Inquests (PFDs)

30/11/2023

2023-0493

Donna Donnellan

Manchester North

[REDACTED] Chief Executive Northern Care Alliance [REDACTED] Chief Executive Pennine Care NHS Trust

On the 23rd January 2023, I commenced an investigation into the death of Donna Marie Donnellan. The investigation concluded on the 25th�September 2023. The medical cause of death was confirmed as 1a) Sudden death on a background of malnutrition 2) Peripheral Neuropathy. I recorded a narrative conclusion that Donna died as a result of complications arising from malnutrition likely due to an atypical eating disorder which was undiagnosed at the time of death.

CIRCUMSTANCES OF DEATH The deceased, Donna, had a long standing history of disordered eating which was characterised by her restricting her diet to certain types of food. In January 2021 she attended North Manchester General Hospital with leg weakness and poor appetite. Donna was diagnosed with peripheral neuropathy and remained in hospital for several weeks before being discharged to an intermediate care unit until the 5th March 2021. As a result of her peripheral neuropathy her mobility declined and she required a zimmer frame and subsequently a wheelchair. It was identified that she required assistance with care including meal preparation. Whilst initially accepting help it was eventually declined and she became increasingly reliant on her family. By September 2022 the Donna�s weight had reduced to 25kg with a BMI of 10 and she was admitted to Fairfield General hospital. She remained an inpatient from the 16th � 28th September 2022. During this admission her weight increased however insufficient consideration was given as to whether she had an atypical eating disorder. During this admission Donna was seen by the Mental Health Liaison Team who concluded that she did not fit the criteria for anorexia and did not appear to have an eating disorder in accordance with the MEED guidance. The court heard a medical doctor disagreed with this assessment and felt Donna did have an eating disorder. However due to a belief that the Mental Health Liaison Team were �specialists�, this view was overruled. Donna should have been referred to the Willows Eating Disorder Service. In addition there should have been a timely referral to the community dieticians. On the 3rd October 2022 the deceased was re-admitted to Fairfield General Hospital with a history of not having eaten for three days, weight loss and chest pain. The medical notes from her previous admission were not available to the treating clinicians. MEED guidance was not followed and she was not seen by a dietician. She should not have been discharged home on the 6th October 2022. She was found deceased at her home address on the 10th October 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:� Family of Donna Donellan � 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.

Other related deaths This report is being sent to: Northern Care Alliance | Pennine Care NHS Trust

26/04/2024

2024-0227

Orlando Davis

West Sussex, Brighton and Hove

[REDACTED] Chief Executive Nursing and Midwifery Council 23 Portland Place London W1B 1PZ [REDACTED] Chief Executive Royal College of Obstetricians and Gynaecologists 10 � 18 Union Street London SE1 1GH � 3. Rt Hon Victoria Atkins Department of Health and Social Security 39 Victoria Street London SW1H 0EU [REDACTED] Chief Executive NHS Sussex Integrated Care Board NHS Sussex Wicker House High Street Worthing BN11 1DU

On 08 October 2021 I commenced an investigation into the death of Orlando Nova DAVIS aged 14 Days. The investigation concluded at the end of the inquest on 14 March 2024. The conclusion of the inquest was a Narrative Conclusion namely:� On 9th September 2021� [REDACTED] (Orlando�s mother) developed hyponatremia during her labour while having a home birth. [REDACTED]�s condition went completely unrecognised during the period of her labour and therefore she did not receive the care and attention that she and her son, Orlando, clinically required. There was a lack of understanding of this rare medical condition by midwives and clinicians and as such there were lost opportunities to treat [REDACTED] both at home and or during her subsequent admission to Worthing hospital. Sadly the failure to recognise this condition resulted in [REDACTED] suffering a number of seizures which led to a restriction of oxygen to Orlando before birth and this resulted in him suffering an irreversible brain injury. Orlando sadly died from this injury on 24th September 2021 at the Royal Sussex County Hospital at the age of just 14 days. Orlando�s death was contributed to by neglect.

