Inquests (PFDs)

04/03/2024

2024-0124

Sandra Senior

Inner North London

1. Chief Executive, London Borough of Camden Council, 5 Pancras Square, London, N1C 4AG

On 6 October 2023, an investigation was commenced into the death of Sandra Elizabeth SENIOR, then aged 58 years. The investigation concluded at the end of an inquest, heard by me, on 28 February 2024. The conclusion of the inquest was suicide, the medical cause of death being: 1a multiple traumatic injuries

On 24 September 2023, Sandra Senior travelled to central London. While there she gained access to Tavistock Chambers, Bloomsbury, WC1A; a building comprising of commercial units on the ground floor, with four floors of residential accommodation above. � [REDACTED] completed suicide [REDACTED]

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

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

25/11/2024

2024-0645

Jaipreet Panesar

Berkshire

1. Chief Executive, Oxford Health NHS Foundation Trust

INVESTIGATION The family requested me to refer to the deceased as Jai. I will reflect that in this report. I conducted an inquest into the death of Jai which concluded on 21st of November 2024. I recorded a conclusion of suicide.

Jai was a 36 year old GP. She was found deceased on 27th of April 2023. I have not detailed all of Jai�s contact with mental health services in this report. Instead, I have focused on aspects of the chronology which are relevant to the concerns I am raising. Jai referred herself to the Crisis Response and Home Treatment Team (�the crisis team�) on 21st of June 2022. She attended three appointments in June and July 2022, and was discharged from the crisis team to Buckinghamshire Talking Therapies (�BTT�) on 29th of July 2022. Whilst under this team, Jai disclosed that she had made previous suicide attempts. From August 2022 onwards, the mental health support that Jai received was from teams other than BTT. These teams used a different electronic records system (called Rio). They are part of the same NHS trust, but it was not possible for clinicians to access both systems. After an attempt to refer Jai to the crisis team (by her GP) on 31st of August 2022, Jai was provided with an appointment date with the community mental health team. The appointment date was 8th of September 2022. Before that appointment could happen, Jai attended accident and emergency (after being encouraged to do so by friends and her GP). She was then admitted as a voluntary patient to a psychiatric ward, until 7th of September 2022. After she was discharged, Jai was under the crisis team for around 10 days. After that, no medium or long term plan was put in place, and she was discharged back to the care of her GP. Jai took her own life in April 2023. She was not under secondary mental health services at the time of her death.

I have sent a copy of my report to the Chief Coroner and to Jai�s family, via their legal representative. I have also sent this report to the following recipients who have an interest in this matter: 1.�� NHS England � I consider that these issues are likely to be national rather than only local; 2.�� Legal representative for the GP practice involved in this case; and 3. [REDACTED], Senior Coroner for Buckinghamshire, as a matter of courtesy. 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.

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

Oxford Health NHS Foundation Trust

14/10/2024

2024-0549

Stephen Dulling

North Yorkshire and York

1. Chief Executive, Tees Esk and Wear Valley NHS Foundation Trust 2. Chief Executive, York and Scarborough Teaching Hospitals NHS Foundation Trust

On 11 September 2023 I commenced an investigation into the death of Stephen Frederick DULLING aged 69. The investigation concluded at the end of the inquest on 07 October 2024. The conclusion of the inquest was that: Stephen Frederick Dulling died from aspiration pneumonia as a consequence of an inappropriate diet as a hospital in-patient at York District Hospital.

On the 31st of August 2023 Stephen Frederick Dulling, who had Parkinson�s Disease, symptoms of dementia and attendant swallowing problems, was admitted to the Acute Medical Unit of York District Hospital. On the morning of the 2nd of September 2023 Mr Dulling was eating toast for breakfast when he started to choke and went into cardiac arrest. He was subsequently found to have copious amounts of toast in his airway and gastric contents in his lungs leading to aspiration pneumonia. Mr Dulling died at the hospital on the 4th of September 2023.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Tees Esk and Wear Valley NHS Foundation Trust | York and Scarborough Teaching Hospitals NHS Foundation Trust

09/01/2024

2024-0014

Tom Sweeting

West London

1. Chief Executive, West London NHS Trust

On 15 October 2021 I commenced an investigation into the death of Tom Sweeting, age 51. The investigation concluded at the end of the inquest on 20 December 2023. Medical cause of death 1a Cerebral hypoxia 1b Hanging The Conclusion was as follows: suicide

Tom suffered a sudden acute deterioration in his mental health, exhibiting signs of a depressive disorder in August 2021. He sought medical assistance and was assessed by the Hounslow liaison psychiatry service on 18th August. At that time he did not disclose any plans to take his own life, but did confirm he was having suicidal thoughts and thoughts that he could not continue living. Due to poor communication from the hospital to the General Practise, the intended prescription for antidepressant medication was not provided. On 20th August 2021 Tom locked himself in the garage at home, [REDACTED] and was found later that morning suspended by ligature. Resuscitation attempts were unsuccessful.

I have sent a copy of my report to the Chief Coroner and to the local safeguarding board where the deceased was under 18 and to the following Interested Persons Family members [REDACTED] � friend [REDACTED] -GP [REDACTED] � GP London Ambulance Service � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any 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: West London NHS Trust

17/11/2023

2023-0460

Sarah Read

Lancashire and Blackburn with Darwen

1. Chief executive, NHS England

On 10 August 2022 I commenced an investigation into the death of Sarah Elizabeth Read, aged 31. The investigation concluded at the end of the inquest. The conclusion of the inquest was: � Sarah Elizabeth READ died on 7 August 2022 at Royal Preston Hospital, Preston in Lancashire. Sarah underwent congenital heart surgery as a child and subsequently required a mechanical mitral valve replacement. As a result of her complex medical history, she was at high risk of thrombus which required intense anticoagulation. Her anticoagulation therapy was adjusted due to pregnancy but despite this she suffered a stroke which led to a decision to terminate the pregnancy which required interruption of anticoagulation to reduce the risk of bleeding. Three days late she suffered another stroke but following an extended stay in hospital she did not recover. � Her medical cause of death was found to be: � 1a Stroke 1b Mitral Valve Replacement 1c Treated infective endocarditis II��� Pregnancy

Circumstances of the death Sarah underwent congenital heart surgery as a child and subsequently required a mechanical mitral valve replacement. As a result of her complex medical history, she was at high risk of thrombus which required intense anticoagulation. Her anticoagulation therapy was adjusted due to pregnancy but despite this she suffered a stroke which led to a decision to terminate the pregnancy which required interruption of anticoagulation to reduce the risk of bleeding. Three days late she suffered another stroke but following an extended stay in hospital she did not recover.

COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ������� The Read family ��������[REDACTED] (partner) ������� Lancashire Teaching Hospitals ������� Manchester University 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 This report is being sent to: NHS England

28/11/2024

2024-0656

Oliver Billings

Devon, Plymouth and Torbay

1. Clare House Surgery, Newport St, Tiverton EX16 6NJ 2. Royal Pharmaceutical Society, 66 East Smithfield, London E1W 1AW 3. Pharmacy2U Limited, Lumina, Park Approach, Thorpe Park, Leeds LS15 8GB

On 7th December 2023 an investigation into the death of Oliver James Billings aged 22 was commenced. The investigation concluded at the end of the inquest on 28th November 2024. The conclusion of the inquest was that Mr Billings� death was due to suicide. The medical cause of his death was established as 1a) Toxic effect of [REDACTED].

Oliver was found deceased at his home address on 6th December 2023 having consumed possibly as many as 266 x 75mg tablets of his prescribed [REDACTED]. It appears that he had hoarded some of his medication and also appears to have acquired 112 tablets on or around 29th November 2023 due to a prescribing error where he changed his choice of chemist from an online pharmacy (�Pharmacy2U�) to a local �Superdrug� store. His Surgery, Clare House Surgery, Tiverton sent an electronic request to Pharmacy2U to cancel the prescription and then issued the second to Superdrug; however, Pharmacy2U had already �pulled down� the prescription before it was cancelled electronically. They then dispatched 112 x 75mg [REDACTED] to Oliver by post on 28th November. This meant that Oliver was still able to collect the second prescription for 112 x 75mg [REDACTED] from Superdrug and was suddenly in possession of 224 tablets. The Surgery sent Oliver a text message asking him to contact Pharmacy2U to �return the prescription to the spine� which presumably he chose to ignore. He had a long-established history of issues with his mental health including anxiety, depression,� self-harm� and� previous� suicidal� ideation.� He� was� also� aware� of� his� own impulsiveness. A note was found by a police officer attending Oliver�s flat on the day he died which stated that he did not have control over his medication and would take them all if left unsupervised. This is sadly what appears to have happened.

I have sent a copy of my report to the Chief Coroner and to Oliver�s parents, Mr and Mrs Billings. I am also under a duty to send 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.

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

Clare House Surgery | Royal Pharmaceutical Society | Pharmacy2U Limited

01/11/2023

2023-0426

Musa Konteh

Inner North London

1. Consular Feedback Team Consular Directorate Foreign, Commonwealth & Development Office King Charles Street London SW1A 2AH

On 29 March 2023, an investigation was commenced into the death of MUSA SIDIQUE KONTEH, then aged 30 years. The investigation concluded at the end of an inquest, heard by me, on 1 November 2023. � The conclusion of the inquest was accidental death, the medical cause of death being: � 1a asphyxia 1b pulmonary oedema as a consequence of drowning.

(1)� Musa and his girlfriend were staying at a beach resort in Sierra Leone on 18/19 March 2023. (2)� On Sunday 19 March 2023, Musa hired a jet ski from the resort. (3)� Having gone out on the jet ski alone, Musa failed to return. (4)� A local eyewitness is said to have seen Musa in the water, but believed him to be swimming at the time and thought nothing of it. (5)� A local search on the afternoon of 19 March 2023, recovered the jet ski but did not find Musa. (6)� On Wednesday 22 March 2023, Musa�s body was found in the water. (7) There was no evidence to suggest that Musa used alcohol prior to taking the jet ski out.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (a)�� [REDACTED] (next of kin) (b)�� [REDACTED] (Mr Konteh�s partner at the 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.

Other related deaths

Consular Feedback Team

09/02/2024

2024-0072

Kazarie Dwaah-Lyder

Inner North London

1. Consultant Paediatric Surgeon British Association of Paediatric Surgeons Royal College of Surgeons 35-43 Lincoln�s Inn Fields London WC2A 3PE � 2. President Royal College of Paediatrics and Child Health 5-11 Theobald�s Road London WC1X 8SH � 3. President Royal College of Radiologists 63 Lincoln�s Inn Fields London WC2A 3JW

On 12 May 2023, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Kazarie Dwaah-Lyder, aged 2� years. The investigation concluded at the end of the inquest earlier today. I made a determination of accidental death. � The medical cause of death was: 1a������ upper gastrointestinal bleed and haemorrhagic shock 1b��� oesophageal tear extending to the aorta 1c������ foreign body in oesophagus.

Kazarie died as a result of swallowing a foreign body (a googly eye) in February 2022. This was investigated by x-ray and fluoroscopy at the time, but the object was not detected and he was then without symptoms for the next 14 months until his emergency admission to hospital on 26 April 2023.

I have sent a copy of my report to the following. � [REDACTED], Kazarie�s mum NHS England [REDACTED], consultant radiologist, Royal London Hospital [REDACTED], consultant paediatric surgeon, Great Ormond Street Hospital for Children 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: British Association of Paediatric Surgeons | Royal college of Paediatrics and Child Health | Royal College of Radiologists

29/09/2023

2023-0358

Frederick Le Grice

Essex

1. Department for Health and Social Care Ministerial Correspondence and Public Enquiries Unit Department of Health and Social Care 39 Victoria Street London SW1H 0EU

On 29th September 2022 I commenced an investigation into the death of Frederick William LE GRICE, aged 80. The investigation concluded at the end of the inquest on 29th September 2023. The conclusion of the inquest was natural causes, and that the medical causes of death were 1a) Pneumonia 1b) Interstitial Lung Disease 1c) Nitrofurantoin Toxicity II Left Ventricular Systolic Dysfunction

Frederick Le Grice suffered with prostate problems, which as is the case, and did in this case, lead to urinary tract infections. There are two particular antibiotics used to treat such infections, Nitrofurantoin and Trimethoprim, along with urology support in hospital. The deceased had still continued to get UTls when on trimethoprim, so his general practitioner prescribed nitrofurantoin. That drug carries with it a known, but rare, risk of lung damage. After using Nitrofurantoin for a number of years, the deceased began to suffer with coughing and breathlessness. He was referred for specialist respiratory advice and some time later, the respiratory consultant advised that he had interstitial lung disease, and the likely cause of the problems was the Nitrofurantoin, and that this should be discontinued, which it was. The deceased died two years later from pneumonia, with the interstitial lung disease and the nitrofurantoin toxicity contributing.

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

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

13/02/2024

2024-0080

Nazerine Anderson

Rutland and North Leicestershire

1. Department for Work & Pensions

On 28 June 2023 I commenced an investigation into the death of Nazerine Frances Anderson aged 52. The investigation concluded at the end of the inquest on 12 February 2024. The conclusion of the inquest was that: � Nazerine Frances Anderson (�Naz�) had a medical history of anxiety and depression which had been managed with medication in primary services until October 2022. Naz was referred to secondary mental health services in November 2022 after a decline in her mental health. Following a voluntary admission to the Bradgate Unit in December of 2022, Naz was diagnosed with Adjustment Disorder the trigger for this having been notification that she was facing a performance review by the Department for Work Pensions (�DWP�). Naz was discharged from the Bradgate Unit in January 2023 and was managed in the community by the Crisis Resolution & Home Treatment team. Naz�s mental health presentation fluctuated and the DWP review continued to preoccupy Naz�s thoughts. The review concluded in May 2023 and between 03 May and 11 May 2023 Naz received 3 different letters setting out different sums of money owed to the DWP. These were sent directly to Naz despite the DWP being in receipt of correspondence from Naz�s daughter asking for all correspondence to be sent through Naz�s daughter, because continued correspondence would be of serious detriment to her mental �health. �On �17 �May �2023, �Naz �took �an �overdose [REDACTED]. She was subsequently admitted to the Leicester Royal Infirmary Emergency Department and transferred to the liver transplant unit at the Queen Elizabeth Hospital in Birmingham. Unfortunately, Naz was not a candidate for liver transplant and developed complications as a result of the irreversible damage caused to her liver. Naz was transferred to the Melton Community Hospital on 17th June 2023, for palliative care and passed away at 19.30 hours on the 19th June 2023 with her family present. � Naz did not intend to die as a result of taking the paracetamol overdose, but sadly developed complications as a result of the damage caused to her liver, which were irreversible.

Nazerine Frances Anderson (Naz) had a history of anxiety and depression stretching back over 20 years. She had no active symptoms of these conditions until 2021 and until November 2022 her symptoms had been managed in primary care services with medication. � Naz�s referral into secondary mental health services in November 2022 followed notification by the DWP that she would have her universal credit reviewed, by the Performance Review Team. � Naz�s mental health deteriorated necessitating a period of informal admission to the Bradgate Unit on the 5th December 2022 and she was diagnosed with Adjustment Disorder, an excessive reaction to stress that involves negative thoughts, strong emotions and changes in a person�s behaviour. I heard evidence from a Consultant Psychiatrist that the trigger stressor for this was the DWP performance review, suggested overpayment and potential debt. � It took 6 months for the DWP review to be completed. During which time there: were at least 6 missed opportunities to use an additional support tab on Naz�s DWP profile to record the details of her vulnerability and alert other DWP personnel. was a failure to pass vital information between the performance review team and universal credit case handling team of the need to correspond with Naz�s daughter, because corresponding with Naz was of serous detriment to her mental health. � Naz�s mental health was managed throughout this time by the secondary heath teams, and for the majority by the Crisis Resolution & Home Treatment team. The Crisis team were responsive throughout this time to Naz�s fluctuating symptoms and needs. � In the 4 weeks prior to the paracetomol overdose, despite a request for all correspondence to be directed through her daughter, Naz received 6 communications from the DWP, 2 telephone calls requiring detailed information of Naz, a journal log she didn�t understand and 3 separate letters which had a cumulative increase of the amount Naz owed of 75%. � 6 days after receiving the last piece of correspondence from the DWP Naz took an overdose [REDACTED]. Those mental health professionals who had worked with Naz throughout 7 months in which her mental health had deteriorated gave evidence to me that the recurrent and predominant cause of Naz�s increased anxiety was the DWP performance review. I find of the basis of the evidence I have heard and read that this was the case.

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

Alcohol, drug and medication related deaths | Mental Health related deaths This report is being sent to: Department for Work and Pensions

05/05/2023

2023-0146

Callum Wong

North London

1. Department of Health and Social Care, 33 Victoria Street, London SW1H 0EU

On the 31st August 2022 I opened an investigation touching the death of Callum Wong who was 17 years old when he died. I opened an inquest on the 23rd September 2022. The inquest concluded on the 27th February 2023. The conclusion of the inquest was �Callum Wong killed himself �, the medical cause of death was 1a Asphixia, 1b Hanging (suspension) and under paragraph 2 Mental Health Issues and Asthma.

On the 27th August 2022 Callum Wong was found having hanged himself Mr Wong had had suicidal thoughts in the past but having been supported by his family, overcame them. When Mr Wong had suicidal thoughts again, patient confidentiality issues resulted in those from whom he sought help, not informing his family.

