Inquests (PFDs)

05/12/2023

2023-0514

Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein

Inner South London

1.�[REDACTED], Chief Executive of the UK Civil Aviation Authority

On 29 October 2019 an inquest was opened into the deaths of Jonathan Neal Goldstein, Hannah Louise Goldstein and Saskia Lucia Goldstein. The inquest was concluded on 5 December 2023. The conclusion of the inquest was a narrative conclusion that each person deceased was either the pilot of or passenger in: � �a light aircraft on 25 August 2019 that was crossing the Swiss Alps in the region of the Simplon Pass. During the flight, the pilot lost control of the aircraft, which stalled at low altitude and collided with the ground. This was due to a lack of anticipation in the management of the flight climb. A lack of training and experience in mountain flying contributed to the accident.�

The deceased (a father, mother and their 6 month old child) were in a light aircraft being flown by the father, Jonathan Goldstein, from North Weald to Perugia, via Troyes and Lausanne. Jonathan Goldstein held a PPL(A) licence but did not have (and was not required to have) any specific training in mountain flying. The accident was investigated by the Swiss Transportation Safety Investigation Board (�STSIB�)(Report 2383), who found that Jonathan �was lacking appropriate training in mountain flying�, and that �a lack of training and experience in mountain flying contributed to the accident.�

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

�Other related deaths | Child Death (from 2015) This report is being sent to: UK Civil Aviation Authority

05/04/2024

2024-0283

Christopher Townsend

Worcestershire

1.�[REDACTED], General Secretary of the Auto Cycle Union 2. [REDACTED]

On 22 June 2023 HMSC David Reid commenced an investigation into the death of Christopher William Townsend, aged 43. The investigation concluded at the end of the inquest on 5 April 2024 which I heard. The conclusion of the inquest was that the medical cause of death was pneumonia as a result of multiple injuries sustained in a motor cycle accident and that Mr Townsend died as a result of an accident.

Christopher William Townsend died on 8 June 2023 at the Queen Elizabeth Hospital, Birmingham. He was involved in a motor accident on 4 June 2023 whilst participating in an organised grass-track motor-cycle and side-car race. He sustained multiple chest and abdominal injuries from which he did not recover

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] (General Secretary Auto Cycle Union and [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.

Road (Highways Safety) related deaths This report is being sent to: Auto Cycle Union | REDACTED

15/05/2023

2023-0159

Julie Hancock

Cornwall and the Isles of Scilly

1.�[REDACTED], Medical Director, Royal Cornwall Hospital, Truro

INVESTIGATION � In March 2022, I commenced an investigation into the death of Julie Louise Hancock, aged 53, who died on 28/3/22. The investigation has not yet concluded and the inquest was adjourned today after the matters I am writing to you about came to light.

Julie had a past medical history that included rheumatoid arthritis and hypertension. In December 2021, she was offered staged bilateral knee replacements. She was assessed by�[REDACTED] as being at high risk of developing a DVT. � She had a nurse-led pre-op assessment on 26/1/22 when, I am told, a further risk assessment was not done, in accordance with policy at the time. � On 2/3/22, she had a right total knee replacement. She was discharged on 5/3/22 and died at home on 28/3/22. At post-mortem, her cause of death was found to be: 1a) Pulmonary embolus 1b) Deep vein thrombosis II) Immobility following right knee replacement

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

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

03/05/2024

2024-0247

Neville Abbott

Dorset

1.�[REDACTED], Service Manager, BCP Council, Civic Centre, Bourne Avenue, Bournemouth, Dorset

On the 11th February 2022, an investigation was commenced into the death of Neville Stephen Abbott, born on the 7th January 1945. � The investigation concluded at the end of the Inquest on the 19th April 2024. The Medical Cause of Death was: 1a Unascertained due to decompositional change. The conclusion of the Inquest recorded that Neville Stephen Abbott died as a consequence of natural causes where the precise medical cause of death could not be ascertained.

Neville Stephen Abbott lived alone at 8 Puddletown Crescent, Poole. Mr Abbott was diagnosed with schizophrenia. On 7th September 2021, following a fall and head injury, Mr Abbott was admitted to Poole Hospital where investigations revealed a new diagnosis of atrial fibrillation. On 8th February 2022 Mr Abbott was found deceased at his home address. A police investigation revealed no suspicious circumstances surrounding his death and no evidence that alcohol, medications or other substances had caused or contributed to his death. A post mortem examination did not reveal a medical cause of death, but did exclude traumatic injury. � Mr Abbott was known both to Adult Social Care (�ASC�) and Community Mental Health Services. Following the diagnosis of atrial fibrillation, which placed Mr Abbott at increased risk of death from stroke, he was advised to take a direct oral anticoagulant to reduce the risk of a stroke. He declined to take the medication when advised to do so by a treating hospital doctor, and further declined following a subsequent GP home visit. He was therefore at risk of self- neglect.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Leigh� Day Solicitors, representing [REDACTED], Neville Stephen Abbott�s daughter [REDACTED]; Clyde and Co Solicitors, representing BCP Council; DAC Beachcroft Solicitors, representing Dorset Healthcare University Foundation Trust � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

13/12/2024

2024-0688

Laura-Jane Seaman

Essex

1.�� Chief Executive Officer Mid & South Essex NHS Trust� 2.�� Director of Midwifery Mid & South Essex NHS Trust� 3.�� Vice President of the Royal College of Obstetricians and Gynaecology for Clinical Quality

On 10 January 2023 I commenced an investigation into the death of LAURA-JANE� KIRSTEN NICOLE SEAMAN, AGE 36. The investigation concluded at the end of the� inquest on 12 August 2024. The conclusion of the inquest was Ia Disseminated� Intravascular Coagulation Ib Massive Peritoneal Haemorrhage from Splenic Capsular and Peritoneal Tears with recent vaginal delivery.�� Narrative Conclusion: Laura-Jane died as a consequence of basic failures by healthcare� professionals to recognise and escalate her loss of consciousness as a maternal�collapse with inability to obtain vital signs that was incorrectly attributed to�malfunctioning equipment rather than obvious clinical deterioration had MEOWS charts� been utilised. Vital signs that were obtained were severely deranged with persistent� tachycardia and hypotension for a period of over 2 � hours and the consequential risk to her life that was obvious. There was a failure of escalation that was mandated, and�action taken with multi-disciplinary consultant led review would have resulted in care and treatment for obvious signs of hypovolemia that was available and would have saved� Laura-Jane�s life. Laura-Jane�s death was avoidable and was contributed to by neglect.

Laura-Jane Seaman died at Broomfield Hospital on 23 December 2022 of Disseminated� Intravascular Coagulation due to Massive Peritoneal Haemorrhage from Splenic�Capsular and Peritoneal Tears with Recent Vaginal Delivery without complication at� 00:58 on 21 December 2022. Laura-Jane complained of feeling bleeding at 02:40, of� feeling dizzy at 03:30 with required vital signs not being taken. Midwives failed to� appropriately escalate Laura-Jane�s maternal collapse at 03:45 whilst semi-recumbent in bed. Laura-Jane was treated for possible dehydration, but her condition continued to� deteriorate. Midwives failed to obtain required vital signs until 04:04 that were annotated� on a piece of paper rather than on Modified Early Obstetric Warnings Scores (MEOWS)� charts with the consequence that her deteriorating condition was not escalated. There�were multiple missed opportunities to escalate and treat Laura-Jane that were required.� Laura-Jane continued to deteriorate with persistent low blood pressure and tachycardia� that were indicative of hypovolemia. Laura-Jane suffered a splenic capsular tear on the�labour ward that caused an intraperitoneal bleed that continued undetected in the� absence of any examination of her abdomen. An urgent blood test taken at 04:45 was�not chased and showed a drop in her haemoglobin that should have been known and� escalated. Laura-Jane repeatedly informed staff she believed she could feel bleeding�and then that she had numbness in her limbs and could not see the midwife who was� right beside her. Laura-Jane was reviewed by the obstetric registrar at about 06:00 and� was suffering chest pain, increased oxygen requirement and shortness of breath due to� hypovolemia. Laura-Jane�s chest was clear, and she was talking in full sentences and�her vital signs and medical records were not reviewed and administered a dose of� therapeutic low molecular weight heparin for suspected pulmonary embolism and in the� absence of an examination of Laura-Jane�s abdomen. Laura-Jane suffered a cardiac� arrest at approximately 06:30 due to a severe reduction in circulating blood volume.� Laura-Jane was resuscitated and suffered a second arrest and again resuscitated and� was given a blood transfusion when her haemoglobin was found to be significantly low.� Laura-Jane underwent cardiac and abdominal scans that confirmed the absence of� features of pulmonary embolism and the presence of intraabdominal haemorrhage. The�major haemorrhage protocol was not called. Laura-Jane was conveyed to theatre for an� emergency laparotomy that found a massive intraabdominal haemorrhage caused by� splenic capsular tear treated appropriately with splenectomy. Advice from the Consultant Intensivist was successfully implemented to treat Laura-Jane who was critically unwell� due to her cardiac arrests. Significant amounts of blood products were administered to� Laura-Jane with the advice of haematology. Protamine was not administered until 10:40� to assist with reversal of low molecular weight heparin. A further laparotomy with�required with second opinions during which Laura-Jane sustained peritoneal tears due�to the condition of the tissues as there was ongoing bleeding with disseminated� intravascular coagulopathy noted. Laura-Jane went to intensive care at about 16:00.� Laura-Jane underwent further surgery on 22 December and on 23 December Laura- Jane underwent a surgery that was attempted to save her life that was not successful.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:�� i. �� Mother of Laura-Jane� ii.�� Partner of Laura-Jane�� iii.�� Obstetric Registrar� iv.� Anaesthetic Registrar� v.�� Consultant Surgeon� vi.� Labour Ward Co-ordinator� vii.� Medical Registrar� viii. Allocated Midwife�� ix.� Care Quality Commission� I have also sent it to the following expert witnesses who may find it useful or of interest x.�� Midwifery Expert� xi.� Consultant Obstetrician & Gynaecologist� xii.� Consultant Haematologist� xiii. Consultant Anaesthetist� xiv. Consultant Surgeon�� xv. NMC� xvi. HSIB now known as Maternity and Newborn Safety Investigation (MSNI) I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. She may send a copy of this report to any person who she believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief� Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Mid & South Essex NHS Trust | Royal College of Obstetricians and Gynaecology for Clinical Quality

27/01/2025

2025-0046

William Bissett

Liverpool and Wirral

1.�� Governor HMP Wymott 2.�� Head of Healthcare HMP Wymott 3.�� Chief Probation Officer For information the report is also being sent to (1) [REDACTED], Housing Manager Fylde Borough Council (2) [REDACTED], Director General of Prisons (3)� HM Inspectorate of Prisons (4)� NHS England

On 26th October 2023 an inquest into the death of William Campbell Bissett born 21st April 1935 was opened. The investigation concluded at the end of the inquest on 22nd January 2025. The conclusion of the inquest was that on 13th October 2023 at some time between midnight and 5.10 am William Campbell Bissett died by hanging. He died by suicide in cell 2/12 on the Haven Unit at HMP Wymott. A failure of advance planning prior to 5th October 2023 for accommodation for Mr Bissett on release and insufficient engagement with him by prison offender management and the probation service may have contributed to his death.

Mr Bissett was serving a long sentence at HMP Wymott in respect of historic sex crimes. On 13th October 2023 at the age of 88 he was due to be released on licence. The terms of his licence included an exclusion zone the effect of which meant that he was not allowed to return to his home and as a result upon release would be living separate from his wife of 56 years. On 6th March 2023 his Prison Offender Manager met with his Community Offender Manager in order to hand over responsibility for release arrangements. Mr Bissett was not present at the handover meeting and was only seen by his Community Offender Manager for the first time on 5th October 2025. An application for emergency accommodation was lodged on 6th October and on 11th October 2023 Mr Bissett was interviewed by housing officers from Fylde Borough Council.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Mr Bissett�s family via their solicitors together with the legal representatives for the Prison and Probation Service, Fylde Borough Council and Greater Manchester Mental Health NHS 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 other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

State Custody related deaths | Suicide (from 2015)

HMP Wymott | HMPPS

07/01/2025

2025-0009

Sheila Nicholls

Buckinghamshire

1.�� Mandeville Grange Nursing Home

The inquest into the death of Ms Sheila Ann Nicholls, aged 80, was opened on 22nd� November 2023. The investigation concluded at the end of the inquest on 23rd October 2024.� The medical cause of death was:� Ia� Hypoxia� Ib� Food Bolus Obstruction of Upper Airway II� Severe Ischaemic Heart Disease (Stented) The Narrative conclusion to the inquest was:� Sheila choked on food during a short period of respite care, at Mandeville Grange� Nursing Home on 19.11.2023. Information on Sheila�s swallowing problem was provided to the nursing home staff by family members, but the nursing home�s assessments and� checklists and handovers either omitted or did not share that information or the risk it� presented, with all relevant staff. Breakfast was therefore given to Sheila that did not�take her swallowing problem into account. Sheila subsequently choked on toast,� suffering hypoxia that led to a cardiac arrest and what was an otherwise avoidable�death. Neglect contributed to the cause of death.

Sheila died due to choking on food only a day after entering the nursing home on� 18.11.2023 as a respite care resident. Her family warned the nursing home of Sheila�s� swallowing difficulties and a need for monitoring whilst eating and to avoid certain foods, but important information went unrecorded and was not shared between staff, resulting�in Sheila being provided with food she should not have been given and/or should have� been prepared differently.� On 19.11.2023 Sheila was given breakfast on which she choked, requiring emergency assistance from staff, only one of whom had valid current life support training, and the� emergency response included ineffective CPR. Sheila died from choking on the food� provided.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� 1.� Sheila�s son� 2.� Sheila�s daughter� 3.� Mandeville Grange Nursing Home� 4. [REDACTED], former clinical lead nurse at Mandeville Grange Nursing Home 5. [REDACTED], RGN, at Mandeville Grange Nursing Home� � I have also sent it to: the Care Quality Commission, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your�response, about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths

Mandeville Grange Nursing Home

31/12/2024

2024-0713

David Crompton

West Yorkshire (Eastern)

1.�� Midway Pharmacy, 46 Chapeltown, Pudsey, LS28 8BL 2.� �General Pharmaceutical Council, Level 14, One Cabot Square, Canary Wharf, London, E14 4QJ

On 23rd December 2024 I commenced an investigation into the death of David Joseph Crompton, aged 44. The investigation concluded at the end of the Inquest on 31st December 2024. The conclusion of the Inquest was a Narrative Conclusion based on the following cause of death: � 1(a) Hypoxic ischaemic encephalopathy 1(b) Out of Hospital Cardiac Arrest 1(c) Cervical Spine Injury secondary to fall (2)�� Epilepsy � This was resulting from a fall downstairs on 13th December 2024.

Mr Crompton had epilepsy and was prescribed, inter alia, the anti-epileptic medication Tegretol.� In April 2024 he was left without the medication for approximately 10 days as the pharmacy could not supply it.� In December 2024 he was again left without the Tegretol.� The pharmacy had left a manuscript �IOU� in relation to Tegretol at his home when other medicines were delivered.� Without his medication his epileptic condition was likely to destabilise and give rise to fits.� His falls both in April and December 2024 occurred when he was left without his essential medication.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- � [REDACTED] (mother), [REDACTED] [REDACTED] (GP), Robin Lane Surgery, Robin Lane, Pudsey, Leeds, LS28 7DE I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drug and medication related deaths

Midway Pharmacy | General Pharmaceutical Council

02/01/2025

2025-0006

Alexandra Roberts

Cheshire

1.�� NHS England

On the 12th July 2023 I commenced an investigation into the death of Alexandra Bronte Roberts.� Alex died on the 14th May 2023.� She was 26 years old.� The investigation concluded�at the end of the inquest on the 17th December 2024 when the medical cause of death was confirmed as 1a Insulin Overdose.

Alex had a long history of mental health issues and had a diagnosis of Type 1 diabetes, requiring daily injections of insulin.�� Alex had a history of self-harm and in August 2022, March 2023 and April 2023 she had attended hospital having intentionally overdosed on her prescribed insulin� medication.� Following the incident in April 2023, Alex was admitted to an acute Mental Health�Ward on an informal basis from which she was discharged on the 10th May 2023. Alex was under the care of the Home Treatment Team and it was recognised at that time,� that in order to mitigate the risk of overdose, Alex�s medication should be prescribed� for to her to collect every two to three days.� This was done in respect of all of Alex�s� medication save for her insulin, which could only be prescribed in the form of pre-filled pens providing her with around ten days supply.�� The Court heard evidence in respect of the efforts that were made by those on the ground to limit the amount of insulin available to Alex at any one time. Consideration was given by the GP as to whether a junior pen could be prescribed in place of a standard pen, the evidence being that the amount of insulin in both the junior and standard pen is the same (300 units).� The only difference between the two pens being how much insulin is released at any one time and therefore having no effect upon the overall amount of insulin available to be administered through repeated use.� There was agreement from all involved in Alex�s care that what was required was a restriction in the amount of insulin available to her.� This was something easily done in respect of her other medication and, the Court heard, something which can be done with other medications, where arrangements can be made for the medication to be prescribed in smaller amounts.��� On the evening of the 13th May 2023, Alex took an intentional overdose of her� prescribed insulin medication, the Court having heard evidence that she had taken all of the insulin in her prescribed pre-filled pens.� She was found deceased the following day.

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

Alcohol, drug and medication related deaths

NHS England

07/02/2023

2023-0046

Ania Sohail

Manchester North

1.�� Secretary of State for Health and Social Care 2.��Chief Executive of Greater Manchester Mental Health NHS Foundation Trust

On 25 June 2021 an investigation into the death of Ania Sohail was commenced. The investigation concluded on 30 January 2023 at the end of the inquest that was held before a jury. The jury recorded the following conclusion;�Suicide with intent. The death was contributed to by the ineffectiveness of all searches but in particular to the search on 18June 2021, inadequate post-leave assessment and the omission of Safety Plans which reflect the risks posed to Ania on 18 June 2021. In respect of the online pharmacies, there was a: a)���� Lack of integrated system or records which could be accessed by multiple pharmacies b)���� Lack of access to the GP Summary Care Records, other pharmacy supplies; and c)���� Lack of consent to the sharing of information.�

CIRCUMSTANCES OF DEATH On 19 June 2021, Ania Sohail collapsed in the lounge area of Griffin Ward, Junction 17 in Prestwich after ingesting � Propranolol tablets which she had secreted onto the ward following periods of home leave. She was taken to North Manchester Hospital and died later that day. A post-mortem examination established that the cause of death was Propranolol toxicity. Ania had been an inpatient on Griffin Ward since June 2020 and for the final 9 months of the admission was detained under section 3 of the Mental Health Act 1983. She had a diagnosis of Emotionally Unstable Personality Disorder and a history of self-harm and suicide attempts. During her admission to Griffin Ward, Ania had purchased Propranolol medication on seven separate occasions from four different on-line pharmacies. On each occasion, Ania had completed an on-line questionnaire in which she denied having a mental disorder and declined consent for the prescriber to share information with her GP. The prescribers were unaware that Ania was accessing Propranolol from multiple on-line pharmacies and that Ania was concealing the fact that she was an inpatient at a psychiatric unit by ordering the Propranolol to be delivered to her home address. The prescribers accepted the information provided by Ania at face value and had they been aware of the above information, it would have altered their prescribing decisions. Before the fatal overdose on 19 June 2021 and whilst an inpatient on Griffin Ward, Ania had taken overdoses of Propranolol on 10 March and 5 June 2021. Searches of her room had been undertaken following each overdose. Home leave had been suspended following the first overdose before beinq gradually reintroduced. Following the second overdose, home leave was reinstated on the basis that pre and post leave assessments would be undertaken and Ania would be searched on return to the ward. Searches were conducted on a trauma informed basis and therefore were limited in nature. Ania�s first home leave following the second overdose was on 18 June 2021. When she returned from leave that evening, Ania was searched by a mental health support worker who confiscated two belts from her bag. Ania denied having any other contraband items on her person. There is no documented �evidence �of �the �two �belts �having �been �found on �Ania �that �evening �or that_ this �was handed over to the nurse in charge of the shift. The nurse in charge of the shift has no recollection of being informed of the two belts or of undertaking a post-leave assessment. The entry within the Day notes does not evidence whether or not a post-leave assessment did in fact take place that evening. Ania collapsed in the lounge area of Griffin Ward at lunch-time the following day. She was on 1:5 observations. The evidence from the support worker with responsibility for undertaking the checks between 10am and 12noon was that for the majority of that time Ania wa in her room with the door closed and that the checks were undertaken by knocking on her door every 5 minutes to check that she was alright. Following her collapse, Ania was conveyed to North Manchester General Hospital where attempts at resuscitation continued until deemed futile. Her death was verified at 15:36 hours that afternoon.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely: Mr and Mrs Sohail General Pharmaceutical Council General Medical Council � Care Quality Commission MHRA UK Meds [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 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) | Alcohol, drugs medication related deaths

Department of Health and Social Care | Greater Manchester Mental Health NHS Foundation Trust

09/05/2024

2024-0255

Linda Heath

East Riding and Hull

1.�� St Andrew�s Surgery Hull� 2.�� Hull University Teaching Hospital 3.�� NHS England� 4.�� Care Quality Commission� 5.�� Nursing and Midwifery Council�� 6.�� City Healthcare Partnership Hull

On 17th February 2023, an inquest was opened and adjourned into the death of Linda� Heath aged 76 years. The investigation concluded at the end of the inquest on 12th April 2024, the conclusion of the inquest was a narrative conclusion.� Box 3 referred to box 4 of the Record of Inquest which read: Linda Heath died on 31st March 2022 at Hull Royal Infirmary from sepsis which was� caused by an infected sacral sore. She had been discharged in February 2022 with a� grade 2/healing sore and a concatenation of management issues by healthcare� professionals including her not being referred for district nursing care led to a worsening� of her condition which, alongside her pre-existing comorbidities, ultimately led to an� admission to Hull Royal Infirmary on 5th March 2022. Despite surgical treatment the� situation worsened, and tissue viability nursing was not reinstituted post operatively.� Ultimately, following difficulties in care with nutrition and hospital acquired infections, Mrs Heath succumbed to sepsis and died on 31st March 2022 following cessation of active� treatment.� Her medical cause of death was recorded as: 1a� Sepsis� 1b Infected sacral sore� 1c� Poor mobility� II��� Pneumonia, multi�level degenerative discopathy, central canal stenosis, atrial fibrillation, chronic kidney disease, hypertension, obesity

Mrs Heath was discharged from hospital on 11th February 2022 with a sacral� sore. The Immediate Discharge Summary (IDS) did not mention that a district� nurse referral was required nor was a referral made by the hospital. Mrs Heath� had a private domiciliary care package in place, but little enquiry was made of� the remit of those carers by the hospital. The nursing summary on 10th February stated that the care would be transferred to the district nursing team to include� dressing selection and equipment required at home. This did not get added to� the IDS.� Mrs Heath lived independently and had the support of her family and the domiciliary carers. She did not have district nursing care.� Mrs Heath telephoned her GP on 14th February 2022 regarding the pressure� sore and was prescribed Zenoderm cream. This was not a face-to-face� appointment. The doctor advised that a photograph be sent of the sore. Carers took a photograph at Mrs Heath�s request, and it was sent to the GP.� No referral to the district nursing service was made. On 17th February Mrs Heath failed to attend a routine bloods appointment as� she was in too much pain from the pressure sore. A district nursing referral was not made either to take the blood samples or to assess the pressure sore. � On 3rd March Mrs Heath once again telephoned the GP and told them her� condition had worsened. This prompted the GP surgery to arrange a home visit which took place on 4th March. Mrs Heath was transferred to hospital following� that visit as the sore had become unmanageable in the community.� Despite surgical treatment and care in Hull Royal Infirmary Mrs Heath sadly died on 31st March 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested� Persons: the family of Linda Heath and their representatives, Hull University Teaching� Hospitals and Community Health Care Partnership as well as the agencies identified at the top of this report.� 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: St Andrew�s Surgery Hull | Hull University Teaching Hospital | NHS England | Care Quality Commission | Nursing and Midwifery Council | City Healthcare Partnership Hull

16/01/2025

2025-0029

Alexander Thomas

Manchester South

1.�� THE CHIEF EXECUTIVE, NATIONAL HIGHWAYS

On 15th August 2024 an investigation was commenced into the death of Alexander� Charles Edward Thomas, aged 42. The investigation concluded at the end of the inquest on 13th January 2025. The conclusion of the inquest was that he died from multiple� injuries consistent with a road traffic collision when he committed suicide.

