Inquests (PFDs)

12/07/2023

2023-0238

Luke Ashton

Leicester City and South Leicestershire

[REDACTED], Chief Executive Officer (�CEO�) of Flutter UK & Ireland, the parent company of �Betfair� (through its legal representatives) [REDACTED], Chief Executive Officer (�CEO�) of the Gambling Commission The Rt. Hon. Lucy Frazer KC, MP, Secretary of State for Culture, Media and Sport

On 06 May 2021 I commenced an investigation into the death of Luke Anthony Ashton aged 40. The investigation concluded at the end of the inquest on 29 June 2023. The conclusion of the inquest was that: � Narrative Conclusion: � Luke Ashton died as a result of his own actions, intending those actions to cause his death. At the time of his death, Luke was suffering from a gambling disorder, which was longstanding, at least from 2019 and which contributed to his decision to take his own life. In the months prior to his death, the evidence showed that Luke had been assessed as a low-risk gambler by the operator with whom he was gambling, although Luke�s gambling activity, deposits made and losses suffered were most intensive in the 10 weeks prior to his death. The same operator did not intervene or interact with Luke, in any meaningful way, between 2019 and the date of Luke�s death, when more efforts to intervene or interact should have been made. Opportunities were missed which may possibly have changed the outcome for Luke. � The cause of death was established as: � I a ([REDACTED]) � I b Gambling Disorder

Luke Ashton was a 40-year-old man who was discovered deceased by attending police officers and paramedics at Carnegie House, Swinton, near Rotherham, South Yorkshire on 22 April 2021, [REDACTED]. His death was confirmed at the scene by one of the attending paramedics.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1.��[REDACTED] , wife of the Deceased (via her legal representatives, Leigh Day & Company). 2.�Flutter Entertainment UK & Ireland (via its legal representatives). � I have also sent it to 1.������ Gamble Aware (Charity, Registered in England No. 4384279) � 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) | Other related deaths This report is being sent to: Betfair | Gambling Commission | Department for Culture, Media and Sport

05/09/2024

2024-0493

Carol Guest

South Yorkshire East

[REDACTED], Chief Executive Officer and [REDACTED], Acting Medical Director, Rotherham Doncaster and South Humber NHS Foundation�Trust

On 9 April 2024 I commenced an investigation into the death of Carol Ann Guest. The investigation� concluded at the end of the inquest. The conclusion of the inquest was� Suicide.� 1a Hanging �� 1b�� � 1c� �� �II

Carol Ann Guest resided at home with her partner and did not have a history of mental health� problems until 2024. These appear to have been triggered by her mother (for whom she had been� caring for for a considerable period of time) being admitted to a care home. There were references� in the GP notes to Ms Guest and her family seeking help and support in relation to mental health� difficulties, which the family felt were escalating. On the 8th March 2024 a family member contacted the GP expressing concerns regarding escalation of symptoms and Ms Guest having taken excess� medication the previous week. The GP did not feel a telephone call that day was indicated but did� feel that urgent referral was necessary but regrettably the urgent referral was not sent until a week� later. Once received by yourselves on Friday the 15th March, Mrs Guest�s referral was placed on� the SPA meeting list for the following Thursday (the 20th March) where it was discussed and� determined that she would not follow the usual pathway and wait for a routine appointment but that� a consultant would visit her the following week. Before that visit could be arranged Ms Guest� hanged herself�[REDACTED] at her home address on the 24th March 2024.

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

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

Rotherham Doncaster and South Humber NHS Foundation�Trust

04/07/2024

2024-0360

David Morris

East London

[REDACTED], Chief Executive Officer, Barking, Havering & Redbridge University Trust � Secretary of State for Health & Social Care � ����������������������������������� [REDACTED], Medicines & Healthcare products Regulatory Agency

On 17/05/2022, this Court commenced an investigation into the death of David John Morris aged 78 years. The investigation concluded at the end of the inquest on 3rd July 2024. The Court returned a narrative conclusion; � �David John Morris died in hospital on 16th May 2022 due to complications of necessary surgery to treat the effects of oesophageal cancer. Mr Morris fell into septic shock due to peritonitis caused by a leak of enteral feed into his abdomen from a gastrostomy apparatus. It has not been possible to determine how the leak arose.� � Mr Morris�s medical cause of death was determined as; � Intra-Abdominal Sepsis Laparoscopic Gastrostomy Oesophageal Cancer II Chronic Obstructive Pulmonary Disease, Ischaemic Heart Disease

David Morris was a 78-year-old man who developed symptoms of abdominal pain and blood-stained vomiting in October 2021. Mr Morris was assessed by his GP who made a number of referrals to specialists under the two week wait pathway. Delays occurred in undertaking diagnostic tests of the deceased, which resulted in a finalised diagnosis of oesophageal cancer only being arrived at in late February 2022. � The onset of cancer resulted in a stricture of the oesophagus which impeded oral intake of nutrition. On 2nd May 2022 Mr Morris underwent a surgical gastrostomy to facilitate enteral feeding through a tube directly into his stomach. � On 3rd May 2022 Mr Morris began to deteriorate whilst treated on a surgical ward, he experienced difficulty in breathing and pain in his left upper quadrant. A leak was detected from his gastroscopy on two occasions during the day but enteral feeding was allowed to continue. Shortly before midnight, the leak re-occurred, Mr Morris was reviewed by a registrar and again, the enteral feed was allowed to continue. � At approximately 07.00 hrs on 4th May 2022, the leak from the gastrostomy was observed to have increased and again a doctor was called for. Mr Morris�s clinical observations were taken and it was noted that he had deteriorated, a mottled rash was observed on his abdomen. � Despite these concerning signs, no clinical action was taken until after 10.30hr, over three hours later, when a surgical registrar reviewed Mr Morris. The surgeon identified septic shock with a likely abdominal cause and Mr Morris was prepared for emergency surgery. � A laparotomy determined that the gastrostomy device had failed, Mr Morris had a gangrenous bowel, caused by peritonitis due to the spillage of stomach content and enteral feed into the abdomen. The ischaemic bowel was removed and re-look surgery was arranged for the following day. � The gastrostomy device was removed and tested for 7 days thereafter, it appeared to be functional. The device was subsequently lost, negating the possibility of further investigation when it was returned to a manufacturer. Human error in the handling of the gastric ballon inflation port on the device remains a potential cause for the deflation and failure of the device. � On the 8th May a final surgery was undertaken to repair the bowel and insert a feeding tube into the small intestine. � Mr Morris declined post-operatively, passing away in hospital on 16th May 2022. � Some time after the death of Mr Morris, the nurse in charge of the ward where the deceased was cared for on 3rd May 2022 was found collapsed and unresponsive at work. The nurse volunteered that they were under the effects of stolen controlled medication that belonged to the hospital. The nurse offered that they had been stealing and self-administering controlled medications during every shift they worked for approximately three years. At inquest, the nurse declined to answer questions on whether their drug misuse could have had a contributary effect of the failure of Mr Morris�s gastrostomy.

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

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

19/09/2024

2024-0503

Gordon Long

East London

[REDACTED], Chief Executive Officer, Barking, Havering & Redbridge University Trust� Sent via email:�[REDACTED]

On 11th July 2023, this court commenced an investigation into the death of Gordon Long aged 73 years. The investigation concluded at the end of the inquest on 18th� September 2024. The court returned a narrative conclusion,�� �George Richard Long died in hospital on 8th July 2023 the day after necessary surgery to amputate his left leg. Mr Long died due to complications of surgery along with the� effects of multiple, pre-existing, serious medical conditions.�� Mr Gordon�s medical cause of death was determined as; 1a: Infective Exacerbation Of Chronic Obstructive Pulmonary Disease And Congestive Cardiac Failure� 1b: Septic/Gangrenous Left Foot Treated With Left Above Knee Amputation,�Ischaemic Heart Disease And Extensive Metastatic Carcinoma To The Liver� 1c.Peripheral Vascular Disease� II. Type 2 Diabetes Mellitus, Atherosclerosis, Dyslipidaemia, Cirrhosis Of The Liver, Depression And Previous Left Sided Cerebrovascular Accident

Mr Long was admitted to hospital by ambulance on 1/7/23. A preliminary diagnosis of� dry gangrene of the left foot was arrived at in the ED. A care plan was arrived at that� involved amongst other things, admission onto a ward and referral to the vascular team for assessment.� Mr Long was not assessed by a vascular specialist until 6th July 2023, by which time he had suffered a significant clinical decline. Surgery to amputate the effected limb was� undertaken on 7th July 2023, he died on 8th July 2023.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Barking, Havering & Redbridge University Trust

29/06/2023

2023-0219

Matthew Phipps

East London

[REDACTED], Chief Executive Officer, Barking, Havering and Redbridge University Hospital NHS Foundation Trust

On 4 October 2022 I commenced an investigation into the death of Mr Matthew John Phipps, aged 56 years. The investigation concluded at the end of the inquest on the 26 June 2023. The conclusion of the inquest was that Mr Phipps died from natural causes.

On the 10 July 2022, Matthew Phipps was admitted to Queens Hospital with a severe, acute kidney injury and a 5 day history of fever, chills, diarrhoea and vomiting. On the 10 July 2022 he also presented with lower abdominal pain, lower back pain and pain in the top of his right leg. He was recognised as being critically unwell and the emergency department requested transfer to the intensive care unit. There was a delay in transferring Matthew to intensive care. He should have been transferred by 2230 on the 10 July 2022, but was not transferred until 0930 on the 11 July 2023. Matthew�s family observed that only one of two bottles of antibiotics prescribed to Matthew in A&E were administered to him. Matthew was not observed as closely as he should have been, given his very concerning clinical condition and there were delays in carrying out necessary blood tests and in commencing renal replacement therapy. The inquest has found however that Matthew presented to hospital on the 10 July 2022 with a likely acute kidney injury, associated with sepsis. As such, his prognosis was very poor, even with optimal treatment. There is no evidence that the failings in the care provided to him contributed to his death.

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

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

24/07/2023

2023-0270

Christine Nakafeero

East London

[REDACTED], Chief Executive Officer, Barts Health NHS Foundation Trust � [REDACTED], National Medical Director, NHS England � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

On 22nd June 2022 this Court commenced an investigation into the death of Christine Nakafeero, age 56 years. The investigation concluded at the end of the inquest between 20th and 21st July 2023. The court returned a narrative conclusion. � �Christine Goodfriday Nakafeero died at home on 21st June 2022 due to a pulmonary embolism caused by a deep vein thrombosis (�DVT�). The DVT was made more likely by: a medical condition, uterine fibroids and the treatment for that condition, tranexamic acid. In 2019 Ms Nakafeero was referred to the gynaecology clinic with a recommendation that she underwent a hysterectomy to effectively treat her uterine fibroids. Due to a breakdown of communication between Ms Nakafeero and the Trust, the surgery was not undertaken. Had the surgery taken place, Ms Nakafeero would probably not have developed a pulmonary embolism in June 2022.� � Ms Nakafeero�s medical cause of death was determined as:� 1a Pulmonary Emboli; 1b Deep Vein Thrombosis; II Uterine Fibroids

Christine Goodfriday Nakafeero was found unresponsive at home on the evening of 21st June 2022. Despite the best efforts of her family and emergency services she was declared deceased that evening. � Her death was caused by a pulmonary embolism, in turn caused by a deep vein thrombosis. � Earlier that day Ms Nakafeero had been discharged from hospital having presented with symptoms of menorrhagia and associated pain and anaemia on 19th June 2022. � Whilst an inpatient, Ms Nakafeero was assessed for risk of venous-thrombo-embolism (�VTE�) risk utilising the Trust�s VTE policy, she was categorised as having zero risk of thrombo-embolism. � Ms Nakafeero had been diagnosed with uterine fibroids since 2019 and had been prescribed tranexamic acid and pain relief to control the symptoms.

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

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

16/10/2023

2023-0386

Claire Twinn

East London

[REDACTED], Chief Executive Officer, Barts Health NHS Foundation Trust � � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

On 16 December 2022 this Court commenced an investigation into the death of Claire Twin aged 47. The investigation concluded at the end of the inquest on 13th October 2023. The conclusion of the inquest was a short-form conclusion of a death by natural causes: � a. BronchopneumoniaVentricular Septa! Defect And Pulmonary Hypertension (Down�s Syndrome)

Claire Twinn was a 47 year old woman who was born with the chromosomal condition, Down�s syndrome. Ms Twinn had a congenital heart defect which resulted in a further condition, Eisenmenger syndrome which adversely affected her respiratory output. Ms Twinn was also assessed to be affected by a severe learning disability. � On 15th December Ms Twinn became unwell with symptoms of; a productive cough with yellow sputum, sickness and diarrhoea. Her family took Ms Twinn to the emergency department of Newham General Hospital. � An initial rapid assessment identified low oxygen saturations at 61% she was treated with oxygen. � Clinical observations were taken and the patient was monitored, blood tests could not be taken as Ms Twinn had a significant phobia of needles. Her learning disability meant that she could not be persuaded to voluntarily provide a blood sample. Similarly, any assessment of potential confusion was made more difficult due to her non-verbal status. � It was decided that a blood sample or 1/V therapy could only be administered if the patient was sedated. Ms Twinn�s complex lung and heart problems meant sedation would carry high risk and was therefore discounted. � Ms Twinn had continuous monitoring of oxygen levels, blood pressure and heart rate. A chest x-ray was undertaken that was interpreted by the emergency team as inconclusive of infection despite that, based on history, chest auscultation and a raised temperature, a working diagnosis of bilateral pneumonia was arrived at. � A senior doctor took over care of the patient. Oxygen requirement was titrated down from high flow oxygen mask to low flow nasal cannula. Achieving saturations 75% at rest without oxygen, this was patients baseline level from medical notes. � Ms Twinn was discharged late in the evening on oral antibiotics, she was found deceased the following morning when her family tried to rouse her from sleep. � The Trust now accepts that the more appropriate course would have been to admit Ms Twinn for observation, monitoring of oxygen levels and providing remedial oxygen therapy if a de-saturation occurred. � The inquest took expert evidence into account in determining that an admission into hospital would not have, on the balance of probability, resulted in Ms Twinn�s death being avoided.

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

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

13/06/2023

2023-0192

Raquel Harper

East London

[REDACTED], Chief Executive Officer, Barts Health NHS Foundation Trust, Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB

On the 26th July 2021 I commenced an investigation into the death of Raquel Mellonie Harper, aged 33 years. The investigation concluded at the end of the inquest on 2nd May 2023. The conclusion of the inquest was a narrative conclusion: � Raquel Harper died as a result of natural causes. Her death was however contributed to by an omission of hospital staff to carry out appropriate investigations and to instigate timely treatment for her pulmonary embolism.

Raquel Harper attended Whipps Cross Hospital on the 23 June 2021. She complained of a 5-day history of shortness of breath and difficulty breathing. Raquel had a low oxygen saturation, a high respiratory rate and a tachycardia. The assessing doctor used the pulmonary embolism rule out criteria (PERC), to rule out the likelihood of a pulmonary embolism causing her symptoms. The PERC test was positive, and a D Dimer should have been carried out. This was not done. A diagnosis of iron deficiency anaemia was made, based upon a low haemoglobin and low MCV level. Raquel was admitted to hospital and suffered from periods of desaturation requiring medical review and assessment. The diagnosis of iron deficiency anaemia was not re-visited and further investigations, such as arterial blood gases were not carried out. In the very early hours of 25 June 2021, Raquel became critically unwell. She required escalation of her care, but this was not provided until she was in a peri-arrest state at around 0330 on 25 June 2021. Raquel suffered a cardiac arrest at around 0400 and received resuscitation and thrombolysis. Sadly, there was no response to the emergency efforts and Raquel passed away at Whipps Cross Hospital on 25 June 2021. Had Raquel received the D Dimer test on the 23 June 2021, in accordance with the Trust�s policy, this is likely to have triggered further investigations which would have resulted in a diagnosis of pulmonary embolism and a treatment dose of lower molecular weight heparin. On the balance of probabilities this would have prevented Raquel�s death on the 25 June 2021.

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

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

20/12/2024

2024-0706

Edith Pye

Worcestershire

[REDACTED], Chief Executive Officer, Care UK Ltd, Connaught House, 850 The Crescent, Colchester, Essex, CO4 9QB.

On 1 May 2024 I commenced an investigation and opened an inquest into the death of Edith Theresa PYE. The investigation concluded at the end of the inquest on 16� December 2024.� The conclusion of the inquest was that Mrs. Pye �died as the result of an accidental fall in a care home. Her death was contributed to by neglect�.

In answer to the questions �when, where and how did Mrs. Pye come by her death?�, I recorded as follows:� �On 29.3.24 Edith Pye sustained a periprosthetic fracture to her left knee after rolling off her bed at Chandler Court Care Home, Bromsgrove, where she lived. At the time� of the fall she had briefly been left unattended while receiving personal care which� should have been provided by at least two carers, but at the time was only being� provided by one. As a result of her injury, she underwent an above knee amputation, and went on to develop a chest infection and pulmonary emboli. Despite treatment,� she continued to decline and was discharged back to the care home for end of life� care, where she died on 28.4.24.�

I have sent a copy of my report to the Chief Coroner and to the following: (a) [REDACTED], Mrs. Pye�s son; (b)� DAC Beachcroft solicitors, who represented Care UK Ltd. at the inquest hearing.� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief� Coroner.

Care Home Health related deaths

Care UK Ltd

08/11/2023

2024-0109

Lee Bowman

South Yorkshire East

[REDACTED], Chief Executive Officer, College of Policing

On 12th January 2022 I commenced an investigation into the death of Lee Bowman born on 10th January 1977. The investigation concluded at the end of the inquest which commenced on the 8th November 2023. The conclusion of the inquest was: � An open conclusion � In box three it was recorded � On 2 November 2021 Lee Bowman was reported missing to police by his family. The last sighting of him was on 31 October 2021. His body was found at 62 Green Arbour Road, between two fence panels in the garden on 3 January 2022 The medical cause of death was: 1a: Unascertained

Lee Bowman was last seen by his family on 29 October 2021 going to his girlfriend�s home address in South Yorkshire. His family did not hear from him after this and that was out of character for Lee who would ordinarily be in touch with his family hourly during the day. � Lee did not possess his own phone and therefore family had to rely on Lee contacting them rather than being able to ring him themselves. � Lee had a number of underlying health conditions including mental health conditions and history of self harm. He also had recently had a diagnosis of liver cirrhosis which was causing him concern. On top of that his father had recently been diagnosed with cancer and that had upset him. � On 31 October 2021 Lee was reported as being seen in the vicinity of his girlfriend�s home address with injuries consistent with being assaulted. This is the last unquestioned sighting of Lee before his body is found. � On 2 November 2021 Lee was reported missing to Nottinghamshire Police by his brother. His brother reports that they haven�t heard from him and that this was out of character for Lee. He also makes reference to mental health problems and that he has not taken it well that his father has been diagnosed with cancer. Nottinghamshire Police determined that this is not a true missing person enquiry at this stage as it is not clear that he is actually missing, and they asked South Yorkshire Police to make enquiries at th.e last known address that Lee was going too. � The log that Nottinghamshire police hold is updated before the addition of information �from South Yorkshire police confirming that they had attended at his girlfriends address and she said she had kicked him out two days previously. � The matter then returned to Nottinghamshire Police who closed the incident down as a deliberately absent individual. � On 4 November 2021 Lee�s father also reported Lee missing as they had still not heard from him. This commenced the missing person investigation from Nottinghamshire Police. � There were a number of sightings reported of Lee when media appeals were issued. These were both in South Yorkshire and Nottinghamshire. These were not necessarily thoroughly checked for accurateness although they were followed up by officers in Nottinghamshire. These sightings gave false assurance that Lee was well and was not contacting family for unknown reasons. � The sightings included a sighting by a police officer and this check was assessed as being particularly reliable however there was insufficient scrutiny applied to that veracity of that sighting. In any event, that sighting was in early November still leaving days unaccounted for. � There was no referral to detectives from Nottinghamshire Police and instead the investigation was transferred to South Yorkshire Police on 28 November 2021. This was closed by South Yorkshire Police as a result of an incorrectly confirmed sighting by a PCSO of Lee. � The case was reopened by South Yorkshire Police on 7 December 2021 following a call from Lee�s family confirmed that he had still not been seen. � When the case was reopened on the 7 December 2021 and then reviewed on the 9 December with the grading being low risk. This was revisited on the 10 December and despite no particular change to the circumstances it was revised to be Medium risk. � On 14 December 2021 the missing person report was regraded as high as it was apparent that the sightings were unconfirmed sightings. This resulted in detectives being asked to lead the investigation who undertook a number of enquiries including CCTV, door to door enquiries and financial and phone enquiries. � It appears that it was not until 31 December 2021 that the police in South Yorkshire became aware of the jacket which Lee was wearing in the last known sighting, being found and that narrowing the search scene to near where Lee was ultimately found. � Between Lee�s reported disappearance on 2 November 2021 right up until his body was found on 3 January 2022 there had been no activity in Lee�s bank account and no contact with his family despite his usual levels of contact with them. � [REDACTED], gave evidence that there were four possible medical explanations for Lee�s death:- Liver disease � Hyperthermia � Drug or alcohol use � Positional asphyxia � However, he also explained that there was not enough pathological evidence to be persuaded by to give a preference and for that reason he had to return unascertained and rely upon the inquest to try and ascertain the circumstances. � There was no evidence heard during the inquest that assists with the circumstances beyond Lee having been seen with injuries in the vicinity of where his body was found on 31 October 2021. � [REDACTED], �was clear that Lee had been where he was found for some time but could not be precise as to when he had died. � The following findings were made during the inquest: � � The decision making around the closure of the Log created when Lee was first reported missing on 2 November 2021 was lacking in clarity and has been largely based on presumption. The log appears to have been closed before the clarity has been received from South Yorkshire Police about whether or not Lee was at his partners address and seems to be based upon intelligence information held by the police rather than risk assessment of the current situation which Lee was in at the time that he went missing. � That said, even if the log had remained open and a missing persons case been commenced it is apparent that a key factor for Nottinghamshire police�s risk assessment when Lee was reported again on 4 November was the fact that his money had gone into his account on 3 November but that it had not been touched. This would not have been the case on the 2 November and therefore it cannot be confirmed whether that would have made a difference to the searches that were conducted for Lee on that date. � On the basis of �[REDACTED], evidence, it cannot be said whether Lee was already dead on 2 November 2021. � The checks conducted by South Yorkshire Police on 2 November 2021 lacked professional curiosity. When it was confirmed that Lee had been kicked out of the house and not seen since there was no sense that this might require any additional follow up or any further enquiries made of his then partner about whether he was ok when he left the address. Whilst this is unlikely to have made a difference to the overall outcome it was a missed opportunity to gather information and intelligence about Lee�s condition at the time he was a missing person. � There was evidence of unconscious bias influencing the decision making and judgments of officer�s risk assessing. For example, there were assumptions that Lee led a chaotic lifestyle and therefore was not missing but choosing not to be found as he was drunk somewhere. This was never triangulated with the fact that he had not touched his bank account and even within the confines of his addiction, he ordinarily maintained contact with his family which he did not do here. Police also relied upon sightings from those who lead similarly �chaotic� lives to demonstrate that Lee was well and just had not been located. Again, this was not weighed against the body of evidence from the family that he was unwell and was not in contact with them which was out of character. � Once detectives took over the inquiry on the 14 December 2021 matters picked up in PACE and enquiries were undertaken with greater clarity and order however in reality nothing had substantially changed in Lee�s position in that time. What was discovered in December 2021 was that the sightings relied upon in fact could not be relied upon and had not been adequately scrutinised. � Unfortunately, the evidence from the pathologist was such that it cannot be said when Lee died and therefore the point at which he could still have been found alive cannot be identified. The decisions in respect of the searches therefore cannot be said, even on the balance of probabilities, to have made a difference to the outcome for Lee.

l have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of Lee Bowman, Deputy Chief Constable of West Yorkshire Police as the National Police Chief Council Lead for Missing Persons, Home Office, Chief Constable of South Yorkshire and Chief Constable of Nottinghamshire Police. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Other related deaths This report is being sent to: College of Policing

19/09/2023

2023-0466

Lauren Bridges

Manchester South

[REDACTED], Chief Executive Officer, Dorset Healthcare University NHS Foundation Trust, Sentinel House, Nuffield Industrial Estate, Nuffield Road, Poole BH17 0RB

On 01.03.22 an investigation commenced into the death of Lauren Elizabeth Bridges who died on 26.02.22, aged 20 years. � The inquest concluded on 01.09.23. � The medical cause of death was 1a) Hypoxic brain injury 1b) Cardiac arrest 1c) Hanging injury � The conclusion of the jury was Lauren Elizabeth Bridges ended her life by ligature. This was misadventure with Lauren not intending to commit suicide. � Missed opportunities for moving Lauren closer to home with acute and PICU beds available during significant periods between July 2021 and February 2022 at St. Ann�s, Seaview and Haven wards, contributed to increased incidents and her death. � The prolonged stay in a PICU placement in Priory Cheadle led to iatrogenic deterioration. This was prolonged by a delayed discharge. There was inadequate communication about Lauren from Dorset Healthcare NHS Trust to relevant parties, and there was insufficient communication about Lauren from Priory Cheadle to relevant parties. � Dorset Healthcare NHS Trust did not recognise the exceptional circumstances of the effects on Lauren being in an out-of-area placement over 260 miles away from home.

Lauren lived in Bournemouth. From March 2020 Lauren had been an in-patient, detained under section 3 of the Mental Health Act 1983. In January 21 Lauren was admitted to a Rehabilitation Unit, at The Priory, Dorking, as an Out-of Area patient. This placement was commissioned by Dorset CCG (as it was then � now Dorset ICB). Dorking is just over 100 miles from Bournemouth. In about mid-June 2021 Lauren�s mental health deteriorated and it was determined on 01.07.21 that Lauren needed to be transferred to a Psychiatric Intensive Care Unit to keep her safe. On 23.07.21 Lauren was transferred to Pankhurst Ward PICU, The Priory, Cheadle. Again, Lauren was an Out-of-Area patient at a distance, now, of some 260 miles from home. This placement was commissioned by Dorset Healthcare NHS Trust. Lauren was ready for step-down from the PICU by 02.09.21. The plan being to seek an acute bed, at or closer to home, while a suitable Rehabilitation Unit was found. Lauren remained in the PICU, at The Priory, Cheadle for the next 5 months, until her death on 26.02.22 following a ligaturing incident on 24.02.22. Over that time Lauren�s mental health deteriorated, with an increasing number of incidents of self-harm. A major factor in Lauren�s deterioration was the distance from her home and family.

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

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

25/09/2024

2024-0513

Jyoti Rao

Manchester South

[REDACTED], Chief Executive Officer, Manchester University NHS Foundation Trust

On 19th June 2024, Alison Mutch, Senior Coroner for Greater Manchester (South), opened an inquest into the death of Jyoti Rao, who died on 20th February 2024 at Tameside General Hospital, Ashton- under-Lyne, aged 56 years. The investigation concluded with an inquest which I heard on 16th� September 2024.� The inquest determined that Miss Rao died as a consequence of:-� 1) a) Hypoxic-ischaemic brain injury;�� b) Sepsis on background of end-stage renal failure with failure of transplanted kidney. II Traumatic nasogastric tube insertion The conclusion of the inquest was a Narrative Conclusion, to the effect that Miss Rao died as a� consequence of complications arising from renal transplantation.

Miss Rao died on the 20th February 2024 at Tameside General Hospital, Ashton-under-Lyne as a� consequence of Hypoxic-ischaemic brain injury due to sepsis on the background of end-stage renal failure with failure of a transplanted kidney. Miss Rao�s death was contributed to by traumatic� nasogastric tube insertion.

