Inquests (PFDs)

23/10/2024

2024-0570

Declan Morrison

Cambridgeshire and Peterborough

1. The Secretary of State for Health and Social Care 2. The Chief Executive, NHS England� 3. The Chief Executive, Cambridgeshire and Peterborough Integrated Care Board

On 4 April 2022 I commenced an investigation into the death of DECLAN GORDON GERARD MORRISON, who died on 2 April 2022, aged 26.� The investigation concluded at the end of the inquest before me and a jury on 3 October 2024. The conclusion of the�Jury was:-� Medical cause of death:-� 1a) Traumatic acute on chronic subdural haemorrhage (operated); Conclusion:-�� Declan died from head injuries caused by him banging his head whilst he was detained at the Section 136 Suite at Fulbourn Hospital under Section 2 of the Mental Health Act.

Declan was just 26 years of age at the date of his tragic death. He had diagnoses which included ASD, ADHD and Learning Disability. Declan was largely non-verbal and�required 24-hour residential care. His needs were highly complex. He lacked mental�capacity to make decisions in his own best interests.� Between 2014 and March 2022 he resided in private placements sourced by Cambridgeshire County Council�s Learning Disability Partnership.� Declan moved into his final placement in May 2021 after the previous placement had� become unable to meet his needs. By the end of 2021(latest) it was agreed by all the� professionals involved in his care and the private care provider that this placement was� also unable to meet Declan�s complex needs. His mental health and behaviour began to deteriorate as a result. The private care provider felt that they could not consequently� keep Declan (and other residents) safe.� Despite attempts to find Declan an alternative appropriate placement CCC�s LDP could� find nothing available either locally or nationally. Demand for such placements outstrips�supply � providers are effectively able to �pick and choose� who they offer placements to. Declan�s mental health and behaviour declined further and as the result of an incident� on 8 March 2022 whereby he was detained under Section 136 of the Mental Health Act.� Declan was taken to Addenbrookes Hospital Emergency Department in Cambridge as a place of safety where he was then further detained under Section 2 of the Mental Health Act. There was no suitable hospital placement available and so Declan was taken to the Section 136 Suite at Fulbourn Hospital in Cambridge.� The evidence was clear � the Section 136 Suite is suitable only as a temporary� placement for those suffering an immediate mental health crisis. It is/was not a suitable� facility for longer term detention and or for someone with Declan�s complex needs. Staff there were not appropriately trained to care for him� Whilst it was hoped that Declan�s placement would be only temporary once again both local and national searches for an appropriate alternative were unsuccessful.� Declan�s mental health declined further in the Section 136 Suite. His behaviour became more agitated and disturbed. As a result, he engaged in self-harming behaviours�including blows to the head.� He was found unresponsive on 18 March 2022 having suffered catastrophic brain� injuries. Tragically Declan died at Addenbrookes Hospital in Cambridge on 2 April 2022. The Integrated Care Board for Cambridgeshire & Peterborough funded a bespoke�residential �Crisis Service� in November 2023. It remained open for 38 weeks (during� which it operated at 98% capacity) before funding was withdrawn.� Had such a�placement been available to Declan it would potentially have avoided the need for him to be detained under the Mental Health Act.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� Declan�s Family/Legal Representatives Cambridgeshire County Council Cambridgeshire & Peterborough NHS Foundation Trust Caretech Holdings Cambridgeshire Constabulary Cambridge University Hospitals Trust. � I am also under a duty to send the Chief Coroner a copy of your response 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.

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

Department of Health and Social Care | NHS England | Cambridgeshire and Peterborough Integrated Care Board

15/11/2024

2024-0634

Emily Lewis

Hampshire, Portsmouth and Southampton

1. Transport Secretary 2. Associated British Ports 3. British Marine 4. British Ports Association 5. British Standards Institution 6. Maritime and Coastguard Agency (Coroner�s Reports) 7. Red Bay Boats LTD 8. Royal Yachting Association 9. UK Major Ports Group 10. UK Harbour Masters� Association

On 25 August 2020 I commenced an investigation into the death of Emily Jane LEWIS aged 15. The investigation concluded at the end of the inquest on 31 October 2024. The conclusion of the inquest was that: On 22nd August 2020 the Deceased died at Southampton General Hospital, Tremona Road, Southampton, Hampshire. Earlier that day she had sustained upper abdominal when the RIB Seadogz, on which she was a passenger, collided with a buoy, projecting her forward into the extended handhold in front of her causing fatal injuries: the Deceased�s liver was compressed against her spinal column leading to transection, along with contusion of the pancreas.

On 22nd August 2020 the Deceased was a passenger on a RIB experience ride on Seadogz, a 600bhp RIB capable of speeds well over 40kts. Following high speed manoeuvres in Southampton Water, Seadogz passed astern of a ferry, went through its wash and struck a buoy at a speed of 38.4kts. The Deceased sustained the fatal injuries set out in Box 3. Seadogz hit the buoy because the skipper did not become aware of its proximity in sufficient time to take avoiding action. To leave matters there would omit the multifactorial issues affecting RIB design, operation, planning, and regulation that contributed to this tragic collision. The skipper had lost positional awareness in the moments before the collision. This was most likely due to a combination of being desensitised to the risk of high- speed rib operations and the high mental workload associated with operating Seadogz alone at high speed near other marine assets. It is highly likely that the skipper�s decision to conduct the transit close to the ferry significantly contributed to his high mental workload and loss of positional awareness. The tasks associated with acting as sole watchkeeper, navigator and passenger attendant undoubtedly increased the skipper�s mental workload: the Small Commercial Vehicle and Pilot Boat Code recommends an additional trained crew member as being fundamental to ensure safe operation of a high speed passenger RIB given the high mental workload of single-handed operation. The skipper�s field of vision ahead was obscured by the passengers in front of him, the raised bow as the RIB planed at high speed, and when the bow rose and dropped having crossed the ferry�s wake in the moments before the collision. Forward visibility complied with BS EN ISO 11591 � but the standard did not evaluate the effect on forward visibility of full loading of passengers with the craft at maximum running trim. The Seadogz seating arrangement provided inadequate passenger protection in the event of a sudden deceleration, the handhold for the Deceased inflicted her fatal injuries. The size of the passengers allocated to the bench seat, including the Deceased meant that they could not effectively brace themselves against forward motion. Neither the SCV nor the Recreational Craft Directive provided specific conditions or guidance re seat design or RIB protection. Had guidance in Maritime Guidance Note 436 (M+F) been followed this may have prompted the skipper to refuse the Deceased boarding. The skipper may have experienced a negative startle response when he suddenly observed the buoy ahead. It is likely that passengers became desensitised to the high speed close passing of navigation buoys and vessels, reducing their ability to alert the skipper to an impending hazard. The MAIB described the Seadogz�s written risk assessment as cursory and generic, it did not consider the risk of impact or collision during a RIB experience ride. No safety management system with external review process or structured approach to learning from the RIB�s previous accidents existed. Significant limitations existed in application of the SCV Code to high-speed passenger craft operators. The framework of licensing can be complex. ABP (the harbour authority) had not assessed the risks of high-speed commercial passenger craft operations in its area, there was no agreement between ABP and operators about maintenance and use of craft. ABP have taken mitigatory steps. MAIB describe the requirements and guidance for operators of commercial high-speed craft as �confusing and inconsistent� Further, �in the last 15 years, the MAIB has investigated numerous accidents involving high-speed passenger craft and made various recommendations to improve the safety of this sector. However, as yet, little has been done to provide proper protection to passengers and crew from these hazards that routinely result in life-changing injury, and occasionally death.�

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (Family) [REDACTED] (�[REDACTED] & [REDACTED]) [REDACTED] (MAIB) [REDACTED] (Insurers for Seadogz) 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) | Other related deaths

Department for Transport | Associated British Ports | British Marine | British Ports Association | British Standards Institution | Maritime and Coastguard Agency | Bay Boats Limited | Royal Yachting Association | UK Major Ports Group | UK Harbour Master�s Association

07/05/2024

2024-0249

Peter Fanning

Birmingham and Solihull

1. University Hospitals Birmingham NHS Foundation Trust

On 8 January 2024 I commenced an investigation into the death of Peter Jason FANNING. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Natural causes

Peter was born with cerebral palsy which caused severe physical impairment. He communicated using a liberator device and received a full package of care at home. He was fed using a gastrostomy tube with a jejunal extension which became dislodged periodically and he suffered from epilepsy and episodes of aspiration pneumonia. In 2022 and 2023 there were repeated dislodgments of his feeding tube resulting in him being admitted to hospital for replacements which impacted on his nutritional state and frailty. He was admitted to the Birmingham Heartlands Hospital on 07/11/23 after a further dislodgement of his feeding tube which was replaced on 15/11/23 due to there only being one radiology list per week for complex feeding tube replacements. He was discharged home on 18/11/23. The feeding tube dislodged again requiring further admission on 24/11/23. The tube was reinserted on 28/11/23 but unfortunately became dislodged again on 30/11/23. Peter was treated for severe pneumonia on 30/11/23. A PICC�s line was inserted on 05/12/23 to provide total parenteral nutrition until a further more permanent feeding tube could be inserted surgically on 13/12/23 but this PICCS line also dislodged on 07/12/23 and had to be replaced on 11/12/23. Peter deteriorated with further symptoms of pneumonia on 15/12/23 and sadly died on 19/12/23. � Following information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a Pneumonia 1b Frailty II�� Epilepsy, Cerebral Palsy

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

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

25/04/2024

2024-0233

David Wellington

Black Country Category: Road (Highways Safety) related deaths This report is being sent to: Walsall MBC

1. Walsall MBC Walsall MBC

On 22/12/23 I commenced an investigation into the death of Mr David WELLINGTON aged 54 years. The investigation concluded at the end of the inquest on 23/4/24. The medical cause for the death of Mr Wellington was; � 1a Haemothorax 1b Fatal chest injuries 1c Road traffic accident � The conclusion of the inquest was Road Traffic Collision.

At approximately 10:34 hrs on Tuesday the 12th December 2023, a fatal road traffic collision occurred on a service road off Leamore Lane, Walsall. The collision occurred between a Renault box van and Mr David WELLINGTON who was a pedestrian. The van was reversing at the time of the collision. As a result of the collision sadly Mr David WELLINGTON died at the scene. � Mr Wellington was a resident at a block of flats accessed via the service road on which the collision took place. � The collision itself was captured in its entirety on nearby CCTV. A police investigation established that Mr Wellington (who was wearing a parker coat with the hood up) had entered the service road through a pedestrian barrier and was positioned in the blind spot of the reversing van and that Mr Wellington would not have been visible to the driver. It is not known whether Mr Wellington had seen the van reversing. The driver of the white van was using his hazard lights but the van did not have warning beeps when reversing as this was not a legal requirement for this size of van.� � The van was noted to be particularly quiet when reversing. It is not known why Mr Wellington. did� not appear to hear the vehicle reversing.

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

Road (Highways Safety) related deaths

04/11/2024

2024-0598

Henry Grierson

West Yorkshire Western

1. [REDACTED]

On 30 April 2024 I commenced an investigation into the death of Henry Joseph GRIERSON aged 17. The investigation concluded at the end of the inquest on 31 October 2024. The conclusion of the inquest was that: See Narrative Conclusion.

Henry was as last seen by his parents on the 20th April 24, at 22:15 hours at his home address when he went to bed. He was described as being in good spirits. After his parents had gone to bed, it is believed Henry has left the address in his fathers mother vehicle and is stopped by the Police and the vehicle was seized by Police at 02:15 hours. Following this it is believed Henry has returned home and written in a diary his intention to commit suicide to his family members and has time stamped these in the diary. The time when he started was 0613 hours and finished it at 06:41 hours. It is then believed Henry has taken a length of blue rope from his father�s shed and has left the area and walked to a wooded area behind the William Henry school in Rastrick. Henry has then [REDACTED]. Henry was found by the a member of the public who was out walking their dog. The emergency services have been contacted and on arrival the Police, have started CPR until the Paramedics arrived who reported life extinct at 10:11 hours.

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

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

[REDACTED]

11/03/2024

2024-0200

Ronald Jepson

Coventry and Warwickshire

1. [REDACTED] 2. [REDACTED]

On 16th March 2023 I commenced an investigation into the death of Mr Ronald James JEPSON (aged 75 years). The investigation concluded at the end the inquest on 19th January 2024 at Coventry Coroners Court. The conclusion of the death of Mr Jepson was that death was �misadventure�, a copy of which I attach to this report.

Ronald James JEPSON had a history of schizophrenia, and resided at Meadow House, a mental healthcare facility. An aspect of Mr Jepson�s care plan was supervision when he was provided a meal/eating, Mr Jepson with a known risk of cramming food into his mouth and thereby choking. On 14th March 2023 Mr Jepson was sat in the TV lounge and provided his supper which consisted of some jam sandwiches. It was inconclusive as to whether the jam sandwiches were cut into sufficiently small pieces. Also in the lounge was another resident with the same meal. Mr Jepson, a short time later, his plate cleared from the room, had an unwitnessed choking episode. Care home staff, upon hearing Mr Jepson �gargling�, came to his location in this emergency situation. 111 was called by care home staff, in due course the matter correctly escalated by the call handler to enable an ambulance to be immediately dispatched. First attempts as resuscitation by care staff were following an appreciable period of time and the cardiopulmonary resuscitation was sub optimal. Ronal Jepson had turned blue (cyanosis) and an ambulance arrived. Despite paramedics attempts at resuscitation at Meadow House care home (a return of spontaneous circulation attained) and at UHCW hospital, Mr Jepson died at hospital on 15th March 2023, the cardiac arrest precipitated by the episode of choking on food, (food lodged in the windpipe and thus air prevented from getting to the lungs thereby damaging vital organs and causing the deceased heart to stop).

I have sent a copy of my report to the following: � HHJ Thomas Teague KC the Chief Coroner of England & Wales Chief Coroner�s Office, 11th Floor Thomas More, Royal Courts of Justice, Strand, London, WC2A 2LL. chiefcoronersoffice@judiciary.gsi.gov.uk Ronald James JEPSON�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 other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. �� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

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

20/10/2021

2023-0199

Freeda Glausiusz

Inner North London

1. [REDACTED] Chief Executive East London NHS Foundation Trust Trust Headquarters 9 Alie Street London E1 8DE

On 25 May 2021 I commenced an investigation into the death of Freeda Glausiusz, aged 32 years. The investigation concluded at the end of the inquest yesterday. � I made a determination at inquest of death by suicide whilst suffering a psychotic episode.

Freeda Glausiusz jumped from her [REDACTED] home on 15 May 2021. Her father had called the crisis line in desperation the day before. His call was not treated with the seriousness it deserved. It is unclear whether any alternative action by the crisis team would have changed the outcome.

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

Suicide (from 2015) This report is being sent to: East London NHS Foundation Trust

12/06/2023

2023-0193

Heather Findlay

Inner North London

1. [REDACTED] Chief Executive Officer East London NHS Foundation Trust (ELFT) Trust Headquarters 9 Alie Street London E1 8DE � 2. [REDACTED] Metropolitan Police Service (MPS) 6th Floor, New Scotland Yard Victoria Embankment London SW1A 2JL � 3. [REDACTED] Chief Executive Officer NHS England Quarry House Quarry Hill Collingham Leeds LS2 7UE � 4. The Rt Hon Suella Bravermen MP Secretary of State for the Home Department House of Commons London SW1A 0AA

On 16 June 2020, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Heather Findlay, aged 28 years. The investigation concluded at the end of the inquest earlier today. � At inquest, the jury came to a conclusion of death by suicide, making a narrative determination that I now attach, and giving a medical cause of death of: � 1a� hypoxic ischaemic encephalopathy 1b� sodium nitrate toxicity

At the time of her death, Heather Findlay was in the care of the East London Foundation Trust (ELFT), detained under section 2 of the Mental Health Act at Mile End Hospital. � At approximately 3pm on 11 June 2020, she was on s17 escorted leave, standing with a healthcare assistant (HCA) at the front gates of the hospital having a cigarette, when she turned to the HCA, said �I�m sorry I have to do this to you� and ran away. � ELFT contacted the Metropolitan Police Service (MPS) at 3.17pm, but by 3.58pm, Ms Findlay had been found by a member of the public in a nearby park.

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

Suicide (from 2015) This report is being sent to: East London NHS Foundation Trust | Metropolitan Police Service | NHS England | Home Office

28/10/2024

2024-0582

Kashim Ali

Inner North London

1. [REDACTED] Chief Executive Officer� East London NHS Foundation Trust Robert Dolan House� Trust Headquarters� 9 Alie Street� London� E1 8DE

On 28 May 2024, an investigation was commenced into the death of Kashim Ali, then aged 56 years. The investigation concluded at the end of an inquest heard by me on 21 October 2024 at Poplar Coroner�s Court.� The inquest concluded that Mr Ali died from natural causes. The medical cause of death was:� 1a cardiac arrest 1b hypertensive heart disease II schizophrenia, hyperkalaemia, type 2 diabetes mellitus

CIRCUMSTANCES OF DEATH Mr Ali was detained under section 3 of the Mental Health Act 1983, on� Millharbour Ward at Mile End Hospital. His detention was for the purposes of providing treatment in relation to his longstanding diagnosis of �treatment� resistant schizophrenia.� On 21 May 2024, shortly after 09:00, Mr Ali was noted to be asleep in his�bed. A few minutes later, he was noted to be totally unresponsive. Emergency procedures were followed, but attempts at resuscitation were not successful. Mr Ali died as a result of cardiac arrest.

I have sent a copy of my report to the Chief Coroner and the following: � 1. [REDACTED]� Mr Ali�s next of kin 2. 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

East London NHS Foundation Trust

16/08/2024

2024-0462

Daniel Klosi

Inner North London

1. [REDACTED] Medical Director� Royal Free Hospital Pond Street� London NW3 2QG� 2. [REDACTED] President� Royal College of Paediatrics and Child Health 5-11 Theobalds Road� London WC1X 8SH� 3. [REDACTED] President� Royal College of Emergency Medicine Octavia House� 54 Ayres Street� London SE1 1EU

On 12 April 2023, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Daniel Klosi, aged 4 years. The investigation concluded at the end of the inquest on 14 August 2024. I made a narrative determination at inquest, a copy of which I attach.

Daniel died on his fourth presentation in a week to the Royal Free Hospital.� His medical cause of death was:� 1a group A streptococcus sepsis

I have sent a copy of my report to the following. [REDACTED] and [REDACTED], Daniel�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.

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

Royal Free Hospital | Royal College of Paediatrics and Child Health | Royal College of Emergency Medicine

25/10/2024

2024-0581

Michael Crane

Inner North London

1. [REDACTED] Metropolitan Police Commissioner New Scotland Yard� London� SW1A 2JL� 2. [REDACTED] Chief Executive Officer Prime Life Limited� Caernarvon House� 121 Knighton Church Road Leicester� Leicestershire� LE2 3JN

On 2 February 2024, an investigation was commenced into the death of� Michael James Crane, then aged 54 years. The investigation concluded at the end of an inquest heard by me on 26 September 2024.� The inquest concluded with a short narrative conclusion in the following� terms: �Drowning in the river Thames, contributed to by the fact that no� missing person report had been made to the police.� The medical cause of death was:� 1a drowning�� II idiopathic left ventricular hypertrophy related cardiomyopathy

CIRCUMSTANCES OF DEATH Michael Crane lived in supported accommodation for those living with mental health diagnoses, at Island Place Residential Home (the Home) in Leicester.� His past medical history included schizophrenia, complicated by substance� misuse, and he was under the care of mental health services in� Leicestershire, by virtue of a Community Treatment Order. His schizophrenia was treated with monthly depot injections, the next of which was due on 16� January 2024.� Sometime during the afternoon of 15 January 2024, Mr Crane was noted to� be �off Unit� by staff at the Home. He had still not returned home by 23:00 that evening. Further checks at 03:00 and 07:00 on 16 January 2024, still noted�Mr Crane�s absence from the Home. While he was noted to be absent, no� action was taken because he was deemed to be �low risk� and had the� freedom to come and go from the Home as he wished. The standard policy at the Home was that they only reported residents missing once they had been� unexpectedly absent from the premises for 24-hours.� At about 05:54 on 16 January 2024, Mr Crane had self-presented to the� Emergency Department at St Thomas� hospital (the Hospital), London, having previously spoken to Metropolitan Police Service (MPS) officers. He was� assessed by the Mental Health Liaison Team at the Hospital and there was�no indication that he needed to be admitted under the Mental Health Act at� that time; the plan was to assist Mr Crane to get back to Leicester so that he� could have his depot injection that day, as planned.� At about 08:30 on 16 January 2024, the Home received a telephone call from the MPS to advise that Mr Crane had gone to the Hospital. The Mental�Health Liaison Team at the Hospital also telephoned the Mental Health� services in Leicestershire that were caring for Mr Crane�s mental health�routinely.�� Shortly after 11:55 on 16 January 2024, Mr Crane was escorted off-site at the Hospital by a member of staff for the purposes of having a cigarette.�However, he left and was seen to board a bus bound for Victoria station.� No service had reported Mr Crane missing at this stage. At approximately 16:40 on 16 January 2024, Mr Crane approached two MPS officers on The Strand and asked them if he was a missing person. The� officers undertook some checks and advised Mr Crane that he was not a� missing person. Mr Crane went with the officers to Charing Cross police� station.� The officers were aware that Mr Crane had been at the Hospital that morning. They also considered that he was dressed inappropriately for the weather� conditions and noted that he was referring to �hearing voices�. However, they� formed the view that he was generally coherent and there were no grounds to detain him under section 136 of the Mental Health Act. One of the officers� telephoned the Home, who advised that they had not reported Mr Crane� missing but that they intended to do so in about 30 minutes� time.� At about 17:30, the officers noted that Mr Crane was becoming more and more anxious to leave the police station and they allowed him to do so.� CCTV footage showed that having left Charing Cross police station at about 17:30, Mr Crane spent about 35 minutes in the general vicinity. His� whereabouts thereafter are not known.� At approximately midday on 18 January 2024, officers from MPS Marine� Policing Unit retrieved a body from the river Thames, near Free Trade Wharf. The body was identified as being that of Michael Crane, who was still wearing the wristband from his brief admission to the Hospital.� At the time of retrieving Mr Crane�s body, the Home had not reported him missing.� It is not possible to say how, where or when, Mr Crane entered the water.

I have sent a copy of my report to the Chief Coroner and the following: � [REDACTED � brother of the deceased ([REDACTED]) Prime Life Limited� Caernarvon House� 121 Knighton Church Road Leicester� Leicestershire� LE2 3JN� ([REDACTED])�������� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who 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.

Police related deaths | Mental Health related deaths | Care Home Health related deaths

Metropolitan Police | Prime Life Limited

09/10/2024

2024-0540

Chamali Bibi

Inner North London

1. [REDACTED] National Medical Director NHS England� Wellington House� 133-135 Waterloo Road� London SE1 8UG

On� 7� March 2023 I commenced�an� investigation�into�the�death�of Chamali Bibi, aged 39 years.�� The inquest was listed for 15 August 2023, but the investigation was not concluded until the end of the inquest on 25 September 2024. �� I made a narrative determination at inquest, which I now attach.

Ms Bibi underwent a right periacetabular osteotomy (PAO) on 01.03.23, during which she suffered haemorrhagic shock that led to a stroke that evening.

I have sent a copy of my report to the following. � [REDACTED], husband of Chamali Bibi [REDACTED], Chief Medical Officer for England 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.

Hospital Death (Clinical Procedures and medical management) related deaths

NHS England

31/10/2024

2024-0605

Wayne Bayley

Inner North London

1. [REDACTED] National Medical Director NHS England� Wellington House� 133-135 Waterloo Road� London SE1 8UG� 2. [REDACTED] Minister of State for Prisons Ministry of Justice� 102 Petty France� London SW1H 9AJ

On� 25� May� 2022,� one� of� my� assistant� coroners, [REDACTED], commenced an investigation into the death of Wayne Bayley, aged 43 years. The investigation concluded at the end of the inquest earlier today. The jury made a narrative determination at inquest, which I attach.� You will see that this includes a finding that death was contributed to by neglect.

Mr Bayley died in HMP Pentonville, some ten hours after a restraint. His medical cause of death was:� 1a acute chest syndrome� 1b hypoxia and chronic sickle cell lung disease 1c sickle cell disease and restraint.

I have sent a copy of my report to the following. [REDACTED] and [REDACTED], parents of Wayne Bayley [REDACTED], HM Prison Pentonville� [REDACTED], Practice Plus Group [REDACTED], Barnet Enfield & Haringey NHS Trust [REDACTED], 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.

State Custody related deaths

NHS England | Ministry of Justice

04/05/2023

2023-0194

Helen Coogan

Inner North London

1. [REDACTED] Ritchie Street Group Practice 34 Ritchie Street London N1 0DG

On 27 October 2022, I commenced an investigation into the death of Helen Coogan aged 77 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest as follows. � �Helen Coogan died in October 2022 from a natural cause, being cancer. She first sought advice from her general practitioner regarding related symptoms in July 2022, but there was no result from the qFIT (faecal immunochemical test) ordered.�

The medical cause of death was: 1a sudden cardiac death 1b metastatic neuroendocrine carcinoma of the ileocaecal valve and coronary artery atheroma� 2 chronic obstructive pulmonary disease, hypertension and atrial fibrillation

I have sent a copy of my report to the following. ���[REDACTED], children of Helen Coogan ���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.

Other related deaths This report is being sent to: Ritchie Street Group Practice

26/06/2023

2023-0213

Matthew Power

Surrey

1. [REDACTED] , Chief Executive Officer, EMIS Health

An inquest into the death of Matthew William Thomas Power was opened on 29 September 2022 and resumed and concluded on 14 June 2023. � The medical cause of death given was: � 1a. Mixed Drug Toxicity. And I determined that Matthew William Thomas POWER died on 17 June 2022 at 01:30 hours at a house in Redhill, Surrey having taken illicit and prescribed drugs over the previous 36 hours resulting in his death from mixed drug toxicity. � My conclusion was this was a drug related death

Mr Power was a 33 year old man living in supported accommodation. He had a history of mental health issues and had been diagnosed with Dissocial Personality Disorder. He also had a history of drug and alcohol abuse dating back to his teenage years. He had been known to take impulsive overdoses of drugs including prescription drugs ([REDACTED]). � On the afternoon of 15 June 2022, Mr Power visited friends in the Redhill area and with them bought and took drugs throughout the next 36 hours until his death in the early hours of 17 June 2023. Toxicology revealed a very high level of cocaine (potentially lethal in itself). It also showed heroin, methadone (which was not prescribed) and codeine at levels that that any of those drugs could have been lethal on its own, but that each opioid was likely to have increased the toxic effects of the other. The codeine was from ingestion of co-codamol. Apart from his mental health medication, Mr Power was prescribed co- codamol for pain relief. He had been prescribed this medication both by his current (since 2020) and previous GPs. It was latterly prescribed because of stockpiling concerns; he had frequently requested co-codamol. In evidence it was accepted that there had been errors in prescribing so that on 14 June 2022 Mr Power collected co-codamol tablets from a local chemist (but not his usual chemist) whilst still receiving his regular prescriptions of those drugs could have been lethal on its own, but that each opioid was likely to have increased the toxic effects of the other. The codeine was from ingestion of co-codamol. � Apart from his mental health medication, Mr Power was prescribed co-codamol for pain relief. He had been prescribed this medication both by his current (since 2020) and previous GPs. It was latterly prescribed [REDACTED] because of stockpiling concerns; he had frequently requested co-codamol. In evidence it was accepted that there had been errors in prescribing so that on 14 June 2022 Mr Power collected co-codamol tablets from a local chemist (but not his usual chemist) whilst still receiving his regular prescriptions�[REDACTED].

