last 30 minutes of their shift. The coding allocated to Lucas did not permit the RRV to be sent. As mentioned above, there was clear evidence through the call of Lucas�s markedly deteriorating condition. There appears to have been no coding reassessment. The Critical Care Dispatcher and the �routine� dispatcher were not in the same location but could see each other�s entries into the computer system in real time as they were made. There was no direct dialogue between them. There was no evidence of a dynamic overview reassessment of the situation as it progressed. Had there been, it is possible, likely even, that the RRV would have been deployed. Medical evidence was clear Lucas would not have survived but that was not known at the time of the call.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] � Deputy Medical Director, Bedfordshire Hospitals NHS Foundation Trust �� who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it . � I may also send a copy of your response to any person� who I� believe may� find it� useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about t he release or t he publication of your response by t he Chief Coroner.

Child Death (from 2015) | Emergency services related deaths (2019 onwards) This report is being sent to: East of England Ambulance Service

06/09/2023

2023-0320

James Jones

North West Wales

[REDACTED] � Interim Chief Executive Betsi Cadwaladr University Health Board

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: Medical Cause of death: 1a Cardiac arrest 1b Bowel ischaemia 1c Superior mesenteric artery occlusion 2 Ischaemic heart disease � Conclusion: Natural Causes

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. In total, Mr Jones waited 17.5 hours to be taken to the anaesthetic room. Mr Jones was intubated in preparation for surgery but suffered a cardiac arrest prior to administration of anaesthetic. � The Consultant Colorectal Surgeon giving evidence at the inquest did not consider the delay to have contributed to the outcome in Mr Jones�s case but was of the view that. continuing failure by Ysbyty Gwynedd to render care in a timely manner, as seen in Mr Jones�s case, may lead to missed opportunities that may prove fatal for other patients.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of James Jones � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Betsi Cadwaladr University Health Board

14/01/2025

2025-0024

Anugrah Abraham

Manchester North

[REDACTED] � National Police Chiefs� Council (NPCC) [REDACTED] � Chief Executive Officer, College of Policing [REDACTED] � West Yorkshire Police

On the 15th March 2023, I commenced an investigation into the death of Anugrah Abraham (�Anu�). Anu died on the 4th March 2023 in Woodland near Red Rock Lane in Bury. He was 21 years old.� The medical cause of death was confirmed as 1a) Hanging. � I recorded a conclusion of Suicide recording the circumstances as follows: �The deceased was a serving West Yorkshire police officer.� He had been on annual leave since the 16th February 2023. He was due to return to work on the 4th March 2023.� The prospect of returning to work is likely to have been a source of distress to the deceased.� On the 3rd March 2023 in the early afternoon he left his home address.� There was nothing in his behaviour which gave rise to concerns from his family.� At 22:50 hours when he had not returned home, Greater Manchester Police were contacted and he was reported missing.� In the early morning of the 4th March 2023 the deceased was located in a wooded area near Red Rock Lane, Radcliffe. He had died as a result of hanging with the intention of ending his life.�

CIRCUMSTANCES OF DEATH In 2021 Anu had joined West Yorkshire Police (�WYP�) under the Police Constable Degree Apprenticeship programme (�PCDA�). This was in conjunction with Leeds Trinity University (�LTU�). At the time it was only possible to join the police if you already had a degree or undertook at degree alongside training to be a police officer. In 2021 the application programme was online and there was no face to face assessment. In addition, a decision had been taken by WYP Chief Officers to remove the in-force interviews. Of note, Anu had not achieved the grades required at A level to undertake a stand alone policing degree. Prior to commencing the PCDA there is no evidence of Anu having any issues with his mental health. � The court heard from a large number of witnesses in respect of various aspects of the PCDA and how it operated in practice.� I found as a matter of fact that : ������� there should have been closer working between the Central Assessment Unit in WYP, in particular the student officer�s assessor and the District Sgts who had day to day line management responsibilities for the officer.� ������� Anu had emerged from his 12 week training at Carr Gate on a development plan. This was not immediately known to his District Sgts and also raised concerns as to the decision to place officers onto patrol when they had failed to demonstrate the skills required of them. ������� Anu was subject to what were described as �Stage 1 meetings in accordance with Regulation 13 of the Police Regulations 2003�. Within WYP, use of regulation 13 had developed into a series of staged meetings. Anu was subject to a �stage1� meeting. It was not immediately clear where the process for implementing various stages of Regulation 13 emanated from. In Anu�s case his District Sgts were not aware Anu was subject to such a review as this information was not shared with them.� ������� The lack of shared information between those taksed with the various aspects of Anu�s management led to mixed, inconsistent messages to Anu as to how he was developing and performing. ������� On the 24th September 2022 Anu was referred to Occupational Health (�ODU�) the waiting time to be seen was three months.� He was not seen until the 15th December 2022. The referral had been for a back injury but also his mental health.� There was an inadequate assessment of his mental health and a lack of consideration of any adjustments required given his mental health issues were linked to his work and the PCDA. ������� During this time he also accessed the Employee Assistance Programme and was referred to a counsellor. In October 2022 it was recorded that he was suffering from severe anxiety and severe depression.� This was linked to the PCDA programme and his work. He reported having suicidal thoughts. This information provided to the counsellor was not shared with WYP.� ������� On the 4th January 2023 Anu had a lengthy meeting with one of his Sgts following which he attended a quarterly review. The serious concerns WYP had as to Anu�s ability were not shared or reflected in the quarterly review. ������� There was a lack of clarity and understanding as to what options were available to students if they wanted to leave the PCDA programme after 2 years but continue with the degree element. Evidence was contradictory as to whether there academic credits could be used to continue on a degree albeit they may have to fund any remaining years. ������� On the 13th January 2023 Anu made direct contact with the OHU where it was acknowledged he appeared to be in �intense mental distress.�� Whilst he was spoken to again later that day, there was no plan documented that he would be seen or re-contacted by OHU, this appeared to be because Anu had made direct contact and it had not been a referral from a senior manager.� Anu should have been offered a face to face appointment. ������� On the 23rd January following further concerns about Anu�s work he had a meeting with a District Sgt and was advised he was being placed on a further development plan. A subsequent email was sent to Anu by his Sgt setting out his development. During the course of this meeting Anu indicated he felt suicidal. An urgent referral was made to OHU.� The subsequent email to Anu in no way was reflective of a caring approach to an individual who was expressing suicidal thoughts.� ������� Following this urgent referral to OHU an appointment was offered for April 2023.� Anu should have been offered an urgent face to face appointment.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- � Family of Anugrah Abraham National Police Chiefs Council College of Policing West Yorkshire Police Leeds Trinity University � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Police related deaths

National Police Chiefs� Council | College of Policing | West Yorkshire Police

14/10/2024

2024-0550

Stephen Sleaford

Leicester City and South Leicestershire

[REDACTED] � Secretary of State for Justice & Lord Chancellor � [REDACTED] � Minister of State for Prisons

On 31 October 2022 I commenced an investigation into the death of Stephen Anthony SLEAFORD aged 49.�The investigation concluded at the end of the inquest on 26 September 2024.�� The conclusion of the inquest was (by way of a narrative conclusion) that: �On the 27th of October 2022, Stephen Anthony Sleaford was found hanging by ligature in his cell at HMP Gartree at 07:12 where he was a serving prisoner.� Prior to this, Stephen complained of pains and health issues, including mental health issues. Due to failings of the prison system, not following the adequate protocols, Stephen was unable to receive the health care and support he required and was pronounced dead on the 27th of October 2022 at 08.01.� The cause of death was established as: I a Hanging by Ligature I b I c II