I have sent a copy of my report to the Chief Coroner, Miss Rao�s brother and sister-in-law, and the�Trust�s legal team.�� I have also sent a copy to Tameside and Glossop Integrated Care NHS Foundation Trust, the Care� Quality Commission and NHS Greater Manchester Integrated Care who may find it useful or of� interest.�� I am also under a duty to send the Chief Coroner a copy of your response.��� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may� make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Manchester University Hospitals NHS Foundation Trust

23/12/2024

2024-0711

Nigel Sweet

Cornwall and Isles of Scilly

[REDACTED], Chief Executive Officer, National Highways

On 18 March 2024 I commenced an investigation into the death of 63 year old� Nigel William Sweet. The investigation concluded at the end of the inquest on 19 December 2024.�� The medical cause of death was found as follows: 1a Multiple Injuries� 1b Road Traffic Collision The four questions � who, when, where and how � were answered as follows: Nigel William SWEET died on 7 March 2024 on the A38 between� Trerulefoot and Tideford Cornwall from injuries sustained after he lost� control of his motorcycle due to rider error whilst attempting to complete� an overtake of another vehicle in wet conditions.� The motorcycle fell onto its side as Nigel lost control.� Nigel was separated from his motorcycle and he slid across the carriageway into the path of an oncoming vehicle which� was unable to avoid him despite emergency braking and steering input. That oncoming vehicle drove over Nigel who suffered unsurvivable injuries as a consequence.� The conclusion of the inquest was as follows: Road Traffic Collision

The reason for the collision was found to be rider error by Nigel, in wet road conditions whilst attempting an overtake in a creeper lane.� A creeper lane is an additional lane, added to a single carriageway for a short� stretch to allow for overtaking.� There are a number on this stretch of the A38 which present road users with brief opportunities to overtake slower moving� vehicles, before the road reverts to single carriageway on both sides.� Nigel had overtaken at least one vehicle and was attempting to overtake a second vehicle by using the additional lane of the creeper lane. There was steady and� oncoming traffic on the other carriageway. Nigel had insufficient space in the� creeper lane to safely complete the overtaking manoeuvre of the second vehicle.� Nigel lost control of his motorcycle whilst under braking at which time he was� likely trying to get back into the single carriageway at the end of the creeper lane. In that sense the creeper lane contributed to the collision. �� The court found that there was nothing that the driver of the oncoming vehicle could have done to avoid Nigel.

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

Road (Highways Safety) related deaths

National Highways

12/08/2024

2024-0443

David Thompson

Manchester North

[REDACTED], Chief Executive Officer, Priory Head Office, Floor 5, 80 Hammersmith Road, London W14 8UD [REDACTED], Chief Executive, NHS Greater Manchester Integrated Care Board Chief Executive Pennine Care NHS Foundation Trust

On the 25th April 2024 I commenced an investigation into the death of Mr David Thompson who died on the 3rd March 2024.� The investigation concluded on the 31st July 2024. The medical cause of death was confirmed as 1a) Hypovovalmic Shock 1b) Deep cuts to left wrist 2) Fatty liver disease (alcohol related), Affective disorder, Acute alcohol intoxication. � A narrative conclusion was recorded; �On a background of a longstanding diagnosis of Affective disorder of which emotional dysregulation was a feature, the deceased died as a result of self-inflicted stab wounds. His diagnosis together with acute alcohol intoxication suggested on the balance of probabilities that his actions were impulsive and he did not intend to end his life.�

CIRCUMSTANCES OF DEATH Mr Thompson had a longstanding diagnosis of bi-polar disorder. �Over the years he had also used alcohol and illicit drugs, albeit at the time of his death he had not used drugs for years and had been abstinent from alcohol for several years. He was under the care of Pennine Care NHS Foundation Trust for his mental health. In June 2023 David had self-harmed by cutting himself and had been admitted to Tameside hospital where he remained as an inpatient until 29th August 2023.� He also underwent Transcranial Magnetic Stimulation therapy at Royal Oldham hospital until the 23rd September 2023. At the time David had health insurance via his employment so he took the opportunity to undergo further inpatient treatment at the Priory hospital in Altrincham.� He was admitted under the care of [REDACTED] on the 23rd September 2023. He remained an inpatient until the 19th October 2023.� On his discharge Mr Thompson relapsed and was then admitted to the Priory Hospital in Dorking from the 28th October until the 8th November 2023. This was as an NHS patient and the location was due to bed availability. Throughout this time Mr Thompson remained under the care of his NHS Psychiatrist [REDACTED] who reviewed him as an outpatient in December 2023. At this time Mr Thompson was stable and a plan was to review him in March 2024. In January 2024 he was reviewed by [REDACTED].� This was the outpatient appointment which had been made following his discharge on the 19th October. It is acknowledged that Mr Thompson was stable at this appointment.� The plan following this appointment included: �to continue to get input from the local NHS Mental health services.� On the 29th February 2024 Mr Thompson was in Budapest accessing dental treatment when he was advised he may require a biopsy due to a possible abnormality on his gums.� He returned home on the 2nd March 2024.� He had intimated some level of distress at this news.� It is also likely that he relapsed and used alcohol. On his return home he did not wish relatives to stay with him. He then consumed alcohol and cut his wrists.� He had attempted to make contact with some family in the middle of the night but due to the time of day his messages were not accessed until the morning.

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

Mental Health related deaths

Priory Group | NHS Greater Manchester Integrated Care Board | Pennine Care NHS Foundation Trust

26/05/2023

2023-0173

Conrad Colson

East London

[REDACTED], Chief Executive Officer, South London & Maudsley NHS Foundation Trust (SLAM), Michael Rutter Centre, London SE5 8AZ ��������������������������������������������� [REDACTED] Acting Chief Executive Officer, North East London Foundation Trust [REDACTED] President, Royal College of Psychiatrists, London Office, 21 Prescot Street, London, E1 8BB [REDACTED] National Medical Director, NHS England � � Rt Hon Steve Barclay MP, Ministerial Correspondence and Public Enquiries Unit, Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU

On 11 March 2022 I commenced an investigation into the death of Conrad Richard James Colson, aged 34 years. The investigation concluded at the end of the inquest on the 18 May 2023. The conclusion of the inquest was a narrative conclusion: Conrad Colson took his own life whilst suffering from severe body dysmorphic disorder. At the time of his death, he was accessing aesthetic dermatology treatments; he was not receiving a therapeutic level of medication and he was not in receipt of any professional mental health support for his body dysmorphic disorder. He had been discharged from mental health services without any robust risk assessment and without the safety net of a fully considered risk management/relapse plan.

Conrad Colson suffered from severe body dysmorphic disorder (BDD). The symptoms from this condition had led to a serious suicide attempt in February 2020. In 2021, following several months on the waiting list, Conrad received highly specialised therapy from the Centre for Anxiety Disorders and Trauma (CADAT). He made significant progress in managing his BDD symptoms during this therapy, however there was a known risk of relapse. He completed the sessions with his CADAT therapist in November 2021. Before and during this therapy, he had also received support from his local mental health trust�s Peer Open Dialogue Team. As he had made such good progress with CADAT and as he had requested discharge from the Peer Open Dialogue Team, he was also discharged from this team in November 2021. There was no joint multi-disciplinary risk assessment and risk management plan on discharge from the teams. The practitioners were aware that Conrad was not taking a therapeutic dose of medication at the time of discharge, but no medical review was arranged for him. At the time of discharge from services, Conrad was also accessing treatment from an aesthetic dermatology clinic. This was not taken into account in his discharge risk assessment. Conrad had raised concerns with the skin clinic about his skin and the treatment, in December 2020; January 2021; March and April 2021. On the 27 and 28 February 2022, Conrad again raised concerns about the appearance of his skin, following treatment at the aesthetic dermatology clinic. His friends became concerned for his welfare when they could not reach him on the 2 March 2022. Emergency services attended and sadly Conrad was found deceased within his home address. The evidence at the inquest revealed that Conrad took his own life.

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

Suicide (from 2015) This report is being sent to: South London & Maudsley NHS Foundation Trust | North East London Foundation Trust | Royal College of Psychiatrists | Department of Health and Social Care | NHS England and Tatiana Aesthetic Dermatology Clinic

18/11/2024

2024-0641

Kevin Ince

Lancashire and Blackburn with Darwen

[REDACTED], Chief Executive Officer, The Priory Group

On 2 November 2023 I commenced an investigation into the death of Kevin Anthony Ince, age 55 years. The investigation concluded at the end of the inquest on15 November 2024. The conclusion of the inquest was natural causes.

Mr Ince was detained under the Mental health Act 1983 at Kemple View Hospital, Langho, Blackburn in Lancashire. On 24 October 2023 he pressed his call bell as he was unwell. It was noted that he was short of breath and panting. Oxygen was administered due to low oxygen saturation levels, whilst waiting for an ambulance. Mr Ince was taken to Royal Blackburn Hospital where his requirement for support with oxygen continued. Whilst in hospital he underwent a series of diagnostic tests whilst treatment continued over the following days. Unfortunately, his condition deteriorated, and he did not recover. He died on 25 October 2023. He died as a result of right ventricular failure caused by acute Interstitial pneumonitis as a result of vaping associated lung injury.

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

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

The Priory Group

07/11/2023

2023-0432

Michael Vincent

Bedfordshire and Luton

[REDACTED], Chief Executive of East of England Ambulance Service [REDACTED], Chief Executive Officer, Royal College of Emergency Medicine��������������������� [REDACTED], Managing Director, Association of Ambulance Chief Executives [REDACTED], National Medical Director, NHS England

On 09 January 2023 I commenced an investigation into the death of Michael John VINCENT aged 79. The investigation concluded at the end of the inquest on 25 May 2023. The conclusion of the inquest was that: � Mr Michael John Vincent died at the Luton and Dunstable Hospital on the 20th December 2022. He was 79 years old. He had fallen the morning before, at home, and had remained on the floor until admittance to the ED at approximately 05:32 on the 20th December 2022. He had made a first call to the East of England Ambulance Service at around 7:29 pm on the 19th December 2022. The call was allocated a C2 category which aims to have an urgent response within an 18 minute time frame. The EEAS was extremely busy that night with previously unseen levels of C2 allocations of ambulances. In addition, the hospitals in the area were queuing ambulances outside ED�s because they were unable to offload patients and then proceed to other calls. That combination meant that despite being allocated an urgent response time Mr Vincent was effectively left on the floor for a very prolonged time. Ultimately he had a cardiac arrest at home and an ambulance attended promptly. He was resuscitated but the �down time� was prolonged. He died as a result of a combination of an undiagnosed bronchopneumonia complicated by severe coronary artery disease and a long lie. On the balance of probabilities it is likely that had he been admitted at the time of the first call he would not have died at the time he did.

Mr Michael John Vincent died at the Luton and Dunstable Hospital on the 20th December 2022. He was 79 years old. He had fallen the morning before, at home, and had remained on the floor until admittance to the ED at approximately 05:32 on the 20th December 2022. He had made a first call to the East of England Ambulance Service at around 7:29 pm on the 19th December 2022. The call was allocated a C2 category which aims to have an urgent response within an 18 minute time frame. The EEAS was extremely busy that night with previously unseen levels of C2 allocations of ambulances. In addition, the hospitals in the area were queuing ambulances outside ED�s because they were unable to offload patients and then proceed to other calls. That combination meant that despite being allocated an urgent response time Mr Vincent was effectively left on the floor for a very prolonged time. Ultimately he had a cardiac arrest at home and an ambulance attended promptly. He was resuscitated but the �down time� was prolonged. He died as a result of a combination of an undiagnosed bronchopneumonia complicated by severe coronary artery disease and a long lie. On the balance of probabilities it is likely that had he been admitted at the time of the first call he would not have died at the time he did.

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

Emergency services related deaths (2019 onwards) This report is being sent to: East of England Ambulance Service NHS Trust | Royal College of Emergency Medicine | Association of Ambulance Chief Executives | NHS England

16/06/2023

2023-0366

Vaughan Whalley

Manchester North

[REDACTED], Chief Executive of Midlands Partnership NHS Foundation Trust

On 23 February 2023 an investigation into the death of Vaughan Lee WHALLEY (the Deceased) was commenced. The investigation concluded at the end of the inquest on 13 June 2023. I recorded a conclusion of Suicide

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 9 August 2023. I, the Area 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.

Suicide (from 2015) This report is being sent to: Midlands Partnership NHS Foundation Trust

28/08/2024

2024-0472

Moira Farnell

Milton Keynes

[REDACTED], Chief Executive of Milton Keynes City Council

On 09 May 2024 I commenced an investigation into the death of Moira FARNELL aged 79. The investigation concluded at the end of the inquest on 17 July 2024. The conclusion of the inquest was that: Accident

The deceased fell on the pavement outside her house, [REDACTED], Bletchley, Milton Keynes on the 18th April 2024. She hit her head on the pavement. She was taken to Milton Keynes University hospital and following a CT scan was diagnosed with a traumatic subdural haematoma. Her condition deteriorated and she died on 6th May 2024 at Milton Keynes University Hospital.

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

Other related deaths

Milton Keynes City Council

19/12/2023

2023-0533

Linda Banks

County Durham and Darlington

[REDACTED], Chief Executive of Tees Esk and Wear Valley Acute NHS Trust

On the 19th of April 2022 an investigation was commenced into the death of Linda Louise Banks, aged 48 years. The investigation concluded at the end of the inquest on the 18th of December 2023. The medical cause of death was 1a) Paracetamol overdose with alcohol misuse. I gave a narrative conclusion as follows:- � Linda Louise Banks died on the 10th of April 2022 at the University Hospital of North Durham. Linda had a history of alcohol misuse and mental health difficulties, including self harm and suicidal ideation. Linda also had learning difficulties which may have increased her vulnerability, which were not identified by vast majority of the mental health professionals, and there is no evidence that consideration was given to any reasonable adjustments that might be necessary, or as to any impact such may have had on her presentation, communication and understanding. � Linda herself, her family and her friends, made multiple contacts with mental health services between February 2022 and her death, as her mental health deteriorated and concerns were expressed as to her safety. Referrals were also made by two external agencies, namely her GP and a home support agency, both expressing concerns about Linda�s presentation. On each occasion risks were considered to be minimal and no further treatment or care was provided by mental health services. � There were a multiplicity of difficulties revealed by a serious incident review which was extensively delayed and not received until the end of January 2023, some 9 months after Linda�s death. It concludes that Linda did not receive the right care at the right time and her needs were not fully met, and included concerns, in summary, in relation to the quality of assessments and triage, quality of safety planning, poor record keeping, and further considers that there was an underestimation of risk and a lack of a trauma informed approach. I also find that these difficulties culminated in advice being given to a friend attempting to support Linda and communicated to her family, from an unknown mental health worker, that they should consider �tough love� and to effectively step back from their intensive support of Linda, thus removing an essential safety net in the absence of any ongoing mental health treatment or support. The identified failings cumulatively contributed to the death more than minimally. � An earlier thematic review which had been completed in November 2021 identified many similar serious issues in the provision of mental health services, to those identified in this case, and it is clear that many of these issues were continuing at the time of Linda�s death in April of 2022 and had not been addressed effectively by the Trust. � On the 9th April 2022 Police forced entry to Linda�s home, as a result of concerns raised by her family and friends and was taken to hospital by ambulance. She was hyperthermic and had low blood sugar and had taken an overdose of medication. Despite attempts to treat her she died in hospital on the 10th April 2022 as a result of the acute complications of paracetamol overdose on a background of alcohol related liver disease

Linda Louise Banks died on the 10th of April 2022 at the University Hospital of North Durham as a result of an overdose of paracetamol against a background of alcohol misuse and subsequent to a deterioration in her mental health.

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

Alcohol, drugs medication related deaths This report is being sent to: Tees Esk and Wear Valley Acute NHS Trust

31/03/2023

2023-0113

Benjamin Hart

Central and South East Kent

[REDACTED], Chief Executive of the NHS Kent and Medway Integrated Care Board Kent & Medway NHS & Social Care Partnership Trust

On 17th October 2022 an investigation was commenced into the death of Benjamin James HART. The investigation concluded at the end of the inquest 28th March 2023. The conclusion of the inquest was a short form conclusion of Suicide 1a�Suspension by the neck

Benjamin Hart, 25 had a medical diagnosis of post-traumatic stress disorder, enduring personality change after a catastrophic experience, emotionally unstable personality disorder borderline type and generalised anxiety disorder. He likely had Asperger�s syndrome. At the time of his death was under the care of the community mental health team following a suicide attempt by hanging in December 2021 following which he was formally sectioned. After his release he was allocated a care coordinator who between May 2022 and his death in October 2022 saw him on only three occasions (his care plan envisaging weekly involvement). The Trust was aware that the relationship between Ben and his care coordinator had broken down but a new care coordinator was not appointed and Ben had no contact from the community mental health team for 5 weeks before his death on 12th October 2023 when he hanged himself at his mother�s home address. He had telephoned the Crisis team three times in the two days before his death, calls which included complaints of having been abandoned by the mental health team, expressions of hopelessness about his future and indications that he felt suicidal. He was informed that the community mental health team would contact him. Although the community mental health team and the care coordinator were notified of Ben�s calls the day before his death, no one attempted contact until after this death had occurred. Kent & Medway NHS partnership Trust accepted at the inquest that the care provided to Ben fell below the standard he could have expected to receive and there were missed opportunities to treat him.

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

Suicide (from 2015) This report is being sent to: NHS Kent and Medway Integrated Care Board | Kent & Medway NHS & Social Care Partnership Trust

2/8/2024

2024-0430

Peter Gregory

Worcestershire

[REDACTED], Chief Executive, Civil Aviation Authority, Aviation House, Beehive Ring Road, Crawley, West Sussex, RH6 0YR.

On 30 June 2023 I commenced an investigation and opened an inquest into the death of Peter GREGORY. The investigation concluded at the end of the inquest on 1 August 2024 � The conclusion of the inquest was that Mr. Gregory �died as the result of an accident�.

In answer to the questions �when, where and how did Mr. Gregory come by his death?�, I recorded as follows: � �On the morning of 25.6.23 a hot air balloon being flown by Peter Gregory, an experienced balloon pilot, suffered a sudden parachute stall in the course of a rapid ascent during a competition race. The parachute stall caused the envelope of Mr. Gregory�s balloon to collapse, and the balloon to descend rapidly to the ground in a field at Ombersley Court, Ombersley. Mr. Gregory suffered fatal injuries in the resulting impact, and was confirmed deceased at the scene a short time later that day.�

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

Other related deaths�| Product related deaths � This report is being sent to: Civil Aviation Authority

03/06/2024

2024-0296

Tcherno Bari

Birmingham and Solihull

[REDACTED], Chief Executive, Birmingham and Solihull Mental Health NHS Foundation Trust (�BSMHFT) [REDACTED], Chief Constable, West Midlands Police (�WMP�) Parties to the National Partnership Agreement: Right Care, Right Person: � Department for Health Home Office College of Policing:�[REDACTED], Chief Executive Officer NHS England: [REDACTED], Chair National Police Chiefs� Council: [REDACTED], Chief Constable Association of Police and Crime Commissioners: [REDACTED], Chief Executive

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

INVESTIGATION and INQUEST � On 05/10/23 I commenced an investigation into the death of Tcherno Bari. The investigation concluded at the end of the inquest on 21/05/24.

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 July 2024. I, the coroner, may extend the period. � Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

Suicide (from 2015) This report is being sent to: Birmingham and Solihull Mental Health Foundation Trust | West Midlands Police | Department of Health and Social Care | Home Office | College of Policing | NHS England | National Police Chiefs� Council | Association of Police and Crime Commissioners

07/03/2024

2024-0128

Adrian James

Inner West London

[REDACTED], Chief Executive, Central and North West London NHS Foundation Trust- via email � [REDACTED], Chief Executive, NHS England- via email

Between 5th and 6th March 2024, evidence was heard before the Coroner touching the death of Mr Adrian Michael James. He had died on the 21st June 2021, aged 39 years at St Mary�s Hospital, Praed Street, London, following dropping from height. � Medical Cause of Death � 1 a Head Injury � b Fall from height � � How, when, where and the deceased came by his death: � On 25th June 2021 at approximately 15:30, Adrian dropped from the 4th floor of the block of flats in which he lived. He sustained a serious head injury which rendered him immediately unconscious and caused his death, despite extensive resuscitation at St Mary�s Hospital at 16:39 hours. � Adrian suffered with Antisocial and Emotionally Unstable Personality Disorders, complicated by depression and substance misuse. He had attempted to take his own life on multiple occasions. He had been more settled in recent years, but his suicidal risk remained high. � In the last months of his life, he was under the care of community mental health services, primary care network (PCN) and was being treated with structured psychological support. From April 2021, building works at his residence exacerbated his paranoia and from 8th June 2021 this manifested as repeated crisis contact with emergency and psychiatric services- more than 25 occasions up to his death from 8th June 2021. � Twice during this time, he was detained on section 136 and then discharged following Mental Health Act Assessment to his usual community care. � His care was reviewed daily from 9th June 2021 in PCN meetings, and he was supported by crisis contact, including a home visit when he failed to respond to welfare check calls. � On 25th June 2021 he was engaging in a structured psychological support session with a psychiatrist, when police attended to check on him following concerns raised about suicidality from a member of the public. � Shortly after police left, he was heard to be screaming and then seen to be hanging off the balcony on the 4th floor of his block of flats. He was seen to let go and fall to his death. � At all assessments in the last weeks of his life he had presented with paranoid ideation and with a background risk of suicide, but no increased intent to take his own life. � It is likely that his death was due to an impulsive act on his part whilst suffering distress due to paranoia as part of his illness. � Conclusion of the Coroner as to the death: He took his own life whilst suffering severe and enduring mental illness

Extensive evidence was taken during the inquest from multiple live witnesses, written statements, and exhibited reports. Of relevance to this report in addition to the findings above, which I do not repeat: � Adrian�s death as an impulsive act, was not easily predicable and preventable and the emotional variability with which he presented made it difficult for him to be assessed, as he could switch quickly from an agitated state to one in which he was relatively calm. At all times he retained capacity. � At no point was he sectionable under the Mental Health Act in the last 2 weeks of his life, although he had been detained by Police twice under section 136. � He accepted treatment through community health services and used crisis interventions for support which are likely to have been roughly equivalent to services that he would have received had he been supported by the Home Treatment Team or equivalent during the material time, as this would likely have been by phone call as this was during Covid lockdown. � However, despite the sheer number of contacts no pro-active treatment past his usual care and response to crisis calls was offered. Note that in the last 14 days of his life he had received 2 Mental Health Act Assessments after s136 detention, been seen by Liaison Psychiatry at Chelsea and Westminster Hospital and made countless calls for support. Despite him continually denying an active suicidal intent, I remain concerned that whilst albeit there were multiple reviews at MDTs insufficient consideration was given to his risk of impulsive suicide and the possibility of mitigating this risk by a pro- active rather than reactive care package. The evidence of distress caused by paranoia was there. It may be that a more structured support plan would have helped to contain his distress between his fortnightly sessions of structured psychological therapy. Despite the obvious deterioration in his paranoia there was no evidence heard that medication was actively considered to help alleviate, this except in hindsight. � Home Treatment Team Care (First Response Team) had been considered on 15th June 2021 as part of his assessment by the AMHP, but there is no evidence in his notes from CNWL, that this was considered after this time, despite further crisis contact. � Adrian was undoubtedly a complex patient to treat, but when he deteriorated, his treatment sessions were left with the specialist doctor in training and he did not receive assessment by the psychiatric consultant in the community, who in fact never met him, either before he started the structured psychological treatment or when he deteriorated. � When the police interrupted his last treatment session, the psychiatrist did not try and call Adrian back to ask how he was and to re- assess his risk, despite the number of crisis contacts, his paranoia with associated distress, his known high background risk of suicide, his risk of impulsivity, emotional instability, and his very recent s136 detentions etc. The doctor discussed what had happened with the team and it was decided to wait and see if police contacted psychiatric services rather than re contact the patient, taking reassurance from police presence, despite police officers wishing to talk to doctor and requesting telephone contact numbers but being unable to secure these before the signal on the call between police and psychiatrist failed. Adrian�s phone number was available to the doctor and the PCN team. Police officers are not mental health clinicians. � The court found that the lack of re contact with Adrian by the psychiatrist after the treatment session was interrupted, was a failure in care. � Police did try and call SPA but hung up after being told that they were 4th in the queue as they expected a wait of hours before being answered at that time. � Police did arrange a follow up visit for Adrian by the police night shift. Adrian had declined LAS attendance and refused a lift from the officers to St Thomas�s Hospital. � However, Adrian had come from the balcony about an hour after the police left. � Police systems have now changed, and Adrian would now be checked by health care rather than police. SPA answer times have also improved. � It was not until the final witness, who was from the PCN, did the level of consideration and care being given by the PCN become apparent. Both the treating consultant and the PCN Service Lead noted the lack of formal regular input from the treating consultant�s team to the PCN MDT. � Whilst it could not be said that the matters outlined above contributed to the death on the facts of this case, concerns remain. � This report has also been sent to NHS England, so that the lessons learned from this death may be applied to mental health care services.

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

Mental Health related deaths | Suicide (from 2015) This report is being sent to: Central and North West London NHS Foundation Trust | NHS England

25/09/2023

2023-0464

Robert Leigh

Manchester West

[REDACTED], Chief Executive, Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, M25 3BL.

INVESTIGATION AND INQUEST � On the 17th of February 2023 I commenced an Investigation into the death of Robert Leigh, 75 years, born 15th of July 1947. � The Investigation concluded at the end of the Inquest on the 26th of July 2023. � The Medical Cause of Death was: la Hanging The Conclusion of the Investigation was Suicide.

1. Robert Leigh (hereinafter referred to as the �Deceased� [REDACTED]�dead at his home address [REDACTED] on the 7th of February 2022, having suspended himself by a ligature attached to a loft beam in the roof space at the premises. � 2. The Deceased was first referred to the Mental Health Services in in October 2020 with a further referral on the 5th of January 2022, following a deliberate self-harm attempt. He was detained under Section 2 of the Mental Health Act 1983 on the 7th of January 2022, and he was discharged on the 16th of June 2022. He had been treated for depressed mood. 3. Following his discharge, the Deceased was visited regularly by his Community Psychiatric Nurse (hereinafter referred to as the �YL�1, and he was able to build a therapeutic relationship with YL, who had been appointed his Care Coordinator. The Deceased and his Partner were able to share their concerns with YL and be supported by the Community Mental Health Team. � 4. On the 25th of October 2022 the Deceased was visited by YL, who found the Deceased to be calm and pleasant in mood. The Deceased reported that he was settled in mood and denied any suicidal thoughts or plans. YL arranged to see the Deceased again on the 15th of November 2022. � 5. At the time YL was visiting the Deceased every 2 weeks but YL was absent from work between the 10th of November 2022 and the 6th of February 2023 and YL had no contact with the Deceased after the 25th of October 2022. � 6. The Deceased lacked a Care Coordinator from the 10th of November 2022 and had no contact with a Care Coordinator after the 25th of October 2022 until a new Care Coordinator was appointed in January 2023 leading to a visit on the 4th of January 2023. � 7. During the period from the 25th of October 2022 to the 4th of January 2023 the Deceased had no visits from a care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed. � 8. Following the absence of YL, a Care Coordinator was not appointed for 2 months and there was no appointment of a Community Psychiatric Nurse to cover the planned 2 weekly visits to the Deceased, which the Deceased and his Partner had found beneficial to his settled mood. � 9. Following the 4th of January 2023, the Deceased only had one further visit from a Community Psychiatric Nurse/Care Coordinator prior to his death and there had been no continuity of care after the 25th of October 2022. � 10. The Deceased was found dead at his home address [REDACTED] on the 7th of February 2022, having suspended himself by a ligature [REDACTED]. His death was verified by Paramedic from the North West Ambulance Service a short time after he was found.

