Inquests (PFDs)

7 March 2019

2019-0112

Matthew Bilby

Lincolnshire

Road (Highways Safety) related deaths

Department for Transport | Lincolnshire County Council

24 January 2019

2019-0487

Arun Viswambaran

London Inner (North)

Suicide (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths

North East London NHS Trust

9 March 2020

2020-0060

Darren Goddard

South Wales Central

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

Cwm Taf Morgannwg University Health Board

15 January 2019

2019-0020

Marie Millward-Winter

Manchester (City)

Care Home Health related deaths

Each Step Nursing Home

12/01/2023

2023-0015

Gary Cooper

Cumbria

(1) The Secretary of State for Culture Media and Sport and (2) The Secretary of State for Health and Social Care CORONER

On 6 July 2022 I commenced an investigation into the death of Gary Dennis COOPER. The investigation concluded at the end of the inquest . The conclusion of the inquest was � Suicide [REDACTED]

Gary Cooper was 41 years old. He lived in Kendal, Cumbria. He suffered from depression and psychosis. On 3rd July 2022 Mr Cooper was found at home. He was unresponsive. An ambulance attended but resuscitation was not possible; Mr Cooper�s death was confirmed at 15:15. A post mortem examination has confirmed that Mr Cooper died [REDACTED] as a result of having ingested [REDACTED].

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

Suicide (from 2015)

Department for Culture Media and Sport | Department of Health and Social Care

22/11/2024

2024-0650

Nicolette McCarthy

East Sussex

(1) The Secretary of State for Health and Social Care. (2) NHS England. (3) National Institute for Health and Care Excellence (NICE)

On 26 September 2023 I commenced an investigation into the death of Nicolette Elizabeth McCARTHY aged 46. The investigation concluded at the end of the inquest on 08 November 2024. The conclusion of the inquest was a narrative conclusion as follows: Nicolette Elizabeth McCarthy died as a result of suicide due to her acute mental ill health and a series of contributory factors. There were a series of failures in the systems and procedures which should have guaranteed her safety.

The jury made the following findings of fact in Box 3 of the Record of Inquest: Nicolette Elizabeth McCarthy was detained to the Woodlands secure unit � under the Mental Health Act � Section 5(2) for concerns of her own safety following attempts to take her life. On the 18th and 19th September there remained a risk that she may attempt to end her own life. On 18th September 2023, Nicolette�s family attended the ward round discussion, there is no evidence that confirmation of escorted or unescorted leave was delivered to them. Any ambiguity could have been avoided if Trust procedures had been followed, written confirmation of the S17 decision provided and acknowledged by the family. It was appropriate to grant in principle unescorted S17 leave but not implement it until written confirmation was provided to the family and the risk assessment updated. Nicolette should not have been required to leave unit grounds. Although the NHS/Sussex Trust have a policy that no smoking should take place within the grounds, there should have been provisions that within secure units secure smoking facilities or indeed an exemption should have been made. As per the Trust�s �Record of Patient leave� form, checks and consideration should have been given to the appropriateness of any items Nicolette had on her person for the leave being taken. As per the Trust�s concession, the Trust did not take immediate action, aligned to Nicolette�s individual clinical risk, when Nicolette did not return to the ward, following her 15 minutes leave (starting at 14:37) on 19 September 2023. The failure to mark Nicolette as AWOL rather than on leave added to the confusion and highlighted gaps in the record keeping. Although staffing levels were low and incidents on 19th September 2023 further impacted staff availability, there was a failure to take steps as outlined in Trust policies following identification of Nicolette�s absence. There were further factors in play: 1) insufficient adherence to recording patient login time in the procedure on the S17 leave sheet. 2) unacceptable delays in taking appropriate action on 19th September. 3) the Trust�s adherence to robust note keeping/updating appears to have been lax and retrospective at times. It is possible that on 19th September 2023, had staff taken prompt action there would have been opportunities by which Nicolette�s death could have been avoided

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (1) Mrs McCarthy�s family. (2) Sussex Partnership 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 | Mental Health related deaths�| Suicide (from 2015)

Department of Health and Social Care | NHS England | National Institute for Health and Care Excellence

29/10/2024

2024-0590

Lee Armstrong

Cumbria

(1) The Transformation Directorate, NHS England and (2) The Secretary of State for Health and Social Care

On� 2nd� February� 2024� an� investigation� was� commenced� into� the� death� of� Lee ARMSTRONG. The investigation concluded at the end of the inquest on 29th October 2024. The conclusion of the inquest was the following narrative:� Lee Armstrong was 24 years old. He lived in [REDACTED], Penrith. Mr Armstrong suffered from Addison�s disease. On 30th January 2024, became unwell. A call was made to the ambulance service at 10:32 in which Mr Armstrong was told to contact his GP. Mr Armstrong became increasingly unwell over the course of the day. A further call was made to the ambulance service at 16:48 and an ambulance attended. Mr Armstrong was deeply unconscious and critically unwell; he was in the midst of an Addisonian Crisis. At 18:20 Mr Armstrong entered cardiac arrest. Mr Armstrong was resuscitated but his brain had been severely injured by the lack of oxygen. Mr Armstrong died as a result at 11:26 on 2nd February 2024.� The medical cause of Mr Armstrong�s death was: 1a Hypoxic-ischaemic encephalopathy 1b Cardiac Arrest 1c Addisonian Crisis, Colitis, Cholecystitis II�Type 1 Diabetes Mellitus

When Mr Armstrong became unwell, he and his partner used the online 111 system. It� indicated that they should dial 999 and call an ambulance. Evidence from an NWAS� representative indicated that: 1) information inputted to the online 111 system is not� available to ambulance call handlers (in contrast to information provided to 111 over the phone), 2) NWAS use the NHS Pathways system to triage 999 calls, and 3) NWAS call� handlers do not have access to details of callers medical records.� In the course of the first 999 call Mr Armstrong reported that he was confused. This is� known to be a symptom of being in Addisonian Crisis. Mr Armstrong was not asked� whether or not he had any pre-existing medical condition. I was told that the expectation is that a patient would volunteer their past medical history. �� Evidence from NWAS indicated that if the call handler had been aware that Mr Armstrong suffered from Addison�s Disease then they would have organised a Category 2 response. Instead a Category 5 was organised with the suggestion that Mr Armstrong contact his�GP. �� Mr Armstrong became progressively more unwell over the course of the day. A Category 1 Ambulance was sent when a further call was made at 16:48.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Mr Armstrong�s family and � NWAS. �� 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)

NHS England | Department of Health and Social Care

07/10/2015

2023-0412

Naiya Diarra

Inner North London

(1) [REDACTED], Chief Executive, National Institute for Health and Care Excellence 10 Spring Gardens London SW1A 2BU

Naiya Diarra died on 25 June 2015, aged 9 months old, from dilated cardiomyopathy, arising from severe Vitamin D deficiency. An inquest into her death was heard on 30 October 2015, at which I recorded a narrative conclusion (see attached).

Naiya was not known to have developed the severe Vitamin D deficiency, from which she ultimately died. I heard evidence that vitamin supplementation was discussed with her mother and instituted through her mother taking additional dietary vitamins and later through use of additional formula feeding. However, it is clear that this was ultimately insufficient to prevent her death. Her sibling was known to be Vitamin D deficient and I saw evidence that health visitors had attended the family home regarding this and had given advice regarding sunlight exposure in particular. However, the significance of her sibling�s deficiency was not recognised by those treating Naiya and I concluded that there was missed opportunities to address this. � I heard evidence that NICE guidance exists regarding the identification and treatment of Vitamin D deficiency

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

Child Death (from 2015) This report is being sent to: National Institute for Health Care Excellence

01/12/2015

2023-0413 Deceased name: Barbara Rawlinson

Coroner name: Richard Brittain

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

(1) [REDACTED], Chief Executive, Royal Free London NHS Foundation Trust Royal Free London NHS Foundation Trust

Barbara Rawlinson died on 16 July 2015, aged 58 years, from complications arising from a diagnosis of uterine sarcoma. An inquest into her death was heard on 11 November 2015, at which I recorded a narrative conclusion (see attached).