Mr Thomas died on 14th August 2024 when he entered the eastbound carriageway of�the M56 motorway between junctions [REDACTED]. A heavy goods vehicle collided with him when� he� deliberately� stood� in� its� path� and� he� sustained� fatal� injuries.� He� had� a longstanding diagnosis of depressive disorder.� The location of the collision was close to where [REDACTED] passes under the M56 motorway and the nearby premises and car parks of the [REDACTED] and the evidence was that Mr Thomas had entered the motorway from the [REDACTED] area.

I have sent a copy of my report to the Chief Coroner and to the following Interested Person Mr Thomas� brother on behalf of Mr Thomas� family. I have also sent it to Chief Superintendent, Greater Manchester Police Roads Policing Unit, who may find it useful or of interest.� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Road (Highways Safety) related deaths | Suicide (from 2015)

National Highways

01/09/2023

2023-0492

Stephen Ratclife

Manchester North

1.�� [REDACTED], Chief Executive Greater Manchester Integrated Care Partnership Board

On the 20th February 2023, I commenced an investigation into the death of Stephen Ratclife, date of birth 6th October 1968 who died on the 6th February 2023 at his home address [REDACTED] . The medical cause of his death was confirmed as 1a) Respiratory Depression due to 1b) Combined Drug Toxicity 2) Developing Liver Cirrhosis and Anxiety and Depression.

CIRCUMSTANCES OF DEATH � � Stephen had a history of illicit drug and alcohol use. Had also had a diagnosis of depression and anxiety. He was under the local drug and alcohol services and for 11 months had been abstinent. He engaged well with his GP. In November 2022 he relapsed and in December 2022 was expressing suicidal thoughts. On the 10th January 2023 he collected his weekly methadone prescription. This was the last contact anyone is known to have had with Mr Ratcliffe until he was found deceased on the 6th February 2023. He had not collected his subsequent presciptions. During the course of the Inquest the court heard evidence that enquiries were also being made of his physical health in particular the need for him to have a blood test HBAc1 to check for diabetes. Due to difficult venous access these blood tests were not done.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- The family of Mr Ratcliffe 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 This report is being sent to: Greater Manchester Integrated Care Partnership Board

05/10/2023

2023-0373

Iris Fordham

East London

1.�� [REDACTED], Chief Executive Officer, Barts Health NHS Foundation Trust � 2.��[REDACTED] of State for Health & Social Care

On 2nd January 2023 this Court commenced an investigation into the death of Iris Elaine Fordham aged 95 years. The investigation concluded at the end of the inquest on 5th October 2023. The court returned a narrative conclusion; � Iris Elaine Fordham died in a step-down care centre on 1st January 2023, she was recovering from a surgical repair of injuries sustained in a fall. Her death was caused by worsening symptoms of Alzheimer�s disease. � � Mrs Fordham�s medical cause of death was determined as� 1. a. Alzheimer�s disease 2.� COVID-19, fractured neck of femur, suspected colorectal cancer

Iris Fordham was admitted to hospital on 22nd November 2022 having sustained an unwitnessed fall in the community, her admission was not to treat any traumatic injury, but rather that concerns existed about her ability to ensure her own safety due to Alzheimer�s disease. � Mrs Fordham was placed on 1:1 nursing care in order to, amongst other things, mitigate the risk of further falls. � Those caring for Mrs Fordham failed to conduct a falls risk assessment, introduce a falls care plan, or conduct an enhanced care assessment when indicated, these successive failings resulted in removal of 1:1 care and then an unwitnessed fall on 25th November 2022. Mrs Fordham sustained a broken neck of femur and underwent a surgical repair. Post surgically, she was transferred to a step-down care centre where she died on 1st January 2023.

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

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

02/08/2024

2024-0427

Sophie Wilson

Durham and Darlington.

1.�� [REDACTED], Chief Executive of North East Ambulance Service

INVESTIGATION On the 11th of July 2023 an investigation was commenced into the death of Sophie Jayne Wilson, aged 26 years. The investigation concluded at the end of an Inquest on the 1st of August 2024. I gave a narrative conclusion which included that the cumulative failings of mental health services and the North East Ambulance Service contributed more than minimally to the death.

Sophie Jayne Wilson was found deceased at her home address on the 2nd of July 2023. She died as a result of an [REDACTED] Overdose. Having disclosed an [REDACTED] overdose to the Crisis team the evening before an ambulance was called on her behalf. Sophie did not engage with the ambulance crew or the paramedic to whom the case was escalated and refused their assistance. They left the scene. There was no assessment of her capacity to decline potentially life-saving assessment and treatment. There was no escalation to the Police to force entry. There was no formal escalation to mental health services. There was no reference to the �familiar face multi agency plan� which neither the ambulance crew or paramedic had seen. Some 21 hours after Sophie had told the crisis team of her overdose and the ambulance had been called, the Police forced entry to her home and found her deceased.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- The family of the deceased, Tees Esk and Wear Valley Foundation Trust (TEWV), and the County Durham and Darlington Trust (CDDFT). I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

�Emergency services related deaths (2019 onwards) | Mental Health related deaths � This report is being sent to: North East Ambulance Service

17/03/2017

2024-0091

Trevor Curry

West Sussex, Brighton and Hove

1.�� [REDACTED], Chief Executive, Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing. BN13 3EP

On 17th June 2016 I commenced an investigation into the death of Trevor John CURRY. The investigation concluded at the end of the inquest on 1yth March 2017. The conclusion of the inquest was a Narrative Conclusion � see attached sheet.

See Record of Inquest

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1. [REDACTED] �[REDACTED] , Head of Legal Services, Sussex Partnership NHS Foundation Trust Secretary of State for Health, Department of Health [REDACTED] � Chief Executive NHS England [REDACTED] � Sussex Partnership Trust [REDACTED] � Millview Hospital �� 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: Sussex Partnership NHS Foundation Trust

21/09/2023

2023-0349

Chantelle Reed

Cambridgeshire and Peterborough

1.��The Royal College of Emergency Medicine 2.�The Royal College of Radiologists 3. NHS England

On 14 January 2021 an investigation into the death of Chantelle Reed was commenced. Chantelle died on 29 October 2020. The investigation concluded at the end of the inquest on 6 September 2023. The conclusion of the inquest was: � Medical Cause of Death: � 1a. Haemopericardium � 1b. Type A aortic dissection � Conclusion � Natural causes, namely an undiagnosed acute aortic dissection, a rare condition, even more so in light of Chantelle�s age and lack of relevant medical history.

1.�Chantelle Reed was a 33 year old lady who had no history of any significant medial conditions. � 2. On 27 October 2020 Chantelle began to experience back and neck pain and feeling of breathlessness. She described the pain as worse than contractions. The pain was sufficient that she felt unable to drive and she was driven to the Emergency Department at Peterborough City Hospital. � 3.�On arrival Chantelle described having throat spasms/back pain. When she was seen by a doctor she advised that her symptoms had resolved and indicated a desire to leave as she did not wish to waste the department�s time. At that time she did not advise of any chest pain or breathlessness. Chantelle also advised she had experienced similar back spasms before following an epidural. � 4.�The doctor did however complete a physical assessment and arrange for blood tests to be performed. Based on the findings at that time, a working diagnosis of musculoskeletal pain was made and Chantelle was discharged with a prescription for diazepam. � 5.�Chantelle did not have any medical history that would cause concern for this condition. Given her age and presentation, I heard expert evidence that �acute thoracic aortic dissection in these circumstances in a young woman to be highly unusual making it so rare that it would not be considered a differential diagnosis without strong clinical evidence�. � 6.�While the expert gave evidence that on 27 October, the abrupt onset of central chest pain radiating to back and throat was consistent with a dissection, he stated that Chantelle had a normal ECG, completely normal physical observation, no abnormality on examination and normal blood tests. He therefore stated this would reassure a responsible emergency physician and it was therefore reasonable, without the benefit of hindsight, to discharge her at that time. � 7.��Overnight on 28 October Chantelle became breathless and developed chest pain and in the early hours of 29 October, after a 111 call, an ambulance was called and Chantelle was taken again to hospital arriving at around 0450 hours. She was complaining of sudden onset chest pain, which was worse on inspiration, vomiting and fever. 8.�There was a delay in Chantelle seeing a doctor after she was triaged, but the length of the delay was not one outside the realm of the usual wait nationwide, particularly in the context of the covid pandemic. � 9.�Various tests were carried out following assessment and she was managed for suspected pulmonary embolism (PE). A chest x-ray was performed and reviewed by the ED clinician and no concerns were noted. A CT pulmonary Angiogram (CTPA) and echocardiogram were requested, but this was later overruled by a Medical Consultant. We heard evidence from that Consultant who felt that Chantelle did not have a PE and likely had an infection and provided antibiotics and indicated she was fit for discharge. Chantelle was moved to the ambulatory majors area of ED when she was noted to be unconscious by another patient who alerted staff. She was rushed to the resuscitation room, but sadly did not survive. � 10. I heard expert evidence that when Chantelle represented to the ED on 29 October, based upon what was known at that time, and Chantelle�s presentation, the suspicion of a PE was reasonable, as was starting treatment for this with anticoagulants in accordance with national guidance, while awaiting the scan results. However, his evidence was that it was not appropriate to decide not to carry out the further investigations requested by the ED Registrar. The expert�s evidence was that Chantelle�s presentation did not fit fully fit with infection, although this should have remained as a differential diagnosis. She should therefore have been admitted and given the antibiotics as an inpatient, where she could be monitored due to the ongoing tachycardia and the raised troponin t, so that the nature of any infection could be established to ensure she was on the correct antibiotics, and also the investigations to confirm or rule out a PE could be undertaken. � 11.�I am mindful that the investigations ordered were not to consider aortic dissection, and the expert was not critical of this, but that the CTPA if undertaken could have shown the dissection as an incidental finding and this was also agreed by an expert Cardio Thoracic Surgeon. � 12. Further, the chest x-ray undertaken on 29 October was subsequently reported as abnormal. The ED expert was not critical of the fact that the ED clinicians did not correctly interpret this and advised that the subtle signs may have been missed by them, especially as it is only with the benefit of hindsight that signs of a dissection would be specifically considered. They were however spotted by the reporting Radiologist, but sadly they did not review and report until after Chantelle�s death and the evidence was that this is nationally not an unusual timescale for such a report. Had the chest x-ray been reported by a Radiologist sooner, the diagnosis would have been made sooner.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � 1.����� Chantelle�s family 2.����� North West Anglia NHS Foundation Trust (Peterborough City Hospital) I have also sent it to the following who may find it useful or of interest. 3.����� Secretary of State for Health 4.����� HSIB 5.����� Aortic Dissection Awareness UK & Ireland 6.����� Heart Research UK (�think aorta� campaign) � 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

The Royal College of Emergency Medicine | The Royal College of Radiologists | NHS England

17/05/2024

2024-0271

Jonathan Szczepanski

Lincolnshire

1.��� Lincolnshire Integrated Care Board

On 31 May 2023 I commenced an investigation into the death of Jonathan Paul SZCZEPANSKI aged 64. � The investigation concluded at the end of the inquest on Monday 13 May 2024. The conclusion of the inquest was: � Medical cause of death: 1(a) Upper Gastrointestinal Haemorrhage 1(b) Duodenal Ulcer 2����Naproxen Treatment � Conclusion Mr Jonathan Paul Szczepanski died from the consequence of a duodenal ulcer to which the prescription of Naproxen without the corresponding Protein Pump Inhibitor (PPI) made a contribution.

Mr Jonathan Paul Szczepanski had a significant medical history which included Parkinson�s Disease, Type 2 Diabetes, Hypertension and Spinal Stenosis. He had several repeat prescriptions from his GP surgery to treat his conditions and to provide pain relief. This included Naproxen, a non-steroid anti-inflammatory drug (NSAID) which had been prescribed regularly since 2016 on a dosage level of 500mg twice daily. No corresponding proton pump inhibitor (PPI) medication had ever been prescribed to address the recognised risk of duodenal ulceration from NSAIDs. No medication reviews had taken place to address or manage the risks of long term NSAID prescription, against the background of his relevant co-morbidities. He was admitted to Boston Pilgrim Hospital on 28 April 2023 with an acute kidney injury due to suspected infection and urinary retention. He was discharged on 2 May 2023 with a repeat prescription of Naproxen � 500mg twice daily. No PPI medication was prescribed. He was admitted to Boston Hospital on 14 May 2023 with symptoms indicative of a gastrointestinal bleed. Despite repeated medical and surgical intervention, he did not respond to treatment and his condition was such that further intervention was not possible. He was placed on end-of-life care until he passed away.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � �[REDACTED], Welby Group, The New Coningsby Surgery, 20 Silver Street, Coningsby, Lincolnshire, LN4 4SG United Lincolnshire Hospitals NHS Trust � I am also under a duty to send a copy of your response to the Chief Coroner and all Interested Persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the Coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

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

10/11/2023

2023-0442

Mason Williams

Warwickshire

1.��� The Chief Executive [REDACTED]�of Warwickshire County Council.

On 16 December 2022, I commenced an investigation into the death of Master Mason Williams (aged 13 years). The investigation concluded at the end of the inquest on 10 November 2023 at Warwick Coroners Court and my conclusion was a Road Traffic Collision

On the 30 November 2022, at about 5.00pm Mason Williams was walking with three friends along the footpath next to Trinity Road, Piccadilly near Kingsbury. A car was travelling along Trinity Road, in the same direction as the boys. At this time, it was dark and the street lighting were not working. Mason and two of his friends decide to hide from a friend who has walked on ahead. As a group they crossed the road onto the opposite verge. Mason attempted to cross the carriageway back to his friend and was struck by a car. He died in hospital 3 days later. The conclusion of the Inquest was a Road Traffic Collison.

I have sent a copy of my report to the following: � � 1.������ HHJ Teague QC the Chief Coroner of England & Wales Chief Coroner�s Office, 11th Floor Thomas More, Royal Courts of Justice, Strand, London, WC2A 2LL. chiefcoronersoffice@judiciary.gsi.gov.uk 2.������ The family of Master Mason Williams I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Child Death (from 2015) | Road (Highways Safety) related deaths This report is being sent to: Warwickshire County Council

05/02/2024

2024-0066

Abdullah Popalzai

Inner North London

1.��� [REDACTED], Chief Executive Officer, NHS England, PO Box 16738, Redditch, B97 9PT

On 4 December 2019, I commenced an investigation into the death of Abdullah Popalzai (20 years). The investigation concluded at the end of the inquest on 29 November 2023. The conclusion of the inquest was that the medical cause of death was 1a Suspension. A conclusion of suicide with an additional narrative was returned by the jury. � The Jury found �Mr Popalzai died in his cell in the inpatient wing at HMP Pentonville on 29 November 2019. He was suspended from a ligature [REDACTED]�. The accompanying narrative read as follows: [REDACTED]. If the cover had been properly present and secured with security screws, Mr Popalzai would not have been able to attach the ligature to this point. � An ACCT was not opened for Mr Popalzai. If an ACCT had been opened, staff on the healthcare wing would have had greater visibility of the self-harm risk to Mr Popalzai identified by the psychiatrist at court. Mr Popalzai was recommended to be admitted to a hospital facility. If a suitable bed and transport had been available earlier, Mr Popalzai could have received urgent medical treatment for his acute psychosis as advised by multiple medical practitioners. It is likely that Mr Popalzai became aware during the night of 28 November 2019 of his impending transfer on 29 November 2019. Mr Popalzai had stated on multiple occasions that he would hang or kill himself if he were to be transferred to a hospital.

Mr Popalzai was a remand prisoner at HMP Pentonville. A Mental Health Act assessment carried out at the Magistrates Court on 24 September 2019 decided that he should be detained under Section 2 of the Mental Health Act. However, as there were no hospital beds available at the time that Mr Popalzai�s case was heard, he was remanded in custody to HMP Pentonville. Mr Popalzai was transferred to the inpatient wing at HMP Pentonville on 29 September 2019. There were significant barriers to communicating with Mr Popalzai as he spoke predominantly in Pashto. Throughout his time in the inpatient unit, Mr Popalzai was acutely psychotic. He was aggressive and most interactions with psychiatrists, healthcare staff and prison officers took place through the cell door. Mr Popalzai consistently refused to take any medication as he did not accept that he was mentally ill. Mr Popalzai stated on several occasions that he would hang himself if transferred to a psychiatric hospital. On 9 October 2019, Mr Popalzai was assessed by a psychiatrist who found that he was psychotic and needed to be transferred to hospital for treatment under section 48 Mental Health Act 1983. The Crystal Ward, which is the psychiatric intensive care unit at the Newham Centre for Mental Health, was identified as the appropriate unit. A second assessment was carried out by a psychiatrist from the Crystal Ward on 18 October. The 2nd psychiatrist agreed that Mr Popalzai should be detained on the Crystal Ward for assessment and treatment under section 48 Mental Health Act on 24 October 2019. However, there were no beds available on Crystal Ward at that time. On 21 November 2019, the Crystal Ward advised that a bed issued by the Ministry of Justice and arrangements were made for Mr Popalzai to be transferred to the Crystal Ward on the afternoon of 29 November 2019. At around 12.30 pm on 29 November 2019, Mr Popalzai was found hanging in his cell. Attempts were made to resuscitate Mr Popalzai but his death was confirmed by paramedics at the scene. The psychiatric evidence was consistent that: 1) the only effective treatment for Mr Popalzai�s psychosis was anti- psychotic medication; 2) anti-psychotic medication could not be given to him against his wishes in a prison setting. As a result, he needed to be transferred to an appropriate psychiatric unit. 3) Mr Popalzai�s mental health deteriorated in the time that he was waiting for a psychiatric bed to become available. I also heard evidence that a significant number of prisoners from HMP Pentonville were transferred to psychiatric units under the Mental Health Act each year. I was told that the experience of psychiatrists at the prison was that the target time of 14 days from 1st assessment to transfer set out in the statutory guidance was seldom met. I was also told that significant delays in beds becoming available were extremely common and delays of up to 6 months were not unheard of.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Ministry of Justice Practice Plus Group (Previously Care UK) Barnet, Enfield and Haringey NHS Foundation Trust East London NHS Foundation Trust The Prison and Probation Ombudsman � I have also sent it to the North East London NHS Foundation Trust who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

State Custody related deaths | Suicide (from 2015) This report is being sent to: NHS England

22/10/2024

2024-0693

Richard Roe

Cambridgeshire & Peterborough

1.�������� NORTH WEST ANGLIA NHS FOUNDATION TRUST

On 25 January 2023 I commenced an investigation into the death of Richard David ROE aged 75. The investigation concluded at the end of the inquest on 17 October 2024. The conclusion of the inquest was that: Mr Roe underwent a pulmonary angiogram at Hinchingbrook Hospital in Huntingdon on 26.09.21. This revealed a pancreatic cyst. A subsequent CT scan on 11.10.21 identified a lesion in excess of 3cm in the tail of the pancreas. The reporting radiologist recommended the scan be reviewed by the Hepato-Biliary MDT but the scan was neither actioned nor viewed. Had it been viewed the scan would have shown the presence of pancreatic cancer. Mr Roe re-presented to Hinchingbrook Hospital in November 2022 and a subsequent CT scan revealed the presence of metastatic pancreatic cancer. Sadly Mr Roe died at his home address,�[REDACTED], at 0832hrs on 20.01.23. Had his pancreatic cancer been identified in October 2021 it is likely that Mr Roe would have undergone surgery and been treated with subsequent chemotherapy. Although the chance of the treatment being curative was low had treatment been provided he would not have died as soon as 20.01.23.

Mr Roe underwent an abdominal CT scan in October 2021. This showed evidence of pancreatic cancer. The CT scan was the subject of a routine referral by the reporting radiologist due to the fact that an earlier pulmonary angiogram had identified a pancreatic cyst(so it was not flagged as an �unexpected finding�). The CT scan was not reviewed or actioned as requested by the radiologist. A subsequent CT scan conducted on 01.12.22 revealed that the pancreatic cancer had metastasised. Mr Roe died on 23.01.23.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Mr Roe�s Family/Legal Representatives I have also sent it to the 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.

Hospital Death (Clinical Procedures and medical management) related deaths

NORTH WEST ANGLIA NHS FOUNDATION TRUST

2/8/2024

2024-0429

James Capstick

Cumbria

1] [REDACTED] Manager, Westmorland Court Care Home, Arnside, Cumbria LA5 0AW.������������������������������������������������������ ������������������������������������������������������������������������������������� � 2] Chief Executive, Care Quality Commission�Citygate, Gallowgate, Newcastle-upon-Tyne NE1 4PA.� 3] Chief Executive Nursing and Midwifery�Council 23 Portland Place, London W1B 1PZ

On 12 October 2022 I commenced an investigation into the death of James Reginald� CAPSTICK. The investigation concluded at the end of the inquest on 21st June 2024. The conclusion of the inquest was a narrative as follows� James Reginald Capstick died in the Royal Infirmary, Lancaster aged 83. He suffered� from Type 1 Diabetes and Autonomic Dysfunction which required him to be nursed laying� down in bed. On 1st December 2021 he was subjected to over 20 minutes of CPR chest� compressions when not actually in cardiac arrest, sustaining 10 fractured ribs. This� massive chest injury led to respiratory insufficiency and an episode of pneumonia which� was treated successfully, however the combination of injury and illness led in turn to his� death on 1st October 2022. The continuation of chest compressions by a registered nurse in the face of clear indications that her patient was not in cardiac arrest but alive was a� gross failure in basic care and can be classed as neglect.� 1a Respiratory Insufficiency and Treated Pneumonia 1b Multiple Healing Rib Fractures 1c II�Type 1 Diabetes with Autonomic Dysfunction

James Reginald Capstick [Reg] was placed in the care of Westmorland court�after a lengthy stay in hospital, he had autonomic dysfunction which cause his blood� pressure to collapse if sat up or standing -requiring him to spend virtually all the time�being nursed in a flat or semi-recumbent position. He had frequent �absent� periods when he might be unresponsive. On 1st December 2021 a lengthy such period led to a 999 call� to the Northwest Ambulance Service. There was great confusion between the call handler and the nurse in charge of the home -demonstrated by transcripts entered into evidence.� This confusion led to over 20 minutes of chest compressions being continued on Reg� despite clear signs of life -basic checks to confirm this were not carried out. Reg was� admitted to hospital having sustained a major chest injury and the ambulance crew raised a safeguarding referral. � � Reg returned to Westmorland Court early in 2022, friends who visited were�very concerned about the quality of care given and made a second safeguarding referral. I heard at inquest that both these referrals were closed by social services. �� Reg became ill in September 2022 and was admitted by ambulance to Royal�Lancaster Infirmary, the admitting crew were very concerned by his appearance, apart� from illness he was said to be dirty, unkempt and emaciated and dehydrated with dry,� caked mouth that did not appear to have had any recent care. A third referral was made� and I heard that this remains open. In hospital Reg�s pneumonia was treated but he� continued to decline and died on 1st October 2022. As a result of the concerns raised the police and ourselves requested a home office postmortem examination

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. [REDACTED] friends and designated next of kin for Reg 2. [REDACTED] solicitor acting for Reg�s estate. 3. [REDACTED] general practitioner. 4. Northwest Ambulance Service. 5. Westmorland and Furness social services department 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.� 2nd August 2024

Care Home Health related deaths� � This report is being sent to: Westmorland Court Care Home | Care Quality Commission | Nursing and Midwifery Council

06/09/2023

2023-0319

Sheila Johnson

Lincolnshire

1� Phoenix Care Centre

On 19 February 2021 I commenced an investigation into the death of Sheila Rosamund JOHNSON aged 91. The investigation concluded at the end of the inquest on 15 November 2022. The conclusion of the inquest was that: � The deceased died on 14th February 2021 at Butterfly Hospice, Rowan Way, Boston after being transferred there from hospital following an unwitnessed fall at her care home resulting in fatal injuries.

Reported to the coroner by [REDACTED]�(Staff Nurse Butterfly Hospice) � Daughter wishing for the coroner to be involved as she believes her mothers death was the consequence of a fall at the care facility. Following fall admitted to Pilgrim Hospital transferred to Hospice. Expected death at the hospice, was admitted on 11-02-2021 I have spoken to the coroners officer [REDACTED] . on 14022021 � Contacted Sidings Medical Centre for patient history. � Contacted NOK (daughter [REDACTED]�� via husband [REDACTED]) who explained that the deceased had been living in Phoenix Care Home for about a year and is believed to have suffered a fall there on 03/02/2021 where she was transferred to PHB with suspected multiple rib fractures and a punctured lung. Due to her age there was nothing other than palliative care and she was subsequently transferred from PHB to Butterfly Hospice where she died on 14/02/2021. � PM examination carried out by [REDACTED] 17/02/2021 � Contacted [REDACTED] (manager � Phoenix Care Centre) who explained the fall occurred on 03/02/2021 at approx. 20.22hrs. She explained that Sheila suffered from advanced dementia and liked to �walk with a purpose� and was allowed to wander around the [REDACTED] building, she was not described as a frail lady with more of a substantial frame to her. [REDACTED] believes she was on two types of medication used for patients with bone issues to build their bone density but can�t remember the names of the medication On the evening of the fall she had gone into a neighbours bedroom while the resident was elsewhere in the building, the room was dark at the time and staff herd her cry out. On entering the room they found her flat on her back on the floor but on top of the beds duvet that had been pulled off the bed. The bed in this room was described as a �Profiling Bed� they are designed with a taller base board and also have a metal bar above the base board, [REDACTED] thought it was possible for her to have fallen onto the base of the bed. On arrival there were no obvious signs of injury to Sheila however she was clearly in pain so the team called 999 for assistance before moving her from the floor. On the arrival of paramedics she was raised to a chair by the paramedics and still in obvious pain so conveyed to Pilgrim Hospital. � PM examination carried out by [REDACTED] who confirmed cause of death related to multiple rib fractures.