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Mr Powers family Greystone House Surgery Copy Also to: ICP Chair Surrey Heartlands Health and Care Partnership (Integrated Care System � 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, drugs medication related deaths This report is being sent to: EMIS Health

07/10/2024

2024-0530

Maeve Boothby O�Neill

Devon, Plymouth and Torbay

1. [REDACTED] / [REDACTED] Department of Health and Social care 2. NHS England 3. NICE 4. Medical Research Council 5. National Institute for Health care and Research 6. Medical Schools Council

On 26th October 2021 Senior Coroner Philip Spinney commenced an investigation into the death of Maeve Bernadette Boothby O� Neill who was 27 years of age at the time she died on 3rd October 2021. The investigation concluded at the end of a 2 week inquest I conducted on 9th August 2024. � I further heard evidence from the hospital trust on the need for a Regulation 28 report on 27th September 2024. The findings I made discussed the fact that despite Maeve having been tube fed on one occasion during admission this was not sufficient for her to recover. The inquest heard that provision of care for patients with severe ME such as that which Maeve suffered from was and is non-existent and that being placed on a ward that did not have expertise in her condition made her admission to hospital very difficult for her to endure. The conclusion of the inquest was Natural Causes and Box 3 recorded that she died at home after 3 admissions were unable to treat the consequences of her severe ME. Maeve Boothby O�Neill was suffering from severe ME during the period the inquest focused on, namely January � October 2021. This meant that she was bed bound and reliant primarily on her mother to provide personal care. She was admitted to hospital on 3 occasions during this period namely on 18th March, 19th May � 3rd June and finally on 25th June -17th August. Despite attempts to treat her these ultimately failed and she died on 3rd October 2021.

Maeve Boothby was 27 at the time of her death. She was diagnosed with ME at Frenchay hospital in 2011 and in 2019 it became so severe that she was bedbound for 21 hours per day. Concerns about her rapid physical deterioration escalated and during 2021 she had three admissions to the RDE on 18th March , 19th May � 3rd June and finally on 25th June � 17th August. These admissions were unsuccessful in preventing Maeve from suffering from malnutrition which was a consequence of her ME for which there is no known cure. Maeve sadly died at home on 3rd October 2021.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED], [REDACTED], Barnfield Surgery, Devon County Council, Royal Devon and Exeter NHS Trust. I have also sent it to the ME Association, [REDACTED], NHS Southwest England and Steve Moore, Chief Executive of the Integrated Health 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 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

Department of Health and Social Care | NHS England | National Institute for Health and Care Excellence | Medical Research Council | National Institute for Health care and Research | Medical Schools Council

04/06/2024

2024-0305

Mohammed Akramuzzaman

Inner North London

1. [REDACTED] Chief Constable British Transport Police BTP Headquarters 25 Camden Road London NW1 9LN

On 5 January 2024, one of my assistant coroners, Ian Potter, commenced an investigation into the death of Mohammed Akramuzzaman, aged 39 years. The investigation concluded at the end of the inquest on 3 June 2024. � I made a determination at inquest that Mr Akramuzzaman died from a combination of an alcohol related condition (not acute intoxication) and hypothermia. He was found beside Euston Station in cardiac arrest at approximately 7am on 8 December 2023. He had been out on the street all night. � His medical cause of death was: 1a) alcohol related ketoacidosis 2���hypothermia.

Concern had been raised by a member of the public the previous evening and British Transport Police did attend, but Mr Akramuzzaman refused medical treatment and BTP did not return. Medical care and a warmer environment at this point would have saved his life.

I have sent a copy of my report to the following. � [REDACTED], cousin of Mohammed Akramuzzaman 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 This report is being sent to: British Transport Police

25/10/2024

2024-0585

Chad Allford

Derby and Derbyshire

1. [REDACTED] Chief Constable Derbyshire Constabulary 2. College of Policing

On 01 December 2021 I commenced an investigation into the death of Chad George ALLFORD aged 23. The investigation concluded at the end of the inquest on 24 October 2024. The conclusion of the inquest was that: On 27th October 2021 Chad Allford died at King�s Mill Hospital. The cause of death is recorded as the effects of Cocaine. Police attended [REDACTED] in Alfreton following a planned operation involving the supply of class A drugs, in order to effect an arrest. After failed attempts to gain entry using keys and an enforcer, police officers gained access through an open door at the rear of the property.� Following confrontation with a police officer Chad placed a package of Cocaine into his mouth.� Police used various tactics in an attempt to retrieve the package and prevent injury or harm to Chad. A police officer called an ambulance, changing the incident from an arrest to a medical emergency as it was suspected that Chad had ingested a class A drug. Chad was assisted out of the property towards the drive where his health quickly declined. Chad started to convulse and was experiencing breathing difficulties. Chad was taken to King�s Mill Hospital, where he later died at 18:21.

See above

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mr Allford�s family Derbyshire Police Legal Services 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.

Police related deaths�| Alcohol, drug and medication related deaths

Derbyshire Constabulary | College of Policing

23/04/2024

2024-0215

Emmanuel Ladapo

Inner North London

1. [REDACTED] Chief Executive Camden & Islington NHS Foundation Trust (C&I) 4th Floor, East Wing St Pancras Hospital 4 St Pancras Way London NW1 0PE

On 13 March 2023 one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Emmanuel Ladapo aged 24 years. The investigation concluded at the end of the inquest yesterday. I made a determination at inquest of death by suicide. I recorded a medical cause of death of: 1a asphyxiation via plastic bag and inhalation of nitrogen gas.

Mr Ladapo had been diagnosed with paranoid schizophrenia and depression. He had undergone several hospital admissions, had been treated by the Camden & Islington (C&I) early intervention service and was at the time of his death being treated by one of the C&I rehabilitation & recovery teams.

I have sent a copy of my report to the following. � [REDACTED], sister of Emmanuel Ladapo Care Quality Commission for England 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.

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

13/11/2023

2023-0445

Igor Szalapski

Inner North London

1. [REDACTED] Chief Executive Depaul UK Sherborne House 4 Decima Street London SE1 4QQ

On 15 May 2023, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Igor Szalapski, aged 18 years. The investigation concluded at the end of the inquest on 1 November 2023. I apologise for the delay in the provision of this report. At inquest, I made a determination of death by suicide.

Igor hanged himself in his room at the Depaul London Youth Hub (a hostel for homeless young people) on Sunday, 30 April 2023.

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

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

14/07/2023

2023-0246

Phoenix Chapman

Inner North London

1. [REDACTED] Chief Executive Homerton Healthcare NHS Foundation Trust Homerton Row London E9 6SR

On 3 August 2022, I commenced an investigation into the death of Phoenix Chapman, a baby who died less than six weeks after he was born. The investigation concluded at the end of the inquest on 7 July 2023. I made a determination at inquest of death by natural causes. � I recorded the medical cause of death as: � 1a) hypoxic ischaemic encephalopathy and bronchopneumonia 1b) peripartum asphyxia 1c) cord compression 2��vaginal breech delivery and unplanned home delivery

Phoenix was born unexpectedly at home and died as a consequence of a cord compression during the second stage of labour. His mother was attended by paramedics, but really what she needed was early hospital obstetric care.

I have sent a copy of my report to the following. � ���[REDACTED], [REDACTED] parents of Phoenix Chapman ���[REDACTED] , chief executive, LAS� ���[REDACTED] , paramedic, LAS ���[REDACTED] , paramedic, LAS ���[REDACTED] , paramedic, LAS ���[REDACTED] , midwife, Homerton ���[REDACTED] , midwife, Homerton ���[REDACTED] , obstetrician, Homerton ���[REDACTED] , obstetrician, Homerton ���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: Homerton Healthcare NHS Foundation Trust

08/05/2024

2024-0257

Sean O�Connor

Inner North London

1. [REDACTED] Chief Executive Officer Canary Wharf Management Limited (CWML) One Canada Square Canary Wharf London E14 5AB

On 2 December 2021, one of my assistant coroners, Sarah Bourke, commenced an investigation into the death of Sean O�Connor aged 34 years. The investigation concluded at the end of the inquest on 1 May 2024. The jury made a determination at inquest of death by accident.

On 24 November 2021, shortly after 10am, Mr O�Connor was electrocuted as a result of contact with a heat pump flow switch terminal, during the course of work at Columbus House 7 Westferry Circus, London. He was a Mitsubishi employee changing the flow switch. � His medical cause of death was: 1a electrocution.

I have sent a copy of my report to the following. � [REDACTED], wife of Sean O�Connor [REDACTED], parents of Sean O�Connor Mitsubishi Electric The London Borough of Tower Hamlets 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.

Accident at Work and Health and Safety related deaths This report is being sent to: Canary Wharf Management Limited

25/07/2024

2024-0403

Elizabeth Holder

East London

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

On 1st March 2024 this Court commenced an investigation into the death of Elizabeth� Grace Holder, aged 88 years. The investigation concluded at the end of the inquest on 24th July 2024 when the Court returned a narrative conclusion:� �Elizabeth Grace Holder died in hospital on 24th February 2024 due to complications of a fall that occurred whilst recovering from surgery as an inpatient. At the time of the fall, Mrs Holder was not properly supervised.�� Mrs Holder�s medical cause of death was determined as; 1a Intraparenchymal haematoma� 1b Fall� II Neck of femur fracture (corrected), intraparenchymal haemorrhage

Elizabeth Grace Holder was an 88-year-old woman with co-morbidities, restricted mobility and a history of falls.� Elizabeth was admitted to hospital on 29th December 2023 by ambulance following a fall, she was admitted to the trauma unit and underwent a surgical repair of a broken hip.� Mrs Holder was noted to be at high risk of falls and had been assessed to require an� enhanced level of nursing care, initially requiring 1:1 nursing care.� Mrs Holder had a difficult recovery and developed a surgical wound infection. During her inpatient recovery period the patient lost physical reserve and was observed to be� increasingly confused, despite this nursing care was reduced to a 1:2 ratio.� On 15th February 2024 it was noted that Mrs Holder had declined further, she was� markedly confused and underwent diagnostic tests resulting in a queried diagnosis of a transient ischaemic accident.� On the evening of 19th February 2024 Elizabeth was observed to be confused and� anxious. Mrs Holder had asked to be taken to the lavatory, her request was refused, and she was told to use the commode by a male Health Care Assistant (�HCA�).�� The HCA did not believe that it was appropriate for him to observe Mrs Holder in the use of the commode and allowed her to proceed unsupervised behind a ward bay curtain.� The HCA did not consider alternative, safer strategies, neither asking the female nurse� allocated to Mrs Holder on the same shift to undertake supervision, nor offering to� supervise use of the commode in the presence of a chaperone.� The fall resulted in a fatal intra-cerebral bleed.

I have sent a copy of my report to the Chief Coroner and to the following Interested� Persons the family of Mrs Holder, 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 � � This report is being sent to: Barts Health Foundation Trust | Secretary of State for Dept. Health and Social Care

23/07/2024

2024-0397

Janet Rice

Durham and Darlington

1. [REDACTED] Chief Executive of County Durham and Darlington NHS Foundation Trust.

On the 22nd of March 2023 an investigation was commenced into the death of Janet Rice. The investigation concluded at the end of the inquest on the 23rd of July 2024 . I gave a narrative conclusion as follows :- Janet Rice, aged 65 years, died at Darlington Memorial Hospital on the 19th of March 2023 as a result of Pulmonary and Cerebral Embolism, subsequent to surgery to repair a hip fracture which she had sustained in an accidental fall on the 19th of February 2023, and in the absence of anti coagulant treatment. The medical cause of death was :- 1a) Pulmonary and Cerebral Embolism 1b) Right sided Neck of Femur Fracture

Janet Rice, 65 years, died in hospital on the 19.3.23 as a result of pulmonary and cerebral embolism, subsequent to surgery to repair a hip fracture which she had sustained in an accidental fall on the 19.2.24. In the aftermath of her surgery the deceased did not receive prophylactic anti coagulant medication consistently. On one occasion this was missed due to a transfer between hospitals. On five further occasions this was omitted as a result of the deceased declining such, at a time when she was suffering an acute delirium, and described variously as confused, paranoid and agitated. No assessment of her capacity to decline the medication was carried out, and therefore no best interests decision was made, nor any further consideration given as to how the known high risk of blood clots subsequent to the surgery could be best or alternatively managed. There was no escalation to an Advanced Nurse Practitioner or Doctor to consider these issues further. It is unlikely that the deceased had capacity to decline treatment but impossible to know what the result of any best interests decision would have been, and whether further or alternative actions would have prevented her death. It is accepted that the omission of anti coagulan contributed more than minimally to the development of the Pulmonary Embolism and thus to death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; the family of the deceased and the Tees, Esk and Wear Valley Foundation Trust (TEWV). 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: County Durham and Darlington NHS Foundation Trust

15/11/2023

2024-0069

Lynda Blackmore

South Wales Central

1. [REDACTED] Chief Executive of the Welsh Ambulance Service Trust 2. Chief Executive of Aneurin Bevan University Health Board 3. [REDACTED]- Minister for Health & Social Services

INVESTIGATION� and INQUEST On 13 February 2023, I commenced an Investigation Into the death of Lynda BLACKMORE. The Investigation concluded at the end of the Inquest on 18 November 2023. The conclusion of the inquest was: The deceased died due to overwhelming Infection, on a background of chronic and deteriorating significant natural disease. I determined the medical cause of her death to be: 1a Sepsis 1b Leg cellulltis due to chronic leg oedema 1c Congestive cardiac failure Type 2 diabetes mellitus, ischaemic heart disease I recorded the following in respect of How, When and Where she came about her death:� Linda Blackmore had established heart failure and diabetes mellitus. In early 2023 there was a further deterioration in her symptoms leading to a painful, bruised and swollen left leg. On 1st February 2023 she became acutely unwell and her GP attended upon her at her home. This led to an emergency call to the ambulance service for urgent conveyance to University Hospital Wales, Heath for specialist vascular treatment. There was a delay in the arrival of the ambulance of some thirteen hours likely due to a combination of mis� categorization of the response, resource availability and hospital handover delays. By the time of her arrival she was diagnosed with sepsis. Whilst treatment was initiated, she did not respond and died there later the same day. The delay in the instigation of necessary�� treatment likely contributed to her death.

CORONER�S CONCERNS During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: The Investigation focused upon the causal significance, If any, of a delay of some thirteen hours, or thereabouts in the provision of an ambulance to the deceased. I received written & oral evidence from [REDACTED] of the Welsh Ambulance Service I Trust (I annex a copy of his witness statement). I refer you in particular, to paragraph�s 43- 49. My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital. As stated in his evidence at para 45, the handover delays experienced at/around the time that the deceased was awaiting assistance were well in excess of the targets enshrined in the Welsh Health Circular of May 2016. such delays pose a risk to the lives of those requiring emergency treatment/conveyance to hospital.

15th November 2023 Graeme O Hughes Senior Coroner for South Wales Central Coroner Area

Emergency services related deaths (2019 onwards) | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Welsh Ambulance Service NHS Trust | Aneurin Bevan University Health Board | Department of Health and Social Care

18/01/2024

2024-0031

REDACTED

Inner North London

1. [REDACTED] Commissioner London Fire Brigade 169 Union Street London SE1 0LL

On 8 August 2023, I commenced an investigation into the death of [REDACTED]. The investigation concluded at the end of the inquest on 15 January 2024. � I made a determination at inquest of death by suicide. [REDACTED] jumped from the roof of his block of flats at 5.33pm on 26 July 2023. � [REDACTED]

Before he jumped off the roof, [REDACTED] called the Metropolitan Police Service (MPS), who in turn called the London Fire Brigade (LFB). When police officers tried to negotiate with him, [REDACTED] appeared receptive to the idea of coming down off the roof safely. Police officers were reluctant to suggest that he return the way he had come, as by now it was raining and they were concerned that he would slip, and so he waited on the roof for firefighters to escort him.

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

Suicide (from 2015) This report is being sent to: London Fire Brigade

11/08/2023

2023-0302

Doris Urch

Inner North London

1. [REDACTED] Managing Director Globe Court Care Home 50 Globe Road London E1 4DS

On 3 March 2023 the Senior Coroner, Mary Hassell, commenced an investigation into the death of Doris Urch aged 90 years. The investigation concluded at the end of the inquest on 27 July 2023. � The Inquest found that on 6th February 2023 Ms Urch fell, after her carer omitted to offer her support whilst ambulating. The risk of falls had been inadequately addressed in the Risk Assessment documentation and procedure. Although the Deceased appeared not to be seriously injured in the wake of the accident it was later confirmed on CT scan that she had suffered a brain injury, from which she later died � I returned a narrative conclusion in the following terms: � On 28th February 2023 Ms Urch died from an intracranial haemorrhage sustained in a fall on 6th February 2023, after her carer omitted to offer support whilst ambulating. � The medical cause of death was � 1a Acute left frontal intracranial haemorrhage 2 Alzheimer�s Dementia

Doris Irene Urch, aged 90, suffered from Alzheimer�s dementia, and age related macular degeneration, and was known to have a high risk of falls. � I was told by [REDACTED], from whom I heard evidence, that the most risky transition was from standing to sitting and that during this transfer the Deceased, due to her visual impairment, would often miss the seat and fall. It was �part of her� which I took to mean an inherent and constant risk.� [REDACTED], the care home manager, candidly accepted that �we all knew you had to watch Doris when she sits down�. � On 6th Mrs Urch was in the lounge of Globe House when she became distressed, lost her balance and fell. � It is clear that Ms Urch was not being supervised or assisted by the only carer present,� [REDACTED] , who was �sitting�with the other residents�. [REDACTED] acknowledged that this was a mistake. � She was taken to Hospital where a CT scan evinced a large acute left frontal intracranial haemorrhage with extensive longstanding cerebral atrophy. It was decided that surgical intervention was not in her best interests and the focus shifted to palliative care. � She passed away on 28th February 2023 at around 03:30 hours.

I have sent a copy of my report to the following. � ��������[REDACTED], aunt of Irene Urch ������� Care Quality Commission for England ������� 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.

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

07/12/2023

2023-0523

Sarah Chappell

Inner North London

1. [REDACTED] Medical Director Medicine Board University College London Hospitals NHS Trust (UCLH) University College Hospital 2nd Floor Central 250 Euston Road London NW1 2PG

On 4 July 2023 I commenced an investigation into the death of Sarah Chappell, aged 43 years. The investigation concluded at the end of the inquest earlier today. I made a determination as follows. � Sarah Chappell died from the recognised long term complications of necessary medical treatment. However, in addition to these, during her last admission to hospital her care was suboptimal because the appropriate team did not take charge. Placement of her nasogastric tube was not managed appropriately over her final weeks. If it had been, she would have survived this episode. � I recorded the medical cause of death as: 1a aspiration of gastric contents 1b adhesional small bowel obstruction 1c status post multiple complex surgeries flowing from an Arnold Chiari type II malformation with spina bifida & complicating hydrocephalus 2������� metastatic adenocarcinoma of the rectum

Sarah Chappell was transferred to University College London Hospital from the Princess Royal University Hospital in Orpington on 31 May 2023. She remained at UCLH until her death on 23 June 2023.

I have sent a copy of my report to the following. � [REDACTED], Sarah Chappell�s parents [REDACTED], surgeonectal surgeon and endocrine surgeon [REDACTED], UCLH neurogastroenterologist Princess Royal University 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.

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

20/10/2023

2023-0419

Trevor Bailey

Inner North London

1. [REDACTED] Medical Director Northwick Park Hospital Watford Road Harrow HA1 3UJ 2. The Senior Partner Church Lane Surgery 282 Church Lane Kingsbury London NW9 8LU

On 18 May 2023, one of my assistant coroners, Edwin Buckett, commenced an investigation into the death of Trevor Bailey aged 63 years. The investigation concluded at the end of the inquest on 18 October. I made a determination at inquest of death by natural causes. � Mr Bailey�s medical cause of death was: � 1a) extensive acute myocardial infarction of the left ventricular wall 1b) severe coronary artery stenosis (stented) 1c) atherosclerosis

Mr Bailey attended Northwick Park Hospital emergency department on 19 April 20223 with chest pain, two and a half weeks before his fatal myocardial infarction on 7 May 2023. He was investigated and discharged without referral to the rapid access chest pain clinic because his test results proved negative and he seemed stable.

I have sent a copy of my report to the following. � ������ [REDACTED], wife of Trevor Bailey �������Care Quality Commission for England �������Professor Chris Whitty, Chief Medical Officer for England ������ [REDACTED] consultant cardiologist, Royal Free Hospital ������ [REDACTED] , GP, Church Lane Surgery �������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.

Other related deaths This report is being sent to: Northwick Park Hospital | Church Lane Surgery

20/10/2023

2023-0521

Michael Hindes

Inner North London

1. [REDACTED] Medical Director South West London & St George�s Mental Health NHS Trust Trinity Building Springfield University Hospital 15 Springfield Drive London SW17 0YF

On 17 May 2023, one of my assistant coroners, Edwin Buckett, commenced an investigation into the death of Michael Hindes, aged 26 years. The investigation concluded at the end of the inquest on 17 October 2023. I made a narrative determination, which I attach.

Michael Hindes killed himself [REDACTED]. One week before he died, he called 999 because he felt suicidal. This was late in the evening on Monday, 8 May. Police attended and took him to St George�s Hospital, where he underwent a half hour mental health assessment, after which he was discharged in the early hours.

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

Suicide (from 2015) This report is being sent to: South West London and St George�s Mental Health NHS Trust

19/01/2024

2024-0083

David Mitchener

Surrey

1. [REDACTED] NaturPlus UK 2. Food Standards Agency 3. Department of Health & Social Care

On 6th June 2023 Area Coroner Simon Wickens commenced an investigation into the death of David Charles Mitchener [age 89]. The investigation concluded at the end of the inquest on 28th December 2023. The conclusion of the inquest was of death by misadventure.

on 10th May 2023 David Mitchener was admitted to East Surrey Hospital with Hypercalacaemia, but despite treatment he died at the hospital on 20th May 2023. Ante-mortem test revealed Vitamin D levels at 380 (the maximum level recordable by the laboratory). A post mortem identified the cause of death to be: 1 a) Congestive cardiac failure and acute on chronic kidney failure b) Hypercalacaemia c) Vitamin D toxicity 2. Ischaemic Heart Disease David Mitchener had been taking vitamin supplements for at least the preceding 9 months, purchased from NaturePlusUK. [REDACTED] there were no warning on or in the packaging detailing the specific risks or side effects of taking Vitamin D supplements.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely [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: NaturPlus UK | Food Standards Agency | Department of Health and Social Care

29/01/2025

2025-0049

Naomi Suleyman

London Inner (South)

1. [REDACTED], CEO Lewisham and Greenwich NHS Trust, University� Hospital Lewisham, Lewisham High Street, Lewisham, London SE13 6LH 2. [REDACTED], Chief Executive, London Borough of Lewisham, Laurence House, 1 Catford Road, London, SE6 4RU

On 14 February 2023 I commenced an investigation into the death of Naomi� SULEYMAN. Ms Suleyman died on 9 February 2023 at University Hospital Lewisham,� London (UHL) part of Lewisham and Greenwich Trust (LGT) where she had been� admitted from her home on 3 January 2023 with complications of an unstageable� pressure ulcer. The investigation concluded on 17 January 2025. I recorded a narrative conclusion:�� Naomi Suleyman died from pneumonia and complications of an unstageable sacral� pressure sore which she developed having deconditioned and become bedbound� following discharge from hospital whilst undergoing assessment of her long-term needs.

Ms Suleyman was admitted to UHL on 06.11.22 with pneumonia. She was noted to have a grade 2 sacral pressure ulcer on admission and subsequently developed a sacral�deep tissue injury (DTI) requiring the input of the tissue viability nurses (TVN). The DTI� appeared to resolve, resulting in her discharge from the TVN caseload, albeit the grade�2 sacral pressure ulcer remained. She was discharged home on 05.12.22 with a�package of care arranged through LGT�s and London Borough of Lewisham�s (LBL)� integrated multi-disciplinary discharge to assess (D2A) service for assessment of her� long-term needs and with a referral to LGT�s District Nursing Service. By 07.12.22 she� had developed a new DTI. The DTI progressed to an unstageable pressure sore and�she was re-admitted to UHL on 03.01.23 with sepsis from pneumonia and from the�sacral pressure sore which had become infected and had progressed to osteomyelitis.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons�� (1) Mrs Suleyman�s family (2) Lewisham and Greenwich NHS Trust and to London Borough of Lambeth (who were not Interested Persons)�� 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

Lewisham and Greenwich NHS Trust | London Borough of Lewisham

25/10/2023

2023-0410

Federica Cavenati

Inner West London

1. Medicines and Healthcare products Regulatory Agency (MHRA)

On 2 November 2021 an investigation commenced into the death of Federica Cavenati, aged 28 years. The investigation concluded at the end of the inquest on 9 October 2023. The conclusion of the inquest was that Federica Cavenati did the act of jumping , London with the intention of taking her own life, which was more than minimally contributed to by service delivery issues, including that she had not taken consistent antidepressant medication for some time since her admission due to her physical condition, arising from an act of self-harm; drinking oven cleaner. The medical cause of death was 1a multiple traumatic injuries and 1b fall from height.

On 12� September� 2021 Federica Cavenati�[REDACTED] cause herself harm. She was admitted to the Chelsea and Westminster Hospital where she was treated for her physical and mental health on a medical ward. She had previously been prescribed anti-depressant medication, however due to her physical health and the unavailability of anti-depressant medication intravenously, she did not receive this medication until she was physically able to, which was shortly before her death. Her 1:1 mental health nursing observation was removed on 17 September 2021. Her last review by the Psychiatry Liaison Team was on 17 October 2021 with no further review taking place. On 15 October 2021 she refused her blood line. On 16 October 2021 she refused her medication (including Ensure supplement) and again on 17 October 2021. On 18 October 2021 she was found . She sustained multiple traumatic injuries resulting her in death on 18 October 2021. The following factors contributed more than minimally to her death: She had not had a recent mental health review.There were no mental health observations.She had not taken consistent anti-depressant medication for some time.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Federica Cavenati�s family, the Chelsea and Westminster Hospital and the Central and North-West London NHS Foundation Trust who operated the Psychiatry Liaison Team. I have also sent it to the National Institute for Health and Care Excellence (NICE) who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: Medicines and Healthcare products Regulatory Agency

05/07/2023

2023-0234

[REDACTED]

Inner North London

1. Metropolitan Police Service (MPS) 6th Floor,New Scotland Yard Victoria Embankment London SW1A 2JL

On 25 March 2021, I commenced an investigation into the death of [REDACTED], aged 44 years. The investigation concluded at the end of the inquest earlier today. I made a determination at inquest that death was drug related. I recorded the medical cause of death as: 1a complications arising from cocaine intoxication.