Mrs Rawlinson presented to her GP in 2014 with post-menopausal bleeding and was referred to the gynaecology team at Barnet Hospital (part of the Royal Free Trust). She underwent ultrasound examinations and hysteroscopies to investigate the cause of this bleeding, which was presumed to be resulting from a fibroid. She was concerned that the diagnosis was cancerous and, in order to reassure her that this was not the case, she underwent a hysterectomy in early 2015. Unfortunately histology of her uterus demonstrated that the cause of the bleeding was a uterine sarcoma. � She was referred to UCLH to receive further treatment of this cancer and underwent a further procedure to remove additional tumour mass which had been demonstrated on CT scanning. Unfortunately, following this procedure she developed a perforated stomach and subsequently a perforated gallbladder. She died after attempts to treat these and further complications. � Mrs Rawlinson�s family raised a concern that no CT scanning had been undertaken prior to the hysterectomy being performed. Mr Broadbent, Consultant Gynaecologist at Barnet Hospital, had been appraised of this concern in writing before the inquest and had provided a supplementary written statement to address this. He set out that he had been reassured by the findings of repeated ultrasound scanning. As such, I did not call him to give evidence. � However, at the inquest I heard from [REDACTED], Consultant Gynaecologist at UCLH who had undertaken Mrs Rawlinson�s second operation. She set out that, in her opinion, a CT scan should have been undertaken prior to the hysterectomy to address the possible (but rare) diagnosis of sarcoma in a post-menopausal woman with ongoing bleeding. I decided that I could conclude the inquest but that this issue warranted a report to prevent future deaths, in order to allow the Royal Free Trust the opportunity to reflect on and respond to these concerns.

I have sent a copy of my report to the Chief Coroner, Mrs Rawlinson�s family, Mrs Rawlinson�s GP and the other NHS Trust involved. � 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

06/06/2024

2024-0307

Robert Fray

Birmingham and Solihull

(1)� [REDACTED], Chief Executive, West Midlands Ambulance Service. (2) [REDACTED], Chair, NHS England

On 24/04/23 I commenced an investigation into the death of Robert John Fray. The investigation concluded at the end of the inquest on 23/05/24.

On 04/04/22 at a dialysis session Mr Fray was advised to attend hospital due to being symptomatic of sepsis. Arrival of an ambulance was delayed due to exceptional but not unprecedented demand. Sequence of 999 telephone calls: � No.1 � was made by a clinician from the Dialysis Treatment Centre at 18:03hrs and triaged by the call assessor via the Healthcare Professional Pathway as a category 3 response. � No.2 � was made by a clinician from the Dialysis Treatment Centre at 19:32hrs and upgraded by the call assessor to a category 2 response. � No.3 � was made by a clinician from the Dialysis Treatment Center at 22:17hrs. It was explained the centre was closing and Mr Fray was going home. He had a NEWS 1. The call assessor maintained the category 2 response upon it being reported there was no change in Mr Fray�s presentation. � No.4 � was made by a neighbour at 23:05hrs with Mr Fray presenting with worsening symptoms. As the address was different, despite Mr Fray�s name being the same, the call assessor did not pick up it was a duplicate and this was triaged as a new category 2 response. � In response to 999 calls no.1-3 an ambulance was dispatched at 23:32hrs and arrived at the Dialysis Treatment Centre at 23:46hrs to find it closed. The ambulance crew telephoned Mr Fray who confirmed he was at home. The ambulance arrived at his home address at 00:00hrs. He had a NEWS 10. � He was admitted to the emergency department at Queen Elizabeth Hospital Birmingham around 01:16hrs on 05/04. Contrary to expectations, the ambulance crew did not pre-alert the hospital to �red flag sepsis� and did not handover Mr Fray�s high NEWS or suspected sepsis verbally upon arrival. The navigation nurse streamed him to �ambulatory majors�. The nurse in charge of �ambulatory majors� recorded clinical observations on the hospital handover sheet that should have triggered a sepsis alert and prompt treatment, which at that stage would have prevented his death. Mr Fray was directed to the waiting area where he remained from 01:16hrs until he was found unconscious in a chair at 16:35hrs. For reasons that remain unknown he did not respond when verbally called for triage at 02:53hrs, and at 04:39hrs he was incorrectly recorded as having left without being treated. The emergency department was under exceptional but not unprecedented pressure during a period of COVID restrictions and there had been no nurse available to monitor the waiting area. Upon

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

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

18/11/2024

2024-0635

Yemisi Cielto-Opaleye

Inner North London

(1)�[REDACTED] Chief Executive� North London Mental Health Partnership Partnership Headquarters� 4th Floor, East Wing� St Pancras Hospital� 4 St Pancras Way� London� NW1 0PE� (2) [REDACTED] ����������������������������� �� Chief Medical Officer� North London Mental Health Partnership Partnership Headquarters� 4th Floor, East Wing� St Pancras Hospital� London� NW1 0PE

On the 21st December 2023 Assistant Coroner Ian Potter began an investigation into the death of Yemisi Cielto-Opaleye who died aged 47, on the 13th December 2023 at St Pancras Hospital, London, N1.� The investigation concluded at the end of an inquest, with a jury which took place over 5 days between 11th � 15th November 2024. This was conducted by myself, Assistant Coroner Edwin Buckett.� The jury made a determination that the deceased died within 3 hours of being� administered� an� Olanzapine� depot� injection� which� caused Olanzapine toxicity, whilst a psychiatric in-patient on Sapphire Ward, St Pancras Hospital, London N1.� The� jury� returned� a� Narrative� Conclusion� which� found� that� neglect contributed to her cause of death.