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

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

24/11/2023

2023-0495

Jane Bennett

Nottingham City and Nottinghamshire

1� [REDACTED] Head of Housing, Mansfield District Council

INVESTIGATION � On 23rd August 2023, I commenced an investigation into the death of Jane BENNETT, aged 52. Mrs. Bennett died on 8th June 2023 at Kings Mill Hospital, Mansfield Road, Sutton-in- Ashfield, Nottinghamshire, NG17 4JL. � A post mortem examination was undertaken by [REDACTED] , at the instruction of HMC for Nottinghamshire. In a report dated 8th August 2023, she gave the cause of death as 1a Acute exacerbation of non-specific interstitial pneumonitis. � In her comments to the Coroner she said: �In the view of history and autopsy findings in my opinion death was due to acute infective exacerbation of interstitial lung disease. Mould in her house could have contributed for the development of interstitial lung disease.�

Mrs. Bennett lived in a house provided by Mansfield District Council from October 2022 until her final admission to hospital in late May 23. She identified severe mould in her property. Photographs are attached. � Mrs Bennett had a diagnosis of interstitial pneumonitis made on CT scan 01/04/23 and she then had frequent admissions to hospital with worsening respiratory function in April and May 2023. � Mrs Bennett was admitted to ITU for the second time on 28/05/23 with type 1 respiratory failure requiring high flow nasal oxygen/NIV, high dose IV steroids, antifungals and antibiotics throughout her admission. She failed to respond to medical management , and sadly died on 8.6.23. � The cause of her interstitial pneumonitis is not clear at this stage, but both the Pathologist and the Respiratory Consultant, [REDACTED]�in his report to the Coroner dated 26.9.23 (report attached) are clear that the mould may be causal or contributory to her death. This will be further explored at a forthcoming Inquest, date to be finalised.

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

Other related deaths This report is being sent to: Mansfield District Council

05/04/2024

2024-0188

Paul Templeton

Suffolk

1� [REDACTED], Chief Executive Officer, Norfolk & Suffolk NHS Foundation Trust

On 24 April 2023 I commenced an investigation into the death of Paul David TEMPLETON aged 65. The investigation concluded at the end of the inquest on 21 February 2024. The conclusion of the inquest was one of: Suicide The medical cause of death was confirmed as: 1a Hypoxic Brain Injury 1b Asphyxiation 1c

The Jury�s answer given in the Record of Inquest to how, when and where the deceased came by his death was as follows: � �Paul Templeton came by his death due to the termination of life support on 20th April 2023 at Ipswich Hospital. Paul died at 5:35am. The circumstances leading to Paul�s admission to hospital where he eventually died began on the morning of 14th April 2023 at Woodlands, Willow Ward. � Between the hours of 8:39am and 9:18am Mr Paul David Templeton [REDACTED] cause asphyxiation. Mr Paul Templeton�s mental state deteriorated during 2022 to the point at which he was severely malnourished and dehydrated. This led to hospitalisation for kidney injury and later transferral to Woodlands under section 2 of the Mental Health Act. Initial and all subsequent assessments seriously fail to recognise that Paul�s prolonged choice not to eat or drink were in fact indications of `action` to end his own life and therefore he should have been considered as a suicide risk.�

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to 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: �Norfolk and Suffolk NHS Foundation Trust

03/08/2023

2023-0283

Leah Barber

West Yorkshire (Western)

1�City of Bradford Metropolitan District Council

On 12 June 2019 I commenced an investigation into the death of Leah BARBER aged 15. The investigation concluded at the end of the inquest on 28 April 2023. The conclusion of the inquest was that: � on 3 June 2019, Leah Barber was found deceased at the Bolton Woods Quarry, Bolton Hall Road in Bradford. Leah was suffering a range of mental health pressures in the last 18 months of her life, and her mental health fluctuated in the terms of the nature and severity of those pressures. She had previous thoughts of taking her own life and had tried to do so on two occasions. [REDACTED] On the morning of 3 June 2019 Leah left a note at her home address for family which indicated an intent to take her own life. From the location within the quarry at which she was discovered and a post-mortem examination it was apparent that Leah had fallen from a height of around 30 metres. The evidence showed that Leah had taken her own life. � The medical cause of death was: � 1a. Multiple injuries with inhalation of water 1b. Fall from a height

As per box 3 (immediately above).

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] � I have also sent it to � 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) | Suicide (from 2015) This report is being sent to: City of Bradford Metropolitan District Council

16/05/2023

2023-0161

Stuart Robinson

Liverpool and Wirral

1�Ministry of Justice (Coroners)

On 05 May 2021 I commenced an investigation into the death of Stuart Michael ROBINSON aged 20. The investigation concluded at the end of the inquest on 15 May 2023. The conclusion of the inquest was that: � Stuart Michael Robinson arrived at HMP Altcourse on 3rd March 2021 after receiving a 26 week sentence for breach of license. He was due to be released on 1st June 2021. He arrived with a history of attempted suicide and self-harm. On the 8th April, a ACCT book was opened following the interception of a letter detailing Mr Robinson�s intention of suicide. Subsequently he was put under a regime of 5 observations an hour and 2 meaningful conversations per day. On the 9th April he underwent a mental health assessment and the first ACCT case review reduced the number of hourly observations to 3, with the number of meaningful conversations remaining at 2 per day. A care plan was put in place as part of this first case review. On the 14th April at a second case review, the observations were removed entirely, however the meaningful conversations remained at 2 per day. On the evening of 18th April Mr Robinson self-harmed, leading to hourly observations being reinstated. This led to the 3rd case review being brought forward to the 19th April. Hourly checks were once again removed and Mr Robinson continued to have 2 meaningful conversations. On 23rd April Mr Robinson self-harmed again, leading to the fourth case review being brought forward. On this same date Mr Robinson�s podmate was released from prison and Mr Robinson was therefore alone in his cell. Mr Robinson was last seen at 7 pm on the 24th April. In the early hours of 25th April between approximately 12 am and 1 am, Mr Robinson applied a ligature [REDACTED] ultimately resulting in his death by suicide. His body was discovered at 5am and a code blue was called. Medical staff attended the scene but it was clear that Mr Robinson was incapable of resuscitation. Mr Robinson was declared dead at 5:16 am.

See above.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] BLM LAW � 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: Ministry of Justice (Coroners)

26/04/2023

2023-0138

Colin Gumm

Lincolnshire

1�[REDACTED] , Legal Services Manager Lincolnshire County Council

On 14 December 2021 I commenced an investigation into the death of Colin Robert GUMM aged 65. The investigation concluded at the end of the inquest on 25 April 2023. The conclusion of the inquest was that: � The deceased (who was a vulnerable adult upon a care package ) died on 27th November 2021 at Lincoln County Hospital, Greetwell Road, Lincoln where he was admitted having been found in a collapsed state by his carers earlier that day. Sadly despite treatment his condition deteriorated and he passed away the same day. A safeguarding referral was subsequently made.

Please refer to above and below

I have sent a copy of my report to the Chief Coroner. � 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: Lincolnshire County Council

30/12/2024

2025-0030

Denise Johnson

Suffolk

1�[REDACTED] � The Chief Executive of East Suffolk and North Essex Foundation Trust

On 26th February 2024 I opened an Inquest into the death of: Denise Ellen Johnson The conclusion of the Inquest on 10th December 2024 was: Dee died from acute small and large bowel infarction secondary to necrotising pancreatitis and intraabdominal sepsis, both recognised complications of severe post ERCP pancreatitis, on the background of obesity, recent treatment for breast Cancer and severe psychological stress The medical cause of death was confirmed as: 1a Multi-organ failure 1b Severe E.coli septicemia 1c Pancreatic necrosis and ischemic bowel perforation 1d CBD stones and post ERCP pancreatitis

Dee was admitted to hospital as an emergency with abdominal pain and jaundice on 13th August 2022. Dee was 42 years of age with a history of obesity, ongoing treatment for breast cancer and depression. Investigations revealed a gallstone in the common bile duct as the cause of her jaundice. An endoscopic retrograde cholangiopancreatography (ERCP) was performed and a plastic stent inserted for drainage. Dee became acutely unwell post ERCP and was diagnosed with acute necrotising pancreatitis. Dee was admitted to ITU for 9 days for supportive care and antibiotics. The care of Dee�s necrotising pancreatitis and associated peri-pancreatic collections via CT Scans, insertion of abdominal drains, treatment plans and clinical updates was managed at Ipswich General Hospital with ongoing advice and guidance from Addenbrooke�s Hepato- Pancreato-Biliary multidisciplinary team. Subsequent CT scanning showed severe pancreatitis with fat necrosis and peripancreatic fluid collections. Dee�s infected peri-pancreatic collections were drained by a series of drains. Dee had regular pain management, physiotherapy and dietician review. The peripancreatic collections were managed by ongoing abdominal drainage, flushing and antibiotics as guided by Microbiology. Despite ITU admission with intensive supportive care her condition deteriorated and Dee died on 24th November 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1.� Dee�s next of kin. I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the Senior 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

East Suffolk and North Essex Foundation Trust

30/01/2025

2025-0054

Shaun Hall

Northamptonshire

1�[REDACTED], Chief Executive of Northamptonshire Healthcare Foundation Trust

On 03 January 2024 I commenced an investigation into the death of Shaun Kenny HALL aged 36. The investigation concluded at the end of the inquest on 29 January 2025. The conclusion of the inquest was: 1a Suicide

Shaun Hall suffered with mixed anxiety, depressive disorder and emotionally unstable personality disorder.� He regularly consulted his GP for these problems.� On 2 November 2023 he attended A&E at Northampton General Hospital having taken an intentional overdose of olanzapine, tramadol and paracetamol.� On the advice of his GP he self- referred to NHS Northamptonshire Talking Therapies on 13 November 2023.� A telephone assessment took place on 20th November 2023.� The Mental Health Support Practitioner was so concerned at Shaun�s presentation that she made a referral to the Urgent Care and Assessment Team the following day. The referral was declined.� Mr Hall was subsequently found deceased in the grounds of Whittlebury Hall on 14th December 2023 having hung himself. My conclusion was suicide.

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)�| Mental Health related deaths

Northamptonshire Healthcare Foundation Trust

28/06/2023

2023-0223

George Griffiths

Herefordshire

1�[REDACTED], Chief Executive, Wye Valley NHS Trust

On 9 May 2022 I commenced an investigation into the death of George Edward GRIFFITHS. The investigation concluded at the end of the inquest on 14 June 2023. The conclusion of the inquest was narrative.

On 01.2.22, Mr Griffiths went from home by ambulance to A&E, County Hospital, Hereford. He was admitted to the hospital for treatment as it was diagnosed he had an acute kidney injury, gastritis, poorly controlled diabetes and infected toes. Profound metabolic acidosis was noted on a VBG test. � He developed worsening hypernatraemia and sepsis. He was also treated for Hyperosmolar Hyperglycaemic State and he was investigated for Fournier�s Gangrene. Mr Griffiths was then transferred to ICU for further care and treatment. � He had long treatment in ICU and following stepdown back to ward developed delirium . Mr Griffiths developed COVID during his hospital stay and treatment for this was given. He was transferred to a ward for elderly care after his long and complicated admission by which time he had developed a significant pressure sore and C diff diarrhoea. � Doctors believe the pressure sore has contributed to death and this occurred during hospital admission.

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

Suicide (from 2015) | Mental Health related deaths This report is being sent to: Wye Valley NHS Trust

19/10/2023

2023-0393

Wayne Milne

Sefton, St Helens and Knowsley

1�[REDACTED], Rocky Lane Medical Centre, Liverpool, L16 1JD

On 01 July 2022 I commenced an investigation into the death of Wayne MILNE aged 43. The investigation concluded at the end of the inquest on 17 October 2023. The conclusion of the inquest was that: � Narrative � Wayne Milne died a natural cause of death from sudden and catastrophic consequences of his aorta rupturing and leading to his death. Wayne had attended AED on 28/02/2022 with chest pain amongst other symptoms but the doctor failed to follow the protocols in place, a cardiac/related cause was not considered, a senior doctor was not consulted and Wayne was discharged. � On 02/03/2022 Wayne called his GP practice at 08.00 hours, he spoke with the practice manager who was not given any information and at 08.02 the practice manager referred Wayne for a return phone call by a nurse, (he preferred a phone call to attending for a medical appointment) which was made at 10.25. Wayne had complained of chest pain which commenced again after he left hospital, (but was not present at the time of the consultation), a pulsation at the back of his head and discomfort when lying on his side, he was told to seek immediate medical attention and to attend the accident and emergency department. The nurse did not call 999 or discuss Wayne�s clinical symptoms with a doctor. � Wayne was subsequently found unresponsive by a family member who had become concerned at 14.43, all attempts at CPR were unsuccessful and it is not known what time Wayne suffered the final catastrophic event. � The doctor failed to follow the low risk chest pain protocol and the nurse did not call 999 when she could have done, nor did she call back to check that Wayne had gone to hospital/called an ambulance. � Earlier appropriate intervention on these two occasions may (possibly) have affected the outcome for Wayne but earlier appropriate intervention would have been likely to have led to Wayne receiving the correct diagnosis/differential diagnosis and potentially life-saving treatment being commenced.

Wayne attended hospital on 28/02/22, he was discharged without the protocols in respect of chest pain being followed, i.e. there was no 2nd ECG, no 2nd Troponin levels and no consultant review even though there should have been. On 02/03/22 Wayne called the GP practice at 08.00 hours, he received a call from a nurse at 10.25, he reported experiencing chest pain, pain when lying on his side and a pulsation at the back of his head since discharge (he was not c/o chest pain during the call). Wayne was told to go to AED (See ROI) , 999 call was not made on behalf of Wayne and the matter was not escalated to a doctor, the nurse did not follow the call up to see if Wayne had attended hospital, call the hospital or the family, even though ion evidence the nurse said an Aortic Aneurysm was one of the differential diagnoses she considered. Wayne was found deceased at c14.38, at his home. The cause of death being 1a Haemopericardium, due to 1b Dissecting Aneurysm of the Aorta II Covid 19.

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: � [REDACTED] � Head of Quality and Safety Improvement NHS Cheshire and Merseyside ICB � Whiston Hospital 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.

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

07/05/2023

2023-0148

Bency Joseph

Essex

1. [REDACTED], CEO, Essex Partnership NHS Foundation Trust

On 9 June 2022 an investigation was commenced into the death of Bency JOSEPH, aged 43 years. Bency Joseph died on the 27 May 2022. The investigation concluded at the inquest on 4 April 2023. The conclusion of the inquest was a Narrative: There was delay in the provision of antipsychotic and anxiolytic medications to Bency Joseph during a four-day period in 24-27 May 2022 and this contributed to her death during a severe psychotic episode with a medical cause of death of �1a Traumatic head injury, 1b Fall from height.

Bency Joseph died instantly on 27 May 2022 from Traumatic Head Injury following a head first fall from an upstairs window at home, she did not have the capacity to formulate an intention to take her own life. Bency Joseph had been suffering with recent mental health issues and attended Broomfield Accident & Emergency Department on 24 May with acute psychotic presentation and assessed as not having capacity. Bency Joseph underwent Mental Health Act assessment on 25 May and referred to the Home Treatment Team and the First Episode Psychosis Team. Bency Joseph was reviewed on 26 May and prescribed urgent medication by the community psychiatrist for a severe psychotic episode and was responding to unseen stimuli and was assessed as not having capacity. Bency Joseph�s mental health deteriorated further at home.

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

Mental Health related deaths This report is being sent to: Essex Partnership NHS Foundation Trust

04/12/2024

2024-0673

Dean Ford

East London

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

On the 19 March 2024 I commenced an investigation into the death of Dean Martin Ford (aged 40).� The investigation concluded at the end of the inquest on the 2� December 2024. The conclusion was that Mr Ford died as a result of suicide.

Mr. Ford suffered a decline in his mental health on the 1 March 2024. He was suffering� from intrusive thoughts relating to past trauma. His partner was concerned about his� mental health and contacted the secondary care crisis team in the very early hours of� the 2 March 2024. Mr. Ford spoke with the crisis contact. The crisis team did not take a� full history or carry out a full risk formulation. Mr. Ford was informed that he would be� referred to the community mental health team. The referral was made, but on the 4� March 2024 the referral for secondary care mental health services was declined. The� reasons for declining the referral were not set out in the records or in the letter to the� general practitioner. No further information was sought from Mr. Ford or from his� partner before declining the referral. There was no formulation of risk in accordance� with the relevant NICE guidelines (issued in September 2022), before declining access�to secondary mental health services. It is not possible to determine, on the balance of� probabilities, what decisions would have been made by the community mental health� team, had a full risk formulation been carried out on 4 March 2024. It is therefore not� possible to state on the balance of probabilities that a full risk formulation on 4 March� 2024 would have prevented Mr Ford�s death on 10 March 2024. On the 6 March 2024,� Mr. Ford had a telephone consultation with his GP. He explained that he had� experienced suicidal thoughts on the 1 March 2024, but stated that he would not act�on these thoughts. He described clear protective factors. The GP prescribed anti- depressants and a review appointment was set for the 20 March 2024. Crisis� information was also provided by the GP. On the evening of the 9 March 2024, Mr.�Ford had a disagreement with his partner. At around 0850 on the 10 March 2024 he�left home. At 1035 he is seen on CCTV buying a length of rope. At 1350 he was found� hanging in Bedfords Park, Romford. Emergency services were called and paramedics� pronounced his life extinct on scene. Police attended and deemed the circumstances as non-suspicious. There were no substances found on toxicology which would have� prevented Mr. Ford from forming an intention to take his own life.

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

Suicide (from 2015) | Mental Health related deaths

North East London Foundation Trust

19/01/2024

2024-0030

William Helstrip

East Riding and Hull

1. [REDACTED], Chief Constable of Humberside Police

On 30th September 2022 I commenced an investigation into the death of William Steven Helstrip, aged 18 years. The investigation concluded at the end of the inquest on 8th January 2024. The conclusion of the inquest was: ACCIDENT

These are set out in my summary and findings of facts which are attached. � William Steven HELSTRIP was found deceased at 5 James Court, Kirkgate, Pocklington, East Riding of Yorkshire on the 26th of May 2022. He died from the combined effects of various drugs including [REDACTED] which he had sourced from the internet. The drugs led to cardiorespiratory depression and death.

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

Alcohol, drug and medication related deaths This report is being sent to: Humberside Police

13/11/2024

2024-0621

Joel Colk

West Sussex, Brighton & Hove

1. [REDACTED], Chief Executive Officer South East Coast Ambulance Service NHS Foundation Trust 2. NHS England & NHS Improvement

On 04 October 2023 I commenced an investigation into the death of Joel Phillip COLK aged 37.�The investigation concluded at the end of the inquest on 12 November 2024. The conclusion of the inquest was that: Joel Phillip Colk died on 2 October 2023 at�[REDACTED], Brighton having intentionally ingested at least 50 times more than the lowest fatal level of [REDACTED] with the intent of taking his own life.

Joel Colk called 999 at 21:46 on 2 October 2023 and spoke with South East Coast Ambulance Service NHS Foundation Trust. Mr Colk reported that he had had ingested 50g of�[REDACTED] and provided his mobile phone number and address. His call was triaged using the NHS Pathways system which resulted as a category 3 disposition for ambulance attendance. An ambulance attended him at 22:47 after the call was upgraded to category 2 at 22:28 as it had not been reviewed by a clinician in accordance with South East Coast Ambulance Service NHS Foundation Trust policy that the call be reviewed within 40 minutes. On attendance Mr Colk was in cardiac arrest and sadly despite the best efforts of clinicians he died at his home address.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Mr Colk Sussex Police Sussex Partnership NHS Foundation Trust I have also sent a copy to the National Ambulance Resilience Unit who I consider may find this 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 | Suicide (from 2015) | Emergency services related deaths (2019 onwards)

South East Coast Ambulance Service NHS Foundation Trust | NHS England & NHS Improvement

20/10/2023

2023-0397

Thomas Doyle

East London

1. [REDACTED], Chief Executive Officer, Barking, Havering & Redbridge 2. Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

On 26th January 2023 this Court commenced an investigation into the death of Thomas Doyle aged 90 years. The investigation concluded at the end of the inquest on19th October 2023. The Court returned a narrative conclusion: � � Thom as Doyle died in hospital on 25th January 2023, he was admitted on 22nd January 2023 on a background of back and chest pain. Whilst undergoing diagnostic processes, Mr Doyle developed sepsis whilst in hospital which caused his death.� � Mr Doyle�s medical cause of death was determined as; 1. Sepsis b. Bronchopneumonia, Pyelonephritis and Empyema of the Gallbladder 2. Hypertension, Frailty

Thomas Doyle was a 90 year old man admitted to hospital on 22nd January 2023 with back and chest pain. He underwent a series of diagnostic tests. � At admission Mr Doyle was found to be experiencing two factors that fall within the systemic inflammatory response syndrome criteria in defining severe sepsis � an elevated white blood cell count and tachycardia. � Despite these findings and in contravention of the Trust policy, a diagnostic process required to confirm or eliminate a diagnosis of sepsis was not commenced at that time. Subsequently, there were a further two missed opportunities to commence the diagnostic pathway in the next 24 hour period. � In the early hours of the morning of 24th January 2023 Mr Doyle suffered a significant drop in blood pressure, intravenous anti-biotics were commenced. Despite appropriate treatment, Mr Doyle continued to deteriorate and subsequently died.