Stephen Sleaford was born on 15 February 1973 in the Boston area of Lincolnshire and he died on 27 October 2022, at Gartree Prison near Market Harborough, Leicestershire. He was 49 years of age when he died. Mr. Sleaford was a prisoner at Gartree and had been for around 11 years prior to his death. He had been accommodated at a number of prisons, but predominantly at Lincoln and Gartree Prisons. In late May 2022, Mr. Sleaford was transferred to Lincoln Prison, for the purpose of accumulated visits, a process whereby he was moved closer to his family, including his father who was unwell and with whom he was very close, so that visiting would be easier for all.� He returned to Gartree Prison on 11 August 2022. Mr. Sleaford saw a prison GP on 25 October 2022, when he complained of struggling with right ankle pain, and had been struggling to sleep since his last co-codamol prescription had ended.� On that day, he was prescribed a short course of medication to try to restore sleep. On the same date, a prison healthcare nurse was asked to see Mr. Sleaford due to the suspicion that he was under the influence of an illicit substance, although he was assessed as not being under the influence. A substance misuse worker went to see him the following day, 26 October 2022, because he had been found with fermenting liquid (brewed alcohol) in his cell and an improvised smoking device.� He was spoken to by that worker, when Mr. Sleaford declined formal substance misuse intervention. In the afternoon of the same day, that is 26 October 2022, Mr. Sleaford was seen by a supervising prison officer and his prisoner status was downgraded from �enhanced� to �basic� level.� He did not react well to that news and told the officer that he would �show [him] basic behaviour� before returning to his cell.�Later that evening, the Prison Officer on duty on Alpha wing (where Mr. Sleaford was accommodated) who knew him and appeared to have a good rapport with him, spoke with him at around 9pm and they had a conversation, when he was seen and appeared to be in a good mood.� The following morning, that is 27 October 2022, during her shift, the same officer re- attended outside the cell around 5:45am, when she did not see Mr. Sleaford, due to the cell door�s observation panel being obscured internally, but she did receive a verbal acknowledgment from him. Later the same morning, when the day staff were on duty, another officer was unable to get a verbal response from Mr. Sleaford, when outside his cell, so that officer went to obtain advice and colleague assistance. He returned with other staff and entered the cell, where Mr. Sleaford was discovered with a ligature around his neck and was believed to be unresponsive. Prison officer staff waited� for� several� minutes� while� further� staff,� including� healthcare� staff,� attended� at� the� cell, followed later by paramedics.� Mr. Sleaford could not be revived and his death was confirmed at the scene by one of the attending paramedics, at 08:01 hours on 27 October 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1)� The Family of the Deceased (namely�[REDACTED] and [REDACTED]), through their legal representatives. 2) Nottinghamshire Healthcare NHS Foundation Trust, as providers of in-prison healthcare at the date of Mr. Sleaford�s death. 3) The legal representatives of His Majesty�s Prison & Probation Service/Ministry of Justice. � I have also sent it to: 1) The Governing Governor � HMP Gartree, Leicestershire. 2) Practice Plus Group Limited, as current providers of in-prison healthcare (since March 2024). 3) The Office of the Prisons & Probation Ombudsman (�PPO�). who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

State Custody related deaths

Ministry of Justice | HM Prison and Probation Service

14/03/2024

2024-0141

Victor Costello

Teesside and Hartlepool

[REDACTED](Chief Executive) Stockton Care Limited Suite 20, Durham Tees Valley Business Centre Orde Wingate way Stockton-on-Tees TS19 0GD

On 13 March 2024, I opened an investigation into the death of Victor Valentine COSTELLO, aged 84. The investigation concluded at the end of the inquest also held on 13 March 2024. I made a determination that death was from natural causes. The medical cause of death was: 1 (a) bronchopneumonia 2 cerebral infarction and generalised atherosclerosis

CIRCUMSTANCES OF DEATH � Mr Costello was a resident at Primrose Court Nursing Home. He was taken to hospital on the morning of the 17th February 2020 and passed away there six days later from naturally occurring disease.

I have sent a copy of my report to:- � Mr Costello�s family The Care Quality Commission. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths This report is being sent to: Stockton Care Limited

22/01/2024

2024-0038

Kate O�Donnell

Teesside and Hartlepool

[REDACTED], Acting Chief Executive Officer, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW

Kate Elizabeth O�Donnell died at James Cook University Hospital, Middlesbrough on 23.03.22. I commenced an investigation into her death. On 17th and 18th January 2024, I held the inquest into her passing. The Medical Cause of her death is: 1a. Multi organ failure 1b. Systemic sepsis II. Hypopituitarism following chemoradiation for intracranial germ cell tumour. � I left a narrative conclusion as follows Kate Elizabeth O�Donnell underwent surgery at James Cook University Hospital on 16.03.22. She was discharged home on 17.03.22. She developed sepsis from the surgery and died at James Cook University Hospital on 23.03.22. The sepsis originated in her gut. The failure to administer prophylactic anti-biotics for the gastro-intestinal surgery contributed to her death.

Miss O�Donnell�s past medical history included a Germ Cell brain tumour which reoccurred at ages 4,7 & 9. She was treated with chemotherapy and radiotherapy. � Aged 9 she received high dose chemotherapy and was consequently paralysed from just below the waist. � She endured resulting chronic nerve pain/damage and was prescribed high daily doses of pain relief medications. � Miss O�Donnell was doubly incontinent. Treatment moved from intermittent catheterisation to a suprapubic catheter. Age 11 she underwent an ACE procedure. This was used for a few years until it was changed to a colostomy. Miss O�Donnell sustained regular infections from the redundant ACE. The infections had a significant impact on her overall health and exacerbated her pain. � It was therefore determined that the ace stoma would be excised. This procedure, along with a cystoscopy, bladder washout & injection of 200 units of Botox took place on 16.03.22. Miss O�Donnell and her family encountered several problems in the immediate run up to the operation, to include the hospital notes being mislaid, not meeting the anaesthetist ahead of the operation, uncertainty about the colorectal surgeon�s involvement, the possibility that the ACE stoma would not be reversed and subsequent confirmation that it would be and on the day of the procedure apparent uncertainty from the urologist as to how the operation would proceed. I accepted that all these points caused the family concern and frustration. I found that the operation was not well planned. � On 11 March 2022 Miss O�Donnell attended the hospital and gave a urine sample. The results showed a resistance to Ciprofloxacin. The consultant gave evidence that he checked the results on the morning of the operation by consulting WebIce. An audit of WebIce was provided which showed that no one accessed WebIce on the day of the operation. I held that the Consultant urologist was not aware of the results of the urine sample before the operation. I determined that on the day of the operation he acted in accordance with his usual practice, rather than to tailor the anti-biotics to the urine test results. He administered prophylactic Gentamicin at the start of the procedure and provided Ciprofloxacin post procedure both for the urological aspects of the surgery. The latter was ineffective as she was resistant to that medication. I found that the Consultant overlooked the provision of prophylactic anti biotics for the gastro-intestinal operation. � I determined that the surgeon was unaware of the classification of surgeries and didn�t know that surgery could be clean-contaminated. He did not know of the SIGN guidelines and that prophylactic anti biotics were highly recommended for that type of gastro-intestinal surgery. I held that a member of the colorectal team should have assisted with the operation. � Post surgery Miss O�Donnell vomited a large amount on a single occasion and was suffering from ongoing pain. Mrs O�Donnell was her daughter�s full-time Carer and was an expert in caring for her daughter. I accepted her evidence that on a good day Kate�s pain would be 7/10. I found that the pain charts detailing Kate�s pain post -surgery were grossly understated. Nurses were informed of her pain but took no action to alleviate the same. The episode of vomiting was not recorded in the notes. � I accepted that generally one-off vomiting and pain may not be enough to prevent discharge with most patients. However, Kate�s vulnerabilities, comorbidities, and extensive involvement with the medical teams, should have ensured extra vigilance and recognition should have been given to her reactions, with medical attention being sought. � I determined that Kate was not physically assessed by a doctor prior to discharge. Kate should not have been discharged without a thorough further medical assessment which had been prompted by accurate medical recordings. The family should not have left hospital without information on sepsis or what to do if Kate was to deteriorate. � In the days following discharge Kate vomited daily, most days suffering several bouts of vomiting. I accepted that the Ciprofloxacin probably supressed the sepsis that Kate was battling post-surgery. � Kate deteriorated and ultimately was taken to James Cook University Hospital on the morning of 23.03.22. She passed away shortly after her arrival. The Trust undertook an internal investigation and produced a Patient Safety Incident Investigation Report. This report was presented at the inquest by one of the Trust�s Clinical Directors. He confirmed that the hospital did not investigate the issue of prescription of prophylactic antibiotics for the gastrointestinal surgery. He accepted that more should have been done to check Kate�s sodium before she was discharged and that a nurse should have contacted a doctor about the pain scores (even on the understated values). � I instructed an independent expert to assist in determining whether any provision or omission in care contributed to Kate�s death. I was informed that the provision of Ciprofloxacin contributed to Kate�s death as it suppressed the sepsis she was fighting. I was also told that the omission of a prophylactic antibiotic for the gastrointestinal surgery contributed to Kate�s death. The expert confirmed that the sepsis from which Kate died developed directly from the surgery undertaken on 16.03.22 and that the sepsis originated in her gut.

I have sent a copy of my report to the following Interested Persons [REDACTED] who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: James Cook University Hospital

01/08/2024

2024-0422

Kieran Lavin

Birmingham and Solihull

[REDACTED], Birmingham and Solihull Mental Health NHS Foundation Trust

On?2 January 2024?I commenced an investigation into the death of?Kieran Lavin. The investigation concluded at the end of the inquest held between 22-25 July 2024.