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

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

Child Death (from 2015) This report is being sent to: Nursing and Midwifery Council | Royal College of Obstetricians and Gynaecologists | Department of Health and Social Care | NHS Sussex Integrated Care Board

25/01/2023

2023-0027

Andrew Largin

Inner North London

[REDACTED] Chief Executive Officer East London NHS Foundation Trust (ELFT)

On 10 February 2022, one of my assistant coroners, Jonathan Stevens, commenced an investigation into the death of Andrew Mark Largin, aged 60 years. The investigation concluded at the end of the inquest last Friday, 20 January 2023. � I made a determination at inquest that Andrew Largin died by suicide. His mental health had been identified as deteriorating by a community rehabilitation team on 1 February 2022. That team notified the home treatment team who had discharged him from their care on 25 January 2023. However, the home treatment team failed to reassess him.

Mr Largin asphyxiated himself in the early hours of 6 February 2022, at the home of his sister and brother in law where he lived. His medical cause of death was: 1a) asphyxia 1b) inhalation of inert gas

I have sent a copy of my report to the following. ���[REDACTED] sister of Andrew Largin 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) | Mental Health related deaths

East London Foundation Trust

19/01/2024

2024-0028

John Gray

Suffolk Category: Other related deaths This report is being sent to: East Suffolk Council

[REDACTED] Chief Executive Officer East Suffolk Council Station Road Melton Woodbridge IP12 1RT East Suffolk Council

On 20 July 2022 I commenced an investigation into the death of: � John Thomas GRAY � The investigation concluded at the end of the inquest on 10 January 2024. The conclusion of the inquest was: � Accidental Death � The medical cause of death was confirmed as: � 1a Pneumonia 1b Fractured Ribs, Splenic and Renal Haematoma 1c Trauma II Frailty, Asthma, Obstructive Sleep Apnoea, Stroke

John Gray died at Ipswich Hospital, Heath Road, Ipswich in Suffolk, on the 13th July 2022. � John had been admitted to the Ipswich Hospital on the 9th July 2022, after his mobility scooter drove off the promenade at Felixstowe beach, after John had fallen asleep. � At the location this occurred, there was no barrier in place to prevent a fall, and the drop was one of several feet. � In his fall, John suffered multiple rib fractures leading to respiratory failure. � John�s condition continued to deteriorate following his admission, and he passed away at 04:30, on the 13th July 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � John�s next of kin East Mobility Services (EA) Ltd Motability Operations Limited Howard House Surgery � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths

29/08/2023

2023-0306

Mizanur Rahman

Inner North London

[REDACTED] Chief Executive Officer Office for Product Safety and Standards 4th Floor Cannon House 18 The Priory Queensway Birmingham B4 6BS

On 17 March 2023, E Buckett, HM Assistant Coroner for Inner North London, commenced an investigation into the death of Mizanur Rahman, aged 41 years. The investigation concluded at the end of the inquest on 17 August 2023. � I made a determination of accidental death. The medical cause of death was: 1(a) Hypoxic brain injury 1(b) Thermal and smoke inhalation injury 2 Bronchopneumonia

Mr Rahman died on 9 March 2023 at the Royal London Hospital from the effects of smoke inhalation during a fire which took place in the early hours of 5 March 2023 at the 4th floor multi-occupancy flat where he resided. The fire was found to have been caused by a faulty lithium ion e-bike battery which was charging at the time. � The e-bike from which the battery came, which was owned by another occupant of the flat, had been heavily modified, notably including a retro- fitted additional battery cage and motor. � I found on the evidence, which included that of a London Fire Brigade Fire Investigation Officer (whose evidence was in turn informed by input from the Chief Scientific Adviser at the Fire Science Department, who had examined the e-bike and remains of the charger\battery), that the fire started with a faulty lithium ion battery, probably a battery and charger which did not match and carried different voltage ratings, leading to thermal runaway and catastrophic failure of the lithium ion battery. � Despite attempts by occupants of the flat to prevent the fire�s escalation, this was not possible and the flat quickly filled with toxic smoke necessitating its evacuation. Sadly, Mr Rahman did not successfully evacuate before he was overcome by the smoke, causing his death.