The circumstances of the death are set out in the Narrative Conclusion of the Jury which was as follows:� �On 5th April 2022 Yemisi was admitted to St Pancras Hospital as a psychiatric inpatient with long standing treatment-resistant schizophrenia. On the 22nd June 2023 she was transferred to Sapphire Ward. She was treated with a wide variety of psychiatric medication administered both orally and by depot injection.� �� Following admission to Sapphire Ward, a decision was made by the consultant along with other hospital staff to introduce Olanzapine to Yemisi�s treatment. Yemisi was administered Olanzapine orally for 3-4 days, falling below the recommended trial period advised before moving to administering by depot injection and was therefore inadequate. As Olanzapine is a non-formulary drug for the Trust, additional requirements are in place to support prescribing decisions. The justification relied upon by the consultant and lead pharmacist for prescribing the drug was unsuitable as the drug does not meet the criteria outlined in Section 62 of the Mental Health Act of being a) life-saving, or b) reversible. In addition, the requirement to seek a second opinion from an independent doctor in certain circumstances when changing medications was not fulfilled as the first depot injection was administered to Yemisi before approval was received from the SOAD. Owing to Yemisi�s known and documented history of refusing vital signs checks requiring participation, the prescribing decision took into account the expected difficulties with conducting these checks. However, there was no robust contingency plan for ensuring these checks took place, the plan itself was insufficient to accommodate Yemisi�s circumstances and went no further than what is mandated in the Olanzapine policy.� �� Yemisi� received� a� first� Olanzapine� depot� injection� on� the� 13th� of November,� where� she� also� did� not� comply� with� vital� signs� checks requiring participation. There were no adverse effects noted and staff indicated� following� this� depot� injection� her� mental� state� improved somewhat. Yemisi�s non-compliance with vital signs checks requiring participation led to the decision being made that both depot injections would be administered relying solely on assessing Respiratory Rate and Level of Consciousness, departing from the Trust�s Olanzapine depot policy.� On the 13th of December 2023, the plan in place was for one of the nurses on Sapphire Ward that day who had completed the Olanzapine training to both prepare and administer the injection, and as per the Olanzapine policy conduct the first set of vital signs checks, and be available� for� the� duration� of� the� 3� hour� observations� unless� this responsibility is delegated to an appropriately qualified member of staff. However this is not what transpired on the day.�� The�� responsibility�� for�� preparing,�� administering,�� monitoring�� and witnessing of these processes was unclear, and divided among multiple members of staff which did not allow for effective continuity resulting in inadequate levels of oversight. Yemisi did not consent to any of the staff members on Sapphire Ward that day administering the injection, and so a qualified member of staff from another ward was asked to come and assist. They did not witness the preparing of the solution but were satisfied that the dose and preparation were as described. This nurse and the preparing nurse initially went to Yemisi�s room to conduct pre- injection vital signs checks but those requiring participation were refused. The absence of a full set of observations should have been escalated to a doctor prior to administering the depot injection, but this was not done. At this stage there was also a missed opportunity to reiterate potential side effects of the drug or symptoms of post-injection syndrome to Yemisi that she may have been able to flag as concerns. One nurse was then asked to leave the room and therefore there was a failure to follow protocol both by not having two members of staff present during the administration of the depot injection, and also that it was administered despite�� the�� requisite�� pre-injection�� vital�� signs�� checks requiring participation not taking place.�� Following� the� injection,� there� was� a� total� lack� of� clarity� around responsibility and delegation of Post-injection checks, where the Nurse in Charge failed to allocate tasks consistent with safe implementation of the� plan.� Communication� was� inadequate� and� no� staff� member� on Sapphire Ward was clear on their responsibility to conduct post-injection checks that day.�� Collectively there was sufficient understanding among staff on the ward of� the� risks� associated� with� Olanzapine� depot� injection,� and� the requirements for post-injection checks (regardless of whether they had completed the training). Despite an awareness of these risks, this failed to translate to adequate safety planning, management and coordination of staff responsibilities or action relating to Yemisi�s care.�� As a result, none of the vital signs checks stipulated in the Trust�s Olanzapine� policy� were� carried� out,� representing� a� gross� failure� to provide basic medical attention to Yemisi. Relevant documentation/templates� for� record� keeping� do� not� provide� clear accountability�� for�� conducting�� these�� checks.�� The�� Trust�s�� own documentation/templates for Olanzapine monitoring do not allow for the total number of checks stipulated (ie. at 90 minutes). The reasoning given for not completing some of the post-injection checks included a number of incidents on the ward that diverted staff resource � there was a failure to escalate high acuity and get additional support. The only check� conducted� was� a� General� Observations� check,� not� a� post- Olanzapine injection check, at 15:30, an hour after administration. This check only involved visual observations from outside Yemisi�s door, and could� not� have� been� sufficient� to� establish� a� patient�s� level� of consciousness.� �� Yemisi was discovered lying face down on the floor in her room at around 17:20 by the nurse in charge who sounded the alarm and called for help from other staff. Multiple staff began attempts to resuscitate her including CPR/chest compressions and establishing whether the defibrillator could be used. An ambulance was called, and paramedics arrived at Yemisi�s room at 17:40. No pulse or �shockable rhythm� was detected by staff or defibrillators from the point she was discovered. London Ambulance Service continued attempts to resuscitate her but pronounced life extinct at 18:45.�� Yemisi died on the 13th December 2023 as a result of the toxic effects of the� Olanzapine� injection� administered� to� her� that� day� and� neglect contributed to her cause of death.�

I have sent a copy of my report to the following. HHJ Alexia Curran, the Chief Coroner of England & Wales� [REDACTED], the sister of Yemisi Cielto-Opaleye. I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he� believes� may� find� it� useful� or� of� interest.� You� may� make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

North London Mental Health Partnership

12/05/2017

2023-0134

Nasar Ahmed

Inner North London

(five separate reports) 1. Chief Medical Officer for England Department of Health Room 114, Richmond House 79 Whitehall London SW1A 2NS 2. Chief Executive, London Ambulance Service NHS Trust 220 Waterloo Road, London SE1 8SD 3.Chief Medical Officer, Barts Health, Royal London Hospital Whitechapel Road London E1 1BB 3a. General Practitioner, Bromley by Bow Health Centre St Leonard�s Street, London E3 3BT 3b. President, British Society for Allergy and Clinical Immunology Studio 16, Cloisters House, 8 Battersea Park Road London SW8 4BG 4. Associate Headteacher, Bow School, 44 Twelvetrees Crescent London E3 3QW 5. Chief Executive Officer, Compass Wellbeing Tower Hamlets Steel�s Lane Health Centre, 384-388 Commercial Road London E1 0LR

On 17 November 2016 I commenced an investigation into the death of Nasar Ahmed, aged 14 years. The investigation concluded at the end of the inquest today. I made a narrative determination, which I attach. I concluded that the medical cause of death was: � 1a post cardiac arrest hypoxic ischaemic brain injury 1b status asthmaticus 1c anaphylaxis 2 bronchial asthma and multiple food allergies

Nasar died following an anaphylactic reaction contributed to by his asthma, when he was in the internal exclusion room at school.

I have sent a copy of my report to the following. � ������� HHJ Mark Lucraft QC, the Chief Coroner of England & Wales ������� Care Quality Commission for England ������� Professor Dame Sally Davies, Chief Medical Officer for England ������� Medicines and Healthcare Products Regulatory Agency ������� National Ambulance Service Medical Directors (NASMeD) ������� Tower Hamlets Child Death Overview Panel ��������[REDACTED], allergy paediatrician, RLH ��������[REDACTED], respiratory paediatrician, RLH ��������[REDACTED], Nasar�s parents � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Other related deaths This report is being sent to: Department of Health and Social Care, London Ambulance Service NHS Trust 2, Royal London Hospital, Bromley by Bow Health Centre, British Society for Allergy and Clinical Immunology, Bow School and Compass Wellbeing Tower Hamlets Steel�s Lane Health Centre

27/04/2023

2023-0140

Ben Shipley

West Yorkshire Western

1 NHS England and NHS Improvement (North)

On 03 September 2019 I commenced an investigation into the death of Ben Alan SHIPLEY aged 22. The investigation concluded at the end of the inquest on 23 February 2023. The conclusion of the inquest was that: � Ben Alan Shipley died on 29th August 2019 having been struck by a train at Milne Viaduct East End after absconding from Huddersfield Royal Infirmary�s Clinical Decisions Unit at 12.30. Ben voluntarily came to A&E on 28th August 2019 at 19.27 after suffering a mental health crisis. He was assessed by 2 mental health psychiatrists and a mental health nurse. He was deemed to require a section 2 detention under the Mental Health Act, but was to remain in A&E for his own safety until a bed was sourced. After a prolonged search, using various communications methods, for a bed lasting approximately 17 hours, Ben absconded from A&E, where he travelled to a railway, [REDACTED]

Ben is a 22yr old single man who lived with his family in Lepton, Huddersfield. � On the 28th of August Ben was seen by his GP who referred Ben to the �Single Point of Access� service. On the 29th of August Ben was at the hospital with is parents, waiting to be sectioned under the mental health act when he ran away. His parents reported him as a missing person. � That afternoon Ben was struck by a train in a rural area of Huddersfield. His life was pronounced extinct at 14:14hrs.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to� Calderdale and Huddersfield Foundation Trust Kirklees Council South West Yorkshire Partnerships 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.

Mental Health related deaths | Railway related deaths This report is being sent to: NHS England and NHS Improvement

15/04/2023

2023-0118

Sara Jones

Stoke on Trent and North Staffordshire

1 Betsi Cadwaladr University Health Board � 2 Chief Executive Royal Stoke University Hospital

On 10 March 2022 I commenced an investigation into the death of Sara Anest JONES aged 25. The investigation concluded at the end of the inquest on 07 March 2023. The conclusion of the inquest was that: � Sara Anest Jones died at the Royal Stoke University Hospital, Stoke-on-Trent on 2nd April 2021 of complications of a bowel injury sustained in a road traffic collision on 30th March 2021. Miss Jones was treated for her injuries at the Royal Stoke University Hospital, Stoke- on-Trent. Those responsible for Miss Jones� care at the Royal Stoke University Hospital did not identify that she had sustained a bowel injury and consequently it remained untreated. Miss Jones developed peritonitis because of the untreated bowel injury, from which she later died.

