Inquests (PFDs)

14/07/2023

2023-0247

Emily Corfield

North Wales East and Central

Adferiad Recovery Betsi Cadwaladr University Health Board (BCUHB)

On 27 September 2021 an investigation was commenced into the death of Emily Corfield (DOB 30/12/79) who died on 19 September 2011. The investigation concluded at the end of the inquest on 11 July 2023. The conclusion of the inquest was an alcohol related death.

The circumstances of the death are as follows : Emily Corfield was aged 41 at the time of her death. She had a past medical history of vitamin B12 deficiency, anxiety, depression and excess alcohol consumption. She had some support for her alcohol misuse. On 20 April 2021 she was admitted into hospital with coffee ground vomiting and chronic alcohol misuse. She was discharged on 26 April 2021 with outpatient OGD and was due for review by alcohol liaison as an outpatient. There was no evidence that she had had an inpatient assessment by the alcohol liaison team. On 30 May 2021 she was admitted into hospital again with coffee ground vomiting and alcohol withdrawal. There was no evidence of the alcohol liaison team involvement whilst an inpatient. Emily discharged herself against advice on 4 June 2021 having the capacity to do so. On 19 September 2021 Emily was found deceased in her bed at her home�[REDACTED].

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 8 September 2023. I, Kate Sutherland, the Coroner, may extend the period. � Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.

Alcohol, drugs medication related deaths This report is being sent to: Adferiad Recovery | Betsi Cadwaladr University Health Board

27/10/2023

2023-0418

Geoffrey Whatling

Norfolk

Amberley Hall Care Home 55 Baldock Drive King�s Lynn PE30 3DQ � Athena Care Homes (UK) Limited Unit 5 Russel House Southfields Business Park Hornsby Way Laindon Essex SS15 6TF

INVESTIGATION � On 02 May 2023 I commenced an investigation into the death of Geoffrey Alan WHATLING aged 82. The investigation has not yet concluded and the inquest has not been heard. � The medical cause of death was: 1a) Infective Exacerbation of Chronic Obstructive Pulmonary Disease 2) Frailty, Old Age

Mr Whatling entered Amberley Hall Care Home on 14 March 2023 for rehabilitation. On 8 April 2023, concerns were raised by Mr Whatling�s family that he was unwell. At 17.37 Mr Whatling scored 7 on the NEWS2 requiring 999 call to be made. 111 was called. Further observations were carried out on 9 April 2023 (NEWS2 score 6), and 07.00 (NEWS2 score 5) and again on 10 April 2023 at 12.13 (NEWS2 score 9/10), when emergency services were called and Mr Whatling was admitted to Queen Elizabeth Hospital. Despite treatment Mr Whatling�s condition continued to deteriorate and he died on 26 April 2023. The medical cause of death is 1a) Infective exacerbation of chronic obstructive pulmonary disease 2. Frailty, old age.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] � NOK I have also sent it to: Department of Health Care Quality Commission (CQC) HSIB Healthwatch Norfolk NHS England & NHS Improvement 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: Amberley Hall Care Home | Athena Care Homes (UK) Limited

06/12/2023

2023-0505

John Lee

Surrey

Angela Stevenson Chief Executive Surrey and Sussex Healthcare NHS Trust Trust Headquarters East Surrey Hospital Canada Avenue Redhill RH1 5RH

INQUEST � An inquest into Mr Lee�s death was opened on 8 December 2022. The inquest was resumed and concluded on 20 November 2023. � The medical cause of Mr Lee�s death was: � 1a. Choking � 2. Dementia � With respect to where, when and how Mr Lee came by his death it was recorded at Box 3 of the Record of Inquest as follows: Mr Lee was an 83 year old man with dementia who lived in a care home. On 17 August 2022 Mr Lee was admitted to East Surrey Hospital following a fall. By 31 August 2022 Mr Lee was medically fit for discharge, however, he remained in hospital while efforts were made to find him a more suitable care home. Whilst he was in hospital Mr Lee was found to have a newly impaired swallow, the primary cause of which was thought to be his worsening dementia, which placed him at risk of choking and aspiration. On 1 September 2022 Mr Lee was assessed by the Speech and Language Team (SALT Team) as being suitable for normal consistency foods, however, a number of recommendations were put in place to minimise the risk of choking and aspiration. These included to monitor him closely whilst he was eating and to check his mouth after eating to locate and remove any food debris. This recommendation was made because dementia patients are known to be at risk of holding food in their mouths and forgetting to chew or swallow it, which presents a risk of subsequent choking. On 2 September 2022 hospital staff did not complete Mr Lee�s food chart from mid-morning onwards and, as such, it has not been possible to establish what and when Mr Lee ate on 2 September 2022, save for the fact that he ate breakfast. However, Mr Lee had food residue in his stomach at post-mortem, which is consistent with him having a eaten a further meal or meals after breakfast. Overnight on 2-3 September 2022 Mr Lee was confused and agitated and repeatedly tried to get out bed. He remained agitated until approximately 3am when he settled down and went to sleep. At approximately 5.30am he was found unresponsive and his death was formally declared by a doctor later that morning on 3 September 2022. A post-mortem examination was conducted which found that Mr Lee had died due to choking on a piece of food. It has not been possible to establish precisely when on 2 September 2022 Mr Lee ate the food that he subsequently choked on. However, having eaten it, he retained it in his mouth for a period of time before subsequently choking on it. Had Mr Lee been closely monitored and provided with effective mouthcare on each occasion that he ate on 2 September 2022, in accordance with the SALT recommendations which were in place for him, he would not have choked and he would not have died. The inquest concluded with a short form conclusion of �Accidental Death� together with the following short narrative conclusion. Mr Lee was not closely monitored or provided with effective mouth care whilst eating on 2 September 2022. Had he been closely monitored, and provided with effective mouth care thereafter, he would not have choked and died on 3 September 2022.

During the course of the inquest the court heard evidence from of the hospital�s SALT team that it was standard practice for dementia patients to have their mouths checked after eating, in order to locate and remove any food debris. This is because dementia patients are known to be at risk of holding food in their mouths and forgetting to chew or swallow it, which presents a risk of subsequent choking. � However, Mr Lee�s mouth care records indicate that he had only received mouth care once daily during the entirety of his hospital stay. � The Court is therefore concerned that there is a risk that dementia patients are not receiving mouth care on each occasion that they eat and that this presents a risk of future deaths.

COPIES I have sent a copy of this report to the following: � Chief Coroner Mr Lee�s family

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

22/08/2024

2024-0469

Tracey Haybittle

Milton Keynes

Apple UK LIMITED Google TomTom National Highways

On 21 November 2023 I commenced an investigation into the death of Tracey Julie HAYBITTLE aged 58. The investigation concluded at the end of the inquest on 16 July 2024. The conclusion of the inquest was that: Road traffic collision

Tracey Julie Haybittle died at the John Radcliffe Hospital on the 17th November 2023. She had been driving along the A5 adjacent to the Little Brickhill junction. Another driver had mistakenly entered the �off� slip road believing it to be the correct turn. It appears she was following audio directions from her satnav application. She proceeded to drive down the slip road at speed and collided head on with Mrs Haybittle�s vehicle. The other driver died at the scene and her female passenger was critically injured but survived.

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

Road (Highways Safety) related deaths

Apple UK Limited | Google | TomTom | National Highways

08/01/2024

2024-0011

David Moore

West Sussex, Brighton and Hove

Association of Anaesthetists Great Britain and Ireland Royal College of Anaesthetists Chief Executive Health Education, England CQC (Care Quality Commission)

On 7th January 2022 I resumed an investigation into the death of David Bryan Moore sitting with a Jury. On 21st July 2022, the investigation was concluded: � The medical cause of death given was: � 1a. Hypoxic ischaemic brain injury 1b. Cardiac arrest 1c. Dislodged tracheostomy tube and delayed replacement � 1d. Burns suffered in an industrial accident requiring a tracheostomy tube � II. Obesity, Hypertension � � The jury determined: � Mr Moore was a self-employed industrial electrician, employed on the 29th May 2021 to change a molded case circuit breaker (MCCB) at a property in Uxbridge. Mr Moore energized the circuit to allow the front doors of the property to open. On doing this the metal plate divider between the MCCB�s made contact with the exposed live bus bars resulting in an electrical flashover. As a result, Mr Moore sustained burns covering 32 % of his body surface area. � Mr Moore was transferred to St Mary�s Hospital where he was intubated, ventilated and had surgical release of burns in his upper arms to improve blood supply. Following this Mr Moore was transferred to the Queen Victoria Hospital, East Grinstead on the same day for further management of his burns.� � On the 3rd June 2021, an adjustable flanged tracheostomy was undertaken, due to the size of Mr Moore�s neck and difficulties arising from his injuries. On the 10th� June 2021 whilst being turned onto his right side to change dressings the tracheostomy became dislodged from his trachea resulting in an hypoxic cardiac arrest. The airway was re-established and following six cycles of CPR he was successfully resuscitated. � It was determined that Mr Moore suffered a non-survivable cerebral hypoxic brain injury. Mr Moore died at 17.20 hours on 14th June 2021 after an agreement was made to withdraw care.

The conclusion of the jury at the Inquest provides a summary of the circumstances which led Mr Moore to be admitted to Queen Victoria Hospital, East Grinstead for ongoing management and describes the circumstances of his death. � During the hearing itself I heard evidence that there was an absence of national and local guidelines for the management of flanged tracheostomy tubes in particular relating to their ongoing assessment of their position in the trachea and in circumstances whereby no specific assessment was ongoing for Mr Moore within the High Dependency Unit for such assessment. As a consequence, Mr Moore�s flanged tracheostomy tube became dislodged and the time taken to re-establish his airway resulted in an hypoxic brain injury incompatible with survival.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons� � I have also sent it to:� See names in paragraph 1 above [REDACTED], Sister [REDACTED], Son [REDACTED], Daughter Chief Executive, Queen Victoria Hospital, East Grinstead Medical Director, Queen Victoria Hospital, East Grinstead Clinical Director, Anaesthetics, Queen Victoria Hospital, East Grinstead who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Association of Anaesthetists Great Britain and Ireland | Royal College of Anaesthetists | Chief Executive Health Education | Care Quality Commission

31/05/2023

2023-0177

Andrew Shambrook

North Wales East and Central

BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW.

On the 28th of March 2022 I commenced an investigation into the death of Andrew John Shambrook (DOB 17.2.77 DOD 27.3.22). The investigation concluded at the end of the inquest on the 28th of April 2023. The cause of death was recorded as being due to 1(a) Hanging and the conclusion of the inquest was that of suicide. � The evidence indicated that Mr Shambrook was under the care of the mental health services and that there had been a referral to the Home Treatment Team, however he did not meet their criteria for treatment.

The circumstances of the death are that Mr Shambrook took his own life by hanging [REDACTED] on the 27th of March 2022.

I have sent a copy of my report to the Family of the Deceased and 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.

Suicide (from 2015) | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board

27/03/2024

2024-0177

Maureen Owens

North Wales (East and Central)

BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW.

On the 15th of August 2023 I commenced an investigation into the death of Maureen Elizabeth Owens (DOB 28.2.43 DOD 9.12.22). The investigation concluded at the end of the inquest on the 20th of March 2024. The cause of death was recorded as being due to 1(a) Multiorgan Failure 1(b) Bilateral Femoral Thrombosis (operated) 1(c) Peripheral and Central Vascular Disease and the conclusion of the inquest was by way of a narrative in the following terms : � The death was due to natural causes, contributed to by operational delays as a result of which the deceased was not afforded the timely care and treatment which may have optimised the prospects of a full recovery

On the 6th of December 2022, whilst a patient at the Maelor Hospital Wrexham, the deceased developed a condition which required urgent vascular surgery, however her transfer for this procedure was delayed and despite subsequent surgical intervention, she deteriorated post-operatively and died at Glan Clwyd Hospital on the 9th of December 2022.

I have sent a copy of my report to the Family of the Deceased and 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 | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board

28/10/2024

2024-0701

Margaret Daly

North Wales (East and Central)

BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW.

On the 14th of June 2024 I commenced an investigation into the death of Margaret Joy Daly �� (DOB 23.10.32 DOD 10.6.24). The investigation concluded at the end of the inquest on the 24th� of October 2024. The cause of death was recorded as being due to 1(a) Traumatic subdural� haematoma (b) A fall 2. Delirium and the conclusion of the inquest was that the death was due to an accident.

The circumstances of the death are that Mrs Daly had been an in-patient at Wrexham Maelor� Hospital and as a result of her being assessed as being at significant risk of falling she was on an enhanced level of observation.� On the evening of the 1st of June 2024, Mrs Daly was exhibiting signs of anxiety and agitation� and a member of nursing staff asked a doctor to review her. As the doctor was too busy to attend the ward, the nurse took Mrs Daly�s prescription chart to the doctor on another ward and he� prescribed a sedative, namely lorazepam which was administered to her at 22.40 that evening� with a further dose being given at 04.30 the following day.� Later that morning Mrs Daly had an unwitnessed fall and sustained the injury which resulted in� her death. The evidence supports a view that it is probable that she fell as a result of the effects of the sedation.

I have sent a copy of my report to the Family of the Deceased and 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.

Wales prevention of future deaths reports (2019 onwards) | Hospital Death (Clinical Procedures and medical management) related deaths

Betsi Cadwaladr University Health Board

01/03/2024

2024-0116

Jennifer Trigger

North Wales (East and Central)

BCUHB, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW.

On the 28th of September 2020 I commenced an investigation into the death of Jennifer Ann Trigger (DOB 27.12.48 DOD 31.1.20). The investigation concluded at the end of the inquest on the 29th of February 2024. The cause of death was recorded as being due to 1(a) Extensive intra-cranial bleed 2. Warfarin Therapy and the conclusion of the inquest was that of natural causes contributed by neglect.

On the evening of the 29th of January 2020, the deceased was admitted to the Wrexham Maelor Hospital after becoming unwell. It was established that she had suffered an acute stroke and as she was on warfarin for a pre-existing condition, she was appropriately prescribed beriplex by way of treatment to reduce the risk of an extension of the bleed in her brain. Although this was prescribed at around 20.45 it was not administered until 07.35 the following morning despite it being a time critical treatment. By this time there had been an extension of the bleed with associated oedema and her condition had deteriorated significantly. Despite medical intervention and treatment in intensive care she was verified deceased at 18.30 on the 31st of January 2020

I have sent a copy of my report to the Family of the Deceased and 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 | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board

10/05/2024

2024-0256

Ben Harrison

North Wales (East and Central)

BOC Limited

On 21 December 2020 an investigation was commenced into the death of Ben Christopher Harrison following his death on 18 December 2020. The Inquest concluded on 10 May 2024 with a narrative conclusion.

The circumstances of the death are as follows : � � Ben was aged 37 at the time of his death on 18 December 2020. He had known psychiatric issues. On 15 December 2020 and whilst a voluntary inpatient at the Ablett Psychiatric Unit, Glan Clwyd Hospital (part of the Betsi Cadwaladr University Local Health Board �BCUHB�) he was found in cardiac arrest with a ligature around his neck, [REDACTED]. He was resuscitated and oxygen cylinder utilised. The cylinder has two valves one on the top and one on the side, both of which must be opened before the cylinder will function. The valve on the side of the cylinder was not opened and so Ben was ventilated only on room air for approximately 5-10 minutes during the resuscitation process.

I have sent a copy of my report to the Family of the Deceased, BCUHB and to the Chief Coroner. � I have also sent a copy of the Report to the following for their information:- � Eluned Morgan, Health Minister for Wales Medicines and Healthcare Regulatory Agency Health Services Safety Investigations Body NHS Wales Executive � 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 | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: BOC Limited

27/02/2023

2023-0079

Sophie Williams

North London

Barnet Enfield and Haringey Mental Health NHS Trust NHS EnglandTavistock and Portman NHS Foundation Trust

On 24 May 2021, the Senior Coroner commenced an investigation into the death of SOPHIE GWEN WILLIAMS, aged 28. The investigation concluded at the end of the inquest (heard before me) on 19 January 2023. The conclusion of the inquest was: � Medical cause of death: 1a Fatal toxic consumption of citalopram, propranolol, and quetiapine � How, when and where and, for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by her death In the early hours of 20 May 2021, Sophie Gwen Williams died at her home, after taking a fatal overdose of prescription medications. She did so in the circumstances set out under 4 below. � Conclusion of the Coroner as to the death Sophie Gwen Williams took the fatal overdose in consequence of being in a psychotic or dissociative state, in which she was not capable of forming (and did not form) any intention to take her own life. To an indeterminate extent, each of the circumstances identified above contributed to her death.

(a)����� Sophie lived her life against the backdrop of being diagnosed with Emotionally Unstable Personality Disorder (�EUPD�), and of having had traumatic experiences, including separation from her family (in more ways than one), the effect of all of which stayed with her, even though some had happened many years ago. (b)���� As a trans person, she was particularly vulnerable to stress. (c)���� After she moved to London, Sophie came to experience episodes of psychosis and dissociation which became increasingly frequent and intensive, during which she lacked capacity freely to make decisions, and was liable not only to self-harm (as happened frequently) but also, in particular, to take an overdose of the drugs prescribed for her (as she did on 23 March 2021). (d)���� She �stockpiled� her prescription drugs, but Barnet, Enfield and Haringey Mental Health NHS Trust (�the Trust�) gave her no warning not to do so, and did not take steps to alert her GP that she was doing so, which contributed to Sophie having access to enough drugs to amount to an overdose. (e)���� The trauma and stress experienced by Sophie could cause or contribute to a dissociative episode, and were a strong risk factor for someone with a personality disorder (as Sophie was). (t)������ The stress, and hence the risk of further psychotic and dissociative episodes � with the risk to her life that those entailed � was present and continuing, and was exacerbated by the following: � (1)�Her concern that the Trust had not provided her with, or with certainty that she had, a long-term care plan. (2)�Her anxiety that the Trust had not provided her with a key-worker, and that she had very limited prospects of quickly and easily getting short-term, crisis help, if she were to need it. (3)�The Structured Clinical Management (SCM�) practitioner at the Trust made remarks to Sophie, as a trans woman, which were highly inappropriate. Sophie may have forgiven her for doing so, but the negative effect of those remarks remained. (4)� Although the Trust recognised �The risks of withdrawing the antipsychotic completely would be that Sophie would experience a deterioration in her symptoms:�.an increase in paranoia,� it advised Sophie to stop her antipsychotic medication, which she had done by 12 May 2021. (5)�The Trust did not conduct its own diagnosis of Sophie�s condition, or conditions. There was thus no check on whether Sophie did (in fact), have dissociative identity disorder, or dissociative amnesia (as was not suspected until after her death), and the treatment which the Trust did provide was determined accordingly. (6)�The Trust did not carry out any, or any adequate, assessment of the ever� present risk of overdose death posed to Sophie by the consequences of the psychotic and dissociative episodes, and by the other stress factors in her life, and thus did not actively consider, and hence did not take, steps to address that risk. (7)��The SCM provided by the Trust was, objectively, appropriate, in relation to certain aspects of the EUPD, but it was not adequate to, and did not, address that present and continuing short-term risk, which was also a recognised aspect of it. Sophie herself did not find it helpful. (8)��The mental health practitioner who conducted the SCM sessions did not fulfil the function of the key-worker to which Sophie had become accustomed in Belfast, and whose support she had found helpful. The announcement (made twice) by the Tavistock and Portman NHS Foundation Trust (�the GIC�) (that time which Sophie had spent waiting for treatment by the Brackenburg GIC in Belfast would not count towards her waiting-time. for the GIC) was �devastating� and left her �raging�. Those effeqts were not negatived by the call which the GIC had promised to make to Sophie, and which she was expecting to receive.

I have sent a copy of my report to the Chief Coroner, and to the following Interested Person: � 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

Barnet Enfield and Haringey Mental Health NHS Trust, NHS England and Tavistock and Portman NHS Foundation Trust

13/05/2024

2024-0258

Elvon Morton

East London

Barts Health NHS Foundation Trust Department of Health and Social Care

On 7th December 2022 this Court commenced an investigation into the death of Elvon Paul Randolph Morton aged 38 years. The investigation concluded at the end of the inquest on 9th May 2024. The conclusion of the inquest was a narrative conclusion; � �Elvon Paul Randolph Morton died in hospital on 7th December 2022 whilst awaiting a CT scan under sedation. His death was caused by the combined effect of septic shock, oxycodone � administered for pain relief, and lorazepam � used as a sedative. � � Mr Morton�s medical cause of death was determined as;� 1a Septic shock (treated) II Chronic Kidney Disease, Hypertensive and Ischaemic Heart Disease

Elvon Morton was a 38-year-old black man with extensive co-morbidity, including hypertension, kidney disease, Class 3 Obesity and angina. � Mr Morton previously presented to hospital on four occasions in four years with upper right abdominal pain diagnosed as gall stones. � On 6/12/22 Mr Morton called 999, he experienced upper right abdominal pain, vomiting, diarrhoea, dizzy spells and shortness of breath. He was taken to hospital by ambulance. � Mr Morton had elevated inflammatory markers, tachycardia, tachypnoea, low blood pressure, acidosis and high lactate levels. Elvon was profoundly dehydrated; creatinine levels indicated an acute kidney injury. Elvon reported severe pain abdomen guarding was observed. � Differential, queried diagnoses of perforated gall bladder & ischaemic bowel were arrived at. The on-call surgical and ICU team were called upon to assist. � Treatment commenced of; fluid resuscitation, wide spectrum anti-biotics pain relief (paracetamol and oxycodone). Elvon was catheterised. An abdominal CT scan (without contrast � for fear of renal toxicity) demonstrated no clear abdominal cause for his symptoms, pulmonary atelectasis and a pleural effusion were observed. � Elvon�s respiratory function deteriorated, air sounds in the base of his lungs were diminished, he was started on oxygen therapy. Elevated blood troponin levels and concern regarding cardiac output meant serial ECGs were ordered. A further CT scan, this time utilising contrast was arranged. � Mr Morton continued to deteriorate, his metabolic acidosis becoming more profound. Mr Morton became agitated and began to take steps to self-discharge. A decision was made that he did not have capacity and a best-interests decision was made to sedate him to facilitate a CT scan and further treatment. A second dose of oxycodone was administered to relieve pain and 4 mgs of Lorazepam were administered as sedation. � Mr Morton was taken to the CT suite where it was observed that his oxygen saturations became erratic, it was noted that he had gone into cardiac arrest. CPR began, a crash team was called, advanced life support continued for over an hour before death was declared. � The inquest determined that the combined effects of oxycodone and lorazepam upon Mr Morton�s background co-morbidity and recent metabolic illness played a contributary factor on his cause of death. � It was accepted by the trust that the safer course for Elvon would have been to anaesthetise and intubate him at an earlier stage in treatment.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mr Morton, 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 th 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 | Department of Health and Social Care

16/01/2023

2023-0016

Sean Duignan

Bedfordshire and Luton

Bedfordshire Police Chief Constable, His Majesty�s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS)

On 10 June 2021 I commenced an investigation into the death of Sean Gerard DUIGNAN aged 44. The investigation concluded at the end of the inquest on 14 November 2022. The conclusion of the inquest was that: � Sean Gerard Duignan was a well respected, well liked and universally helpful base sergeant at the Luton Airport Armed Policing Unit (South Base). On the 29th May 2021 he was arrested following reports of a vehicle being driven erratically and dangerously. A Bedfordshire Police sergeant visited him at his home to conduct what was initially to be a welfare check. Sean was intoxicated with alcohol and was arrested and taken into custody on suspicion of drink or drug driving. He remained in custody until the following afternoon when he was released under investigations. Multiple and serial enquiries were made by members of the custody and health care staff at Milton Keynes Police Custody suite to determine his mental health and to keep him safe. Those checks were repeated on release. They were continued by the police federation representatives and his close friend [REDACTED]. All seemed well. The next day, a day off, Sean travelled to the Luton Airport Armed Policing Unit where the South Base armoury is located. The armoury security was lax and had been for a prolonged period. The computer system used for electronic access was repeatedly failing but seemingly no coherent approach was taken to remedy this. The back up master armoury key was kept in a PIN protected locked box, but the PIN number was universally known. Because of an error in the computerised system an officer was allocated single point access when she should not have been. She unwittingly let Sean, whose own access to the armoury had been restricted without his colleagues being informed, into the armoury. He took a hand gun and ammunition, entered the base gym and shot himself in the head.

