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