Kieran had experienced anxiety and depressive symptoms for around 10 years with worsening symptoms in� late 2023. In November he consulted his GP having inadvertently stopped taking his anti-depressant� medication. On 5/12 he reported worsening symptoms after restarting his medication for two weeks, and said he had thoughts of jumping in front of a vehicle and an overdose, citing the breakdown of his relationship�with his wife as one of the triggers. He was referred to the Crisis team and assessed on 7/12 reporting no� active suicidal plans. His anti-depressant medication was increased, and he agreed to be seen routinely in 4� months. The following day, on 8/12 he booked into a hotel to overdose on his medication with alcohol. He�was surprised to wake up and was admitted to the Emergency Department early on 9/12. Psychiatry & Liaison� referred him to the Psychiatric Decisions Unit (�PDU�) for further assessment as he could not guarantee his� safety. He arrived at the Oleaster Centre, Birmingham at 9:55pm. The following day, early morning on 10/12� during a nurse assessment he said he was angry the overdose attempt had not worked, and if he went home,� he would maybe throw himself in front of a lorry. He cited in part the relationship breakdown with his wife as� one of the triggers for his presentation. Later that day, he was assessed by a consultant psychiatrist whose� impression was of a depressive episode, and that Kieran required informal admission as he did not feel safe to� go home, which Kieran agreed with. The following day, by 11am on 11/12 Kieran proactively contacted a� second nurse reporting when outside the unit for a cigarette he had terrible thoughts, and he does not feel� safe going outside because he thinks he needs to kill himself and he will run and jump in front of a car or train. Around 1-2pm he was assessed by a junior Dr and reported no active suicidal plans, but her impression was he was very anxious and depressed, and the plan was maintained. The long wait for a bed was due to the mental� health service having no available inpatient bed. A private mental health service agreed to admit him in� Willenhall. Kieran�s wife had arrived to drop off some clothes and Kieran asked if his wife could drive him. The� bed manager, also the nurse in charge of the Oleaster Centre, had intended that Kieran be transported via taxi accompanied by a member of staff, but agreed to his wife driving him on the basis Kieran was a voluntary� inpatient, wanted treatment, and assessed his presentation on and off the PDU as raising no safety concerns.� He did not record his risk formulation. He was not aware of the two reports of suicidal ideation via road traffic�collision. Had he looked at the �level 1 risk screening� neither nurse had at this stage updated the �suicide� box.� No record of his suicidal ideation on 10/12 was ever added, and the suicidal ideation reported on the morning� 11/12 was not added until 8:51pm and after the incident had occurred. Whether his wife�s presence would� exacerbate Kieran�s presentation was not fully considered, or the length and nature of the journey. His wife�was not informed of Kieran�s reported suicidal ideation. The mental health service�s policies, procedures and�guidelines did not set out a clear approach to assist regarding what should happen when a patient requests�for family to transfer them to another location for an informal admission. Kieran left with his wife in her car� around 7:45pm. Shortly after 8pm, having just spoken on the phone to his mum, he suddenly proceeded to�open the passenger door whilst in lane 1 of the M5 motorway. His wife attempted to physically stop him�whilst managing to move to the hard-shoulder whereby Kieran exited the passenger door and walked around the rear of the car into the path of an oncoming large lorry in lane 1, and thereafter was struck by a second�car. He was confirmed deceased at the scene from the consequential injuries (1a. Multiple injures). �� The inquest conclusion was: �Suicide, contributed to by a failure to conduct an adequate patient transport risk assessment which would have likely changed the outcome.�

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1.� Kieran�s family.� 2.� Insurers: [REDACTED] ��������������������������������������������� .�� I have also sent it to�[REDACTED], Chief Executive, NHS Birmingham and Solihull Integrated Care Board who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a� copy of this report to any person who he believes may find it useful or of interest. You may make� representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015)� � This report is being sent to: Birmingham and Solihull Mental Health NHS Foundation Trust

27/03/2023

2023-0107

Aoife McAdam

West Yorkshire (Eastern)

[REDACTED], Burton Croft Surgery, 1 Shire Oak Street, Headingley, Leeds LS6 2AF

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. The medical cause of death was 1a) Cardiac Arrest; 1b) Intentional Propranolol Overdose; 2) Anxiety & Mood Disorder. The inquest found that the overdose had been taken as an impulsive act, in respect of which Aoife sought help, the provision of which was delayed.

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:[REDACTED]�(Aoife�s parents); Yorkshire Ambulance Service; NHS England; Leeds Teaching Hospitals NHS Trust; [REDACTED] � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related deaths

Burton Croft Surgery

07/02/2023

2023-0114

Bridget Gormley

Worcestershire

[REDACTED], CEO Barchester Healthcare, 3rd Floor, The Aspect, 12 Finsbury Square, London EC2A 1AS; � [REDACTED], Weightmans LLP, The Hallmark Building, 105 Fenchurch Street, London EC3M 5JG ( legal representative for Barchester Healthcare at inquest )

[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 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.� � The care home in question was Latimer Court Care Home, Darwin Avenue, Worcester WR5 1SP, which is owned and run by Barchester Healthcare. Latimer Court�s registered home manager is Donna Tustin.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] (Mrs. Gormley�s next of kin ). � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths This report is being sent to: Barchester Healthcare | Weightmans LLP

14/09/2023

2023-0436

Jack Farrington

Hampshire, Portsmouth and Southampton

[REDACTED], CEO Portsmouth Hospitals University NHS Trust, [REDACTED], CEO Solent NHS Trust [REDACTED],, CE NHS England

On 08 January 2020 I commenced an investigation into the death of Jack FARRINGTON aged 26. The investigation concluded at the end of the inquest on 27 July 2023. The conclusion of the inquest was that: � On the 2nd January 2020 Jack Farrington died as a result of falling from a bridge. At the time, Jack was detained under section 2 of the Mental Health Act due to recent psychotic episodes. Evidence suggests that Jack�s capacity to make rational decisions was severely compromised. When Jack was lucid he demonstrated a desire to be well and actively sought medical assistance for his condition. In the days prior to his death Jack had voluntarily attended hospital via ambulance. During Jack�s time in hospital, he was able to abscond twice, and was sectioned under the Mental Health Act and transferred to a mental health facility. Following a suspected medical emergency Jack was transported back to hospital under escort. Significant failings in the assessment, recording, sharing of information, accountability and implementing appropriate measures to keep Jack safe contributed to his ability to abscond a third time, resulting in Jack�s death.

Jack Farrington had a long history of mental health difficulties. He moved to Hampshire in 2019 and his mental health started to deteriorate again later that year. He sought help from his GP and the community mental health services. � On the 30th December he called an ambulance in a state of acute distress. He was transported to Queen Alexandra Hospital, Portsmouth (QAH) and assessed in the emergency department (ED). He was moved to the observation ward and seen by a consultant who requested further assessment to determine whether Jack needed to be detained under the Mental Health Act. Before this happened, Jack absconded from the observation ward via the fire door at approximately 9.00am. � Jack was located by the police and returned to the ward where he was detained under s.5(2) of the Mental Health Act. He was subsequently detained under s.2 of the Mental Health Act. � On the 31st December 2019 Jack absconded via the same route despite being under 1:1 supervision by a registered mental health nurse. Jack was located and returned to the ward by the police. � In the early evening of the same day Jack was transferred to St James� Hospital and admitted to the Hawthorn ward. � On the 1st January 2020 Jack threw himself at a glass dividing wall. � On the 2nd January 2020 Jack suffered a medical episode and was transferred by ambulance to the emergency department of QAH. He was accompanied by 1 escort from St James� Hospital and remained within the ED awaiting medical assessment and treatment. � At approximately 10.00am Jack ran from the ED and shortly after this fell from a road bridge sustaining fatal injuries.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � The family of Jack Farrington � I have also sent it to � Midlands Partnership Foundation Trust Equans � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Mental Health related deaths This report is being sent to: Portsmouth Hospitals University NHS Trust | Solent NHS Trust | NHS England