This report touches the death of police sergeant 5353 Sean DUIGNAN who was found deceased at Bedfordshire polices airport unit offices located on Percival way Luton from what is believed to be a self-inflicted gunshot wound. At about 09:15rs on Monday 31st May 2021 officers have been made aware of a concern for the wellbeing of PS DUIGNAN and they have been asked to make a search of the airport policing unit offices located at Percival Way Luton. Officers have conducted the search and have found PS DUIGNAN deceased on the floor of the gym which is located on the ground floor and next-door to the armoury, also on the ground beside him was a police side arm hand gun and two bullets. First aid has commenced and an ambulance has been called, paramedics have attended and continued treatment but unfortunately, he was declared deceased at 09:45hrs by paramedic [REDACTED]. It should be noted the PS DUIGNAN was arrested on Saturday 29th May 2021 for the offence of drink driving and taken to Milton Keynes police station where the drink drive procedure was carried out,

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons ������� The family� ������� Bedfordshire Police Chief Constable ������� Bedfordshire Police Federation ������� Thames Valley Police Chief Constable ������� The IOPC 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.

Suicide (from 2015) | Accident at Work and health and Safety related deaths

Bedfordshire Police Chief Constable and His Majesty�s Inspectorate of Constabulary and Fire and Rescue Services

11/01/2023

2023-0024

Ashley Bullard

West London

Bendpak Inc Liftmaster Ltd Liftmaster Servicing Precision Bodyshop Ltd, formerly Wheel Art Ltd Volvo Car Corporation International Organization of Motor Vehicle manufacturers (OICA) The European Automobile Manufacturers� Association (ACEA) The British Standards Institution

The inquest into the death of Mr Ashley Bullard, aged 32, was opened on 6th December 2018. The investigation concluded at the end of the inquest on 20th December 2022. � The medical cause of death was: 1a Head injury � The jury�s Narrative conclusion to the inquest was: The car was placed by Ashley on outer pick up points, which was one of the set of points recommended by both Volvo and �Autodata�, the industry standard software. The lift was examined after the incident. A feature of the lift, namely freeplay within the arms, contributed to the car not being held by the lift. The combination of the alignment of the pads on the pick up points, the work being carried out on the car and the freeplay within the lift arms contributed to the car falling and as a result caused the death of Ashley Michel Bullard.

Ashley died due to a vehicle leaving a Bendpak XPR9 2-post vehicle lift whilst he was working underneath it, at his place of work Wheel Art Ltd, now called Precision Bodyshop Ltd. The vehicle lift had been installed by Liftmaster Ltd, and was last serviced some 9 months before the incident, by Liftmaster Servicing. The lift had not been serviced in accordance with the Lifting Operations and Lifting Equipment Regulations 1998, nor maintained in accordance with guidance in the lift�s installation and operating manual, and contained grade 4.8 bolts not intended to have been in use at that time. On 28.11.2018, Ashley used the vehicle lift to raise a Volvo S80 car using the outermost lift points, on or near the metal sill that formed the front user jacking points. As Ashley worked on the car, the alignment of the pads and the freeplay within the arms of the vehicle lift contributed to the frame contact pads moving from beneath a structural part of the car to a non-structural part that could not support the vehicle. This led to the car falling, causing Ashley fatal injuries.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1.�Ashley�s family 2. Liftmaster Ltd and Liftmaster Servicing 3. Precision Bodyshop Ltd, formerly Wheel Art Ltd 4. Bendpak Inc 5. Health and Safety Executive I have also sent it to: Society of Motor Manufacturers and Traders (SMMT) [part of ACEA] and Garage Equipment Association Ltd, 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.

Accident at Work and health and Safety related deaths

Bendpak Inc | Liftmaster Ltd | Liftmaster Servicing | Precision Bodyshop Ltd | Volvo Car Corporation | International Organization of Motor Vehicle manufacturers | The European Automobile Manufacturers� Association | The British Standards Institution

28/03/2024

2024-0170

Sarah Adams

Berkshire

Berkshire Healthcare NHS Foundation Trust Cygnet Hospital, Harrow Reading Borough Council Adult Social Care

On 27 May 2022 I commenced an investigation into the death of Sarah Elizabeth ADAMS aged 64. The investigation concluded at the end of the inquest on 18 March 2024. The conclusion of the inquest was that: � Ms Adams died by suicide; however, her death was more than minimally contributed to by care and service delivery issues around her discharge from a voluntary in-patient hospital admission for a relapse of her longstanding paranoid schizophrenia and an intentional medication overdose.

Sarah Adams was found deceased at her home address on 19th May 2022. She died from a self administered overdose of prescribed medication taken with the intention of ending her life. On the balance of probability Ms Adams� death was more than minimally contributed to by care and service delivery issues around her discharge on 18th May 2022 from a voluntary in-patient hospital admission for a relapse of her longstanding paranoid schizophrenia and an intentional medication overdose taken on 4th April 2022. Specifically, a misunderstanding about the Crisis Team visiting Ms Adams on the day of her discharge together with the provision of 5 days of prescribed medication to her likely made a more than minimal contribution to her death. � The following care and service delivery issues possibly made a more than minimal contribution to Ms Adams� death: Delay by the mental health Trust in actioning the care plan on Ms Adams� discharge from the Crisis Team in October 2021, both in respect of allocating a Care Co-ordinator to her and in arranging an Out Patient Appointment and medication review;The mental health Trust�s response to Ms Adams� deterioration in February and March 2022.

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

Suicide (from 2015) | Alcohol, drug and medication related deaths This report is being sent to: Berkshire Healthcare NHS Foundation Trust | Cygnet Hospital | Reading Borough Council Adult Social Care

22/03/2023

2023-0099

Ben Harrison

North Wales East and Central

Betsi Cadwaladr University Health Board

On 21 December 2020 an investigation was commenced into the death of Ben Christopher Harrison following his death on 18 December 2020. � A second pre-Inquest hearing took place on 21 March 2023 following an initial Pre-Inquest hearing last year. � The investigation remains ongoing at this time.

The circumstances of the death are as follows : � � Ben was aged 37 at the time of his death on 18 December 2020. He had known psychiatric issues. On 15 December 2020 and whilst a voluntary inpatient at the Ablett Psychiatric Unit, Glan Clwyd Hospital he was found in cardiac arrest with a ligature around his neck, [REDACTED]. He was resuscitated and oxygen cylinder utilised. The cylinder has two valves, both of which have to be opened before the cylinder will function. The valve on the side of the cylinder was not opened and so Ben was ventilated only on room air. Ben was transferred to Intensive Care Unit and died 3 days later.

I have sent a copy of my report to the Family of the Deceased and 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.

Suicide (from 2015) | Wales prevention of future deaths reports (2019 onwards)

Betsi Cadwaladr University Health Board

22/07/2024

2024-0387

Philips Evans

North Wales (East & Central)

Betsi Cadwaladr University Health Board

On 1 August 2023 an investigation was commenced into the death of Philip Martin Evans (DOB 9/12/1984) who died on 26 July 2023. The investigation concluded at the end of the inquest on 18 July 2024. The conclusion of the inquest was by way of a narrative :- Philip Martin Evans had consumed a large quantity of medication at home and at the time of this consumption the state of his mind was impaired such that it cannot be said that he intended to end his life by this consumption at this time. At hospital, there were missed opportunities to provide treatment which would probably have afforded time to consider and initiate additional treatment options to the extent that death would probably then have not occurred when it did.

The circumstances of the death are as follows :- Philip Martin Evans was aged 38 at the time of his death on 26 July 2023. He had taken approximately 200 different tablets at his home address at around 9-9.30am on 26 July 2023. He was conveyed to Ysbyty Glan Clwyd by a police officer who had attended at his home following a concern for his safety. He was observed and went into cardiac arrest at 15:07. He was transferred to the intensive care unit and died a short time later.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. A copy will also be sent to the Health Minister, [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.

Hospital Death (Clinical Procedures and medical management) related deaths | Alcohol, drug and medication related deaths | Wales prevention of future deaths reports� � This report is being sent to: Betsi Cadwaladr University Health Board

28/02/2024

2024-0110

Nesta Jones

North West Wales

Betsi Cadwaladr University Health Board (BCUHB)

On 11 May 2017 an investigation was commenced into the death of Nesta Jones (DOB 9 July 1939) who died on 8 May 2017. The investigation concluded at the end of the inquest on 28 February 2024. A narrative conclusion was recorded with the cause of death as:� 1a. Bronchopneumonia 1b. Septic arthritis 2. Immunosuppression and rheumatoid arthritis

The circumstances of the death are as follows : Nesta Jones had been in hospital for 39 days at the point she died on 8 May 2017 at Ysbyty Gwynedd. She was admitted by a GP with suspected septic arthritis of a prosthetic left knee on 31 May 2017. She did not undergo aspiration despite it being indicated by Hospital guidelines, until 5 May 2017, at which point she succumbed to the condition, deteriorated and died. Whilst she was under the care of the physicians primarily and whilst she was referred to a number of orthopaedic doctors with suspected septic arthritis, they did not consider septic arthritis and no aspiration� and/or washout was undertaken until 5 May 2017, by which time her condition was irrecoverable.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to Eluned Morgan, Health Minister, for her information. � 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 | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board

14/09/2023

2023-0333 Deceased name: Richard Griffiths Coroner name: Kate Robertson Coroner Area: North Wales East and Central Category: Suicide (from 2015) | Wales prevention of future deaths reports (2019 onwards This report is being sent to: Betsi Cadwaladr University Health Board

Betsi Cadwaladr University Health Board (BCUHB)

On 30 March 2023 an investigation was commenced into the death of Richard Geraint Griffiths (DOB 12/1/70) who died on 26 March 2023. The investigation concluded at the end of the inquest on 14 September 2023. The conclusion of the inquest was suicide.

The circumstances of the death are as follows : Richard Griffiths moved home to the Conwy area from South Gwynedd in October 2022 to live with his mother. He was under the care of the South Gwynedd Community Mental Health Team.� For reasons unknown the transfer of care did not occur. Sadly, on 26 March 2023 he was found suspended [REDACTED] . Once he was found he was cut down and the emergency services were also called. He was pronounced deceased at the location.

I have sent a copy of my report to the Family of the Deceased, to the Chief Coroner and to [REDACTED], Health Minister. � 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.

14/06/2024

2024-0323

Eric Thompson

North Wales (East and Central)

Betsi Cadwaladr University Health Board (BCUHB)

On 11 January 2023 an investigation was commenced into the death of Eric Thompson (DOB 13/4/1941) who died on 28 December 2022. The investigation concluded at the end of the inquest on 14 June 2024. The narrative conclusion of the Inquest was as follows: Eric Thompson died on 28 December 2022 at Ysbyty Glan Clwyd where there were missed opportunities to provide timely care and treatment to prevent the condition, hyperkalaemia, which contributed to his death at this time.

The circumstances of the death are as follows : Eric Thompson presented at Ysbyty Glan Clwyd on 27 December 2022 at 13:58 with confusion and poor mobility on the background of treatment for a urinary tract infection. He had bloods taken at 17:28. An attempt was made by the laboratory to telephone the emergency department with the abnormal results (high potassium). There was no answer. A second attempt was made at 18:35 and the results were relayed to the department. These were not initially documented or escalated but had been included on the system. Eric Thompson remained in the department. At 21:35 a clinician noted a high NEWS score (7) and became aware of the abnormal blood results. Eric Thompson did not receive treatment for the hyperkalaemia. He went into cardiac arrest at 02:50 and died shortly thereafter. He died from cardiac related issues contributed to by hyperkalaemia and diabetes mellitus.

I have sent a copy of my report to the Family of the Deceased and 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 | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board

22/01/2024

2024-0035

Thomas Ithell

North Wales (East and Central)

Betsi Cadwaladr University Health Board (BCUHB)

On 6 December 2022 an investigation was commenced into the death of Thomas Grenville Hammersley Ithell (DOB 24/4/45) who died on 20 November 2022. The investigation concluded at the end of the inquest on 17 January 2024. The conclusion of the inquest was natural causes.

The circumstances of the death are as follows :� Thomas Ithell was aged 77 at the time of his death on 20 November 2022. He was diagnosed with prostate cancer in September 2017 and biopsies revealed bilateral adenocarcinoma of the prostate. He underwent radiotherapy in 2018 and hormone deprivation treatment. From April 2021 onwards his PSA levels increased periodically. In October 2021 his level was 5.5ng/ml having been 1.5ng/m lin April 2021 and 2.7ng/m in July 2021 indicating a recurrence of the cancer and likely incurable. Thomas Ithell was reluctant to undergo further hormone treatment as he found tolerating the side effects difficult. He did not then have his PSA levels tested after November 2021 and was not reviewed at all due to becoming missed to follow up. After he had been seen by the nurse practitioner on 5 November 2021 the letter written by the nurse practitioner for advice from the consultant did not reach the consultant. He was reviewed by a consultant on 22 October 2022 after an urgent suspected cancer GP referral following routine set of blood tests in September 2022, some 10 months later. Mr Ithell died in hospital on 20 November 2022 having been admitted with shortness of breath, the malignancy having caused his death.

I have sent a copy of my report to the Family of the Deceased and 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 This report is being sent to: Betsi Cadwaladr University Health Board

08/09/2023

2023-0322

Lynsey Smalley

North West Wales

Betsi Cadwaladr University Health Board (BCUHB)

On 18 May 2021 I commenced an investigation into the death of Lynsey Sarah Smalley (DOB 6/3/79) who died on 16 May 2021. The investigation concluded at the end of the inquest on 7 September 2023. A narrative conclusion was recorded with the cause of death as:- � 1a Septic Shock 1b Airway burns with inhalation injury � On the 8th April 2021, Lynsey Sarah Smalley deliberately set fire to her bed at her home address during an acute psychotic episode. The smoke from the fire caused inhalation injury which led to her admission to the Intensive Care Unit at Ysbyty Gwynedd, Bangor. Lynsey Sarah Smalley remained in the intensive care unit for several weeks with poor respiratory progress. She did not recover from her injuries and died at Ysbyty Gwynedd, Bangor on 16th May 2021. Given her psychotic episode it cannot be said that she intended to end her life by causing the fire.

The circumstances of the death are as follows : � The deceased was aged 42 at the time of her death on 16 May 2021. She had a past medical history of mixed schitzotypal and emotionally unstable personality disorder with traits of Asperger�s syndrome. She had mobility difficulties and required a bariatric bed due to concerns regarding skin integrity. She lived at home with her brother who cared for her. Lynsey Smalley was known to the Community Mental Health Team (CMHT) since 2005 and had a Care Coordinator who was a Community Psychiatric nurse. She was also open to a Psychiatrist and an Occupational therapist. On 6 April 2021 the CMHT were contacted by Lynsey�s brother who was concerned that Lynsey was acting strangely. A second call was made by her brother with concerns that Lynsey had relapsed and was displaying signs of paranoia, auditory and olfactory hallucinations, irritability, poor sleep and isolating herself in a particular room. A further call was made with reported concerns that Lynsey was lighting candles, had not used her prescribed oxygen and had not been eating, drinking, or sleeping for the past 4 days. It was indicated that there were only certain professionals Lynsey would agree to see but that she had agreed to see the care coordinator the following day. The GP prescribed medication and Lynsey�s brother was advised to contact Police if the situation became difficult. There was a total of 4 calls made by Lynsey�s brother to the out of hours crisis team. In addition, Lynsey�s brother contacted the emergency services for assistance. Police officers attended and a CID16 was completed and sent to the CMHT the following morning. By 9.10am on that same morning the CMHT reviewed the out of hours report. The care coordinator arrived at L�s home at 10.30am. Lynsey was reluctant to engage, and her brother reported concerns including that Lynsey had not slept for several nights, was not eating or drinking. He reported the incident overnight where Police had attended. The Care coordinator returned to the office and discussed with a psychiatrist, who agreed to visit that same day and the Advanced MH practitioner to assess and consider admission. After approximately 10 minutes of the care coordinator leaving Lynsey ignited a fire in the property. Emergency services were contacted. Lynsey was taken to Ysbyty Gwynedd, Bangor where she remained until she passed away on 16th May 2021.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to [REDACTED], Health Minister, for her information. � 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: Barts Health NHS Foundation Trust

24/10/2023

2023-0404

Jennifer Campbell

North West Wales

Betsi Cadwaladr University Health Board (BCUHB)

On 3 March 2022 I commenced an investigation into the death of Jennifer Lydia Campbell (DOB 612/6/48) who died on 24 February 2022. The investigation concluded at the end of the inquest on 24 October 2023. A narrative conclusion was recorded with the cause of death as: � 1a Slower lobe pneumonia, biliary sepsis 1b Obstructing gallstones � � Jennifer Lydia Campbell had an ultrasound scan of her abdomen on 25 October 2021 at the request of her GP following abnormal liver function tests, which showed gallstones. The GP referred her to gastroenterology on 28 October 2021. Following review, a referral was made by the gastroenterologist for Endoscopic retrograde cholangiopancreatography (ERCP) and this was sent to the endoscopy department on 3 November 2021. The referral form was not received by the endoscopy department and the Endoscopic retrograde cholangiopancreatography (ERCP) did not occur. Jennifer Lydia Campbell became unwell on 22 February 2022 and was subsequently admitted into Ysbyty Gwynedd on 23 February 2022 where she was treated for severe infection due to obstructing gallstones and died on 24 February 2022.

The circumstances of the death are as follows: Jennifer Lydia Campbell was aged 73 years of age at the time of her death on 24 February 2022. She had a recent past medical history of gallstones and previous kidney cancer. She underwent blood tests via her GP in October 2021 and in an appointment on 11 October discussed her abnormal liver function test. On 25 October 2021 she underwent ultra sound of the abdomen which showed large gallstones. She was advised she needed a procedure. On 28 October 2022 a referral was sent by her GP to gastroenterology department, marked as routine. On 2 November 2021 the gastroneterologist referred Mrs Campbell directly for ERCP procedure and dictated a letter to her to explain this. A paper referral was completed as per procedure and sent to the endoscopy dept on 03 November 2021. There is no record of the referral form being received by endoscopy and it is not clear why it was not received or what had occurred to it. Jennifer Lydia Campbell received a copy of the letter from the Gastroenterology department dated 3 November 2021 confirming that ECRP was needed, and she had been put on the waiting list. On 21 February 2022 Mrs Campbell started to become unwell, she was in pain and suffering. On 23 February 2022 she attended the Emergency Department due to vomiting for 2 days and not being able to get out of bed. She was admitted but deteriorated and died on 24 February 2022 at Ysbyty Gwynedd from infection and pneumonia due to the obstructing gallstones.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to [REDACTED], Health Minister, for her information. � 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 | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board

18/07/2023

2023-0248

Philip Hawkins

North Wales East and Central

Betsi Cadwaladr University Health Board (BCUHB) Welsh Ambulance Service Trust (WAST)

On 29.03.23 an investigation was commenced into the death of Philip Hawkins (DOB 09.07.1925) who died on 23.03.23. The investigation concluded at the end of the inquest on 18.07.23. The conclusion of the inquest was Accident.

The circumstances of the death are as follows :- On 18.3.23 Mr Hawkins, aged 97, suffered a fall at home and was transferred by ambulance to hospital where he subsequently died.

I have sent a copy of my report to the Family of the Deceased and 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 This report is being sent to: Betsi Cadwaladr University Health Board | Welsh Ambulance Service Trust

08/12/2023

2023-0526

Catherine Jones

North Wales East and Central

Betsi Cadwaladr University Health Board (BCUHB),

On the 11th of November 2016 an investigation was commenced into the death of Catherine Lisa Jones (DOB 24/11/80) who died at Wrexham Maelor Hospital on the 10th of November 2016. The conclusion of the inquest on the 8th of December 2023 and a narrative conclusion was recorded in the following terms : � In 2012 scans identified an ovarian abnormality and as a result Catherine Jones underwent surgery in relation to the same. Subsequently a biopsy obtained during surgery was wrongly classified as benign and she had no follow up. In June 2016 it was identified that there was the development of a malignant disease process which would probably have been identified sooner if the 2013 sample had been correctly classified. Catherine underwent further surgery at that time but the presence of a soft tissue ovoid lesion was not identified either in surgery (or on a subsequent scan) and she did not undergo chemotherapy. Her cancer progressed and spread quickly due to its aggressive nature and whilst in hospital in October 2016 receiving treatment for complications arising from the same, she contracted a Clostridium Difficile infection which accelerated her deterioration. She died at the Wrexham Maelor Hospital on the 10th November 2016 as a result of widespread metastatic ovarian cancer contributed to by Pseudomembranous Colitis.

As per the above narrative conclusion.

I have sent a copy of my report to the Family of the Deceased and 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 This report is being sent to: Betsi Cadwaladr University Health Board | Welsh Government

09/10/2023

2023-0375

Margaret Kelly

North Wales East and Central

Betsi Cadwaladr University Health Board (BCUHB),

On the 11th of April 2022 an investigation was commenced into the death of Margaret Gertrude Kelly (DOB 21/4/39) who died at Gian Clwyd Hospital on the 3l51 of March 2022. The conclusion of the inquest on the 5th of October 2023 was by way of a narrative as detailed in paragraph 4 hereof with the cause of death being recorded as l(a) Multiorgan Failure (b) Intra-abdominal sepsis secondary to bowel perforation l(c) Abdominal wall hernia (operated) following hemicolectomy for adenocarcinoma of large bowel

On the 28th of March 2022, the deceased underwent an elective surgical hernia repair during which it is probable that her bowel became damaged. The following day she was in pain and attended the Emergency Department at Gian Clwyd Hospital as she had been unable to get an answer from the telephone number which she�d been given. She was not seen by a surgical doctor for several hours and by the following morning, the 30th of March, when her condition had deteriorated considerably, further emergency surgery was undertaken to repair the bowel perforation. As a result of there being several missed opportunities to optimize her care and treatment, Mrs Kelly no longer had the resilience to recover from this procedure and she died at Gian Clwyd Hospital on the afternoon of the 31st of March 2022.

I have sent a copy of my report to the Family of the Deceased and 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 This report is being sent to: Betsi Cadwaladr University Health Board

17/08/2023

2023-0298

Malcolm Unwin

North Wales East and Central

Betsi Cadwaladr University Health Board (BCUHB),

On the 23rd of January 2023 an investigation was commenced into the death of Malcolm Ralph Unwin (DOB 15/03/43) who died at Wrexham Maelor Hospital on the 6th of January 2023. The conclusion of the inquest on the 16th of August 2023 was that the death was due to an accident.