On the afternoon of 18 March 2021, [REDACTED] took cocaine and went to a friend�s home. He demonstrated features of acute behavioural disturbance (ABD) and police were called. They recognised this as a medical emergency and sought an ambulance, but [REDACTED] arrested before the ambulance arrived. With police assistance paramedics achieved a return of spontaneous circulation, but [REDACTED] died in hospital the following day.

I have sent a copy of my report to the following. ��[REDACTED] wife of [REDACTED] � [REDACTED] � [REDACTED] � [REDACTED] � [REDACTED] ��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.

Alcohol, drugs medication related deaths This report is being sent to: Metropolitan Police Service

22/04/2024

2024-0211

Angela Carpos

Inner North London

1. MiHomecare Cardinal House, Abbeyfield Road, Nottingham, NG7 2SZ

On 20 January 2023 an investigation was commenced into the death of Angela Marietta Carpos aged 94 years. The investigation concluded at the end of the inquest on 21 December 2023. I made a determination at inquest that Angela died of aspiration pneumonia, the cause of which could not be established.

During the evening of 25 December 2022, whilst being attended by carers, Angela collapsed eating dinner. On being alerted to a concern about Angela�s breathing, her daughter immediately recognised the seriousness of her condition and called an ambulance. Angela went into cardiac arrest but was successfully resuscitated by paramedics. On arrival at hospital her prognosis was poor as she had suffered hypoxia due to respiratory arrest, secondary to aspiration. She died at the Royal Free Hospital later that evening.

I have sent a copy of my report to the following. � Family of Angela Carpos 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.

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

08/06/2023

2023-0184

David Wilson

West Yorkshire (Eastern)

1. Mid Yorkshire Hospitals NHS Trust

On 18 January 2023 I commenced an investigation into the death of David Barnet WILSON, aged 67. The investigation concluded at the end of the Inquest on Tuesday 6 June 2023. The conclusion of the Inquest was a Narrative based upon the following medical cause of death; 1a Sepsis 1b Bowel Perforation (Sigmoidoscopy Procedure Undertaken on 30.12.22) 1c lschaemic Colitis, II End Stage Renal Failure, Abdominal Aortic Aneurysm (operated), lschaemic Heart Disease.

Mr D B Wilson was admitted to hospital on 27 December 2022. A CT scan indicated an inflammation in the distal section of his colon. The established diagnostic procedure to identify the cause of the suspected colitis was a flexible sigmoidoscopy. A recognised complication of this procedure was a colonic perforation.� This happened in this case and resulted in his death the following day, 31 December 2022, at Pinderfields Hospital, Wakefield.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (wife).� I have also sent it to [REDACTED], Ferrybridge Medical Centre, Ferrybridge, WF11 8NQ, 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: Mid Yorkshire Hospitals NHS Trust

19/06/2024

2024-0299

Selina Samarina

Essex

1. Mid and South Essex NHS Partnership

On 11th April 2023, I commenced an investigation into the death of Selina Samarina, aged 2. The investigation concluded at the end of the inquest on 28th May 2024. The conclusion of the inquest was that the deceased died of natural causes, the medical cause of death being that she had died from sepsis and pneumonia, with contributory factors of Down�s Syndrome and Upper Respiratory Tract infection. She died in Broomfield Hospital

Selina had been brought into hospital by her parents with symptoms of fever, a rash and irritability. She was made an urgent referral and the sepsis protocol/ procedure was triggered. That should ordinarily lead to an examination by a senior doctor within an hour. In this case, a very junior doctor was sent over, in part because there was huge demand on the ward services and the available doctors of seniority were otherwise engaged with other patients. Selina�s diagnosis was arrived at by a relatively junior doctor, and other possible diagnoses such as sepsis or pneumonia were not addressed. It was not until two and a half hours later that a doctor of appropriate seniority was available to assess Selina, by which time, as was consistent with the directions from the junior doctor, Selina had gone home with her parents. Evidence was given by the consultant that on that particular day, a Bank Holiday (Good Friday), there would normally be 12 doctors across the Emergency Department and Paediatrics Department, but on that day, there were only 7. This increased workload and the demand for services (which was at a normal level) had played a part in the consultant not being available to review Selina�s condition within the timescale mandated by the sepsis protocol,

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons parents: ([REDACTED]); nurse in charge [REDACTED]. Since the deceased was under 18, it may also be necessary to inform the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. I have also sent it to Health Service England who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) This report is being sent to: South Essex NHS Partnership

01/08/2024

2024-0423

Matthew Braben

West London

1. Ministry of Justice� 2. His Majesty�s Prison and Probation Service

An investigation was commenced into the death of Matthew Paul Braben, aged 30. The investigation concluded on 26 April 2024.� The conclusion of the jury in the inquest was: Suicide.� Matthew�s death was probably the result of systemic failures across multiple� agencies including the Prison services.� A contributing factor to these failures may have� been Covid. There was inadequate communication between agencies and a lack of� information sharing. This probably led to a failure to identify his deteriorating mental�health and increasing suicide risk. This is evidenced by repeated failures to open ACCTs post February. Despite concerns raised by a highly engaged, caring and supportive family, it is probable insufficient weight was given to their attempts to raise the alarm.� The medical cause of death was: 1a Aspyhxia� 1b Suffocation [REDACTION]

Matthew died on 16th August 2021 at HMP Wormwood Scrubs, Du Cane Road,� Hammersmith. Matthew was remanded in custody in January 2021. It was his first time in prison. He was on an ACCT in early February 2021 but not thereafter. He was referred to� be seen by a counselling service. His first-born child was born on 27th July 2021.� The�birth of a child is not listed a risk factor in PSI 64/2011. He was awaiting sentencing. He� was seen by a nurse in prison on 31st July 2021 with cut wrists. His family repeatedly� raised concerns about his mental health. He was first assessed by the counselling� service on 2nd August 2021, declined counselling on 11th August 2021 and was� consequently discharged from that service.� No action was taken by the prison when� repeated concerns were raised by his family on Saturday 14th August 2021. He was last�seen alive on Sunday 15th August 2021.� He was found in his cell on 16th August 2021� after he had tied [REDACTED]�around his neck and tied his wrists and ankles to the bed.�� He died due to asphyxia.� At the time that he did the act that caused his death, he�probably did so with the intention of ending his life. On the balance of probabilities, there� were numerous failings by the prison service that cumulatively contributed to Matthew�s� death, including: a failure to record and keep complete records on NOMIS or otherwise; a� failure to communicate between colleagues and shifts; and a failure to follow up closure�of his ACCT and resignation of wing cleaner role.� It was unacceptable that multiple� opportunities, that would constitute opening an ACCT, were missed (April, July, August� 2021).� The prison failed to act on repeated serious concerns raised by Matthew�s family�on Saturday 14th August through the Safer Custody Helpline.� It is possible that multiple� opportunities were missed to identify concerns with Matthew�s mental health due to the� Key Worker System not being fully implemented throughout HMP Wormwood Scrubs.� Covid may have been a significant contributor to some of these failings due to increased� work pressures and regime changes. On the balance of probabilities, the implementation� of the policy in relation to the opening of ACCTs was inadequate. It was noted by a� Supervising Officer that there was an implied pressure not to open an ACCT due to� associated workload pressures. Post closure period processes for ACCTs were not� adhered to after Matthew arrived in E wing. If these were effectively followed, then risks� could have been more readily identified. This failure probably contributed to Matthew�s� death.� Post Matthew�s arrival to E wing, there were numerous red flags over an extended period across all services (e.g. prison Services, PPG, secondary mental healthcare,� Forward Trust and Atrium) that should have resulted in an ACCT being opened � failure�to do so probably contributed to Matthew�s death. On the balance of probabilities,� Matthew�s risk of suicide was not adequately identified. Post move to E wing and closure�of the ACCT, there were numerous failures to identify suicide risks. Not enough weight� was given to known risk factors such as the birth of Matthew�s daughter, approaching� court dates, first time in prison and feelings of guilt, shame and paranoia. These were not given due credence in comparison to Matthew�s assurances that he was not suicidal.� As� Matthew�s mental health deteriorated towards the end of July, a series of escalating risk� indicators arose. Family concerns were raised to Safer Custody and escalated to the� Supervising Officer and secondary mental health services. No action was taken by the� prison when repeated concerns were raised by his family on Saturday 14th August.�� These inadequacies in the identification of suicide risk cumulatively probably contributed� to Matthew�s death. The Court heard evidence that prisoners were locked in their cells�for up to 23 hours a day, with a negative effect on their mental health. The Court heard� evidence that one of the ways that prisoners could leave their cells is to attend gym, but� that there is a shortage of gym instructors due to the manner of training of gym instructors which entails potential trainees having to attend training at a distant location for significant period of times rather than locally as well as the length of the course, both of which serve� as significant disincentives for staff to be trained as gym instructors.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� � 1. [REDACTED] 2. [REDACTED] 3. [REDACTED] 4. [REDACTED] 5. [REDACTED] 6. Ministry of Justice 7. His Majesty�s Prison and Probation Service� 8. Practice Plus Group� 9. Barnet, Enfield and Haringey Mental Health NHS Trust Forward Trust� 10. Forward Trust� 11. Atrium � 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) | State Custody related deaths� � This report is being sent to: Ministry of Justice | His Majesty�s Prison and Probation Service

31/01/2024

2024-0049

Michael Pender, Jan Klempar and Paul Mullen

Cornwall and the Isles of Scilly

1. Mr A Chisholm, Permanent Secretary (Cabinet Office)

On 31/1/24, I concluded the inquests into the deaths of: Michael Pender, who drowned at Treyarnon beach on 25/5/20;Jan Klempar, who drowned at Porthcurno beach on 25/6/20;Paul Mullen, who drowned at Church Cove on the Lizard on 20/8/20. � The three inquests were heard together as they arose out of a common occurrence namely that, following the relaxation of the national lockdown after the COVID-19 pandemic, they all happened on beaches that would ordinarily have been lifeguarded but were not at the material times. A copy of my judgment is attached.

Mr Pender drowned at Treyarnon beach on 25 May 2020. He lived locally. At the time, the country had just come out of lockdown after the emergence of the COVID-19 pandemic. Lifeguards would ordinarily have been present on the beach but, on that date, were not. Additional signage had been put up and there had been an extensive media campaign to alert the public to the position. Mr Pender was seen to get into difficulty. He was found floating in the water and taken to Padstow lifeboat station where he was confirmed deceased. Mr Klempar drowned at Porthcurno beach on 25 June 2020. [REDACTED], having travelled down from the Midlands for the day with his family. At the time, the country was still coming out of lockdown after the emergence of the COVID-19 pandemic. Lifeguards would ordinarily have been present on the beach but, at the time of the incident, were not. Additional signage had been put up and there had been an extensive media campaign to alert the public to the position. Mr Klempar was seen to get into difficulty. He was found floating in the water and recovered to the beach. Efforts to resuscitate him were unsuccessful. Mr Mullen drowned at Church Cove on the Lizard on 20 August 2020. He was on holiday with his family. At the time, the country was still coming out of lockdown after the emergence of the COVID-19 pandemic. Lifeguards would ordinarily have been present on the beach but, at the time of the incident, were not. Additional signage had been put up and there had been an extensive media campaign to alert the public to the position. The sea was unusually rough due to an approaching storm. Mr Mullen went into the sea after his son got into difficulties. He was found floating in the water and recovered to the beach. Efforts to resuscitate him were unsuccessful.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � The family of Mr Pender; The family of Mr Klempar; The family of Mr Mullen; The RNLI; The MCA; Cornwall Council; The National 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: Cabinet Office

23/11/2023

2023-0468

John Seagrove, Pauline Humphris and Patricia Steggles

Cornwall and the Isles of Scilly

1. Ms V Atkins, MP, Secretary of State for Health and Social Care

Over the past week, I have concluded the following three inquests. John Charles Seagrove Mr Seagrove was an 88-year-old man who died in Royal Cornwall Hospital on 9/7/22. His medical cause of death was found to have been: � 1a) Aspiration pneumonia; 1b) Ischaemic stroke. � On 22 June 2022, he developed symptoms consistent with a stroke. An ambulance was called at 23:21 with the call being classed as a Category 2 disposal meaning an ambulance should attend within an average of 18 minutes and 90% of similar disposals should be actioned within 40 minutes. � Owing to operational pressures, an ambulance arrived at 07:20 the next morning. Mr Seagrove arrived at Royal Cornwall Hospital at 08:09 and was handed over to staff at 10:15 where the handover should be completed within 15 minutes. � Mr Seagrove was found to have suffered an ischaemic stroke. He arrived outside a 4.5 hour window for thrombolysis and according to evidence at the inquest given from [REDACTED], stroke consultant, lost the opportunity to benefit from the reduction in the severity of the stroke such treatment can provide. He deteriorated over the next few weeks and died in the hospital on 9/7/22. I recorded a Conclusion of Natural Causes. Pauline Mary Humphris Mrs Humphris was an 88-year-old lady who lived alone in an isolated location. She had become increasingly frail and immobile to the point she was essentially housebound. In the last months of 2022, she developed a wound to her leg that became infected. This was treated with antibiotics. � Over the New Year, Mrs Humphris deteriorated. An ambulance was called at 18:37 on 1 January 2023 but did not arrive with Mrs Humphris until 07:28 the following morning. There was then a further delay admitting Mrs Humphris into hospital. She continued to deteriorate and died in Royal Cornwall Hospital on 2/1/23. � The medical cause of death was determined to be: 1a) Hypertensive heart disease; II) Cellulitis. � [REDACTED], acute physician, stated: �I was asked to comment on whether the ambulance delay had played a role in her death. She was very unwell by the time she reached hospital with sepsis, pneumonia and cellulitis and the hypoglycaemia was a very bad prognostic sign. The earlier that sepsis is treated with antibiotics the better the outcome and the higher the chance that she would have survived. I cannot say she would have definitely survived if she would have had her treatment earlier but the delay in giving antibiotics in sepsis is a major factor in a poor outcome. The chance of survival would have improved significantly with earlier antibiotics.� � [REDACTED], her friend and executor, said: �Personally, I believe that Paula was entirely let down by a system obviously at breaking point. Whilst one can obviously sympathise with the pressures that doctors, nurses, ambulance staff and 999 operators are under it is simply inconceivable to me that the system has deteriorated to such an extent that an ambulance can take 16 hours to arrive after the first call to the emergency services made by me at 6:30 PM on the previous day.� � I concluded her death was due to Natural Causes. I further found that a delay in the arrival of an ambulance due, in part, to delays admitting patients into hospital, may have contributed to the outcome. � Patricia Joan Steggles � On 30/12/21, Mrs Steggles started to complain of pain in her abdomen and vomiting. An ambulance was called. A paramedic attended who examined her and ruled out a cardiac cause. He felt a stomach bug was likely. In the early hours of 31/12/21, Mrs Steggles called the out of hours service with worsening pain. A doctor attended who felt she had an acute abdomen. He called an ambulance at 02:41. Mrs Steggles did not arrive at the Emergency Dept until 11:52. � She was triaged and seen by a junior doctor in the back of an ambulance. A CT scan was ordered at 15:12 and at 16:20 it was recorded in the notes that Mrs Steggles had a sub-hepatic collection likely due to a perforated gallbladder. She was prescribed IV antibiotics and referred to the surgeons. She was reviewed four hours later when a decision was made to treat her by way of interventional radiology. An on-call service was not available out of hours and so it was felt Mrs Steggles could be treated the following day. She deteriorated and died on the morning of 1/1/22 in Royal Cornwall Hospital. � The inquest heard from [REDACTED], an Emergency Medicine consultant. He said that with the department as crowded as it was, it was not possible to deliver an optimum service. � I asked him whether the situation had improved since this incident. He said there had been an improvement over the summer but over the last 2- 3 weeks there had been times when there were 15-20 ambulances waiting outside the emergency department again. He said that when he chose a career in Emergency Medicine, he never envisaged looking after patients in the back of ambulances. � The inquest also heard from [REDACTED]. He is a consultant upper GI surgeon and the speciality lead for surgery within Royal Cornwall Hospital. [REDACTED] agreed with� [REDACTED], an expert instructed to assist the inquest, that if Mrs Steggles had been brought to hospital earlier, then it was more likely than not she would have survived. � I recorded a Conclusion of a death from natural causes.

The relevant circumstances are set out above. All three deaths feature delays first in emergency ambulance response times and secondly, handing over the patient from the ambulance crew to hospital staff. � I want to be clear that these three deaths are not isolated cases. They are just an illustration of the sorts of cases this area has dealt with regularly over the last two years or so. � I understand my colleague, Assistant Coroner Davies, also feels his duties under PFD Regulations are engaged and he will be writing to you in similar terms in relation to inquests he has conducted.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of John Seagrove; The family of Pauline Humphris; The family of Patricia Steggles; Royal Cornwall Hospital Trust ([REDACTED], Medical Director); South West Ambulance Service Trust ([REDACTED], Medical Director); [REDACTED]� Chief Executive, Integrated Care Board; [REDACTED]� Chief Executive, Cornwall Council � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department of Health and Social Care

11/11/2024

2024-0616

Vera Spencer

Derby and Derbyshire

1. NHS Derby & Derbyshire Integrated Care Board

On 14 December 2023 I commenced an investigation into the death of Vera SPENCER aged 94. The investigation concluded at the end of the inquest on 25 October 2024. The Medical Cause of Death was: 1 (a) Pneumonia (b) Fall 2 Chronic Kidney Disease, Heart Failure The conclusion of the inquest was: Accident

On 6th December 2023 Vera Spencer had a fall at her home address. She was able to use her lifeline alarm which notified her next of kin who attended and called the ambulance service. The ambulance service were first contacted at 22.11pm and an ambulance arrived at 09.01am on the 7th December. By that time Mrs Spencer had been on the floor for 11 hours. Mrs Spencer was taken to hospital where x-rays showed that she had sustained a fractured hip and had showed infective changes in her lung consistent with a chest infection. She was commenced on antibiotics for her chest infection and underwent a surgical repair of her hip on 8th December 2023. Post-operatively Mrs Spencer was stable but late in the evening of the 9th December 2023 her condition deteriorated. By 11th December Mrs Spencer developed breathing difficulties; despite treatment her condition continued to deteriorate and she sadly died on 11th December 2023 at Royal Derby Hospital. The court heard evidence that the ambulance service was under severe pressure on the day of Mrs Spencer�s fall which was due to a combination of high call volumes and long handover delays at local hospitals. It was not possible to determine on the evidence available whether the long lie whilst awaiting an ambulance contributed to the development of pneumonia or whether earlier ambulance attendance and earlier treatment may have prevented Mrs Spencer�s death.

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

Emergency services related deaths (2019 onwards)

NHS Derby & Derbyshire Integrated Care Board

02/10/2024

2024-0528

Alix Knowles

Staffordshire

1. NHS ENGLAND 2. DERBY AND BURTON HOSPITAL 3. ROYAL STOKE UNIVERSITY HOSPITAL

On the 10 January 2024 2017, I commenced an investigation into the death of Miss Alix Elizabeth Knowles.� The investigation concluded at the end of the inquest on 2 October 2024. The conclusion of the inquest was a short form conclusion of:� Suicide The cause of death was: 1a Multiple Traumatic Injuries 1b Fall

i). Miss Knowles was 30 years of age, with in life diagnosis of Emotionally Unstable Personality Disorder and Bi-Polar effective disorder. ii). She had previously expressed suicidal thought and attempted to take her own life. iii). On the 8 December 2023 she attended the Queens Hospital, Burton Upon Trent, Accident and Emergency department via ambulance.�Information given to the department by paramedics was that she had attempted to cut her throat and was threatening to commit suicide. iv). On the 8 December 2023 she was seen by the Mental Health Liaison team, to consider� detention under the Mental Health Act.�The mental health liaison team were not aware of the reasons for her attendance to A&E, because� bank� staff� are� not� allowed� access� to� the� electronic� computer system.� The mental health liaison team made the decision that she would not be detained under the mental health act, and she was discharged home. v). It was heard in evidence that Hospital Trusts cannot access other hospital trusts patient notes, because of the use of different computer systems. vi). In the early hours of the 9 December 2023, Alix Elizabeth Knowles made her way to the bridge above the�[REDACTED], where she jumped onto the road below and was hit by two motor vehicles.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Family. 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 | Mental Health related deaths | Suicide (from 2015)

NHS England | Derby and Burton Hospital | Royal Stoke University Hospital

02/12/2024

2024-0657

Keith Foord

East Sussex

1. NHS England

On 09 May 2022 I commenced an investigation into the death of Keith David FOORD aged 76. The investigation concluded at the end of the inquest on 08 November 2024. The conclusion of the inquest was that: Dr K D Foord sustained a Type A Aortic dissection on 2.5.22. His symptoms caused him to request an ambulance to go to the A and E Department at Conquest Hospital, Hastings arriving at 9.30am that day. An accurate diagnosis was made at 12 midday and arrangements were made with Royal Sussex County Hospital, Brighton to transfer his care to their cardiac surgery unit. A Category 2 ambulance was called for which took 1hr 19 minutes to arrive, 1 hr later than the 18 minute response time required by a Category 2 case. Dr Foord was taken to theatre and underwent a lengthy operation, but the right coronary artery had completely detached from the aorta by the time surgery began which disaffected significantly his chances of survival. Dr Foord died at 7.30am on 3.5.22, the cause of death being:- 1a) Acute type A Aortic Dissection (Emergency Aortic Repair 2/5/22).

Dr Foord died as a result of an Acute type A Aortic Dissection in spite of undergoing emergency repair on 2nd May 2022. He had presented to A and E at The Conquest Hospital where the correct diagnosis was made in a timely manner. He required an ambulance to take him to Royal Sussex County Hospital, Brighton where the regional cardiac surgery is undertaken. His case was categorised as 2 for response time for the ambulance service when all of the clinical, paramedic and expert witnesses whose evidence I heard at the inquest advised that it should be correctly categorised as 1 given the critical requirement for emergency surgery.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- Dr Foord�s family East Sussex Healthcare NHS Trust South East Coast Ambulance Service I have also sent it to Royal Sussex County Hospital Cardiac Surgery Directorate who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards)

NHS England

03/09/2024

2024-0662

Samsam Ateye

West London

1. NHS England

An investigation was commenced into the death of Samsam Haji Ali Ateye, aged 68. The investigation concluded on 30 August 2024. The conclusion in the inquest was:� Complications following surgical procedure. The medical cause of death was 1a Multiorgan failure� 1b Following bio prosthetic aortic valve replacement surgery� 1c Aortic stenosis with ventricular hypertrophy and fibrosis� II Disseminated intravascular coagulopathy and thrombocytopenia with microvascular thrombotic involvement of hands and feet (managed conservatively), adult respiratory distress syndrome and acute bronchopneumonia

Samsam died on 12 May 2023 at Harefield Hospital, Uxbridge. She had been diagnosed� with severe aortic stenosis which was symptomatic. A Multi-Disciplinary Team (MDT)� meeting decided that she would benefit from aortic valve replacement surgery. She had�an out-patient pre-operative Covid-19 Polymerase Chain Reaction (PCR) test performed� on 18 April 2023, which was negative.� She was admitted to hospital on the day of her� surgery on 20 April 2023.� On admission, she had another Covid-19 PCR test performed�on her that morning, before her surgery.� She had aortic valve replacement surgery that� afternoon. Post-operatively, the surgeons who operated on her became aware, that� evening, that the Covid-19 PCR test performed on her on the morning of surgery was� positive.� A subsequent three further Covid-19 tests performed in hospital after 20 April� 2023 were also positive.� Post-operatively, she developed episodes of atrial fibrillation, as� well as sepsis which was probably bacterial and was of unknown origin. She died due to� sepsis which caused Multi-Organ Failure. The inquest heard evidence that the consultant surgeon was very worried upon learning that Samsam was Covid positive as patients who are Covid positive who undergo cardiac surgery have a real risk of excessive� complications and mortality. The inquest heard that policy about pre-operative testing for� Covid for cardiothoracic surgery and the form of that testing was formulated at a national�level by NHS England.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� 1. [REDACTED] 2. [REDACTED] 3. [REDACTED] 4. [REDACTED] 5. [REDACTED] 6. [REDACTED] 7. [REDACTED] 8. [REDACTED] 9. [REDACTED] 10. [REDACTED] 11. [REDACTED] 12. [REDACTED] 13. [REDACTED] 14. [REDACTED] 15. [REDACTED] 16. [REDACTED] 17. [REDACTED] 18. [REDACTED] 19. [REDACTED] 20. [REDACTED] 21. [REDACTED] 22. [REDACTED] 23. Guys and St Thomas� 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 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

NHS England

13/12/2024

2024-0707

James Alderman

West London

1. NHS England 2. Department of Health and Social Care 3. BSI Group 4. Office for Product Safety and Standards

On 26 October 2023 I commenced an investigation into the death of James Robert Michael ALDERMAN. The investigation concluded at the end of the inquest on 21 November 2024.� The conclusion of the inquest was: Baby Jimmy was being breastfed within a baby carrier worn by his mother. After 5 minutes� she found that he was collapsed and although immediate resuscitation was commenced he died 3 days later on 11 October 2023 in St George�s Hospital. Jimmy died because his� airway was occluded as he was not held in a safe position while within the sling. There is� insufficient information available from any source to inform parents of safe positioning of� young babies within carriers and in particular in relation to breastfeeding.� Accidental death 1a Hypoxic Brain Injury 1b Out of Hospital Cardiac Arrest 1c Accidental Suffocation II

The inquest heard that Jimmy was 6 weeks and 6 days old at the time he died, and apart� from a light cold was physically well. He was being breast fed hands free within a baby� carrier/sling, being worn by his mother while she moved around the home. It was accepted� that the sling was being worn snugly, not tightly, and although she could see his face when� she looked down, the TICKS acronym was not met by his position within the sling as Jimmy was too far down. �� The TICKS acronym was prepared by the (now disbanded) UK consortium of sling retailers and manufacturers Tight� In view at all times� Close enough to kiss� Keep chin off the chest Supported back �� There appeared to be no advice in the literature regarding the risk of baby slumping and the� risk therefore of suffocation, particularly if baby is under the age of 4 months, and no advice� that breastfeeding �hands free� a young baby is unsafe, due to the risk of suffocation and not being able to meet every aspect of TICKS.� There appeared to be no helpful visual images of �safe� versus �unsafe� sling/carrier postures.� Evidence was given by the witnesses assisting the inqeust that public information, readily available, not too complex but consistent in message would be welcomed to advise and� instruct.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � family of Jimmy � Boba Inc (Beco) � Madelaine Boot, Sheen Slings and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18). I have also sent it to � The Lullaby Trust � National Childbirth Trust � ROSPA 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. She may send a copy of this report to any person who he believes may find it useful or of� interest. You may make representations to me, the coroner, at the time of your response,� about the release or the publication of your response by the Chief Coroner.