27/08/2024

2024-0471

Alfie Tollett

Devon, Plymouth and Torbay

[REDACTED], CEO of Jaguar Land Rover

On 27th February 2023� I commenced an investigation into the death of Alfie Tollett age 7 . The investigation concluded at the end of the inquest on 16th August 2024 . � The conclusion of the inquest was accident . The circumstances of the death were that on 19th February 2023 the Tollett family attended Plymstock Albion Rugby Football club to watch their eldest son play in a friendly training match against Exmouth RFC. The weather was dry and bright with clear blue skies. The club car park was full and club parking attendants were turning cars away. Alfie�s father parked his Kia Niro with all four wheels on the pavement that runs adjacent to the club car park on Wembury Road. Behind the Kia a white VW Transporter van was parked, unattended, with it�s nearside wheels on the pavement and it�s offside wheels on the road. � Mr and Mrs Tollett went onto the pitches with Alfie and his little brother. Alfie was playing with his football and some other children at the side of the pitches. The rugby match lasted about an hour, once finished Mr Tollett and his two older sons returned to their car for the boys to change their shoes before they went into the clubhouse. Alfie went to the boot of the Kia to change his boots whilst Mr Tollett crouched on the pavement to untie his eldest son�s boots. � Around 11:10 am [REDACTED] and his wife were attending the rugby club to watch their son play in a match. [REDACTED] was driving his wife�s Jaguar ipace �electric vehicle registration number [REDACTED] and his wife was in the front passenger seat. There was a space on the road between the white VW van parked unattended behind Mr Tollett�s Kia and a silver VW van parked further back from the white van. [REDACTED] slowly pulled onto the pavement so his nearside wheels were on the pavement and his offside wheels were on the road. He used his left hand to select the reverse button to straighten the vehicle up. [REDACTED] did not look down at the buttons on the centre consule and relied on feel to select reverse. He looked to his left in preparation to reverse and pressed the accelerator. The Jaguar moved forwards, as reverse had not been selected, failed to notice that the reversing warning alarm had not engaged and collided with the rear of the white VW van causing damage. [REDACTED] did not brake and continued to accelerate pushing the white VW van forwards trapping Alfie between the VW van and his father�s Kia. Mr Tollett immediately got into his car and moved it forward to release Alfie who fell to the ground. He then went to Alfie�s aid but sadly Alfie died shortly afterwards with the cause of death being given as blunt force traumatic chest injuries . There has been no prosecution of the driver [REDACTED] as he died of natural causes shortly after this incident . A team from Jaguar / Landrover were preparing a technical report to assist the police but this was not progressed due to [REDACTED]�s death.

CORONER�S CONCERNS 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. � Although it is accepted that this death was accidental , during the inquest the following information came to light as a result of the investigating police officer giving evidence : There were a number of errors that were made by the driver which caused or contributed to the death . These were Wrongly placing the car in drive instead of reverse Failing to look down at the camera and pressing the button to move forward by touch alone Failing to realise that the reversing warning sound which was said to be very difficult to hear inside the car was not engaged Driving forward and continuing to do so for 8-10 seconds after the accelerator was pressed Failing to press the brake at any time . However, these errors occurred as a result of there being no intermediary step within the Jaguar ipace being necessary to put the car into drive / reverse other than pressing a button . In the police officer�s opinion if there had also been a lever or something similar present in the vehicle that needed to be engaged before a button was pressed this may have alerted [REDACTED] to the fact that he had pushed the incorrect button on the 3 button console .

27th August 2024 �������������������������� Deborah Archer

Child Death (from 2015)

Jaguar Land Rover

25/10/2024

2024-0578

Chloe Every

East London

[REDACTED], CEO, Barking, Havering & Redbridge NHS Foundation Trust Sent via email: [REDACTED] SM-INQUESTS (BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST) [REDACTED] � [REDACTED], Secretary of State for Dept. Health & Social Care Sent via email: [REDACTED]

On 17th November 2023, this court commenced an investigation into the death of Chloe Every, aged 27.� The investigation concluded at the end of the inquest on 21st October 2024. The court returned a narrative conclusion. � Chloe Every died in hospital on 14th May 2019. Chloe�s death was caused by complications of a cardiac arrest sustained on 8th May 2019 whilst in hospital. The cardiac arrest on 8th May was probably contributed to by treatment given to Chloe to manage symptoms of bowel cancer. It is possible that medical procedures undertaken to facilitate diagnosis of Chloe�s cancer contributed to her death. The inquest concluded that multiple actions and omissions of hospital staff during Chloe�s inpatient admission did not comply with local and national guidance. Some of those omissions were actions that would have resulted in contemporary evidence being created relevant to this inquest. I find that there is insufficient contemporary evidence to allow me to undertake proper assessment of all of the factors that are likely to have contributed to Chloe�s death.� � Ms Every�s medical cause of death was determined as; � 1a Multi organ failure 1b Hypoxic Cardiac arrest, subsequent cardiogenic shock 1c Advanced Bowel Cancer (treated with Morphine) II Myotonic Dystrophy

Chloe suffered from a genetic condition, Myotonic Dystrophy. She was also diagnosed with a learning disability. � In late 2018 Chloe was investigated for symptoms indicative of cancer. In Late April 2029 she was admitted to hospital with upper right abdominal pain and an interrupted toilet habit. After diagnostic imaging, a preliminary diagnosis of colon cancer with metastases in the liver was arrived at. � Chloe was admitted into hospital awaiting a flexible sigmoidoscopy, planned for 8th May 2019. � Chloe�s pain increased; she was prescribed morphine. No recorded justification for the use of this powerful drug can be found in hospital records. The identity of one of the prescribing doctors cannot be made out due to the absence of clear records. � On the morning of 8th May 2019, she underwent an enema. Before and during this process, Chloe was observed to be unresponsive. It is Moments after the procedure a crash call was raised as Chloe had sustained a hypoxic cardiac arrest, contributed to by the use of morphine. It is possible that the un-consented enema process contributed to the cardiac arrest. � Chloe was successfully resuscitated and was admitted to the ITU for supportive treatment. � After 5 days her care was stepped down to a respiratory ward, within a matter of hours of transfer, she was found unresponsive and declared deceased.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Ms Every, the Care Quality Commission and to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths

Barking, Havering and Redbridge NHS Foundation Trust | Department of Health and Social Care

30/11/2023

2023-0490

Julia Murphy

Sefton, St Helens and Knowsley

[REDACTED] (manager) � Abbey Wood Lodge Care home

On 28 April 2023 I commenced an investigation into the death of Julia MURPHY aged 89. The investigation concluded at the end of the inquest on 29 November 2023. The conclusion of the inquest was that: Julia Murphy (known as Sheila) sadly died on 09/04/2023 at Southport Hospital Merseyside PR8 6PN. Julia was 89 years of age at the time if her death. � On 06/04/2023 Julia suffered a fall in the care home where she resided, she was admitted to hospital, however, she was too unwell for surgery to the fracture she had sustained when she fell. Notwithstanding all appropriate care and treatment in hospital Julia�s condition deteriorated culminating in her death. � From the time Julia was resident in the care home she suffered 21 falls, the first being on 15/01/2022 and the last being on 06/04/2023. The final fall when Julia sustained a fracture to her hip caused her death. � During her stay in the care home only 3 referrals were made for advice from the specialist falls prevention team, the first on 30/09/2022, the second on 24/11/2022 the day after her 13th fall on 23/11/2023, it is worthy of note, there was no response from the falls prevention referral on the first occasion and a second referral was not made until Julia had fallen again. � A physiotherapist assessed Julia on 10/01/2023 and recommended the use of a zimmer frame, on 19/01/2023 the falls prevention team recommend Julia should use a zimmer frame, a falls sensor mat, a crash mat and they also recommended Julia should be encouraged to come out of her room during the day. A crash mat was deemed inappropriate. � The third referral to the falls team was made on 10/03/2023, this referral stated ��. �Sheila has had 18 falls since 01/01/2022�. Julia had suffered four falls over the 5th & 6th March 2023. � The first referral form (reason for referral box, on page 1) stated �struggling to walk even short distances and is holding to everything when walking. It might be better with a Zimmer frame or something similar to that�. There was no mention in the reason for referral box of Julia�s falls history even though at the time she had fallen 12 times when that fall occurred. The referral form dated 24/11/2022, (reason for referral box) stated �had a few falls since January this year, sensor mat is in place and OT referral was sent on 30/09/22 and that has been chased up today 24/11/2022�. By the 24/11/2022 Julia had fallen 13 times. � The first referral, in the reasons for referral box did not describe the fact that Julia had suffered 12 falls, as it should have done, and it was not followed up as it should have been until the day after she had fallen on 23/11/2022. � The referral on 23/11/2022 stated in the reason for referral box, Julia had a few falls since January this year when in fact at that time she had fallen in the care home 13 times. � Julia was subsequently assessed, and some falls prevention measures were put in place. However, funding was not formally sought for 1-1 supervision as it should have been, the fact that Julia had suffered so many falls was not escalated as it should have been and the final fall i.e. the 21st fall that Julia suffered on 06/04/2023 tragically caused her death.