On the 30th of December 2022 the deceased had unwitnessed fall from bed whilst a patient at the hospital resulting in injuries. The cause of death being 1(a) Head Injury with skull fracture and diffuse axonal injury (b) Mechanical Fall (c) Frailty associated with bladder cancer and prostate cancer.

I have sent a copy of my report to the Family of the Deceased and 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 This report is being sent to: Betsi Cadwaladr University Health Board

06/07/2023

2023-0229

Emlyn Roberts

North Wales East and Central

Betsi Cadwaladr University Health Board (BCUHB), Welsh Ambulance Service Trust (WAST), North Wales Local Authorities

On the 17th March 2022 an investigation was commenced into the death of Emlyn Victor Roberts (DOB 09/05/48) who died at his home on the 14th March 2022. The investigation concluded at the end of the inquest on 5th of July 2023. The conclusion of the inquest was that the death was due to natural causes, namely 1(a) Left Sided Intrathoracic Haemorrhage (b) Ruptured Dissecting Aneurysm of the Arch of the Aorta

The circumstances of the death are that at 20.01 on the 13th of March 2022, the deceased called an ambulance complaining of a sudden onset of pain and trouble breathing. He made a further call at 00.20 but due to an absence of available resources, an ambulance was unable to attend for a further seven hours at 07.27 on the morning of the following day, when he was found deceased at his home. In total there was a delay of almost eleven and a half hours from the initial call for help.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to Eluned Morgan, Health Minister, for her information. 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.

Wales prevention of future deaths reports (2019 onwards) | Emergency services related deaths (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board, Welsh Ambulance Service Trust, North Wales Local Authorities

10/07/2023

2023-0236

Mary Jones

North West Wales

Betsi Cadwaladr University Health Board (BCUHB), Welsh Ambulance Service Trust (WAST), North Wales Local Authorities

On 19 January 2023 an investigation was commenced into the death of Mary Elizabeth Jones (DOB 30/12/36) who died on 14 January 2023. The investigation concluded at the end of the inquest on 7 July 2023. The conclusion of the inquest was that Mary Elizabeth Jones had died from natural causes contributed to by a fall.

The circumstances of the death are as follows : On Sunday 4th December 2022 at around 10am Mary Elizabeth Jones had an unwitnessed fall at home. An ambulance was called which arrived 26 hours and 23 minutes later. She was taken to Ysbyty Gwynedd. She remained on the back of the ambulance due to Emergency Department pressures for a further 8 hours and 23 minutes. She was assessed by a doctor on the back of the ambulance at around 8pm on 5th December. CT scan of her pelvis identified an undisplaced fracture. She deteriorated on 17 December 2022 with low blood pressure and abdominal tenderness and a new oxygen requirements and was receiving antibiotics for a suspected urinary tract infection. By early January 2023 a further deterioration was noted � she was drowsy and eating less and her blood tests showed a drop in haemaglobin. She had a blood and iron tranfusion. An abdominal bleed was diganosed on 6th Janaury and she had a poor prognosis. Palliative care was commenced and she sadly passed away on 14 January 2023 certified at 18:00 hours at Ysbyty Gwynedd.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to Eluned Morgan, Health Minister, for her information. � 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.

Wales prevention of future deaths reports (2019 onwards) | Emergency services related deaths (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board, Welsh Ambulance Service Trust and North Wales Local Authorities

20/06/2023

2023-0202

Leonard Harmsworth

North Wales East and Central

Betsi Cadwaladr University Health Board (BCUHB), Welsh Ambulance Service Trust (WAST), North Wales Local Authorities

On 29 June 2022 an investigation was commenced into the death of Leonard Charles Harmsworth (DOB 29/3/33) who died on 18 June 2022. The investigation concluded at the end of the inquest on 19 June 2023. The conclusion of the inquest was a narrative conclusion.

The circumstances of the death are as follows : � Leonard Charles Harmsworth died on 18 June 2022 at Ysbyty Glan Clwyd from cardiac related issues contributed to by a fractured ankle and immobility due to a fall. He had been admitted on 7 June following a fall at home. He remained under conservative management before undergoing manipulation. He suffered a sudden deterioration following a manipulation of his ankle and died on 18 June 2022.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to Eluned Morgan, Health Minister, for her information. � 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.

Wales prevention of future deaths reports (2019 onwards) | Emergency services related deaths (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board | Welsh Ambulance Service Trust | North Wales Local Authorities

21/06/2023

2023-0203

Jean Frickel

North Wales East and Central

Betsi Cadwaladr University Health Board (BCUHB), Welsh Ambulance Service Trust (WAST), North Wales Local Authorities

On 30 December 2022 an investigation was commenced into the death of Jean Frickel (DOB 4/2/43) who died on 20 December 2022. The investigation concluded at the end of the inquest on 20 June 2023. The conclusion of the inquest was a narrative conclusion as follows: Jean Frickel died on 20/12/22 at her home address from a naturally occurring disease process. The time it took for the ambulance to arrive meant that she was denied the opportunity for possible life extending treatment at hospital.

The circumstances of the death are as follows : Jean Frickel had required an ambulance on 19 December 2022 due to symptoms of shortness of breath and confusion following a GP home visit. She was in reasonably poor health. A call was made by her husband to WAST at 17:09 hours. At 08.07 hours the following morning a further call was made informing WAST that Jean Frickel was unresponsive and not breathing. Paramedics arrived at 08:12 and confirmed that she had died. It took 13 hours and 3 minutes from the initial call for paramedics to arrive. Cardiology evidence indicated that had Mrs Frickel received timely medical treatment then her life may have been prolonged by several weeks.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to Eluned Morgan, Health Minister, for her information. � 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.

Wales prevention of future deaths reports (2019 onwards) | Emergency services related deaths (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board | Welsh Ambulance Service Trust | North Wales Local Authorities

02/02/2024

2024-0051

Philip Taylor

North Wales (East and Central)

Betsi Cadwaladr University Health Board Elysium Healthcare

On 1 September 2023 an investigation was commenced into the death of Philip David Taylor (DOB 12/6/55) who died on 23 August 2023. The investigation concluded at the end of the inquest on 30 January 2024. The conclusion of the inquest was suicide.

The circumstances of the death are as follows � Philip David Taylor had a short history of mental health difficulties from April 2023 for which he was receiving support from the Community Mental Health Team and Home Treatment Team, part of the Betsi Cadwaladr University Local Health Board. On 28 July 2023 he was admitted as an informal patient to a private psychiatric unit at Elysium Ty Grosvenor Hospital, Wrexham. He was admitted to there as there were no beds available within the NHS North Wales area. He was discharged on 15 August 2023 to the care of the Home Treatment Team. On 23 August 2023 Philip Taylor died by suicide at his home address.

I have sent a copy of my report to the Family of the Deceased and 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.

Suicide (from 2015) | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Betsi Cadwaladr University Health Board | Elysium Healthcare

14/05/2023

2023-0461

Thomas Huntley

Hampshire, Portsmouth and Southampton

1�� Director General CEO, HM Prison and Probation Service

On 02 June 2020 an investigation was commenced into the death of Thomas Victor HUNTLEY (aged 54) who had died in HMP Winchester. The investigation concluded at the end of the inquest on 05 April 2023. The inquest, which was held with a jury, ended with a narrative conclusion. � The medical cause of death was 1(a) hanging. The jury concluded, amongst other matters, that: Relevant information about Mr Huntley, namely information from the recall notification and previous �Assessment, Care in Custody and Teamwork� (ACCT) documents, was not recorded on NOMIS. � The risk level recorded in the ACCT document opened on the 23/05/2020 did not reflect a higher level of risk indicated by witness evidence and neither did it align with the guidance on risk levels contained within that document. This caused or contributed to Mr Huntley�s death. � There was a failure to record triggers for self-harm behaviour in the ACCT document. There was a failure to record all relevant risks within the �Caremap� section of the ACCT document. These factors contributed to the death of Mr Huntley. � The level of observations under the ACCT document opened on the 23/05/2020 were not adequate based on the level of risk Mr Huntley posed to himself. This caused or contributed to his death.

Mr Huntley was recalled to prison on the 23/05/2020. Whilst in the community Mr Huntley had been under the care of Steps to Wellbeing for PTSD and anxiety. He had disclosed daily suicidal thoughts to them with no intent to act upon these thoughts. The recall notification of the 22/5/20 stated that Mr Huntley reported low mood and claimed to want to take his own life but was not brave enough to do so. This information from the recall notice was not recorded in the record keeping system which could be accessed by all prison security staff (NOMIS). � Mr Huntley denied thoughts of suicide or self-harm when asked by the police on the 23/02/2020. During the reception process at HMP Winchester he denied thoughts of suicide or self-harm. � On the 25/05/2020 Mr Huntley called for help [REDACTED]. He later disclosed that this had been a planned act with the intent to end his own life. He had taken steps to avoid being discovered and had only called for help when he awoke [REDACTED]. ���������������������������������������������������������������������������������� . Mr Huntley was subsequently taken to hospital and discharged later the same morning. Having left hospital he collapsed and was admitted to the Healthcare wing of the prison for observations. � An ACCT document was opened. This is a way of monitoring persons in custody who are at risk of harm. During previous periods of imprisonment in 2010 and 2016 ACCT documents had been opened for Mr Huntley. These documents were not contained within in core records as should have been the case and still cannot be located. Their existence, and the circumstances of the 2016 ACCT, were recorded on NOMIS. � Mr Huntley was initially placed on 30-minute observations when the 2023 ACCT was opened, this was reduced to hourly observations after the first case review on the 25/05/2020 and then to 3 random observations overnight after the second case review on the 27/05/2020. These changes were made following assessment meetings involving Mr Huntley, prison staff and staff from the NHS Trust providing physical and mental health interventions within the prison. � Mr Huntley denied further thoughts of self-harm or suicide during these meetings. On the 28/05/2020 Mr Huntley was moved from his original cell in the healthcare wing to cell 13. Cell 13 was located in the area of the healthcare unit primarily used for patients with mental health difficulties. Apart from cells 6 and 13 all of the cells in this area were designed to have reduced ligature points. However in 2019 telephone points had been installed in each of these cells which protruded from the wall. The decision to move Mr Huntley was made at a Multi-disciplinary meeting at which no-one who had met Mr Huntley to assess his mental health was present. � On the evening of the 28/05/20 the night duty prison officer completed their rounds at approximately 20.30 and noted that Mr Huntley was sat on the floor of his cell in a partial blind spot. Between 21.00 and 21.30 the nurse on duty knocked on Mr Huntley�s cell door and received a verbal response. � At about 23.30 the prison officer attended to complete the first observations required under the ACCT document for Mr Huntley. They saw that Mr Huntley was in the same position as some 3 hours earlier and Mr Huntley did not respond to him. The officer entered the cell with other prison officers at about 23.35 and found Mr Huntley sat motionless [REDACTED]. � The prison officers cut the ligature and commenced CPR. An emergency call was put out and further prison officers and both on-duty nurses attended. Those present provided CPR to Mr Huntley until the arrival of paramedics. Sadly despite the efforts of staff and the attending medics Mr Huntley could not be revived and his life was declared extinct.

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

State Custody related deaths | Suicide (from 2015) This report is being sent to: HM Prison and Probation Service

10/12/2024

2024-0694

Craig Spiby

Manchester West

1�� The Chief Executive, Bolton Cares, Thicketford Road, Bolton. BL2 2LW

On 30 July 2024 I commenced an investigation into the death of Craig Brendon SPIBY aged 49. The investigation concluded at the end of the inquest on 21 November 2024. The conclusion of the inquest was that: Accident contributed by neglect.

The deceased suffered from Phelan McDermid Syndrome � a rare and debilitating chromosomal disorder, that amongst other symptoms, rendered him susceptible to choking on food and liquids at mealtimes. From 2009, the deceased�s extensive health care needs were being met actively upon him becoming at full time resident at a locally authority funded assisted living facility at�[REDACTED], Farnworth. On the 13th of July 2024, when eating his lunch whilst unsupervised and only indirectly monitored in the kitchen of the residence, he rapidly became collapsed and unresponsive having inadvertently choked on a sandwich. His condition was not appreciated for a significant period, the duty carer on returning to the kitchen erroneously assumed the deceased had fallen asleep until later realising the deceased was totally unresponsive. Despite prompt attendance and attempted resuscitation by emergency paramedics, he failed to respond and at 12.23pm that day was pronounced dead. A post-mortem established the deceased to have choked on a bolus of masticated sandwich that had lodged in his windpipe that would have caused hypoxic driven cerebral malfunction and potential loss of consciousness within four minutes and irreversible cardio- respiratory failure within 10 minutes.

I have sent a copy of my report to the Chief Coroner and to the family of Craig Spiby. I have also sent it to Bolton Council 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.

Care Home Health related deaths

Bolton Cares

12/04/2024

2024-0210

Scott Rider

Milton Keynes

1�� [REDACTED], Minister of State for Prisons, Parole and Probation

On 17 June 2022 I commenced an investigation into the death of Scott William James Rider aged 45. The investigation concluded at the end of the inquest on 20 March 2024. The conclusion at the end of the inquest was that Scott Rider died as the result of: � Suicide

as determined by the jury. � Scott Rider was a prisoner at HMP Woodhill, serving a sentence of Imprisonment for Public Protection. This was a sentence of indeterminate length. The minimum tariff was 23 months. Scott had been in prison for 17 and a half years at his time of death. Scott was transferred to HMP Woodhill on 30th June 2021 and after leaving the induction unit he was moved to House Unit 4A. He had been self- isolating for over 200 days. He was supported by members of staff to the best of their capacity under the circumstances, but did not always engage. There was no outward indication prior to Scott�s death that he had an increased risk of suicide at that time. Scott�s aim was to be transferred to another prison in the North. At the time of Scott�s death, there were inadequate staffing levels and the continuing length of his sentence was uncertain. On the 13th June 2022, Scott was found hanging in his cell with a ligature around his neck.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] sister of Scott Rider. The Governor of HMP Woodhill. The Head of Healthcare at HMP Woodhill. � I have also sent it to: � The Prison and Probation Ombudsman HM Inspector of Prisons Executive Director of Inquest � 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: HM Prison and Probation Services

24/10/2023

2023-0406

Frederick Powell

Lincolnshire

1��Acis HOUSING

On 12 September 2023 I commenced an investigation into the death of Frederick POWELL aged 93. The investigation concluded at the end of the inquest on 24 October 2023. The conclusion of the inquest was that: � The deceased died on 6th September 2023 at 20 St.Martins Close, Blyton , Gainsborough when he fell through a glass door at home suffering life threatening injuries that he failed to recover from.

The deceased died on 6th September 2023 at 20 St.Martins Close, Blyton , Gainsborough when he fell through a glass door at home suffering life threatening injuries that he failed to recover from.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � I have also sent it to Acis HOUSING � 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: Acis Housing

05/06/2024

2024-0313

Gillian Peacock

County Durham and Darlington

1��Chief Executive � County Durham & Darlington NHS Foundation Trust

On 15/03/2023 09:42an investigation was commenced into the death of Gillian PEACOCK 16/08/1962 00:00:00. The investigation concluded at the end of the inquest on 05/06/2024 00:00. The conclusion of the inquest was that Gillian Peacock died on 8th March 2023 at Darlington Memorial Hospital. She suffered from a number of health conditions, but significantly atrial fibrillation for which she was prescribed digoxin. She was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithomycin. It was recorded by a hospital pharmacist on 1st March 2023 in her medical notes that the use of these two drugs can cause digoxin toxicity and an alternative drug or monitoring is advised. No alternative drug was prescribed and no monitoring took place until 7th March 2023 where results showed an elevated level of digoxin. Her digoxin was withheld. She had displayed no recognised symptoms of digoxin toxicity during her stay in hospital. She suffered a cardiac arrest on the morning of 8th March 2023 and died. Post Mortem examination could not ascertain a cause of death. The medical evidence cannot on the balance of probabilities determine the contribution of digoxin & clarithomycin to her death.

CORONER�S CONCERNS � During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) � Gillian Peacock was admitted to hospital on 27th February 2023 and was diagnosed with a chest infection and was prescribed clarithomycin. It was recorded by a hospital pharmacist on 1st March 2023 in her medical notes that the use of these two drugs can cause digoxin toxicity and an alternative drug or monitoring is advised. No alternative drug was prescribed and no monitoring took place until 7th March 2023. � The evidence I have heard is that the treating clinicians had not seen the entry in her medical records. This was in part due to the way the entries are displayed in the records and the �huge� number of entries that are recorded. � I heard that now that any pharmacist entries of significance must be verbally passed to a junior doctor involved in the patient�s care and in turn passed on at ward meetings to the broader group of staff caring for that patient. � I have a concern that the current system does not address the issue of important medical information being recorded in a patient�s notes not being accessible in such a way that clinicians can see and if necessary act on it. � The use of verbal handovers does not in my view fully address my concern that crucial medical information should be recorded in a patient�s medical records in such a way that relevant information is visible to those involved in care. In addition, that it can be accessed immediately without reliance on the verbal passing of information from one member of the treating team to another.

05/06/2024 James E THOMPSON Assistant Coroner for County Durham and Darlington

Hospital Death (Clinical Procedures and medical management) related deaths | Alcohol, drug and medication related deaths This report is being sent to: County Durham and Darlington NHS Foundation Trust

27/04/2023

2023-0141

Vivien Radocz

Cambridgeshire and Peterborough

1��Peterborough City Council � Highways Department

On 03.09.22 I commenced an investigation into the death of Vivien RAD�CZ, aged 28 years. The investigation concluded at the end of the inquest on 07.03.23. The conclusion of the inquest was: Medical cause of death: 1a Drowning Inquest Conclusion � Road Traffic Collision

Vivien was the driver of a Ford Focus motor vehicle travelling west along Old Oundle Road, Wittering at about 1035hrs on 03.09.22. The vehicle failed to negotiate a sharp left hand bend, left the carriageway to the offside before it entered a pond and became submerged upside down in water. Vivien was unable to escape from the submerged vehicle which was not discovered until around 1730hrs that day. Emergency services attended the scene and Fire Officers then extricated Vivien from the vehicle. Sadly her death was confirmed at the scene by a paramedic at 1942hrs

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � AXA INSURANCE; [REDACTED] (mother) � I have also sent it to � The Fenland Road Safety Campaign � 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 This report is being sent to: Peterborough City Council

08/05/2024

2024-0252

Zarah Ravn

Surrey

1��� Ashlea Medical Practice (Linden House)

On 12 September 2023 I commenced an investigation into the death of Zarah RAVN aged 49. The investigation concluded at the end of the inquest on 20 February 2024. The conclusion of the inquest was that: � Miss Zara Ravn, aged 49 years old was found deceased on 3rd September 2023 from mixed drug toxicity at her home address in Leatherhead, where she had consumed a lethal dose of oramorph and oxycodone unprescribed and a prescribed drug of quetiapine leading to mixed drug toxicity.

Miss Zara Ravn, aged 49 years old was found deceased on 3rd September 2023 from mixed drug toxicity at her home address in Leatherhead, where she had consumed a lethal dose of oramorph and oxycodone unprescribed and a prescribed drug of quetiapine leading to mixed drug toxicity.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Family of Zara Ravn � 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, drug and medication related deaths This report is being sent to: Ashlea Medical Practice

28/02/2024

2024-0114

Sylvia Crowther

Bedfordshire and Luton

1��� Chief Constable [REDACTED]

On 20 January 2023 I commenced an investigation into the death of Sylvia Dawn CROWTHER aged 58. The investigation concluded at the end of the inquest on 25 January 2024. The Conclusion of the Inquest was that the Deceased died as result of Suicide.

The Deceased suffered with physical disabilities, mental health issues, and alcoholism. Her husband of 39 years was her main carer. At around 19.15 hours on 3 January 2023, the Deceased reported to Police that her husband was being violent towards her. On attending, the Police could see no visible marks or cuts but arrested her husband; the Deceased made it clear that she did not support any criminal action against him. On 4 January 2023, her husband was bailed until 28 February 2023 with conditions that he was not to return to the marital home. Police also made a Safeguarding Referral to Social Services who organised an urgent welfare visit to the Deceased that same evening. The Deceased refused all care services offered during the visit and stated that she would kill herself if her husband did not return home (but not that evening). The Deceased continued to refuse care when contacted by Social Services the following morning but was provided with the telephone number for the Safeguarding Team. Sometime between 14.45 and 15.45 on 6 January 2023 and, in a distressed state, Sylvia left a message on the Safeguarding Team�s phone requesting help. At 15.06 hours, she also sent a text to her Victim Engagement Officer stating that she could not cope on her own and requesting a call. Although a member of the Safeguarding Team spoke briefly to her on the phone at 16.30 hours, they requested Police to make an urgent welfare visit; a �prompt response� was organised by Police Control Room at 16.56 hours but, owing to service demand, they arrived at 19.24 hours and found the Deceased unresponsive on the living room floor. Despite all resuscitation efforts, paramedics confirmed her death at 20.25 hours. [REDACTED] and notes to her husband and to Police were found at the scene. The notes confirmed an intention to end her life and the note to Police indicated that she felt that they had not listened to her.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] � Head of Social Care, Central Bedfordshire Council � I have also sent it to � [REDACTED] � DHR Report Author � 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: Bedfordshire Police

07/07/2023

2023-0420

Christopher Smith

Nottingham City and Nottinghamshire

1��� Chief Executive of Nottinghamshire Healthcare NHS Foundation Trust

On 06 June 2019 I commenced an investigation into the death of Christopher Howard SMITH. The investigation concluded at the end of an Article 2 compliant inquest, conducted before a jury, between 12 December 2022 and 19 January 2023. The conclusion of the jury was that: � Christopher Howard Smith, was a 35-year-old gentleman who was a serving prisoner at HMP Lowdham Grange, Nottinghamshire. Christopher died on the 19th of May 2019, at Queen�s Medical Centre, Nottingham, from a cardiac arrest, due to a massive Pulmonary Embolism, predisposed by Deep Vein Thrombosis. In spite of prolonged efforts to resuscitate him, Christopher passed away. He had a severe and enduring Mental Health condition known as Schizo-affective disorder which was controlled with anti-psychotic medication (Promethazine and Olanzapine). � The jury found multiple failings in the care and treatment provided by prison and healthcare staff. His death was contributed to by neglect.