Road traffic collision contributed to by neglect

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by May 09, 2023. I, the coroner, may extend the period. � Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

Road (Highways Safety) related deaths This report is being sent to: Royal Stoke University Hospital and Betsi Cadwaladr University Health Board

08/11/2024

2024-0613

Gemma Ralph

Staffordshire and Stoke-on-Trent

1 Cannock Chase Hospital 2 NHS England

On 12 February 2024 I commenced an investigation into the death of Gemma Louise Helen�RALPH aged 39. The investigation concluded at the end of the inquest on 03 October 2024. The conclusion of the inquest was that: Drugs related (anaesthesia). On 26 January 2024� Gemma Louise Helen Ralph passed away at her home address due inhalation of the�anaesthetic sevoflurane without intent to end life. She had access to sevoflurane as a� Theatre Support Assistant at Cannock Chase Hospital and it is probable that is where she� gained access to the anaesthetic that she inhaled and led to her passing.

As per section 3 above.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� Family of Gemma Ralph 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

Cannock Chase Hospital | NHS England

12/08/2024

2024-0442

Craig Steadman

Hampshire, Portsmouth and Southampton

1 Chief Coroner�s Office 2 [REDACTED] 3 [REDACTED] 4 [REDACTED]

On 7th March 2020 an investigation commenced into the death of Craig Steadman aged 32 years. The investigation concluded at the end of the inquest on 1st August 2024. The conclusion of the Jury at Inquest was Medical Cause of death 1a.Ligature Suspension and 2.Mental Illness NARRATIVE CONCLUSION Mr Steadman died by suicide at 01:25 on the 27/02/2022 in cell D36 at 3, West Hill, Romsey Road, Winchester. A probable contributing factor was the extended lock up due to the covid regime and staff shortages meaning that Mr Steadman had not left his cell at all on 26/02/2022. A possible contributing factor was the inadequate implementation of the ACCT process on 26/02/2022

In January 2020 Craig Steadman was released from Custody on Licence but a week later he breached a condition and was remanded back to HMP Winchester on 13th January. He had Diabetes and a mental health history, was on a weekly anti psychotic injection plus a history of multiple self harming incidents including overdosing on�[REDACTED].������ . After being assessed as suitable to hold his own medication he overdosed on�[REDACTED] on 17th January 2020 and was placed on an ACCT which was closed again on 18th January. He struggled with the Covid Lock Down restrictions and lack of contact with his family. On 26th February he self harmed, cutting himself [REDACTED], and the ACCT was reopened. At 00:44 he was found suspended by a ligature [REDACTED]. CPR by staff then paramedics proved futile and he was sadly pronounced deceased at 01:25 on 27th February 2020.

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

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

04/10/2023

2023-0541

Janet Spencer

Nottingham City and Nottinghamshire

1 Corporate Director for Adult Social Care and Public Health, Nottinghamshire County Council, County Hall

On 10 October 2022 I commenced an investigation into the death of Janet Irene SPENCER aged 76. The investigation concluded at the end of the inquest on 21 September 2023. The conclusion of the inquest was: Accident.

(relevant to this report) � Janet had an unwitnessed fall while in the lounge area of her assisted living accommodation on 30 August 2022. She pressed her call buzzer and notified staff. A support worker attended promptly. Janet was conscious. She reported having hit her head. An ambulance was called and paramedics attended. Janet was transported to Kings Mill Hospital where it was identified that she had suffered an acute subdural haematoma. Surgical intervention was deemed not appropriate. Janet was placed on end-of-life care. Despite a period of a few days when she appeared to improve, she did not recover and remained in hospital until her death some 13 days later. Janet died as a result of a traumatic acute subdural haematoma sustained in the fall, with underlying ischaemic heart disease contributing to but not directly causing her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Janet�s daughters Fosse Healthcare Jasmine Healthcare � 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: Nottinghamshire County Council

01/05/2024

2024-0489

George Dillon

Hampshire, Portsmouth and Southampton

1 Hampshire County Council Legal Services

On 01 June 2023 an investigation was commenced into the death of George Robert DILLON aged 19. The investigation concluded at the end of the inquest on 24 April 2024. The conclusion of the inquest was that: On the evening of Thursday 18th May 2023 the Deceased was driving a VW Golf south along a country road, namely Lee Lane, Romsey, in the vicinity of its junction with Spaniard Lane when at around 22.16 to 22.26 he lost control of the car by reason of his speed on a crest in the road, and hit a large tree.� He was the sole occupant of the car.� There is no evidence that any other vehicle was involved.� He suffered catastrophic and unsurvivable injuries.� He was taken to the Neurosurgical Unit at Southampton General Hospital where he died from his injuries on 20th May 2023.

On the evening of Thursday 18th May 2023 the Deceased was driving a VW Golf south along a country road, namely Lee Lane, Romsey, in the vicinity of its junction with Spaniard Lane when at around 22.16 to 22.26 he lost control of the car by reason of his speed on a crest in the road, and hit a large tree.� He was the sole occupant of the car.� There is no evidence that any other vehicle was involved.� He suffered catastrophic and unsurvivable injuries.� He was taken to the Neurosurgical Unit at Southampton General Hospital where he died from his injuries on 20th May 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 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

Hampshire County Council

07/06/2023

2023-0180

Robert Stevenson

West Yorkshire (Western)

1 Medicines & Healthcare products Regulatory Agency (MHRA)

On 22/06/22 I opened an inquest into the death of Robert Newton Stevenson who, at the date of his death was aged 63 years old. The inquest was resumed and concluded on 25/5/23. � I found that the cause of death to be: 1a. asphyxia (hanging) � I arrived at a narrative conclusion: Robert Newton Stevenson intended to take his own life when the balance of his mind was disturbed.

Mr Stevenson was a 63 year old gentleman who was a very respected and experienced Consultant Cardiologist and General Physician at Huddersfield Royal Infirmary, who resigned his post in May 2022 to enter full retirement. � On 6/5/22 he was referred to the urology department for the investigation of possible prostate cancer, when a decision was also made to consult a private Consultant Urologist. In order to relieve his symptoms of prostatitis and to make him ready for an investigative biopsy, he was prescribed Ciprofloxacin on 19/5/22 at a dose of�[REDACTED]. He had no previous history of depression or mental health problems. Subsequently on the morning of 30/5/22 Mr Stevenson left his home address on his own for his usual walk. He had not previously given any indications to his family for them to be concerned for him. Thereafter at approximately 12.30pm his wife received a Facebook message from Mr Stevenson to indicate that he had left a note under the pillow of his bed. � The note was found to be uncharacteristically confused and illogical given his reference to his baseless concerns that he may have developed AIDs after taking a HIV tester kit he had previously bought on line. � Concerns were raised for his welfare, and this trigged an intensive police and family search of the surrounding area. Subsequently, Mr Stevenson was found hanging [REDACTED]. Upon the arrival of the paramedics, although resuscitative attempts were made, it was confirmed very sadly that he had passed away.

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

Suicide (from 2015) | Alcohol, drugs medication related deaths This report is being sent to: Medicines & Healthcare products Regulatory Agency

04/12/2024

2024-0669

Patricia Curtis

Cambridgeshire and Peterborough

1 NHS England 2 Secretary of State for Health

On 21 April 2021 I commenced an investigation into the death of Patricia CURTIS aged 80. The investigation concluded at the end of the inquest on 21 November 2024. The conclusion of the inquest was that: Patricia Curtis died as a result of a known, but extremely rare complication of necessary post operative treatment

Mrs Curtis underwent mitral valve repair, tricuspid valve repair, coronary artery by pass grafting x 3 and atrial appendage exclusion on 17 March 2021 at Royal Papworth Hospital. Her post operative recovery was lengthy and she was repatriated to Bedford Hospital on 1 April 2021.� On 2 April 2023 following arrival at Bedford Hospital Mrs Curtis deteriorated rapidly in the early hours of the morning.� Post mortem examination determined that her cause of death was a haemothorax which on the balance of probability had started to develop gradually following a removal of her chest drain at Royal Papworth Hospital before transfer to Bedford Hospital.� Clinical signs of the haemothorax were first identifiable at 1am on 2 April 2021 when Mrs Curtis� medical assessment detected decreased air entry on her left side following prior examination results which showed equal air entry. Haemothorax did not form part of the differential diagnosis for Mrs Curtis at 1am on 2 April 2021 and she continued to be treated for her presenting complaints of fast atrial fibrillation, low blood pressure and severe heart failure and possible myocardial ischaemia due to low blood pressure.� A chest X-ray was not considered to be necessary as Mrs Curtis was not presenting with a primary lung cause and her respiratory system did not seem particularly affected at that time.� It is not possible to say whether a chest X-ray would have identified a haemothorax.� It was recognised by the treating clinicians that Mrs Curtis was very unwell and it was determined that Mrs Curtis would be unlikely to survive Intensive Care Unit care.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Patricia Curtis Bedford Hospital Royal Papworth Hospital 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. She may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