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

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

07/11/2024

2024-0609

Daniel Pinkney

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

1. Department of Transport 2. Driver Vehicle Standards Agency 3. Royal Society for the Prevention of Accidents

On 30th December 2022, I commenced an investigation into the death of Daniel Pinkney, aged 26 years. The investigation concluded at the end of the inquest on 21st October 2024. The conclusion of the inquest was: ROAD TRAFFIC COLLISION

These are set out in my summary and findings of facts which are attached. At approximately 21:13 hours on 19th December 2022, Daniel PINKNEY was driving his Ford Focus motor car in a northerly direction on the A164 in the Skidby area. He encountered a large amount of surface water on his carriageway whilst travelling at approximately 50 miles per hour. His vehicle was subject to aquaplaning and consequent loss of directional control. As a result, he entered the opposite carriageway and collided with a third party vehicle travelling in the Hessle-bound direction. The force of the impact was such that the engine of Mr. PINKNEY�s vehicle broke free of its mountings and came to lie 28 metres from the vehicle. Mr. PINKNEY suffered devastating head and other injuries which were unsurvivable, and he was declared deceased by paramedics in his vehicle at 21:57 hours on 19th December 2022. Both of the involved vehicles were free from mechanical defects which could have caused or contributed to the accident.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � The insurers of Mr PINKNEY�s vehicle The insurers of the third-party vehicle East Riding of Yorkshire Council The family of Daniel PINKNEY � I am also sending a copy to NHS England and equivalent organisations in the other countries of the United Kingdom. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Road (Highways Safety) related deaths

Department for Transport | Driver Vehicle Standards Agency | Royal Society for the Prevention of Accidents

11/12/2023

2023-0522

Paul Perrott

Plymouth, Torbay and South Devon

1. Devon Partnership NHS Trust 2. [REDACTED], Langdon Hospital 3. [REDACTED], Langdon Hospital

On 7th August 2020 I commenced an investigation into the death of Paul Perrott , age 34 The investigation concluded at the end of a jury inquest on 17th November 2023. The conclusion of the inquest was suicide but the jury answered a number of questions which raised concern over the level of observations and care given to Paul during his time on Ashcombe Ward.

Mr Perrott was an inpatient on Ashcombe Ward , Langdon Hospital detained in hospital under sections 37 and 41 of the Mental Health Act 1983 . He had spent most of his adult life in psychiatric hospital and had a recent history of self harm in that he had attempted to hang himself [REDACTED] on 20th May 2020 before finally succeeding in carrying out the exact same act on 31st July 2020 which this time resulted in his death. Mr Perrott was on 15 minute observations at the time of his death but these were not recorded and no one noticed he was missing until 15 minutes after his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons : [REDACTED] ( Brother of the Deceased ) 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: Devon Partnership NHS Trust | Langdon Hospital

12/08/2024

2024-0507

Geoffrey Toase and Michael Midgley

Kingston Upon Hull and the East Riding of Yorkshire

1. Driver and Vehicle Licensing Agency (DVLA)

On 8 August 2019 an inquest was opened into the deaths of Geoffrey Stewart Toase and Michael William Midgley.� The inquest concluded on 2 August 2024, the conclusion reached was the short form conclusion of road traffic collision.

On 3 August 2019, Mr Toase and Mr Midgley had arranged to spend the day riding their motorcycles around Yorkshire, they were accompanied by two associates. �� At around 3:45pm, whilst travelling down the A166 Garrowby Hill, Mr Toase and Mr Midgley were involved in a head on collision with a car that was travelling from the opposite direction. That car was located wholly on the wrong side of the carriageway at the point at which it collided with Mr Toase and Mr Midgley.�� The driver of the car involved had a number of health-related conditions, including Type 1 Diabetes Mellitus, controlled by insulin injection. As a result of the diabetes, the driver of the car was required to reapply to the DVLA for a license every 3 years.� � At the time of the collision, the driver of the car was, on the balance of probability, suffering a hypoglycaemic episode which had compromised their ability to drive in an appropriate manner.�� Emergency services attended the collision scene swiftly, but the injuries suffered by both Mr Toase and Mr Midgley were such that nothing could be done to save them and they were both declared deceased at the incident scene.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:�� Family of Mr Toase and Mr Midgley;� The driver of the car involved in the collision (via his legal representatives). � I have also sent it to the following who may find it useful or of interest: Department for Transport � I am also under a duty to send 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.

Road (Highways Safety) related deaths

Driver and Vehicle Licensing Agency

18/7/2024

2024-0386

Anna Elliot

Inner North London

1. East London Foundation Trust (ELFT)

On 30 November 2011 an investigation was commenced into the death of Anna Vivien Elliott aged 26 years. The investigation concluded at the end of the inquest on 20 June 2024. The jury made a determination at�inquest Anna suffered from severe and recurrent depression and took�her own life. They also found that her death was contributed to by�neglect.

Anna had severe recurrent depression with psychotic features and� autism spectrum disorder. During an inpatient mental health admission in June and July 2021, Anna had benefitted from ECT treatment. A� further course of ECT was arrange for Anna as an outpatient but this� was postponed on 22 November 2021. This had a negative effect on� Anna, including a deterioration of her mental state.�� On 23 November 2021 Anna was detained under s.2 of the Mental� Health Act due to having thoughts and plans to end her life. She was transferred to Roman Ward at the Mile End Hospital in the early hours of 24 November.�� In the afternoon of 24 November 2021 Anna was found with a non-fixed ligature whilst on general observations. Staff risk assessed her, placed� her on intermittent 15 minute observations and put in place a safety�plan which included locking Anna�s bedroom to ensure she spent the� day in communal areas. The safety plan meant in practical terms that� she was being observed most, if not all of the time, by staff.�� The jury found that there was an inadequate handover from day to�night shift. There were also inadequate staffing levels on the night shift across the mental health unit, including Roman Ward. One of the� support workers allocated to undertake safe and supportive� observations on Roman Ward left to attend two emergency calls on� other wards. Her colleagues were not aware that she had left the ward. This resulted in a failure of staff to undertake Anna�s observations� between 9.03pm and 9.48pm and 9.48pm and 10.58pm. However, the� observation record was filled out to record that the observations had� been conducted.�� A decision was made to let Anna into her room at 9.03pm. The jury� found that there was inadequate consideration given to changing her� safety plan including no conversations had, no questions asked about� Anna�s mood and no risk assessment undertaken. Despite the planned continuation of 15 minute intermittent observations from day to night� shift, the change in her safety plan meant there was a change in how� Anna was to be observed during the night shift. This was inadequately� appreciated, inadequately considered and not risk assessed.� Anna was found in her room at 10:58pm with non-fixed ligatures made from nightwear and contraband items. She was pronounced deceased at 11:57pm.�� During the inquest ELFT made candid and helpful admissions.

I have sent a copy of my report to the following: Family of Anna Elliott Her Honour Judge Alexia Durran, the Chief Coroner of England & Wales Nursing and Midwifery Council CQC 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 | Suicide (from 2015)� � This report is being sent to: East London Foundation Trust (ELFT)

07/11/2023

2023-0430

Irene White

Somerset

1. Frome Nursing Home �Styles Hill �Frome �Somerset BA11 5JR

On the 20th of October 2022 I commenced an investigation into the death of Irene Joy White, aged 77. The investigation concluded at the end of the inquest on the 1st of November 2023. The conclusion of the inquest was �The deceased died of a pulmonary embolous which developed on a background of early discontinuation of thromboprophylaxis and immobility following a fall and fixation operation� with the medical cause of�[REDACTED] death being given as: Ia) Saddle Pulmonary Embolous Ib) Deep Vein Thrombosis Ic) Immobility II) Fractured neck of femur (operated on in June 2022)

Mrs White had a diagnosis of dementia and had lived in her previous care home since November 2019. Unfortunately her cognitive impairment meant that her behaviours put others at serious risk of harm and/or death (she is recorded as having tried to suffocate another resident with a pillow) and so her previous home had identified that they could no longer meet her needs and sought to find another appropriate placement for her due to being unable to manage her unpredictable aggression and �assaults� on other vulnerable residents. � On the 29th May 2022 she was found on the floor of her previous care home having suffered an unwitnessed fall. She was conveyed to hospital where it was revealed she had sustained a fractured hip. She underwent a surgical fixation operation on the same day. � Post operatively she was given two forms of thromboprophylaxis: (i)���� Chemically, with inhixia injections; and (ii)��� Physically with TED compression stockings. � Mrs White was discharged to a new Nursing Home, Frome Nursing Home, on the 17th June 2022 and was discharged with no thromboprophylaxis (either chemical or physical) and no advice. Mrs White was due to have a further nine days of thromboprophylaxis to complete the routine 28-day course (having only had 19 days at the point of discharge). � Frome Nursing Home is an Older Persons Mental Health care home, so can accept residents with complex dementia needs, such as Mrs White. There is at least one qualified and registered Nurse on duty 24/7. � Mrs White had no risk factors that pre-disposed her to developing a DVT; her risk factor was immobility following her fall. � Irene was not provided with any thromboprophylaxis measures and was not mobilised over and above being repositioned every four-hours for skin integrity and pressure-sore prevention. � Mrs White died of a pulmonary embolism, which developed following her fall and immobility, on the 20th of October 2022.

I have sent a copy of my report to: (i)���� the Chief Coroner (ii)��� Mrs White�s family (iii)� Care Quality Commission 2 Redman Place London E20 1JQ � 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: Frome Nursing Home

22/01/2025

2025-0039

Fahmida Khanam

West Yorkshire (East)

1. General Medical Council 2. [REDACTED]

On 12th November 2024 I commenced an investigation into the death of Fahmida Khanam, 74. The investigation concluded on 16th January 2025. The conclusion of the investigation that the� death was due to natural causes, specifically: � � 1a���� Myocardial infarction 1b���� Severe coronary artery atheroma 2������Hypertension, asthma, diabetes mellitus, chronic kidney disease

Mrs Khanam died on 12th November 2024. A post mortem attributed her death to natural causes. It emerged that her husband, [REDACTED] had been treating his wife. The Medical Examiner refused to countersign the cause of death put forward by another doctor in [REDACTED]�s practice. This necessitated a post mortem.

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

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

General Medical Council | REDACTED

07/08/2024

2024-0433

Kevin McDonnell

Nottingham City and Nottinghamshire

1. Governor, HMP Nottingham

On 30 September 2022, I opened an investigation touching the death of Kevin John�McDonnell, aged 47 years.� The inquest into his death concluded before a Jury on 22 July� 2024.� The conclusion of the inquest was that Kevin had died by suicide. The Jury further� recorded a narrative conclusion capturing a series of failings in his prison and health care, which probably more than minimally contributed to his death from suicide.

On 29 September 2022, Kevin was discovered deceased in his cell, having died as a result of ligature asphyxiation. He had a long history of mental ill health, paranoia and self-harm behaviours. He was placed on an ACCT plan and had identified 29 September 2022 as a trigger date when he might be more susceptible to self-harm and suicide on account of this being the anniversary of a relative�s death. There was a failure by prison staff to perform a planned ACCT review on 28 September 2022 and on 29 September 2022. Staff on the wing were unaware of the trigger date identified in the ACCT because this risk pertinent information was not passed on in handover and the ACCT booklet had been taken off of the wing for quality assurance (so was not accessible to staff).� Landing staff were unaware that Kevin was on an ACCT so did not perform any ACCT checks on the morning of his death.� Kevin had appeared agitated overnight and had not slept at all. This information was not shared with day staff.� There was a failure to provide Kevin with the necessary support for his mental health in terms of therapy, medication review and psychiatric assessment.�� Following the death, the ACCT observation and conversation history sheet for 29 September 2022 (which had been blank from the day shift at the time of death) was amended by staff, under the supervision of a senior officer, to record all interactions with Kevin that morning, even though none of those interactions were in fact ACCT checks. This tampering with evidence misled the Prison and Probation Ombudsman�s investigation, and only fully came to light during the inquest.

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

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

27/09/2024

2024-0515

Maria Kelly

Inne South London

1. Gray�s Inn Road Medical Centre �� 2. South Camden Rehabilitation of Recovery Team, North London Mental Health Partnership

On 6 June 2024 an investigation was commenced into the death of Maria Patricia Kelly age 54. The investigation concluded at the end of the inquest on 12 September 2024. I made a determination at inquest natural causes.

Maria Patricia Kelly was found deceased at her home address on 15 May 2024 by police following concerns raised by her neighbours and housing� officer.�� Ms Kelly lived alone and was in poor health. She suffered from a significant� number of medical and mental health problems and was prescribed a number� of medications to treat these. Records show that there had been no contact� with her GP since June 2023 and no contact with mental health services since August 2023. She had last been issued repeat medication on 1 August 2023.� Numerous failed encounters were listed by both organisations. No welfare� check was requested until 14 May 2024 when neighbours raised concerns.� They reported that they may have seen her in January 2024 but could not�been certain. Police initially declined to attend but forced entry the following� day and discovered Ms Kelly deceased, and in a state of partial mummification.

I have sent a copy of my report to the following [REDACTED] HHJ Alexia Durran, the Chief Coroner of England & Wales 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.

Community health care and emergency services related deaths

Gray�s Inn Road Medical Centre | North London Mental Health Partnership

09/09/2024

2024-0485

Ian Deavall

Greater Manchester West

1. HM Prison & Probation Service 2. Ministry of Justice

On 26 January 2023 I commenced an investigation into the death of Ian� William Deavall, age 65. The investigation concluded at the end of the inquest on 9 September 2024.�� The conclusion of the inquest was: � Ian William Deavall died as a consequence of a naturally occurring� cardiac arrest. There was an admitted failure to arrange for Mr� Deavall to be sent to hospital for assessment between 20 and 24� January 2023, however this did not cause or contribute to death on the balance of probabilities.�� The medical cause of death was: 1. Ischaemic heart disease.

The Deceased was remanded in custody to HMP Forest Bank on 7 January� 2023. He had a known history of ischaemic heart disease and hypotension� and was prescribed various medications for the same. The Deceased was� housed on the induction wing throughout his time at the prison and shared a cell. Both the Deceased and his cell mate were believed to be at risk from� other prisoners and were classed as vulnerable prisoners (�VPs�) accordingly.� The inquest heard evidence that both VPs and non-VPs are housed on the� induction wing and that the recognised risk to VP prisoners when co-located with non-VP prisoners is managed by operating two separate regimes to avoid the two demographics coming into contact with one another.�� On 24 January 2023 the Deceased and his cell mate were locked in their cell� when the Deceased suffered a cardiac arrest. His cell mate pressed the� emergency cell bell whereupon a non-VP prisoner (�Prisoner A�), who was� unlocked and conversing with two other prisoners on the landing adjacent to the Deceased�s cell, deactivated the cell bell on the panel outside the cell� before resuming his conversation with the other prisoners. After� approximately 1 minute Prisoner A walked down to the wing office and� alerted officers inside, following which a medical emergency response was�initiated.�� The inquest heard evidence that when an emergency cell bell in the induction wing at HMP Forest Bank is deactivated on the panel outside the cell (i) this� cancels the alert in the wing office; (ii) the only means by which staff can� ascertain in which exact cell the emergency cell bell has been activated (the� light on the panel outside the cell) goes off.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the Family of Mr Deavall, Sodexo Justice Services,� Spectrum Community Health CIC and Med-Co Secure Health Services Ltd. I have also sent it to the Prison and Probation Ombudsman and HMI Prisons who may find it useful or of interest.� I am also under a duty to send a copy of your response to the Chief Coroner. I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he� believes may find it useful or of interest.�� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

State Custody related deaths

HM Prison and Probation Service | Ministry of Justice

11/06/2024

2024-0607

Daniel Beckford

Inner West London

1. HMPPS� 2. HMP Wandsworth

The inquest was opened on 13 July 2021 and concluded at the end of the inquest on 25 April 2024. The conclusion of the jury was a narrative conclusion: �suicide. Based on the evidence, the following possibly made a material contribution to his death; failure to comply with the prison service instruction to facilitate a phone call within the first 24 hours; insufficient support to secure a PIN.�

Daniel Beckford was detained at HMP Wandsworth. He died on 23 June 2023 aged 39 years. His death was confirmed at St George�s Hospital, Tooting Road, London.�� The family requested the deceased is referred to as Daniel. I will reflect this in this report.�� On 14 June 2021, Daniel was remanded to HMP Wandsworth. He had a history of substance misuse, depression and self-harm, which was known. On 16 June 2021 Daniel took an overdose of his prescribed antibiotic medication. On 17 June 2021, he was found hanging in his cell. At the time of his death, Daniel was being monitored via Assessment, Care in Custody and Teamwork (ACCT). He was transferred via LAS to St George�s Hospital and admitted to the General Intensive Care Unit (GICU). He was declared deceased on 23 June 2021. The medical cause of death was:� 1a. Hypoxic ischemic brain injury; 1b. Asphyxia; 1c. Ligature compression of the neck; and II� Coronary artery atheroma The� jury�s� findings� recorded� in� the� Record� of� Inquest� included� that� there� was �insufficient, regular Basic Life Support training, which resulted in Daniel being placed in the recovery position before CPR (chest compressions) commenced.�

I have sent a copy of my report to the Chief Coroner, NUCO Training and to Daniel�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.

State Custody related deaths | Suicide (from 2015)

HMPPS | HMP Wandsworth

11/06/2024

2024-0608

Yuri Hatton

Inner West London

1. HMPPS� 2. HMP Wandsworth

The investigation commenced on 14 November 2018. The inquest was opened on 27 November� 2018� and� concluded� at� the� end� of� the� inquest� on� 12� April� 2024.� The conclusion of the jury was drug related death.

Yuri Hatton was detained at HMP Wandsworth. He died on 9 November 2018 aged 44 years. His death was confirmed at St George�s Hospital, Tooting Road, London.�� The family requested the deceased is referred to as Yuri. I will reflect this in this report. On 7 November 2018 at approximately 18:25 healthcare staff were called to Yuri�s cell who was suspected of taking an opiate overdose. Naloxone was given and the patient was noted to become more alert. He was later seen by healthcare staff at 23:46 and was reported to be awake, alert, breathing easily and watching television from his bed.�� At� approximately� 00:10� on� 8� November� 2018� healthcare� staff� responded� to� a� call regarding Yuri who was found to be breathing abnormally in his cell. A code blue was called,� and� cardiopulmonary� resuscitation� (CPR)� was� commenced.� His� airway� was maintained, and a defibrillator was used which advised no shock at any time. He was found to be in asystole when the London Ambulance Service (LAS) arrived at 00:20. CPR was continued with return of spontaneous circulation at 00:40. Yuri was intubated, given 200mcg of adrenaline and intramuscular Naloxone was administered with no change in his level of consciousness.� He was transferred via LAS� to� St George�s Hospital and admitted to the General Intensive Care Unit (GICU). Whilst on the GICU he remained profoundly unconscious off all sedation and demonstrated features of brain stem death. He was declared deceased at 18:22 on 9 November 2018. The medical cause of death was:� 1a. Bronchopneumonia; 1b. Hypoxic-ischaemic encephalopathy; and 1c. Cardiac arrest resulting from the effects of methadone and mixed drug toxicity. The jury recorded in the Record of Inquest the following 4 failures cumulatively possibly contributed to Yuri�s death:� 1. �To call a code blue and call an ambulance by the substance misuse nurse once naloxone was administered;� 2. To take opportunities to correct the error by the substance misuse nurse by other experienced healthcare staff;�� 3. Inappropriate clinical observations of Yuri post administration of the naloxone;� 4. Inadequate communications (especially during handovers) between the prison staff between themselves or healthcare staff between themselves�.