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

Suicide (from 2015) This report is being sent to: Greater Manchester mental Health NHS Foundation Trust

30/06/2023

2023-0224

Sam Taylor

Herefordshire

[REDACTED], Chief Executive, Herefordshire Council

On 9 November 2022 I commenced an investigation into the death of Sam Malcolm TAYLOR. The investigation concluded at the end of the inquest on 21June 2022. The conclusion of the inquest was narrative.

The deceased SAM MALCOLM TAYLOR suffered mental health issues and had on previous occasions attempted suicide. Paperwork found on the deceased suggested the deceased had recently been admitted into hospital due to a suicide attempt which had left him in a coma for 3 days. Updates on the note stated the deceased would feel suicidal if he returned to the tent he seemed to be staying in. The deceased was found in his tent alone next to the RIVER WYE located by members of the public.

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

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

25/10/2024

2024-0579

Mark Eccles

Herefordshire

[REDACTED], Chief Executive, Herefordshire Council

On 7th July 2022 I commenced an investigation into the death of Mark Francis ECCLES. The investigation concluded at the end of the inquest on 18th October 2024. The conclusion of the inquest was Road Traffic Collision.

The deceased was an advanced motorcyclist.� Whilst on the B4361, Mr Eccles has been approaching the junction with the 92620 on his near side.� A vehicle has been at this junction looking to go straight ahead, and as a result has then pulled out in front of the motorcycle of Mr Eccles.� His death was confirmed at 18:06 on the 30th June 2022.

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

Road (Highways Safety) related deaths

Herefordshire Council

14/10/2024

2024-0548

Caroline Staite

Herefordshire

[REDACTED], Chief Executive, Herefordshire and Worcestershire Health and Care NHS Trust.

On 18 March 2024 I commenced an investigation into the death of Caroline Ann STAITE. The investigation concluded at the end of the inquest on 30 September 2024. The conclusion of the inquest was Suicide.

A member of public on his way home from work, called at 2339 hrs on 8/3/24 stating he was on the Old Bridge Hereford. �They described a body with a backpack, dark clothes, and white trainers in the river and stated the river was flowing fast, that the body had now moved into darkness but was heading towards Victoria foot bridge. Officers were deployed to speak with the informant and additional officers were dispatched to numerous locations along the River Wye.� A female body was recovered near the Canary Bridge, Hereford and Paramedic [REDACTED] pronounced the female deceased at 0241 hours on 9/3/24. The deceased was fully clothed. �The deceased had no obvious injuries.� A [REDACTED] contacted the Police saying his sister had not been seen for 24 hours.� Her name was Caroline Anne STAITE born 2/6/72. The description matched that of the deceased and subsequent formal identification provided confirmation.

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

Suicide (from 2015)�| Mental Health related deaths

Herefordshire and Worcestershire Health and Care NHS Trust

11/10/2024

2024-0541

Oliver Davies

Worcestershire

[REDACTED], Chief Executive, Midlands Partnership NHS Foundation Trust, St. George�s Hospital, Corporation Street, Stafford ST16 3SR.

On 16 January 2023 I commenced an investigation and opened an inquest into the death of Oliver Peter DAVIES. The investigation concluded at the end of the inquest on 11 October 2024 The conclusion of the inquest was as follows: Oliver Davies died as a result of suicide. [ Questionnaire ]: 1.�� (a) During Oliver�s time at HMP Hewell, were sufficient steps taken to ensure a proper and timely review by a GP of Oliver�s mental health needs, and whether mental health medication should be re-prescribed to him? NO (b) If your answer to 1(a) above is YES or CANNOT SAY, go to Question 2; (c) If your answer to 1(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES (d) If your answer to 1(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY (e) If your answer to 1(d) above is NO or CANNOT SAY, please include the following words at the end of Section 3 of the Record of Inquest: �It is admitted that the fact that Oliver was not seen by a GP in the prison before his death represents a failing in the healthcare system provided there. It cannot be concluded that this failing possibly caused or contributed to Oliver�s death on 31 December 2022. 2.� (a) Was information relevant to Oliver�s recent and current mental state shared sufficiently between prison staff, healthcare staff and mental healthcare staff at HMP Hewell, such that Oliver�s ongoing risk of self-harm of suicide could be properly assessed? ���� NO (b) If your answer to 2(a) above is YES or CANNOT SAY, go to Question 3; (c) If your answer to 2(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES (d) If your answer to 2(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY 3. (a) Did the mental health assessment on 6.12.22 consider sufficiently all information relevant to Oliver�s ongoing risk of self-harm or suicide? YES (b) If your answer to 3(a) above is YES or CANNOT SAY, go to Question 4; (c) If your answer to 3(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY (d) If your answer to 3(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY 4. (a) Did the ACCT case review of 30.12.22 consider sufficiently all information relevant to Oliver�s ongoing risk of self-harm or suicide? NO (b) If your answer to 4(a) above is YES or CANNOT SAY, go to Question 5; (c) If your answer to 4(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? NO (d) If your answer to 4(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES 5. (a) Was Oliver kept sufficiently informed of progress regarding his applications for a doctor to review his mental health needs and to consider whether mental health medication should be re-prescribed to him? NO (b) If your answer to 5(a) above is YES or CANNOT SAY, go to Question 6; (c) If your answer to 5(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES (d) If your answer to 5(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY 6. (a) Was Oliver kept sufficiently informed of his allocation to, and forthcoming appointments with, a mental health care-coordinator? NO (b) If your answer to 6(a) above is YES or CANNOT SAY, go to Question 7; (c) If your answer to 6(a) above is NO, did that failure probably cause or contribute to Oliver�s death on 31 December 2022? YES (d) If your answer to 6(c) above is NO or CANNOT SAY, did that failure possibly cause or contribute to Oliver�s death on 31 December 2022? YES/NO/CANNOT SAY 7. Was Oliver�s death contributed to by neglect? YES

In answer to the questions �when, where and how did Oliver come by his death?�, the jury recorded as follows: �Oliver Davies committed suicide in his cell at HMP Hewell by hanging. He died on the 31.12.22.�

I have sent a copy of my report to the Chief Coroner and to the following Interested Parties at the inquest: (a) [REDACTED], Oliver�s mother; (b) HM Prison and Probation Service; (c) Practice Plus Group; (d) West Mercia Police; (e) GEOAmey. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Mental Health related deaths | State Custody related deaths | Suicide (from 2015)

Midlands Partnership NHS Foundation Trust

13/08/2024

2024-0450

Jeffrey Marshall

Surrey

[REDACTED], Chief Executive, NHS England [REDACTED], Chief Executive, National Institute for Health and Care Excellence

The inquest into the death of Jeffrey MARSHALL was opened on 4th January 2024.� Evidence was heard and the inquest was concluded on 13th June 2024.�� Mr Marshall died at St Peter�s Hospital in Chertsey on 13th December 2023, aged 72 years.� � I found the medical cause of death to be: ���� 1a. Ischaemic Stroke� ���� 1b. Thrombosis of Basilar Artery� ���� 1c. Atherosclerosis of Basilar Artery� ���� 2.�� Previous Subdural Haematoma; Hypertension; Diabetes Mellitus;� ���������� Atrial Fibrillation; Cessation of Anticoagulation Therapy� �� I found that whilst the cause of death was natural, it was contributed to by the withholding of anticoagulation therapy over the previous 47 days prior to death. Mr Marshall had sustained a subdural haematoma in a fall on 21st October 2023, following which his anticoagulation therapy was withheld pending further CT scan to check that this had resolved before recommencing anticoagulation.�� Whilst a further CT scan took place on 8th November 2023, this was not reported until 3rd December 2023, and Mr Marshall�s GP was informed by the� Hospital� that� his� anticoagulation� should� be� recommenced� on� 6th December� 2023.� Mr� Marshall� suffered� an� ischaemic� stroke� on� 7th December 2023 as a result of thrombosis of the basilar artery, of which he was at increased risk due to the withholding of anticoagulation therapy. He deteriorated until his death.�� I heard evidence from a Stroke Consultant at Ashford and St Peter�s Hospitals� NHS� Foundation� Trust� that� the� half-life� of� Direct� Oral anticoagulants is short and therefore the benefit of its risk reduction for thrombus is lost within a short period of time, placing the patient at high risk of stroke. She detailed that whilst it is standard protocol to withhold anticoagulation following a head injury, there is no national guidance (e.g. from the National Institute for Health and Care Excellence) to assist in determining when anticoagulation should be recommenced. There is also�� no�� guidance�� for�� clinicians�� to�� discuss�� the�� withholding�� of anticoagulation� and� the� risks/benefits� of� this� with� patients,� to� enable them� to� make�� an� informed� decision�� as� to� when� to� recommence anticoagulation in this scenario.�� I recorded a narrative conclusion of Natural Causes contributed to by withholding�� of�� anticoagulation�� over�� 47�� days�� following�� subdural haematoma.

Mr Marshall died from an ischaemic stroke at St Peter�s Hospital in Chertsey on 13th December 2023.�� He had suffered a fall whilst exiting a car on 21st October 2023, in which he sustained� an� acute� subdural� haematoma.� His� anticoagulation� therapy� of Edoxaban,� prescribed� for� atrial� fibrillation� and� permanent� pacemaker,� was withheld in accordance with NICE guidance.�� Neurosurgeons at St George�s Hospital in Tooting gave advice and reiterated the need to withhold anticoagulation and to monitor the bleed via further CT scan the following day, and again two weeks thereafter.�� The last scan on 8th November 2023 revealed that the haematoma had resolved, but this was requested on a routine basis with a reporting time of 28 days. It was therefore reported on Sunday 3rd December, and Mr Marshall�s GP was advised that anticoagulation could be restarted on 6th December 2023.� �� Mr Marshall suffered a sudden loss of consciousness at home on the evening of 7th December 2023 and was admitted to St Peter�s Hospital, where he was found to have suffered a Basilar Artery Thrombosis and Basilar Territory Infarction. His anticoagulation had been withheld for 47 days on a background of atrial fibrillation�� and�� permanent�� pacemaker,�� increasing�� his�� risk�� of�� thrombus development.�� Mr Marshall�s stroke was not survivable and he died on 13th December 2023.

COPIES� I have sent a copy of this report to the following: 1.� See names in paragraph 1 above� 2. [REDACTED] 3. Ashford & St Peter�s Hospitals NHS Foundation Trust 4. The Chief Coroner� � In addition to this report, I am under a duty to send the Chief Coroner a� copy of your response.�� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who, he�� believes,�� may�� find�� it�� useful�� or�� of�� interest.�� You�� may�� make representations to me at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

NHS England | National Institute for Health and Care Excellence

13/03/2024

2024-0139

Terence Sullivan

Worcestershire

[REDACTED], Chief Executive, National Institute for Health and Care Excellence; [REDACTED], Chief Executive Officer, British Society of Gastroenterology [REDACTED], National Medical Director, NHS England;

On 16 August 2023 I commenced an investigation and opened an inquest into the death of Terence William SULLIVAN. The investigation concluded at the end of the inquest on 28 February 2024. � The conclusion of the inquest was that Mr. Sullivan �Died as the result of complications of necessary surgery, to which the temporary cessation of anticoagulation medication contributed.�

In answer to the questions �when, where and how did Mr. Sullivan come by his death?�, I recorded as follows: � �On 8.8.23 Terence Sullivan underwent a surgical procedure at Worcestershire Royal Hospital to remove a polyp from his sigmoid colon. Mr. Sullivan had been on anticoagulant medication following a previous diagnosis of atrial fibrillation and the insertion of coronary artery stents, and this medication was temporarily suspended so that the procedure on 8.8.23 could go ahead. Following the procedure, Mr. Sullivan suffered an acute myocardial infarction caused by a blockage in a coronary artery stent. Despite treatment, he continued to decline and died in hospital on 10.8.23.�

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: National Institute for Health and Care Excellence | British Society of Gastroenterology | NHS England

17/05/2024

2024-0269

Jada Monoja

Inner North London

[REDACTED], Chief Executive, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ Hon Victoria Atkins MP, Secretary of State for Health and Social Care, The Department for Health and Social Care, 39 Victoria Street, London SW1H 0EU NHS England

On 27/11/2020 an investigation commenced into the death of Jada Monoja, a 33 year old man who died from a self-inflicted knife wound. His inquest was concluded on 23 April 2024. The conclusion of the inquest was that Mr Monoja died by suicide, likely while experiencing delusional and paranoid thoughts.

Mr Monoja had a history of chronic paranoid and delusional thinking. On 15 November 2020 his mother contacted 111 after he disclosed suicidal thinking to her. This was rapidly escalated to mental health services and that evening a member of the Crisis Assessment Team (CAT) assessed Mr Monoja. He denied remaining suicidal, agreed to treatment and was assessed to have capacity. He was referred to the Home Treatment Team (HTT). On 16 November 2020 Mr Monoja was assessed and accepted by the HTT and a care plan agreed. In the early hours of 17 November 2020, his mother woke and found Mr Monoja had left their home. She found him nearby on Cleaver Square, unresponsive. Emergency Services attended but he could not be resuscitated. At home he had left notes of farewell.

I have sent a copy of my report to the Chief Coroner and to the family, as the other Interested Person in this inquest. I have also sent it to Oxleas who may find it useful or of interest, as the other major provider of mental health services in this jurisdictional area. � [REDACTED] for Family(Next of Kin) [REDACTED] Chief Executive, Oxleas NHS Trust Chief Coroner @ Regulation28reports@judiciary.uk � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response.

Suicide (from 2015) This report is being sent to: South London and Maudsley NHS | NHS England | Department of Health and Social Care

15/05/2023

2023-0155

Drew Howe

Manchester South

[REDACTED] Chief Executive, Pennine Care NHS Foundation Trust

On 3rd February 2023, an inquest was opened into the death of Drew Howe who was found dead on 19th October 2022 in a Heavy Goods Vehicle parked on the A18 in Lincolnshire, aged 25 years. The investigation concluded with an inquest which I heard on 25th April 2023. A post mortem examination confirmed that Mr Howe died as a consequence of: 1)a) Suspension by a Ligature around the Neck. The conclusion of the inquest was one of Suicide.

Mr Howe was found dead on 19th October 2022 on the A18 in Lincolnshire having suspended himself by the neck with a ligature in the back of his lorry. Mr Howe had experienced a dramatic deterioration in his mental health and had sought specialist help on numerous occasions. At the time of his death, Mr Howe was awaiting a further assessment by the Military Veterans Service having been discharged by the Access Team without any diagnosis or treatment plan being in place.

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

Suicide (from 2015) | Mental Health related deaths This report is being sent to: Pennine Care NHS Foundation Trust

02/04/2024

2024-0178

Anne Hawkes

South Yorkshire East

[REDACTED] Chief Executive, Rotherham NHS Foundation Trust

On 3 August 2023 I commenced an investigation into the death of Anne HAWKES. The investigation concluded at the end of the inquest . The conclusion of the inquest was � Narrative conclusion. � Mrs Hawkes died in Rotherham District General Hospital on the 15th July 2023 as a consequences of multi organ dysfunction due to an infected hip joint. The infection occurred due to surgical wound breakdown because of pressure caused by fluid overload as a result of poorly managed cardiac failure.

Mrs Hawkes was admitted to Rotherham Hospital on the 3rd of May 2023 following a fall at home. She had sustained a fracture neck of femur and underwent surgical fixation the following day. Mrs Hawkes initially recovered well and was medically fit for discharge by the 11th of May 2023. Mrs Hawkes remained on the orthopaedic ward whilst awaiting social care input prior to discharge. Whilst on the orthopaedic ward, her cardiac failure was not monitored by way of fluid balance charts or daily weights. Her weight on admission had been estimated at 72 kilogrammes, by the 22nd May 2023, her weight had increased to 104.5 kilogrammes. � This increase in weight was not acted upon until the 17th of May 2023 when a referral to cardiology was made, by this time she was very unwell with fluid retention, hyponatremia and deteriorating renal function. Mrs Hawkes was seen by specialist Cardiac failure nurses on the the 22nd May and immediately commenced on intravenous medication to deal with this fluid excess. Mrs Hawkes was transferred to the cardiology ward on the 25th of May 2023. � Whilst on the cardiology ward her weight gradually reduced to 83 kilogrammes. On the 26th June 2023, she was considered stable in relation to her cardiac failure. On the 3rd of June 2023 the surgical wound started to break down. All witnesses at the inquest agreed that the wound breakdown was most likely due to this fluid overload putting pressure on the wound causing it to breakdown. There was no evidence of infection in or around the wound out this time. � Despite the wound starting to break down on the 3rd of June, the referral to tissue viability was not made until the 29th of June 2023. By this time, tissue viability were unable to assist due to the advanced state of dehiscence and they made a referral to the orthopaedic surgeons. A surgical washout was declined by Mrs Hawkes, therefore the wound was managed with dressings and antibiotics. She deteriorated and died on the 15th of July 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me1�� the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

25/03/2024

2024-0163

Jacqueline Cobain

London Inner (South)

[REDACTED] Chief Executive, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ

On the 16 September 2021 an investigation into the death of Jacqueline Anne Cobain commenced, aged 60 years. The investigation concluded at the end of the ?nal day of the inquest on 15 March 2024. The conclusion of the inquest was a short form conclusion of suicide.

Jacqueline Anne Cobain had a past medical history of anxiety and depression, as well as alcohol dependence. She was consulting with her P in relation to these issues and was taking antidepressants. She had also contacted mental health services, although she had cancelled the scheduled appointment and the rescheduled appointment was not until 16 September 2021, however she had submitted her responses to a questionnaire shortly after cancelling her appointment which had included some concerning responses. This questionnaire was not reviewed upon receipt. She had taken an overdose some years before at a time of great stress in her working life and her family believed this was not an attempt to take her life, but rather a consequence of stress, desperation of her work situation and insomnia. During the afternoon of 11 September 2021, she deliberately jumped in front of moving train at Vauxhall London Underground station, London. Her family indicated that she seemed stable, and they were less concerned about her than they had been for some time. She su?ered multiple injuries and died at the scene.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of Mrs Cobain, I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may ?nd 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 ?nd it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Railway related deaths | Suicide (from 2015) This report is being sent to: South London and Maudsley NHS Foundation Trust

26/04/2023

2023-0139

Elsie Leaver

Inner West London

[REDACTED] Chief Executive, St George�s University Hospital NHS Foundation Trust, St George�s Hospital, Blackshaw Road, London. SW17 OQT � The Roehampton Surgery, 191 Roehampton Lane, London, SW15 4HN. � [REDACTED] Chief Executive, NHS South West London Integrated Care Board, First Floor 73-75 Upper Richmond Road, London. SW15 2SR

On the 24th, 25th and 26th�April 2023 evidence was heard touching the death of Mrs Elsie Leaver. She had died on 23rd August 2020, aged 89 years. � Medical Cause of Death � 1 (a) Multiple organ failure (b) Mixed drug overdose � 11 Depressive illness, chronic obstructive pulmonary disease, Ischaemic heart disease, Hypertension, Frailty. How, when, where the deceased came by her death: Mrs Leaver was admitted to St George�s Hospital, (SGH) on 15th August 2020 suffering with phenytoin toxicity. She had an extensive psychiatric history recently complicated by overdose and suicidality. This was not recognised by the clinical team despite evidence available in the electronic records, concerns raised by the family and intermittent agitation. She was deemed to have reduced mental capacity between 16th August 2020 and her discharge for rehabilitation to Queen Mary�s Hospital (QMH) on 18th August 2020, but her bag was not searched. [REDACTED] On transfer to QMH, she was found to have capacity and again refused a bag search. Overnight on 19th August 2020, she expressed suicidality to her family who notified nursing staff at QMH. On 20th August 2020, this suicidality was explored by the SHO who found her not to be actively suicidal and sought no advice from the psychiatric liaison service. On 22nd August 2020, whilst collateral psychiatric history was being sought after she threatened self-discharge, at approximately 15:00 she took an overdose [REDACTED] Mrs Leaver was readmitted to SGH and died there on ITU at 16:37 23rd August 2020 as a result of the overdose. The failures in care and communication together constitute a �total picture� that amounts to neglect. Conclusion of the Coroner as to the death: Mrs Leaver took her own life whilst suffering from depressive illness. Her death was contributed to by neglect.

CIRCUMSTANCE OF DEATH Extensive evidence was taken and accepted by the court. In summary, of relevance to this report: � On 14th August 2020 Mrs Leaver attended SGH with 3 odd episodes though to be due to a TIA and discharged on aspirin. � She re-attended with a history of a fit with a past history of epilepsy on phenytoin on 15th August 2020 and was admitted to SGH under the medical team. The neurologist thought it likely that her phenytoin would be low and when it was found to be in the toxic range ascribed the fit to phenytoin toxicity and she was admitted for monitoring, stopping phenytoin, and restarting once levels back to normal. � No active consideration was given as to the possible cause of this toxicity, which could have been due to overdose, given her psychiatric history as outlined below. � Despite being under active psychiatric care from the CMHT for older persons, being on psychiatric medication, taking a call from the CMHT whilst an inpatient at SGH, having taken an overdose in November 2019, having multiple hospital attendances, including 17th July 2020 with suicidal ideation to Kingston, suffering agitation, concerns being raised about her mental health by her family, a safeguarding concern being raised against her partner/friend, and intermittent agitation requiring diazepam, 1:1 nursing, the attendance of her son and hospital security and presenting with drug toxicity, psychiatric illness was never considered. She was seen by multiple clinicians at SGH, none of whom undertook any psychiatric history, or made any proper inquiry with her relatives, nor of her electronic notes. � This deprived her of a holistic assessment. There was no referral to psychiatric liaison services, nor advice sought from them at either site. � Mrs Leaver therefore did not have a self-harm risk assessment despite her presentation and past history, which would have likely prompted more active searching of her belongings for medication which could be potentially used in an overdose. This could have been undertaken even against her permission when she had reduced capacity in her best interests. � Mrs Leaver had declined a bag search on admission to the ward at SGH which was apparently passed on verbally to the day team. This did not appear to have been acted upon and was not recorded, such that a search never occurred. � This was compounded by the fact that when psychiatric illness was finally being considered at QMH from 20th August 2020, there was only an informal telephone advice available, the quality of which varied with the person who took the call, and anything further required the transfer of Mrs Leaver back to SGH by LAS to A&E. � I understand that the NHS South West London Integrated Care Board declined to provide formal psychiatric cover to QMH, neither formal telephone advise nor staff on site to see patients. � In evidence this was identified as a lacuna in the service provision at QMH, by all the clinicians with whom it was discussed, such that for the last 10 years psychiatric liaison has been providing informal telephone advice without the need for the patient to be transferred back to A&E at SGH. � The Health Information Exchange viewer, ( HIE) available to doctors with in St Georges Hospital Trust at the time, contained a GP summary which did not contain the recent overdose or CMHT treatment as part of the active problem summary, nor even depression as a diagnosis despite a relapsing and remitting history of depression and anxiety going back to 2006. � HIE did contain sections of her RIO notes (psychiatric records) which appear to have been missed and details of attendance with suicidal ideation at Kingston 19th July 2020, which also appears to have been missed or disregarded by the clinicians. � Senior doctors in evidence were not aware of the information on the HIE. � Instead the incomplete past medical history which listed anxiety and dementia appears to have taken at face value. � As above, severe agitation at SGH did not prompt a reconsideration, neither did tearfulness and low mood at QMH. � Concerned phone calls from family were not logged nor passed to clinicians until she expressed active suicidality, and no doctor returned a call to the family until the daughter insisted on the 22?d August 2020 that if no doctor called her back to discuss her concerns about her mother she would attend the hospital despite the pandemic. By then it was all too late. � The lack of psychiatric history taking deprived Mrs Leaver of the opportunity for psychiatric liaison opinion and risk assessment that would have been likely to have discovered medication she had secreted in her bag that she subsequently consumed to lethal effect. � This was despite the fact that for at least 2 out of the three days that she was at SGH from 15th to 18th�August 2020, she was found by nursing staff ta lack full mental capacitay. I understand that considerable training has now been given on this issue so that patients who lack capacity may have their belongings searched to identify and secure dangerous items such as medication. � There were also concerns that her suicidality may have been exacerbated by drug interactions between phenytoin and diazepam. These matters have been addressed by SGH in the training of its clinicians.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons : [REDACTED] Clinical Director, Springfield Hospital, 61, Glenburnie Road, London [REDACTED], children of the Mrs Leaver, by email. 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) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: St Georges University Hospital NHS Foundation Trust, The Roehampton Surgery and NHS South West London Integrated Care Board

11/10/2023

2023-0383

Sarah Holmes

County Durham and Darlington

[REDACTED] Chief Executive, Tees, Esk and Wear Valleys NHS Foundation Trust, West Park Hospital, Edward Pease Way, Darlington, DL2 2TSCare Quality Commission [REDACTED]

INVESTIGATION � On 25th of July 2022 an investigation was commenced into the death of Sarah Elizabeth Holmes, aged 32. The investigation has not yet concluded and the Inquest has not been heard, and is currently listed to commence on the 16th of November 2023.

The deceased had a history of mental health difficulties and self harm and was found dead after a discharge home, subsequent to a mental health assessment, [REDACTED] . The medical cause of death is [REDACTED] Asphyxia

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

Suicide (from 2015) This report is being sent to: Tees, Esk and Wear Valleys NHS | Care Quality Commission

17/02/2023

2023-0061

Jamie Wood

Dorset

[REDACTED] Chief Executive, The Health and Safety Executive

On the 5th February 2021, an investigation was commenced into the death of Jamie Paul Woods, born on the 12th August 1980. The investigation concluded at the end of the Inquest on the 7th December 2022. � The Medical Cause of Death was: 1a Multiple Injuries � The conclusion of the Inquest recorded that Jamie Paul Woods died as a consequence of an accident.

Jamie Paul Woods was a farm worker at Hawkins Farm in Dorset. Hawkins Farm is a family-owned dairy farm. As part of the fabric of some of the buildings on the farm, pre-cast concrete panels were used extensively, predominately as external walls for barns or similar. Typically, the concrete panels, which weigh approximately 800kg, are placed between vertical reinforced steel joists (RSJs), secured to the RSJ by means of a metal bracket bolted to the concrete panel. On Hawkins Farm two concrete panels had been repurposed from another building to form a divide between a �collecting yard� (an area where cattle are held prior to be being encouraged into the milking parlour) and an adjacent barn where straw was stored, with one panel placed on top of the other, to form a wall that was approximately 6 feet in height. The concrete panels did not stretch between the two RSJs present. As a consequence, one side was secured using the above-described method, with the other side being secured using sections of steel �box� (hollow steel tubing) welded to the RSJ and �clipped� against the rear of the concrete panel using a metal bracket. On 30th January 2021, Mr Woods was in the collecting yard when the upper concrete panel that divided the collecting yard from the straw storage came away from its fixing, causing multiple injuries to Mr Woods, who was sadly confirmed deceased at the scene.