NHS England | Department of Health and Social Care

15/10/2024

2024-0553

Tamara Davis

West Sussex, Brighton and Hove

1 NHS England & NHS Improvement 2 Department of Health and Social Care 3 University Sussex NHS Foundation Trust

On 21 December 2022 I commenced an investigation into the death of Tamara DAVIS aged 31.� The investigation concluded at the end of the inquest on 14 October 2024. The conclusion of the inquest was that Ms Davis died from natural causes. As to the statutory questions in section 5 of the Coroners and Justice Act 2009 I recorded: Tamara Davis died on 13 December 2022 at the Royal Sussex County Hospital, Eastern Road, Brighton from multi organ failure which developed due to bronchopneumonia caused by Influenza A infection. She had been admitted to hospital on 10 December 2022 having been unwell for 5 days and was treated but sadly rapidly deteriorated due to the infection and could not recover.

Tamara Davis had attended the Royal Sussex County Hospital on 10 December 2022 having been unwell for 5 days. She was assessed in Resus within the Emergency Department when her NEWS score was 8. She was treated for a suspected chest infection� with� IV� antibiotics,� fluids� and� paracetamol� in� the� early� hours� of� 11 December. Her clinical condition then appeared to be improving. She was moved into the Emergency Department� corridor at 05:30 on 11 December as this was in use for patients.� She� then� waited� to� be� admitted��� to� a� ward� for� further� treatment� and observation. She remained in the ED corridor until 15:20 on 11 December. Tamara then moved to a cubicle in Majors�� within the Emergency Department and thereafter she experienced a significant deterioration in her condition which was treated and resulted in her admission to Intensive Care Unit. Despite treatment with supportive therapy she died on 13 December 2022. I did not find that the period in which Ms Davis was in the Emergency Department corridor caused or contributed to her death.

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

Hospital Death (Clinical Procedures and medical management) related deaths

NHS England & NHS Improvement | Department of Health and Social Care | University Sussex NHS Foundation Trust

21/10/2024

2024-0571

Amanda Gainford

Liverpool and Wirral

1 NHS England & NHS Improvement� (PFDs) 2 Chief Coroner

On 09 December 2022 I commenced an investigation into the death of Amanda Jane GAINFORD aged 52. The investigation concluded at the end of the inquest on 23 October 2024. The conclusion of the inquest was that: Amanda was a 52 year old lady detained under Section 2 Mental Health Act on 13/9/22 after a decline in her mental health.� Amanda was initially on the Harrington ward before transfer to the Brunswick mental health ward at Broadoak hospital on 5/10/22.� Amanda was in poor physical health and had underlying co-morbidities including liver cirrhosis caused by Hepatitis C and alcoholism which caused an enlarged spleen which made it more vulnerable to injury and trauma.� Amanda mobilised using a Zimmer frame in part due to having a cast on her leg due to injuries sustained in a road traffic collision a number of years ago, the leg was pending amputation.� During her time on both Harrington and Brunswick wards, Amanda was being assessed for a psychotic disorder secondary to polysubstance misuse.� Her risks pertained to falls due to immobility, aggression and retaliation of others.� During her time on Brunswick ward Amanda was subject to 1:1 level 4 observations at arms length and during her time on both Harrington and Brunswick wards, it was recorded that she had numerous unwitnessed and witness falls and documented incidents of physical aggression.� On 24/10/22 Amanda came into conflict with another patient in the corridor in which a verbal altercation led to Amanda pushing the other patient and that patient pushing Amanda back.� Amanda proceeded to pick up her Zimmer to her chest and move towards the other patient in which it inadvertently connected with the door fame and the top part of the Zimmer frame subsequently connected with Amanda�s upper abdominal area with some force.� She subsequently went towards the patient again, at which time the patient extended her leg to prevent Amanda coming closer which connected with her lower abdomen.�Amanda thereafter engaged in deliberate actions of banging her head to the toilet wall and throwing herself to the floor in the bathroom and again in her bedroom reopening a cut to her head.� Upon clinical assessment at around 5pm, observations were taken which detailed observations all in the normal range but for a low blood pressure.� Advice was documented in the RIO notes but it was unclear as to the nature and extent of the advice given to health care staff supporting Amanda thereafter.� It was clinically appropriate given Amanda�s condition to give intravenous fluids and an ambulance should have been called, neither action was taken and there was a missed opportunity which may have possibly made her injuries survivable. Further blood pressure monitoring was recorded at around 8pm with no records of checks otherwise.� Amanda�s blood pressure remained low and she presented as pale and jaundiced.� A further clinical assessment by the Doctor took place at 8:15pm.� Amanda became unresponsive and an IV line was inserted to give fluids.� An ambulance was called at 8:24pm by which time it was more likely than not that the prolonged low BP made her injuries unsurvivable.� 2 further calls at 8:42pm and 10:04pm were made to the North West Ambulance Service and an ambulance attended noted as a category 2. Amanda was taken by ambulance which arrived at 23:14pm and conveyed her to Whiston hospital where she suffered a cardiac arrest.� She was transferred to Aintree hospital and discharged from the Mental Health Act detention on 25/10/22.� Amanda died on 4/11/22 at Aintree hospital as a result of multiorgan failure due to splenic laceration and liver cirrhosis, the laceration more likely than not from either the deliberate action with the Zimmer frame or the deliberate falls to the floor on the 24/10/22 after the incident, with the unintended consequence of injury to herself which was fatal.

See above.

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

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

NHS England

09/12/2024

2024-0678

Luke Albiston O�Donnell

Liverpool and Wirral

1 Office of Product Safety and Standards (OPSS) 2 National Fire Chief�s Council 3 The Chief Coroner

On 14 August 2024 I commenced an investigation into the death of Luke Marshall ALBISTON O�DONNELL aged 8. The investigation concluded at the end of the inquest on 05 December 2024.� The conclusion of the inquest was that: Cause of death: 1a Hypoxia and Carbon Monoxide Poisoning Conclusion: Accident

Luke Marshall Albiston O�Donnell was an 8-year-old boy who died in hospital following a fire at his home address. A full investigation was carried out by Merseyside Fire and Rescue Service which found an e-bike was on charge in the front room of the house. The fire commenced as a result of the ignition of a lithium battery, from the e-bike, which has come into contact with combustible materials. The failure of the battery cells has enabled the fire to develop rapidly.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Luke O�Donnell I have also sent it to i. Merseyside Fire and Rescue Service ii. The National Fire and Rescue Service who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any 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.