Julia Murphy (known as Sheila) sadly died on 09/04/2023 at Southport Hospital Merseyside PR8 6PN. Julia was 89 years of age at the time if her death. � On 06/04/2023 Julia suffered a fall in the care home where she resided, she was admitted to hospital, however, she was too unwell for surgery to the fracture she had sustained when she fell. Notwithstanding all appropriate care and treatment in hospital Julia�s condition deteriorated culminating in her death. � From the time Julia was resident in the care home she suffered 21 falls, the first being on 15/01/2022 and the last being on 06/04/2023. The final fall when Julia sustained a fracture to her hip caused her death. � During her stay in the care home only 3 referrals were made for advice from the specialist falls prevention team, the first on 30/09/2022, the second on 24/11/2022 the day after her 13th fall on 23/11/2023, it is worthy of note, there was no response from the falls prevention referral on the first occasion and a second referral was not made until Julia had fallen again. � A physiotherapist assessed Julia on 10/01/2023 and recommended the use of a zimmer frame, on 19/01/2023 the falls prevention team recommend Julia should use a zimmer frame, a falls sensor mat, a crash mat and they also recommended Julia should be encouraged to come out of her room during the day. A crash mat was deemed inappropriate. � The third referral to the falls team was made on 10/03/2023, this referral stated ��. �Sheila has had 18 falls since 01/01/2022�. Julia had suffered four falls over the 5th & 6th March 2023. � The first referral form (reason for referral box, on page 1) stated �struggling to walk even short distances and is holding to everything when walking. It might be better with a Zimmer frame or something similar to that�. There was no mention in the reason for referral box of Julia�s falls history even though at the time she had fallen 12 times when that fall occurred. � The referral form dated 24/11/2022, (reason for referral box) stated �had a few falls since January this year, sensor mat is in place and OT referral was sent on 30/09/22 and that has been chased up today 24/11/2022�. By the 24/11/2022 Julia had fallen 13 times. � The first referral, in the reasons for referral box did not describe the fact that Julia had suffered 12 falls, as it should have done, and it was not followed up as it should have been until the day after she had fallen on 23/11/2022. The referral on 23/11/2022 stated in the reason for referral box, Julia had a few falls since January this year when in fact at that time she had fallen in the care home 13 times. � Julia was subsequently assessed, and some falls prevention measures were put in place. However, funding was not formally sought for 1-1 supervision as it should have been, the fact that Julia had suffered so many falls was not escalated as it should have been and the final fall i.e. the 21st fall that Julia suffered on 06/04/2023 tragically caused her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED]- NOK � I have also sent it to CQC [REDACTED] -Business Unit Head for Urgent Care and Community Services � HCRG Care Group � [REDACTED] � Executive Director of Adult services and Health & well Being � Lancashire County Council � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths This report is being sent to: Abbey Wood Lodge Care Home

04/10/2023

2023-0364

Kellie Poole

Derby and Derbyshire

[REDACTED] , Chief Executive Health and Safety Executive Redgrave Court Merton Road Bootle Merseyside L20 7HS

On 28 April 2022 I commenced an investigation into the death of Kellie Jean POOLE aged 39. The investigation concluded at the end of the inquest on 27 September 2023.

Kellie died on 25 April 2022 on the river bank of the River Goyt near to Whaley Bridge in Derbyshire. She had collapsed in the river whilst participating in a led session of cold water immersion. On the evidence it is likely that the cold water triggered her heart to go out of rhythm which then led to her sudden cardiac death. � On post mortem examination it was identified that Kelly had an abnormal heart, although she had never been diagnosed with or suspected to have a heart condition. It is likely the heart condition prevented recovery from the heart dysrhythmia.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (partner) [REDACTED] (owner of Breatheolution) � I have also sent it to � [REDACTED] (Principal Environmental Health Officer Staffordshire Moorlands District Council/High Peak Borough Council) � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: Health and Safety Executive

01/02/2017

2024-0093

Daniel Bowen

West Sussex, Brighton and Hove

[REDACTED] , Vice Chancellor, University of Sussex, Sussex House, Brighton, BN1 9RH [REDACTED], Deputy Director of Student Experience, University of Sussex, Sussex House, Brighton, BN1 9RH

On 26th September, 2018 I commenced an investigation into the death of Daniel Alexander Jeremiah BOWEN. The investigation concluded at the end of the inquest on 30th January, 2019.The conclusion of the inquest was HE TOOK HIS OWN LIFE.

See Record of Inquest

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] � Mother [REDACTED] � Father [REDACTED] � Sussex University Health Centre, For information [REDACTED] � Head of Campus and Residential Support [REDACTED] � Acting Head of University Counselling Service Secretary of State for Health, Department of Health [REDACTED], Chief Executive, NHS England I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: University of Sussex

22/07/2024

2024-0390

Omar Ahmed

East London

[REDACTED] , lnterim Chief Executive Officer, The East London Foundation NHS Trust (ELFT) Sent via email: [REDACTED] [REDACTED], Chief Executive Officer and [REDACTED] Director of Social Care, The�London Borough�of Newham Sent via email:�[REDACTED] and [REDACTED] � [REDACTED], Secretary of State for Department of Health & Social Care Sent via email: [REDACTED] [REDACTED] Director of Quality and Gompliance, Sunlight Care Group� Sent via email:�[REDACTED]

On 22/11/2023 this Court commenced an investigation into the death of Omar Abdi Ahmed aged 54 years. The investigation� concluded at the end of the inquest on 15th July 2024. The court returned a narrative conclusion; �Omar Abdi Ahmed died on 20th November 2023 in hospital due to hypothermia. Mr Ahmed, an amputee who received domiciliary care three times a day, was found by carers, unresponsive at home on l5th November 2023. Mr Ahmed had developed pneumonia which, along with ischaemic heart disease had contributed to his hypothermia. Mr Ahmed had chosen not to activate his home�s heating system. � Mr Ahmed�s medical cause of death was determined as; � la Hypothermia lb Pneumonia and Ischaemic Heart Disease II Diabetes Mellitus Type II

Omar Abdi Ahmed was a S4-year-old man who lived alone in a flat in Forest Gate. Mr Ahmed had significant comorbidity and had undergone a surgical amputation of one leg and the partial amputation of the other. Mr Ahmed received district nursing care to monitor and treat his wounds. Mr Ahmed had a package of domiciliary� care, commissioned by the local authority to assist him in undertaking the tasks of daily living such as cleaning, personal hygiene, preparing meals and mobilising. The care was contracted to a private provided who undertook three visits per day, a provision that was topped up with an extra 3 hours per week to assist Mr Ahmed with cleaning and community� engagement. Mr Ahmed was admitted to hospital by ambulance on 15th November. On the third domiciliary� care visit of the day on the evening of 1Sth November 2023,Mr Ahmed was found to be unresponsive. The ambulance� service found Mr Ahmed hypothermic� (28c) with reduced consciousness lying in a foetal position in bed. The patient was assessed to be in septic shock and was noted to have recently developed a pressure ulcer. A safeguarding report was made regarding the condition of the deceased who was found to be wearing a soiled incontinence pad. His right leg was dressed in a dirty bandage that had not been changed for two weeks. The flat was unheated and unsanitary. After transfer to hospital diagnoses of sepsis and hypothermia were confirmed, despite treatment Mr Ahmed died at 2059 on 20th November 2023.

I have sent a copy of my report to the Chief Coroner and to the following lnterested Persons The family of Mr Ahmed, the Care Quality Commission and to the local Director of Public Health who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the ,r# the release or the publication of your response.

Community health care and emergency services related deaths� � � This report is being sent to: East London Foundation NHS Trust | London Borough of Newham | Department of Health and Social Care | Sunlight Care Group

06/03/2023

2023-0082

Evelina Vilkiene

East London

[REDACTED] Acting Chief Executive Officer, North East London Foundation Trust

On the 20th June 2022 I commenced an investigation into the death of Evelina Vilkiene aged 45 years. The investigation concluded at the end of the inquest on 2nd March 2023. The conclusion of the inquest a narrative conclusion: � Evelina Vilkiene took her own life whilst under the care of the mental health services. She was at increased risk of harm to herself following a decision to wean her clonazepam medication on the 26 May 2022, but there was no careful risk management plan and there were no significant assessments of her mental health following the 27 May 2022�.