I have sent a copy of my report to the following. � ������� The Next of Kin of Mr Rahman ������� The London Fire Brigade ������� HHJ Thomas Teague QC, Chief Coroner of England & Wales � I am 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: Product Safety and Standards

25/06/2024

2024-0343

Abdul Oryakhel

Avon

[REDACTED] Chief Executive Officer Office for Product Safety and Standards, 4th Floor Cannon House, 18 The Priory, Queensway, Birmingham, B4 6BS � � [REDACTED] Head of private E-scooter Regulation, Traffic and Technology Department for Transport, Great Minster House, 33 Horseferry Road, London, SW1P 4DR � [REDACTED] Metro Mayor The West of England Combined Authority, 70 Redcliff Street, Bristol, BS1 6AL

On 28/9/2022 an investigation was commenced into the death of Abdul Jabar Oryakhel. The investigation concluded at the end of the inquest on 25/6/2024. � The conclusion of the inquest was � Accident. The brief circumstances are as follows: The deceased died on 25 September 2022 at Twinnell House, Stapleton Road, Bristol. He had fallen from the window of his flat on the top floor when he was trying to escape from a fire in the flat caused by the overheating and ignition of a lithium-ion battery pack which caused the fire. The battery was used for an E-bike stored in the cupboard of the flat.

132, Twinnell House is a Bristol City Council owned property and was rented by the deceased�s cousin. His cousin had an E �Bike which was stored in the cupboard in the hallway. � The fire started when the occupants were asleep in the flat on 16th floor. Mr Oryakhel died, 1 received significant burns whilst escaping and the other 2 escaped by crawling out the kitchen window and being rescued by the emergency services. � The deceased, according to another resident, who lives on the 4th floor of Twinnell House, fell past his window at around 2.15am, he called 999, and the police, ambulance and fire services arrived on scene. � [REDACTED] from Avon Fire and Rescue explained that the first 999 call was received at 02.19hrs on 25th September, it was subsequently confirmed that the fire was on 16th floor of the building and it was initially declared a major incident. The fire was contained in the flat as was intended by the building design and fire safety measures. � A fire scene investigation was commenced the next day and [REDACTED] confirmed that the circumstance of the fire based on the investigation of the scene was � the accidental ignition caused by local overheating and catastrophic failure of a Lithium-ion battery pack which in turn caused a thermal runaway and significant fire development in a short space of time. The E- bike and charging equipment was the only possible source of ignition.

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

Other related deaths | Product related deaths This report is being sent to: Office for Product Safety and Standards | Department for Transport | West of England Combined Authority

18/07/2023

2023-0252

Colin Greenway Coroner name: Yvonne Blake Coroner Area: Norfolk Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Queen Elizabeth Hospital

[REDACTED] Chief Executive Officer Queen Elizabeth Hospital Gayton Road King�s Lynn Norfolk PE30 4ET

On 3 November 2022 I commenced an investigation into the death of Colin Vincent GREENWAY aged 63. The investigation concluded at the end of the inquest on 17 July 2023. � The medical cause of death was: 1a)Pulmonary Thromboembolism 2) � The conclusion of the inquest was: Mr Colin Greenway was a relatively fit man he was a football referee. he was overweight but active and his only medication was omeprazole. He went to Cyprus with family and 5 members of his family became unwell with gastroenteritis on 11 October. Mr Greenway came back to the U.K. on the 18 October [REDACTED]. After a few days with no improvement he was persuaded to speak with his GP who advised rest and fluids on the 19th. On 21 October�[REDACTED] took him to a walk in centre who recommended hospital. he was taken to hospital and admitted and treated with IV fluids and antibiotics. A stool sample identified camopylobacter which required specific antibiotics. He was prescribed anticoagulant at half the usual dose despite his risk factors. his blood results improved and on 25 October he was discharged he was eating and drinking. By 28th he was feeling slightly better resting in bed. On 29 October��[REDACTED] came home to find him deceased in bed. At post-mortem he was found to have developed a pulmonary embolus (P.E.).It is not possible to say if the full dose of anticoagulation would have prevented the P.E.