Product related deaths

Office of Product Safety Standards | National Fire Chief�s Council

20/11/2024

2024-0639

Charlotte Roscoe

Manchester (West)

1 Royal Bolton Hospital

On 17 April 2024 I commenced an investigation into the death of Charlotte Ann ROSCOE aged 26. The investigation concluded at the end of the inquest on 19 November 2024.�� The conclusion of the inquest was Natural Causes, and the medical cause of death was: 1a Haemopericardium,�� 1b Rupture roof of Aorta� 1c Dissection of Ascending Aorta

The deceased attended the Royal Bolton Hospital on 22 January 2024, with chest pains and� was suspected to have a chest infection. An ECG was performed and steps were taken to� confirm a working diagnosis of whether there was a pulmonary embolism with a chest X-ray being performed.�� A scan was then requested to confirm if there was a pulmonary embolism, which was�considered by a Radiologist. National Guidance was followed and a VQ test or a CTPA could�be undertaken. Evidence was provided that a CTPA could have been undertaken but was not, because a VQ test was available and either of them was an approved manner of determining� whether there was a Pulmonary Embolism. After considering clinical factors, a VQ test was� done which confirmed that there was no Pulmonary Embolism.�� This test would not detect any cardiac anomalies whereas types of CT scan probably would do and be likely to lead to other tests. No follow up occurred on the chest x ray result which� showed a cardiomegaly (enlargement of the heart) 14/25cm on the basis that a visual� inspection of the image was considered normal. A clinical assessment leading to discharge�was undertaken on 23 January just before 5:00pm and observations were considered normal. These observations were last taken at 7:11am and two sets of observations that should have occurred in the intervening period where not done, the discharge decision was therefore� based on outdated observations and notes of the consultation were not accurate. She�returned to her home address [REDACTED] with a suspected lower�respiratory tract infection, but no formal diagnosis having been made. On arrival home, the� deceased went to bed feeling sick and had not arisen by the time her parents went to work� the following day. On her father�s return home at approximately 3:00pm, she was found to be deceased with her death being verified at 3:38pm by paramedics.�� A post mortem examination found that she had died as a consequence of a dissection of the ascending aorta and ruptured root of aorta leading to haemopericardium. This is a rare� condition, which would have been likely to have been detected by a CTPA scan and� subsequent CTAA scan that would be indicated, however this was not specifically requested� and the VQ test was reasonable with reference to the guidance from the Royal College of� Radiologists to explore whether there was a pulmonary embolism.�� Whilst there was a missed opportunity to detect the unidentified Aortic Dissection by� undertaking a CT scan, it cannot be said on balance of probabilities that this would have prevented death given the catastrophic nature and low survivability rate.

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 The Royal College of Radiologists 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

Royal Bolton Hospital

14/11/2024

2024-0627

John Ellis

Hampshire, Portsmouth and Southampton

1 Royal College of Veterinary Surgeons 2 Veterinary Medicines Directorate

On 11 November 2022 I commenced an investigation into the death of John Robert ELLIS aged 35. The investigation concluded at the end of the inquest on 13 November 2024. The conclusion of the inquest was that: The deceased was a highly regarded young veterinary surgeon, who was experiencing difficulties in some of his personal relationships, as well as financial worries and considerable stress as a result of having recently changed jobs.� On Sunday 06/11/22, he used an intravenous line to self-administer a toxic quantity of�[REDACTED], which he had procured by falsely representing to his former employers that he needed it in order to euthanise a large dog. He was able to access the drug, which he knew to be dangerous, without being challenged as to its purpose. He intended to take his own life and was found deceased in the shower cubicle at [REDACTED] shortly before midnight.

On 11 November 2022 I commenced an investigation into the death of John Robert ELLIS aged 35. The investigation concluded at the end of the inquest on 13 November 2024. The conclusion of the inquest was that: The deceased was a highly regarded young veterinary surgeon, who was experiencing difficulties in some of his personal relationships, as well as financial worries and considerable stress as a result of having recently changed jobs.� On Sunday 06/11/22, he used an intravenous line to self-administer a toxic quantity of�[REDACTED], which he had procured by falsely representing to his former employers that he needed it in order to euthanise a large dog. He was able to access the drug, which he knew to be dangerous, without being challenged as to its purpose. He intended to take his own life and was found deceased in the shower cubicle at [REDACTED] shortly before midnight.

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

Suicide (from 2015)

Royal College of Veterinary Surgeons | �Veterinary Medicines Directorate

08/11/2024

2024-0614

Anne Taylor

Manchester (West)

1 SALFORD ROYAL HOSPITAL FOUNDATION TRUST 2 NHS ENGLAND

On 1 August 2024 I commenced an investigation into the death of Anne Taylor aged 95. The investigation concluded at the end of the inquest on 7 November 2024. The conclusion of the inquest was Accident, and the medical cause of death was Traumatic Intracranial Haemorrhage.

On 17 July 2024, the deceased was on a short holiday break in Blackpool at a hotel with her son sharing a twin room. In the late evening, she banged her head on a bedside cabinet as she turned in bed and then fell out of the bed. She got back into bed, with no complaint of injury. She appeared fine on the following day with no complaints of feeling unwell and spent the day undertaking activities. The planned holiday break ended the day after on Friday 19 July 2024 and she returned home. At 18:30 on 19 July she telephoned her daughter and said she did not feel well. Her son and daughter went to her home and found she had slurred speech. An ambulance was called and she was conveyed to Salford Royal Hospital. During a wait to be seen the deceased became agitated and elected to leave the hospital prior to being assessed after being told of the likely waiting time. It was planned that she would return the following morning when the emergency department was less busy. She returned to hospital on 20 July via ambulance and was assessed. A CT scan found she had suffered a traumatic brain injury with bilateral acute subdural bleed and midline shift. Neurosurgical advice deemed her not fit for acute surgery and she was treated medically, deteriorating over the next week. End of life care was commenced on 29 July 2024, and she passed away on 31 July 2024 at Salford Royal Hospital

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

Hospital Death (Clinical Procedures and medical management) related deaths

SALFORD ROYAL HOSPITAL FOUNDATION TRUST | NHS ENGLAND

25/11/2024

2024-0649

Dean Bray

Hampshire, Portsmouth & Southampton

1 Southern Health Foundation Trust 2 Chief Coroner � PFD Reports

On 12 January 2022 I commenced an investigation into the death of Dean John Mark Anthony BRAY aged 47. The investigation concluded at the end of the inquest on 11 November 2024. The conclusion of the inquest was that: Mr Dean Bray died of Acute Heart Failure on the 29th December 2021 whilst in the seclusion room on Hamtun Ward where there was a failure to adequately act upon and escalate Dean�s high respiratory rate by nursing staff over the 28th and 29th December 2021

Mr Dean Bray died of Acute Heart Failure on the 29th December 2021 whilst in the seclusion room on Hamtun Ward where there was a failure to adequately act upon and escalate Dean�s high respiratory rate by nursing staff over the 28th and 29th December 2021 Narrative Conclusion The Jury�s conclusion is Natural Death contributed to by Neglect. There was a gross failure to escalate Dean�s deteriorating physical presentations on 28th December after 21:43 up until 08:00 on 29th December 2021, based on inadequate monitoring of Dean�s physical health and a lack of recognition of Dean�s medical emergency which, on the balance of probabilities but for the gross failures, Dean�s life probably could have been prolonged.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Southern Health Foundation Trust

22/07/2024

2024-0393

Russell Irvine

Durham & Darlington

1 [REDACTED]

On 10/11/2022 12:04an investigation was commenced into the death of Russell Ian IRVINE 22/07/1971. The investigation concluded at the end of the inquest on 21/06/2024 14:36.� The conclusion of the inquest was that Hanging � 7 November 2022 � HMP Durham, cell E3-03, Old Elvet, Durham, DH1 3HU. See Attached: We believe on the balance of probabilities that Mr Irvine had the intentions and took his own life on the evening of 7 November 2022 by hanging in his prison cell, [REDACTED]. Mr Irvine also left a note in which he stated he was of sound mind. Based on the evidence provided, the facts state that a number of policies and processes were not actioned or put I place correctly. It is evident that Mr Irvine had previously documented risk factors for suicide and self- harm, however these factors were not identified by prison staff during the reception screening process. It is evident that not all of the actions taken by healthcare were in compliance with the relevant policies. It cannot be established on the evidence that these failings caused or contributed to Mr Irvine�s death.