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

Other related deaths

The Health and Safety Executive

20/01/2023

2023-0020

Dorothy Jones

Gwent

[REDACTED] Chief Executive, Welsh Ambulance Service NHS Trust (WAST) Minister for Health and Social Services

INVESTIGATION AND INQUEST � On 11/04/2022 an investigation was opened into the death of Dorothy Anne Jones The investigation concluded at the end of the inquest on: 17/01/2023. The conclusion of the inquest was recorded as: � A narrative conclusion in the following terms: � Dorothy Anne Jones died at home on 29/03/22 from the effects of bronchopneumonia. Her death was contributed to by the failure of Welsh Ambulance Services NHS Trust to convey Mrs Jones to hospital within a reasonable timescale as dictated by her poor clinical condition. The medical cause of death was: 1a Bronchopneumonia 2. Advanced multiple Sclerosis

On 22/03/22, Dorothy Anne Jones developed a chest infection. After failing to respond to antibiotics, she was seen at home by [REDACTED] her GP on 29/03/22. [REDACTED] considered that Mrs Jones needed to be admitted immediately to hospital. Mrs Jones had low oxygen levels and was drowsy and [REDACTED]�requested that an ambulance attends within 2 to 3 hours. Following discussion with the ambulance service they informed�[REDACTED]�that there was a 2- 4 hour wait but that they would attempt to send an ambulance quicker. � Unfortunately, the pressure on the ambulance service and a failure to identify an earlier available resource meant that paramedics did not attend until 20:28, over 9 hours later. On arrival, paramedics confirmed that Mrs Jones had died and could not be revived. On hearing the evidence, I determined that a failure to send an ambulance within a timescale required by the severity of Mrs Jones�s illness, contributed to her death.

COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) The family of Dorothy Anne Jones Health Inspectorate Wales. I am also under a duty to send the Chief Coroner a copy of your response. The Chief coroner may publish either or both in a complete or redacted summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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) | Wales prevention of future deaths reports (2019 onwards)

Welsh Ambulance Service NHS Trust and Department of Health and Social Care

12/7/2024

2024-0372

Sandra Phillpott

Blackpool & Fylde� � Category: Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: Blackpool Teaching Hospitals NHS Foundation Trust

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

The death of Sandra Phillpott on 31st October 2023 was reported to me and I opened an investigation, which concluded by way of an inquest on 5th July 2024.�� I determined that the medical cause of Sandra�s death was: 1a Multi � organ failure�� 1b Sepsis with Disseminated Vascular Coagulation [D.I.C]�� 1c Streptococcus Pneumoniae�� II E.coli 0157 infection; left ventricular hypertrophy; coronary artery atheroma In box 3 of the Record of Inquest I recorded as follows: Sandra Phillpott was aged 57 years. She was regarded as active and previously healthy. At� around 5pm on Friday, 27th October 2023 she returned home after a holiday in Egypt with� her twin Sister. By the time she arrived home she was experiencing some cold-like� symptoms due to a bacterial infection � later identified as E.coli 0157 � contracted whilst in� Egypt from an unidentified source. The situation was complicated after she then developed a pneumococcal infection which left her feeling cold and shivering. Over the course of that� weekend, Sandra remained unwell but did not deteriorate noticeably until the morning of� Monday 30th October 2023. She had largely preferred not to seek medical attention,� expecting her symptoms to improve. After her condition became more concerning she� attended a walk � in � centre from where she was appropriately transferred to the hospital� emergency department. She had to remain in an ambulance for around forty minutes� before she could enter the department. Initial investigations suggested she had a�suspected pulmonary embolism, but she was also showing signs of infection and by 12�noon antibiotics and intravenous fluids had been prescribed. These were not administered� in a timely fashion. Her presentation had not indicated she had a specific pneumococcal� infection until later that afternoon when following a delayed transfer to the intensive� treatment unit a consultant noted a florid rash indicative of pneumococcal sepsis. The�results of bloodtests would later confirm the infection to be Streptoccocus Pneumonaie.� Over subsequent hours, Sandra�s condition deteriorated and her death confirmed at 05.50 hours on 31st October 2023. The likelihood Sandra had sepsis had been under appreciated, and there was a missed opportunity to provide timely antibiotic therapy and fluids, but from the available evidence this would not have altered the fatal outcome because from� around the time antibiotics were prescribed Sandra�s condition was non � survivable. She�died from complications arising from a pneumococcal infection. She had been more� susceptible to dying from such infection due to the effects of heart disease identified at�post mortem examination, and reduced physiological reserves caused by the separate� infection which had been contracted in Egypt.� In box 4 of the Record of Inquest I determined that: Natural causes.

In addition to the contents of section 3 above, the following is of note: As mentioned above, despite showing signs of infection, the necessary treatment was not provided in a timely manner, notably antibiotic therapy and the administration of� intravenous fluids.� Sandra�s shortness of breath, some reported calf pain, and recent flights contributed to a� feeling amongst some of the clinical / nursing staff that she had a likely pulmonary embolism [later ruled out] and this in part contributed to a lack of focus on the possibility she had� developed a potentially fatal infection.� A helpful Patient Safety Incident Investigation [PSII] Report, provided to the court in advance of the inquest by Blackpool Teaching Hospitals NHS Foundation Trust, found that:� There had been delays in sepsis management� The initial treatment had focused upon ruling out a pulmonary embolism and deep vein thrombosis, delaying sepsis management. Sandra had multiple sepsis triggers, but the main focus remain a pulmonary embolism. Having considered all of the above, I have determined that I have a duty to write this report.

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

11/03/2024

2024-0131

Keith Smith

East London

[REDACTED] Church Elm,�Lane Medical Practice, Dagenham

On 6th July 2023, this court commenced an investigation into the death of Keith Smith aged 75 years. The investigation concluded at the end of the inquest on 8th March 2024. The conclusion of the inquest was a short-form conclusion of natural causes. Mr Smith�s medical cause of death was determined as; 1a Acute Myocardial Infarction 1b Severe Stenosis of the Coronary Arteries 1c Atherosclerosis II Hypertension, 2 Diabetes Mellitus

Kevin Smith was diagnosed through MRI as suffering from degeneration of his lumbar spine which caused impingement of his lower sciatic nerve resulting in chronic pain. � Mr Smith experienced a development in his pain in early July 2023 with symptoms of back and chest pain, radiating into his neck. Mr Smith sought medical treatment from his GP in telephone calls with the surgery reception on 3rd, 4th and 5th July 2023. � The response from the surgery was chaotic and at times the behaviour of those taking telephone calls was unprofessional and inappropriate. � On 4th and 5th July 2023 Mr Smith was informed that he would receive a GP call-back, on both days that did not occur. � On the evening of 5th July 2023 Mr Smith�s family, frustrated with the lack of contact called 111 who diverted the call to the 999 service. An ambulance attended upon Mr Smith who, utilising an ECG diagnosed that Mr Smith was suffering a myocardial infarction. Moments later, Mr Smith lapsed into cardiac arrest, despite prompt and effective CPR his death was declare just after midnight on 6th July 2023.

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

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

07/02/2023

2023-0049

Richard Kew

Leicester City and South Leicestershire

[REDACTED] Department of Health and Social Care

On 15 September 2022 I commenced an investigation into the death of Richard Nigel KEW aged 70. The investigation concluded at the end of the inquest on. The conclusion of the inquest was that: � Mr Kew was admitted to the Glenfield Hospital Leicester and underwent a resection of small bowel endocrine tumour with extensive lymphadenectomy and resection of multiple liver metastases on the 21 July 2022. Immediately post-operatively he was admitted to the adult Intensive Care Unit. During mobilisation of Mr Kew on the 22 July there was an inadvertent omission to secure one of the central venous catheter lines with a bung. This omission allowed air entrainment into Mr Kew�s circulation. His condition deteriorated rapidly and whilst he received immediate senior medical attention, he never regained consciousness and died as a direct result of the consequences of the omission on the 05 September 2022.

As above with a cause of death as 1a) Diffuse Hypoxic Brain Injury 1b) Air entrainment via a central venous catheter 1c) Peri-operative requirement for physiological support 1d) Ileocolic anastomosis and resection of liver metastases to treat small bowel neuroendocrine tumour and multiple liver metastases

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] Wife University Hospitals of Leicester � I have also sent it to the Heath and Safety Investigation Board (HSIB) 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

Department of Health and Social Care

19/09/2023

2023-0337

Stephen Cassidy

Avon

[REDACTED] Deputy Director of Patient Safety, Digital at the NHS � [REDACTED], North Bristol NHS Trust.

On 10th March 2023 I commenced an investigation into the death of Stephen William Cassidy. The investigation concluded at an inquest on 18th September 2023. The conclusion of the inquest was � � �Mr Cassidy died from a known drug allergy because its existence was not obtained by hospital medical staff from his Summary Care Record.�

In 2018 Barnet Hospital in London found Mr Cassidy to be allergic to Ceftriaxone and recorded this fact in his Summary Care Record (an electronic patient record). Mr Cassidy appears to have been unaware of his allergy � probably because he experienced it during a period of encephalitis such that he had no clear memory of it. � On 4th March 2023 Mr Cassidy fractured his hip and clinical staff from South Western Ambulance Service NHS Foundation Trust (SWAS) conveyed him by ambulance to Southmead Hospital, Bristol (SMH). SWAS staff were able to access the Summary Care Record, obtain the history of Ceftriaxone allergy and record this in their clinical record. � On admission to SMH a copy of the SWAS clinical record was scanned into the SMH records and a member of SMH emergency department nursing staff noted the Ceftriaxone allergy, but it was not acted upon further. Mr Cassidy was listed for surgical repair of his fractured hip the following day. None of the doctors who assessed Mr Cassidy in the emergency department, the trauma and orthopaedics team or the anaesthetist at his operation were able to access the Summary Care Record to obtain the history of Ceftriaxone allergy and none of them were aware of it. � On 5th March 2023 Mr Cassidy was administered intravenous Ceftriaxone as part of routine induction of anaesthesia for his hip surgery. He immediately suffered a severe anaphylactic reaction to the Ceftriaxone from which he died shortly afterwards despite appropriate and extensive attempts to resuscitate him. � Despite the Ceftriaxone allergy being recorded on his Summary Care Record in 2018 and the potential fatal outcome of such a history being disregarded, the evidence at the Inquest demonstrated that � � a)������ There was no provision for clinical staff at SMH to access patients� Summary Care Record routinely or easily; b)������ This was despite provision existing for SWAS clinical staff to do so before a patient arrived at hospital; c)������� There was no provision for the Summary Care Record to be integrated with SMH�s hospital electronic patient record (known as Careflow/Connect) or the primary care electronic patient record (EMIS � Egton Medical Information System) � such that the Ceftriaxone allergy automatically appeared in SMH�s electronic patient record; d)������ As a result none of the emergency department doctors, the trauma and orthopaedics team or the anaesthetist who administered the antibiotic with induction were able to ascertain Mr Cassidy�s Ceftriaxone allergy; e)������ This led to an avoidable fatal anaphylactic reaction.

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

Alcohol, drugs medication related deaths, Care Home Health related deaths This report is being sent to: Digital | North Bristol NHS Trust

21/12/2023

2023-0545

Nicholas Dymond

Exeter and Greater Devon

[REDACTED] Devon Partnership NHS Trust Wonford House Dryden Road Exeter EX2 5AF

On 13 November 2018 an investigation was commenced into the death of Nicholas James Glavind Dymond. The investigation concluded at the end of the inquest on 19 June 2023. The conclusion of the inquest was suicide. The cause of death was recorded as: 1a) Fatal injuries of head, neck, chest, right leg 1b) Railway accident

Nicholas Dymond had been an intermittent drug user for much of his adult life. In 2018 he began to suffer from paranoia and by October that year he had started to express thoughts of suicide � specifically of jumping in front of a train. His GP referred him to the Mental Health Crisis Team. � Following Nicholas� arrest on 31st October 2018, a Mental Health Act Assessment was carried out. He was discharged and a taxi was arranged to take him home. On arrival of the taxi, Nicholas ran away. He was seen less than 3 hours later to step in front of a train at a local train station. He was pronounced deceased at the scene.

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

Railway related deaths This report is being sent to: Devon Partnership NHS Trust

02/02/2023

2023-0039

Jason Williams

Dorset

[REDACTED] Director General Operations His Majesty�s Prison and Probation Service (HMPPS), [REDACTED] Chief Executive of NHS England, [REDACTED] Governor at HMP Guys Marsh, Shaftesbury, Dorset

On the 13th August 2020 an investigation was commenced into the death of Jason Anthony Williams, born on the 7th January 1981. � The investigation concluded at the end of the Inquest on the 30th January 2023. The Medical Cause of Death was: 1a Synthetic cannabinoid intoxication � The jury reached a narrative conclusion that �Jason deliberately took drugs but did not intend the consequences to be fatal i.e he had no intention to end his life�

As recorded by the jury in Section 3 on the Record of Inquest: At 15.15 hours on the 31st July 2020 Jason Anthony Williams was found unresponsive in his cell, cell 42, Gwent wing, HMP Guys Marsh, Shaftesbury, by prison officers carrying out accommodation fabric check. His death was confirmed a short time later by attending paramedics. Prior to his death he had used psychoactive substances. On 30th July 2020 prison staff on the wing opened a welfare log following suspicion that Jason was under the influence of illicit substances, however the process set out in the Illicit Substances Welfare Document was not fully followed. It cannot be established that this had any causative or contributory bearing on Jason�s death the following day. On 31st July 2020 Jason�s cell door was unlocked by prison staff at 14.14 hours however a welfare check was not conducted upon unlock. It cannot be established that this had any causative or contributory bearing on Jason�s death. i� JASON�S HISTORY OF MISUSE OF DRUGS � Jason�s history of misuse of drugs probably caused or contributed more than minimally to his death. Jason had a habitual drug habit that was documented on assessment on entering HMP Guys Marsh and throughout his custodial sentence. � ii� JASON�S VULNERABILITY We are satisfied that Jason�s vulnerability possibly contributed to his death more than minimally. Jason�s drug dependency in Prison contributed to his vulnerability due to his apparent willingness to take illicit substances. iii� THE DRUG PREVENTION STRATEGIES IN THE PRISON IN JULY 2020 The restrictions imposed in July 2020 due to Covid, impacted the execution of the drug prevention strategy. This possibly contributed more than minimally to Jason�s death. iv. THE MEASURES TAKEN BY THE PRISON FOLLOWING THE SUSPECTED THROWOVER ON 25TH JULY 2020 v THE STEPS TAKEN BY THE PRISON, AND/OR ISMS TO SAFEGUARD JASON FOLLOWING THE SUSPECTED THROWOVER ON 25TH JULY 2020 AND ONCE HE WAS FOUND TO BE UNDER THE INFLUENCE OF PS ON 30TH JULY 2020 No specific instruction was given to staff relating to Jason following the suspected throwover of illicit items and the increase of psychoactive substance incidents around this time. Nor were there any additional briefings to prison officers or notices distributed to prisoners. This possibly contributed more than minimally to Jason�s death. This could be constituted as a safeguarding failure towards Jason from the steps taken by the Prison.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1)� GT Stewart Solicitors on behalf of Jason�s family (2)� Government Legal Department on behalf of the Ministry of Justice (3)� Hill Dickinson LLP on behalf of Practice Plus Group (4)� EDP I am also under a duty to send the Chief Coroner a copy of your response. I have also provided copies to the following who I believe this report will be of interest to: (1)� Hill Dickinson LLP on behalf of Oxleas NHS Foundation Trust (2)� Hill Dickinson LLP on behalf of Change Life Grow �� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related deaths | State Custody related deaths

HM Prison and Probation Service, NHS England and HMP Guys Marsh

09/10/2023

2023-0379

Kirandip Bharaj

Blackpool & Fylde

[REDACTED] Director of Adult Services Blackpool Council Bickerstaffe House 1 Bickerstaffe Square Talbot Road Blackpool FY1 3AH

The death of Kirandip Bharaj [known to her family as Kiran] on 14th September 2019 was reported to me and I opened an investigation, which concluded by way of an inquest on 30th September 2023. � I determined that the medical cause of Kiran�s death was: 1 a Fire fumes inhalation and burns � In box 3 of the Record of Inquest I recorded as follows: � Kiran Bharaj was aged 45 years. She had a history of mental health� issues, having�� been diagnosed with transient psychotic episodes. She also had a known eating disorder, and had maintained a chronic low weight for some time. She was also��� known to be frail, with limited vision and hearing. In May 2019, it was felt there had been a deterioration in her mental health and a mental health assessment was performed but Kiran was not� felt to be� detainable and she� remained in the community with support initially provided to her by a care company, and then with�� the aid of a support worker from adult social care. At shortly before 12.30pm on 14th September 2019, a neighbour� became aware of� a fire in Kiran�s flat and alerted the� fire service. When the emergency services entered her� flat,� they� found� Kiran deceased in the kitchen area. A subsequent fire investigation determined that the fire had been caused by the unintentional ignition of a cotton tea towel by turning on the wrong control on an electrical cooking ring hob. Once a fire had taken hold, and Kiran has become aware of the fire, she approached the location and her clothing caught� fire, and she suffered significant burns. She died quickly from the combined effects of the burns and from inhaling some fumes. In recent weeks, her weight had become more concerning and was being monitored by her GP. Kiran was referred to an eating disorder clinic on 23/07/19, but was not willing to give her consent to this. On 30/08/19, some 15 days before Kiran died, a support worker had raised a concern� when Kiran appeared confused and had been unable to recognise her. In due course, she was the subject of a further metal health assessment on 6th September 2019. By that date, her weight was declining. The assessment was inadequate. There was a failure to sufficiently assess the status of her eating disorder at that time. Her presentation justified a period of detention in a hospital setting where her declining weight could have been stabilised, and the decision not to detain her was a missed opportunity. When social care professionals attended her home on 10th September 2019 and weighed Kiran, her weight� had reduced further.� A� decision was taken to seek an inpatient eating disorder bed. Professionals could have convened an� immediate mental health assessment, which may have led to admission to a general acute or medical bed rather than waiting for a specialist eating disorder bed to materialise. Discussions were held with a hospital on 12th September 2019, but there was no eating disorder unit bed� free at� that time.� One would most likely� have become available within the next seven days but not by the date of Kiran�s death on 14th September 2019. There was some confusion amongst professionals about when a necessary mental health assessment would take place prior to Kiran being able to access the eating disorder bed, and who would be responsible for monitoring her in�� the community prior to hospital admission, but this did not contribute to her death. From the available evidence, it cannot be established that the circumstances surrounding the fatal house fire were more than minimally, trivially or negligibly contributed to by her mental disorder, nor by her eating disorder and how it was managed and responded to. � � In box 4 of the Record of Inquest I determined that Kiran died as a result of: � Accidental death

In addition to the contents of section 3 above, the following is of note: � ������ Notwithstanding that I determined that it could not be established this fatal house fire was contributed to by Kiran�s eating disorder and how it was managed and responded to, I was satisfied that I have a duty to write this report. � ������ At the time of her death, Kiran lived alone her flat with support from adult social care. A support worker assisted her with tasks such as ordering prescriptions, booking taxis, medical appointments, for example. ������ Although Kiran was said to have maintained a chronic low weight for some time, evidence before the inquest suggested that in the weeks prior to her death she lost significant weight, and could take steps to avoid accurate recording of her weight, such as on two occasions when she refused to remove her boots prior to being weighed. Her BMI was 14, and would reduce further. She was said to have been �presenting as not eating, and with an increased level of confusion� and no longer willing to have prescribed ensure drinks, something she had previously agreed to. � ������ The quality of assistance she received from professionals varied. A support worker was proactive in seeking to provide Kiran with the help she needed, By contrast, during an inadequate mental health assessment the extent of her eating disorder and a declining weight was not considered to the degree clearly required. � ������ This inquest was held some time after Kiran�s death, the inquest having been necessarily adjourned on previous occasions for a range of reasons. � ������ The court heard how, at the time Kiran died, in terms of managing and treating an eating disorder the relevant guidance was what is often referred to as the MARSIPAN guidance. Some time later, from around May 2022, the Royal�� College of Psychiatrists replaced that guidance with their up-dated Guidance on�Recognising and Managing Medical Emergencies in Eating Disorders, sometimes known as the MEED guidance. � ������ The court received evidence from a witness who� at the time of Kiran�s death� had been Deputy Head of Adult Social Care and in her witness statement, she explained how it was part of her role to provide some level of oversight, and to identify any gap in services and address these. However, no significant internal investigation into Kiran�s death had taken place since, and no changes have� been made in response to her death. � ������ She confirmed that at the time of Kiran�s death, Adult Social Care staff had not received training on how to recognise indicators of concern in relation to eating disorders. � ������ A support worker explained how what knowledge he had about eating disorders he had accumulated from his experience of dealing with service users allocated� to him previously. � ������ Two approved mental health practitioners [AHMPs] employed by Blackpool Council confirmed this also applied to AMHPs, with training on eating disorders limited to whether they happened to choose an eating disorder module as part of their annual refresher training. � ������ There had been little if any awareness of the MARSIPAN guidance therefore around the time of Kiran�s death. ������ In addition, adult social care witnesses were largely unaware of the more recent MEED guidance, and the court was told no steps had been taken to bring the� new MEED guidance to the attention of staff, nor to provide specific training on eating disorders. � ������ Although the court was told that workers in adult social care do have access to colleagues working in an eating disorder service with who they can discuss their service users, they are only likely to do so upon having recognised that there� may be a potential problem relating to an eating disorder. � Having considered all of the above, I have determined that I have a duty to write this report.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � ��� [REDACTED] [Kiran�s Sister] ����[REDACTED][GP] St Paul�s Medical Centre Dickson Road North Shore Blackpool � 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, redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Blackpool Council

04/11/2024

2024-0594

Polly Friedhoff

Oxfordshire

[REDACTED] Director of Highways and Operations Oxfordshire County Council

On 24 October 2024 at Oxfordshire Coroner�s Court I conducted the inquest into the sad death of Polly Friedhoff, aged 81, who died at the John Radcliffe Hospital on 2� December 2022 from injuries sustained in a collision with a pedal cyclist on 20� November 2022. It occurred on the path beside the River Thames at Iffley Lock, Oxford.� I returned a conclusion of Accident and I attach a copy of the Record of Inquest for your� information.�� I heard oral evidence from the cyclist, investigating police officers�, and, helpfully, from [REDACTED], Operations Manager, Countryside Access and Tree Service,�Oxfordshire County Council (OCC). I was grateful to [REDACTED]/OCC for providing a� witness statement at relatively short notice. I note the towpath is recorded as a public� footpath and it forms part of the Thames Path National Trail. I understand OCC are� responsible for managing the footpath although Iffley Lock itself, through which it� passes, is owned by the Environment Agency.

The brief circumstances are set out in the Record of Inquest but I also attach the�investigating police officer�s report, that of [REDACTED], and also the�aforementioned statement of�[REDACTED] for your information. It will be seen that�raises some safety issues about the path at the end of his report and�[REDACTED] outlines at paragraphs 2.6 and 2.7 that OCC and local Councillors have given�considerable thought to the issue of safety. Mrs Friedhoff�s two son�s have also raised significant concerns which I share (see below).

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

Other related deaths

Oxfordshire County Council

16/05/2023

2023-0156

Benedict Peters

Manchester South

[REDACTED] Group Chief Executive, Manchester University NHS Foundation Trust.

On 27th January 2023, Lauren Costello, Assistant Coroner opened an inquest into the death of Benedict Peters who was found dead on 12th November 2022 whilst staying at his parents� home, aged 25 years. The investigation concluded with an inquest which I heard on 4th May 2023. A post mortem examination confirmed that Mr Peters died as a consequence of: 1a) Haemopericardium; b. Acute aortic dissection. The conclusion of the inquest was a narrative conclusion to the effect that Mr Peters died as a consequence of complications arising from an underlying heart defect which had not been diagnosed during his life.

Mr Peters was found dead at his parents� home on 12th November 2022 having been staying there following his discharge from the Manchester Royal Infirmary Ambulatory Care Unit the previous day. Mr Peters had attended hospital in the early hours of 11th November 2022 having become acutely unwell with chest pain, shortness of breath, a sore throat and an aching arm. In the Emergency Department, an ECG was undertaken which was reported as showing Normal Sinus Rhythm and his recorded observations were essentially normal. Whilst awaiting review, Mr Peters experienced a severe episode of vomiting. Blood tests were taken and Mr Peters� Prothrombin time was noted to be abnormal. Troponin and D-Dimer levels were within normal limits. Mr Peters was reviewed on the Ambulatory Care Unit by a Physician Associate. A Chest X-Ray was performed which was reported as being normal and following discussion with the duty Consultant, Mr Peters was discharged with a diagnosis of panic attack / gastric inflammation and a prescription of Propranolol and Omeprazole.

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

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

16/03/2023

2023-0093

John Ibboston

North Yorkshire and York

[REDACTED] Health & Safety Executive [REDACTED] Road Transport Industry Training Board [REDACTED] COVEY TIMCOM, The Timber Packaging and Pallet Confederation The Director � The Associate of Pallet Networks

On 23 September 2020 I commenced an investigation into the death of John Anthony IBBOTSON aged 57. The investigation concluded at the end of the inquest on 07 February 2023. The conclusion of the inquest was that: � Mr John Anthony Ibbotson was 57 years of age who, at the time of his death worked as a warehouse operative at Systagenix Wound Management Ltd, Airebank Mills, Gargrave, Skipton BD23 3RX. He arrived at work at around 06:30 am on Monday 21st September 2020. Sometime thereafter his colleagues went looking for him as he had not been seen for a while. He was found in the raw materials storage, bulk storage area (RMGJ05), this was an area in which he was authorised to work. He was a trained warehouse operative with up-to-date forklift truck training. He was known to be safety conscious and not a risk taker. Mr Ibbotson was found in a sitting position, leaning forward with a pallet on top of his back. The incident was reported to the police at 08:38. The paramedics pronounced lift extinct at 08:53. On balance of probability, it is more likely than not that the pallets were double stacked and not in the pyramid/brick formation, but likely that one pallet was stacked directly on top of the other. It is unclear what caused the pallet to fall.

As above

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] I have also sent it to British Standards Institute 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.