I have sent a copy of my report to the Chief Coroner, NUCO Training and to Yuri�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.

State Custody related deaths

HMPPS | HMP Wandsworth

02/08/2023

2023-0282

John Shenton

Shropshire, Telford and Wrekin

1. Health & Safety Manager The Range Elsie Margaret House William Prance Road Plymouth PL6 5ZD

On the 25th April 2023 I commenced an investigation into the death of John Neil SHENTON. The investigation concluded at the end of the inquest on the 1st of August 2023 with a conclusion of Accidental Death. The medical cause of death was Ia) Bronchopneumonia Ib) Fractured Ribs and II) Chronic Obstructive Pulmonary Disease, Type II Diabetes Mellitus

On the 17th April 2023 Mr Shenton, together with his wife and son, went to the The Range, Forge Retail Park, Telford TF3 4PB. � Mr Shenton was 82 years of age with limited mobility and was to that extent vulnerable. They initially tried to use the lift in the store but it was not in operation. They went to the first floor by escalator and subsequently Mr Shenton fell stepping on the descending escalator. Mr Shenton sustained injury and sadly as a result died 4 days later at the Princess Royal Hospital, Telford on the 21st April 2023. The circumstances of the accident were investigated and are set out in a report from [REDACTED] Telford & Wrekin Council Environmental Health Officer.

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

Other related deaths This report is being sent to: The Range

01/03/2024

2024-0260

Tina Neverland

Mid Kent and Medway

1. Highways Department Medway Council

On 8th August 2023 I commenced an investigation into the death of Tina NEVERLAND. The investigation concluded at the end of the inquest on the 30th January 2024. The conclusion of the inquest was that the deceased Tina Neverland died as a result of a Road Traffic Collision. � The cause of death having been determined as: 1a Traumatic Brain Injury 1b Road Traffic Collision 1c 2

The deceased Tina Neverland, a pedestrian was walking south along Maidstone Road before using the grassy central reservation on Maidstone Road, Chatham (A229) and has crossed the northbound carriageway when she was hit by a motorcycle which was being driven within the speed limit for the road. She suffered traumatic brain injury following the collision on the 26th July 2023 and despite treatment died at Kings College Hospital on the 30th July 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the family, [REDACTED] and Kent 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.

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

23/12/2024

2025-0041

David Lodge

East Riding of Yorkshire and City of Kingston Upon Hull

1. Hull University Teaching Hospitals NHS Trust. 2. NHS England. 3. Care Quality Commission.

On 20 January 2022, I commenced an investigation into the death of David Christopher Peter Lodge (�Mr Lodge�), aged 40 years. The investigation concluded at the end of the inquest on 20 December 2024. The conclusion of the inquest was Natural Causes contributed to by Neglect. Box 3 of the Record of Inquest read: David Christopher Peter Lodge, who had a learning disability, was found on 12 January 2022 unwell next to his deceased carer/father, after having had up to a four day long lie. He was treated at Hull Royal Infirmary, where he was treated for dehydration, and later died on 13 January 2022 from bilateral pneumonia.� No chest examination was performed and there was a missed opportunity to transfer to the intensive care unit. His medical cause of death was recorded as: 1a�� Bilateral Pneumonia 1b�� Metabolic Acidosis and Hypovolaemia 1c�� Dehydration II�����Autism, Learning Disability, Dysarthria and Immobility.

Mr Lodge had a learning disability and was cared for by his father, who sadly passed away at their home address. Unable to seek assistance, Mr Lodge endured a long lie by his father�s side for up to four days, before being found by another family member. He was taken to Hull Royal Infirmary at 12 January 2022 and sadly died mid-morning at 13 January 2022.� Mr Lodge was being treated for dehydration and died of bilateral pneumonia. Whilst at the hospital, Mr Lodge was agitated and, therefore, given sedative medication on two occasions to calm him down in order to permit full observations.� Meanwhile, Mr Lodge�s NEWS2 scores were consistently high at 8 or 9 for a number of hours and during that time no chest examination was undertaken. Intensive care specialists were consulted by the emergency department treating physicians, and no referral eventuated. Mr Lodge was, instead, transferred to the acute admissions unit, was not medically assessed again and he later suffered a cardiac arrest and died hours later.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of David Christopher Peter Lodge. I am also under a duty to send 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

Hull University Teaching Hospitals NHS Trust | NHS England | Care Quality Commission

04/01/2024

2024-0008

Bernadette Faulkner

Inner North London

1. Lee Rowley MP Minister of State for Housing, Planning and Building Safety, The Department for Levelling Up, Housing & Communities 2 Marsham Street London SW1P 4DF � 2. [REDACTED] Chief Executive, Energy UK, 26 Finsbury Square (4th Floor) London EC2A 1DS

On 13 December 2022, an investigation was commenced into the death of BERNADETTE GRACE FAULKNER, then aged 80 years. The investigation concluded at the end of an inquest, heard by me, on 13 December 2023. � The conclusion of the inquest was accidental death, the medical cause of death being: � 1a respiratory failure 1b lung contusion 1c multiple bilateral rib fractures (out of hospital fall, 2/12/2022) II obstructive sleep apnoea, type 2 diabetes mellitus, hypertension, asthma

Mrs Faulkner rented a flat from her local authority, which was a former Victorian townhouse converted into four separate flats. Her electricity meter (installed in 2001) was in a cupboard, just inside the communal door to the flats, some 7-8 feet off the ground. � Mrs Faulkner, was only 4�10� tall, and had no choice but to access the meter using a stepladder every time she wished to add credit to her pre-payment meter. � On 2 December 2022, Mrs Faulkner purchased credit for her electricity meter and then climbed the stepladder to put the credit onto the meter. In trying to access the meter she fell from the ladder and landed on the floor, where she was discovered some hours later by neighbours. � Mrs Faulkner sadly died in hospital on 8 December 2022, as a direct result of the injuries she sustained in the fall.

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

Other related deaths This report is being sent to: Ministry of Housing, Communities & Local Government | Energy UK

19/09/2024

2024-0504

Evelyn March

West Yorkshire (East)

1. Leeds Teaching Hospitals NHS Trust

On 27.9.23 I commenced an investigation into the death of Evelyn Grace March aged 1 day. The investigation concluded at the end of the Inquest on 18.09.24. The Inquest concluded with a Narrative conclusion including the medical cause of death being� recorded as �unascertained�. It is likely the death was attributable to overlaying arising from the accidental suffocation of the baby by a sleeping adult.

Baby Evelyn Grace March was born on Tuesday 26.9.23 at 04:38 at St James Hospital, following a prolonged labour. She and her parents were discharged home 4 hours after the� birth (08:49 hours).� Around 01:45 hours the baby was brought into her mother�s bed as she was unsettled. As she� was being breastfed the mother probably fell asleep. When she awoke around 04:00 hours the baby was under the mothers breast, in an unresponsive condition. Despite emergency�treatment she could not be revived and was pronounced dead at 07:50 hours on Wednesday�27 September 2023 at Leeds General Infirmary.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons�[REDACTED] (mother) and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)]. I have also sent it to Maternity and Newborn Safety Investigations and [REDACTED], Consultant Paediatric Pathologist 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)

Leeds Teaching Hospitals NHS Trust

02/12/2024

2024-0661

Gloria Linton

West Yorkshire East

1. Lifeway Care Ltd, Unit 7, Suite 705, Ashbrooke Pary, Parkside Lane, Leeds LS11 5SF

On 30/08/2022 I commenced an investigation into the death of Gloria Linton, aged 77. The investigation concluded at the end of the Inquest on 28/11/2024. The conclusion of the Inquest was a narrative conclusion, recording the cause of death as 1a) Pneumonia 1b) Rib fractures due to entrapment in a commode 2) Covid 19 infection, Cerebrovascular Disease, Ischaemic Heart Disease, Osteoporosis, Oropharyngeal Dysphagia (Clinical Diagnosis), and stating in summary that Gloria Linton died from the effects of medical complications arising from bilateral fractures of the posterior and lateral aspects of her ribs after she had become trapped in the aperture of a commode seat while being tended by carers.

On 06/08/2022 carers had taken Gloria Linton in a wheeled commode into her wet room, where she had toileted and been showered while still seated in the commode. Carers assisted her to stand using manual handling techniques so that she could be dried and have moisturising and barrier creams applied to her. Gloria began to open her bowels again and carers attempted to sit her down on the commode, placing her on the commode seat at an angle such that her left leg passed through the gap at the front of the commode seat and her right leg followed, effectively trapping her in the commode seat�s central aperture. She passed further down into the aperture, becoming trapped just below her chest. While trapped she sustained numerous osteoporotic fractures to the back and sides of both her ribcages, through either or both of her own efforts to free herself and the process of being extracted from the commode by the attending emergency services. The rib fractures were found at post mortem to have been a direct contributing cause of the pneumonia that was the immediate cause of Gloria�s death in hospital on 23/08/2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Ms Briony Gosling, Yorkshire Ambulance Service, Leeds Community Healthcare Trust. I have also sent it to the Care Quality Commission who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths

Lifeway Care Ltd

03/07/2023

2023-0227

Liam Bentley

Mid Kent and Medway

1. MINISTER OF STATE FOR PRISONS AND PROBATION

On 13th June 2022 I commenced an investigation into the death of Liam Ryan Wayne Bentley. The investigation concluded at the end of the inquest on 29th June 2023. The conclusion of the inquest was Liam Bentley took his own life ([REDACTED]) but his intention in doing so was unclear. The failure to provide adequate physiological support through SOS and/or a psychologist possibly contributed to the death. Other issues which were deemed to be relevant to the circumstances of the death but could not possibly contribute to the death were as follows. 1. Failure to open an ACCT on or after 16th April. 2. Failure to instigate a care plan 3. Inadequate response to missed medication from 16th April onwards. 4. The Management of the self seclusion plan was inadequate, and failures to implement agreed actions from CSIP and SIM meetings. 5. Ineffective communication between the prison and the health care provider. 6. Staff shortages and gaps in training.

Liam Bentley was transferred to HMP Swaleside on 25th March 2022. He was a serving prisoner with a sentence expiry in 2024. He had ADHD and ASD for which he was medicated with mirtazapine administered by healthcare and at the time of his death atomoxetine, held in possession. He had 19 previous ACCTs for self harm and an attempt at suspension whilst serving his sentence at other establishments. Following his transfer he informed prison staff that he was in fear of other prisoners and wanted a move to another wing. He caused a superficial cut to his hand and said that he wanted to kill himself before anyone else did. An ACCT was not opened, the evidence being that officers after further speaking to him did not regard this as a self harm issue, the focus being to engineer a wing move. He was moved to a different wing but continued to express concerns about prisoners on the new wing. A self seclusion document was opened, a local policy closely aligned to the ACCT process aimed at reintegrating the prisoner to the regime was started but was not managed in accordance with the policy with assessments and reviews being done weeks after they should have been and no management plan were not put in place. Required daily interactions were sometimes done, sometimes not, referrals to psychology and SOS were either not made having been identified as necessary through the self seclusion, CSIP and SIM processes or made and not actioned

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

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

10/12/2024

2024-0682

Karen Day

West Yorkshire (East)

1. Meanwood Group Practice

On 29 July 2022 an investigation was commenced into the death of Karen Lesley Day, aged 58. The investigation concluded at the end of the Inquest on 28 November 2024.� The medical cause of death was�� 1a) Septicaemia�� 1b) Soft tissue infection, Pneumonia������������� � 1c) Traumatic Laceration �� II) Raynaud�s disease. �� The conclusion of the Inquest was: Accident.

Karen Lesley Day sustained a small laceration to her left lower leg in 2021 when she injured it� on a van. She sought help from her GP practice to manage the wound in June 2021 and� appointments with the practice nursing team commenced. Over the course of the following 11� months, Karen attended multiple appointments where the appropriate lower limb framework�was not followed and opportunities to escalate Karen�s deteriorating wound and overall� condition were missed. Karen was admitted to hospital on the 26th May 2021 and was treated� for an acute infection following which she was discharged to the care of the district nursing� team. The lower limb framework was not used consistently and opportunities her increasing� deterioration was not fully recognised and escalated. She was admitted to hospital on the 12th� July 2022 where she was, by this point, extremely unwell. The hospital commenced active� treatment to which she did not respond and care was orientated towards palliation and comfort. Karen died on the 14th July 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely�� � 1. the Leeds Teaching Hospital NHS Trust and 2. the Leeds Community Healthcare NHS Trust and to 3. the family who may find it useful or of interest. I am also copying my report to the Care Quality Commission (CQC) and the Integrated Care Board (ICB).�� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner� may publish either or both 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 at the time of your response, about the release or the publication of your response by the Chief Coroner.

Community health care and emergency services related deaths

Meanwood Group Practice

12/8/2024

2024-0440

Douglas Armstrong

Liverpool and Wirral

1. Medequip UK

On 17 January 2024 I commenced an investigation into the death of Douglas ARMSTRONG aged 88. The investigation concluded at the end of the inquest on 12 August 2024. The conclusion of the inquest was that: On 16 December 2023 the Deceased had an unwitnessed fall at his home address. He sustained a fractured neck of femur, but this was not identified either by two responders from an agency or by the district nurse who attended. As a result his arrival at Arrowe Park Hospital, Arrowe Park Road, Wirral hospital was delayed by around 18 hours, and it is likely that his subsequent surgery was similarly delayed, adding slightly to the mortality risk. He died at the hospital on 5 January due to aspiration pneumonia, which resulted from the accidental injury sustained in the fall. It is unlikely that the delay in hospital admission either caused or materially affected the timing of his death.

On 16 December 2023 the Deceased had an unwitnessed fall at his home address. He sustained a fractured neck of femur, but this was not identified either by two responders from an agency or by the district nurse who attended. As a result his arrival at Arrowe Park Hospital, Arrowe Park Road, Wirral hospital was delayed by around 18 hours, and it is likely that his subsequent surgery was similarly delayed, adding slightly to the mortality risk. He died at the hospital on 5 January due to aspiration pneumonia, which resulted from the accidental injury sustained in the fall. It is unlikely that the delay in hospital admission either caused or materially affected the timing of 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 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 | Community health care and emergency services related deaths � This report is being sent to: Medequip UK

25/09/2023

2023-0347

Carol Leeming

Newcastle upon Tyne and North Tyneside

1. Medical Director, Totally Urgent Care (incorporating Vocare)

On 5th October 2022 I commenced an investigation into the death of Carol Leeming, aged 77. The investigation concluded at the end of the inquest on 20th September 2023. The conclusion of the inquest was natural causes, the medical cause of death being 1a) Coronary artery atheroma; 2) Chronic Obstructive Pulmonary Disease.

Carol had a number of medical conditions. In the months prior to her death she had repeatedly sought advice from her GP. On the afternoon of the day prior to her death Carol rang for an ambulance requesting help and describing having a racing heart. She requested admission to hospital. Her call was triaged for a call back by the out of hours GP service provided by Vocare. The call was returned that evening by a GP working for Vocare. The GP believed that he had requested an ambulance for Carol via an electronic system but there was no such facility and an ambulance was not requested. The GP was unfamiliar with the systems in place. He had recently started working for Vocare and had not completed induction training.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mrs Leeming�s family, Totally Urgent Care (incorporating Vocare), NEAS, and Medical Protection Society. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards) This report is being sent to: Totally Urgent Care

18/07/2024

2024-0400

Noura Hardy

West Sussex, Brighton & Hove

1 [REDACTED]

On 21 March 2023 I commenced an investigation into the death of Noura HARDY aged 73. The investigation concluded at the end of the inquest on 18 June 2024. The conclusion of the inquest was that: Noura Hardy died on the 14th of March 2023 at Royal Sussex County Hospital in Brighton of a cardiac arrest following a septal ablation procedure complicated by perforation of a coronary artery.

Ms. Hardy suffered from severe left ventricular hypertrophy. She was admitted to hospital in March 2023 for a septal ablation procedure. Her coronary artery was perforated before the procedure. She subsequently died of a cardiac arrest.

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

Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: [REDACTED]

02/01/2024

2024-0002

Joy Ebanks

Bedfordshire and Luton

1 [REDACTED] 2��� Kirby Road Surgery

On 14 June 2023 I commenced an investigation into the death of Joy EBANKS aged 59. The investigation concluded at the end of the inquest on 13 December 2023. The conclusion of the inquest was that: � Mrs Joy Ebanks was discovered deceased on the 24th May 2023 at [REDACTED] . She was taking oxycodone and pregabalin as treatment for pain. The medical cause of death was identified as due to oxycodone and pregabalin toxicity.