The jury reached the following findings of fact � On the 23rd April 2019, Christopher was transferred to the segregation unit (known as the RIU). He was seen and recorded to be behaving strangely from the 1st of May and was recorded in the observation log by a PCO as being �off his head�. A variety of staff from the 1st of May onwards, thought his presentation was due to him being under the influence of an NPS. This unusual behaviour included smashing up his cell, not engaging in the daily regime or with staff, and shadow boxing. His condition deteriorated over the course of the following days since the cessation of his mental health medication on the 1st of May. His presentation included an inability to communicate, drooling, vomiting, difficulty breathing, jerking of his limbs and inability to mobilise. This progressive deterioration was noted by both prison and healthcare staff over the following days up to the 8th May when Christopher was hospitalised. Christopher was also not eating or drinking adequately, and concerns were raised in this regard as of the 3rd of May. There were insufficient checks and inadequate record keeping by prison staff and the concerns that Christopher�s presentation raised were not thoroughly escalated through the correct channels between the 1st and the 6th of May. Prison officers were reluctant to challenge Healthcare staff regarding the lack of clinical assessments being carried out. � His progressive deterioration was recorded by both prison and healthcare staff in their respective logs and in spite of this and in spite of the stipulations of rule 45 and PSO 1700, his assessments were inadequate, and his healthcare needs were not met. His failure to take his medication was not adequately assessed nor was his mental capacity questioned. The food and fluid log was not opened until the 7th May and an NPS not opened until the 6th of May. Consequently, there were significant missed opportunities to help Christopher. A NEWS2 score was not calculated until the 8th of May, as which point it was 8. Healthcare staff were not refused or prevented from entering Christopher�s cell, although there were occasions of reluctance from prison staff to open the cell door due his presentation and behaviour. Healthcare staff had adopted the unsafe practice of conducting clinical observations through the observation hatch. � On the 6th of May, Christopher was moved from his cell for hygiene reasons and to facilitate observations via CCTV. An NPS log was opened on that day for the first time but opportunities to examine him were missed. Further opportunities were missed on the 7th of May, when a food and fluid log was opened. There was confusion between physical and mental healthcare staff as to who was responsible for assessing Christopher�s health condition and providing appropriate care. There was insufficient communication between healthcare departments which was exacerbated by chronic understaffing. � On the 8th of May, the GP round was inadequate being conducted quickly through the observation hatch. Once again, opportunities for appropriate clinical observations were missed. � Clinical observations were eventually made by nursing staff for the first time shortly after 1PM on the 8th of May 2019, but there was further significant delay before the ambulance was called via contacting 999 and a code blue was not called at this time. � The 999 call was made at 1:57pm but inaccurate and insufficient information was conveyed to the call centre. A further assumption was made that Christopher was displaying symptoms due to exposure to spice. � On arrival at QMC accident and emergency department, there was no written handover given to hospital staff as per healthcare policy. � On admission, Christopher was very unwell, and hospital staff took the decision to sedate him and put him on artificial ventilation, in order that they could investigate him further. He was rehydrated and was given prophylactic treatment for DVT. There are conflicting accounts as to whether Christopher had swollen foot or feet, but this was not conveyed to the medics at QMC. Based on the fact that a fellow prisoner on RIU and prison staff at Lowdham Grange witnessed Christopher having a swollen foot or feet, we believe that on the balance of probability, Christopher did have swelling of his foot or feet. � Christopher remained on ventilation for 5 days, after which there was an improvement in his condition, but he remained unwell. He was subsequently transferred to the neurology ward on the 17th of May and a diagnosis of probable Neuroleptic Malignant Syndrome was made. This diagnosis was not considered by healthcare staff at HMP Lowdham Grange. � The probable cause of NMS could not be firmly determined based on a lack of clear understanding of the condition, which is rare. We are unable to say whether the condition was caused by either the taking or the cessation of anti-psychotic medication. � Christopher�s extended immobility in his cell resulting from NMS, in combination with his dehydration, predisposed him to the development of DVT which ultimately lead to his death due to Pulmonary Embolism.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons including: � Christopher�s family The Governor of HMP Lowdham Grange HMPPS � The Minister for Prisons and Probation CQC � I have also sent a copy to NHS England (who commission prison healthcare services) and to Sodexo � Sodexo did not manage the prison at the time of Christopher�s death, but have subsequently taken over management of the prison from Serco and I consider it important that they are aware of these historic issues. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

State Custody related deaths | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Nottinghamshire Healthcare NHS Foundation Trust

04/10/2023

2023-0370

Michelle Whitehead

Nottingham City and Nottinghamshire

1��� Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust

On 05 January 2022, I commenced an investigation into the death of Michelle Louise WHITEHEAD, aged 45. The investigation concluded at the end of an inquest, conducted before a Jury, on 21 September 2023. The conclusion of the jury was as follows: � Michelle Louise Whitehead died on Friday 7 May 2021, while an inpatient on the Adult Intensive Care Unit, Kingsmill Hospital, Sutton-in-Ashfield, Nottinghamshire. Her death came as a result of Hyponatraemic Encephalopathy, caused by Acute Hyponatraemia, caused by Psychogenic Polydipsia. � Failings in her care probably more than minimally contributed to her death.

Michelle had been detained pursuant to s.2 of the Mental Health Act 1983 on Monday 3 May 2021, and was taken to the Lucy Wade Unit, Millbrook Hospital. Her detention was necessary because there had been a serious deterioration in her mental health in the days prior. Michelle was displaying symptoms of paranoia, irritability, agitation and reality distortion. In the days following her admission to hospital, she appeared to be experiencing psychotic symptoms and lacked the capacity to make decisions about her health and wellbeing. � There was a single observation by a staff nurse of Michelle excessively consuming water from the tap in her en-suite bathroom at around 15.48 hours on 5 May 2021. As Michelle was nursed on 10-minute observations, and had unsupervised access to water in her room, it is not possible to know how much water she actually consumed or over what period. � After this episode of water consumption, she was administered PRN sedative medication, which took effect by 17.30 hours when she became compliant and got into bed. � Over the course of the next 3 hours, Michelle was assumed by staff to be sleeping. Staff failed to follow the Trust�s Rapid Tranquilisation policy as; � The Rapid Tranquilisation NEWS2 observations were incomplete as Michelle�s consciousness level was not assessed at any time before concerns were raised about her breathing and shortly before 21:00 hours. This led to missed opportunities to detect her likely deteriorating level of consciousness, and to have sought earlier hospital admission. ������� Medical and non-clinical staff did not understand the requirements of the Policy in circumstances where a patient is thought to be asleep. ������� NEWS2 observations were discontinued by a doctor at 19:45 hours despite the policy mandating hourly observations, direct visual observation of the respiratory rate every 15 minutes, and continuous pulse oximetry monitoring until the patient is ambulatory. ������� There was inadequate monitoring of Michelle by staff tasked with performing 2:1 eyesight observations, as staff were distracted by the use of their personal mobile telephones, an activity which was prohibited on the ward. ������� There was a failure by nursing staff to respond promptly to a change in Michelle�s breathing at 20:28 hours, and a delay of 15 minutes in Michelle being placed into the recovery position ������� There was a delay in the Duty Doctor arriving on scene as he did not respond promptly to mobile telephone contact from the switchboard. ������� There was a 10-minute delay in admitting the paramedics to the building � On a balance of probabilities, Michelle suffered a fatal brain injury caused by acute over- hydration of water leading to severely low sodium levels. In this context, the acute over hydration was caused by Psychogenic Polydipsia, a feature of Michelle�s mental ill health which had not been diagnosed. � The Trust�s admitted failure to comply with its Rapid Tranquilisation policy on the evening of 5 May 2021 � in particular by failing to monitor Michelle�s consciousness level, lead to missed opportunities to detect her likely deteriorating level of consciousness and to seek earlier hospital admission � probably more than minimally contributed to her death. � The Trust�s system for training staff on the Rapid Tranquilisation policy was not sufficiently robust, and the policy itself was not sufficiently clear on what staff ought to do if they believe a patient to be asleep after administering tranquilisation.

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

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

05/01/2024

2024-0017

Tammy Watkins

Nottingham and Nottinghamshire

1��� Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust

INVESTIGATION AND INQUEST � On 13 October 2021, I commenced an investigation into the death of Tammy Mary Louise WATKINS, aged 36, which concluded by inquest held before me sitting with a Jury between 9 and 20 October 2023. � The Jury recorded a Narrative Conclusion detailing multiple failings in Tammy�s care which probably more than minimally contributed to her death. The Jury found that Tammy�s death was contributed to by neglect.

Tammy Mary Louise Watkins was detained pursuant to s.45(5) of the Mental Health Act 1983 at the Women�s High Secure Service, Rampton Hospital, Nottinghamshire, when she swallowed a plastic twistable crayon (approx. 17 � 20cm in length), which perforated her bowel, causing her death on 6 June 2021. Tammy was assessed as being at high and ongoing risk of ingesting foreign objects, a risk which had materialised on many occasions prior to her death, and often lead to hospital admission. Her risk of self-harm by ingestion led to the lawful use of mechanical restraints, comprising of mittens, a bio belt, eyesight or arm�s length observations, controlled and supervised access to items when spending time out of her mittens, and a total restriction on Tammy having free access to personal items. On 22 March 2021, hospital staff provided Tammy was a twistable crayon to use while her mittens were removed. The twistable crayon had not been risk assessed or approved for use by Tammy�s MDT, who were responsible for setting her care plan. In those circumstances, the twistable crayon ought not to have been provided to her. If the crayon had been presented to the MDT, her Consultant Psychiatrist would not have approved its use as it would have posed an obvious risk of serious harm if ingested due to its size and plastic structure. Instead, alternative child-safe small wax crayons could have been used to meet the same therapeutic purpose. At this time, the Trust did not have any documented system that set out the requirements for the MDT to approve the use of risk items, but this was nevertheless an expectation on the MDT, which they failed to complete. There is no clear or consistent record of who was observing Tammy or what items she had been granted access to on 22 March 2021. Despite the crayon being noted as �missing� from the pack, no incident report was completed, nor was the Security Manager alerted or any ward level plan initiated to seek to locate the risk item. Tammy started to present with symptoms of a complication of swallowing the item the next day. She reported nausea after eating, vomiting and epigastric tenderness. Mental health staff escalated her symptoms to the physical healthcare team. Tammy reported to the Advanced Clinical Practitioner that she could feel the twistable crayon inside her. The ACP made a plan to monitor for any deterioration and to discuss with the GP the following day. She was not escalated for investigations at the local hospital despite the size of the missing item and Tammy reporting feeling it inside her. The Trust failed to have in place a formal policy relating to the management of the ingestion of foreign bodies. This meant that staff were not all working to a clear plan of how to monitor for, detect and respond to the medical complications of ingesting foreign bodies. The MDT failed to have in place a care plan specific to Tammy�s risk of swallowing, setting out how this should be managed and escalated by ward staff. There was no continuing, co-ordinated investigation to seek to locate the twistable crayon. On the evening of 16th May 2021 Tammy was observed to be vomiting in her toilet and at the same time reaching into the toilet. When asked, Tammy reported that she had swallowed a toothbrush. An out of grounds visit was arranged to take Tammy to Bassetlaw District General hospital. Tammy was examined at Bassetlaw General Hospital and was given an x-ray at 01:33am on 17th May 2021 which did not reveal any foreign bodies. Tammy was booked for an ultrasound scan later that day but was discharged at approximately 9:30am and returned to Rampton Hospital before this could be completed. Staff seem to have taken the negative x-ray result as evidence that there were no foreign bodies in Tammy�s system. Many staff were unaware of the limitations of x-ray in relation to non-radiopaque items or the extent of the imaging. On the evening of 4th June 2021 Tammy reported discomfort and anxiety due to constipation. Given the timing and symptoms we feel this is likely to be the beginning of Tammy�s deterioration. No actions beyond further observations are recorded to have taken place, staff appear to have taken Tammy�s constipation entirely at face value. There is no evidence that the twistable crayon was being considered at this point. Tammy spent most of the day of 5th June 2021 in bed due to worsening symptoms. It is recorded that a mechanical restraint review was undertaken by the duty doctor, but it is unclear whether any physical examination of Tammy was undertaken at this point. By the evening of 5th June Tammy�s temperature and heart rate had begun to spike and mental health staff became concerned. The same duty doctor was contacted during the evening by ward staff as Tammy continued to deteriorate. The duty doctor did not attend the ward or examine Tammy and advised ward staff to provide Tammy with paracetamol. This represents a missed opportunity to have recognised the deteriorating patient and to have sought medical attention. There is no record at this point that Tammy�s symptoms were linked in any way to foreign body ingestion, despite Tammy voicing concern that she may have perforated her bowel. Tammy�s symptoms continued to worsen throughout the early hours of 6th June 2021, including high pulse rate and temperature, anxiety, abdominal pain and vomiting, escalating to projectile vomiting and apparent �faecal� vomit. The Hospital Trust failed to adhere to the NEWS2 Policy when Tammy was acutely unwell. NEWS2 was not recorded as frequently as required, at times the readings were incomplete, and the total score was not acted upon in accordance with the policy. This led to an underestimation of Tammy�s clinical risk, and multiple missed opportunities to have rendered care in an acute hospital which would probably have prevented her death The physical healthcare team and the on-call Duty Doctor failed to recognise Tammy was a deteriorating patient and failed to take steps to arrange her timely transfer to an acute hospital for treatment of her perforated bowel. Over the weekend of 5-6 June 2021 there was a breakdown in communication between the ward staff, physical healthcare staff, duty doctor, and site management as to Tammy�s signs and symptoms which led to a delay in her being transported to hospital to receive treatment for her condition Tammy continued to deteriorate throughout the morning of 6th June 2021, until shortly after 2pm when Tammy�s symptoms were recognised by the physical healthcare team to be so severe that an ambulance would be required to take Tammy to hospital. A number of miscommunications between staff, added to the lack of a clear escalation protocol for staff to follow, resulted in a delay to the ambulance being called, because staff were unclear who should call the medical emergency. The Hospital Trust accepts that multiple failings in Tammy�s care probably more than minimally contributed to her death. Neglect contributed to her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons -Tammy�s Family Doncaster and Bassetlaw NHS Trust I have also sent it to � Nottinghamshire� Police Care Quality Commission Health and Safety Executive NHS England as Commissioners for the healthcare services subject to this report � 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: Nottinghamshire Healthcare NHS Foundation Trust

02/07/2024

2024-0351

Arlo Lambert

Nottingham City and Nottinghamshire

1��� Chief Executive, Sherwood Forest Hospitals NHS Foundation Trust

On 13 March 2023, I commenced an investigation into the death of Arlo River Phoenix Lambert, aged 5 days. The investigation concluded at the end of an inquest on 3 May 2024. The conclusion of the inquest was that Baby Arlo died on 9 March 2023, at the Queen�s Medical Centre, Nottingham, as a result of a hypoxic-ischaemic brain injury, sustained during the intrapartum period, and caused by mismanagement of his medical care at Kingsmill Hospital. His death was contributed to by neglect.

Baby Arlo�s Mother attended the Kingsmill Hospital for induction of labour due to a diagnosis of suboptimal growth, when in fact, the criteria for such had not been met. Labour was slow to establish and doctors failed to recognise Arlo�s compound presentation. � The prolonged labour process increased the risk of infection, resulting in a subclinical infection within the membranes with fetal inflammatory response. The infection tiggered a placental abruption, with frank bleeding noted at 03.40 hours. The commencement of the abruption could have occurred at any time from 02.05 hours when CTG monitoring was ceased and Mother was left to rest. The slow progress of labour, distress of compound presentation, infection and abruption all contributed to Arlo�s hypoxic brain injury from which he died. � There were multiple missed opportunities to have reduced the period of hypoxia by delivering Arlo earlier, and before the final fatal placental abruption, by prioritising progress of labour at 10.40 hours, by following the induction of labour process at 12.40 hours, at the obstetric review at 17.15 hours, or responding to the first episode of blood-stained liquor at 21.18 hours or on ward review at 21.43 hours. � These multiple missed opportunities occurred due to systemic failings including discrepancies between local and national clinical guidance, a failure to escalate significant clinical events, a failure in communication to handover salient information or to review the notes at the commencement of care.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Baby Arlo�s family Sherwood Forest Hospitals (SFH) � to include King�s Mill Hospital, Newark & MCH � I have also sent it to � Care Quality Commission Department of Health and Social Care � 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.

Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Sherwood Forest Hospitals NHS Foundation Trust

02/02/2024

2024-0050

Marjorie McEvoy

Liverpool and Wirral

1��� Clatterbridge Cancer Centre (Liverpool)

On 05 September 2023 I commenced an investigation into the death of Marjorie MCEVOY aged 64. The investigation concluded at the end of the inquest on 02 February 2024. � The cause of death found was: � 1a Gastrointestinal haemorrhage � 1b Treatment for squamous cell carcinoma � II Bronchopneumonia and Chronic Obstructive Pulmonary Disease � The conclusion of the inquest was that: � Marjorie MCEVOY died from a misadventure namely a rare but recognised complication of treatment for cancer.

Mrs Marjorie McEvoy had a medical history of chronic obstructive pulmonary disease, Rheumatoid arthritis and Anal squamous cell carcinoma T2N1. She was on radical treatment with Capecitabine and Mitomycin for radical intent. The cycle commenced on 10/07/2023. Afterwards developed severe mucositis with led to her poor oral intake, diarrhoea and tongue swelling. She was seen by advanced nurse practitioners as well as consultant oncologists. She was admitted in hospital and given antibiotics, IV fluids and supportive care. She also presented Pancytopenia, which was more likely than not chemotherapy related. During admission developed a gastrointestinal bleed related to mucositis. She had multiple blood transfusions and investigations. She recovered initially however had further gastrointestinal bleed on 18th August 2023. She was certified as having died at 04.05 on the 21st August 2023. It is more likely than not that her severe reaction to the treatment was such that stopping the treatment was unlikely to have prevented her death. The quality of the clinical notation from advanced nurse practitioners did not put the oncology team in the best position to react to her care needs.

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. � Chief Coroner (reg28) NHS England & NHS Improvement (PFDs) � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner, and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) This report is being sent to: Clatterbridge Cancer Centre

20/06/2024

2024-0334

Nicola Forster

Bedfordshire and Luton

1��� Commissioner [REDACTED]

On 12 October 2022 I commenced an investigation into the death of Nicola FORSTER aged 45. The investigation concluded at the end of the Inquest on 03 June 2024. The Conclusion of the Inquest was that: � The Deceased intentionally took her own life following a deterioration in her mental health which was exacerbated by the actions of her employer.

The Deceased, a serving Metropolitan Police Service (MPS) Sergeant, had worked for the MPS for over twenty-two and a half years mostly as a front-line officer; in early 2020, she had joined the Learning and Development Team at Hendon as a Public & Personal Safety Instructor Sergeant, which was a job she loved. She had struggled with mental and physical health issues for several years, including work-related PTSD, but had found counselling helpful for dealing with this. Her mental health declined from autumn 2021 when she found herself under increasing pressure at work and lost access to counselling. An Occupational Health Referral was discussed with her line manager but was not progressed until 23 May 2022 when, because her health had impacted on her ability to lead and supervise her Team, she was also issued with informal management action. Although she was always open about her mental health issues, line management decisions made in respect of her reflected a focus on managing upwards and were supported by the Senior Leadership Team; these decisions were at the expense of the Deceased�s personal and occupational welfare and contributed to a further significant deterioration in her mental health. Despite the intervention of the Deceased�s local mental health Crisis Team, who provided her with out-patient care from 21 September 2022, on the morning of 28 September 2022, she was found hanging by a ligature made from her dressing gown belt attached to the landing banisters at her home. Emergency Services attended but her death was confirmed by paramedics at 10.56 hours. She had last been heard from at around 01.00 hours that morning when she had sent a text message to her partner saying that her sleeping medication was not working.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] [REDACTED] [REDACTED] Legal Director ELFT) � I have also sent it to � Mayor of London � 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: Metropolitan Police Service

23/07/2024

2024-0417

Nathan Scantlebury

Cheshire

1��� Department for Health and Social Care 2���Department for Education 3���NHS England

On 02 October 2019 I commenced an investigation into the death of Nathan Tesla George SCANTLEBURY aged 16. The investigation concluded at the end of the inquest on 15 July 2024. The conclusion of the inquest was that: Nathan Tesla George Scantlebury died as a consequence of asphyxia following a�[REDACTED]. The�[REDACTED] event was a deliberate act but it cannot be established on the evidence that he intended the outcome to be fatal. Nate�s death was contributed to by:- 1. A failure to take appropriate steps to ensure Nate�s safety when the [REDACTED] was first observed and whilst it was still loose; and 2. Neglect � Nate�s death was possibly contributed to by:- 1. The lack of availability generally of suitable placements for children with complex mental health needs. 2. Failures by the Local Authority and the Clinical Commissioning Group to adequately assess the suitability of the placement to meet Nate�s needs; 3. A lack of understanding by the local authority and the clinical commissioning group of the way in which the model of care used in the placement worked in practice and whether this would meet Nate�s needs. 4. Failings by the clinical commissioning group and the local authority to ensure that a s117 after-care plan was in place to ensure that all professionals involved in Nate�s care were aware of their respective role and responsibilities

Nathan Scantlebury was just 16 years old at the time of his death. He had a complex mental health needs and was a looked after child, having been so since December 2013. Nate had a significant history of self-harm and spent several periods detained under the Mental Health Act. Nate had previously been placed at a placement in Wales, specialising in providing care to Young People with high risk self-harming behaviours.� Following a serious incident in August 2018, Nate was detained under the Mental Health Act with the placement considering they could no longer keep him safe. Following a period of detention, the only placement available for Nate was in a mainly adult service, with a least restrictive approach adopting a therapeutic risk-taking and recovery- based approach. The service provided care for those aged between 16 and 25. During the course of Nate�s placement, a number of concerns were raised in respect of the suitability of the service for Nate, with a number of self-harming incidents taking place which required hospital treatment. On the 25th September 2019, Nate tied a��[REDACTED] around his neck, initially the [REDACTED] was loose and Nate was left whilst advice was obtained.� Nate was later found laid on his bed, blue in colour and unresponsive with the [REDACTED] tight around his neck.. The [REDACTED] was removed and Nate�s physical observations taken with further advice being sought and observations taken prior to an ambulance being called.� Nate was taken to hospital and pronounced deceased a short time later.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] Liverpool City Council Cheshire and Merseyside Integrated Care Board (Liverpool) I have also sent it to Child Safeguarding Practice Review Panel 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) | Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: Department of Health and Social Care | Department for Education | NHS England

24/01/2024

2024-0164

Brian Chapman

Cambridgeshire and Peterborough

1��� Department for Transport

On 14 July 2020 I commenced an investigation into the death of Brian William CHAPMAN aged 76. The investigation concluded at the end of the inquest on 19 April 2023. The conclusion of the inquest was that: � Medical cause of death � 1a Multiple traumatic injuries; Conclusion � Road Traffic Collision

Mr Chapman was a passenger seated on the upper deck of a bus travelling eastbound on the A47 at Wisbech St Mary on 26.06.18. At approximately 0728hrs the bus driver did not react to the presence of an articulated lorry which was undertaking a right hand turn from a haulage depot on the nearside of the carriageway onto the westbound carriageway of the A47. The bus collided at sped with the lorry trailer which was sat across the eastbound carriageway. Extensive damage was caused to both vehicles and sadly Mr Chapman suffered significant and unsurvivable traumatic injuries. His death was confirmed at the scene by a paramedic at 0826hrs.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Family of [REDACTED] Family of Mr Chapman Legal Representatives for Brett Transport Legal Representatives for First Bus Legal Representatives for [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.

Road (Highways Safety) related deaths This report is being sent to: Department for Transport

13/01/2025

2025-0023

Joseph Walsh

West Yorkshire Western

1��� Department for Transport 2 [REDACTED] (Secretary of State for Transport)

On 30 October 2023 I commenced an investigation into the death of Joseph Samuel WALSH aged 19. The investigation concluded at the end of the inquest on 17 December 2024. The conclusion of the inquest was that: On 20/10/2023, Joseph Samuel Walsh sustained fatal injuries after he lost control of the car her was driving and collided with a brick wall on Brow Lane, Shelf, Halifax. At postmortem his blood alcohol level was 145mg/dL and he was found to have also taken cocaine (0.19mg/L) prior to the collision.