Hanging � 7 November 2022 � HMP Durham, cell E3-03, Old Elvet, Durham, DH1 3HU. See Attached: We believe on the balance of probabilities that Mr Irvine had the intentions and took his own life on the evening of 7 November 2022 by hanging in his prison cell, [REDACTED]. Mr Irvine also left a note in which he stated he was of sound mind. Based on the evidence provided, the facts state that a number of policies and processes were not actioned or put I place correctly. It is evident that Mr Irvine had previously documented risk factors for suicide and self- harm, however these factors were not identified by prison staff during the reception screening process. It is evident that not all of the actions taken by healthcare were in compliance with the relevant policies. It cannot be established on the evidence that these failings caused or contributed to Mr Irvine�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] [REDACTED] � I have also sent it to [REDACTED] HMP Durham 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: [REDACTED]

21/05/2024

2024-0279

Colin McCallum

Cambridgeshire and Peterborough

1 [REDACTED]

On 17 July 2023 I commenced an investigation into the death of Colin Neil Duncan MCCALLUM aged 62. The investigation concluded at the end of the inquest on 16 May 2024. The conclusion of the inquest was that: � Mr McCallum was driving his Ford Focus westbound along the A1307 dual carriageway at Hemingford in Cambridgeshire at around 1545hrs on 14.07.23. It was raining heavily at that time. Mr McCallum was driving in lane two of the carriageway when his vehicle struck a patch of water. He lost control of the vehicle which crossed the carriageway to the nearside before entering the grassed hard shoulder where it struck a stationary vehicle which had stopped to assist another driver. Mr McCallum�s vehicle then continued into the adjacent treeline before coming to a sudden halt. Emergency Services were called to the scene. Sadly Mr McCallum had suffered severe traumatic injuries as a result of the collision and despite attempts at resuscitation his death was confirmed at 1715hrs.

Mr McCallum was driving his Ford Focus westbound along the A1307 dual carriageway at Hemingford in Cambridgeshire at around 1545hrs on 14.07.23. It was raining heavily at that time. Mr McCallum was driving in lane two of the carriageway when his vehicle struck a patch of water. He lost control of the vehicle which crossed the carriageway to the nearside before entering the grassed hard shoulder where it struck a stationary vehicle which had stopped to assist another driver. Mr McCallum�s vehicle then continued into the adjacent treeline before coming to a sudden halt. Emergency Services were called to the scene. Sadly Mr McCallum had suffered severe traumatic injuries as a result of the collision and despite attempts at resuscitation his death was confirmed at 1715hrs.

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.

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

07/05/2024

2024-0355

Matthew Scott

Derby and Derbyshire

1 [REDACTED]

On 21 March 2023 I commenced an investigation into the death of Matthew SCOTT aged 24. The investigation concluded at the end of the inquest on 22 April 2024. The conclusion of the inquest was that: � Matthew James Scott died on 11th March 2023 whilst travelling east on Station Road, Melbourne. The road had a speed limit of 40mph. He was travelling to his place of work at East Midlands airport when he hit a lengthy defective and subsided stretch of road which was filled with ice. That combined with his speed, which was likely to be in excess of 40mph, caused him to lose control, impact with a tree and sadly resulted in his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] [REDACTED] I have also sent it to � [REDACTED] PROJECT ENGINEER HIGHWAYS AUTHORITY � 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: REDACTED

26/06/2023

2023-0287

Anthony Rockall

Buckinghamshire

1 [REDACTED]

On 28th April 2022 I commenced an investigation into the death of Anthony William Rockall, aged 68 years. The investigation concluded at the end of the inquest on 15th June 2023. The conclusion of the inquest was misadventure.

Tony Rockall died during the early evening of 26th April 2022 at John Radcliffe Hospital, Oxford from the head injury he sustained when he fell from the tailgate of his truck the previous afternoon. The injury was sustained whilst another person was trying to offload a pallet of bricks from the truck at a reclamation yard in Aston Clinton, Buckinghamshire. It is likely that the pallet truck, which appears to have been longer than the depth of tailgate, had become stuck and Tony, who had been standing in a small area at the back corner of the tailgate, fell backwards to the ground whilst the pallet truck was stuck. It is not possible to ascertain whether Tony had a medical event leading to the fall, however his presence on the tailgate was in connection with the unloading of the truck.

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

Other related deaths This report is being sent to: REDACTED

29/07/2024

2024-0428

Scott Punshon

Durham and Darlington.

1 [REDACTED]

On 23/08/2023 13:37an investigation was commenced into the death of Scott Andrew PUNSHON 16/06/1987. The investigation concluded at the end of the inquest on 30/05/2024 11:00.� The conclusion of the inquest was that Scott Andrew Punshon was a 36 year old man who was found deceased, lying on the road (the A689 Road near Howden Le Wear) on the 12th August 2023. He was walking home from Crook in the early hours, having spent the evening with friends drinking. The collision investigation and the injuries identified at post mortem showed that he had been lying in the road when the car struck him. Toxicology showed a blood alcohol of 280mg/100mls and evidence that he had consumed cocaine and cannabis..

Scott Andrew Punshon was a 36 year old man who was found deceased, lying on the road (the A689 Road near Howden Le Wear) on the 12th August 2023. He was walking home from Crook in the early hours, having spent the evening with friends drinking. The collision investigation and the injuries identified at post mortem showed that he had been lying in the road when the car struck him. Toxicology showed a blood alcohol of 280mg/100mls and evidence that he had consumed cocaine and cannabis.

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.

Road (Highways Safety) related deaths� � This report is being sent to: [REDACTED]

21/04/2016

2016-0155

Margaret Rogerson

Manchester West

Care Home Health related deaths

BUPA; Mill View Nursing Home; The Right Honourable Jeremy Hunt MP

21/04/2016

2016-0151

Keith Harper

Essex

Road (Highways Safety) related deaths

The Highways Agency

2 January 2019

2019-0001

Alexandre Parr

Wiltshire and Swindon

Service Personnel related deaths

Civil Aviation Authority

29 July 2016

2016 � 0275

Danny Sweet

Cornwall and the Isles of Scilly

Hospital Death (Clinical Procedures and medical management) related deaths

Cornwall Partnership Foundation Trust

17 January 2019

2019-0023

Mark Harris

Suffolk

Mental Health related deaths; Emergency services related deaths (2019 onwards)

Melbourne Ambulance Station; Emergency Operation Centre Norwich

18 April 2016

2016-0156

Doreen Mattinson

London Inner North

Care Home Health related deaths

Acorn Lodge Care Home

21/04/2016

2016-0153

Derrick Rose-Fowler

Shropshire, Telford and Wrekin

State Custody related deaths

HMP Stoke Heath; Ministry of Justice

27 July 2017

2017-0328

Sheila Gaskin

South Wales Central

Hospital Death (Clinical Procedures and medical management) related deaths

Welsh Government Office; Care Quality Commission

30/01/2020

2020-0129

Julie O�Connor

Avon

Community healthcare related deaths

Department for Health and Social Care; Royal College of Obstetricians and Gynaecologists

22 January 2019

2019-0026

Ann Swoffer

Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

University Hospitals Birmingham NHS Trust

21/04/2016

2016-0157

Richard Grant

Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Black Country Partnership NHS Foundation Trust

19/04/2016

2016-0147

Leslie Carswell

Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

Sandwell and West Birmingham NHS Trust; University Hospital Birmingham NHS Foundation Trust

20 March 2019

2019-0096

Pamela Sunter

South Yorkshire (West)

Hospital Death (Clinical Procedures and medical management) related deaths

Cancer Alliance

26 February 2019

2019-0067

John Thorp

London (West)

Hospital Death (Clinical Procedures and medical management) related deaths

London North West University NHS Trust

15 July 2019

2019-0509

Lucy Lee

Surrey

Other related deaths

Surrey Police; The National Police Chief�s Council; The Home Secretary; Department of Health; British Medical Association

4 April 2019

2019-0136

Lesley Armstrong

North Northumberland

Police related deaths

Northumbria Police

18 December 2018

2018-0388

John Delahaye

Birmingham and Solihull

Suicide (from 2015); State Custody related deaths

NHS England;� Birmingham and Solihull Mental Health NHS Trust; G4S; MOJ; Birmingham Community NHS Trust

26 February 2019

2019-0081

Kathleen McGeary

Nottinghamshire

Hospital Death (Clinical Procedures and medical management) related deaths

Doncaster and Bassetlaw Teaching Hospitals NHS Trust

3 March 2020

2020-0050

Shaun Turner

Manchester South

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

Department of Health

10 September 2018

2018-0292

Gladys Williams

North Wales (East and Central)