Evelina Vilkiene suffered from a first psychotic episode in November 2021 and required care from the mental health services. She was admitted to the care of the intensive home treatment team and then transferred to the care of the early intervention in psychosis team. In April 2022 she presented in crisis again, presenting with severe depression. She was accepted again by the home treatment team and remained under their intensive support until 21 May 2022. There was no detailed risk assessment at the time of step-down, or jointly agreed risk management plan. At the time of step-down she presented as anxious in relation to her medication and showed a dependence to clonazepam. A medical plan was set to wean her off the clonazepam on the 26 May 2022, with no carefully devised risk management plan put in place. There was no care co-ordinator visit following the medical review on the 26 May 2022. On the 7 June 2022, Evelina was found hanging in the basement of her home address. A paramedic pronounced her life extinct on scene. Police deemed the circumstances as non- suspicious. A note was found which contains Evelina�s stated intention to take her own life.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of Evelina Vilkiene, Care Quality Commission. I have also sent it to the Local Director of Public Health who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

�Suicide (from 2015)| Mental Health related deaths

North East London Foundation Trust

28/04/2023

2023-0143

Winbourne Charles

East London

[REDACTED] Acting Chief Executive Officer, North East London Foundation Trust � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

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. The Court returned a conclusion of: � �Suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed.� � Mr Charles� medical cause of death was determined as; 1a Suspension

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, the family of Mr Charles; the Care Quality Commission; The Nursing & Midwifery Council; the General Medical Council; the Metropolitan Police Service. I have also sent it to the local Director of Public Health who may find it useful or of interest. ������ Mr Charles� family. �������� The Care Quality Commission. ������ The Nursing and Midwifery Council ������ The General Medical Council ������ The Metropolitan Police Service ������ The local Director of Public Health I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Suicide (from 2015) This report is being sent to: North East London Foundation Trust | Department of Health and Social Care

15/02/2023

2023-0059

Raniya Khan

Berkshire

[REDACTED] Acting Chief Executive, Royal Berkshire NHS Foundation Trust

I conducted an inquest into death of Raniya Rizwan Khan at Reading Town Hall, which concluded on 9th February 2023. I recorded a conclusion of natural causes. Her cause of death was: 1a Multi-organ failure 1b Severe arterial pulmonary hypertension of unknown cause

Raniya was born at 07:52 hours on 9th May 2020. Although I heard evidence about her attendance at the day assessment unit (�DAU�) the day before the birth, and about her neonatal management, the focus of the inquest was on her labour management from the time of her admission to the labour ward at 03:45 on 9th May. Her care by a band 6 agency midwife from that time until shift change at around 7am was the focus of the investigation. I found in evidence that this midwife: 1. Failed to recognise a pathological trace. Both the trust�s internal investigation and the report of an independent expert concluded that it should have been classified as pathological from 06:40 hours. This was largely because of reduced variability. � 2. Conducted so called �fresh eyes� reviews herself for this patient, rather than asking a colleague to do so. The reasons she gave for this significant, repeated and undocumented deviation from policy were inconsistent with the rest of the evidence, and I found them unlikely to be true. � 3. Recorded the maternal rather than fetal heart rate for part of the trace. My understanding is that this can happen (briefly) even in experienced hands, but this was not recognised at the time by the midwife. � 4. Did nothing to escalate or investigate the mother�s high pulse rate. � 5. Did not take regular temperature readings, despite spontaneous rupture of membranes happening some hours before, when Mrs Rizwan was admitted to the DAU and was given paracetamol for a raised temperature. Raniya was transferred to Great Ormond Street Hospital on 15th May 2020, when her condition deteriorated. Despite extensive consideration and re-consideration of all relevant treatment options, Raniya died at Great Ormond Street Hospital on 28th May 2020. I concluded that earlier delivery was unlikely to have changed the outcome. Despite extensive investigation (including genetic investigations) at a very senior level, it has not been possible to identify the cause of Raniya�s pulmonary hypertension.

I have sent a copy of my report to the Chief Coroner and Raniya�s family. I have also sent a copy of this to, [REDACTED] Chief Executive, NHS Professionals, [REDACTED] Chief Executive, Nursing and Midwifery Council Although NHS P and NMC are not required to submit a formal response, I am mindful of their roles in training, assessment (for NHS P) and registration of midwives (for NMC) It is likely that, should a similar case arise, I will include them as Interested Persons. I am also under a duty to send a copy of your response to the Chief Coroner and all Interested Persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths

Royal Berkshire NHS Foundation Trust

29/10/2024

2024-0610

Jamie Harding

Essex

[REDACTED] CEO of Essex Partnership NHS Foundation Trust

On 20th June 2022 I commenced an investigation into the death of Jamie Harding, aged 31 years�. The investigation concluded at the end of a 5-day inquest on 12h April 2024. The medical cause of death was confirmed as: � I (a) Multiple severe Injuries I (b) Fall from Height � II Psychotic Disorder � The Deceased had been under the care of the Essex Partnership NHS Foundation Trust (EPUT) Essex Support and Treatment for Early Psychosis (ESTEP) between 2017 and 2020 and he had been prescribed anti-psychotic medication and allocated a Care Coordinator. The inquest heard evidence that Jamie had engaged relatively well with his care plan and was reporting improvements in his symptoms. However, he began to disengage with services in 2019, which appears to have coincided with the replacement of his Care Coordinator. He was discharged from EPUT services in November 2020. Jamie�s GP continued to be prescribed anti-psychotic medication. Two separate and urgent GP referrals were made to EPUT in November 2021 requesting an urgent review of Jamie, as he was hearing voices, experiencing paranoia, and reporting that his medication was not working. His mother also contacted EPUT directly. On 18 January 2022, Jamie was assessed by EPUT�s First Response Team (FRT) via telephone. Jamie described his symptoms, reported that he was binge drinking, and requested different medication. A plan was put in please for Jamie to self-refer to a drug an alcohol service, and for his case to be discussed in a Multi-Disciplinary Team meeting (�MDT�).� The evidence disclosed that in the six months that followed this assessment there were a series of significant and repeated failures on the part of EPUT employees, together with inadequacies in the systems of operation of EPUT�s First Response Team, in the care, management and treatment provided to Jamie. � My Narrative Conclusion recorded that the Deceased took his own life whilst the balance of his mind was disturbed and, further, recorded that a number of significant and repeated failures contributed to the avoidable death. The cumulative effect of these failures amounted to a gross failure to provide Jamie with basic medical care at a time that his condition clearly required it and, in this respect, neglect directly contributed to Jamie�s death.

On the 3rd of June 2022 Jamie, accompanied by his mother, presented at Basildon Hospital A&E Department in crisis and seeking help for his further deteriorating mental health on a background of some three days lack of sleep and ineffective anti-psychotic medication failing to ameliorate the on-going and extreme paranoia and psychotic symptoms he was experiencing.� In the context of on-going suicidal ideation and a subjective mood score recorded as 0/10, he was appropriately referred to the Mental Health Liaison Team (MHLT) for assessment by the A&E doctor. � The assessment subsequently undertaken by the MHLT practitioner was inadequate and failed to appropriately act upon relevant information available to him including (but not limited to) information provided by Jamie�s mother regarding her son�s on-going suicidal ideation and her (and Jamie�s) expressed request for him to be admitted to hospital as a voluntary in-patient as she, and Jamie, did not feel able to keep him safe. � Although the MHLT clinician gave evidence that he had concluded that Jamie required and would benefit from a period of admission as an in-patient, no such admission was sought or planned.� Instead, Jamie was discharged home with a plan for him to be seen the following day by the Home Treatment Team. He was provided with a (daily) tablet of Zopiclone for the next seven days. Within hours Jamie had taken his own life having fallen a significant height from a window at his home address. � The failure by the MHLT practitioner to initiate the process for Jamie�s admission to an in-patient bed constituted a clear missed opportunity to ensure appropriate and likely effective steps were taken to mitigate his high risk of acting upon his clear suicidal ideation. � The cumulative effect of the series of serious failures in the six months preceding the events of the 3rd of June amounted to a gross failure to provide Jamie with basic medical care at a time that his condition clearly required it.� In this respect, neglect directly and more than minimally contributed to Jamie�s death. � The failures identified included: � a serious failure to adequately follow up a plan identified in an assessment undertaken on the 18th January 2022 by a First Response Team (FRT) Assessor and a Trainee Doctor.� The lack of any adequate follow up led directly to a failure to conduct a full Multi-Disciplinary Team Meeting (MDT) in respect of Jamie�s complex, on-going presentation involving increasing paranoia and psychotic-like symptomology in conjunction with on-going alcohol misuse; � a failure to undertake an urgent medication review over the same six-month period despite repeated requests for the same from GPs, Jamie himself and his mother; � the failure to hold a full MDT was a significant missed opportunity to allocate a Care Coordinator to Jamie and a missed opportunity to involve the Dual Diagnosis Service in Jamie�s care; � absent a full MDT and the allocation of a Care Coordinator, there was a serious missed opportunity to develop an appropriate Care Plan for Jamie and undertake regular, up-dated risk assessments regarding self-harm and suicide; � On the 20th May an EPUT Consultant Psychiatrist declined to undertake a review of Jamie�s medication, or any further form of review as requested by Jamie�s GP: this too was a serious missed opportunity.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � The family of the deceased, via their instructed lawyers at Leigh Day Solicitors. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Mental Health related deaths

Essex Partnership NHS Foundation Trust

10/7/2024

2024-0369

Richard Fitzgerald

East London � � Category: Care Home Health related deaths� � � This report is being sent to: Serencroft

[REDACTED] CEO of Serencroft,�[REDACTED] Serencroft

On 3 July 20231commenced an investigation into the death of Richard Michael�Fitzgerald (aged 71 years). The investigation concluded at the end of the inquest on�the 2 July 2o24.The conclusion� of the inquest was a narrative conclusion:� Richard Fitzgerald died as a result of choking, whilst o resident in a nursing home. His�death was contributed to by the absence of a fult and robust core plan to minimise the�known risk of choking.