Accident at Work and health and Safety related deaths

Health & Safety Executives | Road Transport Industry Training Board | The Timber Packaging and Pallet Confederation | The Associate of Pallet Networks

29/07/2024

2024-0410

Wendy Hammon

Surrey

[REDACTED] Interim Chief Executive Ashford and St. Peter�s Hospitals NHS Foundation Trust

INQUEST An inquest into Mrs Hammon�s death was opened on 27 October 2022. The inquest was resumed on 24-25 June 2024 and concluded on 12 July 2024.� The medical cause of Mrs Hammon�s death was: 1a. Multi-Organ Failure 1b. Non-Occlusive Mesenteric Ischaemia 1c. Small Bowel Obstruction due to Adhesions from Previous Surgery (2011)� 2.� Chronic Kidney Disease�� The inquest concluded with a narrative conclusion as follows: Mrs Hammon had a past medical history which included chronic kidney� disease.�� In 2011 she had developed ischaemic bowel, due to Streptococci A, and�had undergone surgery to remove a portion of her bowel and to create an� ileostomy.�������� As a result of the procedure in 2011 she developed scar tissue� known as adhesions, which are a recognised complication of the� procedure.�� On 30 August 2022 Mrs Hammon was admitted to St. Peter�s Hospital� with abdominal pain, vomiting and a non-functioning stoma.� She was� diagnosed with, and treated non-operatively for, a small bowel�obstruction caused by the adhesions from her surgery in 2011. �� At approximately 15:30 on 5 September 2022 Mrs Hammon began to� complain of severe abdominal pain and at 17:52 a CT scan was requested� to investigate the cause of the pain.� Thereafter, the plan was for the� oncoming night shift to arrange for a senior clinical review of Mrs� Hammon and to chase the CT scan. However, the plan was not� implemented and Mrs Hammon was not seen by the oncoming night shift until 01:00 on 6 September 2022 when she was found to have blood and� pus coming out of an old surgical scar, for which she was commenced on� intravenous antibiotics.�� At 02:41 on 6 September 2022 the CT scan was reported as being strongly� suggestive of mesenteric iscahaemia with infarction complicating a�known small bowel obstruction and thereafter at 10:50 on 6 September�2022 Mrs Hammon underwent an emergency laparotomy, during which� the surgical team found widespread ischaemic bowel, and resected a� significant amount of her small bowel.��� On 7 September 2022 a further relook laparotomy was carried out after� which Mrs Hammon was cared for on the Intensive Care Unit, however,� her condition deteriorated and she died at St. Peter�s Hospital on 9� September 2022.�� Her death was due to Multi-Organ Failure due to Non Occlusive� Mesenteric Ischaemia.� The ischaemia was caused by the small bowel� obstruction which in turn was caused by adhesions from her surgery in� 2011.�� The small bowel obstruction caused the ischaemia firstly by impairing the� blood flow within the lining of the bowel and secondly by causing Mrs� Hammon to become dehydrated, due to vomiting and reduced fluid� absorption from the bowel, which in turn led to her developing� hypovolaemia, acute kidney injury and low blood pressure, which� prompted her body to reduce the blood supply to the bowel in order to� protect other major organs.�� � Mrs Hammon�s death was contributed to by her Chronic Kidney Disease� which made her more susceptible to developing acute kidney failure.�� During the period from 1 September 2022 onwards there was a failure to� accurately monitor Mrs Hammon�s fluid input and output which led to a� failure to provide her with adequate fluid replacement, which contributed to her developing dehydration and related bowel ischaemia.���� �������������������������������������������������������������������������������������� � During the same period there was a failure to identify that Mrs�Hammon�s blood tests showed high CRP levels, which is a non-specific� inflammatory marker and can be consistent with bowel ischaemia. By 4 September 2022 the clinical team caring for Mrs Hammon ought to� have recognised that she had ongoing unexplained high CRP levels, in the context of an ongoing small bowel obstruction, with ongoing vomiting, a� return of abdominal discomfort and a deteriorating kidney function.�� Those matters ought to have prompted a senior clinical review and a CT� scan which would have diagnosed bowel ischaemia and resulted in� emergency surgery on 4 September 2022.� Had Mrs Hammon been taken� for surgery on 4 September 2022 she would have survived.�� On the afternoon of 5 September, when Mrs Hammon developed severe� abdominal pain, she ought to have received a senior clinical review which� would have prompted an expedited CT scan which would have�diagnosed ischaemia and would have resulted in emergency surgery on� the night of 5 September 2022.� Had Mrs Hammon been taken for surgery� on 5 September 2022 she would have survived.� Mrs Hammon�s death was contributed to by neglect.

The circumstances of Mrs Hammon�s death are set out in the narrative conclusion above.

COPIES� I have sent a copy of this report to the following: 1. [REDACTED] Interim Chief Executive, Ashford and St. Peter�s Hospitals NHS Foundation Trust� 2. Chief Coroner�� 3. Mrs Hammon�s family

Hospital Death (Clinical Procedures and medical management) related deaths�� � This report is being sent to: Ashford and St. Peter�s Hospitals NHS Foundation Trust

22/04/2024

2024-0213

David Carpenter

Coventry and Warwickshire

[REDACTED] Managing Director, Dennis Eagle Ltd [REDACTED] Engineering Director, Dennis Eagle Ltd

On 19th January 2023 I commenced an investigation into the death of David John CARPENTER (aged 60 years). The investigation concluded at the end the inquest on 22nd April 2024 at Coventry Coroners Court. The conclusion of the death of Mr Carpenter was that death was �accident� a copy of which I attach to this report.

Mr Carpenter was employed by Coventry City Council as a Refuse Collector. He was based at Whitley Depot, Coventry. His job involved collecting bins from the side of the road and taking them to a bin lorry/Rear Compaction Vehicle (RCV) to empty them. He worked as part of a team with another collector and a driver. The bin lorry involved in the incident was a Dennis Eagle lorry equipped with a Terberg �Omnideka� automatic bin lift system. The Terberg bin lift system comprises two �lifting chairs� which enable two household-sized waste bins to be emptied side by side. Each lifting chair has its own control panel located on the rear of the vehicle. The controls are used by bin crew to switch between different modes of use. The bin lift system can be operated in two modes (manual and/ or automatic) the two lifting chairs capable of operating independently of each other. CCTV cameras are fitted to these vehicles. Mr Carpenter was lifted into the rear hopper of this bin lorry when he activated the proximity start sensor and his coat became caught on the lifting chair comb tooth associated with the bin security switch. The machine through the automatic compaction cycle tragically causing Mr Carpenter fatal injuries.

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

Accident at Work and Health and Safety related deaths This report is being sent to: Dennis Eagle Ltd

30/01/2023

2023-0032

Felice Banfield

Cornwall and the Isles of Scilly

[REDACTED] Medical Director, Royal Cornwall Hospital

On 25/1/23, I concluded an inquest into the death of Felice Eileen Grace Banfield who died in RCHT on 22/10/21. The medical cause of death was recorded as: 1a) Chronic Obstructive Pulmonary Disease and Sarcoidosis I recorded a Conclusion of Natural Causes. I considered adding a rider of neglect but did not do so on the basis that the shortcomings identified � and accepted � were not gross in the sense they were not total and complete. Nevertheless, I felt the circumstances gave rise to a concern and engaged my statutory duty to make this PFD report.

Ms Banfield had a past medical history that included COPD ([REDACTED] felt this was actually Obesity Hypoventilation Syndrome) chronic kidney disease (stage 3) and type 2 diabetes. She used non-invasive ventilation (NIV) at home and brought her machine into RCHT with her when admitted. Her presenting complaint was a painful knee, and the initial differential diagnoses were gout, septic arthritis or a flare of osteo arthritis. Her need for NIV was recognised but following her admission to MAU at 22:20 on 17/10/22, there was a lack of clarity about if and where NIV could be undertaken. As respiratory consultants do not provide an on- call service, it appears to have been decided to leave the issue until the following day when the evidence suggested the matter was simply forgotten. Although presenting with a respiratory element to her condition, her admission was not brought to the attention of respiratory clinicians. On 21/10/21, a respiratory nurse became aware of her presence and took bloods that revealed a mixed respiratory and metabolic acidosis that had caused an AKI. Despite treatment, Ms Banfield deteriorated and died. It was accepted in evidence that this was an avoidable death. The structured judgment review conducted found a poor level of care. There was discussion about the cause for the AKI. While the failure to provide NIV was accepted, it was felt in evidence that the more likely significant driver was a failure to provide adequate fluid and food. Charts to evidence this were not completed.[REDACTED], accepted this had been a problem in MAU for years where there is a rapid turnover of patients and a lack of continuity in medical and nursing care.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Royal Cornwall Hospital

09/7/2024

2024-0366

Nancy Rogers

Cumbria� � Category: Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: University Hospitals Morecambe Bay Trust

[REDACTED] Medical Director, University Hospitals Morecambe Bay Trust University Hospitals Morecambe Bay Trust

On 22 November 2023 I commenced an investigation into the death of Nancy ROGERS. The investigation concluded at the end of the inquest . The conclusion of the inquest on 9th July 2024 was Death from natural causes. The medical cause of death being: 1a Bilateral Haemothorax 1b Ruptured Dissecting Aortic Aneurysm 1c II I also refer to an inquest opened on 10th August 2023 and concluded on 23/11/23 touching on the death on 12th February 2023 of [REDACTED], the medical cause of death being 1a Haemopericardium due to 1b Ruptured Dissecting Aortic�Aneurysm.

18/11/2023 � Nancy collapsed outside on Storey Square, Barrow when she was walking with her sister�[REDACTED] into town. This occurred around 1300hrs. An ambulance was called and Nancy attended A&E. She had tests done however the results were not back and they are due to come back on Monday 20/11/2023. Hospital discharged Nancy back to her home address. They stated she possibly had fluid on her lung which would need a referral. On 19/11/2023 at around 0530hrs [REDACTED] helped Nancy to the toilet; she left the bathroom to give Nancy some privacy and immediately heard her fall.�[REDACTED] went into the bathroom and Nancy was not breathing. CPR was started and the neighbour�[REDACTED] came over as she heard the shouting through the wall. No response to CPR from family attempts and paramedics arrived to continue. Nancy is in the process of selling her home to return to the ��Philippines and this has been causing her some stress.

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�[REDACTED] �who may find it useful or of interest.� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your� response, about the release or the publication of your response by the Chief Coroner.� 9 July 2024

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

11/12/2023

2023-0518

Amarnih Lewis-Daniel

East London

[REDACTED] NHS England

On 1 April 20211 commenced an investigation into the death of Amarnih Louis Lewis� Daniel, aged 24 years. The investigation concluded at the end of the inquest on the 30 November 2023. The conclusion of the inquest was a narrative conclusion delivered by a jury: � Amarnih took the action that led to her falling from [REDACTED] floor window. The evidence does not fully disclose whether she intended the outcome to be fatal.

Amarnih Lewis-Daniel suffered from traits of emotionally unstable personality disorder, mixed anxiety and depression, anger management difficulties and gender dysphoria. She was under assessment for autism spectrum disorder. Amarnih had been referred to the gender identity clinic in August 2018. The inquest heard evidence that Amarnih had suffered bullying and abuse, causing her a great deal of distress . She reported to professionals that she was keen to be accepted by and to receive treatment from the Gender Identity Clinic. Amarnih had sourced hormone medication [REDACTED] The hormone medication was not� supervised by any healthcare professional.� In the months leading up to her death, Amarnih�s mental state declined, and she came into contact with the police, criminal justice system and mental health professionals. �On the 17 March 2021 she jumped [REDACTED] and sustained fatal injuries in the fall. Amarnih was still awaiting care from the Gender Identity Clinic when she passed away.

I have sent a copy of my report to the Chief Coroner and to the following Interested persons: Family of Amarnih Lewis-Daniel , North-East London Foundation Trust and the Tavistock and Portman Clinic. I have also sent a copy to the local Director of Public Health who may find it useful or of interest and to the CQC. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form . He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Other related deaths This report is being sent to: NHS England

17/04/2024

2024-0202

Thomas Wakefield

Cheshire

[REDACTED] NHS England 7 and 8 Wellington Place Leeds LS1 4AP

On 02 January 2024 I commenced an investigation into the death of Thomas Geoffrey WAKEFIELD aged 79. The investigation concluded at the end of the inquest on 10 April 2024. The conclusion of the inquest was that: � Thomas Wakefield died from natural causes. It is not possible to say on balance of probabilities whether Mr Wakefield would have survived if the correct diagnosis had been made on admission.

On 22 September 2023, 79 year old Thomas Wakefield was admitted to Countess of Chester Hospital at 22:22 hours with a three day history of severe stomach pain and sudden collapse at home in the early afternoon. The clinicians were not made aware of the collapse at home. � He was promptly assessed in A&E for concerns with acute kidney injury. The plan was to prescribe intravenous fluids due to hypotension. There was a delay in medical assessment. A CT scan was considered at 05:59 but not ordered or completed. This was a missed opportunity to review the diagnosis of pancreatitis on admission and provide a 50% chance of survival. � He was sadly found deceased in bed at 16:10 hours on 23 September 2023.

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

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

15/12/2023

2023-0525

John Taylor

Teesside and Hartlepool

[REDACTED] North East Ambulance Service NHS Foundation Trust Bernicia House Goldcrest Way Newburn Riverside Newcastle upon Tyne NE15 8NY

On 29 July 2022 I commenced an investigation into the death of John Robert TAYLOR aged 35. The investigation concluded at the end of the inquest on 07 December 2023. The conclusion of the inquest was that: � John Robert Taylor took a deliberate overdose of insulin, probably on 18.07.2022, with the intention of ending his life. He contacted the emergency services for help. The ambulance arrived the following morning. There was a delay of over 13 hours in the arrival of the ambulance. John was transported to the University Hospital of North Tees. He died at the University Hospital of North Tees on 27.07.2022. Johns� death was contributed to by the delay in the arrival of the ambulance � The Medical Cause of his death is: 1a. Aspiration Pneumonia 1b. Hypoglycaemic Brain injury 1c. Insulin Overdose II Morbid Obesity, Asthma, Ischaemic Heart Disease

Mr Taylor contacted the fire brigades befriend service on 18.07.22 expressing suicidal intent and plans. The fire brigade contacted Cleveland police who is turn contacted NEAS at 1557 on that day. After 3 unsuccessful attempts to speak with Mr Taylor, contact was made at 1610 by a call handler. The matter was assessed as requiring a Category 3 response. The ambulance arrived at Mr Taylor�s home at 0523 on 19.07.22, occasioning a delay of over 13 hours. The paramedic tried the door, but access could not be gained. At 0543 a request was to the police to gain entry. The police arrived on scene at 0558. When the police arrived, they noted that the door was unlocked and that the ambulances hadn�t tried the handle. They gained access to the property within one minute. Care and attention were provided to Mr Taylor, and he was transported to UHNT. He died on 27.07.22. I instructed an independent expert who determined that the delay in the ambulance arrival contributed to Mr Taylor�s death. NEAS undertook an SI report. Oral evidence was provided by a Team Leader and a Clinical Section Manager, the latter having authored the SI Report. It was clear that a comprehensive investigation had been undertaken and learning implemented. The author of the SI report was not aware that the door to the property was unlocked, and that access could have been gained over thirty minutes earlier. My concern is that this information has not been offered or elicited nor has it been reported to the SI author. This issue has therefore not been considered within the SI. A further concern is that the Family gave evidence about NEAS previously using a taxi to transport Mr Taylor to hospital on several occasions. The Clinical Section Manager said there was no policy on this and that it is in the operator�s �gift�. She told me there is no evidence that this option was considered on 18-19 July 2022 to transport him to hospital sooner.

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

Emergency services related deaths (2019 onwards) This report is being sent to: North East Ambulance Service NHS Foundation Trust

31/08/2023

2023-0315

Donna Levy

East London

[REDACTED] North East London Foundation Trust (NELFT), CEMEEssex, RM13 8GQ [REDACTED] Chief Executive, London Borough of Redbridge Council, , 0 erational Director of Assurance, � � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care, 39 Victoria St, Westminster, London SW1H 0EU

On 15th December 2022, this Court commenced an investigation into the death of Donna Levy aged 51 years . The investigation concluded at the end of the inquest on 22nd August 2023. The conclusion of the inquest was a narrative conclusion; �Donna Rose Lydia Levy died in hospital on 14th December� 2022� due to complications of a pressure sore she developed in the community. The pressure� sore developed� due to self-neglect despite support from community health organisations.� � Ms Levy�s medical cause of death was determined as; � 1a Sepsis secondary to pressure sore II Frailty secondary to self-neglect

Donna Levy was housebound. She was admitted to hospital by ambulance as she had become critically unwell. On admission she was observed to present with signs of severe self-neglect. � Ms Levy was found to be suffering from a significant number of skin lesions on her chest, armpits, anterior lower legs and the entirety of her posterior lower limbs reaching as far as her sacrum. Ms Levy had moisture lesions on her buttocks and thighs along with an ungradable pressure sore which had become infected. � Ms Levy had severely oedematous lower limbs, the skin on her legs and feet had extensive cellulitis which had caused chronic ulceration, discoloration and a tree-bark texture. Her toenails were long, infected and discoloured. � The deceased had extensive uterine fibroids that had progressed to the stage that they impeded her mobility and continence. � Ms Levy had clinical signs of sepsis and a stage two acute kidney injury. � The patient was admitted to hospital by ambulance and underwent surgical debridement of dead ulcerated skin and tissue, following surgery she succumbed to infection despite maximal medical support and died on 14th December 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the family of Mrs Levy, the Care Quality Commission. I have also sent it to the local Director of Public Health who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete r� redacted or summary form. He may send a copy of this report to any person who e believes may find it useful or of interest.

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: North East London Foundation Trust | London Borough of Redbridge Council | Department for Health and Social Care

15/06/2018

2024-0094

Darren Carrington

West Sussex, Brighton and Hove

[REDACTED] North Laine Medical Centre, 12-14 Gloucester Street, Brighton [REDACTED], Practice Manager, North Laine Medical Centre, 12-14 Gloucester Street, Brighton [REDACTED] Clinical Commissioning Group, Hove Town Hall, Norton Road, Hove

On 18 th April 2018 I commenced an investigation into the death of Darren James CARRINGTON The investigation concluded at the end of the inquest on 6th June 2018. The conclusion of the inquest was MISADVENTURE BEING IMPULSIVE OVERDOSE WHILST UNDER THE INFLUENCE OF ALCOHOL (DRUG RELATED DEATH)

I am enclosing a copy of the Record of Inquest and also the letter (without it�s annexures) from the Controlled Drug Liaison Officer for the City of Brighton and Hove, [REDACTED] which is self-explanatory

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � South East Coast Ambulance Service, [REDACTED] , Sussex Partnership NHS Foundation Trust 3. [REDACTED] Secretary of State for Health, Department of Health [REDACTED], Chief Executive, NHS England [REDACTED], NHS England South (South East) [REDACTED], Gordons Solicitors [REDACTED], Boots UK Limited � I have also sent it to:- [REDACTED], General Pharmaceutical Council [REDACTED],CQC [REDACTED], Sussex Police � Who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drug and medication related deaths This report is being sent to: North Laine Medical Centre | Brighton and Hove Clinical Commissioning Group

18/12/2023

2023-0529

David Hemmings

Inner West London

[REDACTED] Regional Operations Manager, Choice Support, Ground Floor, 100 Westminster Bridge London. SEI 7XA.

On the 12th and 13th December 2023 evidence was heard touching the death of Mr David Hemmings. He had died on the 4th June 2021, aged 73 years. � Medical Cause of Death � 1 a. Peritonitis Wound InfectionComplex right hemipelvic fractures (operated 13/01/2021, 20/02/2021 and 20/5/2021 � � � How, when, where the deceased came by his death: � David suffered with severe learning disability, dementia and poor mobility. He was resident in Concorde House. At approximately 0800 on 12th January 2023, he was found to have fallen within his flat. He was unable to get up without significant assistance. At approximately 11:00, the London Ambulance Service was called as he was distressed and unable to walk. He was taken to St George�s Hospital and found to have sustained severe pelvic fractures and a fractured and displaced right femur. These were surgically treated on 13th January 2021 with pins and plates to the pelvis and reduction of the femur. This was unsuccessful due to osteopenia and some plates were removed on 20th February 2021. He was discharged immobile to Mc Crae Lane on 25th February 2021. From mid-March he developed a wound infection. This was treated in the community by district nurses, GPs and paramedics. The GP advised referral back to the surgeons on 5th May 2021. He was admitted from outpatients back to St George�s Hospital on 13th May 2021 and underwent washout and removal of metal work on 20th May 2021. During this procedure, the peritoneum was breached and despite treatment, he died of peritonitis on 4th June 2021. � Conclusion of the Coroner as to the death: Complications of surgical treatment of injuries sustained in an accidental fall.

Extensive evidence was taken during the inquest from multiple live witnesses, written statements, and exhibited reports. Of relevance to this report: � David was living in a flat within a complex. There was a communal area. Due to pandemic restrictions no communal activities were taking place and he became increasingly socially isolated, exacerbated further by reduced staff availability. He was able to get up unaided and walk but had coordination difficulties worsened by visual impairment and dementia, such that he required the assistance of 2 persons to move around. � On 12th January 2021, there were severe staff shortages such that the manager of the home had worked more than 36 hours without a break and there was only a skeleton crew on duty. � This meant that David was not receiving the 1O hours per day of contact time during the days that he had allocated to him and instead was subject to 30 min checks in the day and hourly checks at night. � Records suggest that he was checked and found asleep at 0750 hours. � At approximately 0800 on 12th Jan 2021, a support worker entered the complex and heard David calling out in a distressed manner. This worker attended David�s flat and found David sat on the floor in hall behind his front door. The worker called for assistance from the manager and together they lifted and supported him to walk backwards to the chair in his bedroom. He was latter assisted to his bed. It was only when he refused at about 10:30 to stand off his bed and was distressed that another manager was consulted and medical assistance sought. � David was unable to communicate verbally due to his learning disability and had not indicated any particular area of pain on his body. � However the injuries that he had sustained in the fall were severe with multiple pelvic fractures and an impaction fracture of the right head of femur. The pelvic fractures involved the hip joint such that the femur was displaced through the pelvic bones into the pelvic cavity. The evidence of the surgeon was that David would have unable to weight bare on the right and could not have been moved without being lifted and with considerable assistance. � Those staff that had moved David would have had to have provided this assistance. � To move an injured person in this way when they were unable to weight bare was unsafe, could have exacerbated any injuries, and was against the training in moving and handling following a fall that those two staff would have received. � Following evidence from the surgeon, I was satisfied that in this particular case, the actions of moving David did not contribute to his death, however I remain concerned. The support worker in evidence could hardly remember what training he had received in relation to moving and handling following a fall. At the time, during the pandemic, the training would have apparently been eLearning and video watching for the support worker. The manager was said to be experienced and committed to his work; however both these staff acted outside their training and moved a severely injured man in a way which could have exacerbated his injuries and would have caused him severe pain. � It was only when a second manager became involved that clinical care was sought.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Sister of Mr Hemmings: [REDACTED] �� St George�s Hospital Legal Department, St George�s Hospital, Blackshaw Road, London. Sw17 OQT � Director Integrated Learning Disability Team, Social Services, 4th Floor Merton Civic Centre, London Road, Morden SM4 5DX. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths This report is being sent to: Choice Support

30/08/2023

2023-0313

Allison Aules

East London

[REDACTED] Royal College of Paediatrics & Child Health, NHS England � ����������������������� [REDACTED] President, Royal College of Psychiatrists, London Office, 21 Prescot Street, London, E1 8BB � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

On 3 August 2022 I commenced an investigation into the death of Allison Vivian Jacome Aules. Allison was 12 years old when she passed away on the 19th July 2022. The investigation concluded at the end of the inquest on the 17th August 2023. The conclusion was that Allison died as a result of suicide, contributed to by neglect.

Allison Aules was referred to the mental health team in May 2021 with concerns around evidence of self-harm, low mood, anxiety and enuresis. Her case was inappropriately screened as routine and the referral was triaged 8 weeks later. Allison was not communicated with at this time, but her mother shared a full account of concerns with the triage psychologist. Additional concerns were raised during triage and the matter was taken to a multi-disciplinary team. The team decided that Allison should be assessed face to face. They determined the case to be low risk and placed it in the green zone. The concerns shared with the service should have resulted in a more urgent face to face assessment. The assessment of Allison took place 9 months later. This was not a face-to-face assessment, as directed by the multi-disciplinary team. There was a telephone discussion, initially with Allison�s mother alone. Allison later spoke to the assessor but there was no full assessment of her mental state. There was no full exploration of the concerns raised in the referral and in the triage discussion. There was no evidence of the assessor determining the cause of Allison�s worrying presentation. There was no carefully documented assessment of risk. There was no carefully devised risk management plan. A decision was made to discharge Allison from the mental health team, with no multi-disciplinary review or liaison with the referrer. Allison continued to receive counselling provided at her school, but this concluded at the end of term, on the 15 July 2022. On the 18 July 2022 Allison was found suspended in her bedroom. The failure to provide basic mental health care to Allison contributed to her death.

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

Child Death (from 2015) | Suicide (from 2015) This report is being sent to: NHS England | Royal College of Psychiatrists | Department for Health & Social Care

22/05/2023

2023-0169

Kaius Tutt

Cornwall and the Isles of Scilly

[REDACTED] Service Director � Connectivity and Environment

On 25 October 2022 I commenced an investigation into the death of Kaius. The investigation concluded at the end of the inquest on 27 April 2023. � The conclusion of the inquest was as follows � Road Traffic Collision � The four questions � who, when, where and how � were answered as follows � Kaius John Paul TUTT died on 14 October 2022 on the A391 Between the SCREDDA and CARCLAZE roundabouts near St Austell Cornwall from trauma after Kaius attempted an overtaking manoeuvre whilst riding his motorcycle and collided with a car being driven on the opposite carriageway. � The medical cause of death was found as follows � 1a) Multiple injuries Comment: There were head, aortic and pelvic injuries that were not compatible with life. Toxicology was negative.

Kaius died from injuries sustained after the motorcycle he was riding collided with a car coming in the opposite direction. At the point of the collision the motorcycle that Kaius was riding was in contravention of solid double white lines. � The collision occurred at approximately 19:05 hours on Friday 14th October 2022, on the A391, St Austell, Cornwall. Kaius was approaching the Carclaze roundabout, riding his Honda 125cc motorcycle towards St Austell having come from the direction of the Scredda roundabout. � The court found that rider error on the part of Kaius was the cause of the collision, contributed to by the faded road markings and a visibility issue at the collision location.

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

Road (Highways Safety) related deaths This report is being sent to: Connectivity and Environment

14/06/2024

2024-0321

Michael Harrison

Cheshire

[REDACTED] Technical manager of ALLMI

On 04 March 2021 I commenced an investigation into the death of Michael HARRISON aged 42. The investigation concluded at the end of the inquest on 10 June 2024. The conclusion of the inquest was that: � Misadventure

Michael Harrison was a driver for a scaffolding firm. On 26 February 2021 he was working at Victoria Mills, Macclesfield Road, Holmes Chapel. Whilst unloading scaffolding from a Hiab truck the Hiab arm (a crane-like device) came down on him, causing crushing injuries which proved fatal. The jury found that he was wearing the remote control over his head and across his chest causing the inadvertent movement of the crane arm. The remote control had not been isolated during the unloading activity

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] [REDACTED] [REDACTED] HSE [REDACTED] Cheshire [REDACTED] Constabulary [REDACTED] Representing 3D Scaffolding � 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.

Accident at Work and Health and Safety related deaths This report is being sent to: ALLMI

10/7/2024

2024-0379

Mahamoud Ali

Inner North London

[REDACTED] The Chief Executive Officer� East London NHS Foundation Trust Trust Headquarters� 9 Alie Street� London�� E1 8DE

On 1 September 2020, an investigation was commenced into the death of Mahamoud Hussain Ali, aged 40 years old.�� The investigation concluded at the end of the inquest on 26 April 2024. The medical cause of death was: 1a. Bronchopneumonia� 1b. Ischaemic encephalopathy 1c. Subdural haematoma� The conclusion of the jury was accident.

On 19� August� 2020,� Mahamoud� Hussain� Ali� fell� in� the� street.� He was� taken� by ambulance to Homerton University Hospital where he was treated in the Emergency Department. A CT scan of his brain showed no intracranial bleeding and no skull fracture. He discharged himself.� �� The same morning, he fell again in the street and was taken back to the same hospital by� ambulance.� A second CT brain� scan� showed� no� change.� Concerns about his behaviour and mental health led to him being admitted overnight.�� Following a mental health assessment conducted by a psychiatrist on 20 August 2020, Mr Ali was detained under section 2 of the Mental Health Act 1983 and transferred to Lea Ward, Mile End Mental Health Hospital, arriving just before 7pm on 20 August 2020. He� was� placed� in� isolation� pending� a� covid� test� and� was� assigned� to� be� under observation every 15 minutes.�� The next day 21 August 2020 at around 1800 he was found unresponsive on the floor of his room. LAS were called and he was taken to Royal London Hospital where a CT scan showed evidence of unsurvivable early brain death and where surgery was considered futile.�� Mahamoud Hussain Ali died on 26 August 2020 at the Royal London Hospital.