Hospital Death (Clinical Procedures and medical management) related deaths

Betsi Cadwaladr University Health Board; Welsh Ambulance Services

12 November 2018

2018-0347

Joseph Page

South Wales Central

Hospital Death (Clinical Procedures and medical management) related deaths

Cardiff & Vale University Health Board

21 January 2019

2019-0116

Alfred Howell

West Yorkshire (East)

Hospital Death (Clinical Procedures and medical management) related deaths

The Mid Yorkshire Hospitals NHS Trust

28 December 2018

2018-0408

Joan Wright

Manchester (South)

Care Home Health related deaths

Department of Health

6 December 2018

2018-0377

Veronica Gregory

Manchester (City)

Care Home Health related deaths

Zinnia Healthcare Limited

14 September 2018

2018-0282

Terence Bennett

Wiltshire and Swindon

Mental Health related deaths; Suicide (from 2015)

Avon and Wiltshire Mental Health NHS Trust

14 February 2020

2020-0040

Marley Slack

Leicester City and South Leicestershire

Child Death (from 2015); Other related deaths

Staffordshire, Shropshire and Black Country New born and Maternity Network

21 December 2018

2018-0401

Diane Greenslade

Gwent

Community health care and emergency services related deaths

Welsh Ambulance Services; Aneurin Bevan University Health Board

21 December 2018

2018-0403

Dorina Zangari

London (East)

Community health care and emergency services related deaths

National Fire Chiefs

11 September 2018

2018-0289

Kevin Sherwood

Hertfordshire

Railway related deaths; Suicide (from 2015)

Network Rail

13 August 2018

2018-0281

Nana Boateng

Wiltshire and Swindon

Road (Highways Safety) related deaths

Wiltshire Council

22 November 2018

2018-0365

Matthew Craven

Manchester (South)

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

Pennine Care NHS Trust

21 December 2018

2018-0403

Mihaela Lazar

London (East)

Community health care and emergency services related deaths

National Fire Chiefs

17 December 2018

2018-0410

Agnes Lambert

London Inner (North)

Hospital Death (Clinical Procedures and medical management) related deaths

Camden & Islington NHS Trust

26 February 2019

2019-0066

Christopher Moss

Staffordshire South

State Custody related deaths; Suicide (from 2015)

MOJ

4 October 2018

2018-0414

Michael Wheeler

Birmingham and Solihull

Hospital Death (Clinical Procedures and medical management) related deaths

NHS England; Birmingham Clinical Commissioning Group

18 February 2020

2020-0030

Liam Clark

Staffordshire South

Road (Highways Safety) related deaths

Commissioner for Highways

16 July 2018

2018-0358

Tyrone Evans

Coventry

Road (Highways Safety) related deaths

Driver & Vehicle Licensing Agency

26 November 2018

2018-0303

Jack Riding

Liverpool & Wirral

Other related deaths

Goals Soccer Centres PLC; Football Association

6 August 2018

2018-0275

Susan Elliott

Sunderland

Hospital Death (Clinical Procedures and medical management) related deaths

City Hospitals NHS Trust

29 May 2018

2018-0277

Brian Bicat

West Yorkshire (West)

Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care | Medicines and Healthcare products Regulatory Agency | NHS Improvement; Alliance Pharmaceutical | Diprobase Bayer Public Limited | NHS England | Bradford District Care Foundation Trust

6 August 2018

2018-0276

Phylliss Letcher

Isles of Scilly

Care Home Health related deaths

Crossroads House Care Home

4 February 2020

2020-0020

Gordon Gillott

Derby and Derbyshire

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

East Midlands Ambulance Service; Chesterfield Royal Hospital; Royal Derby Hospital

14 January 2019

2019-0056

Dane Pearson

Manchester (South)

Mental Health related deaths; Suicide (from 2015)

Greater Manchester Police; Home Office

14 August 2018

2018-0300

Enric Elliott

London Inner (West)

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

Whittington Health NHS Trust

10 September 2018

2018-0291

Darren Urquhart

Hertfordshire

Railway related deaths

Network Rail

21 February 2019

2019-0095

Terrence Smith

Surrey

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

South East Coast Ambulance Service Service; NHS England; Joint Royal Colleges Ambulance Liaison Committee; Mitie Care & Custody; Teesside University Hospitals; Surrey Police; College of Policing

25 March 2020

2020-0079

Dudley Howe

Norfolk

Road (Highways Safety) related deaths

Driver and Vehicle Standards Agency

14 February 2019

2019-0049

Kenneth Whittington

Brighton and Hove

Hospital Death (Clinical Procedures and medical management) related deaths

Brighton and Sussex University Hospitals NHS Trust

26 February 2019

2019-0478

Keith Heatley

South Wales Central

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

ABMU Health Board

25 January 2019

2019-0477

Anne-Marie Nield

Manchester (North)

Other related deaths

Manchester Police

� 26 September 2018

Deceased name: John Waite

Coroners name: Alan Walsh

Category: Hospital Death (Clinical Procedures and medical management) related deaths

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

1 March 2017

2017-0041

Ceriann Richards

South Wales Central

Hospital Death (Clinical Procedures and medical management) related deaths

Welsh Ambulance Service NHS Trust; Royal Gwent Hospital; Neville Hall Hospital; Welsh Government

19 June 2017

2017-0434

Patrick Woods

Bedfordshire and Luton

Hospital Death (Clinical Procedures and medical management) related deaths

Luton & Dunstable University Hospital NHS Trust; Drager

25 October 2016

2016-0377

Richard Walsh

London Inner (South)

State Custody related deaths; Suicide (from 2015)

Ministry of Justice; Department of Health; Hampshire County Council

7 February 2019

2019-0039

Stephen Kennedy

Birmingham and Solihull

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

Birmingham and Solihull Mental Health NHS Trust; Department of Health and Social Care; Birmingham Cross City Clinical Commissioning Group

20 November 2018

2018-0368

Suleyman Yalcin

London (North)

Alcohol, drug and medication related deaths; Road (Highways Safety) related deaths

Metropolitan Police

11 October 2018

Deceased name: Thomas Lear

Coroners name: Margaret Jones

Category: Suicide (from 2015)

This report is being sent to: Longton Police Station; MOJ Suicide (from 2015)

19 December 2018

2018-0393

Michal Netyks

Liverpool & Wirral

State Custody related deaths

Home Office; MOJ

18 December 2018

2018-0392

Natalie Hunter

Isle of Wight

Hospital Death (Clinical Procedures and medical management) related deaths; Mental Health related deaths; Alcohol, drug and medication related deaths; Suicide (from 2015)

St Mary�s Hospital NHS Trust

14 May 2019

2019-0152

Anthony Walker

Portsmouth and South East Hampshire

Suicide (from 2015); Community health care

Probation Service; Southern Health NHS Trust; SCAS; Portsmouth Hospitals NHS Trust

11 December 2018

2018-0380

Rowan Lloyd

Dorset

Road (Highways Safety) related deaths

Dorset Highways Department

1 April 2019

2019-0108

Andrew Clegg

Wilshire and Swindon

Other related deaths

CQC; Royal Institute of British Architects

20 January 2016

2016-0600

Faiza Ahmed

Inner North London

Emergency Services related deaths | Mental Health related deaths

Metropolitan Police | London Ambulance Service NHS Trust | Department for Work and Pensions

5 December 2018

Ref:

Sylvia Mitchell

Black Country

Hospital Death (Clinical Procedures and medical management) related deaths; Community health care and emergency services related deaths

Sandwell and West Birmingham NHS Trust; Oaks Medical Centre

19 October 2018

2018-0382

Trystan Bryant

Plymouth, Torbay and South Devon

Community health care and emergency services related deaths; Mental Health related deaths

National Police Chiefs� Council | Dyfed-Powys Police

12 May 2020

2020-0111

Harrison Hassall

Leicester City and South Leicestershire

Community healthcare related deaths; Child Death

Department of Health and Social Care

1 August 2018

2018-0369

Jerome Jones

Shropshire, Telford & Wrekin

State Custody related deaths

HMP Stoke; Shropshire Community Health NHS Trust

1 February 2019

2019-0077

Stephen Harte

Birmingham and Solihull

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

Birmingham and Solihull Clinical Commissioning Group; Care Quality Commission