Mrs Ebanks lived alone, she had been self neglecting and not engaging with support services. She suffered from Fibromyalgia, arthritis, agoraphobia. She had been diagnosed with depression and was prescribed both venlafaxine and quetiapine. She used cannabis. On the 24/05/2023, Mrs Ebanks was spoken to on the phone by her care worker at around 12:00 hours and asked for some tobacco to be bought to her during the visit. At around 16:00 hours, her care worker attended, got no response and so let herself in. She found Mrs Ebanks unresponsive, sitting up slumped to the side on the bed and contacted ambulance before attempting CPR. Paramedics attended but were unable to resuscitate her and she was pronounced deceased at the scene. There were previous expressions of suicide but she had not acted on them. � Post mortem examination with toxicology gave the medical cause of death as: 1a Oxycodone toxicity enhanced by pregabalin intake 11 Bronchopneumonia, Coronary arteries atherosclerosis, Hepatic steatosis � Mrs Ebanks had been prescribed opiates since at least 2009. Her medications at the time of death included long acting morphine � Longtec [REDACTED] twice daily together with Pregabalin [REDACTED] twice daily. She had been on this dose since at least 2014. There were periodic supplementations with Shortec [REDACTED] 1-2 tablets up to four times daily (112 provided). The reason for the prescription was for fibromyalgia and �chronic pain� (undefined). Because of her agoraphobia and a dislike of people coming to her home, medication reviews were undertaken largely by telephone. There was evidence of poor communications between the agencies providing her with different aspects of her care. I was told that the practice had been addressing Prescription Drug Dependency and had utilised the Quality and Outcomes Framework Guidance for 2022/2023. Page 5 �Prescription Drug Dependency � Rationale� sets out some reasons for monitoring and rationalising prescription of dependency forming drugs thus: �Opioids are very valuable drugs for acute and palliative/end of life care but have a limited role in the management of chronic pain; for many patients they are not effective. Most prescribing is of short duration only; however, 3% of patients (CQC, 20202) with chronic pain receive continuing prescriptions for opioids for 3 years or more. Prolonged prescribing of these drugs may not be effective and is associated with dependence. Gabapentinoid prescribing has shown a 10 fold increase between 2000 and 2015 from 0.2% of patients in 2000 to 2.1% in 2015 (Cartagena et al. 2017),most of which has been off label and of unknown effectiveness; dependence on these drugs is increasingly recognised as a problem�. � There was evidence of attempts to review the medication prescribed but I remained unclear as to the purpose of the reviews. There was no evidence of any attempt to review the prescriptions of two dependency forming drugs with a view to reducing the dose over time. The opioid prescription was high. Mrs Ebanks was an agoraphobic lady with an ongoing mental health illness and what appears to be a iatrogenic drug dependency.

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

Alcohol, drug and medication related deaths This report is being sent to: Kirby Road Surgery

02/02/2024

2024-0054

Shaun Crossfield

West Yorkshire (Western)

1 [REDACTED] (RPAS) 2 [REDACTED]

On 16 August 2022 I commenced an investigation into the death of Shaun CROSSFIELD aged 54. The investigation concluded at the end of the inquest on 16 March 2023. The conclusion of the inquest was that: � Upon the 9th August 2022, Shaun Crossfield began a flight upon a Paramotor in a field situated at New Church Farm Tong Lane Bradford. Mr Crossfield, whilst in flight suffered the impact of air turbulence, which caused the canopy of his Paramotor to partially collapse, adversely affecting his ability to maintain a normal flight pattern. � Due to further damage to the control mechanisms of the Paramotor, it became uncontrollable, descending into a downward spiral which could not be reversed; resulting in a catastrophic impact with the ground, with an immediate fatal consequence to Mr Crossfield. The Ambulance Service was called to the scene where an attending Paramedic certified the death of Mr Crossfield at 19:19 hours that day

Shaun is a 54yr old man who lives in Gomersal, Cleckheaton with his father. � Shaun is described by his family as an avid flyer of Paramotors. He has been engaged in this activity for around 4-5years at the time of his death. On the 9th of August Shaun has set off from home to head out flying that evening with two friends. At around 19:00hrs Shaun got into difficulties, for reasons not yet known, whereupon he and his Para-Motor then plummeted to the ground. � He was declared dead by paramedics at 19:19hrs.

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

Other related deaths This report is being sent to: RPAS

27/03/2024

2024-0169

Francis Williams

West Sussex, Brighton and Hove

1 [REDACTED] 2 [REDACTED]

On 03 February 2023 I commenced an investigation into the death of Francis Ian WILLIAMS aged 43. The investigation concluded at the end of the inquest on 05 March 2024. The conclusion of the inquest was that: � Francis Williams was the subject of a sentence of imprisonment for public protection (�IPP�), imposed in 2006. He had always struggled with that sentence, believing that he would never be free of it. He had been released in 2009 and by 2018 had had the supervision element of the sentence removed. In 2020, however, and in part following problems experiencing during the Covid lockdown, supervision was reinstated and in March 2021 Francis was recalled to prison. � Francis was re-released in April 2022 and initially seemed to be progressing well once again. In late 2022 and early 2023, however, Francis was struggling once more, and in particular, with alcohol. He had lost one set of specialist accommodation in November 2022. He then had a warning from the new one on 9 January 2023. On 27 January 2023 Francis was finally evicted from that accommodation after he had been drunk the night before and had behaved inappropriately including towards female staff. The probation service sought urgently to find alternative accommodation but without success. They started to take steps to recall him to prison. � Francis realised that is what was likely to happen, and he told his probation officer he was going to kill himself [REDACTED]. She made a warning call to police. On 28 January 2023, however, Francis was found by workmen in a tent in the sunken gardens in Bognor Regis. He had died of a heroin overdose. He was 43 years old.

Francis Williams was the subject of a sentence of imprisonment for public protection (�IPP�), imposed in 2006. He had always struggled with that sentence, believing that he would never be free of it. He had been released in 2009 and by 2018 had had the supervision element of the sentence removed. In 2020, however, and in part following problems experiencing during the Covid lockdown, supervision was reinstated and in March 2021 Francis was recalled to prison. � Francis was re-released in April 2022 and initially seemed to be progressing well once again. In late 2022 and early 2023, however, Francis was struggling once more, and in particular, with alcohol. He had lost one set of specialist accommodation in November 2022. He then had a warning from the new one on 9 January 2023. On 27 January 2023 Francis was finally evicted from that accommodation after he had been drunk the night before and had behaved inappropriately including towards female staff. The probation service sought urgently to find alternative accommodation but without success. They started to take steps to recall him to prison. � Francis realised that is what was likely to happen, and he told his probation officer he was going to kill himself [REDACTED]. She made a warning call to police. On 28 January 2023, however, Francis was found by workmen in a tent in the sunken gardens in Bognor Regis. He had died of a heroin overdose. He was 43 years old.

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

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

06/06/2024

2024-0308

Alan Lee

West Sussex, Brighton and Hove

1 [REDACTED] Care Outlook Ltd 2 [REDACTED] Manager Abbotswood Station Road Rustington Littlehampton BN16 3BJ

On 29 December 2023 I commenced an investigation into the death of Alan Richard LEE aged 76. The investigation concluded at the end of the inquest on 04 June 2024. The conclusion of the inquest was that: � On 17th December 2023 Mr Lee, who had recently been given his dinner in his flat at [REDACTED], Abbotswood, Station Road, Rustington, Littlehampton, West Sussex, choked on a food bolus. The staff who came to his aid did not realise he had chocked and sadly he died before the ambulance arrived.

On 17th December 2023 Mr Lee, who had recently been given his dinner in his flat at [REDACTED], Abbotswood, Station Road, Rustington, Littlehampton, West Sussex, choked on a food bolus. The staff who came to his aid did not realise he had chocked and sadly he died before the ambulance arrived.

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

Care Home Health related deaths This report is being sent to: Care Outlook Ltd | Abbotswood

10/12/2023

2023-0520

Jessica Eastland-Seares

West Sussex, Brighton and Hove

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

On 18 May 2022 I commenced an investigation into the death of Jessica Zoe EASTLAND- SEARES aged 19. The investigation concluded at the end of the inquest on 01 December 2023. The inquest was held with a Jury. The conclusion of the Jury was: � �It is the conclusion of the Jury that systematic failures in Health and Social care led to a series of events, which caused the deceased periods of dysregulation culminating in regular bouts of self-harm, which ultimately ended in death by misadventure.�

At 01.16 am on 17th May 2022 Jessie was pronounced deceased at Caburn ward, Millview Hosptial, Hove. East Sussex. She had been found with a ligature tied around their neck. � Jessie had been diagnosed with Autistic spectrum disorder, ADHD, Complex traumatic stress disorder and emotional unstable personality disorder. � Following a breakdown in the provision of her support package Jessie�s mental health deteriorated and was detained under Section 3 Mental Health Act 1983. She remained in Hospital from 4th March 2022 until the time of her death.

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

Hospital Death (Clinical Procedures and medical management) related deaths | Suicide (from 2015) This report is being sent to: Department of Health and Social Care

23/01/2024

2024-0029

Thomas Langley

Derby and Derbyshire Category: Alcohol, drug and medication related deaths This report is being sent to: Travel Lodge

1 [REDACTED] Travel Lodge Travel Lodge

On 22 May 2019 I commenced an investigation into the death of Thomas Roy LANGLEY aged 24. The investigation concluded at the end of the inquest on 18 January 2024. The conclusion of the inquest was that: � Thomas Roy Langley, date of birth 12th July 1994, of [REDACTED], had a history of mental illness to include depression, schizophrenia, learning difficulties, alcohol and drug misuse; there had been several drug overdoses. On the evening of 21st May 2019, he arrived at the Travel Lodge Hotel, County Ground Derby. During the early hours of 22nd May 2019, he took toxic levels of MDMA [REDACTED], which sadly resulted in his death on 22nd May 2019 at the hotel.

Found collapsed in hotel room.

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 following � [REDACTED]� parents of the deceased Derbyshire County Council Staffordshire County Council South Derbyshire District Council Derbyshire Healthcare NHST Trust North Staffordshire Combined Healthcare Trust / Harplands Hospital Queen�s Hospital Burton � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Alcohol, drug and medication related deaths

05/04/2024

2024-0302

Michael Burke

Suffolk

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

On 15 February 2023 I commenced an investigation into the death of Michael John BURKE aged 75. The investigation concluded at the end of the inquest on 15 February 2024. The conclusion of the inquest was that: � Narrative Conclusion � Michael John BURKE died due to advanced lung disease with a fractured neck of femur sustained due to a fall on 30th January 2023 having made a material contribution. � The medical cause of death was confirmed as: � 1a Hospital Acquired Pneumonia,, Acute Pulmonary Oedema 1b Acute Heart Failure, Cardiomegaly 1c Ischaemic Heart Disease, Chronic Obstructive Pulmonary Disease

Michael John BURKE was described by his family as a kind, loving, strong minded, dignified, intelligent man whose personality filled a room and who was a dedicated father and husband. Mr. Burke was diagnosed with asthma in 1969 for which he received treatment including steroid medication. This condition progressively worsened and he was diagnosed with Chronic Obstructive Pulmonary Disease (COPD) in 2008.� Despite the significant impact this condition had on Mr. Burke�s wellbeing, particularly in his later years, he sought to maintain an active life to the fullest extent possible and was otherwise healthy. � Mr. Burke�s COPD had worsened significantly towards the end of his life with an assessment in 2016 determining that he was suffering from advanced lung disease with only 16% use of his lungs. On the 30th December 2022 Mr. Burke was admitted to hospital with a suspected chest infection. Subsequent assessment determined that he was suffering from Community Acquired Pneumonia and an osteoporotic fracture of his vertebrae. He received treatment for his infection and conservative treatment for the fracture. His recovery was slow, however by 25th January 2023, Mr. Burke was medically fit for discharge; he had recovered from his pneumonia and was suitable to be stepped down for assessment as to care and rehabilitation needs in the community. � He was discharged to a care home on 25th January 2023 for further assessment. The following evening, 26th January 2023, Mr. Burke was found collapsed on the lavatory floor by staff. Although not suffering a traumatic injury, Mr. Burke�s oxygen saturation levels were dangerously low and ambulance were called who transported Mr. Burke to hospital. � On admission Mr. Burke was diagnosed with suffering from a chest infection and delirium caused by both his infection and the effect of the pain medication he was receiving. On 30th January 2023 Mr Burke suffered a fall on the ward whilst trying to get up out of his bed. Limited and inadequate measures had been put in place to mitigate his falls risk and no falls assessment had been undertaken. Mr. Burke was assessed and diagnosed as having suffered a fractured neck of femur. Surgery to address the fracture was delayed due to Mr. Burke�s general condition and very high risk of mortality from surgery. Mr. Burke�s condition continued to deteriorate and by the morning of 2nd February 2023 he was assessed as being at the end of life. Michael John BURKE died on the 2nd February 2023.

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

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

14/05/2024

2024-0263

Carol Divall

East Sussex

1 [REDACTED], Chief Executive of East Sussex Healthcare NHS Trust

On 04 November 2022 I commenced an investigation into the death of Carol Ann DIVALL aged 74. The investigation concluded at the end of the inquest on 26 April 2024. The conclusion of the inquest was that: � C A Divall suffered from Alzheimer�s disease for the previous 7 years before she sustained a hip fracture at home on 15th September 2022. She had been living at home and was looked after by her husband. She was admitted to the Conquest Hospital where it was repaired on 16.9.22. She was not discharged until 24.10.22 to the care of the Community Nursing Team who immediately assessed Mrs Divall as requiring end of life care. Mrs Divall died on 29.10.22 at home.

C A Divall suffered from Alzheimer�s disease for the previous 7 years before she sustained a hip fracture at home on 15th September 2022. She had been living at home and was looked after by her husband. She was admitted to the Conquest Hospital where it was repaired on 16.9.22. She was not discharged until 24.10.22 to the care of the Community Nursing Team who immediately assessed Mrs Divall as requiring end of life care. Mrs Divall died on 29.10.22 at home.

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

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

26/07/2024

2024-0406

Jennifer Bunyan and Marion Bunyan

Cambridgeshire and Peterborough

1 [REDACTED], Chief Executive, Cambridgeshire County Council, New Shire Hall, Alconbury Weald, Cambridgeshire 2 Secretary of State, Department of Transport, Great Minster House, 33 Horseferry Road, London, SW1 4DR

On the 8th June 2020, I commenced investigations into the deaths of Jennifer BUNYAN, aged 24 years and her mother, Marion BUNYAN aged 54 years. The investigations concluded at the end of an inquest on the 25th May 2023. The Conclusion of the inquest was Road Traffic Collision.

Jennifer and Marion Bunyan, the driver of, and a passenger in a motor car respectively, died on the 7th June 2020 in a waterway known as Crease Drain, adjacent to the C117, Puddock Road, Warboys. The cause of their deaths was from drowning when their motor car left the carriageway and travelled over the eastern grass verge where it then descended into the said waterway. The motor car rolled on to its roof. They were unable to extricate themselves from the vehicle and died as a result of the vehicle being partially submerged in water. At the time of her death, Jennifer was pregnant (circa 30 weeks gestation), and her unborn daughter, subsequently named Erin Marion Chatten, died in utero.

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

Road (Highways Safety) related deaths� � This report is being sent to: Cambridgeshire County Council | Department for Transport

15/08/2023

2023-0340

Haik Nikolyan

Buckinghamshire

1 [REDACTED], His Majesty�s Prisons & Probation Service (HMPPS)

On 15 March 2019 I commenced an investigation into the death of Haik Patrick NIKOLYAN aged 21. The investigation concluded at the end of the inquest on 12 July 2023. � The jury recorded a narrative conclusion which stated: Haik was a vulnerable person with Autism Spectrum Disorder, who committed suicide following failures by those organisations who had responsibility to protect him from harm. He had a documented history of mental health difficulties, self-harm, depression, anxiety, suicidal thoughts and suicide attempts. The decision to withdraw prescription medications managing his depression without a documented risk assessment or enhanced monitoring was not in his best interest and led to him experiencing psychological withdrawal symptoms, exacerbating his anxiety and depression. The insufficient security at the prison allowed illegal drugs to circulate which contributed to his bullying and exploitation and created a barrier to accessing prescription medication. � The prolific bullying, exploitation and humiliation that Haik experienced in prison contributed to his declining mental health. Policies, procedures and interventions put in place to safeguard him were ineffective, ill-advised and at times absent. This resulted in ineffective communication, between the Prison, Health and Mental Health services which meant information was recorded but inconsistently shared and acted upon effectively. Furthermore, the absence of a process for escalating concerns put him at heightened risk. � Due consideration for the complexities that Austism Spectrum Disorder can present were not appropriately addressed. Due to a lack of adequate training and the absence of a clinical psychologist, some of his behaviours were interpreted to be dangerous rather than the presentation of Autism Spectrum Disorder. This resulted in the interventions that were in place being ineffective, and incompatible with Haik�s needs and therefore this was an unsuitable custodial environment for him.

Haik committed suicide [REDACTED] and was found unresponsive in his cell in the early hours of 11th March 2019 at HMYOI Aylesbury (as it then was).

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1.���� The Family of Haik Nikolyan 2.���� Ministry of Justice 3.���� Practice Plus Group (formerly Care UK) 4.���� Barnet, Enfield & Haringey Mental Health NHS Trust 5.���� Midlands Partnership NHS Foundation Trust � I have also sent it to: 6.���� Governor [REDACTED], HMP Aylesbury 7.���� HM Prisons & Probation Ombudsman 8.���� The family of Anthony McNally who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

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

30/08/2024

2024-0476

Rachel Gibson

�Cambridgeshire and Peterborough

1 [REDACTED], President of Royal College of Anaesthetists

On 20 July 2022 I commenced an investigation into the death of Rachel Gibson, age 47. The investigation concluded at the end of the inquest on 21 August 2024. The conclusion of the inquest was: Medical Cause of Death: 1a Hypoxic-Ischaemic Brain Injury 1b Cardiorespiratory arrest caused by infiltration of local anaesthetic during surgery 1c Right hip replacement (April 2022) Narrative conclusion: Rachel Gibson sustained irreversible brain damage following cardiac arrest caused by administration of excessive local anaesthetic (Ropivacaine) during surgery.