NHS England | Department of Health and Social Care | BSI Group | Office for Product Safety and Standards

27/06/2024

2024-0431

Emily Collishaw

Outer South London

1. NHS England 2. Minister for Public Health, Department of Health & Social Care 3. Parliamentary Under Secretary for local government funding, Department of Levelling Up, Housing and Communities 4. SE London Integrated Care Board

On 21 September 2023 an investigation was commenced into the death of Emily Rose Collishaw, aged 35. The investigation concluded at the end of the inquest on 18 June 2024. The medical cause of death was recorded at inquest as Sudden Unexplained Death in Alcohol Misuse. The narrative conclusion read: � � Alcohol Related Death: Neither intoxication nor ketoacidosis were the direct cause of death. She was recovering from a recent high alcohol intake and probably died from an associated arrhythmia.

As recorded on the Record of Inquest: � Emily was found dead with rigor mortis in her flat on Wednesday 6th September 2023 in non suspicious circumstances. She was suffering from alcohol dependency, drinking several bottles of wine daily. She had begun treatment for substance misuse with Pier Road Project in December 2022, having regular contact with a key worker. In June 2023 Bexley Home Treatment Team managed her mental health care, following admission to hospital with injuries from a fall, whilst intoxicated. Her family felt that she was not competent to self discharge, a view not supported by a psychiatrist. Clinical staff visited and she was often intoxicated until discharge from their care on 4th July to Pier Road Project. She was referred for in patient rehabilitation suitability assessment, but a placement was not available until November 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] (mother) and [REDACTED] (brother) South London & Maudsley NHS Trust (Pier Project) Oxleas NHS Trust (Bexley Home Treatment Team) Royal College of Psychiatrists � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Alcohol, drug and medication related deaths� � This report is being sent to: NHS England | Department of Health and Social Care | Ministry of Housing, Communities & Local Governments | SE London Integrated Care Board

15/07/2024

2024-0402

Josh Smith

Kingston upon Hull & East Riding

1. NHS England� 2. West Yorkshire Integrated Care Board

On 6 January 2023 an inquest was opened into the death of Josh Andrew Smith, aged 30 years.�� The inquest concluded on 4 July 2024 by way of a narrative conclusion, worded as follows: On a background of longstanding medical complications arising out of quadriplegia sustained in a historic road traffic incident, Josh Andrew Smith died of hypoxic brain injury secondary to an out of hospital cardiac arrest which was caused by underlying natural disease processes.

Mr� Smith� had� a� long-standing� history� of� medical� complications,� consequent� to quadriplegia which arose following injuries he sustained in a road traffic incident in 2009. On 16 December 2022, Mr Smith spoke with a General Practitioner over the telephone and was prescribed antibiotics for a chest infection.�� On 19 December 2022 at approximately 05:49 hours, an ambulance was called for Mr Smith as he had been found unresponsive and was not breathing. The 999 call was placed within a queue and was answered by the ambulance service at 06:05 hours. The ambulance� service� triaged� this� call� and� a� Category� 1� response� was� achieved.� An ambulance arrived with Mr Smith at 06:21 hours,�� Mr Smith was conveyed by ambulance to Hull Royal Infirmary where it was identified that he had suffered a hypoxic brain injury. CT scans also demonstrated evidence of bronchopneumonia and Mr Smith al tested positive for influenza A.�� Despite maximal treatment, Mr Smith�s condition did not improve and he was placed on palliative care. Mr Smith died on the 22 December 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:�� Mr Smith�s family� Yorkshire Ambulance Service NHS Trust Humber Teaching NHS Foundation Trust � I have also sent it to the following who may find it useful or of interest: Association of Ambulance Chief Executives (AACE) 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.� Your response will also be shared with the above named Interested Persons.

Hospital Death (Clinical Procedures and medical management) related deaths | Emergency services related deaths (2019 onwards)� � This report is being sent to: NHS England | West Yorkshire Integrated Care Board

9/7/2024

2024-0364

Miles Hurley

West Sussex, Brighton & Hove� � Category: Mental Health related deaths� � � This report is being sent to: National Police Chiefs� Council | NHS England�| Sussex Police | Midlands Partnership University NHS Foundation Trust | MITIE

1. National Chief Police Council 2. Chief Executive NHS England 3. Chief Constable Sussex Police 4. Midlands Partnership University NHS Foundation Trust Liaison Diversion Service 5. MITIE National Police Chiefs� Council | NHS England�| Sussex Police | Midlands Partnership University NHS Foundation Trust | MITIE

On 7th May 2024 I resumed an investigation into the death of Miles Ethan Hurley sitting with a Jury. On 20th May 2024, the investigation was concluded: The medical cause of death given was: 1a. Multiple Injuries 1b. Acute Psychotic Episode Secondary to Chronic Cannabis Dependency The jury determined: Miles was diagnosed in 2016 with testicular cancer and required surgery and chemotherapy. From this point Miles began to suffer social anxiety, depression, and body dysmorphia. Although he began using cannabis from the age of 13, Miles began using cannabis to self-medicate and developed a chronic cannabis dependency. During this period Miles had limited engagement with his GP or other NHS services, preferring to self-research and self-medicate. This resulted in very limited medical records being held in NHS systems. Miles did seek to reduce his cannabis use during 2019, endeavoured to seek mental health support and was exploring garden therapy and garden work. He received some private mental health care however records are not transferred to NHS systems. During the period 5th � 8th July 2022 Miles became increasingly delusional, agitated and scared with mood swings; fuelled by time alone, time awake and time interacting on the internet. Miles developed a belief in conspiracy theories and formed a view that his family were in a cult. On the 8th July 2022 Miles went missing and caused damage by throwing a breeze block at a Member of the Public�s car. This was reported to the Police by a Member of the Public and a CAD record created. Miles� family also reported Miles as missing and provided information stating this was out of character and that his mental health was impaired. Miles returned to his home of his own volition around 10.30pm on the evening of the 8th July 2022. The Police were unable to attend the Miles� home to complete the Return Home interview. On the 9th July 2022 Miles left home around 8.30am in the family car and interacted with an off-duty police officer at his home address. His wife telephoned the Police via 999 and they described how Miles presented and identified his behaviour as indicating mental health issues. An additional CAD record was added to reflect a Member of the Public�s report that Miles was presenting with mental health issues indicating a risk to himself in a public place. Miles went on to drive dangerously causing high risk to himself and members of the public, including failure to stop, pursuit cancellation and damage to police vehicles. It was noted during the pursuit that Miles �fist bumped� through the window. Miles was arrested around 11.10am on the 9th July 2022 for criminal damage, dangerous driving and driving under the influence. At the time of his arrest Miles was presenting behaviour that could be perceived as intoxication and/or mental ill-health. In the following interactions and prior to being remanded into custody Miles conveyed signs of mental ill-health. Limited information related to these interactions and previous supporting mental health concerns were passed from arresting officers, to transporting officers to custody staff. Miles was remanded into custody around midday 9th July 2022 and subsequently breathalysed to determine his level of intoxication being three times the legal drink driving limit. During custody a mental health assessment was requested from SLDS to ensure mental ill-health was identified. An initial assessment was not undertaken on the basis Miles was intoxicated; however, a second assessment was undertaken on a �provisional� basis despite a level of intoxication still being present. This assessment did not recommend a mental health assessment via Section 136 but did recommend a further SLDS assessment if conditions were met or Miles requested. Miles declined further assessment. The notes from the Mental Health Helpline call were not taken into consideration in this assessment and no further assessment was requested by the Police from a change in behaviour. Miles� family called Police around 12.41pm on Saturday 9th July 2022 to establish his whereabouts and likely custody process, followed by calls to the Sussex Mental Health Line between 4.30pm and 8.09pm to provide information related to his mental health and concerns regarding his safeguarding in the event of being released. The family attended the Crawley Custody suite from lunchtime that Saturday to express their concerns, and during this time were called by Police to put their requests for an Appropriate Adult, a mental health assessment and a solicitor with mental health background. Miles subsequently selected the duty solicitor to attend his interview. Adult Social Services phoned Police around 8.30pm to relay concerns from Miles� family and recommended an Appropriate Adult for lack of mental capacity, a mental health assessment via Section 136. Miles was interviewed shortly thereafter Saturday 9th July 2022 with the duty solicitor in attendance. No further assessment of Miles mental health was undertaken and no overt mental health illness was displayed during his time in custody. During the period from his arrest to release, Miles was assessed and managed well in terms of his physical health needs however in respect of his mental health needs a number of shortcomings were identified: The SLDS assessment was undertaken whilst Miles was intoxicated CAD mental health background information was not communicated through parties handover notes did not reflect information available SLDS service not available after 8pm Saturday. Health information from family/helpline was not passed into records. Decisions were taken without the holistic information available as a result of different systems and abilities to assimilate information. Miles was released from custody to the care of his family around 10.30pm on the 9th July 2022 and returned home to be cared for by his family who took turns at keeping him safe until around 5.00am when he agreed to be taken to A&E. At around 5.00am Miles took his father�s car, despite his parents� endeavours to stop him and intentionally drove towards an HGV lorry on the A23 where a collision caused his death at 5.58am on 10th July 2022 whilst being unaware of the consequences of his actions due to a psychotic episode.

The findings of the jury comprehensively describe the circumstances relating to Mr Hurley�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. [REDACTED] � Family Solicitors 2. West Sussex Social Services 3. Sussex Partnership NHS Foundation Trust 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.

Mental Health related deaths� � �

13/10/2023

2023-0407

Iain Farrell

Dorset

1. National Coasteering Charter

On the 30th May 2019, an investigation was commenced into the death of Iain Richard Farrell, born on the 20th April 1970. The investigation concluded at the end of the Inquest on the 29th September 2023. The Medical Cause of Death was: � 1a Drowning The conclusion of the Inquest recorded that Iain Richard Farrell died as a consequence of misadventure in circumstances where he inhaled sea water after he had become breathless during a swim. After having been extracted from the sea onto a ledge by the instructor, a large wave swept him back into the water. This occurred in a challenging sea state during a led coasteering experience. Prior to starting the activity, Mr Farrell had expressed that he was not a confident swimmer.

On 26th May 2019 Mr Farrell took part in a led coasteering activity at Hedbury Quarry with his two sons,�[REDACTED], and 6 other participants, two of which were also children. None of the group had previous experience of coasteering. Mr Farrell was not a confident swimmer. The group was led by a single� experienced� freelance coasteering guide,�[REDACTED], working for Land and Wave, a local outdoor activities provider. � Hedbury Quarry is a remote location off the South West Coast Path. It is approximately a 20 minute walk from the nearest carpark. It is known that there is no phone signal along this particular stretch of the coastline. � The guide was equipped with safety items, including a floating rope. In a �safety bag�, which was left in a central location on the coasteering route, was further safety equipment, including a VHF radio. � The sea state on 26th May 2019 was challenging at the start of the session and this became worse as the session progressed. � At the start of the session the coasteering group were asked to jump into the water from a sea ledge, assisted by the coasteering guide. They were instructed to swim away from the rocks and form a safety raft, before swimming in a westerly direction. During the swim, Mr Farrell became breathless and exhausted. The guide stayed with Mr Farrell to encourage and support him and subsequently made the decision to lead Mr Farrell to the shore with a view to getting him out of the water and cancelling the session. The rest of the group were instructed to form a safety raft and remain in the sea. � The guide used a length of �floating rope� to tow Mr Farrell to a sea ledge from which they would both be able to leave the coastline. However, once Mr Farrell had managed to climb onto the ledge with the guide, both were swept back into the sea by a large wave. It is likely that, at this point, Mr Farrell inhaled sufficient sea water to begin the process of drowning. Minutes later he became unresponsive in the sea. The guide recovered Mr Farrell to a sea ledge and began CPR. He was unable to make his way to the rescue bag. The remaining coasteering group, who were now drifting further out to sea and westwards, were able to attract the attention of climbers at Hedbury Quarry, who were, in turn, able to access the rescue bag and raise the alarm using the VHF radio. HM Coastguard were contacted approximately 15 minutes after Mr Farrell became unresponsive in the water. The emergency services, including the RNLI, HM Coastguard, South Western Ambulance Service and the Police attended the scene. Despite resuscitation efforts, Mr Farrell was confirmed deceased. There is no regulatory body for coasteering, but written guidance is provided by the National Coasteering Charter (�NCC�). The current guidance was issued in 2015. Coasteering providers and guides are not obliged to follow the guidance, though a significant number of providers and guides are NCC members.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1)� Optimal Solicitors (representing Mrs Farrell and their sons); (2)��[REDACTED] brother of Iain Richard Farrell; (3)��[REDACTED] , sister of Iain Richard Farrell; (4)��[REDACTED] , sister of Iain Richard Farrell; (5)� DAC Beachcroft Solicitors (representing�[REDACTED] , the coasteering guide); (6)� HCR Solicitors (representing Land and Wave, the coasteering provider; (7)� Dorset Council. � I have also sent the report to the following: (1)� Royal National Lifeboat Institute; (2)� Royal Society for the Prevention of Accidents; (3)� Maritime and Coastguard Agency; (4)� Royal Life Saving Society UK; (5)� Surf Life Saving GB; (6)� Adventure Activities Licencing Authority; (7)� Adventure Activities Licencing Service; (8)� Adventure Activity Industry Advisory Committee; (9)� Health and Safety Executive. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: National Coasteering Charter

21/10/2024

2024-0564

Brian Beer

Suffolk

1. National Institute for Health & Care Excellence (NICE)

On 13 March 2024 I commenced an investigation into the death of Brian BEER aged 86. The investigation concluded at the end of the inquest on 06 September 2024. The conclusion of the inquest was that: Narrative Conclusion � Brian Beer, an 86 year old gentleman, died due to a recognised complication of necessary surgery on a fractured hip sustained in an unwitnessed fall. The development of this complication was contributed to by the fact that local guidelines were followed as to the cessation of prophylactic anti-coagulants after surgery, whereas evolving international policy indicates that prophylaxis should be continued for a longer time period. The death was also contributed to by frailty and advanced dementia, which both contributed to the fall and compromised Mr Beer�s physiological reserve, such that his capacity to recover from fracture, surgery and serious illness was compromised. The medical cause of death was confirmed as: 1a Small Bowel Ischaemia 1b Superior Mesenteric Artery Thrombus 1c 2�� Advanced Dementia, Left Hip Hemiarthroplasty 08.01.24 with VTE Prophylaxis for 28 Days

Brian Beer died peacefully at the West Suffolk Hospital on 1 March 2024. He died of small bowel ischaemia, suffered due to a blood clot in an artery that provides blood to the small bowel. Sustaining such a blood clot is a recognised complication of surgery on a hip fracture. Mr Beer underwent a left femur head replacement on 8 January 2024, owing to a hip fracture. This fracture was sustained in an unwitnessed fall at his care home, which was contributed to by advanced dementia and frailty. Although Mr Beer received prophylactic anti-coagulation after the hip surgery, in accordance with and for the duration required by local hospital guidelines, the international policy in this regard is evolving such that patients may be given anti-coagulation after surgery for a longer period of time. The cessation of anti-coagulation in Mr Beer�s case at the time it was ceased contributed to his death.

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

Hospital Death (Clinical Procedures and medical management) related deaths

National Institute of Health and Care Excellence

08/04/2024

2024-0189

Joshua Delaney

London Inner (South)

1. National Medical Director, NHS England

On 7 August 2020 an inquest was opened into the death of Joshua Arthur Stafford Delaney. The inquest was concluded on 28 March 2024. � The medical cause of death was Propranolol toxicity. � The jury�s conclusion at the inquest was a narrative conclusion, including a conclusion that the deceased took an overdose while conscious of what he was doing and that he intended to end his life, but that after the act he regretted his decision.

The deceased, aged 19 at the time of his death, was a young man with a history of mental illness and suicidal ideation, and who had made previous suicide attempts. � During the year prior to the index events, he had been prescribed Mirtazapine for anxiety and to help with sleep. Following his discharge from the Community Mental Health Team, he attended his GP in October 2019, with symptoms of anxiety and physical symptoms including palpitations and tachycardia. He was prescribed Propranolol [REDACTED] to be taken [REDACTED] times a day for [REDACTED] days, and given [REDACTED] tablets for this purpose. He was given further prescriptions of [REDACTED] tablets of Propranolol at the beginning of November 2019, and again on 4 January 2020. He had seen his GP in early December 2019, who had intended that the deceased move to taking Propranolol �as required� in order to wean him off its use. � In the early hours of 19 January 2020, the deceased took a large overdose of Propranolol, estimated by the toxicologist to have been [REDACTED], and was found collapsed. Despite prolonged attempts at resuscitation by the paramedics and in hospital, he died on 19 January 2020.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED], the South London and Maudsley NHS Foundation Trust, and the Metropolitan Police. � 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: NHS England

13/08/2024

2024-0452

Margaret Huntley

Teesside and Hartlepool

1. North East Ambulance Service NHS Foundation Trust. 2. NHS England. 3. Association of Ambulance Chief Executives. 4. Royal College of General Practitioners.

On 16 December 2022 I commenced an investigation into the death of Margaret HUNTLEY, aged 63. The investigation concluded at the end of the inquest on 9 August 2024. The medical cause of death was recorded as: 1a) Multi-Organ Failure 1b) Dehydration; Lack of exogenous steroids; Covid-19 infection. The Conclusion of the inquest was a narrative conclusion as follows: Margaret Huntley died as a result of multi-organ failure which was caused by dehydration, lack of exogenous steroids, and Covid-19 infection. Margaret�s death was contributed to by delays in identifying that she required exogenous steroid medication, and delays in the prescription and administration of that exogenous steroid medication.

Margaret Huntley died on 10 December 2022 at the University Hospital of North Tees, Hardwick Road, Stockton on Tees. Margaret was prescribed and dependent on exogenous steroid medication, hydrocortisone, following a previous hypophysectomy procedure due to a benign non-functioning pituitary adenoma. Following a period of illness primarily diarrhoea, nausea and vomiting, Margaret was seen at an urgent care centre on 3 December 2022 and prescribed� anti-emetic medication. On 5 December 2022, Margaret called 999 and requested an Ambulance; during this telephone call, Margaret stated that she took hydrocortisone. Margaret was reviewed by a Paramedic on 5 December 2022 and again on 7 December 2022 with the treatment pathway being for GP review. Margaret�s prescribed medications were not ascertained or recorded by the attending Paramedic on those dates and the attending Paramedic was not aware that Margaret was prescribed exogenous steroid medication. On� 8�December�2022,� in� the� presence� of� attending� Paramedics,� Margaret� lost consciousness and she was transported to the University Hospital of North Tees. Margaret�s prescribed medications were recorded during this Paramedic attendance; however, the recorded medications did not include, and the attending Paramedics were not aware of, the prescribed exogenous steroid medication, hydrocortisone. Margaret was admitted to the Emergency Department of the University Hospital of North Tees at 17:37 on 8 December 2022 and was transferred to the Emergency Assessment Unit at 05:09 on 9 December 2022. At 05:41 on 9 December 2022, Margaret was prescribed 10mg oral hydrocortisone which was administered to her at 09:09. At 10:00 on 9 December 2022, Margaret clinically deteriorated, and�� she�� received�� treatment�� which�� included��� 100mg��� of�� intravenous hydrocortisone medication for suspected Addison�s Crisis. Margaret was transferred to the critical care unit and diagnosed to have Disseminated Intravascular Coagulation. Despite treatment, Margaret deteriorated and sadly died on 10 December 2022. Margaret died as a result of multi-organ failure which was caused by dehydration, lack of exogenous steroids, and covid-19 infection. Margaret�s death was contributed to by delays in� identifying� that� she� required� exogenous� steroid� medication,� and� delays� in� the prescription and administration of exogenous steroid medication.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of Margaret Huntley. North Tees and Hartlepool 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 NHS Foundation Trust | NHS England | Association of Ambulance Chief Executives | Royal College of General Practitioners

12/04/2024

2024-0193

Eleanor Smith

Northumberland

1. Northumbria Healthcare NHS Foundation Trust

On 28 September 2023 I commenced an investigation into the death of Eleanor Smith Deceased. The investigation concluded at the end of the inquest on 11 April�2024. The conclusion of the inquest was a narrative conclusion: Died due to an infection the source of which could not be ascertained together with the physiological stress of a surgical procedure contributed to by underlying natural disease and an injury sustained in an accidental fall. It is not possible to say to what extent antibiotics were effectively administered or whether the delay affected the outcome. � The cause of death was: � 1a. Infection of unknown aetioloav 1b Frailty of old age II Left ventricular systolic dysfunction, Atrial fibrillation, Left neck of femur fracture

On 17 September 2023 within Crossway, 1 Swinhoe Road, Beadnell Eleanor Smith suffered an unwitnessed fall using her walker when she stumbled and fell against the doorpost of the bathroom door. She was conveyed to Northumbria Specialist Emergency Care Hospital where an x-ray identified she had sustained a fracture to the left neck of femur. No infection was identified on admission. She was too unwell to undergo surgery initially and underwent surgical repair of the fracture with insertion of a left dynamic hip screw without complication on 19 September 2023. Postoperatively she developed an infection with a rising white cell count and CRP. There was a significant delay in the administration of intravenous antibiotics which were first administered at 18.00 hours on 23 September 2023 although it is not possible to say to what extent antibiotics were effectively administered or whether the delay affected the outcome. Investigations undertaken were unable to identify the source of the infection and despite treatment she continued to deteriorate and died within Northumbria Specialist Emergency Care Hospital on 24 September 2023.

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

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

23/10/2023

2023-0399

Karlton Donaghey

Newcastle upon Tyne and North Tyneside

1. Office for Product Safety and Standards Department for Business and Trade

On 5th July 2022 an investigation was commenced into the death of Karlton Noah DONAGHEY. An inquest into his death was opened on 7th September 2023. � � On 25th September 2023 I resumed and concluded an inquest into his death. � I concluded that medical cause of death for Karlton was; 1a Diffuse hypoxic ischaemic encephalopathy 1b Asphyxia from a helium balloon accident (on 23/6/22)

Karlton was a 5 year old boy at the time of his death. He was made a present of a large helium filled balloon at local fairground in the days prior to his death. On 23rd June 2022 whilst momentarily alone in his home he placed the balloon over his head He became quickly overcome by the helium and despite prompt rescue, he suffered a hypoxic brain injury and subsequently died in hospital on 29th June 2022.

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

Child Death (from 2015) This report is being sent to: Product Safety and Standards

11/11/2024

2024-0617

Kirsten Hocking

West Sussex, Brighton & Hove

1. Probation Service 2. Steps2Recovery

On 01 June 2023 I commenced an investigation into the death of Kirsten HOCKING aged 31. The investigation concluded at the end of the inquest on 08 November 2024. The conclusion of the inquest was that: Kirsten Hocking was 31 years old when she died as a result of a heroin overdose. She had been released from prison on 19 May 2023, and found in a public toilet in Worthing on 20 May 2023. She was taken to Worthing Hospital where she died at 16:45 on 24 May 2023.

Kirsten Hocking was 31 years old when she died as a result of a heroin overdose. She had been released from prison on 19 May 2023, and found in a public toilet in Worthing on 20 May 2023. She was taken to Worthing Hospital where she died at 16:45 on 24 May 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Change Grow Live (West Sussex) [REDACTED] [REDACTED] [REDACTED] Forward Trust 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.

State Custody related deaths

HMPPS | Steps2Recovery

25/10/2024

2024-0573

Martin Stubbs

West Yorkshire (Eastern)

1. Professional Standards Department, West Yorkshire Police, Laburnum Road, Wakefield �� �������� WF1 3QP � � 2. Independent Office for Police Conduct (IOPC), PO Box 473, Sale, M33 0BW

On 29/08/2024 I commenced an investigation into the death of Martin Ian Stubbs, aged 50. The investigation concluded at the end of the Inquest on 24/10/2024. The conclusion of the Inquest was that Mr Stubbs� death was a suicide by hanging. He had hanged himself at his home address on 26/08/2024 and left notes to his family indicative of an intention to end his life. The medical cause of death was 1a) Hanging.

Mr Stubbs was a serving Police Officer. On 29/11/2022, nine days after receiving a long service and good conduct award at a formal ceremony in Wakefield, he was arrested by officers from West Yorkshire Police Professional Standards Department and bailed. He was suspended from duty. He remained suspended and on bail until his death. He had sought medical advice and assistance because of the mental strain of being suspended for so long, and a note recovered from the scene stated his belief that West Yorkshire Police had contributed to his death.

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.

Police related deaths | Suicide (from 2015)

West Yorkshire Police | Independent Office for Police Conduct

18/10/2024

2024-0561

Geoffrey Cheney

West Yorkshire Western

1. Radis Community Care

On 22 January 2024 I commenced an investigation into the death of Geoffrey Stuart CHENEY aged 71. The investigation concluded at the end of the inquest on 11 October 2024. The conclusion of the inquest was that: Geoffrey Stuart Cheney hung himself and a short form conclusion of suicide was recorded.

On 8th November 2023 an initial assessment for home treatment was undertaken on Geoffrey Stuart Cheney by the Kirklees Outreach Team.� In that assessment Geoffrey indicated that he regularly had suicidal thoughts, including [REDACTED] in his flat to hang himself.� His family asked that�[REDACTED] be removed. Geoffrey was admitted as a voluntary patient and after some time was deemed to be fit enough to have unescorted leave.� He undertook that successfully on a number of occasions. On 16th January 2024 he went to his home at [REDACTED] on unescorted leave.� He put the chain on the door and hung himself [REDACTED] that was still in place.

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 Pinnacle Group Limited 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) | Community health care and emergency services related deaths

Radis Community Care

02/12/2024

2024-0663

Norma Tellam

Cornwall & the Isles of Scilly

1. Royal Cornwall Hospital NHS Trust 2. Cornwall Partnership NHS Foundation Trust 3. University Hospitals Plymouth NHS Trust

On 21 April 2023 an investigation was commenced into the death of Norma Ann Patricia Tellam. I concluded the investigation at the end of the inquest on 8 April 2024. The� conclusion of the inquest was Accidental Death. The cause of death was;� 1a Upper Gastro Intestinal Haemorrhage 1b Proximal Femoral Fracture (operated) 1c Fall

On 22 January 2023 Norma Ann Patricia Tellam suffered an unwitnessed fall near her� home sustaining a left proximal femoral fracture. On 23 January 2023 Mrs Tellam� underwent surgery at the Royal Cornwall Hospital Truro to repair the fracture using a� femoral intramedullary nail together with additional metalwork to stabilise and strengthen the repair. On 1 February 2023 Mrs Tellam was transferred to Liskeard Community� Hospital for further rehabilitation with a planned review by the orthopaedic department at the Royal Cornwall Hospital within 6 weeks. �� On 4 February 2023 clinical staff became concerned that Mrs Tellam surgical hip wound might be infected. Mrs Tellam was sent to the emergency department at Derriford Hospital� University Hospitals Plymouth rather than to the Royal Cornwall Hospital where the original operation was carried out. Mrs Tellam was returned to Liskeard hospital on 5 February� 2023 after an infection was discounted. �� On 10 February 2023 Mrs Tellam was sent again to Derriford Hospital with symptoms of a� suspected infection. A chest infection was subsequently diagnosed and Mrs Tellam was� admitted to Derriford Hospital where she remained until 21 February 2023 having� subsequently developed Covid. On 11 February 2023 whilst Mrs Tellam was at Derriford� Hospital her hip was x-rayed and reviewed by an orthopaedic consultant who identified� some movement in the metalwork from the operation particularly a nail in the femoral head. He anticipated that Mrs Tellam would need to have some extra surgery and that she would� be transferred back to the Royal Cornwall Hospital in Truro, where the original operation� had been carried out and under whose care she remained, as soon as her chest infection� resolved. �� Mrs Tellam was returned to Liskeard Community Hospital on 21 February 2023 where� attempts were made to rehabilitate her and improve her mobility. In the light of issues� highlighted by the x-rays taken at Derriford, it would have been good practice to return Mrs Tellam to the Royal Cornwall Hospital for follow up. �� Mrs Tellam continued to experience significant levels of pain from the hip joint and was x- rayed at Liskeard on 16 March 2023.. The x-ray identified that the nail in the femoral head had moved further and was now protruding into the hip socket. It is likely that the� movement was caused by the rehabilitation. �� The x-ray was discussed with the orthopaedic team at Royal Cornwall Hospital. Mrs Tellam was re-admitted to Royal Cornwall Hospital from Liskeard Community Hospital where she� underwent on 23 March 2023 a operation to remove the metalwork from the original� operation and subsequent total hip replacement. �� Mrs Tellam initially made satisfactory progress after the operation however on 16 April� 2023 she became very unwell suffering an upper gastro intestinal bleed and died at 0630� on 16 April 2023. It is likely that the bleed was caused by necessary anti-inflammatory and pain killing medication.