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

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

29/04/2024

2024-0265

William Stockil

West Sussex, Brighton and Hove

[REDACTED] Vice President of Oracle Corporation UK Limited National Medical Director, NHS England & NHS Improvement

On 23 September 2022 I commenced an investigation into the death of William Richard STOCKIL aged 74. The investigation concluded at the end of the inquest on 25 April 2024. The conclusion of the inquest was that: � William Richard Stockil died on 6 September 2022 at Royal Surrey County Hospital, Egerton Road, Guildford, Surrey from a pneumonia. This developed following his admission for treatment of conditions caused by a long lie at his home where he had been on the floor for more than 8 hours on 31 August 2022.

On 31 August 2022 Mr Stockil was admitted to hospital having been found on the floor at home that day by his family. He was reportedly walking when his legs gave way and he was unable to get himself up. He had evidence of rhabdomyolysis and dehydration on admission. � I heard evidence that there was a suspicion Mr Stockil may have an infection due to infection markers, but I also heard that this could have been a result of inflammation following being on the floor. In any event he was prescribed broad spectrum antibiotics to cover an infection having been seen by a Dr at 1am on 1 September 2022. � Mr Stockil�s prescription was completed using the Trust�s electronic prescription system. It was intended by the Dr that he would receive IV 1.2mg of Co-amoxiclav once every 8 hours. When inputting the prescription, the Dr inadvertently selected 18 rather than 8 hourly administration using the drop down menu. The Dr prescribed the medication for 72 hours on the basis that Mr Stockil was awaiting blood results and that once those were received, likely within 72 hours, there would be a review of his medications. � On 3 September 2022 Mr Stockil received the last dose of the prescription made on 1 September 2022. It had not been extended. The electronic prescription system sent out alerts to any member of staff who accessed his medical records on the system to make them aware that his prescription was due to end. It is not clear who received these but I heard evidence that they may have been received by a number of staff who would not consider that this was relevant to their role in the care of Mr Stockil and as such �clicked� off the alerts to them on the system. It was not the case that the alerts were only sent to prescribers but instead anyone who accessed his medical records for whatever reason. � The alerts were not picked up or actioned by any clinician. The system sent out the pre-agreed number of alerts and then stopped sending the alerts. � Mr Stockil received no further antibiotics until 5 September 2022 when he developed signs of infection and clinicians prescribed further antibiotics. The Court found that the cessation of medication was not on the balance of probabilities causative or contributory to Mr Stockil�s death.

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

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

15/08/2023

2023-0291

Ian Darwin

County Durham and Darlington

[REDACTED] ����������������������������������� , Chief Executive Tees Esk and Wear Valleys NHS Foundation Trust West Park Hospital Edward Pease Way Darlington DL2 2TS [REDACTED] National Director of Patient Safety NHS England Wellington House, 133-135 Waterloo Road, London, SE1 8UG CQC

INVESTIGATION � On 7th March 2023 I commenced an investigation into the death of Ian Darwin, 42. The investigation has not yet concluded and the inquest has not yet been heard.

Death was caused by multiple injuries, Ian Darwin being found below , [REDACTED] Durham.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Tees Esk and Wear Valleys NHS Foundation Trust

17/04/2024

2024-0201

Jade Griffiths-Jones

Birmingham and Solihull

[REDACTED] � CEO Birmingham Integrated Care Board [REDACTED] � NHS England, Midlands Regional Director The Rt Hon Victoria Atkins MP � Secretary of State for Health and Social Care

On 4 December 2023 I commenced an investigation into the death of Jade Marie GRIFFITHS-JONES. The investigation concluded at the end of the inquest. The conclusion of the inquest was; �Death was due to natural causes in combination with a delay in ambulance attendance arising from increased demand for ambulances and significant hospital delays.�

Mrs Griffiths-Jones died at the Queen Elizabeth Hospital on the 4th June 2023 as a result of severe and fatal hypoxic brain injury sustained during a cardiac arrest at around 15:00 hours on the 31st May 2023 caused by coronary artery disease. An ambulance had initially been called when Mrs Griffith-Jones started to suffer chest pain at 13:33 but an ambulance was not available to attend due to increased demand and delays handing over patients at hospitals. If an ambulance could have attended within national target times Mrs Griffith- Jones would have arrived at hospital before suffering a cardiac arrest and would have been likely to survive. � Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a Hypoxic-ischaemic brain damage 1b Cardiac arrest 1c Coronary artery disease � percutaneous coronary intervention � II Diabetes mellitus

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

Emergency services related deaths (2019 onwards) This report is being sent to: Birmingham Integrated Care Board | NHS England | Department of Health and Social Care

07/12/2023

2023-0510

Katharine Fox

Essex

[REDACTED] � CEO Essex Partnership University Trust The Lodge, Lodge Approach Wickford, Essex, SS11 7XX

On 26 October 2022 I commenced an investigation into the death of KATHARINE ANNE FOX, aged 51. The investigation concluded at the end of the inquest on 1st December 2023. The conclusion of the inquest was that the deceased had died from hanging, and the conclusion was suicide.

Katharine Fox was being treated at home following a stay as an in-patient in Broomfield Hospital. Some of that stay had involved the deceased being detained under section 2 Mental Health Act 1983. While being treated in hospital, the deceased obtained psychology treatment in the form of a series of sessions with a trainee psychologist with whom she built a good clinical relationship and from which she reported benefiting significantly. Following her discharge from hospital, this psychology treatment effectively came to an end, since the procedures for receiving this treatment in the community were passed to an entirely separate set of clinicians. There was an entirely separate procedure for referral and provision of psychology sessions, with a very significant wait, and the deceased never in fact secured access to those services in the months between being discharged (in May 2022) and her death in October 2022. I was also told by the witness conducting EPUT�s own investigation that the teams use separate notes, and it may not always be possible for those notes to be accessed by other teams. This included evidence that a different computer system is used in the north of the county from in the south.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) [REDACTED] (2)� EPUT � The Lodge, Lodge Approach, Wickford, Essex, SS11 7XX I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: Essex Partnership University Trust

09/01/2024

2024-0016

Karena Wicking

Cumbria

[REDACTED] � CEO of North Cumbria Integrated Care

On 16 February 2023 I commenced an investigation into the death of Karena WICKINGS. The investigation concluded at the end of the inquest . The conclusion of the inquest was � Death from complications arising from an essential surgical procedure. 1a Pulmonary Embolism

Karena Wickings � aged 58 died in her home in Brampton, Cumbria on 5th February 2023. She had been admitted to hospital two months previously for laparoscopic surgery to remove a screening detected colonic cancer. She had a prolonged admission due to multiple postoperative complications requiring further surgeries. Throughout her admission she was given anticoagulant prophylaxis in the form of enoxaparin. Her clinical condition was improving and it seemed as if the cancer had been fully removed but at the time of discharge her mobility remained significantly restricted. Anticoagulant prophylaxis stopped when she left the hospital and it is unclear if ongoing indication was considered. It is more likely than not that the lack of ongoing prophylaxis led to the formation of thrombosis in her left leg and her death due to pulmonary embolism.

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

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

16/12/2024

2024-0696

Anne Leake

Staffordshire and Stoke-on-Trent

[REDACTED] � Chairman of University Hospitals of North Midlands NHS Trust

On 13th June 2024 I commenced an investigation into the death of Anne Patricia Leake, aged 67. The investigation concluded at the end of the inquest on 9th December 2024. � The medical cause of death was: � 1a Hypoxic brain injury 1b Cardiac arrest 1c Ventricular arrhythmia � The narrative conclusion was: � Natural causes contributed to by neglect.

Mrs Leake suffered arrhythmia and cardiac arrest on 17th April 2024.� She was admitted to the Royal Stoke University Hospital and a multi-disciplinary team (MDT) of doctors decided that she was to have heart valve surgery and have an Implantable Cardioverter Defibrillator (ICD) fitted before she was released from hospital.� The purpose of the ICD was to prevent Mrs Leake from suffering future cardiac arrhythmia and cardiac arrest. � A few days later, Mrs Leake underwent heart valve surgery as planned, but she was then mistakenly released from hospital without having fitted the ICD which she needed. � Three days after she was released from hospital Mrs Leake suffered a cardiac arrhythmia of the type which an ICD is designed to address, and she died as a result. � I found that the failure to fit the ICD was causative of Mrs Leake�s death and it amounted to neglect. � The decision of the MDT to fit the ICD was overlooked by the doctors who released Mrs Leake from hospital because the note of the MDT meeting which made this decision was not recorded on the medical notes which they were working from.

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

Hospital Death (Clinical Procedures and medical management) related deaths

University Hospitals of North Midlands NHS Trust

28/11/2023

2023-0484

Ann Pearce

West Sussex, Brighton and Hove

[REDACTED] � Chief Executive University Hospitals Sussex NHS Foundation Trust

On 13 April 2022 I commenced an investigation into the death of Ann Dorothy PEARCE aged 61. The investigation concluded at the end of the inquest on 27 November 2023. The conclusion of the inquest was a narrative which stated: � Ann Dorothy Pearce sustained a fracture of her tibial spine on 26 March 2022 having fallen from her bicycle in Burgess Hill that day. She was taken to the Princess Royal Hospital for treatment and discharged on 28 March 2022. On 1 April 2022 she became unwell at home and an ambulance attended and took her to the Princess Royal Hospital for treatment where she was diagnosed with a massive pulmonary embolism. She was treated but sadly died on 1 April 2022.

Ann Dorothy Pearce was taken to the Princess Royal Hospital for treatment and was discharged on 28 March 2022. During her admission she was immobilised in a brace and on discharge was only partially weight bearing. The Venous Thromboembolism Prevention Policy of University Hospitals Sussex NHS Foundation Trust version 1.4 required that this should be undertaken on admission and reviewed on the daily ward round. No Venous Thromboembolism assessment was undertaken during her admission or on discharge. She became unwell at home on 1 April 2022 and was taken to hospital for treatment but sadly died from a massive pulmonary embolism that day.

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 This report is being sent to: University Hospitals Sussex NHS Foundation Trust

01/02/2024

2024-0058

Lucas Pollard

Bedfordshire and Luton

[REDACTED] � Chief Executive, East of England Ambulance Service

On 08 June 2023 I commenced an investigation into the death of Lucas Tyler POLLARD aged 14. The investigation concluded at the end of the inquest on 18 January 2024. The conclusion of the inquest was that: � Lucas Tyler Pollard was aged 14 at the time of his death on the 1st June 2023. He had been given a new electric moped the day before. He had no prior experience of riding the moped. It was in sound mechanical order although the tyres were significantly underinflated. It was not designed to carry pillion passengers. He went out to ride it with a friend in the early hours of the 1st June 2023 in Leighton Buzzard. It was dry and there was very little other traffic. He was driving east along Leighton Road and his friend was riding pillion when the bike tilted to the right (offside) and then struck a sign post at approximately 20 miles per hour. He sustained very severe injuries to his chest, liver, spleen and pelvis and suffered catastrophic internal haemorrhage. A category 1 ambulance with a target response time of 7 minutes was dispatched from Luton Ambulance Station. It was known that the journey time would be in excess of 20 minutes. A critical care clinician considered the deployment of an air ambulance. That had an estimated journey time of greater than 40 minutes and was not dispatched. There was a rapid response vehicle based at the Leighton Buzzard Ambulance station with an estimated response of 3 minutes. That was dispatched by the computer aided dispatch system but then cancelled by a dispatcher as it would contravene East of England Ambulance Service End of Shift Policy. Deployment of the rapid response vehicle would have enabled aid to be given to Lucas much before the arrival of the ambulance from Luton. There was no discussion between the critical care clinician and the dispatcher. However, I found that the multiple injuries suffered by Lucas during the collision were catastrophic and mean�t that he would not survive the collision whatever aid had been provided.

Lucas Tyler Pollard was aged 14 when he died at the Luton and Dunstable University Hospital. He had been driving his new electric moped at about 1.30 am on the 1st June 2023 when he collided with street furniture and sustained catastrophic unsurvivable injuries. He had no prior experience of riding the moped. A nearby resident heard the collision and went to his aid and called emergency services. The call recording illustrates the first-aider�s increasing concern as Lucas deteriorated. Lucas can be heard in the background very clearly to be deteriorating rapidly and significantly. A Category 1 (C1) ambulance was dispatched followed by another as there were two casualties. C1 reflects an emergency response travelling with blue lights and sirens. The EEAST uses a computer aided dispatch (CAD) system which also automatically dispatched a solo paramedic in a rapid response vehicle (RRV). Fire co-responders were also deployed. A General Broadcast (GB) was not made. A GB is an alert to any other nearby resources who might possibly assist. EEAST policy requires a GB where there are no nearby resources. The first ambulance sent was based at the Luton ambulance station meaning it was greater than 20 minutes away. The second ambulance was also greater than 20 minutes away. The target response time for a C1 ambulance is an average of 7 minutes and 15 minutes for 90% of calls. It was known at the time of dispatch that it would greatly exceed the target time. A Critical Care Dispatcher was aware of the call and nature and considered deploying a Critical Care Team (CCT) but opted to let the crew from the first ambulance to assess and report. This was despite the crew being at least 20 minutes away. The nearest CCT was 42 minutes away by air. It was night which presents difficulties in safe landing etc. It was accepted on reflection that the CCT should have been sent. The RRV was 3 minutes from the scene. The proximity of the RRV was not revealed in the EEAS Serious Incident Investigation Report but emerged during questioning. The RRV was dispatched by the CAD but then immediately cancelled by a dispatcher due to the Trust�s End of Shift Policy seemingly without regard to the actuality of the situation, that the two dispatched ambulances were more than 20 minutes away, a CCT was not dispatched and that a RRV 3 minutes away could have rendered essential aid. The End of Shift Policy limits the calls crews can be dispatched to within the last one hour and last 30 minutes of their shift. The coding allocated to Lucas did not permit the RRV to be sent. As mentioned above, there was clear evidence through the call of Lucas�s markedly deteriorating condition. There appears to have been no coding reassessment. The Critical Care Dispatcher and the �routine� dispatcher were not in the same location but could see each other�s entries into the computer system in real time as they were made. There was no direct dialogue between them. There was no evidence of a dynamic overview reassessment of the situation as it progressed. Had there been, it is possible, likely even, that the RRV would have been deployed. Medical evidence was clear Lucas would not have survived but that was not known at the time of the call.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] � Deputy Medical Director, Bedfordshire Hospitals 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 t he release or t he publication of your response by t he Chief Coroner.

Child Death (from 2015) | Emergency services related deaths (2019 onwards) This report is being sent to: East of England Ambulance Service

06/09/2023

2023-0320

James Jones

North West Wales

[REDACTED] � Interim Chief Executive Betsi Cadwaladr University Health Board

On 09/06/2022 I commenced an investigation into the death of JAMES JONES. The investigation concluded at the end of the inquest on 30/08/2023. The conclusion of the inquest was: Medical Cause of death: 1a Cardiac arrest 1b Bowel ischaemia 1c Superior mesenteric artery occlusion 2 Ischaemic heart disease � Conclusion: Natural Causes

When James Jones was transported to Ysbyty Gwynedd by ambulance on the 27th June 2021, he had a 4-6 day history of abdominal and chest pain with vomiting. He had not opened his bowels for a few days and had reduced urine output. � Mr Jones arrived at Ysbyty Gwynedd at 21.33hrs on the 27th June 2021. He was admitted to the Emergency Department�s Red Zone at 22.34hrs and was observed by nursing staff throughout the night. � Mr Jones was first seen by a Doctor at 6.18am with the assessment recorded at 07.22am. X-rays were performed and at 7.43am, the suspicion of a small bowel obstruction was confirmed, with evidence of dilated small bowel loops on abdominal Xray. Mr Jones was then referred to the surgical senior house officer who reviewed the X-rays and agreed to further assessment. A decision to perform explorative surgery was made at 12.45pm and Mr Jones was taken to the anaesthetic room in preparation for surgery at 3.20pm. Between his arrival at the hospital and being taken to the anaesthetic room in preparation for explorative surgery, Mr Jones experienced the following delays: ���������� Approximately 10 hours to be seen by a Doctor in the Emergency Department � He was triaged at 22.15hrs on the 27th June 2021 and assigned to triage category 2. The evidence was that the aim is for a Dr to see triage category 2 patients within 10 minutes but the wait for Mr Jones from the point of triage to seeing a Dr was 8.5 hours. ���������� A further four hours for a scan to be performed and the results to be available. ���������� A further 3 and a half hours before he was taken to the anaesthetic room. In total, Mr Jones waited 17.5 hours to be taken to the anaesthetic room. Mr Jones was intubated in preparation for surgery but suffered a cardiac arrest prior to administration of anaesthetic. � The Consultant Colorectal Surgeon giving evidence at the inquest did not consider the delay to have contributed to the outcome in Mr Jones�s case but was of the view that. continuing failure by Ysbyty Gwynedd to render care in a timely manner, as seen in Mr Jones�s case, may lead to missed opportunities that may prove fatal for other patients.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Betsi Cadwaladr University Health Board

14/01/2025

2025-0024

Anugrah Abraham

Manchester North

[REDACTED] � National Police Chiefs� Council (NPCC) [REDACTED] � Chief Executive Officer, College of Policing [REDACTED] � West Yorkshire Police

On the 15th March 2023, I commenced an investigation into the death of Anugrah Abraham (�Anu�). Anu died on the 4th March 2023 in Woodland near Red Rock Lane in Bury. He was 21 years old.� The medical cause of death was confirmed as 1a) Hanging. � I recorded a conclusion of Suicide recording the circumstances as follows: �The deceased was a serving West Yorkshire police officer.� He had been on annual leave since the 16th February 2023. He was due to return to work on the 4th March 2023.� The prospect of returning to work is likely to have been a source of distress to the deceased.� On the 3rd March 2023 in the early afternoon he left his home address.� There was nothing in his behaviour which gave rise to concerns from his family.� At 22:50 hours when he had not returned home, Greater Manchester Police were contacted and he was reported missing.� In the early morning of the 4th March 2023 the deceased was located in a wooded area near Red Rock Lane, Radcliffe. He had died as a result of hanging with the intention of ending his life.�

CIRCUMSTANCES OF DEATH In 2021 Anu had joined West Yorkshire Police (�WYP�) under the Police Constable Degree Apprenticeship programme (�PCDA�). This was in conjunction with Leeds Trinity University (�LTU�). At the time it was only possible to join the police if you already had a degree or undertook at degree alongside training to be a police officer. In 2021 the application programme was online and there was no face to face assessment. In addition, a decision had been taken by WYP Chief Officers to remove the in-force interviews. Of note, Anu had not achieved the grades required at A level to undertake a stand alone policing degree. Prior to commencing the PCDA there is no evidence of Anu having any issues with his mental health. � The court heard from a large number of witnesses in respect of various aspects of the PCDA and how it operated in practice.� I found as a matter of fact that : ������� there should have been closer working between the Central Assessment Unit in WYP, in particular the student officer�s assessor and the District Sgts who had day to day line management responsibilities for the officer.� ������� Anu had emerged from his 12 week training at Carr Gate on a development plan. This was not immediately known to his District Sgts and also raised concerns as to the decision to place officers onto patrol when they had failed to demonstrate the skills required of them. ������� Anu was subject to what were described as �Stage 1 meetings in accordance with Regulation 13 of the Police Regulations 2003�. Within WYP, use of regulation 13 had developed into a series of staged meetings. Anu was subject to a �stage1� meeting. It was not immediately clear where the process for implementing various stages of Regulation 13 emanated from. In Anu�s case his District Sgts were not aware Anu was subject to such a review as this information was not shared with them.� ������� The lack of shared information between those taksed with the various aspects of Anu�s management led to mixed, inconsistent messages to Anu as to how he was developing and performing. ������� On the 24th September 2022 Anu was referred to Occupational Health (�ODU�) the waiting time to be seen was three months.� He was not seen until the 15th December 2022. The referral had been for a back injury but also his mental health.� There was an inadequate assessment of his mental health and a lack of consideration of any adjustments required given his mental health issues were linked to his work and the PCDA. ������� During this time he also accessed the Employee Assistance Programme and was referred to a counsellor. In October 2022 it was recorded that he was suffering from severe anxiety and severe depression.� This was linked to the PCDA programme and his work. He reported having suicidal thoughts. This information provided to the counsellor was not shared with WYP.� ������� On the 4th January 2023 Anu had a lengthy meeting with one of his Sgts following which he attended a quarterly review. The serious concerns WYP had as to Anu�s ability were not shared or reflected in the quarterly review. ������� There was a lack of clarity and understanding as to what options were available to students if they wanted to leave the PCDA programme after 2 years but continue with the degree element. Evidence was contradictory as to whether there academic credits could be used to continue on a degree albeit they may have to fund any remaining years. ������� On the 13th January 2023 Anu made direct contact with the OHU where it was acknowledged he appeared to be in �intense mental distress.�� Whilst he was spoken to again later that day, there was no plan documented that he would be seen or re-contacted by OHU, this appeared to be because Anu had made direct contact and it had not been a referral from a senior manager.� Anu should have been offered a face to face appointment. ������� On the 23rd January following further concerns about Anu�s work he had a meeting with a District Sgt and was advised he was being placed on a further development plan. A subsequent email was sent to Anu by his Sgt setting out his development. During the course of this meeting Anu indicated he felt suicidal. An urgent referral was made to OHU.� The subsequent email to Anu in no way was reflective of a caring approach to an individual who was expressing suicidal thoughts.� ������� Following this urgent referral to OHU an appointment was offered for April 2023.� Anu should have been offered an urgent face to face appointment.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- � Family of Anugrah Abraham National Police Chiefs Council College of Policing West Yorkshire Police Leeds Trinity University � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Police related deaths

National Police Chiefs� Council | College of Policing | West Yorkshire Police

14/10/2024

2024-0550

Stephen Sleaford

Leicester City and South Leicestershire

[REDACTED] � Secretary of State for Justice & Lord Chancellor � [REDACTED] � Minister of State for Prisons

On 31 October 2022 I commenced an investigation into the death of Stephen Anthony SLEAFORD aged 49.�The investigation concluded at the end of the inquest on 26 September 2024.�� The conclusion of the inquest was (by way of a narrative conclusion) that: �On the 27th of October 2022, Stephen Anthony Sleaford was found hanging by ligature in his cell at HMP Gartree at 07:12 where he was a serving prisoner.� Prior to this, Stephen complained of pains and health issues, including mental health issues. Due to failings of the prison system, not following the adequate protocols, Stephen was unable to receive the health care and support he required and was pronounced dead on the 27th of October 2022 at 08.01.� The cause of death was established as: I a Hanging by Ligature I b I c II

Stephen Sleaford was born on 15 February 1973 in the Boston area of Lincolnshire and he died on 27 October 2022, at Gartree Prison near Market Harborough, Leicestershire. He was 49 years of age when he died. Mr. Sleaford was a prisoner at Gartree and had been for around 11 years prior to his death. He had been accommodated at a number of prisons, but predominantly at Lincoln and Gartree Prisons. In late May 2022, Mr. Sleaford was transferred to Lincoln Prison, for the purpose of accumulated visits, a process whereby he was moved closer to his family, including his father who was unwell and with whom he was very close, so that visiting would be easier for all.� He returned to Gartree Prison on 11 August 2022. Mr. Sleaford saw a prison GP on 25 October 2022, when he complained of struggling with right ankle pain, and had been struggling to sleep since his last co-codamol prescription had ended.� On that day, he was prescribed a short course of medication to try to restore sleep. On the same date, a prison healthcare nurse was asked to see Mr. Sleaford due to the suspicion that he was under the influence of an illicit substance, although he was assessed as not being under the influence. A substance misuse worker went to see him the following day, 26 October 2022, because he had been found with fermenting liquid (brewed alcohol) in his cell and an improvised smoking device.� He was spoken to by that worker, when Mr. Sleaford declined formal substance misuse intervention. In the afternoon of the same day, that is 26 October 2022, Mr. Sleaford was seen by a supervising prison officer and his prisoner status was downgraded from �enhanced� to �basic� level.� He did not react well to that news and told the officer that he would �show [him] basic behaviour� before returning to his cell.�Later that evening, the Prison Officer on duty on Alpha wing (where Mr. Sleaford was accommodated) who knew him and appeared to have a good rapport with him, spoke with him at around 9pm and they had a conversation, when he was seen and appeared to be in a good mood.� The following morning, that is 27 October 2022, during her shift, the same officer re- attended outside the cell around 5:45am, when she did not see Mr. Sleaford, due to the cell door�s observation panel being obscured internally, but she did receive a verbal acknowledgment from him. Later the same morning, when the day staff were on duty, another officer was unable to get a verbal response from Mr. Sleaford, when outside his cell, so that officer went to obtain advice and colleague assistance. He returned with other staff and entered the cell, where Mr. Sleaford was discovered with a ligature around his neck and was believed to be unresponsive. Prison officer staff waited� for� several� minutes� while� further� staff,� including� healthcare� staff,� attended� at� the� cell, followed later by paramedics.� Mr. Sleaford could not be revived and his death was confirmed at the scene by one of the attending paramedics, at 08:01 hours on 27 October 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1)� The Family of the Deceased (namely�[REDACTED] and [REDACTED]), through their legal representatives. 2) Nottinghamshire Healthcare NHS Foundation Trust, as providers of in-prison healthcare at the date of Mr. Sleaford�s death. 3) The legal representatives of His Majesty�s Prison & Probation Service/Ministry of Justice. � I have also sent it to: 1) The Governing Governor � HMP Gartree, Leicestershire. 2) Practice Plus Group Limited, as current providers of in-prison healthcare (since March 2024). 3) The Office of the Prisons & Probation Ombudsman (�PPO�). 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

Ministry of Justice | HM Prison and Probation Service

14/03/2024

2024-0141

Victor Costello

Teesside and Hartlepool

[REDACTED](Chief Executive) Stockton Care Limited Suite 20, Durham Tees Valley Business Centre Orde Wingate way Stockton-on-Tees TS19 0GD

On 13 March 2024, I opened an investigation into the death of Victor Valentine COSTELLO, aged 84. The investigation concluded at the end of the inquest also held on 13 March 2024. I made a determination that death was from natural causes. The medical cause of death was: 1 (a) bronchopneumonia 2 cerebral infarction and generalised atherosclerosis

CIRCUMSTANCES OF DEATH � Mr Costello was a resident at Primrose Court Nursing Home. He was taken to hospital on the morning of the 17th February 2020 and passed away there six days later from naturally occurring disease.

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

Care Home Health related deaths This report is being sent to: Stockton Care Limited

22/01/2024

2024-0038

Kate O�Donnell

Teesside and Hartlepool

[REDACTED], Acting Chief Executive Officer, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW

Kate Elizabeth O�Donnell died at James Cook University Hospital, Middlesbrough on 23.03.22. I commenced an investigation into her death. On 17th and 18th January 2024, I held the inquest into her passing. The Medical Cause of her death is: 1a. Multi organ failure 1b. Systemic sepsis II. Hypopituitarism following chemoradiation for intracranial germ cell tumour. � I left a narrative conclusion as follows Kate Elizabeth O�Donnell underwent surgery at James Cook University Hospital on 16.03.22. She was discharged home on 17.03.22. She developed sepsis from the surgery and died at James Cook University Hospital on 23.03.22. The sepsis originated in her gut. The failure to administer prophylactic anti-biotics for the gastro-intestinal surgery contributed to her death.