Dr Rachel Gibson had severe osteoarthritis and underwent hip replacement surgery at Spire Lea Hospital, Cambridge on 12 April 2022. Towards the end of the procedure an infiltration of Ropivacaine was used in excess of the recommended dose. Upon return to her room she suffered an�� unwitnessed�cardiac arrest.�She was resuscitated�and transferred to Addenbrooke�s Hospital where she was found to have sustained irreversible brain damage. She died at Addenbrooke�s Hospital on 14 July 2022. The evidence was that it is routine practice before the procedure for the anaesthetist to give oral instructions to the scrub nurse specifying the type and dose of local anaesthetic to be used to infiltrate the operation site. Towards the end of the operation the scrub nurse hands the local anaesthetic to the surgeon who then carries out the infiltration. The intention in this case was for a 0.2% solution of Ropivacaine to be diluted 50/50 with normal saline before it was infiltrated. The evidence suggested that this was not done. The result was that excessive Ropivacaine was administered by mistake. The evidence at the inquest was that this type of practice is common nationally.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Dr Gibson�s family Spire Lea Hospital [REDACTED] [REDACTED] [REDACTED] � I� have� also� sent� it� to�[REDACTED] and�[REDACTED] (who� gave� expert� evidence) Addenbrooke�s Hospital (where Dr Gibson died) 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

The Royal College of Anaesthetists

24/07/2024

2024-0398

Shahida Khan

Hampshire, Portsmouth and Southampton

1 [REDACTED], interim CEO Voyage Care Cloverdale

On 05 January 2023 I commenced an investigation into the death of Shahida KHAN aged 46. The investigation concluded at the end of the inquest on 23 April 2024. The conclusion of the inquest was that: The deceased died on 17th December 2022 at Cloverdale Care Home, [REDACTED]. � The deceased was given by another substantial quantities of prescribed [REDACTED] and [REDACTED] together with a substantial quantity of�[REDACTED]�which caused toxicity in consequence of which the deceased suffered respiratory depression. The deceased had a history of epilepsy. The substantial quantity of�[REDACTED]�caused the deceased to suffer three seizures immediately prior to her death which contributed to the death. How the deceased came to be given substantial quantities of [REDACTED] and [REDACTED] cannot be ascertained.

The deceased died on 17th December 2022 at Cloverdale Care Home, [REDACTED]. The deceased was given by another substantial quantities of prescribed [REDACTED] together with a substantial quantity of�[REDACTED]�which caused toxicity in consequence of which the deceased suffered respiratory depression. The deceased had a history of epilepsy. The substantial quantity of�[REDACTED]�caused the deceased to suffer three seizures immediately prior to her death which contributed to the death. How the deceased came to be given substantial quantities of��[REDACTED] and [REDACTED] cannot be ascertained.

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

Care Home Health related deaths�| Alcohol, drug and medication related deaths� � This report is being sent to: Voyage Care Cloverdale

18/12/2024

2025-0010

Sylvia Savage

Durham and Darlington

1 [REDACTED]- CEO � FOUR SEASONS HEALTHCARE

On 02/05/2023 10:55an investigation was commenced into the death of Sylvia Margaret Louisa SAVAGE 16/09/1938 00:00:00. The investigation concluded at the end of the inquest on 12/12/2024 00:00.� The conclusion of the inquest was that Sylvia Margaret Louisa Savage died on 25th April 2023 at the University Hospital of North Durham from bronchopneumonia. Her death was the the consequence of a fall from her bed and the injuries she sustained on the 18th March 2023 at the Redwell Hills Care Home, Consett, County Durham and commenced a decline in her health which despite medical treatment and care led to her death..

Sylvia Margaret Louisa Savage died on 25th April 2023 at the University Hospital of North Durham from bronchopneumonia. Her death was the the consequence of a fall from her bed and the injuries she sustained on the 18th March 2023 at the Redwell Hills Care Home, Consett, County Durham and commenced a decline in her health which despite medical treatment and care led to her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] COUNTY DURHAM & DARLINGTON NHS FOUNDATION TRUST I have also sent it to Care Quality Commission � Newcastle Upon Tyne [REDACTED] � DURHAM COUNTY COUNCIL � SOCIAL CARE [REDACTED] � INFORMATION COMMISSIONER OFFICER IN CHARGE � SAFEGUARDING DEPARTMENT DURHAM CONSTABULARY who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths

Four Seasons Healthcare

28/03/2024

2024-0664

Daniela Pani

Berkshire

1 [REDACTED]� CEO Berkshire Healthcare NHS Foundation Trust 2 British Transport Police 3 [REDACTED]� Interim Managing Director South Western Railway

On 04 July 2023 I commenced an investigation into the death of Daniela Vitalia PANI aged 57. The investigation concluded at the end of the inquest on 28 March 2024. The conclusion of the inquest was that: On the 29th June 2023 Daniela Vitalia Pani died at�[REDACTED] after deliberately leaving the platform as a train approached and remaining on the tracks until she was struck by the train.� She had suffered from a serious and enduring mental health problem for most of her adult life and was under the care of the mental health services at the time of her death

Daniela had suffered from bi-polar affective disorder for many years.� Over the course of 2022 her mental health deteriorated and she then came under the care of the Community Mental Health Team (CMHT) and Crisis Resolution Home Treatment Team (CRHTT); which are services provided by the Berkshire Healthcare NHS Foundation Trust. In May 2023 this culminated in her admission, as a voluntary patient, to an in-patient ward at Prospect Park Hospital.� Daniela was discharged from Prospect Park Hospital on the 26th June 2023 after her condition appeared to have stabilised.� There was a care package in place for her in the community involving the CMHT and a care agency. On the 28th June 2023 Daniela was due to have a review meeting with a member of the CMHT. This is known as a 72 hour review and is required due to the knowledge that there is a heightened risk to persons at periods of transition; such as discharge from an in-patient unit.� Daniela telephoned the CMHT on that morning to say that she was unwell and to cancel the visit to her. The CMHT best practice guidance states that a 72 hour review should take place face to face and that telephone reviews should only be used as a rare exception once all avenues to arrange a face to face meeting have been exhausted. After speaking to her manager, the CMHT member undertook the 72 hour review meeting with Daniela via telephone on the 28th June 2023.� During this review Daniela denied that she had any intent to harm herself. Later that day Daniela twice called the CRHTT Crisis Line.� The CRHTT nurse on duty reassured Daniela, carried out some safety planning and assessed Daniela as not posing an imminent risk to herself such that required an immediate intervention. On the 29th June 2023 Daniela got a taxi to [REDACTED] and entered the station.� As a train approached the platform shortly after 9.00am Daniela jumped onto the tracks and was struck by the train.� The impact caused a severe head injury and Daniela was sadly declared deceased at the scene.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Miss Pani I have also sent it to Network Rail 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.

Railway related deaths�| Suicide (from 2015) | Mental Health related deaths

Berkshire Healthcare NHS Foundation Trust | British Transport Police | South Western Railways

24/01/2025

2025-0044

Neville McKenzie

Birmingham and Solihull Districts

1) Birmingham and Solihull Integrated Care Board� 2) The Health and Safety Executive

On 6 September 2024 I commenced an investigation into the death of Neville Daniel Elisha� MCKENZIE. The investigation concluded at the end of the inquest. The conclusion of the inquest was that death was due to accidental choking as a consequence of cognitive impairment.

Mr McKenzie died at City Hospital, Birmingham on the 25th August 2024 as a result of the�effects of a cardiac arrest caused by an incident of choking on the 13th August 2024 at his� care home. Mr McKenzie was recognised to be at risk of choking because his dementia� meant he would eat quickly and put too much food in his mouth. Consequently, his care�plan was for him to be supervised eating and encouraged to sit and eat slowly. On this� occasion he had eaten his lunch under the general supervision of staff and left the dining� room without giving any cause for concern. A short time later he was witnessed to be� choking by staff who immediately commenced manoeuvres to try and remove the food from his airway but this was unsuccessful and he went into cardiac arrest. He received CPR and� was successfully resuscitated by paramedics and transferred to hospital but had suffered�an un-survivable brain injury.� Based on information from the Deceased�s treating clinicians the medical cause of death was� determined to be:� �1a Hypoxic brain injury �� �1b Cardio respiratory arrest �� �1c Choking �� �1d �� �II Dementia

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

Care Home Health related deaths

Birmingham and Solihull Integrated Care Board�| The Health and Safety Executive

24/09/2024

2024-0510

George Coulthard

South Manchester

1) Care Quality Commission�� 2) Greater Manchester Integrated Care� 3) Secretary of State for Health and Social Care

On 6th February 2024 I commenced an investigation into the death of George Neville� COULTHARD. The investigation concluded on the 29th August 2024 and the� conclusion was one of Narrative: Died from natural causes contributed to by the complications of an accidental fall and the complications of necessary� anticoagulation medication. The medical cause of death was 1a) Frailty;�������������������������������������������������������������������������������������������������������������� � II)� Chronic Kidney Disease, Atrial Fibrillation (anticoagulated), Fall� leading to necrotic skin wounds, Gastrointestinal bleed.

George Neville Coulthard had an accidental fall and sustained wounds to his skin as a consequence. He was in significant pain and discomfort as a consequence� and the wounds deteriorated. As a consequence of his increasing frailty he had a� further fall and a long lie. He was admitted to Wythenshawe Hospital. His skin� was treated proactively whilst he was an inpatient and slowly his wounds� improved. Whilst an inpatient he had a series of gastrointestinal bleeds probably� as a consequence of his anticoagulant medication. The bleeds and the�intervention following the first bleed increased his overall frailty and reduced his� physiological reserves further. On 18th December 2023 it was agreed he should� be discharged to a care home given his deterioration and the fact he was unlikely� to improve further. He was not discharged until 11th January due to there being� no care home beds available for him. He was discharged on 11th January 2024 to Hilltop Hall Care Home. The basis of the discharge and expectations were not� clear. He was then transferred to Bramhall Manor for rehabilitation which was�not compatible with the assessment of 18h December. He continued to�deteriorate and died at Bramhall Manor on 27th January 2024.

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

Hospital Death (Clinical Procedures and medical management) related deaths

CQC | Department of Health | Greater Manchester Integrated Care

27/10/2023

2023-0416

Andrew Nichols

Worcestershire

1) Chief Executive, National Institute for Health and Care Excellence (NICE)

On 7 July 2022 an investigation was commenced into the death of Andrew Etlered Nichols. The investigation concluded at the end of the inquest hearing on 25 October 2023 at Stourport Coroner�s Court, in the Worcestershire Coroner Area. The conclusion (a �narrative� conclusion in Section 4 of the Record of Inquest) was determined as follows: �Andrew Nichols died as a direct result of blood clots forming in the vein of his leg and circulating to block the veins of his lungs. Andrew not receiving anticoagulation medication when discharged from hospital contributed to his death. Andrew�s immobility, which had occurred as a result of a very rare side-effect following vaccination, contributed to his death.�

Andrew Nichols was in his early fifties (he was 52 when he died in June 2022), with no significant past medical history, when he received a vaccination in April 2021, as part of the national programme in response to the Covid-19 pandemic. Andrew suffered an extremely rare and serious side-effect of vaccination, and within days developed the neurological condition acute disseminated encephalomyelitis (known as ADEM). In consequence, Andrew spent over a year in hospital, mostly in intensive care, as he required respiratory, nutrition and organ support and was wholly dependent on professionals for daily care. Andrew was immobile and required hoisting when being moved out of bed. Early on in his hospital admission, Andrew suffered bilateral pulmonary emboli, which were thought to have developed owing to him having become acutely unwell and immobile (not vaccine-induced thrombotic thrombocytopaenia (VITT)). Andrew was commenced on anticoagulation medication and this continued during his stay in hospital. At the inquest, evidence was given by a consultant haematologist, who stated that, owing to Andrew having two specific risk factors for the development of deep vein thrombosis (namely ongoing immobility and previous thrombosis/emboli), anticoagulation medication would remain clinically indicated, whether he remained in hospital or not. In May 2022, Andrew was discharged from hospital to a specialist neuro- rehabilitation community care centre. Upon discharge, the hospital did not include anticoagulation medication in the list of prescribed medication that Andrew should continue to receive in the community. At the inquest, the hospital accepted that to not do so was a failing on their behalf. It was not clear why this failing happened; however, a finding was made that the most likely reason was that clinicians routinely considered anticoagulation medication was prescribed for patients in hospital, but an assessment of whether it would continue to be required in the community would be made by professionals involved there. Andrew attended a different acute hospital on two further occasions (these were short admissions to provide respiratory support and to treat and monitor infection) later in May, and then in June 2022 � once again, Andrew received anticoagulation medication during his stay in hospital, but not upon discharge. � The inquest heard that the neurorehabilitation community care centre did not, at the time of Andrew�s death, perform their own assessments on new patients� risk of venous thrombosis (VTE risk assessment), but instead were reliant on information being provided by hospitals and would facilitate prescribed medication being given to patients (including anticoagulation medication), in accordance with discharge information. The centre now has a new policy in place, requiring VTE risk and assessment to be considered when patients are discharged from hospital into their care. The inquest heard evidence from the Director of Services at the centre, who stated that she had spoken to colleagues at other similar community care organisations, who also did not routinely carry out VTE risk assessments on patients, as part of their practice. � Andrew suffered a fatal deep vein thrombosis and pulmonary embolism at the neurorehabilitation centre on 27 June 2022. � Following medical evidence heard at the inquest, the cause of death was determined in Section 2 of the Record of Inquest as: � 1a � pulmonary embolism 1b � deep vein thrombosis 2 � acute disseminated encephalomyelitis (vaccine-induced) � Section 3 of the Record of Inquest (which answered how, when and where Mr Nichols came by his death) was determined as follows: � �Andrew Nichols had no significant medical history at the time he received a vaccination in April 2021, as part of the national programme in response to the Covid-19 pandemic. Within a few days, Andrew became very unwell and was diagnosed with acute disseminated encephalomyelitis (ADEM), a severe neurological condition which had developed as a side-effect of vaccination. Andrew received specialist care for over a year, primarily in hospital, but latterly at a neuro-rehabilitation centre. Andrew had been prescribed anticoagulant medication whilst in hospital, owing to his immobility and risk of developing blood clots. Andrew should have continued to receive this medication, however, upon discharge from hospital to the rehabilitation centre, he did not. Andrew became acutely unwell on 27 June 2022, going into cardiac arrest. Despite prolonged attempts at resuscitation by nursing and paramedic professionals, Andrew was pronounced deceased later the same day, upon arrival at the Worcestershire Royal Hospital.�

COPIES AND PUBLICATION I have sent a copy of my report to Interested Persons � these being: �� the family of Andrew Nichols �� University Hospitals Birmingham NHS Trust �� Inspire Neurocare Worcester �� Medicines and Healthcare Products Regulation Agency (MHRA). I have also sent a copy of my report to the Chief Coroner. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

03/07/2024

2024-0356

Lee McHale

Manchester South

1) Department for Levelling Up, Housing and Communities (Local Government.)

On 28th November 2023 I commenced an investigation into the death of Lee Francis MCHALE. The investigation concluded on the 17th June 2024 and the conclusion was one of suicide. The medical cause of death was 1a) Multi Organ Failure 1b Paracetamol Overdose

On 23rd November 2023 Lee Francis McHale was admitted to hospital. He had taken [REDACTED] paracetamol tablets the day before. He was treated but continued to deteriorate. On 25th November 2023 he died at Tameside General Hospital. The inquest heard that he had incurred debts prior to his death as a consequence of the gap between his housing benefit entitlement and actual rent. This arose due to the �bedroom tax�. He had a larger property from when he had fostered children. However he had had to give up fostering and was as a consequence reliant on benefits. He was at risk of eviction at the time of his death.

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

Suicide (from 2015) | Alcohol, drug and medication related deaths This report is being sent to: Ministry of Housing, Communities & Local Government

10/09/2024

2024-0486

James Astley

South Manchester

1) Downshaw Lodge 2) Care Quality Commission

On 25th January 2024 I commenced an investigation into the death of James� Astley. The investigation concluded on the13th August 2024 and the conclusion was one of Narrative: Died from natural causes contributed to by dehydration� and poor nutritional status. The medical cause of death was 1a) Urosepsis,� vascular dementia II) Frailty, dehydration, poor nutritional status.

James Astley had dementia and was immobile. His nutritional status declined� significantly from November 2023. In December his swallow deteriorated and� led to him becoming increasingly frail. On 2nd January he was started on� antibiotics. On 3rd January he was seen again by a GP and found to have� deteriorated further. He was admitted to Tameside General Hospital where he was treated for urosepsis and dehydration. Despite treatment he continued to deteriorate due to his frailty. He died at Tameside General hospital on 22nd� January 2024.

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

Care Home Health related deaths

Downshaw Lodge | Care Quality Commission

20/06/2024

2024-0333

Lee-Ann Ince

Manchester South

1) Greater Manchester Integrated Care Board.

On 10th May 2023 I commenced an investigation into the death of Lee- Ann Sarah INCE. The investigation concluded on the 22nd May2024 and the conclusion was one of suicide. The medical cause of death was 1a) hanging.

Lee Ann Sarah Ince was a victim of domestic abuse, who was in a coercive and controlling relationship. The prolonged exposure to domestic abuse during the relationship had a significant impact on her mental health. On 9th May 2023 she was found unresponsive attached to a ligature.

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

Suicide (from 2015) This report is being sent to: Greater Manchester Integrated Care

15/01/2024

2024-0021

Rhys Hill

Manchester South

1) Lancashire Teaching Hospitals; 2) NHS England

On 9th February 2023 I commenced an investigation into the death of Rhys Lennon Hill. The investigation concluded on the 20th December 2023 and the conclusion was one of Narrative: Died from a complication of a previous surgical procedure, where the complication was not identified until after his death. The medical cause of death was 1a) Pulmonary Embolus; 1b) Deep Vein Thrombosis formation in the context of recent Primary Lumbar Discectomy

Rhys Lennon Hill had spinal surgery at the Royal Preston Hospital. On 30th January 2023 Rhys was offered his Dalteparin. He refused it. On the balance of probabilities that refusal was linked to the time it was offered at and because he was in some discomfort. The refusal of Dalteparin was not escalated to the clinical team and there is no evidence that the risk presented by the omission of the dose of Dalteparin was evaluated by the treating clinicians. � Rhys was discharged on 30th January 2023 from the Royal Preston Hospital. The Trust policy required that at discharge a patient and their family members must be provided with verbal and written information about VTE. The Trust policy was not followed. As a consequence, Rhys and his family did not have clear instructions on how to reduce the risk of developing a VTE and the symptoms to look for. This probably increased the risk of Rhys developing a VTE. � On 9th February 2023 Rhys collapsed at his home address and attempts to resuscitate him were unsuccessful. A post-mortem examination found that he had died from a pulmonary embolus due to a deep vein thrombosis. On the balance of probabilities, the cause of his deep vein thrombosis was the recent surgery he had had undertaken. The risk of him developing a deep vein thrombosis was increased by the Trust discharge policy not being followed and a risk assessment not being undertaken following his refusal of the Dalteparin on the morning of the discharge.