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

Royal Cornwall Hospital NHS Trust | Cornwall Partnership NHS Foundation Trust | University Hospitals Plymouth NHS Trust

30/01/2024

2024-0045

Nicolas Gerasimidis

Cornwall and the Isles of Scilly

1. Rt Hon V Atkins, MP, Secretary of State for Health and Social Care

On 3/6/23, I concluded the inquest into the death of Nicolas Gerasimidis. He was found hanged at his home address on 3/6/23. � I recorded a conclusion of Suicide at inquest.

Mr Gerasimidis had a history of mental illness manifesting as OCD and anxiety. In 2022, his condition deteriorated. His GP referred him twice to the Community Mental Health Team but the referrals were rejected with medication being prescribed instead, together with advice to contact Talking Therapies. � He was taken on to CMHT workload after being assessed by the Psychiatric Liaison Team in Royal Cornwall Hospital in November 2022. The preferred course of treatment was psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention. There was a waiting list of a year. � In May 2023, Mr Gerasimidis became worse. It was felt an informal admission to hospital was required but a bed was not available. He was found hanged at his home address on 3/6/23.

I have sent a copy of my report to the Chief Coroner and to the following Interested or proper Persons: � The family; [REDACTED] Chief Executive, Cornwall Partnership Foundation Trust; [REDACTED], Chief Executive, Integrated Care Board; [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.

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

26/04/2024

2024-0225

Charlie Millers

Manchester North

1. Rt Hon Victoria Atkins, Department of Health And Social Care, 39 Victoria Street, London, SW1H 0EU

On the 17th December 2020, I commenced an investigation into the death of Charlie Millers. Charlie died on the 7th December 2020. The investigation concluded on the 25th April 2024. The medical cause of death was confirmed as 1a) Hypoxic Brain Injury 2) ADHD, Emotionally Unstable Personality Disorder, Mixed Conduct Disorder and Autism. A jury recorded a narrative conclusion.

CIRCUMSTANCES OF DEATH On the 2nd December 2020 Charlie was detained under Section 2 Mental Health Act 1983 on Junction 17 the Child Adolescent Mental Health unit at Prestwich Hospital. At 22:31 hours he was found in his room having tied a ligature. He died 5 days later in Salford Royal Hospital. This was Charlie�s third inpatient admission since July 2020. During his most recent admission it was accepted that his self harming behaviour had escalated in frequency and severity. It was recognised by his clinical team that being an inpatient was not assisting Charlie. Charlie had returned from home leave at 19:45 hours on the 2nd December, it was known and recognised that return from home leave was a time when Charlie would ligature. Charlie was therefore on 1:5 minute observations with increased 1-1 support if he required it. At the time the Trust Observation Policy allowed two forms to be used in order to conduct 1:5 observations: One form ensured the staff member recorded details every 5 mins. None of these forms were completed on the evening of the 2nd December for Charlie. Indeed for his entire three admissions , spanning almost three months, only one such form was located. � A second form meant staff only had to sign once at the end of the period of observations ie hourly. (�Level 2 hourly form�) In addition there was a separate Level 3 Observation 1:15 minute form which was completed for all young persons who as a matter of routine were checked every 15 minutes. The court heard evidence that at the commencement of each shift the nurse in charge allocated staff members their roles for the shift. This would change hourly and should be detailed on the allocation sheet. In addition the court heard that the staff member completing 1:5 minute checks on a young person would be different from the person completing the 1:15 minute checks on all the young people. � � On the 2nd December Staff the a/location sheet shows; 8-9am � No-one allocated to Charlie�s 1:5 obs. HB allocated to 1:15 obs for everyone. 9-10pm Staff Member HB allocated to Charlie�s 1:5 obs. D allocated to 1:15 obs for everyone 10-11pm Staff Member D (female) allocated to Charlie�s 1:5 obs. M allocated to 1:15 obs for everyone. � � Level 3 1:15 Form Between 9pm � 9.45 D signs every 15 minutes to say 1:15 obs completed on all yps 10pm -10.30 staff HO signs to say 1:15 obs completed on all yps. � Level 2 Hourly Form for Charlie�s 1:5 observations 8-9pm signed by 0� 0-told the court h-e signe-d th-is forrn al -ap,-n but -h ad not done the-ob servations, the space was blank and he used more space for his entry at 9pm 9-10pm signed by D pm signed by HO (Charlie was found at 22:31 hours) The evidence therefore suggests that if Charlie�s 1:5 observations were being undertaken from 9pm onwards, they were being undertaken by the same member of staff who was undertaking 1:15 minute checks on the other young persons . His final ligature was the fourth one Charlie had tied from returning back to the ward at 7.45pm. Previous Observation Issues Death of RT In October 2020 another young person had died on a different ward at this site. During the course of that Inquest it was found observations were not being conducted appropriately in that staff were not completing observation checks. As a result, management were supposed to be auditing observation documentation daily. Albeit it was acknowledged audits of paperwork would not evidence if staff were falsifying the documentation ie competing the paperwork but not doing the check. A regulation 28 report was issued following this Inquest. Death of AS In June 2021 another young person died on another ward in Junction 17. At the time this individual was on 1:5 minute observations. A similar regulation 28 report was issued in respect of the 1:5 documentation and the evidence to the court at that stage was that there was no other 1:5 observation record other than the Level 2 hourly form. The court was concerned as there was no record to say 1:5 checks were done. In light of the evidence in Charlie�s case this appears inaccurate. At this time the audit by senior managers, which had been put in place in October 2020 should have been ongoing Investigations and Reviews Greater Manchester Mental Health Trust Root Cause Serious Incident Reports. All three deaths were reviewed internally by GMMH. In respect of the investigation into Charlie�s death the review was completed by clinical team members. Whilst some inhouse training is provided as to how to conduct reviews, they are not trained investigators. The Inquest ascertained that not all the staff who were on duty on the night Charlie ligatured were spoken to or asked for statements. The findings of the investigation relied on the completed observation sheets to reach a finding that i) Charlie�s 1:5 observations were conducted (ii) that they were conducted by the staff member who was already completing 1:15 obs. There was no questioning as to the accuracy of this or how this was possible. Nor whether this was in line with Trust policy, nor whether this was a safe practice for all the young persons on the ward. It did not consider whether the senior manager audits were being conducted. � Following the deaths of Charlie and the other young persons NHS England commissioned an Independent desktop review of the three cases. This review had access to the Trust�s Root Cause Analysis Serious Investigation Reports and simply relied on their findings. This review did not highlight any concerns. Greater Manchester Police � In January 2023 the Inquest into Char lie�s death was adjourned following identification of the 1:5 observation sheet detailing an entry for every 5 minutes. GMP were asked to review this case to consider if there were potentially any individual criminal offences or corporate offences. GMP reported that there was no evidence of any criminal offences. At this time GMP were also considering wider issues relating to concerns raised from the BBC Panorama programme about the Edenfield unit which is based on this site. GMP also investigated the other two deaths. � Not all the members of staff who were on duty that night were spoken to. Three members of staff were interviewed. D and HO confirmed they were doing the 5 minute observations as they signed the hourly sheet. This investigation does not appeared to have considered how this was possible if the staff were conducting 1:15 checks on the other young people. Nor whether this was in line with Trust policies or whether it made for a safe environment for all the young persons. � Independent Review of Greater Manchester Mental Health NHS Foundation Trust December 2023 by Professor Oliver Shanley. This report was England following the BBC programme which aired in September 2022. [REDACTED] gave evidence to the court in Charlie�s Inquest. He told the court that as part of his investigation in September 2023 his team requested copies of the audits of observations by senior managers. He requested them from June, July and August 2023. He was subsequently advised that it had been discovered by the Trust that there, �was no formal system and process in the form of governance and the application of this audit was at ward level.� Evidence showed in July 2021 the audit was completed 17 times out of 28 (61 %0. In 2022 it was completed 25 times out of 52 (48%) and in 2023 it was completed 9 times out of 36 (25%). In conclusion Professor Shanley found (para 9.103 ): � �The Trust reviewed and ratified their Therapeutic Engagement and Observation Policy in September 2023. However, it is noteworthy that it doesn�t address the original problem. There was no issue with the policy and the Trust was able to demonstrate that a number of staff working on that ward understood the policy and its implementation, but for reasons that are stiff� not fully understood, they failed to follow its guidance.� � No investigation was conducted.by the Care Quality Commission who were aware of Charlie�s death. � No investigation was conducted by the Health Services Investigations Body and it does not appear they were made aware of this case. Without oversight of all cases and issues it is not clear whether the report of Charlie�s death in isolation would meet their criteria.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:� Family of Charlie Millers Greater Manchester Mental Health Trust NHS England Care Quality Commission Trafford Children�s Services Trafford Community CAMHS Service � As they are referenced in this Regulation 28 PFD I have also forwarded the same to Greater Manchester Police and the Health Services Safety Investigations Body � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

26/06/2024

2024-0353

Raymond Watkins

Manchester North

1. Rt Hon Victoria Atkins, Department of Health And Social Care, 39 Victoria Street, London, SW1H 0EU

On the 21st December 2022, I commenced an investigation into the death of Raymond Horace Watkins. Raymond Watkins died on the 28th November 2022 at Royal Oldham hospital. The investigation concluded on the 26th June 2024. The medical cause of death was confirmed as 1a) Septicaemia 1b) Insulin controlled Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, lschaemic Heart Disease, Pressure Ulcers 2) Cerebrovascular Accident

CIRCUMSTANCESOF DEATH Mr Watkins had been admitted to hospital on the 4th November 2022. During this admission he was placed on end of life palliative care and his usual medications including his insulin were stopped. He was discharged from hospital on the 10th November 2022 to his care home. The following day Mr Watkins advised the home, his GP and others that he wanted to restart his medications including his insulin. At this stage Mr Watkins had capacity and his clinical picture had improved. The GP prescribed his insulin and the authorisation required by the District Nurses for them to administer the same. The court heard that an authorisation is required before District Nurses can administer the same. Due to administrative errors both within the GP practice and the District Nurse practice this prescription was not authorised before Mr Watkins was readmitted to hospital on the 22nd November 2022. An initial forensic post mortem had considered the medical cause of death to be directly attributable to the lack of insulin however further expert evidence concluded that the prescribing of further insulin would, in this case not have been appropriate and in any event would not have made any difference. The cause of death was therefore revised. However it was acknowledged by all Interested Persons and the expert that the breakdown in communication between the GP and District Nurses was indefensible and could in a different case have been causative. � � As a result of their investigation into this case the Northern Care Alliance has developed and rolled out across 4 areas of Greater Manchester a �Time Critical Medicine� process for District Nurses advising them as to which medicines are considered time critical and what steps to take if authorisations are not correctly completed on receipt. This includes: � Contacting the Prescriber and immediately raising a datix incident Returning to the prescriber within 2 hours if correct authorisation is not received Escalation by end of shift to a manager Escalation following morning to the Assistant Director of Nursing The implementation of this Standard Operating Procedure which came into place in March 2024, led to the number of datix incidents increasing significantly, highlighting the widespread issue. However since its implementation this has raised the awareness amongst GPs and prescribers of errors and the numbers have declined dramatically to the point where practices are making real differences to the ability for patients to access such medicines.

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

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

04/11/2024

2024-0595

Janet Brown Townend

City of Kingston Upon Hull and the County of the East Riding of Yorkshire

1. Safeguarding Adults Team, East Riding of Yorkshire Council

On 18th October 2023 I commenced an investigation into the death of Janet Brown Townend, aged 80 years. The investigation concluded at the end of the inquest on 25th October 2024. � The narrative conclusion of the inquest was: � On 15th October 2023, Janet Brown Townend aged 80 years died at HRI from sepsis which she developed from an infected wound on her foot. She was diabetic and she sustained an injury to her foot on 19th September 2024 and this developed into a further wound under her foot due to poor circulation that became necrotic and infected. She was admitted to hospital on 7th October 2024. Despite surgical treatment her infection worsened and she succumbed to sepsis. Her comorbidities contributed to her lack of ability to deal with the infection.

Janet Brown Townend had a number of comorbidities. Following a heart attack in August 2023 she was in receipt of a care package, sourced by East Riding of Yorkshire Council, and provided by A&B Healthcare Ltd. � Ms Townend sustained an injury to her toe on 19th September 2023. Her carers contacted the podiatry team. She was seen by a Band 7 specialist in diabetic foot service on 26th September 2024. There were concerns regarding her reduced circulation and peripheral neuropathy and she was referred to see the vascular team. An appointment was made for 5th October 2023. It was thought there was a fracture to her toe with an open wound. Ms Townend was prescribed antibiotics and was to be seen by community nurses twice a week to apply dressings. � Carers continued to attend 3 times a day to assist with meal preparation and personal care. � The Yorkshire Ambulance Service Patient Transport Service was booked by Ms � Janet Brown Townend had a number of comorbidities. Following a heart attack in August 2023 she was in receipt of a care package, sourced by East Riding of Yorkshire Council, and provided by A&B Healthcare Ltd. � Ms Townend sustained an injury to her toe on 19th September 2023. Her carers contacted the podiatry team. She was seen by a Band 7 specialist in diabetic foot service on 26th September 2024. There were concerns regarding her reduced circulation and peripheral neuropathy and she was referred to see the vascular team. An appointment was made for 5th October 2023. It was thought there was a fracture to her toe with an open wound. Ms Townend was prescribed antibiotics and was to be seen by community nurses twice a week to apply dressings. � Carers continued to attend 3 times a day to assist with meal preparation and personal care. � The Yorkshire Ambulance Service Patient Transport Service was booked by Ms Townend to take her to her vascular appointment on 5th October 2024. Unfortunately, when they attended to take her, they were unable to do so as one crew member was not able to mobilise Ms Townend safely to the vehicle due to her limited mobility. As a result, Ms Townend cancelled the appointment, and a further appointment was rebooked for 12th October 2024. � On 6th October 2023 carers observed Ms Townend struggling to sit up. A Health Care Assistant (HCA) from the Community Nurses� Team attended and was concerned as to Ms Townend�s foot and the level of exudate. Her toe was black underneath. The HCA sent photographs to a senior nurse who determined Ms Townend should be seen the following day by a registered nurse. � The next day, 7th October 2023, the registered nurse attended at the same time as a carer in the morning. Ms Townend presented as vacant and confused. An ambulance was called. Her leg was warm and swollen. A black necrotic area was noted to her foot. Ms Townend�s daughters also attended at this time. Her daughter described a smell of dead flesh and her mother being delirious and slumped in a chair and having been in the same clothes for 2 days. The ambulance took her to hospital. She had a cardiac arrest on the way but was resuscitated. � As a result of what the ambulance practitioner witnessed, she submitted a Safeguarding Adult Concern to East Riding of Yorkshire Council regarding neglect and acts of omission due to the care she had received and the injury to her foot � On admission to Hull Royal Infirmary, she had an infection to her left foot and sepsis. Bacteria was found on her foot which caused an infection leading to sepsis. She was given antibiotics and the next day had a debridement and amputation of 2 toes. � Although initially there was clinical improvement in Ms Townend�s condition she deteriorated and despite treatment died on 15th October 2023. � The medical cause of death was determined as: 1a Sepsis 1b Infected wound of the left foot (operated 8/10/2023) 2 Ischemic heart disease; Diabetes mellitus; Chronic kidney disease.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; the family of Janet Brown Townend. � 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 | Community health care and emergency services related deaths

East Riding of Yorkshire Council

22/04/2024

2024-0212

Chanyang Li

Inner North London

1. Scape Living Student Accommodation, Scape Operations Ltd, Link Company Matters Limited, Cardale Park, Harrogate, North Yorkshire HG3 1RY; cc Neil Smith, Managing Director, 6th Floor, 65 Gresham Street, London, United Kingdom, EC2V 7NQ

An investigation was commenced into the death of Chanyang Li, aged 23 years, on 16 October 2023. The investigation concluded at the end of the inquest on 5 April 2024. I made a determination at inquest of suicide.

At the time of his death, Chenyang was a third year undergraduate student on a BSc Statistics, Economics and Finance degree programme at UCL. On 30 September 2023 Chenyang returned to Scape Bloomsbury at approximately 8.30am. He made his way to the 6th floor and let himself in to a friend�s apartment. � Having entered the apartment, Yang went immediately to the window and climbed out of it, falling onto the concrete below. He died shortly afterwards from multiple severe injuries. A police investigation described the window as follows: The window�is situated within the kitchen/ lounge space. Window is metal framed, right side hung. The window has a windowsill in front of the interior side which is 74ccm from the interior floor, sill width is 38cm from front of sill to window. Beneath the window is a small fixed panel window. Window is 125cm from the interior floor, 44cm in width, 76cm in height. At the time of attendance, the window was open to its widest aperture which is 55cm. � The National Code of Standards for Larger Developments for student accommodation not managed and controlled by educational establishments, under which Scope Bloomsbury is accredited, states at paragraph 6.30: All windows above ground-floor level will be fitted with stops to prevent over-opening.

I have sent a copy of my report to the following. � Family of Chanyang Li [REDACTED] Director of Student Support and Wellbeing and Safeguarding Lead, UCL National Code Administrator and Unipol Student Home: 155-157 Woodhouse Lane, Leeds, LS2 2ED NUS, [REDACTED] Association for Student Residential Accommodation, HHJ Thomas Teague QC, the Chief Coroner of England & Wales � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Suicide (from 2015) This report is being sent to: Scape Living Student Accommodation

24/04/2024

2024-0580

Derek Hand

Derby and Derbyshire

1. Scottish Dental Clinical Effectiveness Programme

On 12 September 2023 I commenced an investigation into the death of Derek HAND aged 93. The investigation concluded at the end of the inquest on 24 April 2024. The conclusion of the inquest was that: Mr Hand died on 01 September 2023 at Chesterfield Royal Hospital. He was admitted on 26 July 2023 following a tooth extraction on the 25 July 2023, following which he experienced continued bleeding from the extraction site. Mr Hand was on Clopidogrel, an anti-platelet medication, and the tooth extraction was carried out in accordance with the guidance for patients on anti-platelet medication, however the site did not stop bleeding, despite sutures and packing of the site. An ambulance was called at approximately 1am on 26 July, Mr Hand lost consciousness when the ambulance crew was present and was transported to Chesterfield Royal Hospital where he was treated with a blood transfusion and high flow oxygen. His presentation initially improved and discharge was being planned during August. However, Mr Hand developed difficulties swallowing and subsequent aspiration pneumonia. His condition deteriorated at the end of August and he was placed on end of life care before passing away on 01 September 2023.

Attended ED on 26/07/23 with history of tooth extraction earlier in the day, had bleeding, returned to dentist who stitched the area, bleeding stopped at that time, started bleeding again and called ambulance. He had an episode of seizure with ambulance crew that lasted for only a few seconds, self resolved with urinary incontinence. In ED he was given fluid for resuscitation. He had 2 episodes of seizures in ED, became unresponsive in ED after second episode., GCS dropped to 5/15, he was given� IV leviteracetam(Keppra).His oxygen saturation was low, started on high flow oxygen, BP dropped to 42 systolic, red cells transfusion started and BP improved to 84/16. He became agitated and confused so he was given midazolam subcut. He continued to deteriorate with hypotension, bradycardia and low GCS so decision was made to start palliative care. EOL revoked on 28/7/23 due to clinical improvement. Chest Xray showed subtle reticular shadowing in right lower zone. He was treated with IV antibiotic and kept him Nil by mouth. NG tube was inserted on 02/8/23 for nutrition. Started oral trial on 08/08 as per SALT review along with NG feed. NG tube displaced on 10/08, new NG tune re-inserted. MRI brain was done on 16/8/23 to investigate cause for poor swallowing but no acute cause identified. On 30/8/23 Blood Culture showed streptococcus growth and started on Metronidazole in addition to ceftriaxone that he was already on. He continued to deteriorate so decision was made to proceed with EOL care after discussion with family.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] I have also sent it to [REDACTED], solicitor to [REDACTED], Dentist 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

Scottish Dental Clinical Effectiveness Programme

29/11/2024

2024-0665

Charlie Owen

Berkshire

1. Secretary of State for Defence

On 15 September 2023 I commenced an investigation into the death of Charlie Anthony OWEN aged 25.� The investigation concluded at the end of the inquest on 29 November 2024. The conclusion of the inquest was that: The deceased ended his life by suicide. The assessment of the level of risk posed was appropriate as was the overall plan to address this risk. However there was a failure to pass on all of the pertinent risk management information to those making decisions; the full purpose of asking the deceased to return to barracks was not communicated effectively to him, protective factors mitigating the resulting lack of proximity to family, including meeting him or assessing his welfare on arrival, were not considered.� These factors taken together may possibly have contributed to his death on that day.

On the 11th September 2023 Charlie Anthony Owen was found deceased in his room at the Combermere Barracks, Windsor.� On the 5th September 2023 he had taken action to end his own life which he aborted and sought help from his lieutenant.� This was the second time that he had made, and aborted, an attempt to end his own life; both�of�which�occurred in the context�of�relationship�breakdown. The army arranged a medical and mental health assessment and Charlie denied current intent to end his life in all subsequent conversations with medical and army personnel. Charlie was still assessed as posing a risk to himself and was called back to his battalion.� This was for further assessment and treatment as well as a return to work.� Not all relevant information was shared and considered when plans were made for his return. He left his family home in Wales on the 10th September; having prepared notes indicating an intent to end his life at some point prior to this. After returning to barracks he hung himself.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Charlie Owen I have also sent it to MOD Defence Inquests Unit (DIU) 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.

Service Personnel related deaths | Suicide (from 2015)

Ministry of Defence

24/07/2024

2024-0479

Regan Smith

�Suffolk

1. Secretary of State for Department of Health & Social Care

On 20 December 2023 I commenced an investigation into the death of Regan Edwin James SMITH aged 11. The investigation concluded at the end of the inquest on 23 July 2024. The conclusion of the inquest was that: Narrative Conclusion � Regan�s death was the result of an untreated natural cause, following a missed opportunity to provide medication which would have prevented his death from occurring. The medical cause of death was confirmed as: 1a) Multiorgan Failure 1b) Acute Liver Failure 1c) Diabetic Ketoacidosis

Regan Smith was declared deceased at the Kings College Hospital, Camberwell, in London on the 31st January 2023. On the 23rd January 2023 Regan had begun to breathe in a strange manner, so following a call to NHS 111 he was taken to the Accident and Emergency Department of the Ipswich Hospital. Once there Regan�s father spoke to a doctor who said he would only be checking for laryngitis, so his father took him home with a view to seeing a GP the next day. On the 24th January 2023 Regan was seen at his GP Surgery and laryngitis was diagnosed. On the 25th January 2023 Regan�s breathing changed rapidly, so an ambulance was called. A finger prick test was conducted by the ambulance crew showing Regan�s blood glucose level was much higher than it should have been. Regan was taken to the Accident and Emergency Department of the Ipswich Hospital, but the patient handover between the ambulance personnel and Accident and Emergency personnel was conducted in such a manner as to be ineffective. As a result, the earlier blood glucose test was not recorded on the Accident and Emergency records, and therefore not taken into consideration by treating clinicians at the Ipswich Hospital. Due to Regan�s blood glucose level, he should have had further tests conducted, and it is more likely than not that he would have been immediately admitted, with treatment started to reduce his blood sugar level. However, in the absence of the initial blood glucose level result, no further glucose blood testing was undertaken, and Regan was discharged home with his father later that evening. On the 26th January 2023 Regan collapsed at home, and was taken initially to the Ipswich Hospital, but was transferred to Addenbrookes Hospital due to the seriousness of his condition. Regan had severe metabolic acidosis caused by previously undiagnosed diabetes. Once in the Paediatric Intensive Care Unit at Addenbrookes it was identified that Regan�s liver was beginning to fail, so he was transferred to a specialist unit at the Kings College Hospital in London. Once at the Kings College Hospital Regan�s condition continued to deteriorate until his sad death on the 31st January 2023

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] Chief Executive Officer East of England Ambulance Service NHS Trust Chief Executive Officer East Suffolk & North Essex NHS Trust Chief Executive Officer Cambridge University Hospital (Addenbrookes) NHS Trust Chief Executive Officer Kings College Hospital 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.

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

Department of Health and Social Care

8/8/2024

2024-0436

Gillian Stokes

Surrey

1. Secretary of State for Health & Social Care � 2. President of the Royal College of Radiologists � 3. Chief Executive of the Royal College of Nurses � 4. Medical Director of Ashford & St Peters Trust Medical 5. Family of Mrs Gillian Patricia Stokes

On 15th June 2023, I commenced an investigation into the death of Mrs Gillian Patricia� Stokes. The investigation concluded at the end of the inquest on 8th July 2024. The� conclusion of the inquest was: on 2nd June 2023, Mrs Gillian Patricia Stokes died at the age of 74 years old from sarcoma of the right chest wall at Woking & Sam Beare� Hospice, Woking. Sarcoma is a known complication of life-saving historic radiotherapy� treatment for previous breast cancer in 2013.