On the evening of 20/10/23 Joseph was driving his vehicle on Brow Lane with some passengers. It is believed that his vehicle collided with a substantial stone wall to the offside of the road before bouncing back from the wall and coming to a stop in the centre of the road. Police and paramedics attended and Joseph was pronounced deceased at the scene at 23.54.

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

Road (Highways Safety) related deaths

Department for Transport

20/05/2024

2024-0277

Miriam Stone

Derby and Derbyshire

1��� Derbyshire Healthcare NHS Trust

On 23 February 2022 I commenced an investigation into the death of Miriam STONE aged 41. The investigation concluded at the end of the inquest on 07 May 2024. � The medical cause of death was: � 1 (a) Hypoxic Brain Injury Cardiac Arrest Ligature Application and Plastic Bag Asphyxia � The conclusion of the jury at inquest was a narrative conclusion, namely that: � �Miriam carried out the deliberate act of ligating herself [REDACTED] on 18th February 2022, but in doing so, it is not possible to ascertain her intention.� � The jury found that a lack of formal risk assessment, a safety assessment which did not include all relevant risks and an inadequate care plan were probable contributing factors in Miriam�s death. In addition, the jury found that the level of observations were likely assumed rather than individually assessed and that the level set, namely Level 3 every 15 minutes, was not appropriate.

The circumstances are summarised in the findings of the jury: � � Miriam Stone died on the 20th February 2022 at the Intensive Care unit at the Hospital. Miriam has a history of various mental health disorders including Emotionally Unstable Personality Disorder, Schizoaffective Disorder, Schizophrenia and Bipolar. Miriam was admitted on numerous occasions and had a long history of self-harm by various methods [REDACTED]. � Miriam was admitted to Hospital on the 15th February 2022 following an overdose. Whilst in hospital, Miriam undertook actions of self-harming and was distressed culminating in ligation whilst under 15 minute observations. This resulted in a decision to detain Miriam under Section 2 of the Mental Health Act. Miriam was admitted to the Mental Health Unit on the 17th February 2022 as considered to be a high risk of self-harm or completed suicide and hospital considered a place of safety and assessment. � Upon admission Miriam was presenting as calm and not in distress and was being monitored at 15 minute intervals. Miriam was interacting with staff but was not formally assessed� by� clinical� staff� and� a� safety� assessment� was� only� partially� completed.��� No documented decision as to levels of observation or suicide risk exists to determine decisions made as to risk. � On the morning of the 18th February 2022, 13 minutes after being observed by staff, Miriam was not observable in her bed space and staff recognising the ward toilet door was locked, subsequently found Miriam in the toilet [REDACTED]. This was swiftly removed and revealed a ligature around Miriam�s neck [REDACTED]. � Miriam was taken to hospital where she was intubated and ventilated. Despite treatment, her condition deteriorated and she died on 20th February 2022.

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

Suicide (from 2015)

Derbyshire Healthcare NHS Trust

04/01/2024

2024-0146

Stephen Coster

East Sussex

1��� HM Prison and Probation Service

On 13 May 2022 I commenced an investigation into the death of Stephen COSTER aged 43. The investigation concluded at the end of the inquest on 04 December 2023. The conclusion of the inquest was that: � Stephen was detained at HMP Lewes on 26.4.2022 on remand. Stephen was found in his cell on the floor naked between 5am-5.30am on the morning 3rd May 2022. Prison officers called for health care to attend Stephen�s cell. Medical staff attended, very limited examination was made. At this time no treatment was given. Stephen was left in his cell in the same condition. Health care staff advised Prison staff to undertake observations. It was recorded Stephen was under the influence. At approximately 8.30am, Stephen was checked in his cell. His condition had deteriorated. Prison staff asked for healthcare to attend. Healthcare staff deemed it necessary for an ambulance to be called. Following assessment ambulance staff advised Stephen should immediately be taken to hospital. There is evidence that delays to paperwork resulted in the ambulance being unable to leave the prison grounds. The Paramedic clearly stated that Stephen should be taken to hospital immediately with life threatening conditions. Paperwork was eventually completed. The ambulance was able to leave prison at 10.29am, Stephen arrived at hospital at 10.45am. Stephen was taken to resuscitation, and received treatment at the hospital.

Stephen Coster died as a result of 1a Meningo encephalitis owing to Streptococcus pneumoniae at Royal Sussex County Hospital, Brighton. The jury found that delay by the prison staff and healthcare staff in enabling the correct treatment to be given to Stephen Coster in HMP Lewes more than negligibly, minimally and trivially contributed to his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Family of Stephen Coster Practice Plus Group I have also sent it to South East Coast Ambulance Service NHS Foundation Trust Prisons and Probation Ombudsman Independent Advisory Panel on Deaths in Custody HM Inspectorate of Prisons who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

State Custody related deaths This report is being sent to: HM Prison and Probation Service

12/03/2024

2024-0134

Giuseppe Tabone and Andrew Evans

East Sussex

1��� HM Prison and Probation Service

On 01 July 2022, I commenced an investigation into the deaths of Giuseppe TABONE aged 58 and Andrew EVANS, aged 34, who both died on 28 June 2022 in HMP Lewes. The investigation concluded at the end of the joint inquest into their deaths on 26 February 2024. The conclusion of the inquest was that: � Andrew Evans and Giuseppe Tabone died as a result of Misadventure by Drug Related Overdose. This was caused by a synthetic opioid namely isotonitazene. Due to the potency of the drug, 500 times more powerful than Morphine, it is likely they became unconscious very quickly and died. � There were admitted failures by Prison staff to carry out roll checks at 19.30 and 20.45 on 27th June 2022. It is not possible to say whether had those checks been carried out their lives would have been saved. Isotonitazene had not been encountered in prison before therefore had the anit-drug Naloxone been administered it may not have been effective as a normal single dose is used but for isotonitazene multiple doses may be needed.

Giuseppe and Andrew died from the intentional inhalation of isotonitazene at HMP Lewes. [REDACTED] Clinical evidence of the onset of death is inconclusive but suggests it is likely that Giuseppe and Andrew fell unconscious shortly after inhaling the substance.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Practice Plus Group The family of Giuseppe Tabone The family of Andrew Evans � I have also sent it to � HM Inspectorate of Prisons � 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, drug and medication related deaths This report is being sent to: HM Prison and Probation Service

05/02/2024

2024-0057

Kyle Goater

West Yorkshire (Western)

1��� Ilkley Town Council

On 23 July 2021 I commenced an investigation into the death of Kyle James GOATER aged 25. The investigation concluded at the end of the inquest on 19 September 2023. The conclusion of the inquest was that: � Upon the 20th July 2021, Kyle James Goater was travelling along Moor Road away from Ilkley, when his motor vehicle in good working order, approached a rising crest in the road which reduced his visibility of the road ahead. The road continued into a dip where a parked vehicle stood in a layby adjacent to the carriageway, on the offside. Unbeknown to Mr Goater an RAC van was stationary within the lane travelled by him indicating to turn right into the layby. Upon reaching the crest of the road Mr Goater became aware of the stationary RAC van, and braked to avoid a collision, which could not be avoided. As a result a of the collision between Mr Goater�s car and the RAC van, a third vehicle travelling in the opposite direction became involved in the collision. Following the collision Mr Goater remained initially unable to free himself from his car, having suffered chest injuries which impacted upon his ability to breathe freely. The Ambulance Service was called to attend the scene, and whilst awaiting the arrival of a resource allocated to the incident, Mr Goater suffered a Cardiac Arrest: CPR was initially administered by the Police personnel prior to the attendance of the Ambulance crew , and then continued by a Paramedic, which failed to revive Mr Goater; with his death being certified at 18:58 hours at the collision scene that day.

Kyle is a 25yr old young man who resides alone in Keighley. � On Tuesday the 20th of July, Kyle has been the driver of a MGZS Motor Vehicle travelling from Ilkley towards Menston. As he has crested the brow of a hill he has collided with two separate vehicles. Kyle�s vehicle sustained substantial damage. � Police Officers from Bradford Road�s Policing have attended the report of this collision. Initially Kyle was talking and mobilising at the scene of the incident. Kyle then began to complain of chest pain. His breathing then became shallow and he went into arrest. CPR was commenced by officers on scene. CPR continued until paramedics arrived on scene, they then took over. The paramedics continued CPR, until life was pronounced extinct at 18:58hrs.

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

Road (Highways Safety) related deaths This report is being sent to: Ilkley Town Council

03/06/2024

2024-0300

Isabella McCreadie

Surrey

1��� Inquests � Frimley Health Foundation Trust (FPH Frimley Park Hospital) 2 [REDACTED] 3 [REDACTED]

On 03 July 2023 I commenced an investigation into the death of Isabella MCCREADIE aged 90. The investigation concluded at the end of the inquest on 03 June 2024. The conclusion of the inquest was that: � On 24th April 2023 Mrs McCreadie at the age of 90 years old suffered a mechanical fall at home resulting in a comminuted fracture of the distal femur and fracture of her humerus. She was admitted to hospital and had an operation to repair the fracture to her distal femur.� Mrs McCreadie suffered known complications following the major operation including low haemoglobin and delirium. She also developed a hospital acquired stage 4 pressure sore on her sacrum. Mrs McCreadie did not have the physiological reserves and died on 6th June 2023 at 18:30 at home in a residential address in Camberly of pneumonia.

On 24th April 2023 Mrs McCreadie at the age of 90 years old suffered a mechanical fall at home resulting in a comminuted fracture of the distal femur and fracture of her humerus. She was admitted to hospital and had an operation to repair the fracture to her distal femur.� Mrs McCreadie suffered known complications following the major operation including low haemoglobin and delirium. She also developed a hospital acquired stage 4 pressure sore on her sacrum. Mrs McCreadie did not have the physiological reserves and died on 6th June 2023 at 18:30 at home in a residential address in Camberly of pneumonia.

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

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

04/12/2023

2023-0496

Angela Collins

Bedfordshire and Luton

1��� Interim Chief Executive ELFT �[REDACTED]

On 12 September 2022 I commenced an investigation into the death of Angela Dawn COLLINS aged 50. The investigation concluded at the end of the inquest on 30 November 2023. The Conclusion of the Inquest was a Narrative Conclusion: � �The Deceased died from an overdose of prescription drugs taken whilst she was suffering from severe mental and emotional distress�.

The Inquest found that: � The Deceased had a history of depression which was made significantly worse by the death of one of her children in 2012. After taking a prescription drug overdose in February 2022, she came under the care of the Community Mental Health Team. After taking a further intentional prescription drug overdose on 3 May 2022, she was provided with a period of in- patient psychiatric treatment. Although she was discharged back to the Community Mental Health Team following her discharge, she did not attend her appointment with the Community Psychiatrist on 14 July 2022. By early August 2022, although it was clear that her mental health had deteriorated and that her relationship with her Community Mental Health Team Key Worker had broken down, she was not seen by any clinically qualified staff and had limited mental health support. A crisis point was reached when she awoke in the early hours of 18 August 2022 in distress and, after packing a bag which included half a week�s medication, left her home at 04.00 hours. Police subsequently attended her home and found a note suggesting a possible intention to harm herself. She was deemed to be a high-risk missing person and, after an effective search by police, she was located at the Travelodge in Toddington; although she denied being suicidal, police made further referrals to the Mental Health Team and Social/Children Services with concerns for her welfare. Although requested by Social/Children Services to see her, the Community Health Team did not go to see her but, instead, attempted to contact her by telephone. When the Deceased called them back at around 16.09 hours, her call was answered by administrative staff and, when she could not be put through to the clinically trained Duty Officer, she terminated the call. Although the Duty Officer called her back shortly after, she did not answer and no further action was taken. At around midnight, Travelodge staff found the Deceased slumped in the hallway outside her room. On informing them that she had depression, Covid 19, and had taken an overdose [REDACTED], they called an ambulance. Owing to service demand, there was a 3 hour wait for an ambulance and, when the paramedics arrived at 03.43, they found her in cardiac arrest on the bed in her room. Despite all resuscitation efforts, her death was confirmed at 04.29 hours. A bag containing multiple packs of medication [REDACTED]was found under the bed and post- mortem examination confirmed that she had a blood level of [REDACTED] within the fatal range as well as an excess of [REDACTED]. A note found at the scene included the words �if I should die..�

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Team Manger of Children Services, Central Bedfordshire Council � [REDACTED} [REDACTED] � Next of Kin � I have also sent it to � DDC of Bedfordshire Police � [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.

Alcohol, drugs medication related deaths | Suicide (from 2015) This report is being sent to: ELFT

21/09/2023

2023-0345

Melvyn Blount

Derby and Derbyshire

1��� Lister House Oakwood

On 19 January 2023 I commenced an investigation into the death of Melvyn Lee BLOUNT aged 64. The investigation concluded at the end of the inquest on 21 September 2023. The conclusion of the inquest was that: � Melvyn Blount tied a [REDACTED]Ligature [REDACTED]. From the evidence it has not been possible to determine what his intention was when he did so. In the days leading up to his death he was increasingly confused and expressing delusional thoughts. He died from asphyxiation which was caused by the act of him tying the ligature [REDACTED] ���������� .

Melvyn Blount experienced a sudden and significant decline in his mental health and was having delusional thoughts. He had a telephone consultation with a mental health nurse on the 10th of January 2023 who concluded that the most likely cause was lack of sleep. Mr Blount was prescribed sleeping tablets. The mental health nurse was a non prescriber and sought the assistance of a GP to prescribe zopliclone. His condition deteriorated and on the 12th of January his wife instigated a further telephone consultation by the mental health nurse who referred him for an appointment with a General Practitioner to investigate whether there was a physical cause for his decline in mental health. In that telephone consultation his family requested a face to face appointment and he was referred back to the mental health team. On the 13th of January he was seen by a second mental health nurse who was concerned that his presentation was due to a mental disorder rather than arising from a physical cause but ordered blood tests to exclude that as a possibility. Melvyn Blount was displaying delusional thoughts during his consultation. The nurse did not instigate any further investigation of, or seek support for, his potential mental disorder and was reliant upon his family providing that support and keeping him safe. His family were not warned not to leave him alone. On the 14th of January 2023 Melvyn Blount [REDACTED] causing him to asphyxiate. Emergency services were called by his wife and he was taken to the Royal Derby Hospital where he was found to have died.

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

Mental Health related deaths | Alcohol, drugs medication related death This report is being sent to: Lister House Oakwood

12/10/2023

2023-0384

John Hoare

West Yorkshire (Western)

1��� Low Moor Medical Practice

On 15 April 2020 I commenced an investigation into the death of John HOARE aged 62. The investigation concluded at the end of the inquest on 12 October 2023. The conclusion of the inquest was that: � John Hoare died a natural death occurring while, preventably, detained under the Mental Health Act 1983.

John Hoare was born on 03 February 1958. He died at 06.30am on 31 March 2020 at Airedale General Hospital. He had a diagnosis of schizoaffective disorder. He had admissions at Bradford Royal Infirmary between 15 November and 04 December 2019 and 14 December and 14 January 2020. He suffered from confusion, cognitive and memory problems and lithium toxicity. He was discharged from Bradford Royal Infirmary to Norman Lodge Care Home. This resulted in a change of medical practice from Shipley to Low Moor Medical Centre. Concurrently his established Community Mental Health Care Coordinator changed � he did not have one on discharge from hospital. The new one was allocated on 24 January and was able to first meet with John on 05 March. John required a number of prescribed medications for his condition, including, crucially, lithium citrate. This was clearly referenced in the discharge letter and the Norman House care plan. Lithium was dispensed and administered between 15 and 24 January per his prescription. It was not supplied with the next 28 days medication. On 20-21 January a decision was made by GPs that blood tests were required before the prescription for lithium could resume. These confirmed by 04 February that John`s lithium was below therapeutic levels. For the purposes of the next prescription period, commencing from 17 February, however, lithium was not included. There had been GP oversight of this but there was a failure to recognise and act on the omission. John`s mental health declined critically from 03 march 2023. Advanced Nurse Practitioners attended Norman House 2-3 time per week. On 04 March, for the first time, an Advanced Nurse Practitioner examined John. She said she would prescribe lithium. It was dispensed and administered on 05 March. Therefore John did not receive lithium between 24 January and 05 March.� By the time it was resumed his condition was so severe that he required to be detained under Section 4 of the Mental Health Act 1983, in the early hours of 06 March 2020. He was admitted to the Bracken and then Fern wards of Airedale Centre for Mental Health. While admitted, albeit there were no other reported cases among staff or residents, he contracted Covid 19. This required his admission to Airedale General Hospital on 27 March 2020, where he subsequently died. He remained detained under section at the time of his death. James had been in a dependent position while at Norman House. Lithium could have resumed no later than 04 February and should have resumed no later than 17 February 2020, and it did not. There was a gross failure to provide basic medical attention insofar as: there was reference to lithium on the discharge summary; Johns�s case required specific attention; there was obvious evidence on system 1 available to be seen; John`s needs as a new patient should have been carefully considered; lithium prescribing, dispensing and administration should attract particular care and attention; there was an inherent importance in not delaying or interrupting lithium; there had been numerous requests and reminders from the care home about the provision of lithium; there was a material delay during which nothing was done by the GPs` surgery; there was failure to identify that delay; that failure led to the precise consequence that the lithium was intended to avoid. As a result of this gross failure, John required to be detained and admitted to Airedale Centre for Mental Health. The omission of the lithium contributed to his condition more than other factors. John contracted Covid 19 while admitted at Airedale Centre for Mental Health, most likely in the Fern Ward, possibly from a member of staff. While it is possible that he was at a greater risk of infection while in the Fern Ward than he would have been at Norman House, or any other environment at that time, it cannot be so concluded on a balance of probabilities. Therefore it cannot be concluded, on a balance of probabilities, that his death from Covid 19 was caused by his being detained under section, albeit the detention was preventable.

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

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

22/02/2024

2024-0101

Jamie Pilkington

Staffordshire and Stoke on Trent

1��� Midlands Partnership Foundation Trust (MPFT)

On 23 March 2023 I commenced an investigation into the death of Jamie Peter Norman PILKINGTON aged 51. The investigation concluded at the end of the inquest on 13 February 2024. The conclusion of the inquest was that of �Road traffic collision�

The deceased passed away in his vehicle which had left the road, struck a tree and caught fire in the early hours of the morning of 12th March 2023 on Port Lane, a short distance from Whitehouse Lane, Codsall, Staffordshire. He was confirmed deceased at the scene. He was, at the time of the collision, under the care of the Mental Health Services and had been expressing suicidal thoughts, something with which he had suffered for many years. There was no evidence to suggest that he left the road intentionally.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to the family of the deceased 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 | Mental Health related deaths This report is being sent to: Midlands Partnership Foundation Trust

04/08/2023

2023-0284

Harry Stobie

Milton Keynes

1��� Milton Keynes University Hospital

On 03 April 2023 I commenced an investigation into the death of Harry Arthur STOBIE aged 77. The investigation concluded at the end of the inquest on 20 July 2023. The conclusion of the inquest was that: � Narrative Conclusion � Died as a result of a haemoperitoneum after insertion of a PEG tube, that is a recognised complication of a necessary medical procedure.

The deceased suffered a stroke on 15th February 2023 and was admitted to Milton Keynes University hospital and transferred to John Radcliffe hospital for a thrombectomy and was repatriated back to Milton Keynes on the 20th February 2023, he underwent a PEG insertion on the 23rd March 2023 caused a large haemoperitoneum that was not recognised at the time. His condition deteriorated and he died on 26th March 2023.

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

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

21/12/2023

2023-0547

Wyndham Thomas

Nottingham City and Nottinghamshire

1��� Minister for Prisons and Probation, Ministry of Justice, Petty France, London

Wyndham Richard Thomas died on 6 November 2018, at the Queens Medical Centre, Nottingham. He was a serving prisoner. A coronial inquest into his death was opened on 29 November 2018. � An inquest before a jury was resumed on 22 May 2022 but the jury were discharged due to a serious irregularity. � The inquest was re-listed before the next available court and resumed before a jury on 30 January 2023, concluding on 10 February 2023.

CIRCUMSTANCES OF DEATH The following represents the findings of fact returned by the jury: � Wyndham Richard Thomas was a prisoner transferred to HMP Nottingham on 29th of October 2018. He had been at HMP Nottingham previously (July � October 2018). Wyndham was serving a life sentence, with a minimum tariff of 10 years which commenced on 9th of April 1998. He ligated and was found unconscious in his cell at 18:04 on 4th of November 2018. He had moved prisons a great deal � 13 prisons in the previous 3 years and had transferred from HMP Norwich. This had made it difficult for his family (based in South Wales) to maintain contact. He had been managed on ACCTs many times � 25 ACCTs between 2016 and 2018. Wyndham had also been prescribed medication for anxiety and depression. He began self-harming in 2016 and first ligated on 3rd of October 2016, because of a lack of tobacco. On arrival at HMP Nottingham on 29th of October 2018 he went onto F Wing. During the safer custody interview several triggers were added to his ACCT plan. These were: That he managed his self-harm [REDACTED] That he had a parole decision coming up on the 31st of October which was a cause of stress for Wyndham (parole was refused on the 31st of October) That he had taken [REDACTED] (and so was referred to the substance misuse team) News about his daughter�s [REDACTED] which coincided with the anniversary of his sister�s [REDACTED]. That he had issues with going onto B wing because of drugs related issues. Wyndham remained on F Wing until 2nd of November and when an officer tried to relocate him from F to B wing Wyndham struck him. At this point (1.30 pm) he was forcibly removed and placed in the segregation unit. An ACCT case review followed at 15:10 during which his healthcare safety segregation paperwork was signed. The Governor�s Defensible Decision to Segregate a prisoner on an open ACCT was completed. Wyndham did not receive an assessment of his mental health within 24 hours of segregation. There were no certified safer cells to house Wyndham in, even if they had referred to his history of ligation. No care map was produced, and Wyndham was tasked by the Governor chairing the meeting with writing his goals over the weekend. Wyndham�s level of risk was increased from �low� to �raised� but his observation was reduced to every 2 hours. There were no measures put in place to reduce his risk of self-harm as there had been no meaningful risk assessment carried out. An officer collected Wyndham�s last [REDACTED] from his cell on F wing at 17:30. Wyndham had been asking for access to�[REDACTED] and had been refused by the Governor in the afternoon. On Saturday 3rd of November, from early in the morning, Wyndham was pressing the cell bell regularly to request more [REDACTED]. He made a number of demands, one of which was a listener. This was refused and Wyndham rejected the Samaritans phone that was offered. It was a source of ongoing frustration between prison officers and Wyndham. He was �up and down�, becoming verbally aggressive in response to repeated refusals. At 15:30 the Governor carried out his daily review of Wyndham�s continuing segregation. Wyndham moved cells in the afternoon. At approximately 18:30 Wyndham showed his escalating frustration by banging his head against the cell window and door. Self-harm, using [REDACTED] was inflicted on Wyndham�s left forearm on the site of an earlier wound and the ACCT book was updated at 19:00. Healthcare was called but Wyndham refused treatment and a dressing was passed under the door. As staff were relying on Wyndham�s presentation and were unaware of any risk relevant information, no further action was taken and there was no review of Wyndham�s ACCT following this self-harm incident. Had the records been consulted at this point the risks would have been apparent. Wyndham was seen the following morning � on Sunday 4th � by a healthcare nurse and around 9:30am the Governor�s daily review was carried out, at which point[REDACTED]were again refused. Wyndham made repeated use of the cell bell in the morning to request [REDACTED] . Wyndham was continuing to request vapes and being refused. A radio was provided around 17:00 as a distraction. He was still verbally abusive when his cell bell was answered at 17:45. An officer checked on Wyndham at 17:54 and observed Wyndham for 17 seconds before walking away. Wyndham was standing between the sink and the cell door, almost out of view. He was standing up and breathing although there was no verbal interaction. The officer returned at 18:04, realised that something was amiss and radioed for assistance. He could see the top of Wyndham�s head below the observation panel against the door and a ligature running down the side of the observation panel. 3 officers entered the cell at 18:06 and cut the ligature, [REDACTED]. An officer and nurse commenced CPR and a second nurse arrived with the emergency bag at 18:07. A code blue was called but it is not conclusive at what time precisely. Wyndham was transferred to the Intensive Care Unit at QMC, at approximately 18:45. On the 6th of November 16:40 Wyndham was pronounced dead.