Miss O�Donnell�s past medical history included a Germ Cell brain tumour which reoccurred at ages 4,7 & 9. She was treated with chemotherapy and radiotherapy. � Aged 9 she received high dose chemotherapy and was consequently paralysed from just below the waist. � She endured resulting chronic nerve pain/damage and was prescribed high daily doses of pain relief medications. � Miss O�Donnell was doubly incontinent. Treatment moved from intermittent catheterisation to a suprapubic catheter. Age 11 she underwent an ACE procedure. This was used for a few years until it was changed to a colostomy. Miss O�Donnell sustained regular infections from the redundant ACE. The infections had a significant impact on her overall health and exacerbated her pain. � It was therefore determined that the ace stoma would be excised. This procedure, along with a cystoscopy, bladder washout & injection of 200 units of Botox took place on 16.03.22. Miss O�Donnell and her family encountered several problems in the immediate run up to the operation, to include the hospital notes being mislaid, not meeting the anaesthetist ahead of the operation, uncertainty about the colorectal surgeon�s involvement, the possibility that the ACE stoma would not be reversed and subsequent confirmation that it would be and on the day of the procedure apparent uncertainty from the urologist as to how the operation would proceed. I accepted that all these points caused the family concern and frustration. I found that the operation was not well planned. � On 11 March 2022 Miss O�Donnell attended the hospital and gave a urine sample. The results showed a resistance to Ciprofloxacin. The consultant gave evidence that he checked the results on the morning of the operation by consulting WebIce. An audit of WebIce was provided which showed that no one accessed WebIce on the day of the operation. I held that the Consultant urologist was not aware of the results of the urine sample before the operation. I determined that on the day of the operation he acted in accordance with his usual practice, rather than to tailor the anti-biotics to the urine test results. He administered prophylactic Gentamicin at the start of the procedure and provided Ciprofloxacin post procedure both for the urological aspects of the surgery. The latter was ineffective as she was resistant to that medication. I found that the Consultant overlooked the provision of prophylactic anti biotics for the gastro-intestinal operation. � I determined that the surgeon was unaware of the classification of surgeries and didn�t know that surgery could be clean-contaminated. He did not know of the SIGN guidelines and that prophylactic anti biotics were highly recommended for that type of gastro-intestinal surgery. I held that a member of the colorectal team should have assisted with the operation. � Post surgery Miss O�Donnell vomited a large amount on a single occasion and was suffering from ongoing pain. Mrs O�Donnell was her daughter�s full-time Carer and was an expert in caring for her daughter. I accepted her evidence that on a good day Kate�s pain would be 7/10. I found that the pain charts detailing Kate�s pain post -surgery were grossly understated. Nurses were informed of her pain but took no action to alleviate the same. The episode of vomiting was not recorded in the notes. � I accepted that generally one-off vomiting and pain may not be enough to prevent discharge with most patients. However, Kate�s vulnerabilities, comorbidities, and extensive involvement with the medical teams, should have ensured extra vigilance and recognition should have been given to her reactions, with medical attention being sought. � I determined that Kate was not physically assessed by a doctor prior to discharge. Kate should not have been discharged without a thorough further medical assessment which had been prompted by accurate medical recordings. The family should not have left hospital without information on sepsis or what to do if Kate was to deteriorate. � In the days following discharge Kate vomited daily, most days suffering several bouts of vomiting. I accepted that the Ciprofloxacin probably supressed the sepsis that Kate was battling post-surgery. � Kate deteriorated and ultimately was taken to James Cook University Hospital on the morning of 23.03.22. She passed away shortly after her arrival. The Trust undertook an internal investigation and produced a Patient Safety Incident Investigation Report. This report was presented at the inquest by one of the Trust�s Clinical Directors. He confirmed that the hospital did not investigate the issue of prescription of prophylactic antibiotics for the gastrointestinal surgery. He accepted that more should have been done to check Kate�s sodium before she was discharged and that a nurse should have contacted a doctor about the pain scores (even on the understated values). � I instructed an independent expert to assist in determining whether any provision or omission in care contributed to Kate�s death. I was informed that the provision of Ciprofloxacin contributed to Kate�s death as it suppressed the sepsis she was fighting. I was also told that the omission of a prophylactic antibiotic for the gastrointestinal surgery contributed to Kate�s death. The expert confirmed that the sepsis from which Kate died developed directly from the surgery undertaken on 16.03.22 and that the sepsis originated in her gut.

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

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

01/08/2024

2024-0422

Kieran Lavin

Birmingham and Solihull

[REDACTED], Birmingham and Solihull Mental Health NHS Foundation Trust

On?2 January 2024?I commenced an investigation into the death of?Kieran Lavin. The investigation concluded at the end of the inquest held between 22-25 July 2024.

Kieran had experienced anxiety and depressive symptoms for around 10 years with worsening symptoms in� late 2023. In November he consulted his GP having inadvertently stopped taking his anti-depressant� medication. On 5/12 he reported worsening symptoms after restarting his medication for two weeks, and said he had thoughts of jumping in front of a vehicle and an overdose, citing the breakdown of his relationship�with his wife as one of the triggers. He was referred to the Crisis team and assessed on 7/12 reporting no� active suicidal plans. His anti-depressant medication was increased, and he agreed to be seen routinely in 4� months. The following day, on 8/12 he booked into a hotel to overdose on his medication with alcohol. He�was surprised to wake up and was admitted to the Emergency Department early on 9/12. Psychiatry & Liaison� referred him to the Psychiatric Decisions Unit (�PDU�) for further assessment as he could not guarantee his� safety. He arrived at the Oleaster Centre, Birmingham at 9:55pm. The following day, early morning on 10/12� during a nurse assessment he said he was angry the overdose attempt had not worked, and if he went home,� he would maybe throw himself in front of a lorry. He cited in part the relationship breakdown with his wife as� one of the triggers for his presentation. Later that day, he was assessed by a consultant psychiatrist whose� impression was of a depressive episode, and that Kieran required informal admission as he did not feel safe to� go home, which Kieran agreed with. The following day, by 11am on 11/12 Kieran proactively contacted a� second nurse reporting when outside the unit for a cigarette he had terrible thoughts, and he does not feel� safe going outside because he thinks he needs to kill himself and he will run and jump in front of a car or train. Around 1-2pm he was assessed by a junior Dr and reported no active suicidal plans, but her impression was he was very anxious and depressed, and the plan was maintained. The long wait for a bed was due to the mental� health service having no available inpatient bed. A private mental health service agreed to admit him in� Willenhall. Kieran�s wife had arrived to drop off some clothes and Kieran asked if his wife could drive him. The� bed manager, also the nurse in charge of the Oleaster Centre, had intended that Kieran be transported via taxi accompanied by a member of staff, but agreed to his wife driving him on the basis Kieran was a voluntary� inpatient, wanted treatment, and assessed his presentation on and off the PDU as raising no safety concerns.� He did not record his risk formulation. He was not aware of the two reports of suicidal ideation via road traffic�collision. Had he looked at the �level 1 risk screening� neither nurse had at this stage updated the �suicide� box.� No record of his suicidal ideation on 10/12 was ever added, and the suicidal ideation reported on the morning� 11/12 was not added until 8:51pm and after the incident had occurred. Whether his wife�s presence would� exacerbate Kieran�s presentation was not fully considered, or the length and nature of the journey. His wife�was not informed of Kieran�s reported suicidal ideation. The mental health service�s policies, procedures and�guidelines did not set out a clear approach to assist regarding what should happen when a patient requests�for family to transfer them to another location for an informal admission. Kieran left with his wife in her car� around 7:45pm. Shortly after 8pm, having just spoken on the phone to his mum, he suddenly proceeded to�open the passenger door whilst in lane 1 of the M5 motorway. His wife attempted to physically stop him�whilst managing to move to the hard-shoulder whereby Kieran exited the passenger door and walked around the rear of the car into the path of an oncoming large lorry in lane 1, and thereafter was struck by a second�car. He was confirmed deceased at the scene from the consequential injuries (1a. Multiple injures). �� The inquest conclusion was: �Suicide, contributed to by a failure to conduct an adequate patient transport risk assessment which would have likely changed the outcome.�

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

Suicide (from 2015)� � This report is being sent to: Birmingham and Solihull Mental Health NHS Foundation Trust

27/03/2023

2023-0107

Aoife McAdam

West Yorkshire (Eastern)

[REDACTED], Burton Croft Surgery, 1 Shire Oak Street, Headingley, Leeds LS6 2AF

On 13th September 2021 I commenced an investigation into the death of Aoife Rose McAdam, aged 19. The investigation concluded at the end of the Inquest on 24th March 2023. The conclusion of the Inquest was that Aoife�s death was a misadventure. The medical cause of death was 1a) Cardiac Arrest; 1b) Intentional Propranolol Overdose; 2) Anxiety & Mood Disorder. The inquest found that the overdose had been taken as an impulsive act, in respect of which Aoife sought help, the provision of which was delayed.

Aoife died on 4th September 2021 in Leeds General Infirmary where she had been brought at 0823 hours having taken a significant overdose of propranolol at about 0430 hours. She rang the Crisis Team and NHS 111 within 30 minutes of taking the overdose. There were two opportunities missed to send her an ambulance sooner which would on the balance of probabilities have meant her reaching hospital at least two hours earlier than she eventually did.

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

Alcohol, drugs medication related deaths

Burton Croft Surgery

07/02/2023

2023-0114

Bridget Gormley

Worcestershire

[REDACTED], CEO Barchester Healthcare, 3rd Floor, The Aspect, 12 Finsbury Square, London EC2A 1AS; � [REDACTED], Weightmans LLP, The Hallmark Building, 105 Fenchurch Street, London EC3M 5JG ( legal representative for Barchester Healthcare at inquest )

[the details below are fictional] � On 3 August 2022 I commenced an investigation and opened an inquest into the death of Bridget GORMLEY. The investigation concluded at the end of the inquest on 8 February 2023. � The conclusion of the inquest was that Mrs. Gormley died as the result of an accident.

In answer to the questions �when, where and how did Mrs. Gormley come by her death?�, I recorded as follows: �On 20.7.22 Bridget Gormley, who had had an increasing number of falls since the end of March 2022, fell again at the care home in Worcester where she lived. She was taken by ambulance to the Alexandra Hospital, Redditch, where she was found to have sustained significant traumatic intracranial bleeding. She was transferred to Worcestershire Royal Hospital where, despite treatment, she continued to decline and died on 31.7.22.� � The care home in question was Latimer Court Care Home, Darwin Avenue, Worcester WR5 1SP, which is owned and run by Barchester Healthcare. Latimer Court�s registered home manager is Donna Tustin.

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

Care Home Health related deaths This report is being sent to: Barchester Healthcare | Weightmans LLP

14/09/2023

2023-0436

Jack Farrington

Hampshire, Portsmouth and Southampton

[REDACTED], CEO Portsmouth Hospitals University NHS Trust, [REDACTED], CEO Solent NHS Trust [REDACTED],, CE NHS England

On 08 January 2020 I commenced an investigation into the death of Jack FARRINGTON aged 26. The investigation concluded at the end of the inquest on 27 July 2023. The conclusion of the inquest was that: � On the 2nd January 2020 Jack Farrington died as a result of falling from a bridge. At the time, Jack was detained under section 2 of the Mental Health Act due to recent psychotic episodes. Evidence suggests that Jack�s capacity to make rational decisions was severely compromised. When Jack was lucid he demonstrated a desire to be well and actively sought medical assistance for his condition. In the days prior to his death Jack had voluntarily attended hospital via ambulance. During Jack�s time in hospital, he was able to abscond twice, and was sectioned under the Mental Health Act and transferred to a mental health facility. Following a suspected medical emergency Jack was transported back to hospital under escort. Significant failings in the assessment, recording, sharing of information, accountability and implementing appropriate measures to keep Jack safe contributed to his ability to abscond a third time, resulting in Jack�s death.

Jack Farrington had a long history of mental health difficulties. He moved to Hampshire in 2019 and his mental health started to deteriorate again later that year. He sought help from his GP and the community mental health services. � On the 30th December he called an ambulance in a state of acute distress. He was transported to Queen Alexandra Hospital, Portsmouth (QAH) and assessed in the emergency department (ED). He was moved to the observation ward and seen by a consultant who requested further assessment to determine whether Jack needed to be detained under the Mental Health Act. Before this happened, Jack absconded from the observation ward via the fire door at approximately 9.00am. � Jack was located by the police and returned to the ward where he was detained under s.5(2) of the Mental Health Act. He was subsequently detained under s.2 of the Mental Health Act. � On the 31st December 2019 Jack absconded via the same route despite being under 1:1 supervision by a registered mental health nurse. Jack was located and returned to the ward by the police. � In the early evening of the same day Jack was transferred to St James� Hospital and admitted to the Hawthorn ward. � On the 1st January 2020 Jack threw himself at a glass dividing wall. � On the 2nd January 2020 Jack suffered a medical episode and was transferred by ambulance to the emergency department of QAH. He was accompanied by 1 escort from St James� Hospital and remained within the ED awaiting medical assessment and treatment. � At approximately 10.00am Jack ran from the ED and shortly after this fell from a road bridge sustaining fatal injuries.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � The family of Jack Farrington � I have also sent it to � Midlands Partnership Foundation Trust Equans � 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 This report is being sent to: Portsmouth Hospitals University NHS Trust | Solent NHS Trust | NHS England

27/08/2024

2024-0471

Alfie Tollett

Devon, Plymouth and Torbay

[REDACTED], CEO of Jaguar Land Rover

On 27th February 2023� I commenced an investigation into the death of Alfie Tollett age 7 . The investigation concluded at the end of the inquest on 16th August 2024 . � The conclusion of the inquest was accident . The circumstances of the death were that on 19th February 2023 the Tollett family attended Plymstock Albion Rugby Football club to watch their eldest son play in a friendly training match against Exmouth RFC. The weather was dry and bright with clear blue skies. The club car park was full and club parking attendants were turning cars away. Alfie�s father parked his Kia Niro with all four wheels on the pavement that runs adjacent to the club car park on Wembury Road. Behind the Kia a white VW Transporter van was parked, unattended, with it�s nearside wheels on the pavement and it�s offside wheels on the road. � Mr and Mrs Tollett went onto the pitches with Alfie and his little brother. Alfie was playing with his football and some other children at the side of the pitches. The rugby match lasted about an hour, once finished Mr Tollett and his two older sons returned to their car for the boys to change their shoes before they went into the clubhouse. Alfie went to the boot of the Kia to change his boots whilst Mr Tollett crouched on the pavement to untie his eldest son�s boots. � Around 11:10 am [REDACTED] and his wife were attending the rugby club to watch their son play in a match. [REDACTED] was driving his wife�s Jaguar ipace �electric vehicle registration number [REDACTED] and his wife was in the front passenger seat. There was a space on the road between the white VW van parked unattended behind Mr Tollett�s Kia and a silver VW van parked further back from the white van. [REDACTED] slowly pulled onto the pavement so his nearside wheels were on the pavement and his offside wheels were on the road. He used his left hand to select the reverse button to straighten the vehicle up. [REDACTED] did not look down at the buttons on the centre consule and relied on feel to select reverse. He looked to his left in preparation to reverse and pressed the accelerator. The Jaguar moved forwards, as reverse had not been selected, failed to notice that the reversing warning alarm had not engaged and collided with the rear of the white VW van causing damage. [REDACTED] did not brake and continued to accelerate pushing the white VW van forwards trapping Alfie between the VW van and his father�s Kia. Mr Tollett immediately got into his car and moved it forward to release Alfie who fell to the ground. He then went to Alfie�s aid but sadly Alfie died shortly afterwards with the cause of death being given as blunt force traumatic chest injuries . There has been no prosecution of the driver [REDACTED] as he died of natural causes shortly after this incident . A team from Jaguar / Landrover were preparing a technical report to assist the police but this was not progressed due to [REDACTED]�s death.

CORONER�S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. � The MATTERS OF CONCERN are as follows. � Although it is accepted that this death was accidental , during the inquest the following information came to light as a result of the investigating police officer giving evidence : There were a number of errors that were made by the driver which caused or contributed to the death . These were Wrongly placing the car in drive instead of reverse Failing to look down at the camera and pressing the button to move forward by touch alone Failing to realise that the reversing warning sound which was said to be very difficult to hear inside the car was not engaged Driving forward and continuing to do so for 8-10 seconds after the accelerator was pressed Failing to press the brake at any time . However, these errors occurred as a result of there being no intermediary step within the Jaguar ipace being necessary to put the car into drive / reverse other than pressing a button . In the police officer�s opinion if there had also been a lever or something similar present in the vehicle that needed to be engaged before a button was pressed this may have alerted [REDACTED] to the fact that he had pushed the incorrect button on the 3 button console .

27th August 2024 �������������������������� Deborah Archer

Child Death (from 2015)

Jaguar Land Rover

25/10/2024

2024-0578

Chloe Every

East London

[REDACTED], CEO, Barking, Havering & Redbridge NHS Foundation Trust Sent via email: [REDACTED] SM-INQUESTS (BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST) [REDACTED] � [REDACTED], Secretary of State for Dept. Health & Social Care Sent via email: [REDACTED]

On 17th November 2023, this court commenced an investigation into the death of Chloe Every, aged 27.� The investigation concluded at the end of the inquest on 21st October 2024. The court returned a narrative conclusion. � Chloe Every died in hospital on 14th May 2019. Chloe�s death was caused by complications of a cardiac arrest sustained on 8th May 2019 whilst in hospital. The cardiac arrest on 8th May was probably contributed to by treatment given to Chloe to manage symptoms of bowel cancer. It is possible that medical procedures undertaken to facilitate diagnosis of Chloe�s cancer contributed to her death. The inquest concluded that multiple actions and omissions of hospital staff during Chloe�s inpatient admission did not comply with local and national guidance. Some of those omissions were actions that would have resulted in contemporary evidence being created relevant to this inquest. I find that there is insufficient contemporary evidence to allow me to undertake proper assessment of all of the factors that are likely to have contributed to Chloe�s death.� � Ms Every�s medical cause of death was determined as; � 1a Multi organ failure 1b Hypoxic Cardiac arrest, subsequent cardiogenic shock 1c Advanced Bowel Cancer (treated with Morphine) II Myotonic Dystrophy

Chloe suffered from a genetic condition, Myotonic Dystrophy. She was also diagnosed with a learning disability. � In late 2018 Chloe was investigated for symptoms indicative of cancer. In Late April 2029 she was admitted to hospital with upper right abdominal pain and an interrupted toilet habit. After diagnostic imaging, a preliminary diagnosis of colon cancer with metastases in the liver was arrived at. � Chloe was admitted into hospital awaiting a flexible sigmoidoscopy, planned for 8th May 2019. � Chloe�s pain increased; she was prescribed morphine. No recorded justification for the use of this powerful drug can be found in hospital records. The identity of one of the prescribing doctors cannot be made out due to the absence of clear records. � On the morning of 8th May 2019, she underwent an enema. Before and during this process, Chloe was observed to be unresponsive. It is Moments after the procedure a crash call was raised as Chloe had sustained a hypoxic cardiac arrest, contributed to by the use of morphine. It is possible that the un-consented enema process contributed to the cardiac arrest. � Chloe was successfully resuscitated and was admitted to the ITU for supportive treatment. � After 5 days her care was stepped down to a respiratory ward, within a matter of hours of transfer, she was found unresponsive and declared deceased.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Barking, Havering and Redbridge NHS Foundation Trust | Department of Health and Social Care

30/11/2023

2023-0490

Julia Murphy

Sefton, St Helens and Knowsley

[REDACTED] (manager) � Abbey Wood Lodge Care home

On 28 April 2023 I commenced an investigation into the death of Julia MURPHY aged 89. The investigation concluded at the end of the inquest on 29 November 2023. The conclusion of the inquest was that: Julia Murphy (known as Sheila) sadly died on 09/04/2023 at Southport Hospital Merseyside PR8 6PN. Julia was 89 years of age at the time if her death. � On 06/04/2023 Julia suffered a fall in the care home where she resided, she was admitted to hospital, however, she was too unwell for surgery to the fracture she had sustained when she fell. Notwithstanding all appropriate care and treatment in hospital Julia�s condition deteriorated culminating in her death. � From the time Julia was resident in the care home she suffered 21 falls, the first being on 15/01/2022 and the last being on 06/04/2023. The final fall when Julia sustained a fracture to her hip caused her death. � During her stay in the care home only 3 referrals were made for advice from the specialist falls prevention team, the first on 30/09/2022, the second on 24/11/2022 the day after her 13th fall on 23/11/2023, it is worthy of note, there was no response from the falls prevention referral on the first occasion and a second referral was not made until Julia had fallen again. � A physiotherapist assessed Julia on 10/01/2023 and recommended the use of a zimmer frame, on 19/01/2023 the falls prevention team recommend Julia should use a zimmer frame, a falls sensor mat, a crash mat and they also recommended Julia should be encouraged to come out of her room during the day. A crash mat was deemed inappropriate. � The third referral to the falls team was made on 10/03/2023, this referral stated ��. �Sheila has had 18 falls since 01/01/2022�. Julia had suffered four falls over the 5th & 6th March 2023. � The first referral form (reason for referral box, on page 1) stated �struggling to walk even short distances and is holding to everything when walking. It might be better with a Zimmer frame or something similar to that�. There was no mention in the reason for referral box of Julia�s falls history even though at the time she had fallen 12 times when that fall occurred. The referral form dated 24/11/2022, (reason for referral box) stated �had a few falls since January this year, sensor mat is in place and OT referral was sent on 30/09/22 and that has been chased up today 24/11/2022�. By the 24/11/2022 Julia had fallen 13 times. � The first referral, in the reasons for referral box did not describe the fact that Julia had suffered 12 falls, as it should have done, and it was not followed up as it should have been until the day after she had fallen on 23/11/2022. � The referral on 23/11/2022 stated in the reason for referral box, Julia had a few falls since January this year when in fact at that time she had fallen in the care home 13 times. � Julia was subsequently assessed, and some falls prevention measures were put in place. However, funding was not formally sought for 1-1 supervision as it should have been, the fact that Julia had suffered so many falls was not escalated as it should have been and the final fall i.e. the 21st fall that Julia suffered on 06/04/2023 tragically caused her death.

Julia Murphy (known as Sheila) sadly died on 09/04/2023 at Southport Hospital Merseyside PR8 6PN. Julia was 89 years of age at the time if her death. � On 06/04/2023 Julia suffered a fall in the care home where she resided, she was admitted to hospital, however, she was too unwell for surgery to the fracture she had sustained when she fell. Notwithstanding all appropriate care and treatment in hospital Julia�s condition deteriorated culminating in her death. � From the time Julia was resident in the care home she suffered 21 falls, the first being on 15/01/2022 and the last being on 06/04/2023. The final fall when Julia sustained a fracture to her hip caused her death. � During her stay in the care home only 3 referrals were made for advice from the specialist falls prevention team, the first on 30/09/2022, the second on 24/11/2022 the day after her 13th fall on 23/11/2023, it is worthy of note, there was no response from the falls prevention referral on the first occasion and a second referral was not made until Julia had fallen again. � A physiotherapist assessed Julia on 10/01/2023 and recommended the use of a zimmer frame, on 19/01/2023 the falls prevention team recommend Julia should use a zimmer frame, a falls sensor mat, a crash mat and they also recommended Julia should be encouraged to come out of her room during the day. A crash mat was deemed inappropriate. � The third referral to the falls team was made on 10/03/2023, this referral stated ��. �Sheila has had 18 falls since 01/01/2022�. Julia had suffered four falls over the 5th & 6th March 2023. � The first referral form (reason for referral box, on page 1) stated �struggling to walk even short distances and is holding to everything when walking. It might be better with a Zimmer frame or something similar to that�. There was no mention in the reason for referral box of Julia�s falls history even though at the time she had fallen 12 times when that fall occurred. � The referral form dated 24/11/2022, (reason for referral box) stated �had a few falls since January this year, sensor mat is in place and OT referral was sent on 30/09/22 and that has been chased up today 24/11/2022�. By the 24/11/2022 Julia had fallen 13 times. � The first referral, in the reasons for referral box did not describe the fact that Julia had suffered 12 falls, as it should have done, and it was not followed up as it should have been until the day after she had fallen on 23/11/2022. The referral on 23/11/2022 stated in the reason for referral box, Julia had a few falls since January this year when in fact at that time she had fallen in the care home 13 times. � Julia was subsequently assessed, and some falls prevention measures were put in place. However, funding was not formally sought for 1-1 supervision as it should have been, the fact that Julia had suffered so many falls was not escalated as it should have been and the final fall i.e. the 21st fall that Julia suffered on 06/04/2023 tragically caused her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED]- NOK � I have also sent it to CQC [REDACTED] -Business Unit Head for Urgent Care and Community Services � HCRG Care Group � [REDACTED] � Executive Director of Adult services and Health & well Being � Lancashire County Council � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any 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: Abbey Wood Lodge Care Home

04/10/2023

2023-0364

Kellie Poole

Derby and Derbyshire

[REDACTED] , Chief Executive Health and Safety Executive Redgrave Court Merton Road Bootle Merseyside L20 7HS

On 28 April 2022 I commenced an investigation into the death of Kellie Jean POOLE aged 39. The investigation concluded at the end of the inquest on 27 September 2023.

Kellie died on 25 April 2022 on the river bank of the River Goyt near to Whaley Bridge in Derbyshire. She had collapsed in the river whilst participating in a led session of cold water immersion. On the evidence it is likely that the cold water triggered her heart to go out of rhythm which then led to her sudden cardiac death. � On post mortem examination it was identified that Kelly had an abnormal heart, although she had never been diagnosed with or suspected to have a heart condition. It is likely the heart condition prevented recovery from the heart dysrhythmia.

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

Other related deaths This report is being sent to: Health and Safety Executive

01/02/2017

2024-0093

Daniel Bowen

West Sussex, Brighton and Hove

[REDACTED] , Vice Chancellor, University of Sussex, Sussex House, Brighton, BN1 9RH [REDACTED], Deputy Director of Student Experience, University of Sussex, Sussex House, Brighton, BN1 9RH

On 26th September, 2018 I commenced an investigation into the death of Daniel Alexander Jeremiah BOWEN. The investigation concluded at the end of the inquest on 30th January, 2019.The conclusion of the inquest was HE TOOK HIS OWN LIFE.

See Record of Inquest

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] � Mother [REDACTED] � Father [REDACTED] � Sussex University Health Centre, For information [REDACTED] � Head of Campus and Residential Support [REDACTED] � Acting Head of University Counselling Service Secretary of State for Health, Department of Health [REDACTED], Chief Executive, NHS England I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: University of Sussex

22/07/2024

2024-0390

Omar Ahmed

East London

[REDACTED] , lnterim Chief Executive Officer, The East London Foundation NHS Trust (ELFT) Sent via email: [REDACTED] [REDACTED], Chief Executive Officer and [REDACTED] Director of Social Care, The�London Borough�of Newham Sent via email:�[REDACTED] and [REDACTED] � [REDACTED], Secretary of State for Department of Health & Social Care Sent via email: [REDACTED] [REDACTED] Director of Quality and Gompliance, Sunlight Care Group� Sent via email:�[REDACTED]

On 22/11/2023 this Court commenced an investigation into the death of Omar Abdi Ahmed aged 54 years. The investigation� concluded at the end of the inquest on 15th July 2024. The court returned a narrative conclusion; �Omar Abdi Ahmed died on 20th November 2023 in hospital due to hypothermia. Mr Ahmed, an amputee who received domiciliary care three times a day, was found by carers, unresponsive at home on l5th November 2023. Mr Ahmed had developed pneumonia which, along with ischaemic heart disease had contributed to his hypothermia. Mr Ahmed had chosen not to activate his home�s heating system. � Mr Ahmed�s medical cause of death was determined as; � la Hypothermia lb Pneumonia and Ischaemic Heart Disease II Diabetes Mellitus Type II

Omar Abdi Ahmed was a S4-year-old man who lived alone in a flat in Forest Gate. Mr Ahmed had significant comorbidity and had undergone a surgical amputation of one leg and the partial amputation of the other. Mr Ahmed received district nursing care to monitor and treat his wounds. Mr Ahmed had a package of domiciliary� care, commissioned by the local authority to assist him in undertaking the tasks of daily living such as cleaning, personal hygiene, preparing meals and mobilising. The care was contracted to a private provided who undertook three visits per day, a provision that was topped up with an extra 3 hours per week to assist Mr Ahmed with cleaning and community� engagement. Mr Ahmed was admitted to hospital by ambulance on 15th November. On the third domiciliary� care visit of the day on the evening of 1Sth November 2023,Mr Ahmed was found to be unresponsive. The ambulance� service found Mr Ahmed hypothermic� (28c) with reduced consciousness lying in a foetal position in bed. The patient was assessed to be in septic shock and was noted to have recently developed a pressure ulcer. A safeguarding report was made regarding the condition of the deceased who was found to be wearing a soiled incontinence pad. His right leg was dressed in a dirty bandage that had not been changed for two weeks. The flat was unheated and unsanitary. After transfer to hospital diagnoses of sepsis and hypothermia were confirmed, despite treatment Mr Ahmed died at 2059 on 20th November 2023.