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

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

27/08/2024

2024-0470

Dave Onawelo

East London

1. [REDACTED], Chief Executive Officer, Barts Health NHS Foundation�Trust Sent via email:� � 2. [REDACTED} Secretary of State for Department of Health and Social Care Sent via email:

On 30th December 2023 this court commenced an investigation into the death of Dave�Yola Onawelo, aged 34 years old. The investigation� concluded at the end of the inquest�on 20th August 2024 when the court returned a narrative conclusion.� �Dave Yola Onawelo died in hospital on 30th December 2023. Dave suffered from sickle�cell anaemia, on the morning of 30th December 2023 he felt unwell and was assessed�by paramedics, he was advised to go to hospital but he declined. Later that day, Dave�called a second ambulance and was transferred to�hospital. Whilst awaiting assessment Dave deteriorated and suffered an acute respiratory failure caused by an untreated sickle cell crisis. Earlier intervention and treatment may have avoided a fatal outcome.� Mr Onawelo�s medical cause of death was determined� as; 1a Acute respiratory failure 1b Acute chest syndrome 1c Sickle cell disease

Mr Onawelo was 34 he was diagnosed with sickle cell anaemia. On the morning of 30th December 2023 he felt unwell following a recent sickle cell crisis, he rang 111 an ambulance was sent to his home at 11.56. On assessment at 12.40 Dave had a moderately fast breathing and heart rate and high blood pressure, his pain was assessed as 6/10. Mr Onawelo was observed to have good oxygen saturation levels and no temperature. Dave was advised to attend hospital, but he declined. Later that afternoon Dave called for an ambulance� due to a change in presentation,� he had developed difficulty in breathing. Clinical observations� at 16.38 were unchanged, he agreed to go to hospital. At the local emergency� department (�ED�) a handover occurred at 17.23, at this time Dave was not examined and no clinical observations or bloods were taken. At 17.27, Dave was assessed, he explained that he believed that he was in a sickle cell crisis, partial observations� were taken and he was deemed not to be acutely unwell and�therefore suitable for the lnitial Assessment (�IA�) section of the ED. He and his mother were asked to remain in the waiting area. Whilst waiting, Mrs Onawelo became concerned regarding her son�s deterioration and sought attention from hospital staff. A streamer told her that she was being anxious and a senior nurse refused to assist telling Mrs Onawelo that she was �busy with 6 acute patients�. lt was only at 18.49 when Mrs Onawelo confronted medical and nursing staff�within the lA section that a nurse checked upon Dave. Mr Onawelo appeared drowsy and was slouched to one side. Dave was taken into the lA section in a wheelchair and observations� were taken which showed values consistent as those observed earlier, his chest was auscultated�and found to be clear. Whilst being cannulated a doctor noticed that Dave appeared unwell and so made provision for him to be taken into a resuscitation bay. Dave then began to experience� seizures and sustained a cardiac arrest. A venous blood gas test demonstrated� that Dave was profoundly anaemic and acidotic, he had raised lactate and potassium levels and a critically low blood sugar level.� Resuscitative efforts were commenced but discontinued at 19.48

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

Hospital Death (Clinical Procedures and medical management) related deaths

Barts Health NHS Foundation�Trust | Department of Health and Social Care

30/08/2024

2024-0474

Terence Clark

�East London

1. [REDACTED], Chief Executive Officer, Barts Health NHS Foundation�Trust Sent via email:�[REDACTED] 2. [REDACTED], Secretary of State for Department of Health and Social Care Sent via email: [REDACTED]

On 3rd November 2023 this court commenced� an investigation into the death of Terence�Harry Clark, aged 76. The investigation� concluded at the end of the inquest on 27th August 2024 when the court returned a narrative conclusion.� �Terence Harry Clark died in hospital on 1st November 2023. Mr Clark had numerous�co-morbidities including an impaired swallow. On 26th October 2023 he was admitted to hospital by ambulance with aspiration pneumonia. On 1st November 2023 he was fitted�with a naso-gastric tube which required radiological confirmation of its siting. Mr Clark�sustained a cardiac arrest whilst waiting unescorted in the X-ray waiting area.�� Mr Clarks medical cause of death was determined� as; a Aspiration Pneumonia 1b Right Frontal Lobe lschaemic Stroke, Dementia ll Chronic Obstructive Pulmonary Disease, Diabetes Mellitus

Terence Harry Clark was 76-year-old man with considerable co-morbidity, including a�compromised� swallow, dysphagia. Mr Clark was admitted to hospital by ambulance� on the evening of 26th October 2023�with difficulty in breathing. Mr Clark was diagnosed with bilateral aspiration pneumonia.�The deceased was admitted and treated with anti-biotics. Mr Clark was assessed by the speech and language team who advised that to protect�his ainvay from further aspiration he should be made subject to a nil by mouth order�pending the trialof feeding using a naso-gastric� (�NG�) tube. On 1st November 2023 Mr Clark underwent� NG tube insertion which required an x-ray to�ensure that the tip of the tube was correctly sited in his stomach, and not in an airway. lt�is reported that prior to an x-ray no feed was introduced via the apparatus. Against Trust policy, Mr Clark was sent to the imaging suite unescorted by nursing or�medical staff. Mr Clark�s x-ray was never completed, passing members of trust staff�found Mr Clark, unresponsive in the imaging suite waiting area and alerted their�radiology colleagues. As Mr Clark was unescorted, little was known about the patient. CPR was commenced and subsequently discontinued when it was learned that the patient had a do not�attempt cardio-pulmonary resuscitation� order in place. Mr Clark was declared deceased

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

Hospital Death (Clinical Procedures and medical management) related deaths

Barts Health NHS Foundation�Trust | Department of Health and Social Care

24/01/2025

2025-0048

Charlie Marriage

Inner South London

1. [REDACTED], Chief Executive of NHS England, Skipton House, 80 London Road, London, SE1 6LH

On 1 July 2021 an investigation into the death of Charlie Marriage commenced. The investigation concluded with an inquest hearing starting on 9 December 2024 and a conclusion hearing on 21 January 2025. The conclusion of the inquest was that Mr Marriage died from SUDEP (Sudden Unexpected Death in Epilepsy), but this in the context of, and likely contributed to, by his lack of medication, despite his efforts to obtain it over the course of two days.

Mr Marriage had a longstanding diagnosis of idiopathic generalised epilepsy and suffered grand mal seizures with no warning. The risk of these had become well managed with medication, in particular Fycompa (Perampanel). On Thursday 24 June 2021 he would finish his medication, but he expected to pick up a repeat prescription from a pharmacy in Uxbridge (he studied at Brunel University) the following day. He was then notified to self-isolate for Covid, which prevented the long journey to pick up his repeat medication. The following day he sought to obtain a new repeat prescription via his GP practice for a local pharmacy, but this was not recognised to be urgent in time. Both the GP practice and the university pharmacy were closed over the weekend. On Saturday 26 June he called 111, which promptly arranged for a �referral� for his medication to be sent to a local pharmacy. There it was not promptly identified that the Fycompa could not be supplied, resulting in several wasted calls to 111, and the loss of time and motivation. He was referred back to 111 by the pharmacist, though it was they that should have sought to find a solution. 111 identified that a clinician would be required to help resolve the situation, but Mr Marriage did not receive a call back from one. That night he suffered a seizure that caused his death at home. The lack of Fycompa likely increased the prospect of a severe seizure and contributed to his death. The growing risk of him suffering SUDEP over the 48 hours since his last dose had not been recognised or resulted in appropriate prioritisation, safety-netting, or an emergency supply.

I have sent a copy of my report to the Chief Coroner and to the following other Interested Persons: the family of Mr Marriage, the Waterloo Health Centre, a then receptionist for the GP practice, SuperDrug, the locum pharmacist employed in a particular SuperDrug branch at the time, the London Ambulance Service, and Derbyshire Health United. 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 by the Chief Coroner.

Alcohol, drug and medication related deaths

NHS England

16/07/2024

2024-0407

Jessica de Souza

Surrey

1. [REDACTED], Chief Executive of the National Institute for Health and Clinical Practice�� 2. [REDACTED], Chief Executive Officer of the Royal Pharmaceutical Society 3. [REDACTED], Chief Executive Officer of the BMJ Group

Following an inquest opened on the 14th�February 2023 The inquest was concluded on the 16th April 2024. The cause of death was: 1a.) Suspension The conclusion was Suicide.

Jessica de Souza was diagnosed with bipolar disorder. She suffered an acute manic episode in the summer of 2022. She was detained under section and� prescribed aripiprazole. Her condition stabilised. She was discharged to the� Home Treatment Team on the 10th November 2022.�� On the 1st December 2022 her care was transferred to the Community Mental� Health Team. She was offered an appointment to see her community psychiatrist on the 19th December 2022 but the appointment letter arrived after that date. The appointment was rescheduled for the 16th January 2023.�� She suffered a family bereavement on the 16th January 2023 and rang cancelling the appointment. She was spoken to by the psychiatrist and offered a further� appointment on the 30th January 2023 when she rang saying she wasn�t feeling� well following her bereavement.�� She was not seen face to face for an assessment by either her community� psychiatrist or her care coordinator. Support was not put in place by the� community team following the bereavement. Her family were not given� information about signs of relapse. Her prescribed medication, aripiprazole, was not effective to prevent her developing a depressive episode.�� She developed depression and took her own life by hanging herself at her home at [REDACTED] on the 1st February 2023.

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

Suicide (from 2015)�| Mental Health related deaths� � This report is being sent to: National Institute for Health and Clinical Practice | Royal Pharmaceutical Society | BMJ Group

27/03/2024

2024-0183

Michaela Hall

Cornwall and the Isles of Scilly

1. [REDACTED], Chief Executive, Cornwall Council

On 22/3/24, I concluded the inquest into the death of Michaela Hall. � I recorded the cause of death as 1a) Stab Wound to the Right Eye Socket and Brain

Michaela was a 49-year-old mother of two who lived at [REDACTED] Cornwall. In early 2018, she worked as a volunteer for an organisation providing support to prisoners to assist them in making a fresh start. She lost her role as a consequence of being unable to maintain professional boundaries. Later that year, she was employed by a charity providing support to vulnerable and at-risk individuals. That charity was not aware of the circumstances in which she lost her previous role. Michaela started a relationship with one of her clients, a prolific offender. He assaulted her on a number of occasions and was recalled to prison. Upon his release, their relationship continued as did the incidents of domestic violence. In April 2021, her partner pleaded guilty to two counts of common assault upon Michaela in respect of which he was sentenced to a Community Order. He was assessed as posing a medium risk of serious harm to Michaela and allocated to a Community Rehabilitation Company for offender management. On 31 May 2021, her partner stabbed Michaela through the eye. Acting upon information received, the police attended her home address but did not enter it. Michaela was found deceased the next day. Life was formally pronounced extinct at 22: 56 on 1 June 2021. Michaela�s partner was subsequently convicted of her murder. I recorded the following conclusion. Michaela Hall was unlawfully killed. Shortcomings in a recruitment process meant she was employed in a role she was known to be temperamentally unsuitable for, given an inability to respect and maintain professional boundaries. Subsequently, a pre- sentence report was wrongly completed by an individual who was insufficiently qualified or experienced to undertake the task. The risk of serious harm Michaela�s partner posed to her was wrongly assessed as medium rather than high. This meant her partner�s management in the community was inappropriately allocated to a Community Rehabilitation Company rather than the National Probation Service. Had the shortcomings and errors not occurred, it is more likely than not that Michaela would not have died when she did.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Michaela�s parents and older son; Michaela�s younger son; National Probation Service; Kent Surrey and Sussex CRC; [REDACTED] Police; [REDACTED] � I have also copied this report to the Domestic Abuse Commissioner. � 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: Devon & Cornwall Police | Chief Probation Officer | Cornwall Council

22/06/2023

2023-0204

Christopher Stevens

Cornwall and the Isles of Scilly

1. [REDACTED], Chief Medical Officer, CPFT

On 21/6/23, I concluded an inquest into the death of Christopher Stevens, aged 58, who was found deceased on 11/2/22. The medical cause of death was recorded as: 1a) Exsanguination 1b) Multiple incised wounds � I recorded a Conclusion of Suicide.

Chris had enjoyed a long period of relative stability with his mental health until 2020/21. In the period that followed there were two serious attempts at overdose both of which resulted in lengthy admissions into ICU. He was admitted to Longreach and was known to the in-patient team. � On 6//1/23, he was admitted into RCHT following an overdose. He was then transferred to Longreach and admitted on to Perran Ward on 22/1/23 before being transferred to Carbis and Cove wards on 25/1/23 and 6/2/23 respectively. � He was admitted as an informal patient and, prior to his transfer to Cove ward, had a number of episodes of escorted leave. � On 8/2/23, the inquest heard that Cove ward was understaffed with only one of three rostered nurses due to attend. Accordingly, the ward manager, [REDACTED], came to work early to assist her nursing colleagues. While treating another patient with suspected sepsis, Chris requested leave to go into the hospital�s grounds. [REDACTED] accepted in evidence she had not had time to read Chris�s RiO records and she did not then appreciate that his previous leave had only been escorted. She delegated to an HCA, in effect, to check that leave was appropriate before authorising it without conducting her own assessment of risk. � There was a short delay in appreciating that Chris had not returned to the ward as anticipated. His body was discovered three days later.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ��[REDACTED] � cousin of Chris; � 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: CPFT

26/07/2024

2024-0409

Zara Aleena

East London

1. [REDACTED], Chief Probation Officer, HM Prisons & Probation Service Sent via email: [REDACTED] 2. [REDACTED], Lord Chancellor and Secretary of State for Justice Service �� Sent via email: [REDACTED] 3. [REDACTED], The Commissioner of Police of the Metropolis Sent via email: [REDACTED] � 4. [REDACTED], Interim CEO Redbridge Council Sent via email:�[REDACTED] � 5. [REDACTED], Secretary of State for the Home Office Sent via email: [REDACTED]

On 6 July 2022 I commenced an investigation into the death of Zara Natasha Aleena, (aged 35). The investigation concluded at the end of the inquest on the 26 June 2024. The conclusion of the jury was a narrative conclusion:� (1) Zara was unlawfully killed. The sole, direct cause of death was the action of the attacker. �� (2) Zara�s death was contributed to by the failure of multiple state agencies�to act in accordance to policies and procedures; to share intelligence;� accurately assess risk of serious harm; act and plan in response to the� risk in a sufficient, timely and coordinated way. �� (3) Specifically, failures which contributed to Zara�s death included: �� 3.1) Serious failures to appropriately assess risk by HMPPS. The risk�remained at medium and should have been high from February 2021� based on factors including: a) Failure to identify significant events which� should have led to re-evaluation to high risk. b) Inadequate information� sharing. c) Inadequate decision making. d) Inadequate supervision and� inadequate formalised training across multiple agencies. e) Inadequate� understanding of roles and responsibilities across multiple agencies in� the risk assessment process.�� 3.2) The decision to recall was significantly delayed: a) If risk was� correctly assessed as high it would have justified an emergency recall to� prison, initiating a more urgent response. Even as medium risk,� reasonable recall opportunities were overlooked and based on the� evidence recall could have commenced on 20th June 2022. b)� Insufficient, proactive supervision and lack of formal review, leading to� late decision to recall. c) Failure to countersign the recall within 24 hours as per the policy requirements.�� 3.3) Attempts to arrest the offender, post recall were impeded by a� number of factors including: a) Inaccurate data on the recall. b) Lack of� professional curiosity and follow-ups on Saturday 25th June 2022. c) The� PNC �Missing� Marker not updated in a timely fashion. d) Closure of the�CAD.�� 3.4) A failure to define, understand and execute roles and�responsibilities across multiple agencies, to manage the offender� effectively.

Zara Aleena died at 0958 on 26th June 2022 at the Royal London Hospital. She died as a result of a severe traumatic brain injury that she sustained during an unprovoked attack by a lone male unknown to her. The attack occurred at�about 0219 on 26th June 2022 whilst she was walking home along Cranbrook� Road in Ilford. The attacker was in the community under the supervision of the Probation Service and at the time of the commission of the attack was subject� to a recall to prison.

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

Other related deaths� � � This report is being sent to: HM Prisons and Probation Service | Ministry of Justice | The Metropolitan Police Service | Redbridge Council | The Home Office

20/10/2023

2023-0400

Valerie Simmons

Cornwall and the Isles of Scilly

1. [REDACTED], Community Nurse Locality Team Lead

On 20/10/2023, I concluded an inquest into the death of Valerie Ann Simmons who died on 11/01/2023. . The medical cause of death was recorded as: 1a) Hypovolaemic Shock 1b) Left Thigh Haematoma 1c Low Molecular Weight Heparin and Warfarin Therapy with high INR for Metallic Mitral Valve Replacement. II Ischaemic Heart Disease, Congestive Cardiac Failure, Frailty � I recorded a Narrative Conclusion that Mrs Simmons died from a known complication (bleeding) of a necessary medical procedure (anti- coagulation.)

Mrs Simmons was well known to the community nursing team. She had a past medical history that included a mitral valve replacement in 2007 following which she was prescribed warfarin with a target therapeutic INR of 3.5. In December 2022, it was noted her INR levels were sub- therapeutic and so she was prescribed bridging Fragmin therapy. Her NEWS score was recorded as 5. Community nurses attended daily. On 7/1/23, she had an injection of Fragmin into her left thigh. On 8/1/23, she was found to have developed a large haematoma. In spite of her changed presentation, there were no recorded observations that objectively demonstrated she was otherwise �well.� Her INR was tested on 9/1/23 and found to be 4.9. A doctor attended and advised admission into hospital which Mrs Simmons initially declined. She subsequently changed her mind but an email to advise the doctor did not reach him. An ambulance was later called, and Mrs Simmons was admitted into Royal Cornwall Hospital. She deteriorated and died in the hospital on 11/1/23.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:[REDACTED]����������������������������������������������������������������������������������������� . � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to 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: Community Nurse Locality Team Lead

30/01/2025

2025-0051

James Siddons

London Inner (South)

1. [REDACTED], Director, Mills Family Ltd, Ashfield Lane, Chislehurst, Kent� BR7 6LQ� 2. [REDACTED], Chief Executive, London Borough of Bromley, Civic Centre, Stockwell Close, Bromley, Kent. BR1 3UH

On 10 February 2022 I commenced an investigation into the death of James Collier SIDDONS, aged 91 years. The investigation concluded at the end of� the inquest on 24 January 2025. The conclusion of the inquest was that Mr� Siddons died on 31 January 2022 at University Hospital Lewisham, London (UHL). The medical cause of death was recorded as� 1a Sepsis� 1b Aspiration pneumonia and pyelonephritis� 2 Ischaemic heart disease, osteoporosis, previous stroke, Alzheimer�s disease I concluded with the following narrative Mr Siddons died in hospital from sepsis to which he had become increasingly� vulnerable due to deteriorating life-limiting medical conditions.� He had been� admitted to hospital having sustained a fractured humerus whilst resident at a nursing home.

Mr Siddons had been admitted to UHL on 18 January 2022 having sustained�a fracture of his left humerus at Sloane Nursing Home, Beckenham. The� precise circumstances of the injury have not been established. Mr Siddons� suffered from a significant number of co-morbidities including but not limited to Alzheimer�s disease, osteoporosis, ischaemic heart disease and previous� stroke resulting in very severe frailty. Mr Siddons made a good recovery from� the facture and was waiting for a new nursing home placement when he� developed raised inflammatory markers suggestive of infection. There was� radiological evidence of aspiration pneumonia to which he was vulnerable due todysphagia as a manifestation of late-stage Alzheimer�s disease. He had�also developed pyelonephritis. He died suddenly from sepsis, his condition� having remained stable, despite appropriate treatment with antibiotics, on 31� January 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mr Siddons� family. I have also sent it to [Lewisham and Greenwich NHS� Trust 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

London Borough of Bromley | Mills Family Ltd

23/07/2024

2024-0396

Fredrick Dunbavin

Dorset

1. [REDACTED], Director� Seascape Homes and Property Limited

On the 14th December 2023, an investigation was commenced into the death of Frederick Barrie Dunbavin, born on the 30th June 1948.� The investigation concluded at the end of the Inquest on the 9th July 2024. The Medical Cause of Death was: 1a Multiple Injuries 1b 1c 2 Complete Occlusion of the Left Coronary Artery The conclusion of the Inquest recorded that Frederick Barrie Dunbavin died as a consequence of an accident.

Frederick� Barrie� Dunbavin,� who� was� diagnosed� with� dementia� and� who experienced periods of confusion, fell from a wooded area in the grounds of the Treetop Apartments�[REDACTED] onto a concrete path that runs to the rear of the St Stephen�s church hall.�� As a consequence of the fall, Mr Dunbavin sustained multiple injuries, which caused his death. A police investigation revealed there is a low wooden fence separating the wooded area from a parking area at the apartment complex. However, there is a gap in the fence, allowing easy access to the woodland, and no barrier between the wooded area and the drop onto the path that runs to the rear of the church hall.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� (1) [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.

Other related deaths� � � This report is being sent to: Seascape Homes and Property Limited

14/11/2024

2024-0630

Catherine Forbes

Oxfordshire

1. [REDACTED], General Manager, The Yacht Harbour Association Ltd

INVESTIGATION AND INQUEST On 10 April 2024 at Oxfordshire Coroner�s Court I conducted the inquest into the� tragic death of Catherine Forbes, aged 57, at Thames and Kennet Marina,� Caversham. She was a resident in her boat at the marina but drowned after�falling into the marina late on 31 March 2023. She was discovered the following� morning. A subsequent post mortem examination confirmed that the cause of� death was drowning. I returned a conclusion of �Accident� and attach a copy of the Record of Inquest for your information.� I announced at inquest that I would consider making a Regulation 28 Reports for� the Prevention of Future Deaths following some further enquiries and� submissions. You will no doubt recall that I wrote to you on 25 April 2024 and you responded on 28 May 2024. I consider that I am now under a duty to make this report.� I heard oral evidence at the inquest from the Marina Manager for Tingdene Ltd. I� was provided with documentation prior to inquest and, importantly, further� documents afterwards in respect safety improvements relating to ladders and risk assessments. I also heard evidence in relation to the YHA and the fact that� Tingdene held your Gold Anchor Award at this marina.

The brief circumstances are set out in the attached Record of Inquest but I also� attach the Final Police Report of [REDACTED] dated 4 December 2023. The�drowning was unwitnessed but Ms Forbes was said to be a strong swimmer and� there is clear evidence that she swam to a nearby ladder and tried to use it to� climb out. She appears to have thrown her handbag from the water onto the� pontoon. There were marks on the toes of her boots indicative of her trying to get out. This particular ladder was 1.5m in length with 3 rungs in the water but the�bottom rung extended no more than 600mm beneath the surface of the water. It� would have required Ms Forbes to raise her legs up high and have the necessary strength to pull herself up. It appears that, sadly, she was unable to do so before� succumbing to the cold and drowning.

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

Other related deaths

The Yacht Harbour Association Ltd

05/12/2024

2024-0671

Mazeedat Adeoye

East London

1. [REDACTED], Head of National Police Air Service. Sent via email: [REDACTED] 2. [REDACTED], Chief Executive Officer and [REDACTED], Director of Social Care, The London Borough of Newham��� � Sent via email: [REDACTED] �� 3. [REDACTED], Secretary of State for Health & Social Care Sent via Email: [REDACTED] 4. [REDACTED], Chair of the Board, Social Work England Sent via email: [REDACTED]

On 30th January 2022, this Court commenced an investigation into the death of� Mazeedat Opeyemi Adeoye, aged 2-years. The investigation concluded at the end of the inquest on 29th November 2024. The court returned a narrative conclusion. Mazeedat Adeoye, a two-year-old girl died on 29/1/22 in the rear garden of domestic premises in Dagenham, East London.� Whilst playing alone and inadequately supervised in the garden, Mazeedat fell head first into a plastic refuse bin that contained water. Despite the level of water in the bin being no more than 9cms in depth, Mazeedat drowned.� At the time of her death, Mazeedat had been entrusted into the care of an acquaintance of her mother. Mazeedat�s mother had allowed her daughter to be cared for in these circumstances as a matter of last resort. Despite significant efforts, Mazeedat�s mother had been unable to secure state assistance for childcare.� Mazeedat�s mother could not care for her daughter on 29/1/22, as she was required to attend hospital with her baby who had undergone heart surgery. Mazeedat was not permitted to accompany her mother into the hospital ward. Mazeedat�s mother was a single parent without family or friends to rely upon for support.� Local� authority� child� services� failed� to� support� Mazeedat�s� family� and� put� in� place appropriate support for Mazeedat�s care at this time.� By virtue of her age and the fact that Mazeedat was assessed to be a child in need under s.17 Children�s Act 1989 she was obviously in a dependent position and could not maintain her safety herself.� The combined failures of the local authority and those caring for Mazeedat on 29th January 2022 taken cumulatively, constitute a gross failure. Those aggregated failures, on the balance of probability more than minimally contributed to Mazeedat�s death.� There was a missed opportunity to provide effective care in the form of an offer of a temporary fostering placement which would have probably resulted in the avoidance of Mazeedat�s death.� Mazeedat�s medical cause of death was determined as; 1.a. Drowning

Mazeedat Adeoye was a 2-year-old girl who was born in Nigeria. Mazeedat�s mother� brought her to the UK in the spring of 2021 under a visitor visa, the family overstayed in the UK, lacking resources to return to the UK.� Mazeedat�s mother was pregnant when she came to the UK. In September 2021 Mrs� Adeoye was referred to Newham social services,� no recourse to public funds� team� (�NRPF�) by an NHS ante-natal care. health visitor. Mazeedat was eventually assessed in mid-October to be a �child in need�, at risk of harm and destitution, pursuant to s.17� The Children Act 1989. The family were provided accommodation and subsistence� payments.� Mrs Adeoye sought temporary foster care for Mazeedat on three occasions when she� was temporarily unable to care for her daughter. In October 2021, a request was made� when Mrs Adeoye was scheduled to give birth. A second request was made in� November 2021 when Mazeedat�s baby brother was admitted to hospital for emergency inpatient care. The final request was made on 21st January 2022, when Mrs Adeoye�s� infant son was required to undergo emergency heart surgery.�� In all 3 instances, Newham child services failed to facilitate an agreement with Mrs� Adeoye to provide temporary foster care. Instead, on each occasion, Mrs Adeoye was asked to find a care solution herself, despite her consistent assertion that she had no�family or support network. The result of social service�s abrogation of their statutory duties was that Mazeedat was� placed at risk of harm whilst, respectively, being cared for by midwives on a labour ward, living on a children�s ward and finally, being cared for by an unproven volunteer.�� On 29th January 2022, whilst playing alone and unsupervised in the rear garden of the� home of the volunteer carer, Mazeedat fell into a plastic refuse bin containing water and drowned.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mazeedat, to the Child Death Overview Panel (where the� deceased was under 18)]. I have also sent it to the local Director of Public Health.� I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� �� I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest.�� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Child Death (from 2015)

National Police Air Service | London Borough of Newham | Department of Health and Social Care | Social Work England

14/11/2024

2024-0622

Hannah Aitken

Surrey

1. [REDACTED], Home Secretary 2. [REDACTED], Secretary of State for Health and Social Care

Hannah Mary Aitken died on 14th September 2023, aged 22. Her inquest was opened on 28th September 2023.�Evidence was heard between 30th September and 4th October 2024 and Findings and Conclusion were given on 7th November 2024. I recorded a conclusion of Suicide. I found the medical cause of death to be: 1a. [REDACTED] 2.�Autism, Attention Deficit Hyperactivity Disorder, Anxiety and Depression

On�� 14th�� September�� 2023,�� Hannah�� Aitken�� died�� at�� her�� supported accommodation in Caterham, Surrey, from an overdose of a poisonous substance, namely [REDACTED], which she had obtained� [REDACTED]. Miss Aitken confirmed with the company by email on 30th August 2023 that she intended to use this for [REDACTED]. The substance was recorded as delivered�on the�afternoon�of�14th�September.�� Miss�Aitken�was subsequently heard to call out to her support workers for help, stating she�had� taken� an�overdose.�She�would�not�provide�details�of�the substance and had hidden the packaging. She became unresponsive and subsequently�suffered�cardiac arrest,�from�which�she�could�not�be resuscitated despite prompt attendance and efforts from South East Coast Ambulance. Miss Aitken had a long-standing mental health background of autism spectrum disorder and attention deficit hyperactivity disorder, requiring extensive periods of inpatient admission, and was under the care of the Tandridge� Community� Mental� Health� Recovery� Service,� Surrey� and Borders Partnership.�Miss Aitken detailed an intention to end her life in a notebook, which was written some weeks prior to her death at around the time of ordering the substance. This was located on her bed after her death.