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

State Custody related deaths | Suicide (from 2015) This report is being sent to: HM Prison and Probation Services

21/05/2024

2024-0282

Emma Morris

Cheshire

1��� NHS England

On 29 September 2023 I commenced an investigation into the death of Emma Louise MORRIS aged 39. The investigation concluded at the end of the inquest on 15 May 2024. The conclusion of the inquest was that: � Suicide

Emma Morris had a medical history of anxiety and depression. She had suffered a deterioration in her mental health and on the 20th September 2023, deliberately walked in front of a bus on the slip road of junction 39, Chester, heading towards the A55. A gatekeeping assessment had been completed by a mental health practitioner of the Crisis Resolution and Home Treatment Team on the 19th September where the practitioner found that an informal inpatient admission to a mental health ward was clinically indicated, but this could not be facilitated immediately as there were no beds available nationally. She was therefore under the care of the Crisis Resolution Home Treatment Team at the time of death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � The family of Emma Morris Cheshire and Wirral Partnership 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 | Suicide (from 2015) This report is being sent to: NHS England

16/11/2023

2024-0126

John Singleton

Cheshire

1��� NHS England

On 16 September 2019 I commenced an investigation into the death of John Joseph SINGLETON aged 42. The investigation concluded at the end of the inquest on 16 November 2023. The conclusion of the inquest was that: � Suicide

John Joseph Singleton [REDACTED] with a history of depression following significant family bereavements and epilepsy secondary to a head injury. Compliance with medications for these conditions had previously been sporadic. John had a history of previous incarcerations when he arrived at HMP Risley in May 2019 to serve a 10 month sentence for attempted burglary. In August 2019 John began acting bizarrely, had fixed thoughts of persecution and paranoia but did not disclose any thought of self-harm or suicide ideation. Periods of intermittent self-isolation followed these paranoid thoughts. An Assessment, Care in Custody and Teamwork document was initiated on Saturday 31st August 2019 to identify the issues, offer support and put monitoring in place, but John�s mental health continued to deteriorate. On 1st September 2019 during the prison transition period from night to day state, John was on his own in his locked cell [REDACTED] with the intention of ending his life. At 7:56am access to the cell was gained and John was found hanging [REDACTED]. The ligature was cut to release John and appropriate emergency response made. Upon arrival paramedics took over emergency care, obtained a cardiac output and transferred John to Warrington Hospital where he later died on the 10th September 2019 at 17:25. Aspects of the systems relating to medicines non-compliance and mental health referrals at HMP Risley were lacking but did not cause or contribute to John�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Bridgewater Community Healthcare Greater Manchester Mental Health Trust HMP Risley 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) | State Custody related deaths This report is being sent to: NHS England

18/12/2024

2024-0695

Eleanor Aldred-Owen

Liverpool and Wirral

1��� NHS England 2���Chief Coroner

On 11 October 2023 I commenced an investigation into the death of Eleanor Hazel ALDRED-OWEN aged 1. The investigation concluded at the end of the inquest on 18 December 2024. The conclusion of the inquest was that: The conclusion of the inquest was that cause of death: 1a. Severe hypoxia ischaemic encephalopathy (with coning) 1b. Cardio respiratory arrest 1c. Right tension pneumothorax Conclusion: Misadventure contributed to by neglect.

Eleanor was admitted to Alder Hey Children�s Hospital on 29th September 2023 for elective craniofacial surgery. There was no associated problems or genetic abnormalities, and Eleanor was otherwise well. The procedure for bicoronal synostosis was uneventful except that Eleanor�s tracheal tube dislodged towards the end of the procedure and she required reintubating. Eleanor returned to the ward following her surgery and was seemingly stable apart from being tachycardic. Over a period of several hours, she deteriorated with increased breathing and respiratory distress. At 22:35 hours Eleanor sustained a cardiac arrest and required full resuscitation over the course of 20 minutes until return of spontaneous circulation was achieved. A chest x ray that had been ordered at 22:03 hours and was performed at 22:18 hours was grossly abnormal but this was not raised or concerns escalated with any of the medical or nursing staff on the ward. The x ray was not reviewed until 22:40 hours and revealed a right sided tension pneumothorax, which was decompressed and a drain inserted. There was a period of approximately 30 minutes between the x ray being taken at 22:18 hours and bilateral needle decompression being performed at 22:48 hours, effective resuscitation was unlikely to have occurred until the bilateral needle decompression was performed on Eleanor, this delay in the decompression being performed more likely than not contributed to the subsequent ischaemia suffered by Eleanor. Eleanor was transferred to the paediatric intensive care unit and over the course of the next two days became gradually unstable, a CT scan of her head was obtained which showed catastrophic hypoxic ischaemic change with evidence of coning. Life sustaining measures were then withdrawn and Eleanor sadly died on 2nd October 2023.

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

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

NHS England

27/11/2023

2023-0481

Amirah Khalifa

Liverpool and Wirral

1��� NHS England & NHS Improvement (PFDs)

On 06 February 2023 I commenced an investigation into the death of Amirah KHALIFA aged 42. The investigation concluded at the end of the inquest on 24 November 2023. The conclusion of the inquest was that: � Narrative Conclusion: Inappropriate and prolonged administration of steroids contributed to by neglect.

Amirah Khalifa was a 41 year old lady who had a complex medical history, including a presumed hepatocellular carcinoma for which she underwent a TACE (trans arterial chemoembolization) in 2016. On 31 August 2018 Amirah was admitted to the Royal Liverpool Hospital presenting with vomiting and right upper quadrant pain, a known complication after a TACE procedure. Various medications were prescribed but the pain was ongoing. On 11 September 2018, whilst still in hospital, Amirah was prescribed dexamethasone (a steroid), initially [REDACTED] twice daily and �then [REDACTED] once a day. She was then discharged from hospital. A discharge summary was sent to her General Practice (GP) requesting the steroid medication to be reviewed. When the steroids were prescribed there was no indication noted as to the length of the intended treatment course in the clinical notes or in the discharge letter issued by the hospital team. In April 2019 the steroids were noted as a repeat prescription in the GP records rather than an acute prescription. It is unclear upon what basis this was done. On 12 June 2019 Amirah was admitted to the Royal Liverpool University Hospital with dizzy spells. It was noted that her high blood pressure was poorly controlled. Her dexamethasone was continued in hospital and on discharge. A discharge summary was sent to her GP practice with the steroids to be continued. On 12 September 2019 Amirah was admitted to the Royal Liverpool hospital with similar symptoms. Her dexamethasone was continued again in hospital and on discharge. Throughout 2019-2022 Amirah had numerous consultations with various specialists in the Royal Liverpool University Hospital. On 29 December 2022 Amirah was admitted to the Royal Liverpool University Hospital feeling generally unwell and with leg pain. Treating medical professionals deemed that Amirah�s case was complex and multiple organ systems were investigated and treated. Despite active treatment Amirah deteriorated and died on 31 January 2023. The post mortem examination found it was more likely than not Amirah died as a result of multiple organ failure caused by sepsis and intestinal haemorrhage as a result of long term steroid therapy. Throughout, on each discharge from hospital, a discharge letter was sent to Amirah�s GP and was generally to continue the dexamethasone. There were a number of failures relating to the care and treatment afforded to Amirah; through numerous appointments an incomplete medication history was taken and documented which did not include dexamethasone. Amirah had multiple complex conditions and was under the care of numerous specialists, many of whom clearly did not appreciate she was on steroids, and had been, for a lengthy period of time. Amirah was seen by numerous clinicians both in the hospital and in the community and at no stage was it questioned as to why she was still on the steroids, and why at the high dose she was on. Evidence has been heard that it was rare for a patient to be on these steroids at this dose for a lengthy period of time. Amirah presented with symptoms clearly suggestive of the possibility of complications of steroid use, namely uncontrollable blood pressure, diabetes, swelling and cognitive impairment. There was a failure to recognise these obvious presentations and the link between them and the long term steroid use. There was a failure to document in the clinical notes and / or in the discharge letter, the indication or length of the dexamethasone tablets. This failure prevented adequate instructions being provided to Amirah�s GP as to the intended length of the dexamethasone treatment and monitoring of the same. There was a failure for the GP to clarify the discharge with the hospital and to review the medication, this failure was exacerbated by the fact the prescription was changed to repeat from acute with no apparent reason. Overall, there was a catalogue of missed opportunities both in hospital as well as in the community to identify that Amirah remained unnecessarily on dexamethasone tablets despite multiple reviews as an inpatient and outpatient. Even when the ongoing prescription was identified, and Amirah was symptomatic of Cushing�s disease and steroid induced diabetes the correct action to wean treatment completely was not undertaken. It is a basic and fundamental expectation for a clinician in charge of a patient�s care to monitor and review prescribed medication, particularly acute medication such as steroids. There was a failure to do this for Amirah despite the fact that there were numerous opportunities to do so over a lengthy period of time. The accumulation of failures through the primary and secondary care services has led to a gross failure to provide basic medical attention to Amirah who was in a dependent position and had every reason to rely upon those who had management of her care and treatment to prescribe, monitor and review her medication. It is more likely than not the inappropriate and prolonged administration of steroids caused Amirah�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � ��[REDACTED] Royal Liverpool University Hospital Sandringham Medical Centre � 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.

Alcohol, drugs medication related deaths | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS England | NHS Improvement

11/05/2023

2023-0149

Nicholas Pennicott

West Sussex

1��� NHS England & NHS Improvement (reg 28 reports)

On 24 August 2021 I commenced an investigation into the death of Nicholas John PENNICOTT aged 61. The investigation concluded at the end of the inquest on 19 April 2023. The conclusion of the inquest was that: � On 19th August 2021 Nicholas, who was suffering from Guillain Barre Syndrome, suffered a cardiac arrest at his home address. Nicholas� health had been deteriorating and at the time of his death he had been waiting over 8 weeks to see a neurologist following an urgent referral. This delay had caused him additional stress and anxiety. � The conclusion of the Inquest was that Nicholas had died from natural causes.

Mr PENNICOTT�s health had been deteriorating since March 2021 and this resulted in an admission to A&E at St Richards Hospital on 23rd June 2021. Following this admission Mr PENNICOTT was referred to see a Neurologist , as an urgent referral, as an outpatient. At the time he was suffering from Guillain Barre Syndrome. Despite his GP and family chasing up this appointment he was not offered an appointment until 19th August 2021. Sadly he suffered a cardiac arrest in the early hours of the very day that his appointment was due to take place.

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

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

03/07/2024

2024-0354

Ruth Eggleton

Nottingham City and Nottinghamshire

1��� National Institute for Health and Care Excellence

On 10 May 2023, I commenced an investigation into the death of Ruth Diane Eggleton. The investigation concluded at the end of the inquest on 2 July 2024. The conclusion of the inquest was a narrative conclusion: � Ruth Diane Eggleton fell whilst gardening, sustaining a head injury. Rivaroxaban was not withheld or reversed, and Mrs Eggleton was discharged from hospital on 2 April 2023, both of which more than minimally, negligibly or trivially contributed to her death from traumatic subdural haemorrhage.

On 2 April 2023, Ruth Diane Eggleton fell in her garden, sustaining a brain injury. A CT head scan undertaken on 2 April 2023 revealed a small subdural haemorrhage. Mrs Eggleton was anticoagulated with Rivaroxaban which was neither reversed nor discontinued on 2 April 2023. Mrs Eggleton was discharged from hospital on 2 April 2023. � Had Mrs Eggleton remained in hospital for neurological observations in accordance with NICE guidelines, she would have more than likely survived as those observations would have revealed Mrs Eggleton�s deterioration early on which would have led to reversal and cessation of Rivaroxaban, and allowed for surgical evacuation of the haemorrhage before Diane was too neurologically compromised. The subdural haemorrhage continued to ooze, contributed to by ongoing anticoagulation with Rivaroxaban. The continuation of Rivaroxaban more than minimally contributed to Mrs Eggletons� death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED]� [REDACTED]� [REDACTED]� Doncaster & Bassetlaw Teaching Hospitals Sheffield Teaching Hospitals � I have also sent it to � Department of Health and Social Care DHSC The Royal College of Surgeons The Society of British Neurological Surgeons Royal College of Pathologists British Society of Haematology Royal Society of Medicine The Royal College of Physicians British Cardiac Society � 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 Institute for Health and Care Excellence

18/04/2024

2024-0208

Michael Briggs

Derby and Derbyshire

1��� National Institute for Health and Care Excellence

On 13 January 2023 I commenced an investigation into the death of Michael BRIGGS aged 79. The investigation concluded at the end of the inquest on 21 March 2024.

On 7th November 2022 Michael Briggs consulted with his dentist as to undergoing dental extractions due to pain. He was advised to discuss the safety of such a procedure with his GP as he was taking anticoagulants. On 26th November he returned to his dentist and, having indicated to the dentist that there were no issues with him undergoing the procedure, he proceeded to have three extractions. The procedure was uneventful, and he returned home to recuperate. On 30th November 2022 Mr Briggs was admitted to A & E with a fever and reported a history of bleeding following the extraction. Blood cultures confirmed the presence of staphylococcus aureus and, as Mr Briggs had a bio-prosthetic aortic valve, it was suspected that he had developed infective endocarditis. The diagnosis was confirmed by Trans-oesophageal Echo on 14th December 2022 and he was treated with antibiotics. Despite treatment his condition continued to deteriorate. He was recognised as approaching the end of his life and sadly died at Royal Derby Hospital on 11th January 2023. � The court heard evidence that infective endocarditis is a recognised complication of invasive dental procedures for those who have certain underlying health conditions such as valve replacements. For such patients the provision of antibiotic prophylaxis may reduce the risk of developing infective endocarditis. On the evidence before the court, it is not possible to determine whether prophylactic antibiotics would have made a difference to the outcome in Mr Brigg�s case. � Narrative conclusion: Michael Briggs died due to recognised complications arising from a dental extraction procedure.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] DENTIST Royal Derby Hospital � Legal Services � 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 Institute for Health and Care Excellence

12/12/2023

2024-0001

Reece Nelson

North Lincolnshire and Grimsby

1��� Navigo

On 07 March 2022 I commenced an investigation into the death of Reece William NELSON aged 23. The investigation concluded at the end of the inquest on 05 December 2023. The conclusion of the inquest was that: � Reece Nelson was found hanging [REDACTED] on the 28th February 2022 at his home address of Richmond Road, Grimsby. Paramedics attended and pronounced death.

Reece Nelson was found hanging [REDACTED] on the 28th February 2022 at his home address of Richmond Road, Grimsby. Paramedics attended and pronounced death.

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 � 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: Navigo

20/07/2023

2023-0273

Andrew Vizard

Nottinghamshire

1��� Nottinghamshire Healthcare Trust � NHCT

On 11 November 2022 I commenced an investigation into the death of Andrew Vizard, aged 58 years. The investigation concluded at the end of the inquest which took place before myself as coroner sitting alone on 6 July 2023. My conclusion at the end of the inquest was: � Natural causes.

Andrew Vizard was 58 years old when he died on 14 July 2022 at Queen�s Medical Centre, Nottingham. He died from a pulmonary embolism. � At the time of his death, he was detained on the Rowan 1 Ward of Highbury Hospital under section 2 of the Mental Health Act 1983 and was subject to constant 1:1 observations. He had a relatively short but significant history of mental ill-health dating back to March 2021. Andrew also had the following physical health conditions: Systemic Hypertension; Hypertensive Heart Disease; Ischaemic Heart Disease; and Obstructive Sleep Apnoea. None of these conditions caused or contributed to his death. Andrew�s hypertension was identified upon admission to Rowan 1 on 2 July 2022 and was monitored regularly throughout his admission. � On 14 July 2022, at approximately 12:23pm, the healthcare assistant responsible for observing Andrew became concerned about him snoring loudly. At approximately 12:25 she asked a colleague peer support worker for a second opinion. At approximately 12:27, that colleague left and returned one minute later with the Ward Manager. Andrew was still breathing at that time but he was unresponsive to voice or pain. A minute after that, at approximately 12:29, other members of staff arrived with physical monitoring equipment and a life support bag. The ward trainee GP was summoned and arrived at Andrew�s room at 12:32. He identified that Andrew was in cardiac arrest and commenced CPR. An ambulance was called at 12:34:06, over 10 minutes after concerns were first identified. Further, the staff who performed CPR prior to the attendance of the paramedics were unaware that the life support bag contained a Bag Valve Mask. In its place, they used a rebreather mask to deliver oxygen. That device will provide oxygen but, unlike a Bag Valve Mask, will not assist to push that oxygen around the body. A single paramedic and a double crewed ambulance attended within 3 and 15 minutes of the 999 call respectively. Paramedics provided emergency care and achieved return of spontaneous circulation at 12:50pm. Andrew sadly suffered a further cardiac arrest at 13:20. He was transported under blue lights to Queen�s Medical Centre, arriving at 13:34. He continued to receive emergency treatment at hospital. Sadly, he did not recover and was declared deceased at 14:05 on 14 July 2022. � The Serious Incident Investigation revealed several concerning issues with the staff response when concerns arose for Andrew�s wellbeing on 14th July 2022. I heard evidence that appropriate action has since been taken to address those issues, with further work ongoing. � However, in respect of the timeliness of the response to the emergency situation, the Serious Incident Investigation concluded that �the response to Mr AV when he went into a medical emergency, found that the staff reacted immediately to the situation.� One of the authors of that report and the current Service Manager of Highbury Hospital gave evidence at the inquest. They both expressed views consistent with that conclusion. � I found this difficult to reconcile with the chronology of events above.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1.��Andrew�s family 2.�Nottinghamshire Healthcare Trust who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about 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: Nottingham Healthcare Trust

27/04/2023

2023-0142

Milan Hamza

Cambridgeshire and Peterborough

1��� Peterborough City Council � Highways Department

On 03.09.22 I commenced an investigation into the death of Milan Peter HAMZA (Otherwise known as Milan Peter RADOCZ), aged 8 years. The investigation concluded at the end of the inquest on 07.03.23. The conclusion of the inquest was: � Medical cause of death: 1a Drowning Inquest Conclusion � Road Traffic Collision

Milan was the front seat passenger in a vehicle travelling west along Old Oundle Road, Wittering at about 1035hrs on 03.09.22. The vehicle failed to negotiate a sharp left hand bend, left the carriageway to the offside before it entered a pond and became submerged upside down in water. Milan was unable to escape from the submerged vehicle which was not discovered until around 1730hrs that day. Emergency Services attended the scene and Fire Officers then extracted Milan from the submerged vehicle. He was rushed to Peterborough City Hospital but sadly his death was confirmed at 1944hrs.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � AXA INSURANCE (grandmother) � I have also sent it to � The Fenland Road Safety Campaign � 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 | Child Death (from 2015) This report is being sent to: Cambridgeshire County Council

09/05/2024

2024-0253

Samantha Angel

Hampshire, Portsmouth and Southampton

1��� Queen Alexandra Hospital Legal Department

On 27 September 2022 I commenced an investigation into the death of Samantha Jane ANGEL aged 55. The investigation concluded at the end of the inquest on 25 April 2024. The conclusion of the inquest was that: On the 16th September 2022, the deceased, Samantha Jane Angel, was found hanged at her home at [REDACTED] Hampshire. She was under stress, as a result �of a work investigation. The deceased further discovered on the 16th September, that she had been consistently lied to and her money misused leading to great distress. Acting on impulse, she took the action to end her life that evening.

On the 16th September 2022, the deceased, Samantha Jane Angel, was found hanged at her home at [REDACTED] , Hampshire. She was under stress, as a result of a work investigation. The deceased further discovered on the 16th September, that she had been consistently lied to and her money misused leading to great distress. Acting on impulse, she took the action to end her life that evening.

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 [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: Queen Alexandra Hospital

15/05/2023

2023-0240

Roy Walklet

Stoke on Trent and North Staffordshire

1��� Royal Stoke University Hospital

On 20 April 2022 I commenced an investigation into the death of Roy WALKLET aged 62. The investigation concluded at the end of the inquest on 03 April 2023. The conclusion of the inquest was that: � Roy Walklet died on 9th April 2022 at the Royal Stoke University Hospital, Stoke-on-Trent of multiorgan failure caused by a massive gastroduodenal haemorrhage which was contributed to by the taking of ibuprofen. Mr Walklet had attended hospital on 12th March 2022 complaining of abdominal pain. Gallstones were identified and these were assumed to be the cause of the abdominal pain. An endoscopy test which could have been administered to check for an ulcer was not carried out at that stage. Mr Walklet was readmitted to hospital on 7th April 2022 suffering from a bleeding duodenal ulcer. Despite attempts to stem the bleeding he suffered multiple large bleeds which caused his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 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.

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

18/12/2023

2023-0542

Carl Owston

West Sussex, Brighton and Hove

1��� Rt Honourable Victoria Atkins Secretary of State for Health & Social Care

On 19 January 2023 I commenced an investigation into the death of Carl Anthony OWSTON aged 34. The investigation concluded at the end of the inquest on 18 December 2023. The conclusion of the inquest was that: � Carl Owston died on the 10th of January 2023 at his home[REDACTED] from sudden unexplained death in alcohol misuse with steatosis and steatohepatitis.

Carl Owston died on the 10th of January 2023 at his home [REDACTED] from sudden unexplained death in alcohol misuse with steatosis and steatohepatitis.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] � Arch Healthcare [REDACTED] � Mother [REDACTED] � Father [REDACTED] -Sussex Partnership NHS Foundation Trust [REDACTED] � St Mungo�s [REDACTED] � Brighton & Hove City Council � � 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: Department of Health and Social Care

18/04/2024

2024-0205

Archie Bruce

West Yorkshire (Western)

1��� Rugby Football League

On 17/09/2020 I opened an inquest into the death of Archie Campbell Bruce who, at the date of his death was aged 20 years. The inquest was resumed and concluded on 17th January 2024 I found that the cause of death to be: 1a. Central nervous system depression 1b. Combined toxic effects of tramadol, cocaine, alcohol and buprenorphine. � I arrived at a conclusion of accident.