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

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

29/05/2024

2024-0288

Elizabeth McCann

Manchester South

1) Ministry of Justice 2) Home Office 3) Greater Manchester Police 4) Department of Health and Social Care 5) Pennine Care NHS Foundation Trust

On 26th August 2022 I commenced an investigation into the death of Elizabeth Sarah Jayne McCann. The investigation concluded on the 19th April 2024 and the conclusion was one of unlawful killing. The medical cause of death was 1a) Ligature strangulation.

Elizabeth Sarah Jayne McCann was raped and murdered on 25th August 2022 at the home address of her murderer, [REDACTED], Ashton- under-Lyne. Her murderer was on a life licence at the time and on the Sex Offenders Register as a consequence of his convictions in 2009 for rape, sexual assault and Section 20 assault. � He had met Elizabeth through the Health and Wellbeing College run by Pennine Care. Whilst he was on licence, he had been signposted by Probation to the Wellbeing College run by Pennine Care NHS Foundation Trust. The College and Probation had previously agreed the college would accept some Probation clients. � There was a failure by the college and Probation to set up a clear, documented system for how this would work and how risk would be managed. Within the college there was a failure to ensure that there was a system for how this information from Probation would be received and scrutinised effectively. There was a failure by the college to set up a risk management system for attendees such as him. As a consequence of these failures her murderer joined the college without any risk assessment having been undertaken and without the college recognising the risk he posed. It is probable that had there been an effective system in operation that: either he would not have been accepted at the college at all or would not have been accepted without a stringent plan to manage his risk, these failures by the college and Probation probably contributed to Elizabeth�s death. � It was known to Greater Manchester Police (GMP) and Probation that he posed a risk in certain circumstances. The areas of focus for an increase in risk were alcohol use, lone females, intimacy and rejection. Whilst he was being supervised under licence and in accordance with the Sex Offenders Register management, both his Probation Officer and Police Offender Manager had caseloads far in excess of what were safely manageable. This was because Greater Manchester Police had failed over a period of years to adequately staff the Sexual Offender Management Unit and the Probation service did not have sufficient probation officers available due to recruitment challenges. � Whilst managing him in March 2022, he disclosed to his Police Offender Manager that he had recently had a small relapse with alcohol but Change Grow Live had declined to assist him. That information was not shared with Probation and not investigated further probably due to the excessive workload of the Police unit. � On 6th April he disclosed to Probation that he had met a woman and believed it would develop into an intimate relationship. The information was shared that day with Greater Manchester Police. There was a failure by Greater Manchester Police and Probation to action that information. In addition, the officer working for Greater Manchester Police who was spoken to failed to appropriately record the information. This was probably due to the excessive workload in the unit against the staff numbers. � On 12th April when it was indicated that the woman had decided not to pursue the relationship with him, Police and Probation failed to exhibit any professional curiosity as to whether the relationship was as described and in particular failed to speak to the woman; and failed to recognise that the basis on which his risk had been assessed was changing. There was a failure to consider if additional work needed to be undertaken with him. It is probable that the large caseloads contributed to the lack of � professional curiosity as it meant there was little time available to consider the emerging picture. It is possible that this lack of action by Greater Manchester Police and Probation contributed to Elizabeth�s death. � In July 2022 he approached a woman he had met at college at a public house in Ashton. He was under the influence of alcohol. He touched her and tried to kiss her without her consent. She reported the incident to the college Senior Management team because she was very concerned about the incident. The college Senior Manager failed to recognise it was a safeguarding issue and spoke to him informally. � On 18th August 2022 she made it clear to him that she did not want a relationship with him. Had there not been a failure by the college and Probation to set up an effective referral system and had there not been a failure by the college to set up a system for dealing with emails from Probation then it is probable the college would have known his status and have escalated the event to Probation and recognised it as high risk in relation to his behaviour. It is probable that the college would have taken action that would have prevented him from accessing the college after the reported incident. It is probable that Probation would have recognised this was a deteriorating situation, reassessed risk and taken steps to reduce the risk he posed to the public and in particular to women. None of these actions happened as a consequence of the failure to have an effective system in place to manage high risk referrals such as him. As a consequence, he continued at the college and Probation were unaware of these events and no action was taken by them. � It is probable that had there not been a failure to share the July 2022 incident which was caused by the previous failures Elizabeth McCann would not have died on the day she did.

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

Other related deaths This report is being sent to: Ministry of Justice | Home Office | Greater Manchester Police | Department of Health and Social Care | Pennine Care NHS Foundation Trust

05/06/2024

2024-0304

Bernard Compton

Manchester South

1) NHS England

On 25th October 2023 I commenced an investigation into the death of Bernard Compton. The investigation concluded on the 9th May 2024 and the conclusion was one of NARRATIVE: Died from a complication of a myocardial infarction when delays in identifying he had a myocardial infarction meant that the time for a successful percutaneous coronary intervention had passed. The medical cause of death was 1a) Left ventricular rupture with Hemopericardium; 1b) Acute myocardial infarction; 1c) Coronary artery disease II Tobacco smoking.

On 13th October 2023 at about 20:23 Bernard Compton rang North West Ambulance Service reporting pain under his left arm, shortness of breath, shaking and sweating. He was categorised as a category 3. He was then assessed further and a taxi was sent to take him to hospital. � He arrived at Tameside General Hospital at 21:37. He was streamed for an ECG based on his symptoms which included chest pain since 3pm that day. The ECG took place at 22:15. The machine indicated on the print out that he was having a myocardial infarction. � It was misinterpreted by a doctor. It was to be repeated within 30 minutes. That did not happen. He was triaged at 23:24. A triage should have taken place within fifteen minutes but did not due to significant demand on the department. He was categorised as urgent and should have seen a clinician within ten minutes. He was sent to sit in the main waiting area. � At 02:06 the results of his bloods taken at 22:20 were reported on the hospital�s electronic system. They showed a significantly raised troponin. He was still in the waiting area. He had not seen a member of staff or been checked on. His results on the system were not reviewed until 05:12 due to demands on the staff. He had not been reviewed since he was triaged. � He had left the department due to the wait and not being seen. Greater Manchester Police and the North West Ambulance Service were alerted. Greater Manchester Police returned him to Tameside General Hospital as delays with North West Ambulance meant there was a 45 minute wait for all category 2 cases, even though it was known he was probably having a heart attack. � He was transferred to Wythenshawe (a tertiary cardiac centre) at 07:47. By that time the optimum 12 hour window for a successful intervention by percutaneous coronary intervention had passed. He remained at Wythenshawe. � On 19th October 2023 he had a left ventricular rupture, as a consequence of the previous myocardial infarction and the damage it had caused to his heart and died.

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

Emergency services related deaths (2019 onwards) This report is being sent to: NHS England

13/06/2024

2024-0316

Linda McLaughlin

Manchester South

1) NHS England

On 1st November 2023 I commenced an investigation into the death of Linda MCLAUGHLIN. The investigation concluded on the 16th May 2024 and the conclusion was one of NARRATIVE: Died from bronchopneumonia contributed to by the complications of previous drug therapy. The medical cause of death was 1a) Bronchopneumonia II) Drug induced Interstitial Lung disease, Chronic Myeloid Leukaemia, Steroid therapy.

In 2014 Linda McLaughlin was diagnosed with Chronic Myeloid Leukaemia (CML) and treated with a tyrosine kinase inhibitor drug (nilotinib). She responded well to the treatment and by October 2021 was in molecular remission. She remained on a low dose of nilotinib. In April 2023 she was becoming increasingly breathless and went to Royal Oldham Hospital where a scan in May 2023 found she had developed interstitial lung disease probably as a consequence of nilotinib treatment. She was treated with steroids for interstitial lung disease and the nilotinib was stopped. On 23rd October 2023 she was admitted to Tameside General Hospital where she was treated for bronchopneumonia and was very unwell. She deteriorated and died at Tameside General Hospital on 27th October 2023

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

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

29/05/2024

2024-0292

George Broadhurst

Manchester South

1) NHS England

On 12th October 2023 I commenced an investigation into the death of� George Barry Broadhurst. The investigation concluded on the 30th April 2024 and the conclusion was one of Narrative: Died from the� complications of a fracture sustained in an accidental fall where the� fracture was not recognised immediately. The medical cause of death was 1a) Pulmonary Embolism and Community Associated� Pneumonia 1b) Infected traumatic thoracic vertebral fracture 1c)� Fall.

George Barry Broadhurst lived independently and was mobile. Around� the 4th September 2023 he had an accidental fall at his home address. He reported to his GP that he had injured his lower back and was in pain. He� was advised to attend A&E but declined. He managed with pain relief at� home. He continued to manage at home until 25th September 2023 when� he went to Tameside General Hospital. An x-ray was taken. He was� discharged. The x-ray showed a fracture of the vertebrae but this was not� identified at that time. A radiologist reported on the x-ray 2 days later and� it was to be reviewed by a Consultant but was not done due to backlogs.� On 1st October 2023 he went to Stepping Hill Hospital with worsening� back pain. The fracture was identified and he was discharged home with� pain relief and treatment for a lower respiratory tract infection and with� support in the community. At home he deteriorated rapidly. He was readmitted on 7th October to Stepping Hill Hospital. He had a collapsed�lung, pulmonary embolism and an infected fractured vertebra. The� collapsed lung and pulmonary embolism were as a consequence of lack of mobility due to the fracture. He deteriorated and died at Stepping Hill� Hospital on 10th October 2023.

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; 2) Weightmans LLP on behalf of Tameside General Hospital and; 3) Browne Jacobson LLP on behalf of Stepping Hill Hospital, 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: NHS England

03/05/2024

2024-0245

Michael Clarke

Manchester South

1) NHS England 2) Greater Manchester Integrated Care

On 1st August 2023 I commenced an investigation into the death of Michael Clarke. The investigation concluded on the 28th March 2024 and the conclusion was one of Narrative: Died from the complications of urosepsis following a previous medical procedure, contributed to by his underlying health conditions. The medical cause of death was 1a) Multiple organ failure 1b) Urosepsis on the background of a cystoscopy on 26/07/23 II) Diabetes mellitus, end stage kidney disease, atrial fibrillation, hypertension.

Michael Clarke had a complex medical history that included diabetes, end stage renal failure, hypertension, and atrial fibrillation. He required dialysis three times a week. On 20th July 2023 Michael Clarke saw his GP for a suspected urinary tract infection and reported blood in his urine. He was prescribed antibiotics for the suspected infection and referred on the 2 week pathway for investigation of the cause of the bleeding. On 26th July 2023 he was seen in the cystoscopy clinic under the 2 week wait referral pathway. The urine culture from the sample on 21st July showed mixed growth. The cystoscopy found no evidence of cancer although there was evidence of significant bladder debris that was cleared out. On 28th July 2023 Michael Clarke felt very unwell. At 21:20 a call was placed to Northwest Ambulance Service by the out of hours nurse indicating they were concerned he had sepsis and an ambulance was required. The call was categorised as a category 3 which meant an ambulance should have been dispatched in 1 hour. Due to demand the wait was in excess of 4 hours. The nurse indicated 1 hour was an acceptable time frame. After 1 hour no ambulance attended and a further call was made. The category remained at 3. At 23:38 a further call was made and the call was categorised as a category 2 call. An ambulance arrived and took him to hospital. At Tameside General Hospital he was diagnosed with suspected urosepsis probably triggered by the cystoscopy. He was started on intravenous antibiotics and was moved to the Intensive Care Unit for full organ support. He continued to deteriorate and died at Tameside General Hospital on 30th July 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely [REDACTED] on behalf of the family, Tameside General Hospital 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: NHS England | Greater Manchester Integrated Care

17/7/2024

2024-0381

David Almond

South Manchester

1) NHS England 2) East Cheshire NHS Trust

On 8th January 2024 I commenced an investigation into the death of� David Nicholas ALMOND. The investigation concluded on the 8th July 2024 and the conclusion was one of Narrative: Died from the� complications of thrombophilia when he had not been placed on lifelong anticoagulants when he should have been. The medical� cause of death was 1a) Massive pulmonary embolism 1b)� Thrombophilia.

David Nicholas Almond had a family history of deep vein thrombosis. He� was diagnosed with thrombophilia in 2013. That information was in his�GP records. On 7th September 2022 he was diagnosed with a deep vein� thrombosis at Macclesfield District General Hospital and started on� anticoagulant medication and referred to the deep vein thrombosis clinic.� The notes indicate that thrombophilia and a family history of deep vein� thrombosis were mentioned. On 21st September 2022 he had a� telephone appointment with the deep vein thrombosis clinic. His family� history and diagnosis of thrombophilia was not explored fully and he was� not placed on lifetime anticoagulation. He should have been. On 25th� September 2023 he complained of breathlessness on exertion. He was� seen by an advanced nursing practitioner at his GP surgery. The possible risk of an embolism was not recognised and he was sent for an x ray� which would not diagnose a pulmonary embolism. The x ray was clear.� He was not seen again although the x ray excluded other potential�causes of his breathlessness. On 3rd January 2024 he collapsed at his� home address and was taken to Stepping Hill Hospital where a massive�pulmonary embolism was found. He deteriorated and died at Stepping Hill Hospital on 5th January 2024.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely�������� ���� [REDACTED] on behalf of the family, GTD�Healthcare, 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: NHS England | East Cheshire NHS Trust

21/07/2023

2023-0265

Marion Nickson

Manchester South

1) NHS England and; 2) Care Quality Commission

On 20th February 2023 I commenced an investigation into the death of Marion Nickson. The investigation concluded on the 6th July 2023 and the conclusion was one of Narrative: Died from the complications of an accidental fall sustained when not observed in hospital exacerbated by necessary anticoagulation therapy and when an inpatient following a pneumothorax a complication of a necessary medical procedure. The medical cause of death was 1a) Traumatic acute subdural bleed on the background of anticoagulation therapy; 1b) Fall; II) Iatrogenic pneumothorax during pacemaker insertion, complete heart block, ischaemic heart disease, acute coronary syndrome

Marion Nickson was admitted to Macclesfield Hospital on 26th January 2023 after a fall at her home address. It was identified she had had a heart attack and needed a pacemaker. Whilst at Macclesfield she had a fall on 27th January whilst unobserved in a bay where she should have been observed but she sustained no significant injury. She was transferred to Stepping Hill Hospital as a day patient on 2nd February 2023 for a pacemaker to be fitted. During the fitting she sustained a pneumothorax a recognised complication of the pacemaker fitting. A chest drain was fitted and she was admitted to Stepping Hill Hospital whilst the chest drain was required. On the 12th February 2023 she had an unwitnessed fall but sustained no significant injury, She was identified as having acute coronary syndrome and treated with anticoagulants. On 13th February the chest drain was removed and on 14th February she was deemed to be medically optimised for discharged. She was in a bay where a member of staff should have remained at all times. That did not happen. Whilst unobserved she had an accidental fall when she tried to mobilise independently from her chair. She was sent for a CT scan and a bleed to the brain was identified. She deteriorated rapidly and died at Stepping Hill Hospital on 14th February 2023 as a consequence of her head injury.

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

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

21/07/2023

2023-0266

Corinne Haslam

Manchester South

1) Rt. Hon. Steve Barclay MP, Secretary of State for Health and Social Care; 2)[REDACTED] , Chief Executive, Pennine Care NHS Foundation Trust

On 8th April 2022, I opened an inquest into the death of Corinne Haslam who died on 18th March 2022 at Tameside General Hospital, Ashton-under-Lyne, aged 55 years. The investigation concluded with an inquest which I heard between 13th and 16th March 2023. The inquest determined that Mrs Haslam died as a consequence of:- � 1) a) Acute left ventricular failure; b)� Myocardial ischaemia and acute exacerbation of chronic obstructive pulmonary disease c)� Left ventricular hypertrophy d)� II) Pulmonary thromboemboli (treated); Agitation arising in the context of severe and enduring mental illness The conclusion of the inquest was one of Natural Causes.

Mrs Haslam died on 18th March 2022 at Tameside General Hospital, Ashton-under-Lyne, as a consequence of complications arising from myocardial ischaemia and an acute exacerbation of Chronic Obstructive Pulmonary Disease, against a background of undiagnosed left ventricular hypertrophy. Mrs Haslam�s death was contributed to by physiological consequences of pulmonary thromboemboli which had been treated, and agitation in the context of severe and enduring mental illness. Mrs Haslam was admitted to Taylor Ward, Tameside General Hospital in January 2022 following an acute deterioration in her mental health which could not be safely managed in the community. Whilst initially an informal patient, Mrs Haslam was subsequently detained under the Mental Health Act. Mrs Haslam reported a range of physical symptoms on the ward including chest pain and breathlessness, and attended the Emergency Department at Tameside General Hospital on 7th March 2022 when an acute exacerbation of COPD was diagnosed and treatment started. On 13th March 2022, Mrs Haslam returned to the Emergency Department with similar symptoms, and pulmonary thromboemboli were suspected due to abnormal blood results. Anticoagulant treatment was prescribed and continued to be administered following Mrs Haslam�s return to Taylor Ward. On 17th March 2022, Mrs Haslam became breathless again and was initially managed on the ward by means of monitoring, nebulisers and limited oxygen therapy. Following a significant deterioration at around 22:00, Mrs Haslam was transferred back to the Emergency Department by ambulance, dying there in the early hours of the following morning.