CIRCUMSTANCES� OF THE DEATH� Richard Fitzgerald suffered from Alzheimer�s Dementia. He was admitted to Gable�Court Care Home in October 2022. ln March 2023 he suffered a choking episode and�required admission to hospital. Following his discharge from hospital, he underwent a�speech and language therapy (SALT) assessment. This assessment confirmed no organic�swallow issue, but Mr Fitzgerald was at risk of choking due to him overfilling his mouth�and due to him eating too quickly. A care plan was directed by the SALT team to�minimise his risk of choking. The nutritional care plan in Gable Court was updated to�include the SALT recommendations. Staff in the Care Home were aware of Mr�Fitzgerald sometimes eating food outside of mealtimes; food that was not safely�prepared for him. There is no evidence that this risk was brought to the attention of�the SALT team. This risk of accessing food not safely prepared for him, was not�assessed or managed by the care home staff. ln addition, due to his dementia, Mr�Fitzgerald did not always allow the close supervision that had been directed by the�SALT team. On the morning of the 24 June 2023, Mr Fitzgerald had his breakfast in his�bedroom. This was supervised by a senior carer. After finishing his breakfast, the senior�carer was with another patient when she heard a wheezing sound. She found Mr�Fitzgerald having difficulty in breathing and she pressed the emergency alarm at 0916.� It is most likely that Mr Fitzgerald had accessed uncut food from the breakfast trolley.�Members of the housekeeping staff immediately attended and attempted measures to�clear the food blockage (backslaps and abdominal thrusts). After pressing the�emergency buzzer a second time, more staff members attended. Abdominal thrusts�were attempted by male care staff. The ambulance was called at O9I7. During the call�to the ambulance� service, Mr Fitzgerald was having increased difficulty in breathing.�Very shortly before the first paramedic�s� arrival, Mr Fitzgerald stopped breathing and� had a very low oxygen saturation. The first paramedic�arrived at his side by 0923/0924.�Mr Fitzgerald was found to be in cardiac arrest. The care home staff were not providing�any resuscitative measures when the paramedic� arrived. The emergency policy in place�required the care home staff to commence basic life support. This was not done. There�is however no evidence, on the balance of probabilities, that this would have�prevented Mr Fitzgerald�s death. The paramedic team were able to remove the food�blockage from the airway and they carried out advanced life support. They were able to�achieve a return of spontaneous circulation and they transferred Mr Fitzgerald to King�George Hospital. Sadly the return of spontaneous circulation was not maintained.� Resuscitation continued, but sadly, Mr Fitzgerald�had suffered a catastrophic hypoxic brain injury. He passed at King George Hospital on the 26 June 2023.

I have sent a copy of my report to the Chief Coroner and to the family of Richard�Fitzgerald, the Care Quality Commission,� London Borough of Redbridge (Safeguarding team), and the local Director of Public Health who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all�interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it�useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary�form. He may send a copy of this report to any person who he believes may find it�useful or of interest. � You may make representations to me, the coroner, at the time of your response, about�the release or the publication of your response.

Care Home Health related deaths� � �

09/02/2023

2023-0050

George Kearsey

East London

[REDACTED] CEO, Barking, Havering & Redbridge NHS Trust � � [REDACTED] RT Honorable Therese Coffey, Secretary of State for Health & Social Care

On 10th June 2022, this court commenced an investigation into the death of George Frederick Kearsey aged 87 years., The investigation concluded at the end of the inquest held on 8th February 2022. I made a determination of a short form conclusion of accidental death. � Mr Kearsey�s medical cause of death was determined as; � I a Aspiration Pneumonia 1b Dementia, left sided 7th and 8th rib fractures. II Type 2 Diabetes, Chronic Kidney Disease , Aortic Stenosis, dehydration

George Frederick Kearsey sustained injuries in a fall at home on 20 May 2022. The deceased was taken to hospital by ambulance on 21 May 2022. After preliminary diagnostic tests he was admitted into hospital to allow pain management whilst awaiting an MRI scan. � Mr Kearsey developed aspiration pneumonia and was thereafter ordered nil fluids by mouth. As a consequence of this decision, he was prescribed Iv fluids. Mr Kearsey deteriorated and died on the evening of 8 June 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Kearsey, the Care Quality Commission. I have also sent it to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he elieves may find it useful or of interest. You may make representations to me, the coroner, at the tim of your response, about the release or the publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths

Barking, Havering & Redbridge NHS Trust | Department of Health and Social Care

27/01/2023

2023-0036

Jayden Booroff

Essex

[REDACTED] CEO, Essex Partnership NHS Foundation Trust Chief Constable of Essex Police

On 17 November 2020 an investigation into the death of Jayden Andrew BOOROFF, aged 23 years. Jayden Andrew Booroff died on the 23 October 2020. The investigation concluded at the end of the 10-day inquest on 25 November 2022. The conclusion of the inquest was narrative, Jayden�s use of illicit drugs and alcohol contributed heavily to his psychotic condition and if this had been addressed earlier, it may have made a difference to his health, wellbeing and treatment. More consideration should have been given to Jayden�s relevant family history and more weight should have been given to this alongside the diagnosis that his psychosis was triggered by drug and alcohol use only. The layout of The Linden Centre in particular the areas around the main doors was not appropriate for ensuring the safety of its more vulnerable patients. Procedures around the use and allocation of Pinpoint alarms was inadequate. The Policy recording and reporting absconsions from The Linden Centre was not clear enough and led to a lack of awareness and a delay in addressing the flaws in the system. Responsibility for Jayden was not in line with policy and this contributed to a reduction in observation levels and inconsistencies in prescribed medications. Communication between all healthcare professionals involved in Jayden�s treatment was unsatisfactory, with mistakes being made in updating key documents. Risk assessments were not updated accurately enough or in good time, and failed to capture important information, including historical and emerging information. Whilst there are lessons to be learnt following Jayden�s absconsion from the Linden Centre, the response from the emergency services and [railway] were appropriate, and any alternative actions would not have altered the eventual outcome within the time that was available to them. � � with a medical cause of death of 1a Severe Multiple Injuries due to a train collision.

Jayden Andrew Booroff died of Severe Multiple Injuries after being struck by a train on the tracks adjacent to Widford Road, Chelmsford. He had been admitted to The Linden Centre on 19th October 2020 after experiencing a psychotic episode whilst staying with friends in Bristol. At 19:56 on 23rd October, Jayden was able to abscond from The Linden Centre after tailgating a member of staff Jayden ran from the building and travelled by foot towards Chelmsford Town Centre. At 21:45, Jayden was struck by a train and killed. There were a number of contributing factors that led to Jayden�s absconsion, lack of capture and subsequent death: 1.�Jayden had a history of illicit drug and alcohol use which contributed to his psychosis and led to intrusive thoughts, threats to self-harm and fear of being detained. 2. There was a family history of mental history which was not considered strongly enough. 3. There were a number of structural and environmental vulnerabilities that impacted staff and patient security and safety. 4. Inconsistencies with level of patient care, record keeping and communication.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ����[REDACTED] (Mother of Jayden) and Simpson Millar Solicitors ����British Transport Police and Weightmans Solicitors ����Care Quality Commission � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Railway related deaths

Essex Partnership NHS Foundation Trust and Essex Police

27/01/2023

2023-0030

Toby Barwick

East London

[REDACTED] CEO, The University College London Hospitals NHS Foundation Trust,� [REDACTED] RT Honorable Therese Coffey, Secretary of State for Health & Social Care

On 17th February 2021 this Court commenced an investigation into the death of Toby Wilbur Barwick age 2 months (date of birth 24/11/2020). The investigation concluded at the end of the inquest held between the 23rd and 26th January 2023. I arrived at a short form conclusion of open conclusion . � The medical cause of death was determined following a post-mortem examination; 1a Unascertained

Toby Barwick was born on 24th November 2020 at University College Hospital in London at 37 weeks gestation with a low birth weight of 2.1kgs. On 12th February 2021 Toby�s mother walked to her sister�s home carrying her son at her chest in a fabric baby carrier device. On arrival at approximately 13.00hrs, Toby was sleeping. Mrs Barwick allowed Toby to nap in the carrier whilst she spoke to her sister, sitting on a sofa. Just before 14.15 Mrs Barwick found that her son was unresponsive, she shouted for help and removed him from the baby carrier. Emergency services were called and CPR was commenced . The ambulance service arrived and took over conduct of resuscitation , Toby was taken by ambulance to the local hospital. At hospital resuscitation continued until, at 15.43 doctors determined that continued action would be futile and Toby�s death was declared .