On 18/08/2019 Archie Campbell Bruce was found unresponsive in his hotel room at The Sporting Village, 272 Route De Launaguet in Toulouse France, after he spent the late evening of 17/08/2019 socialising and drinking with fellow players after his debut playing for the Batley Rugby Club. Despite attempts to resuscitate him, upon the arrival of the paramedics he was found to have died. At post mortem his blood was found to contain alcohol ([REDACTED], cocaine ([REDACTED]), buprenorphine ([REDACTED]) and a fatal quantity of Tramadol (� [REDACTED]). There is no evidence to suggest that he had any previous history of drug abuse. It is found more likely than not that when he took the drugs, he misjudged their combined toxicity with fatal unintended consequences.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] Batley Bulldogs Rugby Club [REDACTED] � I have also sent it to � Chief Coroner�s Office (Reg 28s) � 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, drug and medication related deaths This report is being sent to: Rugby Football League

16/11/2023

2023-0458

Terence Duncan

Berkshire

1��� Secretary of State � Department for Transport

On 09 November 2022 I commenced an investigation into the death of Terence Charles Scott DUNCAN aged 48. The investigation concluded at the end of the inquest on 16 November 2023. The conclusion of the inquest was that: � On the 30th October 2022 Terence Charles Scott Duncan died on the A4 Bath Road, Slough having been run over by a lorry. He had deliberately started to pass under the skeleton- trailer in front of the trailer wheels in order to cross the road when the lorry moved off.

On the 30th October 2022 an articulated lorry was travelling through Slough on the A4. The traffic was very heavy due to a closure of the M4. The lorry trailer was an unloaded trailer designed to carry a shipping container. � The lorry moved off from a set of traffic lights and its route was blocked for a few seconds by another vehicle. This caused the trailer to obstruct a pedestrian crossing. � Mr Duncan was crossing the road and made the decision to duck under the skeleton of the trailer rather than walking around the vehicle. He had a clear view through the trailer unit when he did this. Sadly the lorry moved off before Mr Duncan reached the far side of the road and he was run over by the rear nearside tyres.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] (the mother of Mr Duncan) � I have also sent it to � Thames Valley 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 This report is being sent to: Department for Transport

27/11/2023

2024-0065

Margaret Austin

County Durham and Darlington

1��� Stanley Park Care Centre

On 21/09/2023 11:12an investigation was commenced into the death of Margaret AUSTIN 13/03/1933 00:00:00. The investigation concluded at the end of the inquest on 27/11/2023 00:00. The conclusion of the inquest was that Margaret Austin, who was 90 years of age and had a diagnosis of mixed dementia, died on the 17th of September 2023 at her care home. The deceased had sustained a pubic rami fracture in an unwitnessed accidental fall from her bed, at her care home, on the 1st of July 2023, and this contributed to her overall decline and ultimately to her death.

Mrs Austin passed away at Stanley Park Care Home. She had recently suffered a fractured pubic rami due to an unwitnessed fall.

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

Care Home Health related deaths This report is being sent to: Stanley Park Care Centre

14/09/2023

2023-0332

Marcel Wochna Coroner name: Jason Pegg Coroner Area: Hampshire, Portsmouth and Southampton Category: Child Death (from 2015)� | Other related deaths This report is being sent to: Hampshire & Isle of Wight Constubulary

1��� The Chief Constable HAMPSHIRE & ISLE OF WIGHT CONSTABULARY

INVESTIGATION AND INQUEST � On 17th November 2021 I commenced an investigation into the death of Marcel Maksymilian WOCHNA aged 15. The investigation concluded at the end of the inquest heard between 4th and 13th September 2023 sitting with a jury. The conclusion of the inquest was: � Narrative Conclusion: On 8th November 2021 the deceased drowned in the River Itchen, Southampton, Hampshire. The deceased jumped into the River Itchen feet first, voluntarily to evade arrest. There was insufficient immediate action taken by attending officers to attempt to rescue Marcel once he had entered the water which probably contributed to his death. The police officers had inadequate knowledge of the working by water policy. Marcel�s death was contributed to be neglect.

Two police officers attended Cobden Marina located on the River Itchen during the early hours of 8th November 2021. It was a dark, cold night, the river temperature was 12 degrees Celsius. The pontoon was unstable causing it to wobble. The police officers found the deceased and another young male on a moored boat. � The other male, who was described as �compliant enough�, was moved onto the pontoon and handcuffed to the rear. The officers decided before arriving at the scene that they would handcuff any suspect found. � The deceased then exited the boat and stood on the pontoon and held by an officer. The deceased pulled away from the officer and deliberately jumped into the River Itchen. � When the deceased jumped into the river the attending police officers did nothing. The officers believed that the deceased had swam away. The officers did not recognise that there was a real and immediate risk to the life of the deceased when he entered the water. Neither officer had heard of Cold Water Shock. � Expert evidence indicated that Cold Water Shock is likely to incapacitate within 2 minutes, cardio-pulmonary arrest is likely to follow within 4-5 minutes. � Hampshire Constabulary had at the relevant time, and continues to have, a �Working near Water Procedure [21344]�. The Procedure sets out the risks of operating near water, including Cold Water Shock, together with mitigating measures and the necessity for a dynamic risk assessment when operating close to water. Neither officer had seen nor was aware of the �Working near Water Procedure� on 8th November 2021. One officer had served for 11 years, one had recently completed their training. Both officers operated from a police station covering the River Itchen which flows through a busy city and has Southampton Water to the south. � The attending officers accepted that had they been aware of the Procedure on 8th November 2021 they would have known of the real and immediate risk to life associated with Cold Water Shock. � In 2011 Hampshire Constabulary introduced their own Constabulary wide on-line training package relating to working near water. That training package makes no mention of Cold Water Shock. The training package makes no mention of the procedure to adopt when seeking to effect a rescue from water namely, �Shout, Reach, Throw, Row, Go�. The �Shout, Reach, Throw, Row, Go� is a recognised procedure and utilised by Hampshire Constabulary Marine Unit. � Hampshire Marine Unit apply handcuffs as a last resort to detain a person when operating near water, which includes on a pontoon. When handcuffs are used as a last resort the detained person is handcuffed to the front in order to afford the detained person the opportunity to tread water or take hold of an object in the event they come to be in the water. The risks of handcuffing a person to the rear whilst in close proximity to water were not recognised by the attending (Non-Marine Unit) officers.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] (Mother of the deceased) � 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, HM Coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

09/11/2023

2023-0459

Alfie Mains-Forster

County Durham and Darlington

1��� The Directors of Clevermed Limited 86-90 Paul Street 3rd Floor London EC2A 4NE � 2. The Chief Executive Officer of Clevermed Limited Clevermed Level 6, Edinburgh Quay 133 Fountainridge Edinburgh EH3 9QG

On 29/06/2022 13:30an investigation was commenced into the death of Alfie Neil MAINS- FORSTER 13/06/2022. The investigation concluded at the end of the inquest on 09/11/2023 14:51. The conclusion of the inquest was that Alfie died a natural death contributed to by neglect.

Alfie was born at 38+1 weeks at 01.35 on 13 June 2022 at the Royal Victoria Infirmary, Newcastle Upon Tyne. His mother had risk factors � gestational diabetes, a congenital heart condition and heightened blood pressure. At 4 minutes of age Alfie was noted as �grunting�. At 03.55 observations were documented on the NEWTT chart. Two were in the amber category � respiratory rate of 72 rpm and Oxygen saturation of 88%. The Mother was concerned and there was cyanosis around the mouth and nose. Intermittent grunting was noticed. At a review noted up at 5am, having probably occurred at around 04.30, saturation was 89.93%. On re-testing with a monitor from the resuscitate it was found to be 97%. The assessment found that there were no other signs of respiratory distress. The evidence from the Trust has included that given the maternal risk factors, once the two amber category observation at 03.55 had been documented, antibiotics should immediately have been administered to Alfie on a pre-emptive basis. In the event antibiotics were not applied, nor was close monitoring implemented. Alfie�s temperature fluctuated. At 05.15 he was 37.5 degrees. By 14.00 he was 37 degrees. The fluctuation was to some extent influenced by environmental factors. He was noted as intermittently groaning at 06.30. There were complications with feeding. He underwent a tongue-tie procedure at 10.20. At 11.30 the complications were persisting. At around 16.45 Alfie was discharged home. He became increasingly unsettled, crying consistently. This worsened such that the parents called 999. Pre-alert to the Emergency Department of University Hospital of North Durham at 00.02 on 14 June 2022 stated that Alfie was in cardiac arrest. Despite intensive treatment, and a brief return of cardiac output at 00.40, Alfie declined and died at 01.50. The medical cause of death provided following postmortem was 1)a) severe congenital pneumonia and meningitis, b) suspected acute chorioamnionitis. Reflecting the concession in the evidence of the Trust witnesses, the omission of antibiotics from 03.55 on 13 June 2022 is more likely than not to have contributed directly to Alfie�s death and, but for this omission, he would not have died.

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] Consultant Neonatologist Royal Victoria Infirmary Queen Victoria Road Newcastle Upon Tyne NE1 4LP � 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.

Child Death (from 2015) This report is being sent to: Clevermed Limited

28/06/2024

2024-0350

Debra Bates

Derby and Derbyshire

1��� The Park Surgery (Heanor)

On 22 June 2023 I commenced an investigation into the death of Debra BATES aged 55. The investigation concluded at the end of the inquest on 13 June 2024. The conclusion of the inquest was that: � Debra Bates was found dead at home on 15 June 2023. Post mortem toxicology found prescribed medication at above therapeutic levels in her blood. On the evidence Debra has taken a mixture of prescribed medication in quantities that have had an enhanced sedative and respiratory depressant effect leading to her death. For many years Debra has suffered with her mental health and chronic pain. This was managed by the specialist healthcare teams and her GP. On 12 April 2023 following an admission to hospital following an overdose causing opiate toxicity it was recommended that the prescribing of her medication be changed to 4 day and 3 day prescriptions to minimise the risk of overdose. This did not happen. Debra continued to be prescribed her medication at 7 day intervals plus breakthrough pain medication as required. Debra had a chaotic approach to taking her medication. Whilst limiting the amount of medication prescribed to Debra at regular intervals would have reduced the amount she had access to at anyone time it cannot be established on the evidence that it would have prevented the overdose and her death.

Debra Bates was found dead at home on 15 June 2023. Post mortem toxicology found prescribed medication at above therapeutic levels in her blood. On the evidence Debra has taken a mixture of prescribed medication in quantities that have had an enhanced sedative and respiratory depressant effect leading to her death. For many years Debra has suffered with her mental health and chronic pain. This was managed by the specialist healthcare teams and her GP. On 12 April 2023 following an admission to hospital following an overdose causing opiate toxicity it was recommended that the prescribing of her medication be changed to 4 day and 3 day prescriptions to minimise the risk of overdose. This did not happen. Debra continued to be prescribed her medication at 7 day intervals plus breakthrough pain medication as required. Debra had a chaotic approach to taking her medication. Whilst limiting the amount of medication prescribed to Debra at regular intervals would have reduced the amount she had access to at anyone time it cannot be established on the evidence that it would have prevented the overdose and her death.

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

Care Home Health related deaths This report is being sent to: The Park Surgery

29/06/2023

2023-0217

Peter Walker

Suffolk

1��� The Right Honourable Mark HARPER MP 2 [REDACTED]3��� Chief Coroner�s Office

On 04 April 2022 I commenced an investigation into the death of Peter John WALKER aged 87. The investigation concluded at the end of the inquest on 21 June 2023. The conclusion of the inquest was that: � Accident The medical cause of death was confirmed as: 1a Multiple Traumatic Injuries 1b Aircraft Crash

Peter Walker came by his death at Beccles Aerodrome, Ellough Airfield, near Beccles in Suffolk on Thursday 24th March 2022. � Peter had been flying alone in a CT2K Microlight aircraft, registration G-CBDJ, that had attempted to land at Beccles Aerodrome, at approximately 13:55 that afternoon. � Upon landing Peter�s aircraft was seen to bounce 5 to 10 feet into the air before touching down again heavily, nose wheel first. � The aircraft bounced a second time and then the nose pitched markedly upwards. � The aircraft reached a height of approximately 100ft, veered to the left and rolled nose downwards before crashing in a field adjacent to the runway. Peter received multiple injuries and was declared deceased at the scene short while later. At the time of his death Peter was 87 years old.

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

Other related deaths This report is being sent to: Department for Transport

15/02/2024

2024-0085

Sean Crawford

County Durham and Darlington

1��� The Rt Hon Victoria Atkins MP � Secretary of State for Health and Social Care Department for health and Social Care 39 Victoria Street London SW1H 0EU 2 Content Director BNF Publications 3��� Chief Eexecutive Medicines and Healthcare Products Regulatory Agency

On 30/12/2020 12:36 an investigation was commenced into the death of Sean Benjamin CRAWFORD [born 29/12/1978]. The investigation concluded at the end of the inquest on 13/02/2024 09:20. The conclusion of the inquest was that Sean died on 18 December 2020 at [REDACTED] Darlington. His death resulted from the �Unpredicted combined toxic effect of alcohol and clozapine�.

Sean died on 18 December 2020 at [REDACTED] Darlington. His death resulted from the combined toxic effect of alcohol and clozapine (individually not at toxic levels) acting to suppress his central nervous system.

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

Alcohol, drug and medication related deaths This report is being sent to: Department of Health and Social Care | BNF Publications | Medicine and Healthcare Products Regulatory Agency

05/10/2023

2023-0368

Lilian Board

Lincolnshire

1��� ULH NHS Trust Legal Services

On 08 February 2023 I commenced an investigation into the death of Lilian Margaret BOARD aged 91. The investigation concluded at the end of the inquest on 05 October 2023. The conclusion of the inquest was that: � The deceased died on 1st February 2023 at Lincoln County Hospital, Greetwell Road, Lincoln after intentionally ingesting��[REDACTED] tablets the day before. A note of intent was left.

91 years old who lived alone, no carers but had friend and family for support, the deceased has a known history of Depression, T2DM, Heart failure and was under geriatric team for worsening mobility. Family report that on 31.01.23 the deceased had taken possibly [REDACTED] (prescribed by GP), she had contacted a friend and told them she had taken the medication, friend has then subsequently called family who attend the property and find the deceased slumped by her bedside with a glass of water and empty blister packs, the deceased was unresponsive emergency services attended and admitted the deceased to LCH where she presented to A/E after taking fatal overdose [REDACTED]. She had written a letter for family saying that she wants to end her life. Had respiratory arrest for which she received Flumazenil boluses (5 in total) after which she was kept in A/E resus and started on Flumazenil infusion. ITU was involved and she was able to maintain her airway so planned to keep in resus. Her GCS was 15 after Flumazenil but remained drowsy. She was also started on iv antibiotics for clinical suspicion of aspiration pneumonia. Infusion was later stopped after covering for half life of zopiclone of 8 hours. She was then moved to MEAU on 1.2.23 where she became drowsy again and had stat dose of Flumazenil. Was later reviewed by consultant and started on EOL care after discussion with family. She passed away on 1.2.23. � [REDACTED] at Lincoln County Hospital can provide a cause of death: 1a��[REDACTED] toxicity � Spoken with family who are aware that an Inquest maybe required given the history, they do not have any concerns regarding care or treatment, have requested for family to provide the letters which were left by the deceased. family were present and seen the deceased at LCH.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to � ULH NHS Trust Legal Services � 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) | Alcohol, drugs medication related death | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: United Lincolnshire Hospitals NHS Trust

14/05/2024

2024-0261

Margaret Clement

Lancashire and Blackburn with Darwen

1.� [REDACTED], Chief Executive East Lancashire Teaching Hospitals

On 23 June 2022 I commenced an investigation into the death of Margaret Clement (92 years old). The investigation concluded at the end of the inquest on 8 May 2024. The conclusion of the inquest was: � Margaret CLEMENT died on 15 June 2022 at Royal Blackburn Hospital, Blackburn. Following a fall, Mrs CLEMENT was admitted to hospital where a fractured neck of femur was diagnosed and operated upon on 23 May 2023. Mrs CLEMENT was prescribed anticoagulation following the operation to reduce the risk of clotting. She was discharged to Pendle Community hospital for rehabilitation on 10 June 2022. She had suspected melaena in the evening on 12 June 2022. She then developed significant rectal bleeding in the morning of 14 June 2022 and was admitted to Royal Blackburn Hospital following vomiting blood later in the evening. An upper gastrointestinal bleed was then diagnosed which led to a cerebrovascular accident from which she did not recover

Please see box 3 above.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Margaret Clement�s 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 This report is being sent to: East Lancashire Teaching Hospitals

19/12/2023

2023-0532

Margaret Waylett

East London

1.� [REDACTED], Chief Executive Officer, Barts Health NHS Foundation Trust

On 4 November 2022 I commenced an investigation into the death of Margaret Ann Waylett age 78. The investigation concluded at the end of the inquest on the 15 December 2023. The conclusion was a narrative conclusion: � Mrs Waylett died as a result of acute cardiac failure following a necessary surgical procedure. Post operative care was not provided in accordance with clear policies and expected standards of practice. Her death was contributed to by neglect.

Mrs Waylett suffered a humerus fracture in early October 2022. She consulted with orthopaedic surgeons and it was decided that surgery would be appropriate to maintain her levels of independence. She underwent surgery on the 13 October 2022 and the orthopaedic outcome was satisfactory. Post-operatively, Mrs Waylett�s recovery was complicated by ongoing low blood pressure and intermittent oxygen requirements. From the early hours of 17 October 2022, she required a medical assessment, with medical intervention to address a likely pulmonary oedema and likely urinary tract infection. She did not receive the necessary medical intervention and on the 19 October 2022, she suffered a cardiac arrest on the ward. Resuscitation was provided and she was admitted to the intensive care unit. Sadly, she did not recover and she passed away at Whipps Cross Hospital in the early hours of the 20 October 2022. Had Mrs Waylett received the necessary medical intervention from the 17 October 2022 or even on the morning of the 19 October 2022, it is likely that her death would have been avoided.

I have sent a copy of my report to the Chief Coroner, to the family of Margaret Waylett, 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.

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

24/11/2023

2023-0470

Teresa Chmielek

Manchester North

1.� [REDACTED], Chief Executive, Pennine Care NHS Foundation Trust

On 20 June 2023, an investigation into the death of Teresa Chmielek was commenced. The investigation concluded at the end of the inquest on 23 November 2023, I recorded a conclusion of suicide.

CIRCUMSTANCES OF DEATH On 17 June 2023, the Deceased took her own life at her home address [REDACTED] � 12 days before her death, the Deceased had been referred to mental health services by an Advanced Nurse Practitioner at the GP practice who had concerns about her risk of suicide. The referral was dealt with by the Single Point of Entry (SPoE) for Older People at the Royal Oldham Hospital and the Deceased was discussed at a screening MDT meeting which took place on 8 June 2023. Despite the fact that the referral included the fact that the Deceased was reported to have made a recent attempt to take her own life, the referral was rejected without any contact having been made with the Deceased or a face to face review.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:� Family of the Deceased � 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: Pennine Care NHS Foundation Trust

01/08/2023

2023-0329

David Andrews

Hertfordshire

1.� [REDACTED], Deputy Chief Executive, Executive Director of Resources, Hertfordshire County Council.

On 21 July 2022 I commenced an investigation into the death of David Alistair Andrews, 63. The investigation concluded at the end of the inquest on 14 July 2023. The conclusion of the inquest was road traffic collision.

CORONER�S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. That on this particular stretch of road heavy goods vehicles are permitted to stop in order to unload, thereby effectively blocking the southbound carriageway.

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

Road (Highways Safety) related deaths This report is being sent to: Hertfordshire County Council

24/04/2024

2024-0218

Olayemi Kehinde

East London

1.� [REDACTED], North East London Foundation Trust (NELFT), CEME Centre, March Way, Rainham, Essex, RM13 8GQ

On 27th October 2023, this court commenced an investigation into the death of Olayemi Oluwarotimi Kodjo Kehinde aged 34 years. The investigation concluded at the end of the inquest on 23rd April 2024. The court returned a short form conclusion of �Road Traffic Collision�; � Mr Kehinde�s medical cause of death was determined as; � HaemothoraxBlunt Force Trauma (Road Traffic Collision)

Olayemi Oluwarotimi Kodjo Kehinde was a 34-year-old man with a history of schizophrenic illness. Mr Kehinde walked into fast-moving traffic on a busy dual carriageway on 26th October 2023. Mr Kehinde was struck by a van and later that day died from his injuries.

I have sent a copy of my report to the Chief Coroner and to the following; the family of Mr Kehinde. 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 the time of your response, about the release or the publication of your response.

Road (Highways Safety) related deaths This report is being sent to: North East London Foundation Trust

11/05/2023

2023-0162

Julie Nolan

North Northumberland and South Northumberland

1.� �Maria Mallaband Care Group and Countrywide Care Homes

On 4 February 2022 I commenced an investigation into the death of Julie Elizabeth Nolan Deceased . The investigation concluded at the end of the inquest on 25 April 2023. The conclusion of the inquest was a narrative conclusion: Died as a result of significant progression of wound damage to the left foot leading to the development osteomyelitis whilst a nursing resident in a care home from 24 December 2021 to 24 January 2022 contributed to by underlying natural disease � The cause of death was: 1a Acute Osteomyelitis Left Foot, Bronchopneumonia II Diabetes Mellitus, Chronic Kidney Disease, Stroke

The deceased had underlying natural disease including diabetes mellitus, hypertension, chronic kidney disease and peripheral vascular disease which placed her at risk of the development of pressure damage and ulceration. On 18 March 2021 the deceased underwent an amputation of her left fourth toe and on 7 July 2021 underwent a left femoro-anterior tibial bypass. On 5 November 2021 the deceased suffered a total anterior cerebral infarction leaving her unable to swallow and requiring feeding through a PEG tub. � The deceased was admitted to a care home on 24 December 2021. Upon admission a body map was completed with three areas of pressure damage noted to areas of the left foot described as scabbed and blistered. � The deceased was identified as very high risk of developing pressure damage. There was limited documentation of wound management and pressure care and it is unclear the extent to which wound management and repositioning was provided in line with the care plans. There was no referral to tissue viability specialists. � On 24 January 2022 the deceased was conveyed by ambulance to Northumbria Specialist Emergency Care Hospital, Cramlington unwell with raised inflammatory markers indicating infection and further significant pressure damage to her left foot. It was reported she had also vomited in her PEG tube whilst which may have led to aspiration. � The deceased was found to have acute osteomyelitis and received active treatment including intravenous antibiotics. On 26 January 2022 the deceased was transferred �from Northumbria�Specialist�Emergency�Care Hospital, Cramlington to Wansbeck General Hospital. Whilst awaiting transfer to the Freeman Hospital for specialist vascular review the deceased deteriorated with a temperature, low oxygen levels and a high heart rate likely as the progression of infection in her chest, foot or both. � On 30 January 2022 the deceased suddenly deteriorated with difficulty breathing, low oxygen saturations and died within Wansbeck General Hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Julie Nolan Deceased. 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: Maria Mallaband Care Group and Countrywide Care Homes

24/11/2023

2023-0476

Zulfiqar Hussain

Manchester North

1.�& Partners, Croft Shifa Health Centre, Bellfield Road, ROCHDALE

On 18 July 2023 an investigation into the death of Zulfiqar HUSSAIN was commenced. The investigation concluded at the end of the inquest on 12 October 2023. The conclusion of the inquest was drug related and the cause of death was: 1a Combined drug toxicity II Bronchopneumonia

CIRCUMSTANCES OF DEATH Zulfiqar Hussain was 48 years old at the time of his death. He suffered with mental health issues and was receiving mental health care from the community mental health team. He was also a chronic illicit substance user and had received regular support from Turning Point. On 2 April 2023, the deceased was found at his home address having died from combined drug toxicity leading to significant respiratory depression, which was compounded by the presence of pneumonia. It was not possible, on the evidence available, to determine whether the deceased had ingested the drugs with the intention of ending his life. During the course of the inquest, the Court heard evidence about correspondence sent to the GP practice by Turning Point and the Mental Health Team. An adverse medication marker should have been prominently placed on the deceased�s electronic medical records as a result of correspondence from Turning Point. However, this was not done. There were at least 2 occasions when correspondence from the mental health team should have prompted a clinical review by a clinician. These did not take place and the Court heard that this was most likely because the correspondence was filed by administration staff without it having been seen by a clinician. Whilst the evidence does not reach the requisite standard to show that the deceased�s death would have been averted had correspondence been reviewed by clinicians at the GP practice, it meant that opportunities to provide the deceased with support and care and to foster his engagement with health services were missed. It is regrettable that this Court has previously issued a Regulation 28 report to your practice on the lack of robust processes to ensure clinician review of correspondence and, despite assurances, the situation in which correspondence is filed by administration staff without any clinician review pertains (see Regulation 28 report dated 23 December 2021).