COPIES I have sent a copy of this report to the following: 1. See names in paragraph 1 above 2. [REDACTED], [REDACTED]�and [REDACTED], c/o�[REDACTED] Associate Solicitor, Leigh Day, Panagram, 27 Goswell Road, London EC1M 7AJ 3. The Chief Coroner In addition to this report, I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who, he�� believes,�� may�� find�� it�� useful�� or�� of�� interest.�� You�� may�� make representations to me at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

Home Office | Department of Health and Social Care

19/09/2024

2024-0505

Robin van Caliskan

Cornwall and the Isles of Scilly

1. [REDACTED], Managing Director, Atlantic Reach Limited

On 18/9/24, I concluded the inquest into the death of Robin van Caliskan. A jury found the cause of death as 1a) Drowning. A jury recorded a conclusion of Accidental death.

On 31/7/23, Robin, who was aged five, came with his family to Atlantic� Reach holiday park in Whitecross, near Newquay for a short holiday.� Later that afternoon, the family decided to go for a swim in an indoor pool. There were no lifeguards on duty.� The main pool was described as busy and was close to the stipulated maximum capacity. As it was the main holiday season, the pool users included a number of children.� For a brief period of time, Robin was not under the direct supervision of� his parents. He was found face down in the main pool and recovered to� the side where resuscitation was attempted. This was unsuccessful and there was recognition of life extinct at 17:55.

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

Atlantic Reach Limited

08/10/2024

2024-0536

David Martin

Cornwall and the Isles of Scilly

1. [REDACTED], Medical Director, Royal Cornwall Hospital

On 8/10/24, I concluded the inquest into the death of David Charles Martin who died in RCHT on 17/9/22.� I recorded the cause of death as:� 1a) Left ventricular cardiac failure (post-stenting) 1b) Coronary artery thrombosis� 1c) Coronary artery disease� II) Atrial fibrillation; Chronic kidney disease� I recorded a conclusion of Natural Causes.

Mr Martin was an 83-year-old man with a history of progressive heart� failure. He was admitted into Royal Cornwall Hospital on 30/8/22 with� deteriorating symptoms. He had a diagnostic angiogram on 5/9/22 before a decision was made at a cardiology MDT on 12/9/22 that he was not for� surgical intervention and was offered stenting (PCI) instead. The� procedure took place on 16/9/22. It was Trust policy that patients� undergoing PCI should have dual anti-platelet therapy (DAPT.) In error,� Mr Martin was prescribed Aspirin only and the oversight was only� identified post-operatively when Mr Martin was immediately given a� loading dose of a second anti-platelet therapy. Mr Martin collapsed later� that afternoon. He was resuscitated but then deteriorated and died in the� hospital on 17/9/22. It is unlikely the cause of Mr Martin�s collapse was a� clot in an inserted stent and thus the oversight in the provision of a�second anti-platelet therapy was not causative of Mr Martin�s demise.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Royal Cornwall Hospital

20/08/2024

2024-0464

Hannah Jacobs

East London

1. [REDACTED], National Medical Director, NHS England Sent via email: 2. [REDACTED], Chief Executive Office, Royal College of Paediatrics Sent via email : 3. [REDACTED], President of Royal College of Physicians Sent via email: 4. British Society for Allergy & Clinical Immunology Sent via email: � 5. [REDACTED], Chief Executive Officer, General Dental Council Sent via email: 6. [REDACTED], Chief Executive & Registrar, Pharmaceutical Council

On 17th June 2023 I commenced� an investigation� into the death of Miss Hannah Eniola Angela Ayomipo Jacobs aged 13 years. The investigation concluded at the end of the inquest on 16th August 2024. The conclusion of the inquest was a narrative: On 8th February 2023 Hannah was served a dairy hot chocolate at Costa Coffee Barking despite her mother informing staff of a dairy allergy. Neither she nor her mother were carrying an Adrenaline Auto lnjector which had been prescribed.� Next, they went to the dentist where Hannah took some sips of her drink and developed symptoms of excessive saliva. During the brief time they were at the dental surgery it was not recognised that this was the beginning of an anaphylactic� reaction. Hannah and her mother rushed to the Day Night Pharmacy where Hannah collapsed. LAS attended promptly, began resuscitation,� and took her to Newham University Hospital where she was pronounced dead the same day

Hannah was 13 with severe allergies to eggs, dairy and wheat. She was going to the dentist before school. Her mother was told she couldn�t take her prescribed� Epi-pen into school as she was to keep 2 at home and 2 at school. Hannah�s mother was not carrying an Epi-pen either. They went into Costa Coffee on the way to the dentist where they were incorrectly served dairy hot chocolates.� This was due to a failure of communication and a failure to follow the correct allergy process in Costa Coffee. They then went into the dentist and Hannah took a sip of her drink and felt unwell. She went into the dentist�s room spitting out fluid which the dentist believed to be her drink combined with saliva. Hannah refused treatment and left the dentist with her mother to go to a local pharmacy for treatment. Her mother noticed Hannah�s lips were swollen and asked for cetirizine from the pharmacist. Then she asked for an Epi-pen but due to a national shortage there was only one in stock, a 150 micrograms rather than the 500 Hannah had be prescribed. This was given but sadly Hannah went in to cardiac arrest and could not be resuscitated.

I have sent a copy of my report to the Chief Coroner and to the following lnterested Persons Hannah�s family, FSA, Costa Coffee, SBR Trading Royal Free NHS Trust, LBBD, to the Child Death Overview Panel (CDOP) (where the deceased was under 18). 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.

Child Death (from 2015)

NHS England | Royal College of Paediatrics | Royal College of Physicians | British Society for Allergy and Clinical Immunology | General Dental Council | Pharmaceutical Council

29/09/2024

2024-0520

James Turner

Cornwall and Isles of Scilly

1. [REDACTED], Principal Transport Officer (Road Safety) Cornwall Council 2. [REDACTED], Little Trethew, Horningtops, Liskeard, Cornwall

On 1st August 2023 I commenced an investigation into the death of 49-year-old James Edward Turner. The investigation concluded at the end of the inquest on 2 September 2024.�� The medical cause of death was found as follows: 1a Head and Chest Injuries The four questions � who, when, where and how � were answered as follows: James Edward TURNER died on 25 July 2023 on the B3252 southeast of Liskeard� Cornwall, from trauma when the motorbike he was riding collided with the offside of a twin axle trailer, laden with grain, that was being towed by a tractor across the� B3252 from a field into the Fursdon Farm entrance opposite the field.� The conclusion of the inquest was as follows: Road Traffic Collision

1. James died whilst riding his KAWASAKI 1000cc motorcycle in a south-easterly direction on the B3252.� 2. The B3252 at the point of the collision is a single carriageway and is subject to the national speed limit which is 60 miles per hour (mph) for the Kawasaki.� 3. James collided with the offside of a twin axle trailer that was being towed by a� tractor. The trailer was laden with grain and being towed across the B3252 from a field opposite the junction of Fursdon Farm. �� 4. The trailer had effectively blocked the road down which James had been riding. Forensic evidence indicated that James was braking until the moment before� impact. James appears to have maintained the Kawasaki in an upright position� whilst braking which implies rider input right up until the point of impact.� 5. James was killed instantly, and his motorcycle caught fire shortly after impact. 6. The court found that James was riding at excessive speed in the period� immediately before the collision and that it is likely that James� excessive speed has contributed to this collision.� 7. The police conducted a visibility study using the same tractor and laden trailer involved in the collision together with an unmarked police motorcycle, which� revealed the following:�� a) The rider of the police motorcycle, when positioned towards the centre�of the road, recognised something at the field entrance at a distance of 159.6m from the entrance, and was able to identify it as a tractor at� 132.6m.�� b) The tractor driver identified the motorcycle between 86.7m and 100.1m depending upon the motorcyclist�s position within the width of the road. 86.7m when the rider was close to the road edge and 100.1m when he was nearer towards the centre hazard white line.�� c) From a stationary position with the front of the tractor level with the� entrance to the field, it took approximately 15 seconds for the tractor and trailer to emerge from the field and enter the farm entrance,� completely clearing the road.� 8. Calculations indicate that at a speed of up to 64mph, even with a response time of� 2.5 seconds, James would still have been able to stop even if he only identified the tractor at the latest point when it could be identified as a tractor.� 9. The court noted that at 60mph it would take 4 seconds for a road user to cover the 100m visibility that the tractor driver has at the centre hazard white line. On the� basis of this study the court found that visibility at the site of the collision was� limited for tractor drivers emerging from the field.�� 10. Furthermore, the court heard evidence of recent road traffic data that some motorists are speeding at that location.� 11. Due to the concerns surrounding the poor view of the road from the field entrance, Cornwall Council recommended the following actions, which at the date of the� Inquest had not been implemented.� Recommendation No1: Relocation of the field access opposite Fursdon Farm. This recommendation needs to be agreed with the landowner Mr� Richard Harper.� Recommendation No2: Prescribed advanced warning signs to be provided at agreed location(s) on the B3252 to warn of �Farm Traffic�, replacing the� temporary posters currently in situ.� The Council indicated that this�measure would be implemented as and when recommendation no1 is� implemented.

I have sent a copy of my report to the Chief Coroner and to James� family. I have also sent it to Police Lead Investigator�[REDACTED], and to [REDACTED] who may find it useful or of interest . I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form and may send a copy of this report to any person who he believes may find it useful or of� interest. You may make 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

Cornwall Council | Little Trethew Horningtops

20/08/2024

2024-0465

Hannah Jacobs

East London

1. [REDACTED], Secretary of State for Dept. Health & Social Care Sent via email: 2. [REDACTED], Secretary of State for Education Sent via email:

On 17th February 2023 I commenced an investigation� into the death of Miss Hannah Eniola Angela Ayomipo Jacobs aged 13 years. The investigation concluded at the end of the inquest on 19th August 2024. The conclusion of the inquest was a narrative conclusion: On 8th February 2023 Hannah was served a dairy hot chocolate at Costa Coffee Barking despite her mother informing staff of a dairy allergy. Neither she nor her mother were carrying an Epi-pen which had been prescribed. Next, they went to the dentist where Hannah took some sips of her drink and developed symptoms of excessive saliva. During the brief time they were at the dental surgery it was not recognised that this was the beginning of an anaphylactic� reaction. Hannah and her mother rushed to the Day and Night pharmacy where Hannah collapsed LAS attended promptly, began resuscitation,� and took her to Newham University Hospital where she was pronounced� dead the same day.

Hannah was 13 years old and had been diagnosed with severe allergies to eggs, wheat and dairy milk. She was prescribed an Epi-pen and antihistamines� to manage her allergy. On 8th February 2023 she was going to school after a dental appointment.� She was accompanied by her mother. Neither of them carried an EpiPen with them. The school kept 2 at the school and if Hannah went in with one it would be confiscated for the duration of the day. Hannah and her mother went into Costa Coffee Station Road Barking just before 11am on 8th February 2023.They had done this before with no problems. As usual her mother ordered 2 soya milk hot chocolate drinks. There was a lack of communication between the mother and the barista. The barista acknowledged that she heard that Hannah had an allergy but did not follow the correct procedure�in place, which was to show them the allergy book kept at the till and clarify which drink they could safely have. Hannah and her mother were served dairy milk hot chocolates. They took them into the dental practice and at 10.59 Hannah took 3 sips and felt unwell. She went into the toilet and rang her mother by mobile phone and informed her she didn�t think the drink was made with soya milk. When she came out of the toilet and went up to the dentist, she was spitting out what seemed excessive saliva. She then refused the treatment, left the dentist�s room to go�back to the toilet. Her mother followed shortly after and decided to go the pharmacy opposite to get some antihistamines.� The entered the pharmacy at�11.11 am and as they did, Hannah collapsed to the floor. Her mother asked for cetirizine which had previously helped before. lt was given to no effect. An EpiPen was requested but due to a national shortage of adrenaline auto injectors the pharmacist� had only 1 paediatric injector which was of an insufficient dosage. However, it was given, and the LAS were called. They attempted to resuscitate Hannah but she died at Newham University Hospital as a result of anaphylaxis due to consumption of dairy.

I have sent a copy of my report to the Chief Coroner and to the following lnterested Persons Hannah�s family, FSA, Costa Coffee, SBR Trading Royal Free NHS Trust, LBBD, to the Child Death Overview Panel (CDOP) (where the deceased was under 18). 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.

Child Death (from 2015)

Department of Health and Social Care | Department for Education

10/10/2024

2024-0538

Sunnah Khan and Joseph Abbess

Dorset

1. [REDACTED], Secretary of State for Education

On the 2nd June 2023, an investigation was commenced into the deaths of Sunnah Summayah Khan, born on the 11th January 2011 and Joseph Ian Abbess born on 22nd�November 2005.� �The investigation concluded at the end of the Inquest on the 4th October 2024. The medical causes of death were: Ia Drowning The conclusion of both of the Inquests was accident

On the 31st May 2023 both Sunnah, who was 12 years of age, and Joe, who was� 17� years� of� age,� travelled� to� Bournemouth� to� spend� the� day� at Bournemouth East Beach. Sunnah had travelled with her family and Joe had travelled with his friends. Neither knew each other. At some point after 15.14 hours they, separately, entered the waters at the beach in the designated safer swim zone, where they remained. At approximately 15.45 hours an intense flash rip current occurred in the waters, and both became separated from those they were with in the water. At approximately 16.18 hours, Joe was seen in an unresponsive condition faced down in the water. He was recovered from the water straight away and despite attempts at resuscitation and a brief period of return of spontaneous circulation, his death was confirmed later that day. At approximately 16.45 hours, Sunnah was seen in an unresponsive condition faced down in the water at the shoreline. She was recovered from the water straight away and despite attempts at resuscitation, her death was confirmed later that day.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� (1) Sunnah�s family (2) Joe�s family (3) Royal National Lifeboat Institution (4) Maritime and Coastguard Agency on behalf of His Majesty�s Coastguard (5) BCP Council (6) South West Ambulance Service NHS Foundation Trust I am also under a duty to send the Chief Coroner a copy of your response. I� have� also� sent� a� copy� of� this� report� to� the� following� persons� for� their awareness:� � a) The National Water Safety Forum b) The Royal Lifeguarding Saving Society The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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) | Other related deaths

Department for Education

10/01/2025

2025-0016

Ava Hodgkinson

Lancashire and Blackburn with Darwen

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

On 21 August 2023 I commenced an investigation into the death of Ava Grace Hodgkinson, age 2. The investigation concluded at the end of the inquest on 8 January 2025. The conclusion of the inquest was that Ava died from natural causes due to overwhelming sepsis caused by Streptococcus A infection..

Ava Grace HODGKINSON died on 14 December 2022, at Ormskirk District General Hospital, Ormskirk in Lancashire. Following a short illness Ava was examined by a G.P. where no infection was found, but antibiotics were prescribed. The following morning, Ava took the first dose of antibiotics, however her condition later worsened and she was driven to Ormskirk District General Hospital in the early afternoon, where, upon arrival, she was noted to be in cardiac arrest and despite attempts to resuscitate, she did not recover. Miss HODGKINSON died of overwhelming Sepsis, resulting from Group A Streptococcus infection.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr & Mrs Hodgkinson (Ava�s parents), the Department of Health and Socoial Care and to the Lancashire�s Safeguarding Board I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

Department of Health and Social Care

20/09/2024

2024-0625

Susan Dear

Berkshire

1. [REDACTED], Secretary of State for Health and Social Care 2. NHS ENGLAND

On 23 May 2024 I opened an inquest into the death of Mrs Susan Dear on 4 January 2023 aged 72. The inquest concluded on 9 September 2024.�� The family requested that I refer to Mrs Dear as Susan, which this report will reflect. The conclusion of the inquest was that Susan had died of natural causes (Pulmonary Embolism due to underlying Deep Vein Thrombosis).

Susan was suffering abdominal pain, and her family called 999 at 10.20 pm on 3 January and that call was triaged at category 3 (meaning that an ambulance was expected to be on scene within 120 minutes).��� At that time the inquest heard that there were 48 patients awaiting ambulances, 7 were waiting for category 2 ambulances with the longest wait time being 1 hour 12 minutes,� 19 patients were waiting for category 3 ambulances with the longest wait time being 7� hour 55 minutes.� �� Susan�s symptoms deteriorated and a second 999 call made at 2.32 on 4 January was triaged at category 2 (meaning that an ambulance was expected to be on scene within 40 minutes). At that time the area was in OPEL 4, the highest OPEL level, indicating Extreme� Pressure on resources. There were 37 patients waiting for ambulances. 9 patients� were awaiting category 2 ambulances with the longest wait being 5 hours 53 minutes, and 26 patients were awaiting Category 3 ambulances, with the longest waiting time� being 14 hours 39 minutes.� �� There was no ambulance resource available to respond at any time to Susan. At around 5 am Susan�s family decided they could wait no longer and drove her to hospital, where she was recognised as deceased shortly after arrival at 6.02 am.�� On the evidence at inquest I did not find that the ambulance delay contributed to Susan�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons�� 1. [REDACTED] (Susan�s husband), 2. South Central Ambulance Service and 3. The Finchampstead Surgery. I have also sent it to The CQC and The Association of Ambulance Chief Executives who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your� response, about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards)

Department of Health and Social Care | NHS England

06/11/2024

2024-0604

Simon Boyd

Manchester South

1. [REDACTED], Secretary of State for Health and Social Care 2. [REDACTED], Chief Executive, NHS England

On 21st June 2024, Anna Morris KC, Assistant Coroner for Manchester South, opened an inquest into the death of Simon Boyd who died at his home on 1st June 2024 aged 52 years. The investigation� concluded with an inquest which I heard on 4th October and 4th November 2024.� The inquest determined Mr Boyd died as a consequence of:� 1) a) Myocardial Infarction;� 1) b) Coronary Artery Disease� II) Hypertension� At the end of the inquest, I recorded the following Narrative Conclusion:� Mr Boyd died as a consequence of a Myocardial Infarction which was first diagnosed after his death� despite him seeking help from urgent and emergency care services.

Mr Boyd had a relatively complex medical background including aortic root dilation, hypertension,� chronic fatigue syndrome and sleep apnoea. On 31st May 2024, he telephoned NHS 111 and had a� remote assessment with a Clinical Assessor where he reported dizziness, lethargy and sweating. He� was given self-care advice and advised to consult with his own GP or call NHS 111 if symptoms� persisted. Safety-netting took place with Mr Boyd being told of red-flag symptoms.� At around 05:23 on 1st June 2024, Mr Boyd rang 999 requesting an ambulance as a result of� breathlessness. Whilst a Category 3 ambulance response was originally initiated, review by the� NWAS C3 service led to an onward referral being made to the Greater Manchester Clinical� Assessment Service. �� The referral was accepted and Mr Boyd was spoken to by a doctor who took a similar history and� referred him to the local Out of Hours Service, cancelling the ambulance response.�� Once it was established Mr Boyd was unable to make his own way to the Out of Hours Centre, Mr� Boyd was spoken to by a further doctor, who triaged him for a routine (same day) home visit.� The visiting doctor arrived at Mr Boyd�s property at around 08:34 but was unable to gain entry.�� Once police arrived, entry was forced and Mr Boyd was found unresponsive. Attempts to revive him were unsuccessful.

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

Emergency services related deaths (2019 onwards)

Department of Health and Social Care | NHS England

23/01/2025

2025-0043

Brian Kneale

Blackpool & Fylde

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

On 15th July 2024, I commenced an investigation into the death of Brian Kneale, Aged 70 years. The investigation concluded at the end of the inquest on 14th� January 2025. The conclusion of the inquest was that Brian died of natural� causes.� The medical cause of his death was:� 1 a�� Acute circulatory failure �� 1 b��Coronary heart disease, congestive cardiomyopathy and�bronchopneumonia complicated by haemorrhagic lung infarct

In paragraph 3 of the Record of Inquest, I recorded as follows: Brian Kneale was aged 70 years. Reportedly unwell for over a week with� evidence of vomiting episodes and worsening shortness of breath, he� attended hospital in Blackpool at approximately 3 pm on 27th June 2024.� After assessment, concerns were raised he had developed aspiration� pneumonia and heart failure. He was placed on the sepsis pathway but did� not receive antibiotic therapy until the early hours of the following day. He� was felt to be dehydrated and intravenous antibiotics were administered.� From the available evidence, the quantity of fluids given is unclear, although by the afternoon of 28th June 2024 a portable chest x-ray revealed signs of� fluid overload. Given that Brian had heart failure, a kidney injury and was� showing signs of infection, the amount of fluids given probably contributed to� worsening heart failure. Reviewed by an Intensive Treatment Unit doctor, his� prognosis was felt to be poor, and Brain died at 21.45 hours on 29th June 2024 in the presence of his family. A subsequent post mortem examination� confirmed he died from the combined effects of heart failure and� bronchopneumonia.� The following is of note: ��� Upon assessment after arrival at hospital, concerns were raised that�Brian was in heart failure.�� ��� During the course of the investigation, his family have raised concerns�about the extent of fluids administered during his hospital admission,� which had contributed to worsening heart failure.�� ��� Having heard the available evidence, I was in agreement this was� probably the case, particularly given that Brian had shown signs of acute kidney injury, and infection.�� ��� Bearing in mind the amount of fluids to be administered in this case�required an element of caution, the fluid balance charts had not been� recorded appropriately. They did not provide a reliable picture.� ��� I received helpful evidence from a Consultant in Acute Medicine, who� explained that during the Autumn of 2024 he had carried out a piece of�work with the aim of improving how fluid balances are monitored and� recorded for patients in the Emergency Department, but also the Acute� Medical Unit. Notwithstanding he had not worked at the hospital since� October 2024, he felt some improvements had been made, but he� remained concerned about the position in the Emergency Department,� which remained challenging.�� ��� I was left with the impression that clinicians were at times having to� make difficult judgements in the interests of patients when they did not�have a clear picture about fluid balances.� ��� Whether a hospital patient has been given an appropriate amount of�fluids is a vital element of a patient�s care, and when this does not�happen effectively for whatever reason, it can understandably cause�bereaved relatives significant concern.� ��� I have a concern that although it seems the hospital Trust is aware there is an issue regarding accurate fluid balance monitoring, the current� position is patients remain at risk if decisions may have to be made by� clinicians in the absence of accurate fluid balance charts.� ��� This issue can also have an impact upon reviews conducted internally by a hospital trust, and the extent to which these can be relied upon. The� authors of such reviews, in the event appropriate lessons are learned,� need to be able to form an accurate impression about the level of care� given to patients.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� ��� The Family of Mr Brian Kneale 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

Blackpool Teaching Hospitals NHS Foundation Trust

13/08/2024

2024-0451

Elizabeth Van Der Drift

Inner North London

1. [REDACTED]� Chief Executive Officer� Office for Product Safety and Standards Cannon House� 18 The Priory� Birmingham� B4 6BS� 2. [REDACTED]�������������������������������������������������� �� Secretary of State for Health and Social Care 39 Victoria Street� London� SW1H 0EU� 3. [REDACTED]� Director General� UK Cleaning Product Industry Association

On 21 March 2024, an investigation was commenced into the death of ELIZABETH VAN DER-DRIFT, then aged 93 years. The investigation� concluded at the end of inquest heard by me on 1 August 2024.� The inquest concluded with a short-form conclusion of accidental death. The medical cause of death was:� 1a aspiration pneumonia� 1b ingestion of toxic substance (laundry detergent) 1c dementia

CIRCUMSTANCES OF DEATH Ms Van Der-Drift had lived with dementia for a number of years. Her� condition was such that she often could not recall when she last consumed food and she would often go in search of something to eat.�� Sometime on the night of 13/14 March 2024, she gained access to laundry� detergent tablets/pods that were brightly coloured. Given the nature of the� packaging and the tablets/pods, I determined that, given her cognitive� impairment as a result of the dementia, Ms Van Der-Drift likely believed that� they were some form of sweet or confectionary. Having gained access to the� tablets/pods, she bit into at least one of them. Shortly thereafter, Ms Van Der- Drift was found complaining of stomach pain and shortness of breath.� An ambulance conveyed Ms Van Der-Drift to hospital where, despite� treatment, her condition deteriorated, and she died in hospital on 19 March 2024.