Mrs Stokes died of radiation induced sarcoma, which originated in the chest wall.� She� had a history of breast cancer confirmed in a referral by Woking & Sam Beare Hospice. Nine months prior to her death, Mrs Stokes had an investigation into pain in her right� breast. She first attended her GP on 26th October who referred her to a Breast Clinic at� Ashford Hospital. The radiation induced sarcoma was not found on an ultrasound on 10 November 2022.� She attended a Breast Clinic, and her symptoms were investigated, which was said by� the hospital clinicians to be in line with National Guidelines of symptomatic symptoms of patients with breast implants with suspected ALCL (Anaplastic large cell lymphoma).�� The guidance given on investigations, does not include what investigations need to be� carried out on patients with a history of radiation with an implant to ensure the entirety of the chest wall is checked for masses.� �� Furthermore, there is no guidance for clinicians to consider the rare diagnosis of� radiation induced sarcoma, which is said by specialists at the Royal Marsden to be a growing issue, due to the increasing use of radiation combined with reconstructive� surgery in the form of implants.� History of Mrs Stokes treatment� Mrs Stokes was first diagnosed with breast cancer in 2013 and was given chemotherapy and radiotherapy treatments, which included radiation of the chest wall.� She also had a� mastectomy followed by reconstructive surgery which included a breast implant.� � � Between 2013-2018 she returned to the Breast Clinic at Ashford hospital on several �occasions, as she was unhappy with the implant.� She had complained that it had been� positioned too high, was misshapen and too large.� She had a breast reduction and a� further operation to remove some of the scar tissue and excess skin. Due to the multiple operations she continued to have soft tissue scarring and it remained uncomfortable, but she decided not to have any further surgery.� Mrs Stokes had 5 years of surveillance scanning following her breast cancer diagnosis�in case the breast cancer should reoccur.� The latency period for radiation induced� sarcoma can be up to 10 years.� She had an MRI scan on 7th August 2022 to�investigate other issues unrelated to the breast cancer, the scan covered the area where the cancer was later found, but at that time no mass was present.� In October 2022, she reported to her GP surgery that she had a swelling in her breast� area, which resulted in pain around her breast, down her right arm and armpit.� She was referred to the Breast Clinic at Ashford via her GP.� �� As recommended in National Guidelines, the patient underwent a triple assessment for� symptomatic breast disease. The triple assessment consists of 1. Clinical Examination,� 2. Imaging; and 3.� Biopsy of any abnormal finding. Mrs Stokes was seen at the Breast Clinic within the 2-week period of an urgent referral.� �� At the Breast clinic, Mrs Stokes initial clinical examination was conducted by a Nurse� Diagnostician.� The Nurse confirmed in evidence that her examination of Mrs Stokes� chest wall was limited by her breast implant. If she had not had a breast implant, she� would have been able to palpate the mastectomy area and rub it.� This was not possible due to the implant.� �� Mrs Stokes was referred for a mammogram on her left breast, as cancer can often� appear in the other breast following first diagnosis of breast cancer.� This was clear. She was also referred for an ultrasound of her right breast, this was in line with the� national guidance called ABS Best Practice Diagnostic Guidelines Symptomatic Breast. The concern by all three clinicians following Mrs Stokes Presentation at One Stop Clinic, following the clinical examination by the Nurse, an ultrasound by the Radiologist and the Surgeon, was that Mrs Stokes may have an issue regarding ALCL (Anaplastic large cell�lymphoma � a fast and rare growing cancer). This was because liquid was found� surrounding the breast implant.� Some fluid was taken for testing and no malignant cells�or makers or ALCL were found.� This is in accordance with the Royal College of� Radiologists Guidance on screening and symptomatic breast imaging 4th edition, breast� specialists must be aware of the possibility of this rare complication of implant breast� augmentation.� Radiation induced sarcoma was not considered as a possible diagnosis, as the cases� that the Nurse, Radiologist and the Surgeon have experienced present with focal mass or skin change, clinically with a focal mass abnormality associated on imaging which� was not found on ultrasound with Mrs Stokes.�� In evidence and confirmed at the inquest, the radiologist who carried out the�examination in November 2022 confirmed that the examination normally should include� examination of the skin down to the chest wall (which lies posterior to the implant) for� focal masses. In Mrs Stokes case, the position of the implant meant that the radiologist could not see posteriorly to the breast implant with ultrasound imaging, as the image� cannot go beyond the implant and therefore not down to the chest wall.�� The Radiologist confirmed that she could see the surface of the implant and around the� implant, where there was a moderate amount of fluid, but no mass in the breast tissue� and no nodularity related to the surface of the implant. There was therefore in the� clinicians view no suspicion of a sarcoma because no mass was visible on the surface of the breast tissue or around the implant. The implant capsule demonstrated a smooth� contour with no irregularity or nodule surrounding the implant.�I asked both the Nurse and the Radiologist if the fact that they could not carry out a full� examination down to the chest wall was raised at MDT when deciding what�management steps to take next.� I was advised it was not, as it was not a consideration� that there was a focal mass behind the implant.� The patient wanted the implant out and she had not tested positive for ALCL.���������������� � At inquest, I was told by the surgeon that they could not MRI all patients who were in this position.� Furthermore, they confirmed that the guidance did not require them to.�Whereas there is specific guidance for ALCL cases which are also very rare in number� but can be tested by a cytology test (by taking a sample of fluid).� In written evidence doctors from the Royal Marsden, who considered Mrs Stokes case at MDT after the sarcoma was diagnosed, wrote in written evidence that sarcomas are very fast growing and it is evident in this case that Mrs Stokes was as it was not present in�the MRI in August 2022.� �� I had further written witness evidence from a colleague of the Radiologist from Ashford� Hospital who advised whilst they were unable to see anything on ultrasound to suggest� a focal mass was present in November 2022, given the size of the mass on 27 January 2023, there is a possibility that it may have been present if an MRI scan was used in� November 2023, but it is impossible to say.� Royal Marsden also advised that it was not possible to say.� After the One Stop Clinic following the aspiration the Nurse advised in evidence Mrs� Stokes should have had a further review after two weeks, as indicated in the paperwork, but this was not followed through by the hospital and the message was not clearly� communicated to the family.� This would have allowed for further follow up in case the� bulge had increased in size and in pain, but Mrs Stokes was not seen again until�January 2023, as she was reclassed as a cosmetic case following the negative ALCL� tests.������ ���� � Mrs Stokes attended again for an operation on 26th January 2023 and the staging CT scan on 15th March 2023 her sarcoma was classed as inoperable by Royal Marsden. Mrs Stokes was treated palliatively and passed away on 2nd June 2024.� I had invited Ashford Hospital for submissions, but have not received any before completing this report.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of the deceased.� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 & Social Care | Royal College of Radiologists | Royal College of Nursing | Ashford and St Peter�s Hospitals NHS Foundation Trust

08/05/2024

2024-0250

Bobilya Mulonge

Manchester South

1. Secretary of State for Health and Social Care

On 24th May 2023 an investigation was commenced into the death of Bobilya Mulonge then aged 62 years. The investigation concluded at the end of the inquest on 19th April 2024. The conclusion of the inquest was a narrative conclusion that Mrs Mulonge died as a result of congestive cardiac failure against a background of hypertensive heart disease. Ambulance response times probably contributed to her death. � � The medical cause of death being: � 1 (a) Congestive Cardiac Failure (b) Hypertensive Heart Disease � II) Chronic Kidney disease and Type II diabetes mellitus

Mrs Mulonge had multiple co-morbidities including hypertension with a history of hypertensive crisis, stroke, diabetes and she had multiple hospital admissions in 2022. On 24 November 2022 at 06:09 an ambulance was called because her breathing was laboured, and her consciousness was reducing. During the call she became unconscious. When an ambulance arrived 72 minutes later, at 07:24, she was in cardiac arrest. Her heart was restarted but despite appropriate treatment she continued to deteriorate and died at 10:45 on 24 November 2022 at Tameside General Hospital, as a result of congestive cardiac failure against a background of hypertensive heart disease, chronic kidney disease and type II diabetes mellitus. The Inquest heard that the North West Ambulance Service was unable to meet average response standards at the time of the 999 call mainly due to the fact that ambulances were unable to clear the region�s hospitals because of the long waiting times there. In addition, there were high call volumes. A level 4 incident plan was commenced as a result. A number of measures have been undertaken by the North West Ambulance Service to address emergency response times including: Regular meetings take place between the North West Ambulance Service and NHS Trusts in the region to discuss the delays at a regional level. There are faster communications between senior leaders in the North West Ambulance Service and NHS Trusts when there is a period of high demand or delay. North West Ambulance Service managers are deployed to struggling Accident and Emergency departments. A delayed handover checklist is in place. Patients are triaged to assess if they can wait in a waiting room to release ambulances � this is called Fit to Sit. Patients who can be safely grouped with other patients and looked after by one ambulance crew rather than in individual ambulances are placed together to release ambulances. The North West Ambulance Service now has an option to remove crews with 15 minutes notice to the hospital. Batch Divert is in place which allows the North West Ambulance Service to send an ambulance to another hospital. The inquest heard that waiting times across the North West region are still impacted by problems clearing the regions hospitals despite the above measures.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) [REDACTED] on behalf of the family and;2) North West Ambulance Service, 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. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Emergency services related deaths (2019 onwards) This report is being sent to: Department of Health and Social Care

04/01/2024

2024-0006

Elizabeth Roberts

Manchester South

1. Secretary of State for Health and Social Care

On 24th May 2023 an investigation was commenced into the death of Elizabeth Roberts then aged 91 years. The investigation concluded at the end of the inquest on 19th December 2023. I recorded a narrative conclusion that Mrs Roberts died from sepsis with congestive cardiac failure due to underlying ischemic and valvular heart disease with the superimposed physiological burden of sacral ulceration on a background of severe frailty. � The medical cause of death being: � 1a. Sepsis with congestive cardiac failure � 1b. Ischaemic & hypertensive heart disease with superimposed sacral ulceration on background of severe frailty

Mrs Roberts was severely frail and bedbound with urinary and faecal incontinence. She had ischaemic and hypertensive heart disease and developed a large sacral sore with associated sepsis. These conditions precipitated congestive cardiac failure. She was admitted to Tameside General Hospital on 19th May 2023 where despite treatment, she died the same day of Sepsis with congestive cardiac failure. � The inquest heard that Mrs Roberts was supported by care agency carers four times per day and the District Nursing Team. Following a Tissue Viability assessment on 20th April 2023 the frequency of visits by the District Nursing team was increased to daily until Mrs Roberts was admitted to Tameside General Hospital on 19th May 2023. � The Inquest heard that the care agency raised concerns with Adult Social Care because her dressings were not being changed daily. In addition, Mrs Robert�s family raised concerns as did the hospital nurse responsible for Mrs Robert�s care on 19th May 2023. As a result, an investigation was opened by the District Nursing Service. � The Inquest heard that insufficient dressing changes for a sacral sore can lead to localised and systemic infection due to the risk of a sore in that area of the body being contaminated with urine and faeces. � The family were told on several occasions that the nursing team did not have time to change dressings. On 17th May 2023 a nurse did not attend to care for Mrs Roberts due to demands upon the District Nursing Team. The team offered instead an out of hours visit that would have disturbed Mrs Roberts and her family from sleep and so this was not accepted. � The Inquest heard that there are ongoing staffing issues within the District Nursing Team. � Following the Serious Incident Investigation, a number of measures have been undertaken by the Tameside and Glossop Integrated Care NHS Foundation Trust to address issues identified with the care of Mrs Roberts and with the district nursing service generally including: � Introduction of weekly compliance checks for Waterlow, MUST and body mapping policies. All District Nursing Visits deferred to the out of hours service must be approved by Sister of Team leader. � However, the Inquest heard that despite a number of steps taken locally to manage the District Nursing Service such as using a variety of different staffing grades for visits, staffing shortages cannot be rectified by local action without a change of approach nationally.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] [REDACTED], legal representative for the 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. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of 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: Department of Health and Social Care

04/11/2024

2024-0606

Jagjeet Singh

Inner North London

1. Secretary of State for Health and Social Care, Department of Health and Social Care�������������� � 2. Chief Executive, NHS England

On 18 March 2024 an investigation was commenced into the death of� Jagjeet Singh (age 52 years). The investigation concluded at the end of the inquest on 29 October 2024. The medical cause of death was 1a.� acute respiratory depression, 1b. fatal morphine and methadone toxicity, 2. emphysema and bronchopneumonia. The conclusion at�inquest was drug related.

Jagjeet Singh had a long history of intravenous substance misuse,� associated physical health problems and a mental health diagnosis of� EUPD. He spent long and numerous periods in hospital for his physical health, self-harm and suicide attempts, drug overdoses and as a�mental health patient. Between 20 August 2023 and 6 March 2024 he� was an inpatient on a mental health ward but spent periods on medical� wards. Following his discharge from hospital, on 7 March 2024 Mr� Singh went to Mr Singh�s home were they drank beer together and Mr� Singh injected heroin. Mr Singh was alive when his friend left the�property that evening but when he returned the following day, Mr Singh was deceased on the kitchen floor with a syringe next to him.

I have sent a copy of my report to the following. [REDACTED] [REDACTED], 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

NHS England | Department of Health and Social Care

05/12/2023

2023-0498

Kyra Aslam

South Yorkshire (Western)

1. Sheffield Children�s Hospital

On 27 October 2022 I commenced an investigation into the death of Kyra Ali Aslam born on 21 March 2022. The investigation concluded at the end of the inquest on 6 July 2023. The conclusion of the inquest was: Kyra Ali Aslam was admitted to Sheffield Children�s Hospital on 11 August 2022 for a planned procedure to reverse a stoma which had been created in March 2022. Kyra did not recover from the surgical intervention deteriorating relatively rapidly over the course of 2 days. She died at Sheffield Children�s Hospital on 13 August 2022. � The medical cause of death was: � 1a: Faecal peritonitis, bowel infarction and sepsis 1b: Leaking of anastomosis 1c: Closure of colostomy

1.� The consent process for Kyra�s planned surgery in August 2021 did not amount to fully informed consent on the part of Kyra�s parents. It is clear that a decision had been made about the course of action to be pursued and this was put to the parents without description of the risks. The option to delay the surgery until after Kyra was 12 months old which was suggested as a possible consideration with the SI report, was not in accordance with the clinical view of the consultant responsible for Kyra�s care. Having heard evidence from both Kyra�s mother that she was informed this was a much more straight forward surgery than the original surgery which Kyra had and the evidence of the consultant that he could not recall exactly what was discussed with Kyra�s family but he would not have offered them clinically unsuitable options (ie waiting until after Kyra was 1 year old) The risks of the procedure were not adequately explained to Kyra�s parents at the time of the procedure by the consultant. The consent for the procedure was in effect done twice, there was no evidence either way of what risks were described to Kyra�s family by the anaesthetic consultant who also sought consent for the procedure. 2. Notwithstanding my finding above, it is clear that it would never have been a clinical option open to Kyra�s family to simply wait until after Kyra was older than 12 months for the procedure. That does not negate the fact that informed consent requires adequate explanation of the risks involved in the procedure being undertaken (including in this case the 1-2% risk of anastomosis). On the balance of probabilities that the finding that fully informed consent was not provided by Kyra�s family on the basis of the evidence from Kyra�s mother that the impression she was left with was that this was a much less risky procedure this does not change the evidence of the consultant that this surgery was a necessary surgery and it was the only clinically suitable option for Kyra. Therefore even in the context of full disclosure of the data of all of the risks, on the balance of probabilities the surgery would have proceeded and therefore the outcome for Kyra would have been the same. � 3. On the basis of the evidence available it was not evident to the consultant or his colleagues, during the procedure, that there was any interruption to the blood supply to Kyra or that there was any issue with the suturing and sealing of the bowel. It was not obvious to the consultant or his colleagues that there was likely to be future issues with the blood supply to the bowel or anastomosis. � 4. Kyra was unwell after the surgery and her mother was identifying that she was not behaving either how she normally would or how she had after her earlier surgery which Kyra�s mother had been led to believe was a much more significant surgery. Kyra mother�s concerns were explained by the medical team as matters which were normal within the context of pain, anaesthetic response and surgery. On the balance of probabilities I find that insufficient weight was placed on Kyra�s mothers concerns. These ought to have been more clearly explored with her to understand whether there was anything in �mother�s intuition� that ought to lead medics to consider alternative causes for Kyra�s presentation. However, in the circumstances the explanations preferred by the medical teams were within the context of reasonable medical opinion and therefore I am satisfied that on 11 August 2021 the insufficient weight placed on Kyra�s mother�s observations did not make a difference to the outcome for Kyra. � 5. On 12 August 2021 Kyra began vomiting. This was a concern for the nursing staff, along with the temperature and the fact that her heart rate was elevated. It was on the 12 August 2021 that I heard evidence the nursing staff were thinking Kyra may have sepsis. Kyra was prescribed antibiotics and was given IV fluid to try and support her. � 6. The nursing staff had significant concerns about Kyra and raised those concerns with medical staff as frequently as they felt able to do. I am satisfied on the basis of the evidence which I have heard, that the nursing staff supporting Kyra raised the concerns as soon as they were able to do so and as regularly as required to safeguard Kyra. � 7. It is apparent that anastomosis within 48 hours of the procedure is a rare condition. The result of that is that it was not something which was high on the list of differential diagnosis the medics were considering and instead the medics formed the view that ileus was the most likely cause of the deterioration. � 8. This was a possible diagnosis that all of the medics were working towards and that none of the medics considered that escalation to intensive care was required. I also heard evidence from the Consultant that even if he had been considering sepsis he would not have escalated care to intensive care as Kyra�s management was suitable for ward level management. � 9. On the balance of probabilities, that insufficient weight was placed on the nursing concerns about Kyra. The nursing staff were the best placed to identify the overall holistic view of Kyra�s condition and they had significant concerns about her deterioration. � 10. The medics appeared to place little weight on the observations and concerns instead placing significant weight on their own observations and the lack of expected signs of anastomosis and/or peritonitis. � 11. That said, the diagnosis which the medics were considering the most likely was within the range of possible reasonable diagnosis which applied to Kyra�s presentation. On the balance of probabilities that the medics had not ruled out sepsis or other conditions for Kyra but that they incorrectly worked on the basis of what they believed the most likely diagnosis. The findings cannot be made with the benefit of hindsight, clearly their diagnosis was the wrong one and this was apparent during the surgery on the 13 August 2021. However the working diagnosis was within the spectrum of reasonable possible diagnosis and the treatment the medics provided was appropriate for that diagnosis.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Kyra�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 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) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Sheffield Children�s NHS Foundation Trust

10/05/2023

2023-0376

James Philliskirk

South Yorkshire (Western) Category: Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Sheffield Children�s NHS Foundation Trust

1. Sheffield Children�s NHS Foundation Trust Sheffield Children�s NHS Foundation Trust

On 13 October 2022 I commenced an investigation into the death of James Philliskirk born on 11 January 2021. The investigation concluded at the end of the inquest on 24 April 2023. The conclusion of the inquest was:- � James was referred to hospital on 12 May 2022. Following a number of assessments in hospital, James was misdiagnosed and was not provided with treatment in line with departmental guidance. He developed sepsis and died at home on 13 May 2022. His death was contributed to by neglect. The medical cause of death was: 1a: Sepsis 1b: Group A streptococcus skin infection

James had had chicken pox and recovered in April 2022. He returned to nursery and on 10 May 2022 nursery reported that James was more clingy than normal and seemed like he may be unwell. His parents monitored him and determined on 12 May 2022 that they would seek medical support. They saw the family GP who reviewed James, heard that there may have been exposure to Scarlett Fever at nursery and heard him make a groaning noise which concerned him so he sent James into Sheffield Children�s Hospital A&E with his father. � James was seen by a triage nurse and a clinical fellow and a diagnosis of chicken pox was made. James had a lesion on his right wrist which ought to have been looked at more closely and the fact that he had recently had and recovered from chicken pox ought to have generated a senior review of his condition. James was sent home. � James� mother returned from work and felt that he was more unwell. As a result she sought support from 111 who spent some time speaking to James� mother and heard James groaning. They asked James� parents to take him into A&E within the hour but the sooner the better for further assessment. � James returned to A&E with his mother and was reviewed by the same triage nurse. He was reviewed by a junior doctor who formed the view that the first episode of chicken pox must be a mis-diagnosis and he persisted with a diagnosis of chicken pox. Again, the fact that James had been brought back into A&E so soon and the suggestion of a reinfection with chicken pox should have generated a senior clinical review but it did not. � James was sent home and continued to be unwell that evening. His mother and father determined they would return the following day however James died at home in the night. � A post mortem revealed that he had developed sepsis. � I heard evidence from the Hospital that had James been sent into A&E through the usual GP referral route then he would have been triaged and seen in the medical unit which would have greater level of senior oversight, a different set of more detailed guidance for re infection with chicken pox and would have stayed for longer making it more likely that the groaning would have been heard. All of this would make it more likely that James would have lived. � There were however significant opportunities for James� condition to be identified in A&E notwithstanding this process change. It was also apparent in evidence that James should have had senior escalation and the lesion on his wrist should have been identified as being different from a normal presentation of chicken pox. � A&E hold a handbook which provides advice and guidance on a vast array of conditions which may be seen in A&E. This is inevitably not as detailed as the medical guidance issued to specialties at the hospital. Crucial sections of the specialist guidance were not easily identifiable in the A&E handbook including the need to seek senior advice in certain circumstances or identify the risks from recent reinfection of chicken pox. This guidance therefore was not able to influence decision making of clinicians looking after James in hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED]������ and Sheffield Children�s 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 other person who I believe may find it useful or of interest. In this case I have sent a copy of this report to NHS England, NHS Digital and to NHS South Yorkshire ICB. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of 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) | Hospital Death (Clinical Procedures and medical management) related deaths

27/03/2024

2024-0173

Saffra Winn

South Yorkshire West

1. Sheffield City Council

On 29 September 2022 an investigation was commenced into the death of Saffra Harriett Winn. An inquest started on 18 March and concluded on 19 March 2024. The cause of death was: 1 (a) Multiple injuries 1 (b) Fall from height

At approximately 5.55am on 24 July 2022, Saffra was found on the pavement between two blocks of high-rise flats, known as Martin and Burlington. Emergency services were called, and police and paramedics attended the scene. On arrival, paramedics notes that Saffra was unconscious, was not breathing and had suffered extensive injuries that were beyond medical assistance and were incompatible with life. Life was declared extinct by paramedics at 6.08am. � The police conducted an investigation, and saw that the window of Saffra�s flat, [REDACTED], was open above the area where she was found. The police concluded that it was likely that Saffra had jumped or fallen from the window of her [REDACTED] flat [REDACTED]. The police came to that conclusion for the following reasons: � CCTV was reviewed from the flats which showed Saffra falling from the building and showed that no person had entered or exited her flat during the relevant times. The flat door was locked from the inside, with the key in the lock. There were foot/scuff marks on the internal and external window sills. There was no evidence of an intention by Saffra to take her own life. � The council did not conduct a post-incident safety inspection of the windows in the flat, beyond the usual post-tenancy inspection. The police found that the safety restrictor on the window had been manually disengaged to allow it to open fully.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any 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: Sheffield City Council

20/11/2023

2023-0517

Gareth Etchells-Height

South Yorkshire (Western)

1. Sheffield Health and Social Care Trust

On 20 September 2022 an investigation was commences into the death of Gareth Etchells-Height born on 13 July 1979. The investigation concluded at the end of the inquest on 10 October 2023. The conclusion of the inquest was a narrative one and read: Following a deterioration in his mental health, Gareth Micheal Etchells-Heights died at the Wainwright Centre, 48 Wainwright Crescent, Sheffield, where he was found [REDACTED] by support staff with a ligature�[REDACTED]. Gareth intended to take his own life. There were various missed opportunities during Gareth�s care, and his death was contributed to by a missed opportunity to communicate to him that he would not be discharged from the Wainwright Centre on 25 April 2022. The cause of death was: (1)(a) Asphyxiation by ligature

In January 2022, Gareth�s mental health began to deteriorate culminating in an incident on 17 February 2022 when he was attended up by the British Transport Police at Sheffield Train Station and placed on a s.136, meaning that he was removed from the train station to a place of safety at the Longley Centre in Sheffield. � Gareth was then subject to an assessment under the Mental Health Act between 23:05 hours on 17/02/2022 and 03:15 hours on 18/02/2022. During this assessment, Gareth was presenting with symptoms of psychosis, including delusional and persecutory thoughts. The assessment that was made of Gareth was that it was unclear whether the psychosis was long standing, or drug induced, and that Gareth was at risk of death by misadventure or retaliatory action. � In circumstances where there was a query about whether the psychosis was drug induced, that �usual practice would be to monitor for 2 -3 days if drug induced psychosis�; this was not done on 18/02/2022. � Gareth stayed for the remainder of the morning in the s.136 suite at the Longley Centre before leaving at approximately 11:30 hours. At approximately 14:30 Gareth phone HTT worried about his own safety. By 16:16 hours on 18/02/2022, the police had re-referred Gareth for assessment at the Longley Centre using their s.136 powers. He was then re- assessed between 14:00 and 19:45 hrs on 19/02/2022. � The view that was taken by the assessing team was that Gareth�s paranoid beliefs had progressed to identifying individuals colluding against him and that his �presentation was markedly different� to the previous assessment. It was assessed that the risk of �significant self-harm was very high and � that the only option was to admit to hospital under s.2 of the MHA.� � Gareth was then admitted to Maple Ward on 19 February 2022 and remained an inpatient until 22nd March 2022, when he was moved to a step-down bed at Wainwright Crescent. It should be noted that Gareth�s section expired on 18th March 2022, and so he remained for the final few days as a voluntary inpatient. � Sadly, Gareth�s condition continued to deteriorate until in the early hours of the morning on 24 April 2022, he tied a ligature [REDACTED] at Wainwright Crescent Before Gareth died, he wrote a collection of notes were referred to as suicide notes.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. In this case I have sent a copy of this report to the CQC, the Local Authority and South Yorkshire Integrated Care Board. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of 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: Sheffield Health and Social Care Trust

02/06/2024

2024-0552

Sewa Chaddha

Berkshire

1. Slough Pharmacy (formerly Lloyds Pharmacy) 10 Upton Lee Parade, Wexham Road, Slough 2. Berkshire Integrated Care Board 3.�[REDACTED], Contractor Support Officer, Community Pharmacy England, Thames Valley 4. Chief Executive, Local Pharmacy Commission 5. Chief Executive, General Pharmaceutical Council 6. Chief Executive, National Pharmaceutical Association 7. NHS Specialist Pharmacy Service 8. Medication And Healthcare Products Regulatory Agency

On 27 March 2024 I commenced an investigation into the death of Sewa Kaur Chaddha, then aged 82. The investigation concluded at the end of the inquest on 24 May 2024. The conclusion of the inquest was accident, the medical cause of death being: I a Hyponatraemia I b Treatment for Hypoglycaemia I c Ingestion of Hypoglycaemic Medication II Frailty of Old Age, Decompensated Heart Failure, Cognitive Impairment

(1) Mrs Chaddha had been living with her husband in Slough. They both had a number of physical health conditions requiring multiple prescribed medications. They both had cognitive impairment due to their age. (2) On 5 May 2023 Mrs Chaddha was found collapsed on the floor at their home. It was discovered that she had been taking her husbands medication instead of her own for several days, including diabetes medication. Her blood sugar levels were found to be extremely low. (3) She died on 10 May 2023 at Wexham Park Hospital of hyponatraemia caused by the necessary treatment for hypoglycaemia which was in turn caused by the accidental ingestion of hypoglycaemic medication.