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

Community health care and emergency services related deaths� � � This report is being sent to: East London Foundation NHS Trust | London Borough of Newham | Department of Health and Social Care | Sunlight Care Group

06/03/2023

2023-0082

Evelina Vilkiene

East London

[REDACTED] Acting Chief Executive Officer, North East London Foundation Trust

On the 20th June 2022 I commenced an investigation into the death of Evelina Vilkiene aged 45 years. The investigation concluded at the end of the inquest on 2nd March 2023. The conclusion of the inquest a narrative conclusion: � Evelina Vilkiene took her own life whilst under the care of the mental health services. She was at increased risk of harm to herself following a decision to wean her clonazepam medication on the 26 May 2022, but there was no careful risk management plan and there were no significant assessments of her mental health following the 27 May 2022�.

Evelina Vilkiene suffered from a first psychotic episode in November 2021 and required care from the mental health services. She was admitted to the care of the intensive home treatment team and then transferred to the care of the early intervention in psychosis team. In April 2022 she presented in crisis again, presenting with severe depression. She was accepted again by the home treatment team and remained under their intensive support until 21 May 2022. There was no detailed risk assessment at the time of step-down, or jointly agreed risk management plan. At the time of step-down she presented as anxious in relation to her medication and showed a dependence to clonazepam. A medical plan was set to wean her off the clonazepam on the 26 May 2022, with no carefully devised risk management plan put in place. There was no care co-ordinator visit following the medical review on the 26 May 2022. On the 7 June 2022, Evelina was found hanging in the basement of her home address. A paramedic pronounced her life extinct on scene. Police deemed the circumstances as non- suspicious. A note was found which contains Evelina�s stated intention to take her own life.

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

�Suicide (from 2015)| Mental Health related deaths

North East London Foundation Trust

28/04/2023

2023-0143

Winbourne Charles

East London

[REDACTED] Acting Chief Executive Officer, North East London Foundation Trust � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

On 11th April 2021 this Court commenced an investigation into the death of Winbourne Gregory Charles, aged 58. The investigation concluded at the end of the inquest held before a jury between the 17th and 21st April 2023. The Court returned a conclusion of: � �Suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed.� � Mr Charles� medical cause of death was determined as; 1a Suspension

Winbourne Gregory Charles was a admitted into hospital under section 2 of the Mental Health Act 1983 in November 2020 following an attempt to take his own life. In December 2020 on a diagnosis of depressive illness incorporating psychotic symptoms, Mr Charles was made subject to an order under section 3 of the Mental Health Act 1983. � On 10th April 2021 Mr Charles was found unresponsive, suspended [REDACTED] �on the mental health ward.

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

Suicide (from 2015) This report is being sent to: North East London Foundation Trust | Department of Health and Social Care

15/02/2023

2023-0059

Raniya Khan

Berkshire

[REDACTED] Acting Chief Executive, Royal Berkshire NHS Foundation Trust

I conducted an inquest into death of Raniya Rizwan Khan at Reading Town Hall, which concluded on 9th February 2023. I recorded a conclusion of natural causes. Her cause of death was: 1a Multi-organ failure 1b Severe arterial pulmonary hypertension of unknown cause

Raniya was born at 07:52 hours on 9th May 2020. Although I heard evidence about her attendance at the day assessment unit (�DAU�) the day before the birth, and about her neonatal management, the focus of the inquest was on her labour management from the time of her admission to the labour ward at 03:45 on 9th May. Her care by a band 6 agency midwife from that time until shift change at around 7am was the focus of the investigation. I found in evidence that this midwife: 1. Failed to recognise a pathological trace. Both the trust�s internal investigation and the report of an independent expert concluded that it should have been classified as pathological from 06:40 hours. This was largely because of reduced variability. � 2. Conducted so called �fresh eyes� reviews herself for this patient, rather than asking a colleague to do so. The reasons she gave for this significant, repeated and undocumented deviation from policy were inconsistent with the rest of the evidence, and I found them unlikely to be true. � 3. Recorded the maternal rather than fetal heart rate for part of the trace. My understanding is that this can happen (briefly) even in experienced hands, but this was not recognised at the time by the midwife. � 4. Did nothing to escalate or investigate the mother�s high pulse rate. � 5. Did not take regular temperature readings, despite spontaneous rupture of membranes happening some hours before, when Mrs Rizwan was admitted to the DAU and was given paracetamol for a raised temperature. Raniya was transferred to Great Ormond Street Hospital on 15th May 2020, when her condition deteriorated. Despite extensive consideration and re-consideration of all relevant treatment options, Raniya died at Great Ormond Street Hospital on 28th May 2020. I concluded that earlier delivery was unlikely to have changed the outcome. Despite extensive investigation (including genetic investigations) at a very senior level, it has not been possible to identify the cause of Raniya�s pulmonary hypertension.

I have sent a copy of my report to the Chief Coroner and Raniya�s family. I have also sent a copy of this to, [REDACTED] Chief Executive, NHS Professionals, [REDACTED] Chief Executive, Nursing and Midwifery Council Although NHS P and NMC are not required to submit a formal response, I am mindful of their roles in training, assessment (for NHS P) and registration of midwives (for NMC) It is likely that, should a similar case arise, I will include them as Interested Persons. I am also under a duty to send a copy of your response to the Chief Coroner and all Interested Persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

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

Royal Berkshire NHS Foundation Trust

29/10/2024

2024-0610

Jamie Harding

Essex

[REDACTED] CEO of Essex Partnership NHS Foundation Trust

On 20th June 2022 I commenced an investigation into the death of Jamie Harding, aged 31 years�. The investigation concluded at the end of a 5-day inquest on 12h April 2024. The medical cause of death was confirmed as: � I (a) Multiple severe Injuries I (b) Fall from Height � II Psychotic Disorder � The Deceased had been under the care of the Essex Partnership NHS Foundation Trust (EPUT) Essex Support and Treatment for Early Psychosis (ESTEP) between 2017 and 2020 and he had been prescribed anti-psychotic medication and allocated a Care Coordinator. The inquest heard evidence that Jamie had engaged relatively well with his care plan and was reporting improvements in his symptoms. However, he began to disengage with services in 2019, which appears to have coincided with the replacement of his Care Coordinator. He was discharged from EPUT services in November 2020. Jamie�s GP continued to be prescribed anti-psychotic medication. Two separate and urgent GP referrals were made to EPUT in November 2021 requesting an urgent review of Jamie, as he was hearing voices, experiencing paranoia, and reporting that his medication was not working. His mother also contacted EPUT directly. On 18 January 2022, Jamie was assessed by EPUT�s First Response Team (FRT) via telephone. Jamie described his symptoms, reported that he was binge drinking, and requested different medication. A plan was put in please for Jamie to self-refer to a drug an alcohol service, and for his case to be discussed in a Multi-Disciplinary Team meeting (�MDT�).� The evidence disclosed that in the six months that followed this assessment there were a series of significant and repeated failures on the part of EPUT employees, together with inadequacies in the systems of operation of EPUT�s First Response Team, in the care, management and treatment provided to Jamie. � My Narrative Conclusion recorded that the Deceased took his own life whilst the balance of his mind was disturbed and, further, recorded that a number of significant and repeated failures contributed to the avoidable death. The cumulative effect of these failures amounted to a gross failure to provide Jamie with basic medical care at a time that his condition clearly required it and, in this respect, neglect directly contributed to Jamie�s death.

On the 3rd of June 2022 Jamie, accompanied by his mother, presented at Basildon Hospital A&E Department in crisis and seeking help for his further deteriorating mental health on a background of some three days lack of sleep and ineffective anti-psychotic medication failing to ameliorate the on-going and extreme paranoia and psychotic symptoms he was experiencing.� In the context of on-going suicidal ideation and a subjective mood score recorded as 0/10, he was appropriately referred to the Mental Health Liaison Team (MHLT) for assessment by the A&E doctor. � The assessment subsequently undertaken by the MHLT practitioner was inadequate and failed to appropriately act upon relevant information available to him including (but not limited to) information provided by Jamie�s mother regarding her son�s on-going suicidal ideation and her (and Jamie�s) expressed request for him to be admitted to hospital as a voluntary in-patient as she, and Jamie, did not feel able to keep him safe. � Although the MHLT clinician gave evidence that he had concluded that Jamie required and would benefit from a period of admission as an in-patient, no such admission was sought or planned.� Instead, Jamie was discharged home with a plan for him to be seen the following day by the Home Treatment Team. He was provided with a (daily) tablet of Zopiclone for the next seven days. Within hours Jamie had taken his own life having fallen a significant height from a window at his home address. � The failure by the MHLT practitioner to initiate the process for Jamie�s admission to an in-patient bed constituted a clear missed opportunity to ensure appropriate and likely effective steps were taken to mitigate his high risk of acting upon his clear suicidal ideation. � The cumulative effect of the series of serious failures in the six months preceding the events of the 3rd of June amounted to a gross failure to provide Jamie with basic medical care at a time that his condition clearly required it.� In this respect, neglect directly and more than minimally contributed to Jamie�s death. � The failures identified included: � a serious failure to adequately follow up a plan identified in an assessment undertaken on the 18th January 2022 by a First Response Team (FRT) Assessor and a Trainee Doctor.� The lack of any adequate follow up led directly to a failure to conduct a full Multi-Disciplinary Team Meeting (MDT) in respect of Jamie�s complex, on-going presentation involving increasing paranoia and psychotic-like symptomology in conjunction with on-going alcohol misuse; � a failure to undertake an urgent medication review over the same six-month period despite repeated requests for the same from GPs, Jamie himself and his mother; � the failure to hold a full MDT was a significant missed opportunity to allocate a Care Coordinator to Jamie and a missed opportunity to involve the Dual Diagnosis Service in Jamie�s care; � absent a full MDT and the allocation of a Care Coordinator, there was a serious missed opportunity to develop an appropriate Care Plan for Jamie and undertake regular, up-dated risk assessments regarding self-harm and suicide; � On the 20th May an EPUT Consultant Psychiatrist declined to undertake a review of Jamie�s medication, or any further form of review as requested by Jamie�s GP: this too was a serious missed opportunity.

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

Suicide (from 2015) | Mental Health related deaths

Essex Partnership NHS Foundation Trust

10/7/2024

2024-0369

Richard Fitzgerald

East London � � Category: Care Home Health related deaths� � � This report is being sent to: Serencroft

[REDACTED] CEO of Serencroft,�[REDACTED] Serencroft

On 3 July 20231commenced an investigation into the death of Richard Michael�Fitzgerald (aged 71 years). The investigation concluded at the end of the inquest on�the 2 July 2o24.The conclusion� of the inquest was a narrative conclusion:� Richard Fitzgerald died as a result of choking, whilst o resident in a nursing home. His�death was contributed to by the absence of a fult and robust core plan to minimise the�known risk of choking.

CIRCUMSTANCES� OF THE DEATH� Richard Fitzgerald suffered from Alzheimer�s Dementia. He was admitted to Gable�Court Care Home in October 2022. ln March 2023 he suffered a choking episode and�required admission to hospital. Following his discharge from hospital, he underwent a�speech and language therapy (SALT) assessment. This assessment confirmed no organic�swallow issue, but Mr Fitzgerald was at risk of choking due to him overfilling his mouth�and due to him eating too quickly. A care plan was directed by the SALT team to�minimise his risk of choking. The nutritional care plan in Gable Court was updated to�include the SALT recommendations. Staff in the Care Home were aware of Mr�Fitzgerald sometimes eating food outside of mealtimes; food that was not safely�prepared for him. There is no evidence that this risk was brought to the attention of�the SALT team. This risk of accessing food not safely prepared for him, was not�assessed or managed by the care home staff. ln addition, due to his dementia, Mr�Fitzgerald did not always allow the close supervision that had been directed by the�SALT team. On the morning of the 24 June 2023, Mr Fitzgerald had his breakfast in his�bedroom. This was supervised by a senior carer. After finishing his breakfast, the senior�carer was with another patient when she heard a wheezing sound. She found Mr�Fitzgerald having difficulty in breathing and she pressed the emergency alarm at 0916.� It is most likely that Mr Fitzgerald had accessed uncut food from the breakfast trolley.�Members of the housekeeping staff immediately attended and attempted measures to�clear the food blockage (backslaps and abdominal thrusts). After pressing the�emergency buzzer a second time, more staff members attended. Abdominal thrusts�were attempted by male care staff. The ambulance was called at O9I7. During the call�to the ambulance� service, Mr Fitzgerald was having increased difficulty in breathing.�Very shortly before the first paramedic�s� arrival, Mr Fitzgerald stopped breathing and� had a very low oxygen saturation. The first paramedic�arrived at his side by 0923/0924.�Mr Fitzgerald was found to be in cardiac arrest. The care home staff were not providing�any resuscitative measures when the paramedic� arrived. The emergency policy in place�required the care home staff to commence basic life support. This was not done. There�is however no evidence, on the balance of probabilities, that this would have�prevented Mr Fitzgerald�s death. The paramedic team were able to remove the food�blockage from the airway and they carried out advanced life support. They were able to�achieve a return of spontaneous circulation and they transferred Mr Fitzgerald to King�George Hospital. Sadly the return of spontaneous circulation was not maintained.� Resuscitation continued, but sadly, Mr Fitzgerald�had suffered a catastrophic hypoxic brain injury. He passed at King George Hospital on the 26 June 2023.

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

Care Home Health related deaths� � �

09/02/2023

2023-0050

George Kearsey

East London

[REDACTED] CEO, Barking, Havering & Redbridge NHS Trust � � [REDACTED] RT Honorable Therese Coffey, Secretary of State for Health & Social Care

On 10th June 2022, this court commenced an investigation into the death of George Frederick Kearsey aged 87 years., The investigation concluded at the end of the inquest held on 8th February 2022. I made a determination of a short form conclusion of accidental death. � Mr Kearsey�s medical cause of death was determined as; � I a Aspiration Pneumonia 1b Dementia, left sided 7th and 8th rib fractures. II Type 2 Diabetes, Chronic Kidney Disease , Aortic Stenosis, dehydration

George Frederick Kearsey sustained injuries in a fall at home on 20 May 2022. The deceased was taken to hospital by ambulance on 21 May 2022. After preliminary diagnostic tests he was admitted into hospital to allow pain management whilst awaiting an MRI scan. � Mr Kearsey developed aspiration pneumonia and was thereafter ordered nil fluids by mouth. As a consequence of this decision, he was prescribed Iv fluids. Mr Kearsey deteriorated and died on the evening of 8 June 2022.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Barking, Havering & Redbridge NHS Trust | Department of Health and Social Care

27/01/2023

2023-0036

Jayden Booroff

Essex

[REDACTED] CEO, Essex Partnership NHS Foundation Trust Chief Constable of Essex Police

On 17 November 2020 an investigation into the death of Jayden Andrew BOOROFF, aged 23 years. Jayden Andrew Booroff died on the 23 October 2020. The investigation concluded at the end of the 10-day inquest on 25 November 2022. The conclusion of the inquest was narrative, Jayden�s use of illicit drugs and alcohol contributed heavily to his psychotic condition and if this had been addressed earlier, it may have made a difference to his health, wellbeing and treatment. More consideration should have been given to Jayden�s relevant family history and more weight should have been given to this alongside the diagnosis that his psychosis was triggered by drug and alcohol use only. The layout of The Linden Centre in particular the areas around the main doors was not appropriate for ensuring the safety of its more vulnerable patients. Procedures around the use and allocation of Pinpoint alarms was inadequate. The Policy recording and reporting absconsions from The Linden Centre was not clear enough and led to a lack of awareness and a delay in addressing the flaws in the system. Responsibility for Jayden was not in line with policy and this contributed to a reduction in observation levels and inconsistencies in prescribed medications. Communication between all healthcare professionals involved in Jayden�s treatment was unsatisfactory, with mistakes being made in updating key documents. Risk assessments were not updated accurately enough or in good time, and failed to capture important information, including historical and emerging information. Whilst there are lessons to be learnt following Jayden�s absconsion from the Linden Centre, the response from the emergency services and [railway] were appropriate, and any alternative actions would not have altered the eventual outcome within the time that was available to them. � � with a medical cause of death of 1a Severe Multiple Injuries due to a train collision.

Jayden Andrew Booroff died of Severe Multiple Injuries after being struck by a train on the tracks adjacent to Widford Road, Chelmsford. He had been admitted to The Linden Centre on 19th October 2020 after experiencing a psychotic episode whilst staying with friends in Bristol. At 19:56 on 23rd October, Jayden was able to abscond from The Linden Centre after tailgating a member of staff Jayden ran from the building and travelled by foot towards Chelmsford Town Centre. At 21:45, Jayden was struck by a train and killed. There were a number of contributing factors that led to Jayden�s absconsion, lack of capture and subsequent death: 1.�Jayden had a history of illicit drug and alcohol use which contributed to his psychosis and led to intrusive thoughts, threats to self-harm and fear of being detained. 2. There was a family history of mental history which was not considered strongly enough. 3. There were a number of structural and environmental vulnerabilities that impacted staff and patient security and safety. 4. Inconsistencies with level of patient care, record keeping and communication.

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

Railway related deaths

Essex Partnership NHS Foundation Trust and Essex Police

27/01/2023

2023-0030

Toby Barwick

East London

[REDACTED] CEO, The University College London Hospitals NHS Foundation Trust,� [REDACTED] RT Honorable Therese Coffey, Secretary of State for Health & Social Care

On 17th February 2021 this Court commenced an investigation into the death of Toby Wilbur Barwick age 2 months (date of birth 24/11/2020). The investigation concluded at the end of the inquest held between the 23rd and 26th January 2023. I arrived at a short form conclusion of open conclusion . � The medical cause of death was determined following a post-mortem examination; 1a Unascertained

Toby Barwick was born on 24th November 2020 at University College Hospital in London at 37 weeks gestation with a low birth weight of 2.1kgs. On 12th February 2021 Toby�s mother walked to her sister�s home carrying her son at her chest in a fabric baby carrier device. On arrival at approximately 13.00hrs, Toby was sleeping. Mrs Barwick allowed Toby to nap in the carrier whilst she spoke to her sister, sitting on a sofa. Just before 14.15 Mrs Barwick found that her son was unresponsive, she shouted for help and removed him from the baby carrier. Emergency services were called and CPR was commenced . The ambulance service arrived and took over conduct of resuscitation , Toby was taken by ambulance to the local hospital. At hospital resuscitation continued until, at 15.43 doctors determined that continued action would be futile and Toby�s death was declared .

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

Child Death (from 2015)

The University College London Hospitals NHS Foundation Trust | Department of Health & Social Care

29/03/2023

2023-0109

Angela Kearn

Surrey

[REDACTED] Chair of the General Medical Council [REDACTED] Chair of National Trading Standards������������������ [REDACTED] Chief Executive of the Royal Society for the Prevention of Accidents [REDACTED] Chief Executive Officer, Decathlon UK

Following an investigation opened on the 2nd March 2020 and an inquest opened on the 5th March 2020 the inquest was concluded on the 20th December 2022. � The cause of death was: � 1a.) Immersion Pulmonary Oedema II.) Hypertension and Menopause treated by Hormone Replacement Therapy The narrative conclusion was: Angela Jean Kearn was suffering from hypertension and taking hormone replacement therapy. On the 13th January 2020 she was snorkelling using a full face mask. She developed immersion pulmonary oedema and died at the Nile Hospial, Hurghada Egypt. Hypertension, hormone replacement therapy and the use of the full face mask each more than minimally contributed to the death

i.)��Angela Kearn was aged 63 when she died. She had recently been diagnosed with hypertension which was being treated with atenolol. She was also taking hormone replacement therapy. ii.)�For the previous 5 years she had been using a Decathlon Easybreath full face snorkel mask when on holiday. iii.) On the 13th January 2020 she was snorkelling using the full face mask when she expressed concerns and was accompanied back to the beach. She collapsed and died. iv.) Expert evidence at the inquest identified immersion pulmonary oedema as the cause of the death. This is caused by the build-up of fluid in the lungs as a result of an increase in pulmonary capillary pressure caused by water pressure when the chest is submerged. This is exacerbated by hypertension and hormone replacement therapy. Negative pressure in the lungs causes fluid from the blood vessels to be drawn into the lungs. v.)�The use of a full face snorkel mask contributed to the death in two ways: a.) because negative pressure in the lungs is increased as a result of the increased effort of breathing caused by inhalation through the snorkel tube and mask, and b.) because respiratory effort is increased by the inhalation of elevated carbon dioxide levels caused by inhaling air drawn through a dead space in the mask. Both exacerbate the negative pressure in the lungs and increase the effects of immersion pulmonary oedema.

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

Other related deaths

General Medical Council | National Trading Standards | Royal Society for the Prevention of Accidents | Decathlon UK

31/07/2024

2024-0455

Maria de Ceita

North London

[REDACTED] Chief Executive North Middlesex University Hospital NHS Trust Sterling Way London N18 1QX c/o [REDACTED]

On the 05 July 2023 I opened an investigation touching upon the death of Maria Francisca Teixeira de Ceita, aged 87 years old. I opened an inquest on the 27 July 2023. The inquest concluded on the 16 February 2024. The conclusion of the inquest was: �Maria de Ceita died as a result of brain damage caused by an unwitnessed fall while she was a hospital in-patient on 04 July 2023�. The following factors contributed to her death: a) Not recording that Ms de Ceita required one-to-one supervision on the ward; b) Not recording an update to that plan; c) Not putting in place one-to-one supervision on the 3-4 July 2023; and d) Lack of effective communication between staff on the ward.

Maria de Ceita was born on the 26 March 1935 in Goa, India. She was 87 years old when she died on 04 July 2023 in North Middlesex Hospital, as a result of an unwitnessed fall earlier that day by her hospital bed, which caused her a fatal brain injury. Ms de Ceita was known by the hospital to be at risk of falling and at the time of the fall she should have been under one-to-one supervision by hospital staff.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Miss de Ceita�s family

Hospital Death (Clinical Procedures and medical management) related deaths

North Middlesex University Hospital NHS Trust

13/02/2023

2023-0056

Michael Roberts

Inner North London

[REDACTED] Chief Executive Disclosure and Barring Service (DBS) PO Box 3961 Royal Wootton Bassett SN4 4HF � [REDACTED] Commissioner Metropolitan Police Service (MPS) New Scotland Yard Victoria Embankment London SW1A 2JF

On 30 August 2022, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Michael Roberts aged 50 years. The investigation concluded at the end of the inquest on 7 February 2023. I made a determination at inquest of suicide.

Mr Roberts shot himself on the evening of Saturday, 20 August 2022, using a gun he took from his place of work. He did not own any guns. He was alone and made no attempt to shoot any other person. However, he had suggested to his partner that he could kill her.

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

Suicide (from 2015)

Disclosure and Barring Services, Metropolitan Police Services and Proof Master

11/01/2023

2023-0011

Carol Welch

Warwickshire

[REDACTED] Chief Executive George Eliot Hospital NHS Trust, College Street, Nuneaton, Warwickshire, CV10 7DJ

On 10 May 2022, the senior coroner commenced an investigation into the death of Carol Ann Welch aged 47. The investigation concluded at the end of the inquest on 6 January 2023. � The conclusion of the inquest was a narrative conclusion: � The deceased died of natural causes as a result of an undiagnosed cerebral aneurysm with subsequent spontaneous subarachnoid haemorrhage.

Carol became unwell on the 27 April 2022 due to a cerebral aneurysm, this initially presented with similar symptoms to the migraines she tended to suffer from. She attended the emergency department of the George Eliot Hospital NHS Trust (GEH) and was sent home with a diagnosis of migraine. � By the 28 April 2022 Carol was experiencing a sentinel bleed, and this led to a change in symptoms. She returned to GEH. � The changes in symptoms were such that further investigations should have been undertaken (either a CT scan or a lumbar puncture) and such an investigation may or may not have revealed the presence of an aneurysm and that Carol was at risk of a subarachnoid haemorrhage. � However, due to an incorrect diagnosis of migraine, further investigations did not take place and Carol was sent home. � A further safety check, as laid down by Royal College of Emergency Medicine guidelines, was not followed. The guidelines state that where there is an unexpected return to the emergency department with 72 hours, there should be a discussion with a consultant before discharge. Carol suffered a cardiac arrest on 30 April 2022 and was admitted to the University Hospital Coventry and Warwickshire where she died on 1 May 2022.

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

Hospital Death (Clinical Procedures and medical management) related deaths

George Eilot Hospital NHS Trust

06/06/2024

2024-0310

Anoush Summers

Inner North London

[REDACTED] Chief Executive London Borough Hackney Town Hall Mare Street London E8 1EA � [REDACTED] Director of Supreme Care Services Limited 9 Crown Parade Morden Surrey SM4 5DA

On the 22nd January 2024 Assistant Coroner Sarah Bourke began an investigation into the death of Anoush Summers who died aged 77, on the 14th January 2024 at Homerton University Hospital, Homerton Row, London, E9. � The investigation concluded at the end of the inquest on 6th June 2024 conducted by myself, Assistant Coroner Edwin Buckett. I made a determination at inquest that the deceased died as a result of hypothermia which resulted from a fall at home following a long lie.

The narrative conclusion was as follows: � The deceased was a frail lady who was prone to falls. She lived at home, alone, with carers who visited her twice a day. She had a wrist alarm. The wrist alarm was reported as broken and not working on the 6.1.2024, but it was not repaired or replaced. Sometime after 4.45pm on 11.1.2024, the deceased fell at home. She was found the next day on the 12.1.2024 at 9am, by a carer, wearing her wrist alarm and taken to hospital where she died on 14.1.2024 of hypothermia. The absence of a working wrist alarm prevented her from being found sooner that she was and probably contributed to her death.

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

Other related deaths This report is being sent to: London Borough Hackney | Supreme Care Services Limited

09/02/2024

2024-0182

Susan Young

West Sussex, Brighton and Hove

[REDACTED] Chief Executive NHS Sussex Integrated Care Board Wicker House High Street Worthing BN11 1DJ

On 22nd December 2022 I commenced an investigation into the death of Susan Mary Young aged 57 . The investigation concluded at the end of the inquest on 31st January 2024. The overall conclusion of the inquest was a narrative conclusion which stated that �Susan Mary Young died from an accidental ingestion of prescribed co-codamol tablets.�

On 20th December 2022 Susan died at her home address at [REDACTED] West Sussex. Susan had been feeling unwell and had been prescribed antibiotics for an ear infection and co-codamol tablets as pain relief. Sadly due to the pain she was in Susan took too many tablets over a short period of time and this led to a fatal toxicity. There was no evidence that this was a deliberate act to end her life

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- � The family of Susan Young South East Coast Ambulance Service NHS Foundation Trust Bognor Medical Centre � 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) This report is being sent to: NHS Sussex Integrated Care Board