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

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

23/08/2024

2024-0468

Allan Hamilton

South Manchester

1) SSP Health 2) Department of Health and Social Care

On 20th November 2023 I commenced an investigation into the death of Allan Robin� Hamilton. The investigation concluded on the 16th July 2024 and the conclusion was one of Narrative:� Died from Lobar pneumonia after a request for advice from his� GP practice was not actioned until 3 days after it was sent to them. The� medical cause of death was 1a) Lobar Pneumonia II) Ischaemic Heart Disease

Allan Robin Hamilton sent an email to his GP practice on 14th November 2023� indicating he was having breathing difficulties and seeking advice. The email�was not responded to until 17th November when he was sent an email asking if�he still needed an appointment. On 19th November 2023 he was found� unresponsive at his home address. A Post-mortem examination found he had died as a consequence of lobar pneumonia. On the balance of probabilities, he would�not have died on the day he did had he seen a doctor on 14th November 2023.

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

Community health care and emergency services related deaths

SSP Health | Department of Health and Social Care

19/07/2023

2023-0257

Bernhard Marek Coroner name: Alison Mutch Coroner Area: Manchester South Category: Emergency services related deaths (2019 onwards) This report is being sent to: Department of Health and Social Care | Greater Manchester Integrated Care

1) Secretary of State for Health and Social Care, and; 2) Greater Manchester Integrated Care

On 11th January 2023 I commenced an investigation into the death of Bernhard John Marek .The investigation concluded on the 31st May 2023 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Hospital Associated Pneumonia; 1b) Fractured Neck of Femur (operated); II) Squamous Cell Carcinoma Lung, Acute Kidney Injury

Bernhard John Marek (date of birth 2nd October 1946) had an accidental fall whilst walking from his car to a coffee shop. He could not weight bear following the fall. An ambulance was called. There was a 16 hour wait for an ambulance at that point. He was outside in the street in December. He was moved with assistance from members of the public to his car and driven home where an ambulance was again called for. He remained in his car whilst waiting for an ambulance as he could not mobilise from the car. The ambulance took him to Stepping Hill Hospital. He was diagnosed with a fracture to the neck of femur and admitted after a 9 hour wait in the emergency department. He was operated on. Post operatively his kidney function deteriorated further from his baseline. He required oxygen and his early warning score fluctuated. On 6th January 2023 he deteriorated rapidly having developed pneumonia. He died in Stepping Hill Hospital on 6th January 2023.

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

21/07/2023

2023-0264

Thomas Barton

Manchester South

1) Secretary of State for Health and Social Care; 2) Greater Manchester Integrated Care

On 1st February 2023 I commenced an investigation into the death of Thomas Barton. The investigation concluded on the 27th June 2023 and the conclusion was one of Narrative: Died from complications of aspiration pneumonia following a prolonged hospital stay contributed to by COVID which he contracted when discharge was delayed. The medical cause of death was 1a) Frailty; 1b) Aspiration Pneumonia on a background of Dysphagia; II) Covid, Urinary Tract Infection

Thomas Barton lived independently at his home address. He developed a urinary tract infection and required hospital treatment. He was admitted on 15th November 2022 to Wythenshawe hospital and then moved to Trafford General Hospital. He responded to treatment. To facilitate his discharge he needed additional support at home and remained in Trafford General Hospital whilst care arrangements were organised. Whilst waiting for the package of care to be put in place he developed COVID 19 in hospital. As a consequence he deteriorated and developed dysphagia as a consequence of his frailty which led to him developing aspiration pneumonia. Despite treatment he became increasingly frail. He was discharged on end of life care to Flixton Manor Nursing Home on 24th January 2023 and died there on 27th January 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely [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 This report is being sent to: Department of Health and Social Care | Greater Manchester Integrated Care

01/05/2024

2024-0236

Jordan Howarth

Manchester South

1) Tameside General Hospital 2) Secretary of State for Health and Social Care

On 17th April 2023, I commenced an investigation into the death of Jordan George James Fogg HOWARTH. The investigation concluded on the 20th March 2024 and the conclusion was one of Narrative: Died from the complications of a severe inflammatory response contributed to by neglect. The medical cause of death was 1a) Multi-Organ Failure on the background of a severe inflammatory response of unknown aetiology.

Jordan George James Fogg Howarth was a fit, healthy 25-year-old. He was admitted to Tameside General Hospital on 3rd April 2023 when he was unwell and deteriorating. The cause of his deteriorating condition was unclear. Tests found no surgical cause and no evidence of infection. It was suspected that there may be an auto immune reaction. There was no co-ordinated approach between specialists to identify the cause of his deterioration. There was no continuity of his care. On the evening of the 4th April he should have been escalated for a further critical care review under the Trust policy. It did not happen. He was moved to another ward. It was not recognised that he had triggered for a critical care review and that one had not been requested. On the morning of 5th April 2023, his condition was clearly deteriorating. A critical care outreach review at about 12:35 identified he needed to be admitted to ICU and a review be undertaken by an ICU consultant because all of his observations were consistent with his body shutting down and going into shock. His condition was escalated to the ICU consultant who decided not to review him and not to admit him to ICU despite his declining clinical picture. He should have been reviewed and admitted to ICU at that point. He was not admitted until five hours later when his condition had deteriorated even further. Earlier admission to ICU would have prevented such a rapid deterioration and allowed for earlier support to have been provided to his organs. Following admission to ICU his symptoms were consistent with his organs failing and requiring full support. He had a cardiac arrest at about 3:30am on 6th April 2023 and could not be resuscitated. On the balance of probabilities had he been reviewed and admitted to ICU following the first review by the critical care outreach team on 5th April he would not have died when he did.

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

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

02/05/2024

2024-0240

Frederick Boyd

Manchester South

1) The Lakes Care Centre 2) Care Quality Commission

On 12th September 2023, I commenced an investigation into the death of Frederick Martin Gerard BOYD. The investigation concluded on the 12th March 2024 and the conclusion was one of Narrative: Died from the complications of long-term catheterisation contributed to by neglect. The medical cause of death was 1a) Peritonitis 1b) Bladder perforation due to long-term urinary catheterisation II) Paraplegia resulting from injuries sustained in a Road Traffic Collision (2012)

Frederick Martin Gerard Boyd had a long-term catheter. He was a resident of the Lakes Care Home. He complained of severe abdominal pain on 10th September 2023.He was given pain relief. No observations were taken to assess how unwell he was. During the course of the night there were no formal observations taken. There is no documentation to indicate that effective and regular checks were carried out during the night. On 11th September at about 6am he was found unresponsive in bed. A postmortem found he had died from peritonitis due to a bladder perforation caused by long term catheterisation.

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

Care Home Health related deaths This report is being sent to: The Lakes Care Centre | Care Quality Commission

19/06/2024

2024-0327

Thomas Gibson

Manchester South

1) [REDACTED] , Group Chief Executive Officer, Manchester University NHS Foundation Trust; and 2) [REDACTED] , Chief Executive, National Institute for Health and Care Excellence

On 1ST November 2023, Lauren Costello, Assistant Coroner for Manchester South, opened an inquest into the death of Thomas Gibson who was found to have died at his home on 7th June 2023, aged 40 years. The investigation concluded with an inquest which I heard on 4th and 5th June 2024. The inquest determined Mr Gibson died as a consequence of: � 1) a) Sudden cardiac death; � 1)b) Idiopathic myocardial fibrosis. � Acute on chronic colitis � At the end of the inquest, I recorded the following Narrative Conclusion: � Mr Gibson died at his home as a consequence of sudden cardiac death due to myocardial fibrosis. Eleven days previously, Mr Gibson had been seen at his local hospital which provides specialist cardiac services, where the clinical team assessing him did not appreciate that ECGs showed him to be experiencing complete heart block. Had this been appreciated, Mr Gibson would have been admitted under the care of the cardiologists and a series of investigations undertaken which would probably have culminated in an implantable device such as a pacemaker being fitted. It is likely these measures would have avoided his death.

Mr Gibson was found dead at home on 7th June 2023. A post mortem examination determined the primary cause of his death arose from idiopathic myocardial fibrosis which had not been diagnosed during his lifetime. Mr Gibson was not known to have any chronic health problems. During May 2023, Mr Gibson developed a gastrointestinal illness for which he initially sought medical attention via his local GP Surgery. As his symptoms did not improve, a call was made to NHS 111 which resulted in Mr Gibson being advised to attend the Emergency Department at Wythenshawe Hospital. There, a series of initial tests were undertaken, including an ECG. The ECG machine self-generated a report indicating that the ECG was abnormal, showing features of Long QT syndrome. Having reviewed this ECG, a junior doctor initiated treatment for Long QT syndrome, and referred Mr Gibson to the medical team. A junior doctor in medicine reviewed Mr Gibson later in the day, by which stage lab results from a stool sample taken in the community had been reported as showing the presence of Campylobacter. A repeat ECG was undertaken. This again came with a self-generated report indicating the ECG was abnormal, but the junior doctor considered it to show a heart in normal sinus rhythm. The ECG was discussed in isolation with the Medical Registrar who, whilst recognising the ECG was abnormal, did not consider any immediate additional action was indicated. Mr Gibson was discharged from hospital. The discharge letter which was sent to his GP makes no mention of the ECGs undertaken, or the fact that Mr Gibson had received treatment in the Emergency Department in response to an ECG abnormality.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Manchester University NHS Foundation Trust | National Institution for Health and Care Excellence

18/7/2024

2024-0384

Sasha Drysdale

Manchester South

1) [REDACTED] National Institute for Health�and Care Excellence; 2) [REDACTED] Viatris UK Healthcare Ltd; 3) [REDACTED], Britannia Pharmaceutical Ltd; and 4) [REDACTED], Leyden Delta Ltd.

On 28th April 2023, Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest into the death of Sasha Drysdale who died on 28th March 2023 at Beckett Place, Buckton Building,� Tameside General Hospital, aged 52 years. The investigation concluded with an inquest which was� heard before a jury between 8th � 12th July 2024.� The inquest determined Miss Drysdale died as a consequence of:� 1) a) Acute Myeloid Leukaemia (Transformed from Myelodysplastic Syndrome)� At the end of the inquest, the jury returned a conclusion of Natural Causes.

Sasha Drysdale died on 28th March 2023 at Beckett Place, Tameside General Hospital, Ashton-under- Lyne as a consequence of Acute Myeloid Leukaemia (Transformed from Myelodysplastic Syndrome). Miss Drysdale was a patient on the ward who, at the time of her death, was detained under section� 3 Mental Health Act 1983 (as amended).� � Miss Drysdale had previously been prescribed the anti-psychotic medication Clozapine as a consequence of treatment-resistant schizoaffective disorder.

I have sent a copy of my report to the Chief Coroner, and�[REDACTED]. � I have also sent a copy to the Medicines and Healthcare products Regulatory Agency and the legal� representatives of Pennine Care NHS Foundation Trust, The Christie NHS Foundation Trust, and� Tameside and Glossop Integrated Care NHS Foundation Trust, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response.��� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may� send a copy of this report to any person who he believes may find it useful or of interest. You may� make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths � This report is being sent to: National Institute for Health and Care Excellence | Viatris UK Healthcare Ltd | Britannia Pharmaceutical Ltd | Leyden Delta Ltd

08/01/2025

2025-0008

Matthew Brierley

Cumbria

1) [REDACTED], Secretary of State for Justice 2) [REDACTED], Staff Officer to National Police Chiefs� Council 3) [REDACTED], CEO College of Policing

On 1st May 2024 I commenced an investigation into the death of Matthew BRIERLEY, aged 39. The investigation concluded at the end of the inquest on 16th December 2024 . The�short form conclusion of the inquest was one of Suicide� Medical cause of death was 1a Asphyxia

The record of inquest was as follows: �Matthew Brierley died in the carpark of Buttermere� Court Hotel, Buttermere, Cumbria on 24th April 2024. He was under great personal stress due to a police investigation and bail conditions imposed. It is most likely that this stress�caused him to take his own life by [REDACTED] asphyxiation�.����������������������������������������������������������������� � � Matthew had been arrested at his home in Fareham on 16th March, Hampshire police having received information that he was linked to a Paypal account used to purchase indecent� images of children in 2023. Matthew denied the allegation in a �no comment� interview and�was bailed pending enquiries and examination of his computer and mobile devices. Bail� conditions precluded him from living or sleeping at home or having any unsupervised contact� with his biological children or stepdaughter. His employers the Border Force were also� informed and Matthew was suspended from work. On 23rd April Matthew left Hampshire� driving north to Buttermere, a place that had special meaning for him. The following morning� he was found deceased in his car [REDACTED]. He left several final messages in his car.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Matthew�s widow and father. I have also sent it to DI�[REDACTED] of Hampshire�Constabulary 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) | Police related deaths

Ministry of Justice | National Police Chiefs� Council | College of Policing

15/10/2024

2024-0555

Stephen Stringer

Manchester South

1)The Secretary of State for Health and Social Care 2) Derby and Derbyshire Integrated Care Board

On 8th April 2024 I commenced an investigation into the death of��Stephen Charles STRINGER .The investigation concluded on the 25thSeptember 2024� and the conclusion was one of Narrative: Died�from squamous cell carcinoma of the glottis where the significance of his symptoms including a prolonged period of hoarse voice was� not appreciated until the cancer had progressed to Stage 4.The� medical cause of death was 1a Squamous cell carcinoma of the� glottis; II Asbestos-related interstitial lung disease, Ischaemic heart disease

Stephen Charles Stringer developed a hoarse voice from January 2023.� The prolonged nature of his hoarse voice and its ongoing deterioration� was not explored in detail or noted as a potential cancer red flag until�23rd October 2023. He was referred at that point on the 2 week wait to� ENT. He was diagnosed by biopsy on 9th January 2024 with stage 4� squamous cell carcinoma of the glottis. He was treated palliatively. Earlier referral to ENT would probably have led to earlier detection of the cancer� and increased the treatment options available.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care | Derby and Derbyshire Integrated Care Board

17/10/2024

2024-0559

Leslie Swindells

Manchester South

1)� GTD Healthcare� 2)� Secretary of State for Health and Social Care

On 7th June 2024 I commenced an investigation into the death of Leslie Andrew SWINDELLS .The investigation concluded on the 4th October� 2024 and the conclusion was one of� narrative: Died from the� consequences of a self-inflicted puncture wound when his�deteriorating mental health condition was not sufficiently� recognised or acted upon within the primary care setting when he� sought help. The medical cause of death was� 1a) Exsanguination� 1b) Transection of the right internal jugular vein 1c) Puncture�wounds to the neck

Leslie Andrew Swindells had a complex mental health background. He� was prescribed olanzapine and venlafaxine for his mental health and had� been stable within the community. In May 2024 he started to display� symptoms consistent with his mental health deteriorating including� symptoms of paranoia. His family contacted the GP practice on 21st May� 2024 with their concerns. An appointment was made for 2 days later with�a mental health assistant practitioner. He should have been offered a� same day appointment or referred to the Emergency Department. On�23rd May 2024 he spoke to a mental health assistant practitioner who�was not qualified to assess him or his needs. They lacked the expertise to deal with him. A referral was to be made to secondary care. It was not� made. His deteriorating condition and the increased risk he presented�was not recognised due to the lack of experience of the practitioner and� steps to mitigate the risk were not taken. He was not given any safety� netting advice, was not escalated to a GP to be seen that day, his suicidal ideation was not explored. He was told he would be contacted following a� referral. His mental health continued to deteriorate and on 29th May 2021�he was found unresponsive at his home address [REDACTED] from self-inflicted puncture wounds to the neck.

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

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

GTD Healthcare | Department of Health and Social Care

18/09/2024

2024-0499

David Power

Greater Manchester South

1)� Pennine Care NHS Trust

On the 30th August 2023, I commenced an investigation into the death� of David Paul Power. I heard an inquest into his death commencing on the 10th September 2024. I returned my conclusions on the 12th� September 2024.

The deceased was 28 years old at the time of his death. He lived at� home with his family. He had struggled with mixed anxiety and� depression for a prolonged period since the death of this parents when he was a child. In September 2022, the deceased made a serious� attempt to take his own life by hanging. He was seen at A&E and� referred to the Home Treatment Team.� The Home Treatment Team referred him to a service to receive� psychological/ talking therapies. He was not accepted for by this�service (then called Healthy Minds) because they had a policy that they would not accept referrals for individuals who they did not consider to�be sufficiently stable. One of the criteria for stability was that the� individual should not have attempted suicide or serious self-harm for 3� months. This meant that David was not accepted for this service but was referred by them to the Living Well Neighbourhood mental health team also who in turn referred him to a peer support coach, provided by the Big Life Group.�� He was discharged from peer support coaching on the 24th April� following a lack of engagement but requested that he be considered� again by a multi-disciplinary team meeting. The Living Well� Neighbourhood mental health team also discharged him on the 24th� April 2023 without a further multidisciplinary meeting. It is now accepted by the neighbourhood mental health team that he should not have been discharged on that date.�� On the 9th May 2023 the deceased was sent a letter by the� neighbourhood mental health team which stated that they were� discharging him, and that they did not provide the psychological� services he had requested. This was incorrect. It is likely that the� deceased interpreted that letter to mean that he would not be provided with the help he had requested.�� I found that the impact of this letter contributed to a deterioration in his mental health in the period leading to his death and that the deceased became withdrawn and isolated.�� The deceased�s grandmother discovered the deceased hanging in the early hours of the 7th August 2023.�[REDACTED}. Paramedics attended but pronounced� his life to be extinct. Notes found near the deceased indicated a clear�intention to end his own life.�� I found that the deceased intentionally took his own life on the 7th� August 2023 following a decline in his mental health which was� exacerbated by receiving a letter on the 9th May 2023 discharging him from the neighbourhood mental health team.

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

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

Pennine Care NHS Trust

16/10/2024

2024-0558

Paul Clark

Manchester South

1)� Royal College of General Practitioners� 2)� Greater Manchester Integrated Care Board

On 17th May 2024 I commenced an investigation into the death of Paul Michael Clark. The investigation concluded on the 8th October 2024 and the conclusion� was one of accidental death. The medical cause of death was drug toxicity.

On 12th May 2024, Paul Michael Clark was found unresponsive at his home�address [REDACTED]. Post mortem examination included toxicology. He was found to have high and fatal level of his prescribed zomorph and pregabalin in� his system.