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. I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] I have also sent it to [REDACTED], Kumar Medical Centre who 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

Slough Pharmacy | �Berkshire Integrated Care Board | Community Pharmacy England | Local Pharmacy Commission | General Pharmaceutical Council | National Pharmaceutical Association | NHS Specialist Pharmacy Service | Medication And Healthcare Products Regulatory Agency

20/01/2024

2024-0036

Rachel Mortimer

South Yorkshire West Category: Suicide (from 2015) | Alcohol, drug and medication related deaths This report is being sent to: South West Yorkshire Partnership Trust

1. South West Yorkshire Partnership Trust South West Yorkshire Partnership Trust

On 10 July 2023 I commenced an investigation into the death of Rachel Louise MORTIMER. The investigation concluded at the end of the inquest on 12 January 2024. The conclusion of the inquest was suicide. � The medical cause of death was: � 1a�� Hanging in the context of cocaine and alcohol usage 1b 1c � II

On 25 June 2023 Rachel Mortimer took her own life . She was found by her son in her garden hanging�[REDACTED]. In December 2022 Rachel Mortimer took an overdose of [REDACTED]. A Mental health act assessment was undertaken but she was not deemed to require sectioning at this time. On 18 June 2023 Rachel was seen by the Mental Health Liaison Team (MHLT) at Barnsley Hospital after taking an overdose of prescribed [REDACTED] and trying to hang herself. She said she had been having suicidal thoughts for a long time, she did not regret her actions and that thoughts of her family did not stop her. She was assessed by the MHLT as having risk of future impulsive self harm and suicide when using alcohol and risk of further deterioration of her mental state without timely appropriate mental health support to develop coping skills. She was referred to IHBTT and was discharged from hospital. No MHA assessment was undertaken. She was seen by IHBTT and her risks of emotional dysregulation without engaging in therapy and risk of harmful alcohol use were identified. She was to be referred to BSARCS and told to refer herself to recovery services as mitigation. She was assessed as low risk of suicide even though she had initially stated she was not regretful of what done and disappointed that she had not died, she was assessed as not having current suicidal thoughts or intentions of suicide and wanted to engage in therapy. She was provided with contact numbers to call if she wanted to discuss her mental health at any time. � Unfortunately, whilst she was referred to BSARCS she was not accepted. Despite this being a risk factor no other mitigation was offered at this time and therefore the risk was not mitigated. �� On 21 June at 4pm IBHTT Rachel�s mother contacted IHBTT with concerns, she was told that Rachel should contact the GP for access to services and that they could not provide any information due to data protection. At no point was Mrs Mortimer provided any information on what to do if she was concerned for Rachels safety such as taking her to ED or that Rachel could contact certain mental health services to discuss her feelings in a crisis. A further call was made at 5.30pm, an hour and a half later, by Rachel�s son, who expressed concerns that she was expressing suicidal ideas, again no signposting was given. A further call was made on the same day by paramedics with concerns and again they were told that she had been advised to contact her GP. No signposting was provided or consideration given to the fact previously identified risks which had not been mitigated and she was drinking which had been identified as having a risk of future impulsive self harm and suicide. � Despite these 3 contacts by family and paramedics, at no point was any safety netting in terms of the options available if they were concerned provided, such as to take her to ED or for her to call any mental health services given. A phone call was made that evening to Rachel but as Police were with her she was unable to discuss and asked for a call back later which was not answered. � IHBTT discussed Rachel on 22 June 2023 and decided she should be called for a review of her mental state and risks and to offer secondary mental health follow up. 7 telephone calls were made between 22 and 26 June with no success. IHBTT knowing that she had had 2 previous suicide attempts, had risk factors that had not been mitigated and had recently been contacted on by family with significant concerns that she was suicidal the IHBTT treatment team took no further action and on 26 June, with no contact, assessed her as low risk due to lack of contact.

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

13/08/2024

2024-0454

Kial Thurman

Staffordshire and Stoke-on-Trent

1. Staffordshire County Council

On 18th December 2023 an investigation was commenced into the death of Kial Ryce� Thurman. The investigation concluded at the end of the inquest on 2nd August 2024. The� conclusion of the inquest was that Kial Ryce Thurman died in a road traffic collision on 1st December 2023.

Kial was driving a transit van at speed along the A518 in the Lower Loxley area of� Staffordshire heading in the direction of Uttoxeter when he lost control while navigating a� right-hand bend immediately before a bridge that crossed the River Blythe.� Either because Kial over-corrected his steering, or because the van hit the nearside kerb and rebounded,� the van entered the opposing carriageway and into the path of an HGV. The impact�caused the van to enter the river.� Kial suffered multiple injuries and died at the scene.

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

Staffordshire County Council

25/05/2023

2023-0176

Jean Hardy

Newcastle upon Tyne and North Tyneside

1. Sunderland City Council

On 14 February 2020 I commenced an investigation into the death of Jean HARDY. The investigation concluded at the end of the inquest on 24th April 2023. The conclusion of the inquest was � Road Traffic Collision 1a Multi-Organ Failure � 1b Head, Chest and Pelvic Injuries

On 4th February 2020 Jean Hardy (JH), a 71-year-old lady (generally fit and well), crossed the B1286 Doxford Parkway Sunderland from the Southside to the Westbound carriageway. She did so, at a point where there was no designated pedestrian crossing, when it was dark and when the carriageway was illuminated by street lighting. � JH was struck by a motor vehicle and sustained multiple Injuries that led to her death within RVI Newcastle Upon Tyne on 8th February 2020.

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

Road (Highways Safety) related deaths This report is being sent to: Sunderland City Council

15/07/2024

2024-0373

Megan Davison

Hertfordshire

1. THE SECRETARY OF STATE FOR HEALTH� 2.THE CHIEF EXECUTIVE OFFICER AND CHIEF FINANCE OFFICER OF HERTFORDSHIRE AND WEST ESSEX INTEGRATED CARE BOARD

On 7 August 2017 an investigation was commenced by the Senior Coroner for Hertfordshire into� the death of Megan Leanne DAVISON. The investigation concluded at the end of an inquest� heard on 28th March 2018.� The first inquest conclusion was quashed and a fresh investigation directed by the High Court on 17th May 2022. A second inquest was heard by me from 24th June 2024 to 10th July 2024.� The conclusion of the inquest was: �� Ms Davison died by suicide in the context of personality disorder and Type 1 diabetes with� disordered eating (also known as T1DE).� The medical cause of death was:� 1a Suspension �� 1b�� � 1c� �� �II� Personality Disorder and Type 1 Diabetes with Disordered Eating (also known as T1DE)

Megan Davison was found deceased at her home address on 4th August 2017, having hanged herself with the intention of ending her life. �� The following issues possibly made a more than minimal contribution to Ms Davison�s death: � (a) Ms Davison�s discharge from the care of the Mental Health Trust on 1st August 2017; � (b) Lack of integration between mental health and physical healthcare systems; � (c) Absence of a recognised diagnosis for Type 1 Diabetes with Disordered Eating (also known as T1DE) and absence of pathways of care for T1DE and Diabetic Ketoacidosis (by way of� physical and mental health protocols);� � (d) Lack of consolidated records and direct communication systems between different parts of the healthcare system.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Megan Davison�s family Hertfordshire Partnership University NHS Foundation Trust The Priory Hayes Grove Royal Free London NHS Trust East and North Hertfordshire NHS Trust North Middlesex University Hospital NHS Trust I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015)� � This report is being sent to: Department of Health and Social Care | Hertfordshire and West Essex Integrated Care Board

27/03/2024

2024-0176

Matthew Terrill

South Yorkshire West

1. The Chief Constable, South Yorkshire Police Headquarters, Carbrook House, 5 Carbrook Hall Road, Sheffield, S9 2EH

On 30 April 2020 an investigation was commenced into the death of Matthew Terrill. An inquest started on 19 February 2024 and concluded on 8 March 2024. � The cause of death was: � 1(a) Cardiorespiratory arrest. 1(b) Hypoxic ischemic brain injury. 1(c) �Cocaine, [REDACTED](synthetic cannabinoids), heroin, pregabalin, gabapentin and dihydrocodeine toxicity (with associated acute agitation), and ischemic heart disease.

On 22 April 2020, Matthew Terrill was taken into custody at Shepcote Lane Custody Suite, Sheffield by officers from South Yorkshire Police who had arrested him in the community. At the time of his arrest, Matthew was intoxicated by drugs (including, Cocaine, [REDACTED](synthetic cannabinoids), heroin, pregabalin, gabapentin and dihydrocodeine). � An ambulance was called by officers in the community at 11.27am and cancelled at 11.43am. Matthew arrived at Shepcote Custody Suite at 11.56am. There is an attempted booking in procedure for Matthew between approximately 11.57am and 12.05pm, during which time Matthew was exhibiting behaviour of drug intoxication, possibly combined with acute mental health symptoms, and ultimately required restraint by officers. Matthew was restrained and escorted to a cell before he was assessed by healthcare professionals stationed at Shepcote Lane, of which there were two on shift and available. Healthcare professionals were unable to assess Matthew in his cell during the restraint by officers, which lasted for approximately 11 minutes. Matthew was then put on level 4 constant observations with two police officers (including the arresting officer) assigned to him. This period of observation lasted roughly between 12.16pm and 13.28pm, when it was noted that Matthew was no longer breathing. No further medical assessment was carried out during the period of observation. The evidence before the Court was that the officers assigned to constant observations had limited experience of carrying out the task and had not been briefed by the custody sergeant.

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

Alcohol, drug and medication related deaths This report is being sent to: South Yorkshire Police Headquarters

10/01/2025

2025-0017

Eden Street

City of Kingston Upon Hull and the County of the East Riding of Yorkshire

1. The Chief Executive of the Humber Teaching NHS Foundation Trust

On 1st July 2021, I commenced an investigation into the death of Eden Anna Street, aged 13 years. The investigation concluded at the end of the inquest on 11th December 2024. The conclusion of the inquest was: SUICIDE.

Eden Anna Street displayed traits from a very early age which would be consistent with Autism. Several of her family members were also affected with neurodiversity issues. Her Mother was concerned about her behaviour and communication issues and referrals to the Child and Adolescent Mental Health Services took place, although the first referral was rejected. She was also diagnosed with Tourette�s Syndrome and when the diagnosis was made, her tics and involuntary movements improved. She was on the waiting list for both creative therapy as well as the East Yorkshire Autistic Service. She received good pastoral support from her school. Despite concern about suicidal thoughts that she had written on the school lavatory wall which resulted in her mother contacting CAMHS, which occasioned an immediate risk assessment to take place, nothing immediate was identified. A decision was made to expedite the start of creative therapy but due to the practitioner�s care load being full of cases of equal, if not greater acuity, this did not prove possible. Eden was found suspended by her sister in the bedroom�[REDACTED]. The emergency services attended and continued resuscitation that had been started by her parents, but despite this, she could not be revived and was declared deceased on the night of 27th June 2021. It is not possible to determine on the evidence available whether earlier diagnosis of Autism or the institution of creative therapy would have avoided her death on the day it occurred.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family:�������� [REDACTED] Humber Teaching Chief Executive; ERYC; safeguarding Children Kingston Upon Hull . 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. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child death (from 2015) | Suicide (from 2015)

Humber Teaching NHS Foundation Trust

02/08/2024

2024-0424

Raymond Brattley

Kingston Upon Hull and the County of the East Riding of Yorkshire

1. The Chief Executive of the Royal Society for the Prevention of Accidents

On 16th January 2024, I commenced an investigation into the death of Raymond Brattley, aged 71 years. The investigation concluded at the end of the inquest on 13th June 2024. The conclusion of the inquest was: ACCIDENT

These are set out in my summary and findings of facts which are attached. � � Raymond BRATTLEY was a heavy cigarette smoker, who on a number of previous occasions placed partly extinguished cigarette ends into a wastepaper bin in his flat, which subsequently caught fire, but these were successfully extinguished. On 8th January 2024, a fire resulted in his flat from careless smoking, which engulfed Mr Brattley resulting in him developing widespread full thickness burns to his entire body from which he rapidly died at the scene.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of Raymond BRATTLEY, the CQC, the Station Manager and Fire Investigator at Humberside Fire and Rescue Service, Humber Mental Health, [REDACTED] Of Howes Percival Solicitors and the Chief Inspector for the Crown Premises Fire Safety Inspectorate. � 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: Royal Society for the Prevention of Accidents

02/12/2024

2024-0658

Alfie Hinton

West Yorkshire Western

1. Airedale NHS Foundation Trust

On 21 May 2019 I commenced an investigation into the death of Alfie HINTON aged 23 minutes.� The investigation concluded at the end of the inquest on 13 November 2024.� The conclusion of the inquest was that: Baby Alfie Hinton died as a consequence of hypoxic ischemic brain injury sustained during the intrapartum period arising from delays in the management of his medical care.������� His death was contributed to by neglect.

Baby Alfie Hinton died at Airedale Hospital on the 10th May 2019 as a consequence of complete umbilical cord occlusion leading to hypoxic ischemic brain injury. In the days leading up to his death and whilst in utero, Alfie experienced a period of chronic hypoxia arising from placental insufficiency which made him more vulnerable to any further hypoxic events. On� the� 8th����� May� 2019,� Alfie�s� mum� was� admitted� to� hospital� through� the� Maternity Assessment Centre for Induction of Labour as a consequence of extremely high levels of bile acids, which were recorded at 149, with anything over 100 increasing the risk of stillbirth tenfold.� Induction of labour was requested �as soon as possible�, the expectation being� that� the� induction� would� commence,� at� the� latest,� the� following� morning,� but induction was in fact commenced at 2250 hours on the 9th May 2019, following a significant delay arising from the unavailability of beds on the Labour Ward. Once Induction of Labour commenced, the plan was for six hourly fetal monitoring with additional monitoring at the point when contractions commenced.� At some point between 0700 hours and 0904 hours on the morning of the 10th May 2019, Alfie experienced an acute hypoxic event from which he recovered, the effects of this event would have been recognised earlier had monitoring taken place on time or alternatively at the point when contractions commenced.�� At the time contractions commenced, staff on the ward were engaged with other patients, consequently, there was no one to inform.� The scheduled six hourly monitoring was delayed by 39 minutes with bradycardia being identified soon after the commencement of the trace. The bradycardia was not acted upon immediately and therefore preparations for birth were delayed.� There were further delays once preparations commenced and at some point during the 12 minutes prior to Alfie�s delivery at 1441, a complete cord occlusion occurred from which Alfie was unable to recover. Upon delivery his heart was slow and despite resuscitation attempts Alfie did not survive. Alfie�s death was confirmed at 1504 hours the same day.

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

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

Airedale NHS Foundation Trust

27/11/2023

2023-0474

Mohammed Akram

Inner North London

1. Barnet Enfield and Haringey Mental Health NHS Trust

On 27 March 2023 an investigation was commenced into the death of Mohammed Zeeshan Akram, date of birth 22 November 1993. The investigation concluded at the end of the inquest on 6 September 2023. The conclusion was suicide. The medical cause of death was 1a. multiorgan failure; 1b. acute ethylene glycol toxicity; 2. mental health disorder.

Zee had a history of suicidal ideation and reported suicide attempts dating back to his childhood. In February 2019 he was diagnosed with a psychotic disorder. He received support for his mental health from the Crisis Team in 2019 and spent two days as a mental health inpatient. � In December 2022 Zee reported panic attacks and auditory hallucinations. He was taken on by the Crisis Team who prescribed diazepam, zopiclone, olanzapine and fluoxetine. On 30 December there was a joint review by the Home Treatment Team and Haringey (BEH) Early Intervention Service (EIS) at St Ann�s Hospital and Zee was allocated a care coordinator. On 30 December Zee was discharged from the Home Treatment Team who wrote asking the GP to continue repeating his medications which were zopiclone [REDACTED]olanzapine [REDACTED], fluoxetine [REDACTED]and diazepam [REDACTED]. � In February 2023 Zee�s mental health deteriorated. On 15 February he reported EIS that he was experiencing negative side effects from his medication but that he felt mostly optimistic. He requested a reduction of olanzapine. � There was an exchange of text messages between Zee and a dual diagnosis recovery worker between 17 February and 15 March in which Zee appeared upbeat, said that he was attending work and gave no cause for the recovery worker to be concerned. � On 16 March Zee attended an appointment and informed his recovery worker that he had stopped taking his olanzapine and fluoxetine 2 weeks previously due to numbness that had led to suicidal ideation. The recovery worker went out of his way to arrange an urgent medical review for Monday 20 March. Zee was given safety netting advice. � After this appointment, Zee went to [REDACTED] where he spent several hours contemplating throwing himself into the Thames. He did not inform his recovery worker of this or contact the crisis team. � On Friday 17 March the recovery worker sent Zee a text message with the appointment for a medical review on Monday 20 March. Zee replied that he was unable to make the appointment as he was working on the Monday and so the appointment was rearranged for Tuesday 21 March. � On 20 March Zee did not attend work. A friend went to his flat and found Zee unresponsive. Zee was taken to the Whittington Hospital where he died on 21 March 2023.

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

Suicide (from 2015) This report is being sent to: Barnet Enfield and Haringey Mental Health NHS Trust

13/01/2025

2025-0019

Aarav Chopra

Birmingham and Solihull

1. Birmingham Women�s and Children�s NHS Foundation Trust 2. Department of Health & Social Care

On 23 May 2024 I commenced an investigation into the death of Aarav Pal CHOPRA. The� investigation concluded at the end of the inquest. The conclusion of the inquest was:� Aarav died from the consequences of a cardiac arrest caused by severe bleeding following� damage to an intercostal artery during a liver biopsy which went undiagnosed and untreated at the time of the procedure. His death was contributed to by poor planning before the procedure when� there was no consideration of stopping antiplatelet medication, poor written and oral� communication about the complication that occurred during the procedure all of which hampered� treatment after his collapse. His death was contributed to by neglect.

Aarav was born with biliary atresia which meant the bile flow out of his liver was blocked. Due to� this a Kasai portoenterostomy was undertaken on 26/10/20 to bypass the blockage and ensure the bile drained into the intestine. In February 2023 he presented with fever and worsening jaundice� and was treated as an inpatient for cholangitis and worsening liver failure. He was placed on the� transplant list in April 2023 and received a transplant on 15/08/23. Post transplant he developed� hepatic artery thrombosis, which is a recognised complication of liver transplant, requiring further�surgery to reconstruct the blood flow for the liver and bile ducts. The bile ducts were found to have� been damaged by this complication. He was placed on dual antiplatelet therapy to try to avoid any� further similar complications. The effect of antiplatelet medication is to impede the ability of the� blood to clot effectively. Aarav went on to develop rejection of the graft liver and was found to have severe stenosis of the reconstructed bile ducts and had drains inserted. The rejection was treated,� and he was able to go home on 23/10/23 on immunosuppressant medication to return for further� tests a short time later. He was admitted on 20/11/23 for those further tests which included a� percutaneous transhepatic cholangiogram (PTC), a liver biopsy and removal of a vas catheter line� which were all undertaken on 21/11/23. Prior to the procedure no consideration was given to� stopping his dual antiplatelet therapy which should have been stopped a week before and the� clinicians involved in the procedure were unaware he was on antiplatelet medication. The PTC� proceeded without problem. The first attempt at the liver biopsy was undertaken by a trainee who� placed a coaxial needle into the 7th intercostal space. The needle could not be seen on imaging� and was withdrawn. It was not appreciated at the time that the needle did not follow the correct� pathway which damaged an intercostal artery which started to bleed. A second attempt was made� in the 8th intercostal space, and a liver biopsy was obtained. A vas catheter was removed. A�fluoroscopy undertaken at the end of the procedure at 12.10 identified blood in the pleural space� (haemothorax) but this was not identified as significant at the time and was not treated or�communicated to other staff caring for Aarav. The operation record did not record that 2 attempts�were made to obtain a liver biopsy nor that there were any concerns about a haemothorax. In�recovery Aarav was agitated and 2 out of 4 blood pressures could not be recorded. He returned to� the ward at 12.50 after 20 minutes in recovery and only 1 blood pressure could be recorded at�13.15 which was low and at the same time he had a high heart rate. Aarav continued to be agitated and cold and it was not appreciated that he needed further review. Aarav went into cardiac arrest�at 13.30 and received resuscitation for 28 minutes before being moved to PICU for stabilisation. An US at 14.00 confirmed a large haemothorax however a chest drain was not inserted at this time.� There was no joined up discussion about how to best treat Aarav and it was unclear who was� leading decision making for the complication that had occurred. Aarav was taken back to the� interventional radiology theatre at around 16.30/17.00 where they identified a puncture of the intercostal artery which was embolised and a chest drain was inserted. On return to PICU it was confirmed that sadly Aarav had suffered a hypoxic brain injury during the prolonged arrest and he�passed away on 22/11/23. Had the haemothorax been addressed at the time of the procedure Aarav would likely have been monitored and treated before the cardiac arrest.� Following a post mortem, the medical cause of death was determined to be:� �1a�� Hypoxic ischaemic encephalopathy� �1b�� Significant bleeding into the pleural space with pressure on the heart� �1c�� Damage to the intercostal artery during liver biopsy� �1d �� �II���� Liver transplant due to biliary atresia

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

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

Birmingham Women�s and Children�s NHS Foundation Trust | Department of Health & Social Care

30/08/2024

2024-0475

Felix Hartley

�West Sussex

1. British Association of Perinatal Medicine 2. NHS England & NHS Improvement 3. University Hospitals Sussex NHS Foundation Trust

On 15 March 2023 I commenced an investigation into the death of Felix Burton HARTLEY aged 1 Days.� The investigation concluded at the end of the inquest on 19 August 2024. The conclusion of the inquest was that: Felix Burton Hartley was born at 41+5 days without a heartbeat on 19 February 2023 at the Princess Royal Hospital, Haywards Heath, West Sussex. He was resuscitated after his birth but had been without a heartbeat for around 20 minutes at the time of his birth. He received treatment but sadly could not recover from the hypoxia and chorioamnionitis which was present at his birth. The chorioamnionitis was not known prior to his birth but would have impacted his physiological reserve to withstand the hypoxia.

Felix Burton Hartley was born at 41+5 days without a heartbeat on 19 February 2023 at the Princess Royal Hospital, Haywards Heath, West Sussex. He was resuscitated after his birth but had been without a heartbeat for around 20 minutes at the time of his birth. He received treatment but sadly could not recover from the hypoxia and chorioamnionitis which was present at his birth. The chorioamnionitis was not known prior to his birth but would have impacted his physiological reserve to withstand the hypoxia.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] [REDACTED]� Maternity and Newborn Safety Investigations Special Health Authority (MSNI) 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)

British Association of Perinatal Medicine | NHS England | University Hospitals Sussex NHS Foundation Trust

18/06/2024

2024-0328

Jacob Shorter

South Yorkshire West

1. Calderdale Council

On 19 October 2023 I commenced an investigation into the death of Jacob Lee Shorter, 19 years old. The investigation concluded at the end of the inquest on 18 June 2024. The conclusion of the inquest was suicide. The medical cause of death was 1a multiple injuries including complete disruption of the torso and skull fracture. .

Jacob was in long term foster care. Following his 18th birthday he was under the pathways leaving care team. He was subject to an education, health and care plan and was still receiving support from William Henry Smith School and received therapy sessions from them. He was seen by a pathways advisor and had an independent visitor in place. In May and June 2023 professionals meetings concerns were expressed about his low mood and he was encouraged to attend his GP with his foster carer. The GP report confirms there was no low moods or anxiety reports apart from the 24 November 2023 appointment that he attended with his foster carer where treatment was discussed and he wanted to think about his options. His foster carer contacted the local authority in September 2023 after he had told her his feelings had gone downhill and she was not given any strategies to help him. The independent visitor discussed his wellbeing with him on 3 December 2023 where he said he had felt suicidal in the past but did not currently feel this way. This information was not passed on to his foster carer or to the pathways team. He was seen again on 31 December 2023 where he was reported to be doing well and no concerns were raised about his emotional wellbeing. On new years day Jacob left home and mentioned about having choices to his foster carer. He did not say where he was going and did not return home. On 1 January 2024 Jacob made his way onto the train tracks at Heeley Loop in Sheffield. He was seen on the track in the four foot area. [REDACTED] � It was dark and raining heavily that evening. The train driver applied the emergency brake. Jacob made no attempt to move. There was no time to sound the horn. Unfortunately the train was unable to stop in time and impacted with Jacob causing fatal injuries. Investigations were undertaken that could not establish how Jacob had accessed the train lines. In that area I heard there is more than standard security, with fences and walls. There is pedestrian access and vehicle access gates, but these were locked and everything was in order.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of Jacob Lee Shorter 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) | Railway related deaths This report is being sent to: Calderdale Council

20/12/2023

2023-0536

Joanne Constable

Cambridgeshire and Peterborough

1. Cambridgeshire County Council

On 10 August 2020 I commenced an investigation into the death of Joanne Comstable aged 52 years. The investigation concluded at the end of the inquest on 30 October 2020. The conclusion of the inquest was that: � Joanne died from multiple unsurvivable injuries sustained in a road traffic collision on the A141 Isle of Ely Way in Cambridgeshire when the motorcycle on which she was a passenger was in collision with a tractor whose view of the road was obscured by overhanging trees and vegetation.

On 2 August 2020, Joanne Constable was the passenger on a motorbike which collided with a trailer being pulled by a tractor as it turned right out of a field onto the A141 Isle of Ely Way near Wimblington, Cambridgeshire. Due to vegetation growth of trees and bushes on the verge of the public highway, the tractor driver�s line of sight was obstructed, making it impossible to assess whether there was adequate time and distance to safely exit the junction. Consequently, the motorbike�s path was blocked by the trailer and the rider could not take evasive action in time to avoid the collision. Mrs Constable was thrown from the motorbike in the collision, sustaining multiple injuries and she was pronounced deceased at 1150 hours.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Family of Joanne Constable 2. [REDACTED] The insurers for�[REDACTED] as landowner and tractor driver respectively Cambridgeshire County Council. � I have also sent it to Cambridgeshire Constabulary who investigated the road traffic collision and therefore may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form.� He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

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

10/10/2024

2024-0539

Florence Stewart

Milton Keynes

1. Central North West London NHS Foundation Trust

On 26 January 2024 I commenced an investigation into the death of Florence Elizabeth Catherine STEWART aged 27. The investigation concluded at the end of the inquest on 09 October 2024. The conclusion of the inquest was that: Narrative conclusion Narrative conclusion � suicide whilst suffering from mental illness having been admitted as a voluntary patient to the Campbell Centre Milton Keynes following her detention under s. 136 of the mental health act, after an incident when she was assaulted on 18th January 2024.

The deceased suffered from mental illness and was admitted to the Campbell Centre in Milton Keynes as a voluntary patient following her detention under S.136 of the Mental Health Act after an incident when she was assaulted om 18th January 2024. When an inpatient she was subject to high level intermittent observations. She [REDACTED] but this was unknown to members of staff. The observations were not carried out efficiently and the detection of her hanging was delayed. She hanged herself�[REDACTED] and suffered a hypoxic brain injury on the 20th January 2024. When found she was attached to a defibrillator�the pads were incorrectly placed. She was given oxygen but the oxygen bottle ran out of oxygen during resuscitation. She died at Milton Keynes University Hospital on 23rd January 2024.