I have sent a copy of my report to the Chief Coroner and to the following: [REDACTED] � daughter of Elizabeth Van Der-Drift. � The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person she� believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or� publication of your response by the Chief Coroner.

�Product related deaths

Office for Product Safety and Standards | Department of�Health and Social Care | UK Cleaning Product Industry Association�| Sainsburys

28/10/2024

2024-0583

Ian Hegarty

Inner North London

1. [REDACTED]������������������������������ �� Group Chief Executive� Barts Health NHS Trust� Executive Offices� Ground Floor� Pathology and Pharmacy Building The Royal London Hospital� 80 Newark Street� London� E1 2ES

On 17 June 2024, an investigation was commenced into the death of Ian� Gilmore Hegarty, then aged 89 years. The investigation concluded at the end of an inquest heard by me on 23 October 2024 at Poplar Coroner�s Court.� The inquest concluded with a short-form conclusion of �accidental death�. The medical cause of death was:� 1a hypovolaemic shock 1b traumatic fracture of right femur 1c frailty syndrome, vascular dementia II HIV encephalitis

CIRCUMSTANCES OF DEATH Mr Ian Hegarty was admitted to hospital on 5 June 2024, following a fall at� home and increased confusion. He did not sustain any traumatic injury as a result of the fall at home.� On 14 June 2024, Mr Hegarty was transferred to the Royal London Hospital� for management of his underlying health conditions. He underwent a falls risk assessment following admission, which assessed him as being at moderate� risk of falls. The ward put mitigation measures in place to address the falls� risk, which included being placed in a bay where all four patients were� constantly within the sight of an allocated member of staff who was expected� to remain in the bay at all times.� On 16 June 2024, the allocated member of staff left bay. In doing so, they did not follow the protocol that had been put in place to reduce the risk of falls for all patients in that bay. During the period of time in which the allocated�member of staff was not within the bay, Mr Hegarty had an unwitnessed fall,� causing him to sustain a fracture to his right neck of femur.� Shortly after the fall, Mr Hegarty�s blood pressure dropped. Despite�treatment, his clinical condition deteriorated and he died in the Royal London Hospital in the early morning of 17 June 2024.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Barts Health NHS Trust

14/11/2024

2024-0626

Miranda Avanzi

Inner North London

1. [REDACTED]���������������������������������� �� Chief Executive� Ofcom� Riverside House� 2a Southwark Bridge Road London� SE1 9HA� 2. [REDACTED] ������������������������������������������ �� Secretary of State for Culture, Media and Sport 100 Parliament Street� London� SW1A 2BQ

On 18 July 2024, an investigation was commenced into the death of Miranda Emilia AVANZI, aged 58 years at the time of her death.� The investigation concluded at the end of an inquest on 12 November 2024. The conclusion of the inquest was �suicide�.� The medical cause of death was: 1a suspension by ligature

On 9 July 2024, Miranda Avanzi was found unresponsive at her home address, partially suspended by a ligature [REDACTED]. Her death was verified by a paramedic shortly thereafter.� Ms Avanti left notes of intent, clearly indicating a settled intention to end her own life, and instructions that she should not be resuscitated.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� The family of Ms Avanzi. 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 completed or redacted or summary form. She may send a copy of this report to any person who she� believes may find it useful or of interest. You may make representations to� me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Suicide (from 2015)

OFCOM | Department for Culture, Media and Sport

07/08/2024

2024-0432

Malika Hibu

Inner North London

1. [REDACTED} Chief Executive�Peabody Trust,�45 Westminster Bridge Road London SE1 7JB�� 2. [REDACTED] Chief Executive�Islington Borough Council, Islington Town Hall�Upper Street�London N1 2UD� 3. [REDACTED] Mayor of London�City Hall,�Kamal Chunchie Way London E16 1ZE� 4. [REDACTED] Secretary of State for Housing, Communities and Local Government,�House of Commons�London SW1A 0AA

On� 27� February� 2024,� one� of� my� assistant� coroners, Ian� Potter, commenced an investigation into the death of Malika Hibu aged 5 years. The investigation concluded at the end of the inquest on 17 July 2024.�� I made a narrative determination at inquest, which I attach to this report.

Malika Hibu was a little girl with autism spectrum disorder who lived in Crest Buildings (a 2015 housing development) just beside Regent�s Canal.� On 17 February 2024, she left her home without her mother�s knowledge and went to play at the canal�s edge.� At 3.57pm, she fell in. Malika� was� discovered� face� down� in� the� water� 25� minutes� later. Strenuous efforts were made to resuscitate her, but she was pronounced dead in hospital a short time later.� She had drowned.

I have sent a copy of my report to the following: [REDACTED], Malika�s parents�� HHJ Alexia Durran, the Chief Coroner of England & Wales I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she� believes� may� find� it� useful� or� of� interest.� You� may� make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

�Child Death (from 2015) � This report is being sent to: Peabody Trust | Islington Borough Council | Mayor of London | Ministry of�Housing, Communities and Local Government

05/11/2024

2024-0603

Barrie Forster

Cornwall and the Isles of Scilly

1. �[REDACTED] Secretary of State for Housing, Communities, and Local Government�� 2. [REDACTED] Secretary of State for Justice

On 5/11/24, I concluded the inquest into the death of Barrie Forster. I recorded the cause of death as:� 1a) Multi-organ failure;� 1b) Acute Upper Gastro-Intestinal Haemorrhage in a Man with Ischaemic Heart Disease and on Treatment with Apixaban; Craniofacial Trauma� Necessitating Surgical Repair (Operation 21/11/2020).� I recorded a conclusion that Barrie was unlawfully killed. In the event� proper assessments had been made of the risk the perpetrator posed to� Barrie and/or of the suitability of Barrie�s address as somewhere for the� perpetrator to live, it is more likely than not that the perpetrator would not� have been permitted to live at Barrie�s address upon release from custody and the assault would not have occurred when it did.

Barrie was assaulted on 20/11/20. The perpetrator, [REDACTED], had been released from custody two days earlier. [REDACTED] had recently had three spells in custody the last two sentences having been imposed after offences committed against his sister who had the protection of a� Restraining Order.�� The risk [REDACTED] posed to Barrie had not been assessed properly or at all by the Probation Service particularly in light of a complaint of sexual� assault by Barrie Forster against another family member and in the context of recent assaults by�[REDACTED] against other members of the family. Additionally, no, or no adequate, assessment had been made by the�Probation Service of the suitability of Barrie�s address as a place at which�[REDACTED] could reside after his release from custody.� After an earlier release from custody�[REDACTED] had been found a bed in�approved premises where he had stayed for six months. Thereafter, he� had stayed in two B&Bs in another county before returning to Cornwall� where he was homeless for a period, living in a tent at different locations. After his most recent custodial sentence, a formal application for a bed at� approved premises had not been made but, informally, members of the� Probation Service had been told one was not available. Discussions were ongoing with the Council�s homelessness team, but accommodation had�not been secured.�[REDACTED] had earlier convictions for arson. The�Probation Service had thought�[REDACTED] would be found a room at a� Travelodge or similar.� In the event, on the day of his release from custody, it was brought to the�attention of the Probation Service that�[REDACTED] intended to sleep on a sofa at his father�s address. The suitability of this accommodation was not�considered. The risk�[REDACTED] presented to Barrie was not assessed. Had� this been done, I found it was more likely that not�[REDACTED] would not have�been permitted to live with his father and the assault would not have� occurred when it did.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� [REDACTED] � (sister) Probation Service 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

Ministry of Housing, Communities, and Local Government | Ministry of Justice

22/05/2023

2023-0168

Karl Mitchell

Avon

1.The Rt Hon Mark Harper MP, Secretary of State for Transport 2. [REDACTED] Wife of the Deceased 3. Health and Safety Executive 4. Titan Containers Limited 5. Chief Coroner

On 29th September 2021 I commenced an investigation into the death of Mr. Karl Mitchell age 50 years. The investigation concluded at the end of the inquest on 23rd March 2023. The conclusion was that the medical cause of death was l( a) Cerebral oedema; 1(b) Hypoxic brain injury; 1(c) Traumatic crush injury to chest, and the conclusion of the jury as to the death was �Accident�

The Deceased was a lorry driver with Titan Containers Limited a company who provided shipping type containers to various sites which were then used for storage and as temporary site facilities. The containers were loaded and off loaded using a lorry mounted crane. The lorry used by the Deceased was fitted with a hydraulic stabiliser beam and swing-up (rotating) hydraulic stabilising leg at each corner. These were deployed during the loading and off loading procedure so as to stabilise the vehicle whilst the crane was in use. On 23rd September 2021 the Deceased was delivering a container to a local primary school for the purposes of temporary storage during building works. The Deceased successfully off loaded the container and was in the process of retracting the nearside front stabiliser beam when he was crushed by the swing up (rotating) leg causing him to suffer a cardiac arrest. The fire and rescue services attended and he was released using the �jaws of life�. He was attended by paramedics and conveyed to hospital where he died on 25th September 2021 as a result of his injuries. On this particular vehicle the control panel for the stabiliser beams and legs was mounted on the front nearside of the vehicle adjacent to the lorry mounted crane. In order to stow, in this case, the nearside stabiliser beam for road use it is necessary to rotate the swing up leg through 180� from the downward position to the vertical position. This enables the beam and leg to be stowed behind the cab of the vehicle when it is being driven on the road. Whilst carrying out this procedure the operator, in this case the Deceased, stands at the control panel with their back to retracting beam and leg. The swing up leg on the nearside when rotating upwards rotates in anticlockwise direction. Therefore the leg rotates directly behind the operator standing at the control panel. Whilst carrying out this procedure the Deceased was unaware that the swing up leg had not rotated fully to the upright position but was at an angle of approximately 80� from the downwards position. Therefore as the beam continued to be retracted the swing up leg crushed the Deceased against the control panel. Whilst further retraction of the beam could be stopped the hydraulic pressure remained trapping the Deceased and causing crush injuries.

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

Accident at Work and health and Safety related deaths | Other related deaths This report is being sent to: Department for Transport | Health and Safety Executive | Titan Containers Limited

11/01/2024

2024-0015

Nicholas Cork

Inner North London

1.[REDACTED] Chief Executive Sapphire Independent Living 1 Holmes Road Kentish Town London NW5 3AA

On 15 June 2023, an investigation was commenced into the death of NICHOLAS CORK, then aged 57 years. The investigation concluded at the end of an inquest, heard by me, on 5 January 2024. � The inquest concluded with a short narrative conclusion which set out that, �while substance misuse did not directly cause Mr Cork�s death, it did more than minimally contribute to it.� The medical cause of death was: � 1a bronchopneumonia 1b chronic obstructive pulmonary disease II liver cirrhosis, substance misuse disorder, diabetes mellitus.

CIRCUMSTANCES OF DEATH � Mr Cork lived in supported accommodation at Conway House, 18-22 Quex Road, London, NW6 4PL, which is a service operated by Sapphire Independent Housing. The funding for Mr Cork�s placement at Conway House was provided by the Local Authority. Mr Cork had been resident at Conway House since 2022. Following his arrival at Conway House in 2022, staff assessed him as being �at risk� due to a combination of his physical health conditions, his ongoing substance misuse issues, and his continued engagement with aspects of the criminal justice system. � In the early morning of 22 May 2023, Mr Cork was found unresponsive in his room and an ambulance was called. Paramedics verified the fact of his death 06:28 on 22 May 2023.

I have sent a copy of my report to the Chief Coroner and to the following: � Director of Adult and Social Care, London Borough of Camden. � 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 he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Community health care and emergency services related deaths This report is being sent to: Sapphire Independent Living

17/10/2023

2023-0387

Tracey Rose

East Riding and Hull

1.[REDACTED], Chief Medical Officer, Hull & East Yorkshire, NHS Trust

On 5th February 2023 I commenced an investigation into the death of Tracey Elizabeth Rose, aged 52 years. The investigation concluded at the end of the inquest on 2nd October 2023. The conclusion of the inquest was: ACCIDENT

These are set out in my summary and findings of facts which are attached. � Tracey Elizabeth Rose suffered an injury on 2nd January 2023 resulting in a fracture of the right tibial plateau. This was treated by open reduction and internal fixation on 4th January 2023. She was at higher risk of thromboembolic disease due to obesity and systemic lupus erythematosus and at discharge was recommended to have a course of six weeks dalteparin. Due to a dispensing issue, she missed up to three doses. She was readmitted to Hull Royal Infirmary on 25th January with shortness of breath and dizziness. She was suspected of having a pulmonary embolism which was subsequently confirmed, but despite embolectomy using interventional radiological techniques in which a large amount of thrombus was retrieved, her heart did not restart and she died on 25th January 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � ��[REDACTED], Next of Kin � I am also sending a copy to NHS England and equivalent organisations in the other countries of the United Kingdom. � 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: Hull and East Yorkshire NHS Trust

05/02/2024

2024-0074

Emily Harkleroad

County Durham and Darlington

1.[REDACTED], Executive Medical Director of the County Durham and Darlington NHS Foundation Trust

CORONER�S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

INVESTIGATION and INQUEST On 6 January 2023 an Inquest was opened into the death of Emily Kate Harkleroad, aged 31. The investigation concluded at the end of the inquest on 17 January 2024. The medical cause of death was Pulmonary Embolism. The conclusion of the Inquest was a narrative conclusion: The Deceased death was due to natural causes. However, on a balance of probabilities, Deceased�s death would have been preventable had appropriate medical treatment been provided.

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 1 April 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: County Durham and Darlington NHS Foundation Trust | Oracle Health UK

26/06/2024

2024-0342

Brian Colby

Inner North London

1.[REDACTED], President and Chief Executive Officer, HCA Healthcare UK, 2 Cavendish Square, London, W1G 0PU.

On 25 September 2023, an investigation was commenced into the death of BRIAN JOHN COLBY, then aged 75 years. The investigation concluded at the end of an inquest, heard by me, on 24 June 2024. � The conclusion of the inquest was �natural causes�, the medical cause of death being: 1a acute left sided subdural haematoma (on anticoagulation) II ischaemic heart disease, carcinoma of the liver, chronic kidney disease, interstitial lung disease

Brian Colby was an in-patient at The Princess Grace Hospital having had elective surgery. He was in the intensive care unit for treatment of aspiration pneumonia and his condition was improving. � On the morning of 16 September 2023, he had a spontaneous, catastrophic intra-cranial event, which was unrelated to his earlier surgery, but likely worsened by his anticoagulation medication. Later that day he was transferred to the National Hospital for Neurology and Neurosurgery where, following assessment and discussion with his family, he was placed on a palliative care pathway. He died later that evening.

I have sent a copy of my report to the Chief Coroner and the following Interested Persons: � Mr Colby�s wife and children � Legal representative acting on behalf [REDACTED] Legal representative acting on behalf of [REDACTED] Legal representative acting on behalf of [REDACTED] � I have also sent a copy of my report to the Care Quality Commission, for 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. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

11/12/2024

2024-0684

Nonie Atshiki

Inner North London

1.� Chief Executive Officer St Mungo�s� 3 Thomas More Street� London E1W 1YW

On 31 July 2024 I commenced an investigation into the death of Nonie Atshiki, aged 35 years. The investigation concluded at the end of the inquest on 2 December 2024. �� I made a determination at inquest that death was drug and alcohol related.

Nonie Atshiki was found in the stairwell of the hostel where she lived, St Mungo�s in Endell Street, shortly after 4am on 13 July 2024.� Her medical cause of death was:� 1a acute cardiac failure� 1b cocaine use and long term alcohol excess.

I have sent a copy of my report to the following. The father of Nonie Atshiki�� HHJ Alexia Durran, the Chief Coroner of England & Wales I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she� believes� may� find� it� useful� or� of� interest.� You� may� make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Alcohol, drug and medication related deaths

St Mungo�s

20/01/2025

2025-0045

REDACTED

Inner North London

1.� Chief Executive Officer The Unite Group plc Temple Back Bristol BS1 6FL

On 6 August 2024, I commenced an investigation into the death of Student A, aged 21 years at the time of his death. An inquest was opened on 7 August 2024. The investigation concluded at the end of an inquest heard by me on 14 January 2025. The conclusion of the inquest was �suicide�. The medical cause of death was: 1a asphyxiation [REDACTED]

CIRCUMSTANCES OF DEATH Student A lived in student accommodation at Somerset Court, Aldenham Street, London. He was last known to be alive on 27 July 2024, having spoken to his mother on the telephone and being seen returning to his address by staff at Somerset Court. The following morning, staff at the accommodation were requested to conduct a welfare check on Student A. At about 10:50 on 28 July 2024, staff noted Student A to be unresponsive (not responding to his name being shouted) in his room, but only saw his legs on the bed from the doorway to the room. Emergency services were called following a subsequent welfare check, at approximately 12:00, in which staff found Student A on his bed with [REDACTED]. Paramedics verified the fact of Student A�s death shortly thereafter. He died of asphyxiation having intended to end his own life.

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

Suicide (from 2015)

The Unite Group plc

15/01/2025

2025-0028

Sheila Wexler

Inner North London

1.� Chief Executive� Nottingham Rehab Limited (trading as NRS Healthcare) Sherwood House� Cartwright Way� Forest Business Park� Bardon Hill� Coalville� Leicestershire� LE67 1UB� 2.� National Medical Director NHS England� Wellington House� 133-155 Waterloo Road� London� SE1 8UG

On 29 February 2024, I commenced an investigation into the death of Sheila Josephine WEXLER, aged 87 years at the time of her death.� The investigation concluded at the end of an inquest on 14 January 2025. The conclusion of the inquest was a short narrative conclusion in the� following terms: �natural causes, contributed to by increased immobility as a result of delayed and defective turning equipment being supplied for the� treatment of a pressure ulcer.�� The medical cause of death was:� 1a bilateral pulmonary embolism� II��dementia, ischaemic cerebral stroke, pneumonia, frailty, grade 4 sacral pressure ulcer

CIRCUMSTANCES OF DEATH Mrs Sheila Wexler lived with dementia and other significant comorbidities for�a number of years. In the months prior to her death, she was thought to be� entering the final phase of her life and a package of maximal home treatment was in place as a ceiling of care.� In January 2024, Mrs Wexler developed an unstageable sacral pressure�ulcer. The district nursing team ordered equipment from an external supplier� (NRS Healthcare) which, among other things, would turn Mrs Wexler�regularly to assist in the treatment of the pressure ulcer. There were delays in some of the equipment arriving and the turning equipment was not properly� functioning. An engineer attended Mrs Wexler�s home, on behalf of NRS� Healthcare, to repair the equipment, but used a pump that was not� compatible with the turning system. As a result of these issues with the� equipment, Mrs Wexler�s immobility was significantly increased for a period of days, which added to her underlying risks of developing a pulmonary� embolism.� Mrs Wexler died at home on 17 February 2024. The immediate cause of her death was bilateral pulmonary embolism. A number of her comorbidities� contributed to this. The increased immobility as a result of delayed and� defective equipment being supplied also more than minimally contributed to� her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� The family of Mrs Sheila Wexler� Central and North West London NHS Trust I have also sent a copy of my report to the following, for information: NHS North East London Integrated Care Board North Central London Integrated Care Board� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted� summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Product related deaths

NRS Healthcare | NHS England

10/01/2025

2025-0014

Joshua Forsdyke

Inner North London

1.� Fresh Student Living�� 2.� University of the Arts, London

On 10 September 2024 an investigation was commenced into the death of Joshua James David Forsdyke �Josh� (aged 19). The investigation concluded at the end of the inquest on 8 January 2025. I made a determination at inquest Joshua took his own life whilst his judgment was impaired due to drugs and alcohol.

Josh moved to London to study in September 2023. He was exposed to easy access to drugs, particularly ketamine, whilst in student halls of� residence. He began buying ketamine and his addiction to illicit drugs� and alcohol appears to have spiralled from there and continued when� he moved out of halls. On 26 August he took ketamine and had an� argument with his girlfriend about his drug use. The following day, he� began drinking alcohol in the morning, before taking tramadol tablets� belonging to a third person. He then left the flat and went to London� Bridge, telling his flat mate that he intended to jump. After behaving� bizarrely on the bridge, he jumped into the River Thames. His body was recovered from the Thames near Butlers Wharf on 31 August 2024.� Toxicology tests showed that Josh had consumed a significant level of alcohol, a toxic of tramadol plus ketamine, shortly before his death.

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

Alcohol, drug and medication related deaths

Fresh Student Living | University of Arts London

03/11/2023

2023-0427

Adam Johnson

South Yorkshire (Western)

1.� Ice Hockey UK, Regus House, Malthouse Avenue, Cardiff Gate Business Park, Cardiff, Mid Glamorgan, CF23 8RU. 2.� English Ice Hockey Association Limited, Ice Sheffield, Coleridge Road, Sheffield, England S9 5DA. � 3.� Elite Ice Hockey League via Horwich Farrelly Limited, PO Box 149 Blyth, NE24 9FZ.

INVESTIGATION On 1 November 2023 I commenced an investigation into the death of Adam Robert Johnson, aged 29 years. The investigation has not yet concluded, and the inquest has not yet been heard.

Adam Johnson was a Professional Ice Hockey Player. On 28 October 2023 he was playing for the Nottingham Panthers in a game against the Sheffield Steelers at the Utilita Arena in Sheffield. � During the game Mr Johnson sustained an incised wound to the neck caused by the skate of another player. He was taken by ambulance to the Northern General Hospital in Sheffield where he died as a result of his injury.

I have sent a copy of my report to: 1.���� The Chief Coroner. 2.���� Mr Johnson�s family. � 3.���� The Rt Hon Stuart Andrew MP, Parliamentary Under Secretary of State (Minister for Sport, Tourism and Civil Society, and Minister for Equalities). 4.���� The International Ice Hockey Federation (IIHF) at Brandschenkestrasse 50, Postfach 1817, 8027 Zurich, Switzerland. � 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: Ice Hockey UK | English Ice Hockey

11/12/2024

2024-0683

Fehim Ahmet

Inner North London

1.� National Trading Standards� Estate and Letting Agency Team 1 Sylvan Court� Sylvan Way� Southfields Business Park� Basildon SS15 6TH� 2.� Network Agencies� Estate Agents� 209 Seven Sisters Road Finsbury Park� London� N4 3NG

On� 29� July� 2024,� one� of� my� assistant� coroners,� Melanie� Lee, commenced an investigation into the death of Fehim Ahmet aged 81 years. The investigation concluded at the end of the inquest on 19 November 2024.� I do apologise for the lateness of this report.� The medical cause of death was:� 1a� traumatic brain injury� 2��� traumatic cervical spine injury,�� ��������� chronic obstructive pulmonary disease with cor pulmonale

Whilst sitting in a social club/caf� a little after 7.30pm on 7 July 2024, Mr Ahmet was hit by a man falling through the skylight above.� He died a fortnight later from the injuries sustained.� The man had gone out onto the flat roof of the caf� via a window from the flat above and had sat on a plastic skylight, which had then given way.� The man was in the property having gone round to the flat to see friends who were brand new tenants. They had rented the property from Network Agencies.