Mr Greenway went to Cyprus with his family [REDACTED] all became ill with a gastroenteritis. Mr Greenway returned home to the U.K. on 18 October, he remained unwell with diarrhoea and nausea. He spoke to his GP on 19 October who advised rest and fluids and went with [REDACTED] to a walk in centre on 21 October who advised him to attend hospital. He was taken to the Queen Elizabeth Hospital in King�s Lynn and admitted. He was unwell with acute kidney injury and febrile. He was given IV fluids and antibiotics and urine and stool samples sent. The junior doctor clerking him did not use the clerking booklet when performing a VTE assessment which would have guided�[REDACTED] to prescribe 40mg of enoxaparin an anti- coagulant, instead�[REDACTED ]used the VTE assessment on the electronic prescribing system which is not as detailed as the paper clerking booklet. To prescribe anticoagulants the electronic VTE assessment has to be filled in. Despite Mr Greenway�s known risk factors of age, obesity, recent infection and loss of mobility she prescribed a �renal dose� of 20mg of enoxaparin, half the usual dose. Mr Greenway�s eGFR (measurement of renal function) was 58 and the dose of anticoagulant is only supposed to be reduced if this measurement is below 30. When spoken to after Mr Greenway�s death�[REDACTED] explanation was that�[REDACTED] did this in a excess of caution despite clear guidelines. Mr Greenway remained on this dose for his entire hospital stay. No senior clinician checked this prescription, the consultant who gave evidence assumed the pharmacists would have done a reconciliation. Mr Greenway was discharged and died several days later from a pulmonary embolism. The pharmacy service at weekends at this hospital had been suspended for some time, this consultant was even aware of this. �[REDACTED] said� �[REDACTED]was too busy to check individual patients� new prescriptions on��[REDACTED] ward rounds. The pharmacy reconciliation is meant to operate as a fail safe or safety net, it is the Consultant Doctor�s responsibility to check what their junior unsupervised doctors do at the weekend when a patient is admitted. This consultant didn�t ever speak to this junior doctor about this mis-prescribing or know what action if any had been taken about it. I was informed by a senior nurse that other such drug errors have occurred since Mr Greenway died. Documentation was poor and the TRAINED NURSES are undertaking courses to show them how to complete fluid balance charts which is something I would expect them to already know how to do. The pharmacy service at the hospital is on the Risk register because of a shortage of pharmacists. Whilst the consultants, three saw Mr Greenway, continue refuse to accept responsibility for doctors prescribing this situation continues.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ����[REDACTED] , Spouse ����[REDACTED] , Daughter � I have also sent it to: � ������� The Lord Chancellor ������� The Royal Pharmaceutical Society of Great Britain ������� The Department of Health ������� The Care Quality Commission ������� HSIB ������� Healthwatch Norfolk � 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.

27/04/2023

2023-0144

Caroline Forte

West Sussex

[REDACTED] Chief Executive Officer Royal College of Psychiatrists 21 Prescott Street London E1 8BB [REDACTED] Chief Executive Sussex Partnership Foundation Trust

On 21st February 2022 I commenced an investigation into the death of Caroline Victoria Forte aged 35 years. The investigation was concluded at the end of the Inquest on 14th March 2023. The Inquest was held with Jury. The conclusion of the Jury was a narrative conclusion namely: �Caroline Victoria Forte died as a result of suicide�[REDACTED] Brighton on 20th February 2022. She had a provisional diagnosis of severe depression with psychotic symptoms. Caroline was detained under Section 2 of the Mental Health Act. The following factors contributed to her death: 1. Inadequate communication within Amberley Ward. 2. Inadequate communication between Amberley ward and Caroline�s family. 3. No evidence of an overnight care plan or risk assessment prior to leaving the ward. 4. Failure to follow the section 17 leave of Absence policy.�

Caroline had been struggling with her mental health for some time following the breakdown of a relationship. Since 27th January 2022 she had been receiving treatment as an inpatient (under Section 2 Mental Health Act 1983) on the Amberley Ward at the Department of Psychiatry, Eastbourne Hospital.�[REDACTED] On 18th February 2022 she was granted Section 17 weekend to take place at her parents address. Sadly on 20th February she was found hanging [REDACTED].

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23rd June 2023 I, the coroner, may extend the period. � Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.

Suicide (from 2015) This report is being sent to: Royal College of Psychiatrists, Sussex Partnership Foundation Trust