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

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

Central North West London NHS Foundation Trust

08/12/2023

2023-0516

Charlene Roberts

Manchester North

1. Chair of the Faculty for Eating Disorders Royal College of Psychiatrists 2. Medicines and Healthcare Products Regulatory Agency 3.�[REDACTED], Greater Manchester Health and Social Care Partnership/ Integrated Care Board 4. Chief Executive Officer of NHS England

On the 13th January 2023, I commenced an investigation into the death of Charlene Roberts, date of birth 12th March 1987 who died on the 12th January 2023 at Fairfield General Hospital. The medical cause of her death was confirmed as 1a) Cyclizine Toxicity 2) Aspiration Pneumonia, Anorexia and Factitious Disorder

CIRCUMSTANCES OF DEATH Charlene was an extremely complex patient who could be difficult to engage. She had a complex diagnosis of Anorexia (since early 2000s), Factitious disorder (2019) and cyclizine abuse (2019). All of these were linked to past trauma. It is recognised at the outset of this report that this is a rare presentation. Charlene was under the care of Greater Manchester Eating Disorder Service (Greater Manchester Mental Health Trust), the Community Mental Health Team for her Factitious Disorder (Pennine Care NHS Foundation Trust), a Dual diagnosis worker for her cyclizine abuse. Due to her eating disorder her weight and bloods were monitored by her GP in the community. However her physical health meant she was often admitted to the acute hospitals, in particular North Manchester General Hospital (Manchester Foundation Trust) and Royal Oldham Hospital (Northern Care Alliance.) [REDACTED] She had initially been prescribed cyclizine around 2014 when she was an inpatient. The prescribing of cyclizine had continued unquestioned for over 5 years�and at one point for reasons that could not be ascertained she was prescribed it intravenously. [REDACTED]. However she was consistently found interfering with cannulas and lines (PIC lines) when she was an inpatient and would inject cyclizine in to them. It had been recognised by medical staff that she should not have lines inserted. If there was a clear medical reason for them to be placed when she was an inpatient, she would require 1-1 observations. Her care had been escalated in 2022 to the Multi Risk Management process. It was accepted that Charlene was at a significant risk of death due to her eating disorder and her cyclizine abuse. Charlene had capacity to make decisions in relation to her use of cyclizine. She was not able to be detained under the Mental Health Act 1983. From mid 2022 until the time of her death all professionals accepted that they had run out of ideas and options as to how to make progress with Charlene. She was rejected from nearly 20 inpatient Specialist Eating Disorder Services predominantly due to the dual diagnosis of her substance abuse and eating disorder. There was no treatment for her addiction to cyclizine, only psychological therapy to work on her addiction. On the 10th January 2022 Charlene attended A&E at Fairfield General hospital to have her weekly bloods taken. This was a recent arrangement due to difficulties for the GP in finding somewhere for her to have bloods taken. Due to being compromised Charlene required ultrasound guidance to obtain bloods. She was physically unwell with a suspected infection and was admitted as an inpatient. On the 12th January 2022 Charlene�s condition deteriorated and she went into cardiac arrest. She died at 10:34am. Following her death it was discovered she had left the ward on the 11th January 2022 and taken an uber taxi to a local pharmacist where she had purchased cyclizine. Her cause of death following examination was found to be due to cyclizine toxicity.

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

Alcohol, drugs medication related deaths | Mental Health related deaths This report is being sent to: Royal College of Psychiatrists | Medicines and Healthcare Products Regulatory Agency | Greater Manchester Health and Social Care Partnership/Integrated Care Board | NHS England

26/05/2023

2023-0174

Jessica Hodgkinson

Derby and Derbyshire

1. Chesterfield Royal Hospital NHS Foundation Trust

On 5 October 2021 I commenced an investigation into the death of Jessica Hodgkinson (�Jess�). The investigation concluded at the end of the inquest on 27 January 2023. The narrative conclusion of the inquest was: �Jess died on 14 May 2021 due to a pulmonary embolism that arose from a deep vein thrombosis (the risk of this was increased by the KTS) as well as acute anaphylaxis of unknown cause. There was a failure to ensure that Jess received anticoagulant medication that a clinician had intended should be taken until birth. This failure made a more than minimal, negligible or trivial contribution to Jess� death on 14 May 2021.�

Jess was born on 9 August 1994. Jess died on 14 May 2021 at the Chesterfield Royal Hospital shortly after giving birth to her daughter. Jess had a high risk pregnancy. This was primarily due to Jess� severe hypertension. Jess also had a rare condition known as Klippel-Trenaunay Syndrome (�KTS�) which created an increased risk of Jess developing a deep vein thrombosis/pulmonary embolism. The main challenge during Jess� pregnancy was her hypertension. The inquest found, however, that Jess� hypertension was managed appropriately by her consultant in Chesterfield with input from a specialist renal physician. � As to KTS, the inquest found that there was no documented evidence of clinicians in Chesterfield having properly considered the impact that KTS may have on Jess� pregnancy. The inquest found that this did not, however, contribute to Jess� death. � On 21 April 2021 a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting. The consultant gave evidence at the inquest that the intention was for Jess to continue to receive a daily dose of anticoagulant medication up until birth. Jess was then transferred to a hospital in Sheffield on 22 April 2021. There was a failure to communicate to the hospital in Sheffield the plan for ongoing prophylactic anticoagulant medication to continue until birth. This meant that the team in Sheffield were unaware of the plan for prophylactic anticoagulant medication to continue until birth. Jess was discharged from the hospital in Sheffield on 26 April 2021 back into the care of the team in Chesterfield without any anticoagulant medication. � During the subsequent weeks following the discharge from Sheffield, clinicians in Chesterfield failed to identify that Jess was no longer receiving the anticoagulant medication that Jess� consultant in Chesterfield had intended would be taken until birth. A clinician gave evidence at the inquest that she would have restarted the tinzaparin had she been aware that Jess was no longer receiving it upon her discharge from Sheffield. The inquest found that if Jess had received the daily anticoagulant medication as the clinician in Chesterfield had intended, it is more likely than not that the pulmonary embolism would not have occurred. Therefore, the failure to ensure that Jess received the intended anticoagulant medication up until birth made a more than minimal, negligible or trivial contribution to her death on 14 May 2021. � On 13 May 2021 Jess attended the Chesterfield Royal Hospital and a decision was made to carry out an emergency caesarean section. The procedure was successful and Jess� baby was born. Shortly after delivery, Jess went into cardiac arrest. Despite the very best efforts of the attending clinicians, Jess died on 14 May 2021. A post mortem examination took place. The cause of death was a pulmonary embolism that arose due to a deep vein thrombosis (the risk of this was increased by the KTS). Jess also died as a result of an acute anaphylaxis. It was not possible to identify the cause of the anaphylaxis but the inquest heard evidence that it could have been caused by an antibiotic despite Jess having no known allergies. � The inquest found that the efforts of those involved in the resuscitation were exemplary.

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

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

31/12/2022

Coroner Area: Hampshire, Portsmouth and Southampton Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: REDACTED 2023-0008

Anthony Blower

1. Chief Coroner � PFD Reports 2. [REDACTED] 3. [REDACTED]

On 03 November 2020 I commenced an investigation into the death of Anthony David BLOWER aged 83. The investigation concluded at the end of the inquest on 08 December 2022. The conclusion of the inquest was that: � On the 25th October 2020 Anthony David Blower died at his home address in Sussex Road, Petersfield. He had sustained a number of falls in September 2020, was admitted to hospital and diagnosed with bilateral subdural haematoma. He underwent burr hole surgery on the 26th September 2020. Mr Blower was transferred to Queen Alexandra Hospital on the 13th October 2020 and found on the floor next to his bed at 21.00 on the 14th October 2020, on the 20th and 21st October 2020 his condition declined significantly . A CT scan revealed further bleeding, Mr Blower did not undergo further surgery and received palliative care.

The deceased died following a fall which caused an initial bleed affecting his brain. He suffered from pre-existing cardiac conditions and cerebral amyloid angiopathy which may have contributed to the initial fall and the bleeds to his brain. The impact of his age and multiple medical conditions complicated his treatment and impacted recovery.

10/11/2023

2023-0443

Frances Newbury

Inner North London

1. Chief Executive London Ambulance Service NHS Trust 220 Waterloo Road London SE1 8SD

On 9 June 2023 an investigation was commenced into the death of Frances Ann Newbury aged 61 years. The investigation concluded at the end of the inquest on 10 November 2023. The medical cause of death was 1a. Acute polydrug toxicity ([REDACTED]); 1b. substance misuse disorder; 2. chronic lung disease. The conclusion of the inquest was drug related.

Frances Newbury was found unconscious and not breathing by her partner on the morning of 20 May 2023 at their home address. London Ambulance Service was called at 09:04 and arrived at 09:09. Ms Newbury�s partner reported to the attending paramedics that she had taken [REDACTED] at approximately 21:00 the evening before. � Ms Newbury had a long history of drug abuse,[REDACTED] . At post-mortem she was found to have �popping� scars on the anterior and posterior aspects of both thighs and on both shins. Toxicology examination found [REDACTED] in her system. � During ALS resuscitation attempts, paramedics inserted an igel, used a LUCAS2 device, inserted an intraosseous needle into her left tibial plateau and administered 10 doses of adrenaline, sodium chloride and intravenous glucose.

I have sent a copy of my report to the following. ��������[REDACTED], Partner of Francess Newbury ������� 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.

Alcohol, drug and medication related deaths This report is being sent to: London Ambulance Service NHS Trust

22/12/2023

2024-0104

Larry Spriggs

Surrey

1. Chief Executive Officer Surrey and Borders Partnership NHS Foundation Trust

On 10th June 2021 I commenced an investigation into the death of Larry Stephen SPRIGGS. The investigation concluded at the end of the inquest on 7th December 2022. The inquest was heard without a Jury. � Mr. SPRIGGS died of: 1a. Multiple Injuries � The jury returned the following narrative conclusion: Frimley Park (23rd May � 25th May) Mr Spriggs was admitted to Frimley Park hospital on the 23 rd May 2021 after attempting to commit suicide by overdosing [REDACTED]. He was assessed as suffering a mental health crisis and placed into a highrisk category. He was kept at Frimley Park Hospital until he was transferred to Farnham Road Hospital. Farnham Road (25th May � 27th May) Upon admission to Victoria ward at Farnham Road on the 25th May 2021 at 6:45pm, Mr Spriggs�s risk was assessed as low, compared to the assessment of his risk at Frimley Park hospital as high. Upon clerking-in he presented as calm, regretful and rational, presenting as low risk to self with no suicidal ideation at the time. The reduction from a previously assessed level of high risk to low risk made a possible contribution to his death as this may have impacted the urgency of the risk management plan. The assessment did however recommend that 1-1 observations should continue. During the first night of his stay in Farnham Road Hospital, Mr Spriggs attempted to self-discharge in the early hours of the morning due to high dissatisfaction of the room, isolation and observation regime. Mr Spriggs was persuaded to remain on the ward by staff. The consultant psychiatrist on the ward made a preliminary diagnosis for Mr Spriggs of an acute stress reaction, he noted that Mr Spriggs displayed no symptoms to have reached the threshold for pathological mental illness. The consultant psychiatrist did note that Mr Spriggs displayed fluctuating levels of anxiety from the collateral history. The consultant psychiatrist prescribed no anti- anxiety medication at this time and the failure to do so possibly contributed to Mr Spriggs death. Mr Spriggs was offered anti-hypertension medication following high blood pressure readings on the 26th May 2021 but turned it down. On the 27th May 2021 he decided to proceed with taking this medication when offered again. The decision to reduce Mr Spriggs observations from 1-1 to intermittent was made on the 26th May 2021 following assessment. The reduction in observations to intermittent made a material contribution to Mr Spriggs death. Mr Spriggs was not expecting the environment he was placed into (both the setup of his room and the isolation period which was policy at the time for Covid-19) this led to a higher state of anxiety, reflected in the distressed texts sent to his partner. His partner received additional distressed texts from Mr Spriggs on the 26th May 2021, stating �get me out of here� and �it feels like a prison� and �there is something in my tea� Following a conversation between a member of staff and Mr Spriggs partner, the details of these texts were recorded on Mr Spriggs records. Staff on the following shift failed to make themselves aware of this important information. This failure made a material contribution to Mr Spriggs death 27th May. On the morning of the 27 th May 2021, during a review of his blood test results Mr Spriggs was offered anti-hypertensive medication, vitamin D tablets and sleeping medication, which he was then willing to take. Mr Spriggs had reported to the doctor that his room and the isolation was causing him a lack of sleep and that he was not feeling very well. On the morning of the 27th May 2021� Mr Spriggs was in communication with his partner still telling her that he wanted to leave but that he had to call her back as staff members had entered his room for observations. At 9:48pm on the 27th May 2021, Mr Spriggs was given his medication that had been offered earlier in the day. At approximately 9:52pm on the 27th May 2021, the CCTV picks up the last movement from inside Mr Spriggs room. Between 9:54pm -9:57pm on the 27th May 2021, Mr Spriggs exited the window and fell to the ground which was recorded on CCTV. [REDACTED] � Observations on the night of the 27th May 2021 On the evening of Mr Spriggs death, the observations that were carried out on Mr Spriggs were inadequate. There were inconsistencies in the quality of observations, the observation sheet was pre-populated with observation timings, the timing of observations were not random, inaccurate engagement codes were entered onto the observation sheet and conversations with Mr Spriggs did not take place, these failures made a material contribution to Mr Spriggs death. Following from these inadequate observations, the handover to the next HCA did not take place verbally and the inaccurate observation sheet was left in the lounge on the ward, instead of in the nurses station. Induction training for staff on the evening of 27th May 2021 was inadequate and failed to explain what an observation should include and how they were to be carried out. The second sheet of the formal induction checklist document for the evening of the 27th May 2021 was not signed by the inductor. The effect of these failures meant that arrangements to manage the observation regime were inadequate and made a material contribution to Mr Spriggs death. The death was contributed to by Neglect. The death was caused or more than minimally contributed to by the failure on the part of Surrey and Borders Partnership NHS Foundation Trust to ensure the adequate implementation of intermittent observations in relation to Mr Spriggs�s care. Larry Stephen Spriggs died as a result of misadventure.

The circumstances of the death are recorded in the Jury�s Narrative Conclusion.

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

Mental Health related death This report is being sent to: Surrey and Boarders Partnership NHS Foundation Trust

27/07/2023

2023-0275

Johanne Blackwood

Essex

1. Chief Executive Officer of Essex Partnership NHS Trust, Paul Scott, Essex Partnership University NHS Foundation Trust, The Lodge, Lodge Approach, Runwe/1, Wickford, SS11 7XX

On 15th June 2021 I commenced an investigation into the death of Johanne Blackwood, aged 55 years. The investigation concluded at the end of the inquest on the 11th May 2023. � Johanne Blackwood (known as Jo) died on the 12th of June 2021 when she placed herself in the path of a train [REDACTED] The medical cause of death was confirmed as �1a Multiple traumatic injuries�, 1b �Collision with train (locomotive). � In a narrative conclusion I recorded that the deceased took her own life on a background of diagnoses of severe and long-standing mental health disorders including Persistent Delusional Disorder, Mixed Anxiety and Depressive Disorder and Panic Disorder. I concluded, inter alia, that an inappropriate over� reliance upon family members to keep a vulnerable and high-risk person safe in the community, over an extended period, probably contributed to Jo taking her own life.

A central aspect of Jo�s delusional beliefs was that (a) she had not slept for years and (b) that she suffered from a fatal physical health condition. The desperation engendered by her delusional and medically entirely unfounded beliefs led to a number of suicide attempts and both voluntary and compulsory admissions to mental health units. � On the pt May 2021 Jo had attempted suicide [REDACTED] , some five weeks later, she would end her life. In the light of this incident her community risk assessment, her care plan and her safety plan were not up-dated � as they had not been since the date of her last discharge as a mental health in-patient on the 18th December 2020. � Whilst her high risk of suicide was acknowledged by the community mental health team responsible for her safety � and care, management and treatment � in the community, and notwithstanding the context of the Covid-19 pandemic, I found an inappropriate over-reliance upon her family members, principally her husband and son, to keep Jo safe in the community. This involved the family monitoring Jo 24 hours a day, seven days a week over an extended period and physically preventing her from leaving her home address unaccompanied . � This over-reliance was misguided and placed an unfair and unsustainable burden on the family, particularly in the light of a highly concerning text message sent by Jo to her Care Coordinator threatening suicide on the 11th June, the day before she took her own life. Following receipt of the text and seemingly reassured in part by Jo�s apparent retraction of the threat later that day, there was a failure to undertake an urgent face to face assessment by the community team to establish whether a referral to the Crisis Team was necessary; this specific failure possibly contributed to the subsequent death. � In the circumstances I concluded that an inappropriate over-reliance upon family members to keep such a vulnerable and high-risk person safe in the community, over an extended period of time, probably contributed to Jo taking her own life on the 12th June 2021.

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

Suicide (from 2015) | Railway related deaths This report is being sent to: Essex Partnership NHS Trust

14/03/2024

2024-0144

Ernest Smith

Essex

1. Chief Executive Officer of Princess Alexandra NHS Trust

On 20 April 2023 an investigation was commenced into the death of Ernest Smith, aged 77 years. Ernest Smith died on 10 April 2023. The investigation concluded at the inquest on 26 February 2024. The conclusion of the inquest was narrative: Mr Smith developed left leg haematoma secondary to prophylactic anticoagulation for venous thromboembolism. Mr Smith developed septic infection that did not respond to treatment. With a medical cause of death of 1a Sepsis 1b Hospital Acquired Pneumonia and Infected Haematoma 1c Haematoma Secondary to Anticoagulation, 2 Type II Diabetes Mellitus, Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease

Ernest Smith died at the Princess Alexandra Hospital on 10 April 2023 due to Sepsis due to Hospital Acquired Pneumonia and Infected Haematoma. The Haematoma was secondary to Anticoagulation in a background of Type II Diabetes Mellitus, Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease. Mr Smith was admitted to hospital on 22 February 2023 unwell. Mr Smith received prophylactic anticoagulation to prevent blood clots and was noted to have stripe type bruising on his lower limbs on 10 March and required a medical review that was undertaken on the evening of 12 March and the anticoagulation was stopped on 13th March following the development of a left leg haematoma requiring surgical evacuation and debridement. Mr Smith was discharged for rehabilitation on 17 March and readmitted on 23 March with bleeding from the haematoma. Mr Smith was noted to have purulent infection on 30 March and the surgical team awaited advice from Broomfield Hospital. Antibiotics were commenced on 3 April and Mr Smith was septic on 4 April and underwent debridement of his haematoma on 5 April. Mr Smith continued on antibiotic therapy on the advice of microbiology and developed pneumonia, he deteriorated over 9th April and 10 April.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Wife of Mr Smith � 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: Princess Alexandra NHS Trust

26/09/2024

2024-0514

Charne Petit

Surrey

1. Chief Executive Surrey and Borders Partnership Trust Chair 2. NHS England

On 30th May 2023 an inquest was opened into the death of Charne Nikita Petit. The inquest was concluded on 30th July 2024.�� The medical cause of death was: 1a. Suspension. The narrative conclusion was that: Charne Petit suffered from psychotic delusions which she found extremely� distressing. From 2019 to 2022 she was treated by the early intervention in� psychosis team. Thereafter her care was transferred to the community mental�health team. Her symptoms and mood fluctuated, in addition, on occasions, non- compliance with anti-psychotic medication and use of illicit drugs triggered relapses in her mental health.�� On the 26th March 2023 she suffered a psychotic breakdown and was assessed� under the Mental Health Act and found to meet the requirements for detention�under s2. No mental health bed was available. She was nursed one to one in the� Royal Surrey County Hospital by nurses from the psychiatric liaison team. She was� re-started on aripiprazole and her mood stabilized. She was discharged to the�home treatment team on the 31st March 2023 without an assessment followed by� medical treatment in a mental health hospital.�� On the 24th April she was seen by her care coordinator and reported intrusive� psychotic delusions and struggling to manage her emotions. On the 25th April 2023 she represented to Royal Surrey County Hospital having abused drugs. She was� assessed not to require a mental health assessment and discharged. On the 12th�May 2023 she killed herself by suspending herself�[REDACTED]. The death was preventable with more� effective treatment of her psychosis. The lack of a mental health bed after she was�assessed as detainable under s2 more than minimally contributed to the death.� She died by Suicide

See the details set out in the narrative conclusion. In addition: Ms Petit was reviewed in hospital on the 29th March 2023 by a consultant from the liaison psychiatry team. Her presentation had improved since admission and in his opinion, so� long as she continued to improve, she could be discharged to the home treatment team� and that this was the least restrictive option.�� The effect of the discharge on the 31st March 2023 was that Ms Petit was not admitted to� a mental health hospital under section 2 of the Mental Health Act 1983 and was therefore discharged without having been assessed comprehensively in a mental health hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� Chief Coroner�� Ms Petit�s Family�� Hopewell House�� Royal Surrey County Hospital�� I have also sent it to the Royal College of Psychiatrists and Surrey County Council who may find it useful or of interest.� I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� I may also send a copy of your response to any 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

Surrey and Borders Partnership Trust | NHS England

04/03/2024

2024-0119

Stanley Cummins

County Durham and Darlington

1. Chief Executive of County Durham and Darlington NHS Foundation Trust

On the 16th of September 2022 an investigation into the death of Stanley Cummins, aged 84, was commenced . The investigation concluded at the end of the inquest on 1st of March 2024. The conclusion of the inquest was a narrative conclusion as follows: Stanley Cummins, who was 84 years old, died at his home address on the 2nd of September 2022. His death was caused by a pressure ulcer to his heel which became necrotic and led to sepsis. The pressure ulcer was caused as a result of the deceased sitting for long periods of time in a chair and pushing his heel onto the floor in an attempt to reposition, as he was in discomfort from damage which he had also sustained to his bottom. The pressure damage occurred in his care home between the 18th of July and the 2nd of August 2022, where he had been admitted for rehabilitation. � The ulcer was an avoidable injury with appropriate care and management of the known high risk of pressure damage. Despite pressure damage being noted to the deceased including to his buttocks and legs there were no comprehensive changes to his care regime, to reduce the risks of further damage occurring, or to manage the pressure damage that had already been caused, becoming worse. There was no referral to the District Nursing team or other professionals for further advice in relation to pressure damage. � If the skin had been appropriately monitored it is likely that the early effects of pressure damage to the heel would have also been identified, at which point pressure relief and offloading should have been provided. � Once the deceased returned home and the pressure damage to the left heel was identified, no offloading advice or recommendations were given to family and carers from the nursing team responsible for his care, and it is likely that despite the deceased�s other risk factors for pressure damage and for delayed healing of such, that with appropriate advice and care, namely complete offloading, amongst other measures, that further deterioration and evolution of the wound, would have been avoided. � The deceased died of sepsis, the underlying cause of this was the pressure sore to the left heel which developed into a necrotic ulcer. The wound was preventable with appropriate care and further deterioration of the wound was also preventable. � The death was contributed to by neglect.

Stanley Cummins, who was 84 years old, died at his home address on the 2nd of September 2022 where he had been discharged on a palliative basis. His death was caused by a pressure ulcer to his heel which became necrotic and led to sepsis.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � the family of Stanley Cummins, and to the care home in which he resided for a time. � 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: County Durham and Darlington NHS Foundation Trust

06/05/2024

2024-0286

Peter Dickens

Nottinghamshire

1. Chief Executive, Cygnet Health Care

On the 23rd January 2022, I commenced an investigation into the death of Peter Angus Dickens. The investigation concluded at the end of the inquest on the 28th March 2024 � The conclusion of the inquest was a narrative conclusion as follows: � Peter Dickens died at Bassetlaw District General Hospital on 22.1.22, following an episode of choking on a sandwich at Beeches where he was a resident. He was vulnerable, with autism and severe learning disability, the subject of a Deprivation of Liberty Safeguard order. He required full one to one support for all his needs, including support at mealtimes, to prevent him over filling his mouth and eating too quickly. The choking episode led to airway obstruction and to his death. His risk of choking was known and was a real and imminent risk to his life- he had had previous known episodes of life threatening choking. The Eating and Drinking plan that was in place to reduce choking risk and ensure close one to one support at mealtimes, also set out the process for safe food preparation and that a two plate system should be used to control Peters speed of eating and to ensure he did not overfill his mouth. This Guidance was not followed on the afternoon of his death, and this led directly to the choking incident that led to his death. There was also non compliance with the Eating and Drinking guidance many times prior to the day of Peters death, there was a lack of oversight of compliance with the guidance by Beeches managerial and multidisciplinary team staff, and the guidance was not adapted to reflect Peters high level of stress at Beeches, and how this was affecting the care staff�s ability to comply with the Eating and Drinking guidance. All these omissions in care made a more than minimal, negligible, or trivial contribution to his death. Peters death was contributed to by neglect

Peter died at Bassetlaw District General Hospital on 22.1.22, following an episode of choking on a sandwich, at The Beeches, where he was a resident. Detailed findings as to how, by what means and in what broad circumstances he came by his death, are set out in a written Determination dated 28.3.24, appended to this Regulation 28 report.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED], Parents of Peter Lincolnshire County Council Care Quality Commission � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Cygnet Health Care

28/05/2024

2024-0285

Christine Booker

Dorset

1. Chief Executive, Dorset County Hospital NHS Foundation Trust

On the 8th March 2023, an investigation was commenced into the death of Christine Rita Booker, born on the 6th October 1943. � The investigation concluded at the end of the Inquest on the 17th May 2024. The Medical Cause of Death was: la Haemorrhagic shock � lb Iatrogenic injury of right pelvic blood vessels le 2 � � The conclusion of the Inquest recorded that Christine Rita Booker died as a consequence of a complication of elective hip replacement surgery.

Christine Rita Booker underwent an elective right total hip replacement at the Winterbourne Hospital, operated by Circle Health Group, on 23rd February 2023. During the procedure, and in order to adequately secure the acetabular cup to her hip socket, the consultant orthopaedic surgeon, [REDACTED] drilled a hole in the socket to accommodate a 20mm screw. Blood flowed from the drill hole, which stopped upon the insertion of the screw. Mrs Booker lost approximately 500ml of blood in the operation, which is at the upper level of the expected blood loss. Mrs Booker initially appeared to recover as expected following such a procedure, but became severely unwell at approximately 18.55 when her blood pressure became unrecordable. Measures were taken to resuscitate and stabilise Mrs Booker and she was transferred to Dorset County Hospital for ongoing treatment and imaging. The imaging demonstrated extensive intraperitoneal and extraperitoneal blood, likely as a consequence of the surgery. Following a conversation with a vascular surgeon it was determined that Mrs Booker required embolization of the bedding vessels. However, there is no out of hours interventional radiology at Dorset County Hospital. Therefore, Mrs Booker was transferred to the Royal Bournemouth Hospital for the embolization of the bleeding vessels by interventional radiology. Following the embolization, she initially stabilised, but deteriorated again on 24th February 2023. Christine Rita Booker died at the Royal Bournemouth Hospital on 24th February 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Humphries Kirk Solicitors, representing the family of Mrs Booker; Keystone Law, representing [REDACTED] DAC Beachcroft Solicitors, representing Circle Health Group � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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