I have sent a copy of my report to the following. [REDACTED], son of Fehim Ahmet�� HHJ Alexia Durran, the Chief Coroner of England & Wales I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she� believes� may� find� it� useful� or� of� interest.� You� may� make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Other related deaths

National Trading Standards | Network Agencies Estate Agents

22/01/2025

2025-0040

Joanna Kowalczyk

Gateshead and South Tyneside

1.� North East Ambulance Service 2. [REDACTED]������������������������ �� 3.�General Chiropractic Council

On 26/10/21 an investigation was commenced into the death of Joanna Daria Kowalczyk. The investigation concluded at the end of the inquest on 22/05/25.� The conclusion of the inquest was: Joanna Kowalczyk died due to a combination of the consequences of chiropractic treatment following a naturally occurring medical event, on a background of an undiagnosed medical condition.� The medical cause of death was: 1a) Bronchopneumonia� 1b) Cerebella infarction� 1c) Bilateral vertebral artery dissection� 2) Unspecified connective tissue disorder (undiagnosed)

The� Deceased� had� a� medical� history� which� included� migraine� and� joint hypermobility. It is likely that the Deceased had an unspecified connective tissue disorder which had not been diagnosed, and which made her susceptible to arterial dissections.� On 26/09/21 the Deceased underwent a personal training session at a gym when she felt a crack to her neck whilst using a piece of gym equipment and developed a severe headache. It is likely that she sustained bilateral arterial dissections at this time.�� The Deceased attended the Emergency Department at hospital on 27/09/21 and there was clinical suspicion of a subarachnoid haemorrhage, so a CT scan of the head was undertaken. The scan did not identify a subarachnoid haemorrhage, and a lumbar puncture with admission to hospital was recommended to exclude this diagnosis,� but� the� Deceased� self-discharged� prior� to� undergoing� the� lumbar puncture.� The� Deceased� researched� alternative� treatments� whilst� waiting� at hospital and identified chiropractic treatment.� On 28/09/21 the Deceased attended an initial appointment with a chiropractor with a complaint of neck pain, where an assessment was undertaken, and she was diagnosed with acute severe cervical facet dysfunction and associated muscle dysfunction.� Treatment� in� the� form� of� adjustments� and� manipulation� was recommended which the Deceased consented to.�� The Deceased informed the chiropractor that she had attended hospital and had undergone a CT scan and further investigations were advised, but she had self- discharged,� and� stated� that� the� doctor� was� aware� she� was� coming� to� see� a chiropractor. The chiropractor did not obtain any medical records prior to carrying out treatment.�� The� Deceased� underwent� the� first� adjustment� and� manipulation� chiropractic session on 28/09/21 after which she felt some improvement in her neck pain. The Deceased underwent three further sessions with the chiropractor on 02/10/21, 09/10/21 and 16/10/21.� During the fourth chiropractic session on 16/10/21, after the left adjustment to the neck, the Deceased experienced immediate symptoms of dizziness and room spinning. She developed double vision, tingling in her right hand and right foot, and was struggling to speak. The Deceased vomited whilst at the clinic. It is likely that the Deceased sustained acute dissections in the same location as the previous dissections during the chiropractic manipulation.� The chiropractor had initial concerns that the Deceased was suffering from a stroke so performed a FAST test which was negative. The Deceased�s symptoms began to improve, and she mobilised to a sofa in the treatment room to rest while the chiropractor sought a second opinion from a colleague.�� The Deceased remained in the chiropractic clinic for some hours resting. During that� time,� she� was� advised� to� seek� medical� attention� at� hospital� by� both chiropractors, but she did not wish to attend. An ambulance was not called by either chiropractor in reliance on the improvement in the Deceased�s symptoms.�� The Deceased was unable to walk properly as she left the chiropractic clinic and required assistance from her partner. The chiropractor prepared a handwritten note advising the Deceased to go to A&E if any signs appeared. Those were the signs of stroke from the NHS website.�� As a result of speech difficulty reported during an emergency call, paramedics attended via blue light ambulance later that day and carried out an assessment of the Deceased, including a FAST test due to possible symptoms of stroke, which was negative. The attending paramedic was reassured by a telephone conversation with the treating chiropractor that symptoms of dizziness and migraine were normal after the chiropractic treatment.�� The attending paramedic was not aware that symptoms of stroke could stop after a short period of time and assessed the Deceased based on the Deceased�s reported symptoms at that time.�� A diagnosis of migraine was reached by the paramedic from the reported history, the examination findings, and in reliance on the chiropractor�s reassurance that the chiropractor had no concerns, with a recording of a pain score of 6/10.�� An information for healthcare professionals document was completed by the paramedic before leaving the scene which recorded dizziness symptoms and the Deceased could not open her right eye for a while. Like the previous day, the Deceased was unable to mobilise unaided and required assistance to mobilise from her partner, which was not observed or recorded by the attending paramedic.� Had the� paramedic� observed� and� recorded� the� inability� to� mobilise� unaided,� the Deceased would have been assessed as FAST positive and transported to hospital on 16/10/21.�� On 17/10/21 paramedics attended the Deceased again via blue light ambulance at the highest priority. It was identified that the Deceased was gravely unwell with a reduced level of consciousness, and a FAST test to exclude stroke, could not be performed. A decision was made to transfer to the Emergency Department. The Deceased was unable to mobilise and required the use of a chair to be transported to the ambulance. The Deceased deteriorated in the ambulance on the way to hospital and required intubation and ventilation.�� A CT scan identified a maturing infarction involving the near entirety of the posterior fossa structures and a CT angiogram identified left vertebral artery dissection. Specialist advice was sought, and no treatment was available.�� The Deceased deteriorated and brain stem testing confirmed death at 13.10 on 19/10/21 at the Queen Elizabeth Hospital in Gateshead.� Whilst� it� is� possible� that� investigations� undertaken� on� 16/10/21� either� after attendance� at� hospital� following� the� chiropractic� treatment� or� following� the attendance by paramedics, may have identified the dissection to one of the arteries which was subsequently identified on 17/10/21, this cannot be determined to the requisite standard of proof.� It is not possible to determine whether earlier identification of the dissection on 16/10/21 would have allowed different management and treatment, so as to have changed the tragic outcome.�� An investigation undertaken by the ambulance service found that there was a failure in communications made by the paramedic crew on 17/10/21, but this did not cause or contribute to the death.

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

Hospital Death (Clinical Procedures and medical management) related deaths | Emergency services related deaths (2019 onwards)

North East Ambulance Service | REDACTED | General Chiropractic Council

02/01/2025

2025-0004

Morgan Betchley

West Sussex, Brighton & Hove

1.� Sussex Partnership NHS Foundation Trust, Arundel Road, Worthing, West Sussex,� ����� BN13 3EP via email [REDACTED] 2. [REDACTED] Chief Executive, NHS England, Quarry House, Quarry Hill, ��� Leeds, LS2 7UE via email [REDACTED]

On 21 March 2023, I commenced an investigation into the death of Morgan Rose Betchley, formerly Sladovic, aged 19 years. �The investigation was concluded at the end of the Inquest on 22nd November 2024. The conclusion given by the jury was a narrative conclusion namely: � Morgan died as a result of her own actions. Historical evidence suggests that in all probability Morgan�s intent had been to self-harm as a cry for help and that it was not her intention to end her life. Morgan was a young vulnerable adult who had suffered with her mental health for many years, including a history of self-harm and suicidal ideations.� Following a significant decline in her mental health she was admitted and Sectioned (under Section 2 and Section 136) on multiple occasions to several medical facilities for her safety and to receive an enhanced level of care. � The evidence shows repeated failures to follow policies and procedures by the staff at Meadowfield Hospital. Failures relating to admission process, understanding of existing diagnoses, risk management, record keeping, family involvement and discharge planning prevented Morgan from receiving access to services she needed at the time. We consider it probable that if policies and procedures had been followed Morgan would have benefitted from a level of care more closely aligned to her complex needs, including her diagnosis of Autism. � In the days running up to Morgan�s death, there was a failure to act professionally by some members of hospital staff. Following an earlier incident of assault, the deceased�s attempts to apologise were not handled in a professional manner by senior staff members of Rowan Ward, leading to a fractured therapeutic relationship. Whilst nursing staff did not actively exclude Morgan from receiving care, the situation was made unnecessarily stressful for Morgan. � The evidence of the court focused on the frequency of observations on the night of Morgan�s death. However, whilst it�s possible that more frequent observations may have helped to better understand her level of risk, we feel it more probable that better quality observations and interactions would have led to a great understanding of Morgan�s state of mind.

Morgan had been struggling with her mental health for some time, but there had been a marked deterioration at the end of January 2023 due to various factors. � From January 2023 she had, on a number of occasions, self-harmed and made attempts to take her life in the community, whilst detained under Section 2 of the Mental Health Act 1983, and whilst a voluntary inpatient.� � During this time, Morgan was admitted and discharged from mental health settings, through the consultant led discharge process and via Morgan self-discharging. � On the 27 February 2023 Morgan experienced a psychotic episode which resulted in hospital staff being injured.� As a result of this episode, Morgan self-discharged herself.� Whilst in the hospital grounds Morgan attempted to hang herself from a tree and on this occasion, she was detained by the Police under Section 136 Mental Health Act 1983. � Morgan was detained in the Psychiatric Intensive Care Unit under Section 2 and after assessment the section was rescinded and she was then transferred to Rowan ward on the 3 March 2023, where she remained as a voluntary inpatient. � It was assessed that Morgan should be discharged into the community under the care of the Crisis Team on the 6th March 2023.� Whilst waiting for a discharge meeting with the Crisis Team on the 9th March, in the early hours of the morning, Morgan sadly [REDACTED] hung herself.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � � The family of Morgan Rose Betchley (formerly Sladovic) Sussex Partnership Foundation Trust University Sussex Hospital NHS Foundation Trust West Sussex County 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 | Mental Health related deaths | Suicide (from 2015)

Sussex Partnership NHS Foundation Trust | NHS England

02/01/2025

2025-0005

Joseph Forbes Black

Inner North London

1.� The Secretary of State for Health and Social Care 39 Victoria Street� London� SW1H 0EU� 2.� Chief Executive� NHS England� Wellington House� 133-155 Waterloo Road London� SE1 8UG

On 17 August 2023, an investigation was commenced into the death of� Joseph Benjamin FORBES BLACK, aged 39 years at the time of his death. The investigation concluded at the end of an inquest on 23 December 2024. The conclusion of the inquest was �drug-related death�. The medical cause of death was:� 1a acute polydrug toxicity (heroin, cocaine, metonitazine, protonitazine) 1b substance misuse disorder� II��mental health disorder

CIRCUMSTANCES OF DEATH Joseph Forbes Black had a longstanding history of harmful substance�misuse, against a backdrop of �unspecified schizophrenia�. He engaged well� with the treatment of his schizophrenia and his mental health was considered stable in the time leading up to his death. However, despite being aware of available help, support, and treatment in relation to substance misuse, Mr Forbes Black repeatedly declined to engage.� On 9 August 2023, Mr Forbes Black was found deceased at his home� address. He died as a result of acute polydrug toxicity, which included the� taking of heroin that had been adulterated with protonitazene and� metonitazene. The presence of �nitazenes� more than minimally contributed to his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� The solicitors acting on behalf of Mr Forbes Black�s family North London NHS Foundation Trust� The London Borough of Camden� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted� summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Alcohol, drug and medication related deaths

Department of Health and Social Care | NHS England

31/01/2025

2025-0052

Alexander Channing

Dorset

1.� The Vice Chancellor of Arts University Bournemouth 2.� The Chief Executive of Dorset Healthcare NHS Foundation Trust 3.� The Chief Executive of Devon Partnership NHS Trust

On the 1st February 2022, an investigation was commenced into the death of Alexander Kieran Ari Channing (known as Alec), born on the 17th July 2003. The investigation concluded at the end of the Inquest on the 18th December 2024. The Medical Cause of Death was: 1a Hanging The conclusion of the Inquest recorded that Alexander Channing died as a consequence of suicide in circumstances where decisions were made at the time of discharge from hospital on 19/1/22 not to involve the Home Treatment Team and to postpone a Community Mental Health Team meeting on 25/1/22 which has led to missed opportunities to reassess his risk of suicide, the last missed opportunity being two days before his death.

In�2021� Alec� had� been� diagnosed� with� Emotionally� Unstable� Personality Disorder. He had been detained in hospital under s.2 of the Mental Health Act 1983 between 29/7/21 and 11/8/21. Following discharge he was seen by the Home Treatment Team and then the Community Mental Health Team. There was a delay in the transfer of care from the Community Mental Health Team based where his family lived to the Community Mental Heath Team in his university town. It was believed that the transfer could not take place until he had registered with a GP surgery in his university town. The referral was opened by the new Community Mental Health Team on 24/11/21. Alec was detained in hospital under s.2 of the Mental Health Act 1983 between 7/1/22 and 19/1/22. On discharge a decision was made not to involve the Home Treatment Team. An appointment was fixed for Alec to meet with the Community Mental Health Team on 25/1/22 for an assessment. Alec contracted Covid on or around 25/1/22 and�the�assessment�meeting�was�postponed�as�it�was�deemed necessary for there to be a face to face assessment. On 27/1/22 Alec was found suspended�by�a�ligature�in�his�room�at�his�university�halls�of�residence. Paramedics attended and pronounced him dead at the scene. Dorset Police investigated and found no suspicious circumstances.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Alec�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.

Suicide (from 2015) | Mental Health related deaths

Arts University Bournemouth | Dorset Healthcare NHS Foundation Trust | Devon Partnership NHS Trust

08/12/2023

2023-0509

Jasbir Pahal

West Yorkshire (Eastern)

1.� [REDACTED] Senior Service Specialist, Quarry House � 2.�[REDACTED] Medical Director of Commissioning, NHS England 3. [REDACTED] �Clinical Lead, West Yorkshire and Harrogate Integrated Stroke Delivery Network, Mid Yorkshire � 4. [REDACTED], NHS England National Specialty Adviser for Stroke, East Kent Hospitals University NHS Foundation Trust � 5. [REDACTED], National Clinical Lead for Stroke Medicine, Wirral University Teaching Hospital NHS Foundation Trust � 6. [REDACTED] Chair, NHS West Yorkshire Integrated Care Board � 7. [REDACTED] �Chief Executive, NHS West Yorkshire Integrated Care Board � 8. [REDACTED] �Regional Director, North East and Yorkshire, NHS England � 9.�[REDACTED] �NHS Chief Executive, NHS England 10.�[REDACTED] National Medical Director of NHS England, NHS England

On 21st December 2022 I commenced an investigation into the death of Jasbir Kaur Pahal, aged 42 (03/09/1978). The investigation concluded at the end of the Inquest on 25th October 2023. The conclusion of the Inquest was that Jasbir�s death was caused by an ischaemic stroke. An extensive narrative conclusion is summarised in Section 4 below.

At 0205 hrs on Sunday 13th November 2022, Jasbir Pahal was observed to have fallen out of bed and to be exhibiting signs indicative of having had a stroke. She was taken by ambulance to Calderdale Royal Hospital, arriving in the Emergency Department at 0407 hrs, her arrival being delayed by the acuity of demand upon the ambulance service and adverse weather conditions on the road. A CT scan showed an acute left middle cerebral artery infarction. � Jasbir did not receive thrombolysis (�clot busting medication�) because more than four and a half hours had passed since she had last been seen well the previous evening ,

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Quarry House | NHS England | West Yorkshire and Harrogate Integrated Stroke Delivery Network | Stroke, East Kent Hospitals University NHS Foundation Trust | Wirral University Teaching Hospital NHS Foundation Trust | West Yorkshire Integrated Care Board

15/04/2024

2024-0198

Stevyn Carr

Gateshead and South Tyneside

1.� [REDACTED] � Chief Constable � Northumbria Police

On 22nd November 2021 I commenced an investigation into the death of Stevyn CARR, 34 years old. The investigation concluded at the end of the inquest on 6th March 2024. The conclusion of the inquest was Drug & Alcohol Related. The medical cause of death was; 1a Cardiac Arrhythmia 1b Chronic Excess Alcohol Consumption and Use Of Amphetamine.� I found at inquest, Stevyn Carr died on 16th November 2021 at 17 Lytchfeld, Leam Lane, Gateshead from a cardiac arrhythmia caused by the toxic effects of him voluntarily consuming a quality of alcohol and amphetamines at some point prior to his death. His intention in doing so was not to end his life.

Stevyn Carr contacted Northumbria Police on the evening of 15th November 2021 at 7.22pm. His contact with police call handlers and emergency operators was difficult to understand, due to on balance to his intoxication. He did ask for �Help� and he was told police would attend. The calls to police were assessed a Grade 2 response � normally within an hour. No police attended until they entered Stevyn Carr�s address at 12.02pm on 16th November after members of his family contacted the police at 10.38am to express their concerns for him. He was discovered dead when police entered his home. � On the evidence heard it was not possible to ascertain whether earlier police attendance would have altered the outcome. � From the first call to police to his discovery by police a period of 16 hours 40 minutes elapsed.

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

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

06/07/2023

2023-0230

Gordon Renfrew

Nottinghamshire

1. The Chief Executive, Nottingham University Hospitals NHS Trust

On the 14th June 2022, I commenced an investigation into the death of Gordon Harry Renfrew. The investigation concluded at the end of the inquest on the 28th June 2023 � The conclusion of the inquest was a Narrative as follows: � Gordon Renfrew died on the 14th June 2022 at Queens Medical Centre Nottingham, from extensive cerebral oedema with mass effect leading to brain herniation. This was caused by a large cerebral infarction, occurring early morning on the 7th June 2022, and involving the anterior, middle and posterior lobes of the left cerebral hemisphere. � The infarction was caused by a large occlusion in the left internal carotid artery in the neck, extending to the bifurcation of the internal carotid artery into the anterior and middle cerebral arteries. The occlusion was caused by arterial dissection and clot/thrombus at this site, likely caused by a combination of weakness in the arterial vessel wall from Fibromuscular Dysplasia, and a neck hyperextension injury sustained when diving from a high board on the 31st May 2022 � A Mechanical Thrombectomy was undertaken on the 7th June 22, to try and remove the clot. This was partially successful, but there remained occlusion of the middle cerebral artery, with subsequent additional re-occlusion of the internal carotid artery post procedure. � A Decompression Craniectomy was undertaken on the 10th June 2022, to try and reduce the effect of the severe cerebral oedema, caused by the large infarct � The NICE guidance on Decompression Craniectomy after stroke, was not followed. There should have been detailed, early and repeated discussion with the family as to timing of the Decompression Craniectomy, on the 8th and 9th June 2022. Had this occurred it is very likely that the procedure would have been performed at an earlier time, although it is not possible to say, on a balance of probability, that this would have led to Gordon surviving what was a very severe and extensive stroke.

Gordon died on the 14th June 2022, at Queens Medical Centre (QMC), Nottingham, after a short admission. He had been transferred to QMC, from the Royal Derby Hospital for further management of a severe and extensive stroke. Detailed findings as to how he came by his death are described within a written Determination dated 28.6.23, appended to this report

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1.������ Gordons family- His partner�[REDACTED], and his parents 2.������ The University Hospitals of Derby and Burton NHS Foundation Trust � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

04/03/2024

2024-0117

Kenneth Baylis

Nottinghamshire

1. The Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust

On the 24th January 2023, I commenced an investigation into the death of Kenneth Stanley Baylis. The investigation concluded at the end of the inquest on the 26th January 2024 The conclusion of the inquest was a narrative conclusion as follows: Mr Baylis took his own life on 23rd January 2023 whilst on unescorted leave, when he was an informal inpatient on Kingsley Ward of Millbrook Mental Health Unit. He had a history of depression, and repeated serious and escalating suicide attempts over a fourteen month period leading up to his death. His risk of suicide was real and imminent throughout his final admission from 28.12.22. This was not properly recognised by the treating team with responsibility for his care, due to a failure to involve his family in risk assessment and support and safety planning, a failure to follow procedures regarding unescorted leave for informally admitted patients, and a failure to properly weigh up all the relevant factors which contributed to suicidal risk. The decision on the 10th January 2023, to allow unescorted leave from the ward, was not an appropriate one. All these omissions in care made a more than minimal, negligible, or trivial contribution to his death

Mr Baylis took his own life [REDACTED] on 23.1.23. He died from multiple injuries. He did so with the intention of his actions leading to his death. He made four previous serious and escalating attempts to end his life from November 2021, until finally succeeding on 23rd January 23 � this was despite caring support from his family and from many of the mental health professionals that he met both as an inpatient and when supported by the community teams. � Sadly, however the building picture of increasing risk of suicide was not fully understood by the team on Kingsley ward. During Mr Baylis�s final inpatient psychiatric admission, the seriousness and his intent to die, were significantly underestimated. There was inadequate risk assessment during this last admission, lacking in detail and incomplete. His repeated reporting of lack of suicidal thoughts, and intentions was not adequately challenged. Risk assessment was also severely compromised because there was with no contact made with the family until 12.1.23, and no family involvement in key decisions made by the team. � Mr Baylis was a voluntary patient during his final admission, and was allowed unescorted leave, on 10.1.23, which gave him the opportunity to take his own life. This should not have occurred. Had there been family involvement in the decisions regarding leave arrangements, had there been greater weight given to the repeated, and very recent, very serious suicide attempts, together with more direct involvement requested of the Specialist Depression service, it is unlikely that this incorrect decision would have been made. � Accepting that it would have been difficult to deny him his unescorted leave request, (as this was his wish, and he was an informal patient), had he been told this was not agreed, it would have likely precipitated either a further Mental Health Act assessment, or more likely his agreement to comply, as had occurred in previous admissions. This would have allowed for a longer treatment period, hopefully (if it had been considered) family participation in his care and support plan, as previously, further involvement of the Specialist Depression service, with a more robust management plan, that acknowledged that depression was the most likely explanation for his presentation, and a managed discharge to a safer environment. � The lack of family input during his final admission, to Mr Baylis�s risk assessment and support and safety planning, together with the serious under estimation of the real and imminent risk of death from suicide, and the incorrect decision to allow unescorted leave, all probably made a more than minimal, negligible, or trivial contribution to his death. � Trust Policies and procedures regarding family involvement in assessment of risk, care plans, and MDT meetings, were not followed. The Trust procedure entitled �Care Planned Leave/Time off the ward for inpatient areas of the mental health services division�, was not followed. There was no evidence of joint planning of leave arrangements, to include family, very limited evidence of consideration of identified risks, very limited consideration of any possible leave restrictions, and no contact with family to ask them if they had any concerns about leave arrangements. � Additionally, and importantly, there was no clear evidence of an assessment of Mr Baylis�s mental state, nor a robust assessment of risk, before each period of time off the ward. There is no evidence of completion of the sheet- �Appendix 1 of the Planned Leave procedure : Time Spent off the ward� at any time. Had it been completed it would have captured a signature of the staff member allowing Mr Baylis to leave, details of his time leaving the ward, planned time of return, planned destination, actual time of return. This sheet was not a familiar document to the senior treating team on Kingsley ward. Detailed findings as to how he came by his death are described within a written Determination dated 4.8.23, appended to this report.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Mr Baylis�s family � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � 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: Nottinghamshire Healthcare NHS Foundation Trust

01/09/2023

2023-0391

Gerard Murray

Nottinghamshire

1. The Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust

On the 16th July 2022, I commenced an investigation into the death of Gerard Murray. The investigation concluded at the end of the inquest on the 4th August 2023 The conclusion of the inquest was suicide

Gerard died on the 16th July 2022. He was found deceased, at 15.20 hours on that day. This location was an approximate half mile walk from Bassetlaw Hospital, where Gerard had been an inpatient on the mental health ward B2. [REDACTED]. He had been admitted to ward B2 on 29.6.22, with low mood and suicidal thoughts and plans. He had been treated with an antidepressant and started on Lithium, on 8.7.22, to try and reduce suicidality. His admission was informal, and he was allowed unescorted leave throughout his admission. On 16.7.22 he left the ward at 13.30 hours, and did not return. The ward staff were not aware that he had not returned until the nurse in charge was notified that he could not be found at 16.27 hours on that day. There were reports that he had been seen on the ward by a Health Care Assistant at 14.30 hours, and that he was in his bedroom at 15.30 hours. These reported sightings of him were not substantiated, and were incorrect. � Detailed findings as to how he came by his death are described within a written Determination dated 4.8.23, appended to this report

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � 1.������ Gerard�s family � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � 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: Nottinghamshire Healthcare NHS Foundation Trust

03/04/2024

2024-0187

Meha Carneiro

Nottingham City and Nottinghamshire

1. The Chief Executive, Sherwood Forest Hospitals NHS Foundation Trust

On the 6th December 2022, I commenced an investigation into the death of Meha Carneiro. � The investigation concluded at the end of the inquest on the 1st March 2024 The conclusion of the inquest was a narrative as follows: Meha Carneiro died at 14.28 hours on the 5th December 2022 at the age of 5 years and 7 months, from overwhelming sepsis caused by infection with Group A streptococcus. Meha had Down syndrome. The seriousness of her clinical condition was not recognised when she presented to Kings Mill Hospital on 5.12.22 at 07.39 hours. She was managed with oral fluids, and struggled to have more than a very minimal intake, she had continuing diarrhoea, and was not reviewed by a paediatrician, nor a senior doctor in the Emergency Department, as she should have been. She was not provided with intravenous fluids nor antibiotics as she should have been. The lack of repeated observations, the lack of review of the oral fluid challenge, the lack of senior review, leading to the lack of recognition of the seriousness of her condition, all probably made a more than minimal, negligible or trivial contribution to her death. Had intravenous fluids and antibiotics been provided in the morning of 5.12.22, she would on balance have survived. Her death was contributed to by neglect

Meha died at Kings Mill Hospital on 5.12.22. She had Down syndrome, and was unwell with intermittent fever, cough, abdominal pain and diarrhoea and vomiting over the two to three days prior. She was brought to hospital on the morning of 5.12.22 by her father, and collapsed in cardiac arrest approximately five and a half hours after admission. She could not be resuscitated. Detailed Findings as to how she came by her death are provided in a written Determination dated 1.3.24, appended to this report � .