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- � The family of the Deceased Turning Point The Care Quality Commission The GM 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.

Alcohol, drugs medication related deaths | Mental Health related deaths | Other related deaths This report is being sent to: Croft Shifa Health Centre

09/05/2023

2023-0183

Sandra Finch

Stoke on Trent and North Staffordshire

1.�NHS England; and 2.�West Midlands Ambulance Service

CIRCUMSTANCES OF THE DEATH i)�Sandra Diane Finch was 44 year old woman who had a history of Type 1 diabetes mellitus. She used an insulin pump to administer insulin and had done so since 2005. � ii)�She had recently had a dental procedure and was also recently prescribed antibiotics for an infection. It was accepted by clinicians that this can cause a Type 1 diabetic to need more insulin than they would normally need. � iii) On the 3 December 2021, Sandra Diane Finches glucose levels start to rise. This is picked up by the pump that she used and this sounded regular alarms and gave correctional doses of insulin. � iv)�On the 4 December 2021 Sandra Diane Finch called the West Midlands Ambulance Service and told them she was feeling more sleepy, her glucose was high and she had been vomiting. The categorisation of this call was category 3. This meant she was a medical emergency and required an ambulance. However, before an ambulance could be dispatched a clinical review Was required by the CV team. � v)�The team was under staffed and had no time limit attached for an assessment. As such, an attempt for an assessment did not take place until 10 �hours �later.��At 7:22 a call was�made�to Miss�Finch. This was unanswered. The options available, at this stage, would have been to dispatch an ambulance, or to place the call back, back into the CV Teams work load. This was what happened. � vi)��At 12:47 on the 5 December 2023 the decision was made by the team to categorise the ambulance request as a category 2 and dispatch an ambulance. This arrived� at Sandra Diane Finches address at 13:08 and� she was found to have passed away as a result of ketoacidosis. � vii)�Clinical opinion disagreed that category three was the correct categorisation. It should be have been a category 2. Evidence was heard that the pathway had to be followed rigidly so a computer could decide the category, but accepted that a clinician listening to the answers may well have made a different decision and given the call a category 2 marking. � The view of clinicians was that had the ambulance been despatched within the accepted time limit for a category 3 ambulance, Sandra Diane Finch would not have died when she did.

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. � 1.�That the pathways used by the service to categorise the level of ambulance and ridged and have no capacity for movement away from the path. This led to a type 1 diabetic patient, who was feeling sleepy and with deranged glucose levels, not being classed as a potentially serious situation requiring rapid intervention. Clinical opinion in agreement that this was, but the rigidly of the pathway meant it was categorised incorrectly. � That the use of an assessment team, to asses a category 3 ambulance call, with no time limit for assessments to take place, and no prioritisation system, will lead to further deaths resulting from delays.

9 May 2023� Miss Emma Serrano Area Coroner Stoke on Trent and North Staffordshire

Emergency services related deaths (2019 onwards) This report is being sent to: NHS England and West Midlands Ambulance Service

19/05/2023

2023-0167

Amelia Barbosa

Cambridgeshire and Peterborough

1.�North West Anglia NHS Foundation Trust

On 14 October 2021 an investigation in to the death of Amelia Barbosa was commenced. Amelia died on 13 December 2020, aged 7 days. The investigation concluded at the end of the inquest on 17 May 2023. The conclusion of the inquest was: � Medical Cause of Death 1a Hypoxic Ischaemic Encepalopathy, � 2 Placental pathologies: acute chorioamnionitis and delayed vilious maturation � Conclusion � Died as a result of an acute hypoxic injury in the period immediately before delivery, and which continued during resuscitation, leading to hypoxic ischaemic encephalopathy.

1. In summary, Amelia�s mother had a routine pregnancy and was given a due date of 01 December 2020. She attended Peterborough City Hospital at around 1030 hours on 5 December 2020. � 2.�From very early on, the CTG trace was classified as suspicious on a number of occasions and on some occasions as pathological. Evidence and a report from HSIB confirms that assessment and decision making during this period was appropriate. � 3.�Due to a failure to progress in the second stage of labour and suspected fetal compromise at around 0240 hours, a decision was made for a Category 2 Caesarean section delivery. � The CTG trace was stopped at 0404 hours to enable the Caesarean to take place. 5.�As had been anticipated, there was some difficulty due to Amelia�s head being impacted, but the Obstetrician and senior Midwife worked together and this was resolved within 4 minutes. � 6.�Due to difficulties siting a spinal anaesthetic, and Amelia�s head being impacted, the time from decision to delivery was 83 minutes. Expert evidence confirmed that, on the balance of probabilities, Amelia suffered an acute hypoxic insult commencing around 10 minutes before her delivery and which was ongoing during resuscitation. � 7.�At delivery, no APGAR scores were recorded as they should have been. However, based upon the evidence in the notes, I accepted the hypothesis from HSIB that it is likely that her scores were 0 at 1 minute and 1 at 5 minutes. � 8.�The Midwife took cord blood gases but, as there was no blood in the clamped section of the cord, the blood was taken from a different part of the cord. I heard independent expert evidence from a Consultant Neonatologist that these are not likely to have been reliable as they were taken from close to the base of the placenta rather than the clamped section of cord. � 9.�The evidence of the Midwife at the inquest was that she felt, and she had since discussed this with colleagues who agreed, that if necessary it was fine to take blood from anywhere in the cord. Both the independent expert and the Trust�s own Head of Midwifery, who gave evidence on changes made at the Trust in light of HSIB recommendations, agreed that blood should not be taken from anywhere other than the clamped section of cord. Further, if that was not possible, it must be clearly communicated to the Neonatal/Paediatric team. � 10. There were a number of issues identified with the resuscitation and concerns raised by both HSIB and the independent expert, some of which were addressed by the Trust who produced evidence to confirm how these issues had been resolved. � 11. However, other issues were identified. One such issue was that the independent expert advised that resuscitation attempts should not have stopped until all reversible causes had been considered and treated. Prior to resuscitation stopping, no blood transfusion had been given. Amelia had been described to be very pale. Her haemoglobin level was later found to be 94. Both the expert and HSIB felt a transf usion should have been given. The treating Registrar also gave evidence that, had he been aware of the issue with the cord blood and another issue relating to the condition of the placenta, he would have given a transfusion. The treating Consultant who gave evidence however disagreed. � 12. One of the recommendations from HSIB was for there to be training and feedback to those involved in this case, and others who were not, to learn lessons. � 13.�There was also difficulty inserting an umbilical venous catheter, which I accept can be difficult even in experienced hands, and the delay in intra osseous access, which was contributed to by the lack of correct equipment on the resus trolley, led to a delay in Amelia receiving adrenaline, fluid volume and sodium bicarbonate. The expert recommended that staff undergo training to improve their skills for obtaining UVC and IO access. � 14. While in NICU there was also a delay in Amelia being effectively cooled due to the active cooling machine not working. I was advised that this has now been replaced. � 15. Amelia was transferred to Addenbrooke�s Hospital where the extent of her injuries were confirmed and she sadly died on 13 December 2020.

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

Child Death (from 2015) This report is being sent to: North West Anglia NHS Foundation Trust

28/06/2023

2023-0215

Carol Hatch

West Yorkshire (Eastern)

1.�Spire Healthcare Limited. �F.A.O�[REDACTED], 3 Dorset Rise, London EC4Y SEN

On 20 October 2023 I commenced an investigation into the death of Carol Ann Hatch aged 73. The investigation concluded at the end of the Inquest on 26 June 2023. The conclusion of the Inquest was a Narrative which recorded the medical cause of death as (1a) Sepsis, (1b) Gastric perforation (1c) revision Nissen Fundoplication.

Carol Ann Hatch aged 73 underwent a surgical procedure in 2015 known as a 360 degree Nissen Fundoplication to repair a hiatus hernia and reduce the risk of reflux. On 31 August 2022 she underwent an identical procedure as a further hiatus hernia had developed, causing a recurrence of symptoms. The surgery was performed at the Spire Private Hospital in Leeds. � Mrs Hatch became unwell during the night following the surgery. It was only the following morning when the surgeon returned to the hospital that the extent of her deterioration was appreciated. She was transferred to an NHS hospital in Leeds, underwent emergency surgery within a few hours and was admitted to an intensive care unit. Over the following six weeks she was treated on the intensive care unit for septic shock and organ failure. She died on 18 October 2022 at St James University Hospital in Leeds.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (husband). I have also sent it to RMO Agency, NES Healthcare UK Ltd, 66 High Street Aylesbury WP20 1SE, Stonor Medical Ltd, 112 Green Street, Northampton, NN1 1SY and Mr S.P. L Dexter C/O St James University Hospital Leeds 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: Spire Healthcare Limited

12/05/2023

2023-0160

Tamsin Dolamore

Cornwall and the Isles of Scilly

1.�[REDACTED] , Chief Constable, Devon & Cornwall Police, with a copy for information only (ie no duty to respond) 2. [REDACTED] , Police & Crime Commissioner 3. Network rail 4. Secretary of State for Justice

On 12.5.23, I concluded an inquest into the death of Tamsin Ann Dolamore who died at the age of 24 on 9.1.18. The medical cause of death was recorded as: 1a) Effects of multiple injuries I recorded an Open Conclusion as the evidence of her intent was not sufficiently clear on a balance of probabilities.

Tamsin was raped as a schoolchild. In October 2017, she made a complaint to police that she had been raped again. (Of note, her adoptive parents, to whom a copy of this letter is being sent, were not aware of either incident until after her death.) Her GP reported her life having been turned upside down. It was intended that a SOLO would be appointed after the initial report but, in evidence, it was established that did not happen until the end of October, a delay of approximately a month. � Tamsin was assessed by Outlook South West. It was felt she presented with too much risk and she was discharged from their service with a referral to the CMHT. After assessment by them (three months after the incident) it was felt she did not meet the statutory threshold and she was not taken on to caseload. At the time, there was a process for reviewing patient cases who fell between the two organisations but this had not been done by the time of her death. � Tamsin was referred to the Women�s Centre who conducted a needs assessment. She was advised there was a five-month wait for support. � On 8/1/18, Tamsin fell over 20� from a railway bridge in St Austell on to the railway lines. The fall was unwitnessed and as there was no evidence of her intent in the form of a letter, email, text or similar, I concluded the evidence did not further or fully disclose the means whereby the cause of death arose and so returned an Open Conclusion. � At inquest, I heard evidence from [REDACTED], general manager of Sexual Assault Referral Centre (SARC) of the importance of providing immediate care and support to rape survivors and the negative consequences that can occur where they feel their complaint is not being taken seriously, or there is a delay in the process. Tamsin�s parents were of the view that, at the time she most needed support and assistance, she was largely left to fend for herself. I agreed with that view.

CIRCUMSTANCES OF THE DEATH Tamsin was raped as a schoolchild. In October 2017, she made a complaint to police that she had been raped again. (Of note, her adoptive parents, to whom a copy of this letter is being sent, were not aware of either incident until after her death.) Her GP reported her life having been turned upside down. It was intended that a Sexual Offences Liaison Officer (SOLO) would be appointed after the initial report but, in evidence, it was established that did not happen until the end of October, a delay of approximately a month. Tamsin was assessed by Outlook South West. It was felt she presented with too much risk and she was discharged from their service with a referral to the CMHT. After assessment by them (three months after the incident) it was felt she did not meet the statutory threshold and she was not taken on to caseload. At the time, there was a process for reviewing patients who fell between the two organisations but this had not been done by the time of her death. Tamsin was referred to The Women�s Centre who conducted a needs assessment. She was advised there was a five-month wait for support. On 8/1/18, Tamsin fell over 20� from a railway bridge in St Austell on to the railway lines. The fall was unwitnessed and as there was no evidence of her intent in the form of a letter, email, text or similar, I concluded the evidence did not further or fully disclose the means whereby the cause of death arose and so returned an Open Conclusion. At inquest, I heard evidence from [REDACTED], general manager of Sexual Assault Referral Centre (SARC) of the importance of providing immediate care and support to rape survivors and the negative consequences that can occur where they feel their complaint is not taken seriously, or there is a delay in the process. Tamsin�s parents were of the view that, at the time she most needed support and assistance, she was largely left to fend for herself. I agreed with that view

Other related deaths This report is being sent to: Devon and Cornwall Police | Police and Crime Commissioner | Network Rail

21/12/2018

2018-0405

[REDACTED]

Shropshire, Telford and Wrekin

1.�[REDACTED] Chief Executive, Midlands Partnership Foundation Trust

On 2nd May 2018 I commenced an investigation into the death of�[REDACTED] 18 years of age, and opened an inquest on the 10th May 2018. The investigation was concluded at the end of the inquest on the 14th and 15th November and 17th December 2018. [REDACTED].�������������������������������������� .��� The conclusion of the inquest was suicide.

[REDACTED] was found deceased�[REDACTED]. She was found [REDACTED]. [REDACTED} had mental health issues starting from around 15 to 16 years of age. They resulted in self-harm and 2 suicide attempts the last of which was in September 2017.� Mental health care had been provided to�[REDACTED]�both before and after her 18th birthday�([REDACTED]).� She was in contact with mental health services up until the evening of the 30th April 2018 before she killed herself the next morning.

I have sent a copy of my report to the Chief Coroner and to Lanyon Bowdler solicitors for [REDACTED], mother of [REDACTED] [REDACTED], father of [REDACTED] [REDACTED], brother of [REDACTED] [REDACTED], legal representative of the MPFT 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: Midlands Partnership NHS Foundation Trust

19/05/2023

2023-0166

Emilia Watson

Warwickshire

1.�[REDACTED] Executive Director for Professional Practice, Nursing and Midwifery Council

INVESTIGATIONS and INQUESTS � Emilia Watson died on 5 April 2021, shortly after her birth. Signs of life were recognised and, as such, I had jurisdiction to hear an inquest into her death, which concluded on 18 April 2023. I reached a narrative conclusion which read: � �Emilia Watson died from complications of uteroplacental insufficiency. This in itself is a natural cause of death; however, there were missed opportunities to recognise the development of these complications, which contributed to her death.�

Emilia was born at Warwick Hospital after her mother had been admitted from home for what had been planned to be a homebirth. Concerns were raised about fetal wellbeing, which prompted admission to hospital. � The timeline of events includes two admissions to hospital over the course of the early morning of the 5 April 2021, after concerns were raised by the two midwives involved in these home attendances. � On the second admission concerns were maintained about the fetal heart rate and Emilia was delivered by Caesarean section at approximately 7.22am but she sadly died, despite resuscitation attempts.

I have sent a copy of my report to the Chief Coroner, Emilia Watson�s family, the hospital Trust and the HSIB. � 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: Nursing and Midwifery Council

24/07/2024

2024-0404

Brogen-Lea Storey

Staffordshire and Stoke on Trent

1.�[REDACTED] Road Safety Management, Staffordshire County Council

On 2nd December 2022 I commenced an investigation into the death of Brogen-Lea Debbie Marie Storey. The investigation concluded at the end of the inquest on 11th July 2024. The conclusion of the inquest was that Brogen-Lea died after sustaining catastrophic injuries as a pedestrian in a road traffic collision

Brogen-Lea, a schoolgirl, was walking home in the Cannock area of Staffordshire at about 6:30pm on 29th November 2022. She was late and was likely in a rush. Brogen- Lea emerged from a footpath which is bisected by a busy road subject to a 50mph limit. She continued into the carriageway and was struck by a car. The driver of the car had not seen her, likely because of a combination of her clothing and the failure of streetlamps in the area. Brogen-Lea sustained injuries from which she later died.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. I have also sent it to the family 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)�| Road (Highways Safety) related deaths� � This report is being sent to: Road Safety Management Staffordshire County Council

17/06/2024

2024-0319

Stefan Walker

Swansea Neath and Port Talbot

1.�[REDACTED], CHIEF EXECUTIVE, WELSH AMBULANCE SERVICES UNIVERSITY NHS TRUST

On 7 JULY 2020 the Senior Coroner commenced an investigation into the death of STEFAN WALKER aged 40 (hereafter �STEFAN�), who died on 29 June 2020. � The investigation concluded at the end of the inquest held between 20th and 28th May 2024. � The said investigation was one to which the enhanced investigative obligation, under Article 2 of the European Convention on Human Rights, applied. � The conclusion of the inquest jury was that STEFAN�S death was �Drug related� � the medical cause of death being �buprenorphine and flualprazolam intoxication, and cardiac enlargement� and that, inter alia, �Stefan died in his bedspace at Cefn Coed Hospital, Swansea on 29 June 2020 sometime between 1520 and 1545�.

At the time of his death STEFAN was a detained patient under the Mental Health Act 1983 and receiving in-patient psychiatric treatment on Fendrod Ward on account of his diagnosis of polysubstance misuse, psychosis, Emotionally Unstable Personality Disorder, and ADHD.The evidence that I and the jury heard was to the effect that on both 28th and 29th�June 2020 there were concerns that STEFAN had consumed illicit substances and was displaying symptoms of being physically unwell (overly sedated and drowsy, slurring his speech and tripping over his feet, unable to keep his eyes open and perspiring profusely). He disclosed to staff that he had taken �street diazepam�. In the afternoon of 29 June 2020 he was found unresponsive in his room and attempts were made by nursing staff and paramedics to resuscitate him. The evidence and the jury heard was that STEFAN was displaying no signs of life when he was found. Naloxone and Flumazenil were both administered by a junior doctor and the ward pharmacist with the assistance of the paramedics when they arrived � the Flumazenil only because it was kept on the ward. It was not carried by the paramedics, and I was told that it is not carried by paramedics. Toxicology after his death revealed the presence of both buprenorphine (strong opioid analgesic) and flualprazolam (novel designer benzodiazepine). Flumazenil is a potential antagonist in relation to the novel designer benzodiazepine.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � STEFAN�S Family Swansea Bay University Health Board City and Council of Swansea � 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 | Wales prevention of future deaths reports (2019 onwards) | Emergency services related deaths (2019 onwards) This report is being sent to: Welsh Ambulance Service NHS Trust

29/09/2023

2023-0355

Marion Luckraft

East London

1.�[REDACTED], Chief Executive Officer, Barking, Havering & Redbridge, University Trust

On 19th April 2023 I commenced an investigation into the death of Marion May Luckraft aged 84. The investigation concluded at the end of the inquest on 11th September 2023. The conclusion of the inquest was a short-form conclusion of natural causes. The medical cause of death was found to be; 1a Shock due to biliary sepsis 1b Retroperitoneal duodenal perforation following endoscopic retrograde cholangiopancreatography (ERCP) and placement of pancreatic stent.

Mrs Luckraft was admitted to hospital on 31/3/23 with jaundice. � Diagnostic tests suggested an obstructed biliary system, an ultrasound scan showed a dilated common bile duct (CBD). � Further imaging occurred on 2/4, a CT abdomen with findings suggestive of CBD stricture and possible malignancy. A MRCP (Magnetic Resonance Cholangiopancreatography) provided a corroborative result on 4/4. � On 11/4 an ERCP (Endoscopic Retrograde Cholangiopancreatography) was undertaken and an unsuccessful attempt to insert a stent into the CBD was undertaken. A stent was inserted in the pancreatic duct. � A CT scan 13/4 on showed a duodenal perforation by displaced biliary stent with retroperitoneal gas/fluid. � A number of factors; the patient�s deterioration, an attempt at drainage through interventional radiology, and discussion regarding which hospital site should be utilised, led to delays in transferring the patient to another hospital for a laparotomy and washout which occurred on 16/4. � The patient passed away on 17/4/23 on ITU.

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

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

03/07/2023

2023-0226

Arezou Tirgari

City of London

1.�[REDACTED], Chief Executive of Landsec

I have commenced an investigation into the death of Arezou Tirgari. The investigation has not yet been concluded.

On the evidence currently available to me, I understand that Arezou Tirgari died on the 1st June 2023 after jumping from the roof [REDACTED], a building which is operated by Landsec.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons and other organisations listed below which may find it useful or of interest : � The Family of Arezou Tirgari City of London Planning Department and Environment Department City of London Licensing Team City and Hackney Public Health City of London Police HM Senior Coroner for Inner South London � 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 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.

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

21/02/2024

2024-0097

Oliver Beswetherick

London Inner (South)

1.�[REDACTED], Chief Executive of NHS England, Skipton House, London, SE1 6LH

On 27 November 2020 I commenced an investigation into the death of Mr Oliver Beswetherick, aged 24 years. The investigation concluded at the end of the inquest on 11 December 2023. The conclusion of the inquest was a narrative conclusion.

Mr Beswetherick had suffered from depression and bulimia, since 2015 and 2018 respectively. During 2019 � 2020 he was seen regularly by a therapist and consultant psychiatrist, the latter confirming the diagnosis of bipolar affective disorder type II for which he prescribed medical treatment. Up until 22 August 2020, Mr Beswetherick was well. � On 29 August he attended A&E and was seen by the psychiatric liaison nurse, who, after assessing him wrote to his consultant, whom he was due to see a couple of days later. That review took place on 31 August and the consultant immediately referred Mr Beswetherick back to his GP for urgent referral to the CMTH/ crisis teams. � Mr Beswetherick and his partner sought updates from the practice over the following days, 1-3 September 2023. On 3 September, following further discussions about Mr Beswetherick�s suicidal nature, he was referred by his GP to the CMHT. Their assessment was that he should be seen face to face. However, Mr Beswetherick had moved out of the local catchment area (East London) to south of the river (Southwark). He was therefore advised to attend his local A&E to see the local psychiatric liaison nurse who would be able to refer into the local services. No direct referral to the either the psychiatric liaison nurse or local services was made. � On the morning of 4 September 2020, Mr Beswetherick was identified, having fallen from his flat to the ground. He was pronounced dead at the scene by LAS, the MPS deeming the scene non-suspicious. A note was found.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] NOK�[REDACTED] (Mother) [REDACTED] for Medical Protection [REDACTED] [REDACTED] for East London NHS Foundation Trust for H Evans [REDACTED] for SLAM � 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: NHS England