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Toby Barwick, the Care Quality Commission, the local COOP and the local Director for Public Health who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Child Death (from 2015)

The University College London Hospitals NHS Foundation Trust | Department of Health & Social Care

29/03/2023

2023-0109

Angela Kearn

Surrey

[REDACTED] Chair of the General Medical Council [REDACTED] Chair of National Trading Standards������������������ [REDACTED] Chief Executive of the Royal Society for the Prevention of Accidents [REDACTED] Chief Executive Officer, Decathlon UK

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. � The cause of death was: � 1a.) Immersion Pulmonary Oedema II.) Hypertension and Menopause treated by Hormone Replacement Therapy The narrative conclusion was: Angela Jean Kearn was suffering from hypertension and taking hormone replacement therapy. On the 13th January 2020 she was snorkelling using a full face mask. She developed immersion pulmonary oedema and died at the Nile Hospial, Hurghada Egypt. Hypertension, hormone replacement therapy and the use of the full face mask each more than minimally contributed to the death

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.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] [REDACTED] Decathlon UK � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Other related deaths

General Medical Council | National Trading Standards | Royal Society for the Prevention of Accidents | Decathlon UK

31/07/2024

2024-0455

Maria de Ceita

North London

[REDACTED] Chief Executive North Middlesex University Hospital NHS Trust Sterling Way London N18 1QX c/o [REDACTED]

On the 05 July 2023 I opened an investigation touching upon the death of Maria Francisca Teixeira de Ceita, aged 87 years old. I opened an inquest on the 27 July 2023. The inquest concluded on the 16 February 2024. The conclusion of the inquest was: �Maria de Ceita died as a result of brain damage caused by an unwitnessed fall while she was a hospital in-patient on 04 July 2023�. The following factors contributed to her death: a) Not recording that Ms de Ceita required one-to-one supervision on the ward; b) Not recording an update to that plan; c) Not putting in place one-to-one supervision on the 3-4 July 2023; and d) Lack of effective communication between staff on the ward.

Maria de Ceita was born on the 26 March 1935 in Goa, India. She was 87 years old when she died on 04 July 2023 in North Middlesex Hospital, as a result of an unwitnessed fall earlier that day by her hospital bed, which caused her a fatal brain injury. Ms de Ceita was known by the hospital to be at risk of falling and at the time of the fall she should have been under one-to-one supervision by hospital staff.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Miss de Ceita�s family

Hospital Death (Clinical Procedures and medical management) related deaths

North Middlesex University Hospital NHS Trust

13/02/2023

2023-0056

Michael Roberts

Inner North London

[REDACTED] Chief Executive Disclosure and Barring Service (DBS) PO Box 3961 Royal Wootton Bassett SN4 4HF � [REDACTED] Commissioner Metropolitan Police Service (MPS) New Scotland Yard Victoria Embankment London SW1A 2JF

On 30 August 2022, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Michael Roberts aged 50 years. The investigation concluded at the end of the inquest on 7 February 2023. I made a determination at inquest of suicide.

Mr Roberts shot himself on the evening of Saturday, 20 August 2022, using a gun he took from his place of work. He did not own any guns. He was alone and made no attempt to shoot any other person. However, he had suggested to his partner that he could kill her.

I have sent a copy of my report to the following. � ���[REDACTED], wife of Michael Roberts ���[REDACTED], fianc�e of Michael Roberts ���[REDACTED], proof master, Proof House, London ���[REDACTED] , proof master, Proof House, Birmingham ���HHJ Thomas Teague QC, the Chief Coroner of England & Wales � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Suicide (from 2015)

Disclosure and Barring Services, Metropolitan Police Services and Proof Master

11/01/2023

2023-0011

Carol Welch

Warwickshire

[REDACTED] Chief Executive George Eliot Hospital NHS Trust, College Street, Nuneaton, Warwickshire, CV10 7DJ

On 10 May 2022, the senior coroner commenced an investigation into the death of Carol Ann Welch aged 47. The investigation concluded at the end of the inquest on 6 January 2023. � The conclusion of the inquest was a narrative conclusion: � The deceased died of natural causes as a result of an undiagnosed cerebral aneurysm with subsequent spontaneous subarachnoid haemorrhage.

Carol became unwell on the 27 April 2022 due to a cerebral aneurysm, this initially presented with similar symptoms to the migraines she tended to suffer from. She attended the emergency department of the George Eliot Hospital NHS Trust (GEH) and was sent home with a diagnosis of migraine. � By the 28 April 2022 Carol was experiencing a sentinel bleed, and this led to a change in symptoms. She returned to GEH. � The changes in symptoms were such that further investigations should have been undertaken (either a CT scan or a lumbar puncture) and such an investigation may or may not have revealed the presence of an aneurysm and that Carol was at risk of a subarachnoid haemorrhage. � However, due to an incorrect diagnosis of migraine, further investigations did not take place and Carol was sent home. � A further safety check, as laid down by Royal College of Emergency Medicine guidelines, was not followed. The guidelines state that where there is an unexpected return to the emergency department with 72 hours, there should be a discussion with a consultant before discharge. Carol suffered a cardiac arrest on 30 April 2022 and was admitted to the University Hospital Coventry and Warwickshire where she died on 1 May 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The Welch family I have also sent it to the Royal College of Emergency Medicine who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

George Eilot Hospital NHS Trust

06/06/2024

2024-0310

Anoush Summers

Inner North London

[REDACTED] Chief Executive London Borough Hackney Town Hall Mare Street London E8 1EA � [REDACTED] Director of Supreme Care Services Limited 9 Crown Parade Morden Surrey SM4 5DA

On the 22nd January 2024 Assistant Coroner Sarah Bourke began an investigation into the death of Anoush Summers who died aged 77, on the 14th January 2024 at Homerton University Hospital, Homerton Row, London, E9. � The investigation concluded at the end of the inquest on 6th June 2024 conducted by myself, Assistant Coroner Edwin Buckett. I made a determination at inquest that the deceased died as a result of hypothermia which resulted from a fall at home following a long lie.

The narrative conclusion was as follows: � The deceased was a frail lady who was prone to falls. She lived at home, alone, with carers who visited her twice a day. She had a wrist alarm. The wrist alarm was reported as broken and not working on the 6.1.2024, but it was not repaired or replaced. Sometime after 4.45pm on 11.1.2024, the deceased fell at home. She was found the next day on the 12.1.2024 at 9am, by a carer, wearing her wrist alarm and taken to hospital where she died on 14.1.2024 of hypothermia. The absence of a working wrist alarm prevented her from being found sooner that she was and probably contributed to her death.

I have sent a copy of my report to the following. HHJ Alexia Durran, the Chief Coroner of England & Wales � [REDACTED], the daughter of Anoush Summers. � I am under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: London Borough Hackney | Supreme Care Services Limited

09/02/2024

2024-0182

Susan Young

West Sussex, Brighton and Hove

[REDACTED] Chief Executive NHS Sussex Integrated Care Board Wicker House High Street Worthing BN11 1DJ

On 22nd December 2022 I commenced an investigation into the death of Susan Mary Young aged 57 . The investigation concluded at the end of the inquest on 31st January 2024. The overall conclusion of the inquest was a narrative conclusion which stated that �Susan Mary Young died from an accidental ingestion of prescribed co-codamol tablets.�

On 20th December 2022 Susan died at her home address at [REDACTED] West Sussex. Susan had been feeling unwell and had been prescribed antibiotics for an ear infection and co-codamol tablets as pain relief. Sadly due to the pain she was in Susan took too many tablets over a short period of time and this led to a fatal toxicity. There was no evidence that this was a deliberate act to end her life

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- � The family of Susan Young South East Coast Ambulance Service NHS Foundation Trust Bognor Medical Centre � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards) This report is being sent to: NHS Sussex Integrated Care Board