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Meha�s family � The Care Quality Commission � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any 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: Sherwood Forest Hospitals NHS Foundation Trust

04/04/2024

2024-0185

Tommy Gillman

Nottingham City and Nottinghamshire

1. The Chief Executive, Sherwood Forest Hospitals NHS Foundation Trust

On the 8th December 2022, I commenced an investigation into the death of Tommy Jay Gillman � The investigation concluded at the end of the inquest on the 15th March 2024 The conclusion of the inquest was a narrative as follows: Tommy died on 8.12.22 from sepsis and multi organ failure secondary to Salmonella Brandenburg meningitis. There were missed opportunities to provide him with earlier antibiotics, fluid resuscitation and intensive monitoring from 12.35pm on the 7th of December 2022 at Kings Mill Hospital. Once the severity of his illness had been recognised at approximately 1700 hours on that day, he was provided with prompt treatment for septic shock and meningitis. Sadly however he did not respond to this treatment and died the following day following transfer to Leicester Royal Infirmary. Whilst there were serious missed opportunities to provide earlier treatment of sepsis and meningitis, I cannot say that these issues of care have made a more than minimal negligible or trivial contribution to his death.

Tommy died on 8.12.22 at Leicester Royal Infirmary. He had been transferred there from Kings Mill Hospital (KMH) the previous evening for intensive care management, having presented to the Emergency Department at KMH at 12.35 hours on 7.12.22. He was extremely unwell on presentation to KMH, but he was not treated with antibiotics and intravenous fluids until 17.00 hours on that day. � This final illness was caused by a Salmonella meningitis. This was his second episode of Salmonella meningitis, with both episodes caused by a very rare subspecies of Salmonella, that of Salmonella Brandenberg. The source of the Salmonella infection was not established, despite a full UKHSA investigation, nor was it clear whether the second episode was a reinfection or a relapse following the first Salmonella infection. � Tommy had also had an episode of Group B streptococcal meningitis in the early neonatal period. Whilst the first two episodes of meningitis were treated appropriately, there were a number of missed opportunities to render care to Tommy on 7.12.22, specifically the delay in triage, the incorrect calculation of the Paediatric Observation Priority Score (POPS), and the lack of recognition of how unwell he was on admission. This led to the lack of escalation to a senior doctor, the lack of completion of a Paediatric Early Warning Score (PEWS), the lack of repeat urgent observations (which should have been every 30 minutes reviewing response to urgent fluid boluses) from admission. IV antibiotics should have commenced within 30 to 60 minutes of his presentation to hospital. � Sepsis was clearly present by 1328 on that day, and very likely present at 12:35 although this was not recognised. The sepsis 6 chart, if it had been completed correctly by the paediatric team who have far more experience of assessing young babies, would have identified sepsis and led to immediate treatment with fluids and antibiotics. Additionally there was a further opportunity to render care at 1510 when the repeat observations remained high with the PEWS of nine- again there was no nursing or medical response to Tommy clinical picture of sepsis, at this point � Whilst these issues of care at KMH on 7.12.22 are very serious, it is not possible to say that they caused, or made a more than minimal contribution to Tommy�s death, as he had such a serious and overwhelming infection, and was likely to be unable to mount an effective immune response as he was so young, and had already had two serious infections Detailed Findings as to how he came by her death are provided in a written Determination dated 15.3.24, appended to this report.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Tommy�s family � The Care Quality Commission � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any 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) This report is being sent to: Sherwood Forest Hospitals NHS Foundation Trust

14/10/2024

2024-0551

Janet Seddon

North Yorkshire and York

1. The Chief Executive, York & Scarborough Teaching Hospitals NHS Foundation Trust.

On 20 February 2023 I commenced an investigation into the death of Janet Kathleen SEDDON aged 79. The investigation concluded at the end of the inquest on 09 October 2024. The conclusion of the inquest was that: Janet Kathleen Seddon died as a consequence of naturally occurring disease contributed to by a delay in correctly identifying her abdominal pathology.

On the 30th of January 2023 Janet Kathleen Seddon underwent a CT scan of her abdomen and pelvis at York District Hospital to investigate abdominal symptoms, which was reported as showing a sigmoid stricture containing a presumed faecalith. On the 7th of February 2023 the same CT scan images were re-reviewed and reported as showing a fistula between the gallbladder and duodenum containing an impacted gallstone and indicating impending obstruction of the bowel. Mrs Seddon was surgically assessed at the hospital the same day and consented to an emergency laparotomy. While Mrs Seddon was stable in the immediate post-operative period, her condition steadily deteriorated with signs of developing sepsis. Despite intensive care she died at the hospital on the 9th of February 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] I have also sent it to Department of Health & Social Care � Prevention of Future Death Reporting 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

York & Scarborough Teaching Hospitals NHS Foundation Trust

21/11/2024

2024-0640

Edward Barnard

London Inner (South)

1. The Chief Medical Officer VMD, The Veterinary Medicines Directorate, Veterinary Medicines Directorate, Woodham Lane, New Haw,� Addlestone, Surrey, KT15 3LS�� 2. The Chief Executive Officer, Royal College of Veterinary Surgeons,� Royal College of Veterinary Surgeons, 3 Waterhouse Square, 138-142 Holborn, London EC1N 2SW� 3. The Chief Coroner for England and Wales, Chief Coroner�s Office, Room C09, Royal Courts of Justice, Strand, London, WC2A 2LL

On the 22/1/2024 an investigation commenced into the death of Edward John Youde Barnard born 23/3/1994 and died on 9/1/2024. � The investigation concluded at the end of the inquest on 15 November 2024. The medical cause of death was:� 1(a) Fatal [REDACTED] overdose II My Conclusion as to the death, section 4 Record of Inquest, was �Suicide�

On the 8/1/2024 Edward checked into a hotel and on the following morning he was� found deceased in his room by a staff member. The ambulance and police services� attended, and it was determined that there were no suspicious circumstances. A note was found in the room from Edward to the hotel staff, which stated:� �Please call 999 and report as suicide. I�m sorry I ruined your day.� A postmortem examination and toxicological analysis concluded that the death was caused by a �Fatal [REDACTED] overdose�.� Edward had a history of anxiety and depression and had attended Cognitive� Behaviour Therapy counselling in 2018 he also had a heart defect which was operated in 2021 which had a detrimental effect on his mental well-being.�� I concluded that he took the [REDACTED], with the clear intention of ending his life, after he checked into the hotel room.� The toxicology report recorded a [REDACTED] blood level of [REDACTED] ug/ml and noted the fatal level was [REDACTED] ug/ml.� The toxicology report went on to state that [REDACTED] was a short acting�barbiturate used in the UK only as an anaesthetic agent in Veterinary Medicine.

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

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

Veterinary Medicines Directorate | Royal College of Veterinary Surgeons

21/05/2024

2024-0280

Tracy McCarthy

Inner North London

1. The GP Partners The Tredegar Practice 35 St Stephen�s Road London E3 5JD

On 1 August 2023, an investigation was commenced into the death of TRACY FRANCES MCCARTHY, then aged 50 years. The investigation concluded at the end of an inquest, heard by me, on 15 May 2024. � The inquest conclusion was �drug-related death�. The medical cause of death was: � 1a amitriptyline toxicity II coronary artery disease

CIRCUMSTANCES OF DEATH � Tracy McCarthy was found deceased at her home address on 17 July 2023. She died as a result of her long-term misuse of amitriptyline.

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

Alcohol, drug and medication related deaths This report is being sent to: Tredegar Practice

17/11/2023

2023-0487

Glenn Lockwood

Inner North London

1. The Managing Partners The Limehouse Practice Gill Street Health Centre 11 Gill Street London E14 8HQ

On 9 June 2023, an investigation was commenced into the death of GLENN ANTHONY LOCKWOOD, then aged 48 years. The investigation concluded at the end of an inquest, heard by me, on 15 November 2023. � The conclusion of the inquest was drug related death, the medical cause of death being: � 1a hypoxic brain injury, multiple organ failure and bronchopneumonia following cardiac arrest 1b mixed drug toxicity

1) Mr Lockwood was a known drug user, registered with The Limehouse Practice since February 2021. He did not always engage well. Mr Lockwood was prescribed Pregabalin throughout the time he was registered with The Limehouse Practice. 2) He was receiving support and treatment from a local drug and alcohol support service, which took over prescribing for his opiate replacement therapy, and regularly updated The Limehouse Practice about Mr Lockwood�s treatment and engagement. 3) Mr Lockwood was found unresponsive on the platform of Westferry DLR station on 14 April 2023 and conveyed to hospital where he was treated for a suspected [REDACTED] overdose. He responded to naloxone, but discharged himself from hospital (against medical advice) on 15 April 2023. 4) On 16 April 2023, Mr Lockwood had an out of hospital cardiac arrest and following extensive resuscitation efforts, was conveyed to hospital by ambulance. 5) Despite treatment in hospital, Mr Lockwood died on 2 June 2023.

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

Alcohol, drugs medication related deaths This report is being sent to: The Limehouse Practice

03/01/2024

2024-0004

James Holgate

East Riding and Hull

1. The Minister for Health � [REDACTED]

INVESTIGATION � On 2nd November 2023 I commenced an investigation into the death of James Arthur HOLGATE, aged 89 years. The investigation has not yet concluded, and the inquest has not yet been held. � Mr HOLGATE�s medical cause of death has been given as: 1a Traumatic Intracranial Haemorrhage 1b Fall 2��� Mitral Valve replacement (on warfarin), Hypertension, Atrial Fibrillation, Frailty

On 30th October 2023 Mr HOLGATE age 89 years was admitted to Hull Royal Infirmary with recurrent falls, progressive confusion, slurred speech and progressive decline. While in the care of the Emergency Department Mr HOLGATE sustained a fall. A CT scan showed evidence of a traumatic head injury, Mr HOLGATE was deemed very unwell and not for surgical intervention. Mr HOLGATE deteriorated further and another CT scan showed an ongoing bleed with mass shift which had not been evident on the original CT. Mr HOLGATE was reviewed again and still deemed not fit for intervention and placed on a palliative care pathway. Mr HOLGATE died on 1st November 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � the family of James Arthur HOLGATE. I have also sent it to The Royal College of Surgeons 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: Department of Health and Social Care

14/10/2024

2024-0546

Paul Chase

Liverpool and Wirral

1. The Ministry of Defence Government Department 2. [REDACTED], The Minister for Veterans Affairs 3. The Chief Coroner�s Office

On 25 March 2024 I commenced an investigation into the death of Paul Anthony CHASE, also known as PAUL ANTHONY MALONE, aged 41 years. The investigation concluded at the end of the inquest on 11 October 2024. The conclusion of the inquest was that: Paul Anthony Chase, also known as Paul Anthony Malone, died by Suicide. Paul had a medical history of chronic post-traumatic stress disorder (PTSD) and drug abuse (cocaine).� On the morning of 13 March 2024 Paul was found deceased hanging in Woolton Woods off School Lane, Liverpool, using [REDACTED]. The toxicological analysis revealed the presence of low levels of alcohol and cocaine. The post mortem examination found the medical cause of death to be: 1a Hanging During the inquest evidence was heard how the specialist mental health services for veterans was limited and there was a lack of funding for the services, with some veterans who were desperate for help having to wait 18 months. Evidence was also heard about there being little mental health support to those currently serving in the armed forces which is essentially when the PTSD starts to develop and limited mental health/alcoholism/addiction support for those having left the armed forces.

Paul Anthony Chase, also known as Paul Anthony Malone, was a 41 year old gentleman who had a medical history of chronic post-traumatic stress disorder (PTSD) and drug abuse (cocaine).� On the morning of 13 March 2024 Paul was found deceased hanging in Woolton Woods off School Lane, Liverpool, using [REDACTED]. The toxicological analysis revealed the presence of low levels of alcohol and cocaine. The post mortem examination found the cause of death to be hanging. Paul had been thought to be suffering with post-traumatic stress disorder since leaving the armed forces in 2009 but had not sought medical help until 2020. Over the last three years his mental health had deteriorated. In 2020 the social stresses he experienced resulted in his cocaine use to escalate. In December 2022 he attempted to ligature himself. Paul attended the Royal Liverpool University Hospital accident and emergency department on 22 November 2023 after recent contact with his GP and Mersey Care Crisis line due to suicidal ideations. He was then a voluntary patient at Windsor House Mental Health unit from 24 November 2023-15 December 2023. On 15 December 2023, Paul was discharged from Windsor House and placed in Tom Harrison House, a specialist addiction recovery service for armed forces veterans. This was a 12-week residential programme. On 1 January 2024 Paul tested positive for cocaine and as the Tom Harrison House had a zero tolerance to drugs and alcohol policy (clearly communicated to the residents so Paul would have been aware of this) Paul was asked to leave Tom Harrison House. Paul was given overnight accommodation on 1 January 2024 and then a 6 month support and accommodation package for him at The Block, County Rd, Walton, a veteran charity for rehabilitation for men in crisis. Paul then chose to go back home and there was no further contact. The care and treatment afforded to Paul through Mersey care and Tom Harrison House was reasonable and appropriate. It is more likely than not Paul did have PTSD on leaving the armed forces and it had remained dormant until the social stresses of life triggered the greater symptoms of PTSD. It is more likely than not Paul carried out the act of self-harm with the intention of taking his own life.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. [REDACTED] (wife) 2. Mersey Care NHS Foundation Trust 3. Tom Harrison House (specialist addiction recovery service) I have also sent it to: 1. [REDACTED] (Cabinet Office) 2. [REDACTED] (Ministry of Defence) 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)�| Service Personnel related deaths

Ministry of Defence

01/08/2023

2023-0280

Edward Rhodes

Dorset

1. The Practice Manager, The Beaufort Road Surgery

On the 23rd November 2022, an investigation was commenced into the death of Edward England Rhodes, born on the 9th July 1989. The investigation concluded at the end of the Inquest on the 27th July 2023. The Medical Cause of Death was: 1a Methadone Toxicity � The conclusion of the Inquest recorded. Drug Related Death

Mr Rhodes had a long history of alcohol misuse. He had been admitted to hospital numerous times for alcohol related issues. He lived in supported housing where he was tested regularly for substance misuse. In June 2022 he chose to abstain from alcohol and sought the help and support of agencies to prevent relapse. On 14/7/22 he stated he was over 1 month sober; on 18/8/22 he was 76 days sober; on 2/9/22 he stated he was 90 days sober; and by 16/11/22 he had been abstinent for 4-5 months. At the beginning of November 2022, he relapsed. On 17/11/22 he was found on his partner�s bedroom floor in an unresponsive state and was pronounced dead at the scene. Toxicology revealed the presence of methadone, which was at a level consistent with severe, possibly fatal toxicity for an individual who is na�ve to or occasional user of methadone. Mr Rhodes was not on a methadone prescription at the time of his death.

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

Alcohol, drugs medication related deaths This report is being sent to: The Beaufort Road Surgery

20/07/2023

2023-0260

Peter Harris

City of London

1. The Radiology Clinical Lead and the Clinical Governance Lead for the Barking, Havering and Redbridge University Hospitals NHS Trust

I commenced an investigation into the death of Peter John Harris, aged 73 years, who died at St. Bartholomew�s Hospital, London on the 10th June 2022. The investigation concluded at the end of the inquest on the 11th July 2023. � The conclusion of the inquest was that the medical cause of death was � Ia Multi-Organ Failure Ib Recurrent Global Pericardial effusion Ic Metastatic lung adenocarcinoma T4 N2 M1a II Carcinoma Prostate and my conclusion as to the death was � Natural Causes.

My findings as to the circumstances of the death, as recorded on the Record of Inquest, were as follows: � 1.�On the 11th May 2022 Peter Harris was admitted to Queens Hospital, Romford and was found to have a large pericardial effusion and a diagnosis of stage 4 metastatic lung cancer was made. The condition was untreatable but palliative chemotherapy was planned. However, on the 27th�May 2022 and the 3rd June 2022, the Deceased was re-admitted with non- resolving pneumonia which was treated with anti-biotics. His symptoms worsened and he was found to have a recurrent pericardial effusion and, on the 5th June 2022, he was transferred to St. Bartholomew�s Hospital, London for a �pericardial window� to be performed. However, before going to theatre, the Deceased suffered a cardiac arrest. He was resuscitated and intubated, and he underwent an emergency pericardiocentesis before transfer to the Intensive Treatment Unit. Despite support, attempts to wean the Deceased from sedation were unsuccessful, and he developed multi-organ failure and died at 17.30 hours on the 10th�June 2022. � In 2020, whilst being investigated by the colorectal service at Queens Hospital, a CT scan performed in November 2020 raised the possibility of a malignant process in the lung but this report was not seen by the clinical team. If it had been seen, it is likely that annual review and monitoring would have been arranged and this may have enabled the lung tumour which subsequently developed to have been diagnosed and treated before it reached stage 4. There was, therefore, a lost opportunity to monitor for and, possibly, to diagnose and treat, the lung cancer. However, it is possible that the tumour, which probably developed quickly, would not have been found even by annual review. Consequently, on the evidence, it is not possible to ascertain whether monitoring probably would, or would not, have prevented the Deceased�s death.

I have sent a copy of my report to the Chief Coroner and to the Family of Peter John Harris. � 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.

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

22/02/2024

2024-0102

Matthew Price

West Yorkshire (Eastern)

1. The Rt Hon Alex Chalk KC MP, Minister of Justice.

On 30th June 2023 I commenced an investigation into the death of Matthew Gregory Price. An inquest was concluded on 30 January 2024. The conclusion of the Inquest was that Mr Price died of multiple injuries, with a short-form conclusion of suicide being recorded.

Matthew Gregory Price was aged 48. He was convicted of a s.18 assault by wounding in 2010 when he was aged 35 and has been subject to an Indeterminate Sentence for Public Protection (�IPP�). He served a term of imprisonment before being released back into the community. � Whilst IPP sentences were abolished in 2012, Mr Price remained subject to his sentence which was imposed in 2010. � At the time of his death, Mr Price had engaged legal support in order to make an application for review of his sentence which was at an early stage. Since 2022, a review is initiated at the ten-year mark and yearly thereafter, if appropriate. Mr Price�s first ten- year review was due to take place in November 2023. � At the conclusion of the inquest, I recorded the following facts. � �On the evening of 16 June 2023 Matthew Gregory Price was struck by a train travelling from Leeds to Manchester at Cottingley Railway Station, Cottingley Drive, Cottingley [REDACTED]. He suffered multiple injuries and his death was confirmed by paramedics at 2149 hours. Matthew�s mental well-being had been adversely affected over a significant period of time by the continuing impact of serving an Indeterminate Sentence for Public Protection (IPP). He was especially anxious that seeking help in respect of his mental health could impact negatively when making an application to discharge the sentence further to its imposition in 2010. It is apparent from a text message sent just prior to his death that Matthew intended to take his own life�

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

Suicide (from 2015) | State Custody related deaths This report is being sent to: Ministry of Justice

15/09/2023

2023-0339

Riya Hirani

Inner North London

1. The Rt Hon Steve Barclay MP Secretary of State for Health and Social Care House of Commons London SW1A 0AA � 2. [REDACTED] National Medical Director NHS England Wellington House 133-135 Waterloo Road London SE1 8UG

On 30 December 2022, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Riya Hirani, aged 9 years. The investigation concluded at the end of the inquest yesterday. I made a narrative determination, a copy of which I attach. � Riya�s medical cause of death was: 1a hypoxic ischaemic encephalopathy 1b out of hospital cardiac arrest 1c invasive group A streptococcal infection and influenza B infection

Riya died in Great Ormond Street Hospital, having been transferred there from Northwick Park Hospital in Harrow after she presented in cardiac arrest on the evening of 23 December 2023. However, by that point Riya�s condition was irretrievable, and she died five days later.

I have sent a copy of my report to the following. � �� [REDACTED], the parents of Riya Hirani �� [REDACTED], the parents of Martha Mills ���[REDACTED], medical director, Northwick Park Hospital ���HHJ Thomas Teague QC, the Chief Coroner of England & Wales � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Child Death (from 2015) This report is being sent to: Department of Health and Social Care | NHS England

17/10/2023

2023-0388

Marnie Hill

Dorset

1. The Rt Hon Steve Barclay MP, Secretary of State for Health and Social Care

On the 18th May 2022, an investigation was commenced into the death of� Marnie Emma Hill, born on the 14th April 1973. � The investigation concluded at the end of the Inquest on the 6th October 2023. The Medical Cause of Death was: Ia�� Suffocation�[REDACTED] &�[REDACTED] overdose � The conclusion of the Inquest was suicide.

On the 15th May 2022 Marnie Emma Hill was found in a collapsed and unresponsive condition lying on the bed, in the bedroom at the property she was temporarily residing at, namely 40 Moorlands Road, West Moors,� Ferndown. [REDACTED].

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) [REDACTED] (2) [REDACTED] (3) [REDACTED] (4) NHS England (5) Dorset Healthcare NHS Foundation Trust (6) South West Ambulance Service NHS Foundation Trust (7) The Barcellos Family Practice (8) [REDACTED] I am also under a duty to send the Chief Coroner a copy of your response. I have also provided a copy of this to the British Association for Counselling and Psychotherapy for their awareness. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

07/03/2024

2024-0127

Richard Collins

Dorset

1. The Rt Hon Victoria Atkins MP, Secretary of State for Health and Social Care 2.�[REDACTED] Chief Executive Officer for NHS England

On the 23rd March 2022, an investigation was commenced into the death of Richard Andrew Collins, born on the 16th January 1966. � The investigation concluded at the end of the Inquest on the 29th February 2024. � The medical cause of death was: � Ia Traumatic injuries � The conclusion of the Inquest was road traffic collision.

At approximately 20.45 hours on the 9th February 2022 Richard, who had a diagnosis of bipolar affective disorder, abandoned his vehicle� on the verge of the eastbound carriageway of the A421 in Bedfordshire. Following this he was walking about half a metre into the carriageway of lane one of the eastbound carriageway of the A421 about 1.15km west of the roundabout junction with the A421 towards Bedford, when he was struck by the left front side of� an articulated lorry. He was found a short time later in a collapsed and� unresponsive condition on the grass verge on the side of the A421 and despite resuscitation attempts his death was confirmed.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Richard�s Family Dorset Healthcare University NHS Foundation Trust Chief Constable of Dorset Police Chief Constable of South Yorkshire Police Dorset Council Driver of the articulated lorry � I am also under a duty to send the Chief Coroner a copy of your response. � I have also sent a copy of this report to the following persons for their awareness: � The Rt Hon Mark Harper MP, Secretary of State for Transport Julie Lennard, Chief Executive Officer for the DVLA � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he� believes may find it useful or of interest. You may make 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 of Health and Social Care | NHS England

24/05/2024

2024-0290

Oliver Steeper

Central and South East Kent

1. The Secretary of State for Education

On 12th November 2021 I commenced an investigation into the death of Oliver Steeper who was a 9 month old child. The investigation concluded at the end of the inquest on 23rd May 2024. The conclusion of the jury at the inquest was death due to misadventure.

Oliver was registered by his parents at Jelly Beans Day Nursery in Ashford. Following a period of �settling in� sessions, he commenced two half day nursery sessions a week from September 2021. At home, his parents had started weaning him from milk to pureed baby food, and he had started to try finger foods. Oliver had two partially erupted bottom front teeth and had no other teeth in his mouth. � The family believed that the nursery would be blending and pureeing food for Oliver to eat. The nursery however provided Oliver with finely chopped food at meal times which was different in texture to that which he received at home. At the inquest, evidence highlighted a difference between what Oliver�s parents understood he would be fed, and what the nursery provided Oliver to eat. Moreover, evidence identified an apparent lack of knowledge by the nursery staff regarding the different stages of baby weaning, and a lack of knowledge regarding the importance of gathering a child�s weaning information from parents, recording that information and circulating it with other staff members. � On 23 September 2021, whilst being fed a meal of finely chopped pasta bolognaise at the nursery, Oliver choked and became unconscious. Nursery staff provided initial first aid and an ambulance arrived. Oliver was taken by ambulance to the William Harvey Hospital, Ashford, and was then transferred to the Paediatric Intensive Care Unit at the Evelina London Children�s Hospital. A bronchoscopy on 24 September 2021 revealed food debris occluding more than half of Oliver�s proximal airway, and present in a number of the small airway branches. � Oliver had suffered a hypoxic/ischaemic brain injury due to the cardiorespiratory arrest, which in turn had arisen due to his aspiration of foodstuffs during the choking episode. Oliver�s life support was removed, and he died on the 29th September 2021. � Expert evidence at the inquest from a Consultant in paediatric, pre-hospital first aid, stated that the level of first aid provided by the nursery staff was overall of a poor standard.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:�[REDACTED], Jellybeans Day Nursery Representatives, and Ofsted. � I am also under a duty to send a copy of your response to the Chief Coroner and to 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. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Child Death (from 2015) This report is being sent to: Department for Education