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

Alcohol, drug and medication related deaths

Royal College of General Practitioners�| Greater Manchester Integrated Care Board

17/07/2024

2024-0378

Lorraine Procter

South Manchester

1)� The Secretary of State for Health and Social Care

On 27th December 2023 I commenced an investigation into the death of� Lorraine Julia PROCTER. The investigation concluded on the 25th June� 2024 and the conclusion was one of natural causes. The medical cause of death was 1a) Acute myocardial ischaemia 1b) Coronary artery� atheroma 1c) Ischaemic cardiomyopathy II, Type 2 diabetes mellitus,� chronic obstructive pulmonary disease, sleep apnoea.

Lorraine Julia Proctor had a history of cardiac health issues. She was� discharged from hospital on 2nd March 2023 with an indication she should have a cardiology follow up appointment 3 months later. The appointment should have been in June 2023.It did not take place as the waiting list for routine cardiology appointments was 48 weeks. The inquest was told it� was unlikely the appointment had it taken place would have changed the� treatment she was on. On 22nd December 2023, Lorraine Julia Proctor�was found unresponsive in bed at her home address [REDACTED]. A post-mortem established that the direct cause of her death was 1a) Acute myocardial ischaemia 1b) Coronary artery atheroma 1c) Ischaemic� cardiomyopathy.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely�[REDACTED] on behalf of the family,�Stepping Hill Hospital, 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.

Other related deaths � This report is being sent to: Department of Health and Social Care

16/02/2024

2024-0246

Rosie Young

Worcestershire

1)� [REDACTED], Chief Executive, West Midlands Ambulance Service University NHS Foundation Trust, Millennium Point, Waterfront Business Park, Waterfront Way, Brierley Hill, West Midlands, DY5 1LX.

On 17 November 2021 I commenced an investigation and opened an inquest into the death of Rosie Catherine YOUNG. The investigation concluded at the end of the inquest on 8 February 2024. � Rosie died on 8 November 2021 at The Queen Elizabeth Hospital, Birmingham from a traumatic brain injury. The jury recorded the circumstances in which Rosie had sustained that fatal brain injury as follows: � �On 7.11.2021 Miss Young was seriously injured when she stepped out from the rear door of a moving ambulance travelling on the A422 Worcester to Stratford Road, near Inkberrow, whilst being transported to Hillcrest Psychiatric Unit, Redditch. She died from her injuries in the Queen Elizabeth Hospital, Birmingham on 8.11.2021.� � At the time of these events, Rosie had been detained under s.2 Mental Health Act 1983,and was being transported on vehicle from your Trust, accompanied by staff from your Trust, from the s.136 suite at Newtown Hospital, Worcester to Hillcrest Psychiatric Unit, Redditch. Rosie was a young woman with an extensive mental health history, with established diagnoses of Emotionally Unstable Personality Disorder ( EUPD ) and Autistic Spectrum Disorder. She had had regular contact with mental health services in Worcestershire, and her EUPD was often characterised by impulsive, risk-taking behaviour, including two incidents earlier in 2021 when she had jumped out of moving vehicles. � The conclusion of the jury at the inquest was expressed in two parts. Firstly: �Rosie Young died as a result of stepping from a moving vehicle. It is not possible to determine what her intention was at the time she did this.� � The jury then went on to consider questions relating to potential failings by agencies involved in her care immediately prior to her death. Those questions and the jury�s answers were recorded as follows: � �1. Were previous incidents of Rosie jumping from moving vehicles properly recorded in her mental healthcare notes, so that they would have been readily apparent to the Approved Mental Health Professional ( AMHP ) who was considering her risk of self- harm while being transported to Hillcrest ward on 7.11.21? NO � 1.1 If NO, did that failure probably cause or contribute to Rosie�s death? YES � Were previous incidents of Rosie jumping from moving vehicles properly recorded in previous reports by Approved Mental Health Professionals ( AMHPs ), so that they would have been readily apparent to the AMHP who was considering her risk of self- harm while being transported to Hillcrest ward on 7.11.21? NO � If NO, did that failure probably cause or contribute to Rosie�s death? YES � Was the previous incident on 13.5.21, in which Rosie had jumped from an ambulance while being transported to Worcestershire Royal Hospital, properly recorded by West Midlands Ambulance Service ( WMAS ), so that it would have been readily apparent to WMAS members of staff involved in the arrangements to transport Rosie to Hillcrest ward on 7.11.21? NO � If NO, did that failure probably cause or contribute to Rosie�s death? YES � At the time of Rosie�s death, had WMAS taken any or any sufficient steps to ensure that their staff were aware of, and trained to apply the terms of their own Mental Health Act Transportation Policy? NO � If NO, did that failure probably cause or contribute to Rosie�s death? YES � At the time of Rosie�s death, had Herefordshire and Worcestershire Health and Care NHS Trust ( HWHCT ) taken sufficient steps to ensure that their staff were aware of, and trained to apply the terms of the Mental Health Act Transportation Policy? NO � If NO, did that failure probably cause or contribute to Rosie�s death? YES � At the time of Rosie�s death, had Worcestershire County Council ( WCC ) taken sufficient steps to ensure that their AMHPs were aware of, and trained to apply the terms of the Mental Health Act Transportation Policy? NO � If NO, did that failure probably cause or contribute to Rosie�s death? YES When arranging transport to take Rosie to Hillcrest ward, did the AMHP properly apply the Mental Health Act Transportation Policy and properly assess the risks involved in transporting Rosie to Hillcrest ward? NO � If NO, did that failure probably cause or contribute to Rosie�s death? YES � When arranging transport to take Rosie to Hillcrest ward, did the AMHP properly convey to WMAS the risks which Rosie might present when being transported? NO � If NO, did that failure probably cause or contribute to Rosie�s death? YES � On the morning of 7.11.21 when the ambulance vehicle arrived to take Rosie to Hillcrest ward more than 13 hours after it had originally been requested, should a further updated assessment of the risks involved in transporting Rosie to Hillcrest ward, in line with the requirements of the Mental Health Act Transportation Policy, have been carried out? YES � If YES, did that failure probably cause or contribute to Rosie�s death? CANNOT SAY � If NO or CANNOT SAY, did that failure possibly cause or contribute to Rosie�s death? CANNOT SAY � Were the arrangements made to transport Rosie to Hillcrest ward on 7.11.21 sufficient to meet the risks of selfharm which she posed? NO � If NO, did that failure probably cause or contribute to Rosie�s death? YES � If your answer to Question 10 above is NO, were there sufficient personnel in the back of the ambulance vehicle with Rosie? NO � If your answer to Question 11 above is NO, which one of the following options should have been used? Mental healthcare staff provided by HWHCT to travel in the back of the ambulance vehicle with Rosie? � Police officers to have travelled in the back of the ambulance vehicle with Rosie? YES

See above.

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

Emergency services related deaths (2019 onwards) This report is being sent to: West Midlands Ambulance Service | Herefordshire and Worcestershire Health and Care NHS Trust

26/01/2024

2024-0301

Paul Bradley

Worcestershire

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

On 18 May 2023 I commenced an investigation and opened an inquest into the death of Paul William BRADLEY. The investigation concluded at the end of the inquest on 18 January 2024 � The conclusion of the inquest was that Mr. Bradley �died from natural causes.�

In answer to the questions �when, where and how did Mr. Bradley come by his death?�, I recorded as follows: � �In July 2019 Paul Bradley was diagnosed with renal cancer. Over the next two years his renal tumour was monitored, and by February 2021 it was felt that he should now be considered for a nephrectomy. When he failed to attend a urological appointment in March 2021, this was not followed up by the urology team and no further appointment was arranged until he was referred again by his general practitioner in May 2023, after a CT scan had shown a metastatic renal tumour. He was admitted to the Alexandra Hospital, Redditch for palliative treatment and declined and died there on 17.5.23. The failure to try to arrange a further urological appointment after March 2021 represents a missed opportunity to provide Mr. Bradley with treatment which may have prolonged his life.�

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

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

27/10/2023

2023-0417

Francis Barnes

Berkshire

1)�[REDACTED], CEO at Oxford University Hospitals NHS Foundation Trust.

I have on occasion referred to the deceased as Barney. This is in order to reflect the family�s wishes. � I conducted an inquest into the death of Francis Osborne Barnes, which concluded on 19th�October 2023. I recorded a narrative conclusion as follows: � Mr Barnes suffered a rare and significant complication of surgery. This was likely to have been the biggest factor contributing to Barney�s death. If Barney had been transferred to Oxford University Hospital, consideration would have been given to thrombectomy and/or amputation. It is likely that, if amputation had been needed, this would have happened sooner. This delay contributed to Mr Barnes� death. � His cause of death was: � 1a) Multiple Organ Failure 1b) Femoral Artery Injury during Elective Inguinal Hernia Repair 2) Ischaemic Heart Disease

Mr Barnes underwent an elective hernia repair surgery at Spire Dunedin Hospital in Reading, on 12th of March 2022. During this procedure, his external iliac artery was transected, resulting in a major haemorrhage. An off-duty vascular surgeon attended and was able to place a graft to bypass the damage to the artery. Mr Barnes was transferred to Royal Berkshire Hospital that afternoon. His vascular condition had deteriorated by the time he reached the Royal Berkshire Hospital, and this was evidenced in ultrasound and CT angiogram reports, available from around 10pm that night. Contact was made with the on-call consultant vascular surgeon at the John Radcliffe Hospital in Oxford. He advised that Mr Barnes should not be transferred to the John Radcliffe Hospital. It was clear that Mr Barnes� left leg was deteriorating, and that an amputation was likely to be needed. Most elective amputations are performed at a vascular centre, with the relevant expertise available there. � Mr Barnes underwent amputation at the Royal Berkshire Hospital on the 14th of March, but died there on the 16th of March 2022.

I have sent a copy of my report to the Chief Coroner and to Mr Barnes� family. � I have also sent this report to the following recipients, who have an interest in this matter: 1.���� Royal Berkshire Hospitals NHS Trust (via their legal representative). 2.���� Spire Dunedin Hospital (via their legal representative). 3.���� The senior coroner for Oxfordshire, Mr Darren Salter. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

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

02/04/2024

2024-0180

Alan Soane

Inner North London

1. [REDACTED] NHS England 133-135 Waterloo Road London SE1 8UG � 2. The Rt Hon Victoria Atkins MP Secretary of State for Health and Social Care 39 Victoria Street London SW1H 0EU

On 30 June 2023, an investigation was commenced into the death of ALAN ANDREW SOANE, then aged 84 years. The investigation concluded at the end of an inquest, heard by me, on 18 March 2024. � The inquest concluded with a short narrative conclusion. The medical cause of death was: � 1a intra abdominal sepsis and haemorrhagic shock 1b anastomotic leak following pancreatico-duodenectomy (performed 05/06/2023).

CIRCUMSTANCES OF DEATH � Mr Soane was an otherwise fit and healthy 84 year old man. The circumstances of his death are recorded in the short narrative conclusion that I reached at the inquest, which was: � �Mr Soane underwent an endoscopy and biopsies at his local hospital in Essex in March 2023, which included a duodenal biopsy. The result of the duodenal biopsy was reported as, �Findings are highly suspicious for malignancy, most likely differentiated adenocarcinoma. Immunohistochemical study is requested, and a supplementary report will follow.� As a result, Mr Soane was referred to the Royal London Hospital on a cancer pathway. A multidisciplinary team (MDT) meeting at the Royal London Hospital on 3 May 2023, concluded, among other things, �diagnosis: duodenal cancer (biopsy- proven).� That meeting was undertaken without further biopsy or tests being undertaken. It transpires that the conclusion was not correct. Based on the outcome of the MDT meeting, Mr Soane was given a cancer diagnosis and agreed to complex surgery known as a �Whipples� procedure, which was undertaken on 5 June 2023. Mr Soane died on 26 June 2023, as a direct result of known complications of the Whipples procedure. Mr Soane�s surgeon would not have offered him the Whipples surgery had it not been for the incorrect diagnosis provided.�

I have sent a copy of my report to the Chief Coroner and to the following: � [REDACTED] (Mr Soane�s wife) � [REDACTED], Chief Executive, Royal College of Pathologists, 6 Alie Street, London, E1 8QT � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

18/09/2023

2023-0342

Amarjit Singh

Inner North London

1. [REDACTED] Prison Governor HM Prison Pentonville Caledonian Road London N7 8TT � 2. [REDACTED] Chief Executive Officer Practice Plus Group (PPG) Hawker House 5-6 Napier Road Reading Berkshire RG1 8BW

On 30 November 2021, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Amarjit Singh, aged 41 years. The investigation concluded at the end of the inquest on 8 September 2023. � At inquest, the jury made a determination of death by natural causes, contributed to by neglect.

Mr Singh�s death was epilepsy related. He was found dead in his cell at HMP Pentonville on the morning of 21 November 2021. � In the middle of the night his cellmate had rung the emergency cell bell and told the prison officer who came to the door that Mr Singh had suffered a fit. However, the prison officer did not then seek medical attention for Mr Singh and the cell door remained locked shut for the rest of the night.

I have sent a copy of my report to the following. � ����� [REDACTED], brother of Amarjit Singh ����� [REDACTED], HMPPS Director General Operations ����� HHJ Thomas Teague QC, 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.

State Custody related deaths This report is being sent to: HM Prison Pentonville | Practice Plus Group

04/11/2024

2024-0596

Janet Brown Townend

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

1. A&B Healthcare Ltd 2. Adult Social Services, East Riding of Yorkshire Council 3. Care Quality Commission

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 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 that had caused an infection that led 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 and those agencies as detailed above. � I am also under a duty to send 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

A&B Healthcare Ltd | East Riding of Yorkshire Council | Care Quality Commission

11/11/2024

2024-0615

Alison Binyon

Derby and Derbyshire

1. Adult Social Care, Leicestershire County Council

On 19 September 2019 I commenced an investigation into the death of Alison BINYON aged 24. The investigation concluded at the end of the inquest on 31 October 2024. The conclusion of the inquest was that Alison died due to misadventure. The Medical Cause of Death was: 1 (a) Hypoxic / Ischemic Brain Injury (b) Compression of neck by ligature

Alison had a long history of mental health difficulties and a formal diagnosis of Emotionally Unstable Personality Disorder on a background of Post-Traumatic Stress Disorder. At the time of her death Alison was residing in a residential home which offered specialist support for those with enduring mental health illness. She was supported in the home and received psychological therapy. She was also supported by her local Community Mental Health Trust. Alison�s living arrangements were on a voluntary basis; there were no restrictions on her movements or liberty. Her placement was funded jointly between the local authority and ICB under s.117 of the Mental Health Act 1983. Alison was content with her living arrangements but in June 2019 a decision was made that her mental health had stabilised and that she would therefore be moving to step-down accommodation at some point in the near future. As part of her condition, Alison regularly engaged in acts of self-harm which included episodes of ligation. Against that background, on the evening of 11th September 2019 a staff member went to check on Alison and and found her unresponsive on her bed [REDACTED]. An ambulance was called and Alison was taken to hospital where early CT scans showed a suspected hypoxic brain injury. Over the course of the following day Alison�s physiological condition continued to deteriorate and tests confirmed death by neurological criteria. She sadly died on the 13th September 2019. The court heard evidence that at the time of her death Alison was experiencing several stressors that were causing her anxiety and making her urges to self-harm stronger. This included anxiety about the move from her residential placement and concerns around her benefit entitlements. It is likely that these factors acted as triggers for the self-harm episode that led to her death.

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

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

Leicestershire County Council

24 October 2018

2018-0315

Jennifer Lacey

London Inner (West)

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

NHS England; GPC;

12 March 2020

2020-0069

Jason Pendlebury

Manchester North

Alcohol, Drugs and medication related deaths; Mental health related deaths; other related deaths

Greater Manchester Police; NWAS

11 January 2019

2019-0012

Ricardo Holgate

Birmingham and Solihull

State Custody related deaths

G4S; HM Prisons and Probation Service; MOJ

10 October 2018

2018-0325

Robin McEwan

North Yorkshire

Community health care and emergency services related deaths; Suicide (from 2015)

Harrogate & Rural District Clinical Commissioning Group

2 October 2018

2018-0336

Andrew Collins

South Wales Central

Community health care and emergency services related deaths

Welsh Ambulance Service NHS Trust

27 February 2019

2019-0474

Janie McFadyen

Manchester (City)

Alcohol, drug and medication related deaths

Head of Safeguarding

1 November 2018

2018-0337

Colette Dunn

Milton Keynes

Suicide (from 2015)

Milton Keynes Clinical Commissioning Group

23 October 2018

2018-0318

Nicola Lawrence

West Yorkshire (East)

State Custody related deaths

National Offender Management Service

31 January 2019

2019-0038

Andrew Carr

Birmingham and Solihull

Alcohol, drug and medication related deaths; State Custody related deaths

G4s; HM Prisons and Probation; MOJ

25 March 2019

2019-0090

Nora Bruton

Birmingham and Solihull

Alcohol, drug and medication related deaths; Mental Health related deaths; Hospital Death (Clinical Procedures and medical management) related deaths

Birmingham & Solihull Mental Heath NHS Trust

24 October 2018

2018-0317

Catherine Gibbon

London Inner (North)

Other related deaths

DW Fitness First; UK Active

29 October 2018

2018-0308

Elizabeth Self

South Yorkshire (West)

Hospital Death (Clinical Procedures and medical management) related deaths

NHS England

23 October 2018

2018-0306

Kalma Ram-Henman

Brighton and Hove

Hospital Death (Clinical Procedures and medical management) related deaths

Brighton & Sussex University Hospitals NHS trust

11 January 2019

2019-0018

Elizabeth Curtis

Avon

Hospital Death (Clinical Procedures and medical management) related deaths

NHS Improvements

5 November 2018

2018-0346

Daniel Stokes

South Yorkshire (East)

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

NHS England

29 October 2018

2018-0307

Rosario Cordero-Sanz

London Inner (North)

Community health care and emergency services related deaths

Metropolitan Police Service

2 October 2018

2018-0335

Joshua Edwards

West Yorkshire (East)

Alcohol, drug and medication related deaths; Other related deaths

Leeds City Council

12 December 2019

2019-0503

Raees Rauf

Derby and Derbyshire

Suicide (from 2015)

Bristol University