07/12/2023

2023-0519

Ian Jacka

Cornwall and the Isles of Scilly

[REDACTED] Chief Executive Officer University Hospital Plymouth NHS Trust

On 7 July 2022 I commenced an investigation into the death of 51 year old Ian Jacka. The investigation concluded at the end of the inquest on 23 November 2023. At the end of the Inquest the following was recorded. � The medical cause of death was established on the evidence as follows � � 1a Bilateral bronchopneumonia due to hypoxic brain injury 1b Airway obstruction during intubation 1c Multiple Injuries Due To Fall From Height � The four questions � who, when, where and how � were answered as follows � Ian Jacka died on 15 June 2022 at Derriford Hospital Plymouth Devon from complications following surgery for trauma consistent with a partially witnessed fall from height, whilst under the influence of alcohol, at Chapel Porth, Cornwall on 3rd June 2022. The complications followed surgery on 6th� June 2022 and were likely contributed to by the use a ManuJet ventilator with Cook catheter to support an unsuccessful airway exchange leading to airway obstruction. Ian went into cardiac arrest and was resuscitated but not before suffering hypoxic brain injury. The surgical team proceeded with surgery in the absence of knowledge of the full extent of a serious medical episode suffered by Ian on 5th June 2022. Had the surgical team known of the full extent of that medical episode of 5th June 2022, the surgery would have been delayed for further investigations and assessment which may have resulted in a different outcome. � My conclusion as to the death was as follows � Ian died from complications of necessary medical procedures following polytrauma contributed to by an error of omission on handover from critical care to surgery and by the use a ManuJet ventilator with Cook airway exchange catheter.

On 3 June 2022 Ian had a fall from height, from an unofficial pathway/ embankment, into the National Trust car park, Chapel Porth. Ian fell so that he landed in front of the toilet block in the car park, suffering very serious injuries. Cardiopulmonary resuscitation was conducted at the scene by lifeguards and off duty doctors, before being conveyed to RCHT by ambulance. Ian was examined at hospital and found to have sustained multiple fractures to his skull, spine and ribs. � On 4 June 2022, Ian was transferred to Derriford Hospital for treatment of complex spinal fractures, under the neurosurgical team. � On 5 June 2022 Ian suffered a medical episode which developed into a critical incident in which Ian deteriorated rapidly and required life saving measures. � On 6 June 2022 Ian was taken to theatre for spinal surgery. Before surgery, the critical care flexible endotracheal tube was replaced by an armoured tube.�After surgery, the anaesthetic team commenced an airway exchange, namely removing the armoured tube which had been inserted for the operation, in order to replace it with the more flexible critical care tube. However, having removed the armoured tube, the team were unable to insert the flexible tube despite repeated attempts. Ian then started to desaturate due to lack of oxygen. The Consultant Anaesthetist proceeded to jet ventilate Ian, the first jet was uneventful, the second resulted in massive neck swelling, Ian went into cardiac arrest. The medical team then resorted to cardiopulmonary resuscitation and an emergency tracheostomy. Return of spontaneous circulation occurred after 20-25 minutes During this time Ian suffered hypoxic brain injury from lack of oxygen. � Over the following days, Ian suffered seizures on the intensive care unit and an MRI on 9 June 2022 showed extensive changes consistent with hypoxic brain injury. � On 15 June 2022, Ian�s care was transitioned to end�of-life care. � Ian died in the intensive care unit at Derriford hospital at 17:10 on 15 June 2022.

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.

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

15/03/2023

2023-0091

Tarik Drakes

Dorset

[REDACTED] Chief Executive Officer of Bournemouth Churches Housing Association (BCHA)

On the 8th December 2022, an investigation was commenced into the death of Tarik Roger Drakes, born on the 25th November 1978. The investigation concluded at the end of the Inquest on the 14th March 2023. The Medical Cause of Death was: Ia Opiate toxicity � The conclusion of the Inquest was drug related.

On the 12th November 2022 the deceased, who had a history of using heroin, was found in a collapsed and unresponsive condition in his room at his place of residence which was Room 14 Dorset Lodge, 10 Suffolk Road, Bournemouth. He was taken to the Royal Bournemouth Hospital, Bournemouth where he was found to be in multi organ failure and despite treatment his condition deteriorated, and he died on the 29th November 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Family of Mr Drakes I am also under a duty to send the Chief Coroner a copy of your response. � I have also provided a copy of this to Mr Graham Farrant, Chief Executive of BCP Council for his awareness. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related deaths

Bournemouth Churches Housing Association (BCHA)

08/06/2023

2023-0182

Ivan Ignatov

Dorset

[REDACTED] Chief Executive Officer of the College of Policing Chief Constable [REDACTED], Chair of the National Police Chiefs Council Niche Technology/Niche RMS� [REDACTED] Chief Executive Officer of the Maritime and Coastguard Agency National Strategic Board of the National Police Air Service, [REDACTED] Chief Executive Officer of RNLI,������������������� [REDACTED] Managing Director of the Association of Ambulance Chief Executives,� [REDACTED] Chair of� the National Fire Chiefs CouncilChief Executive Officer of� NHS England Chief Constable�[REDACTED], Dorset Police, Chief Fire Officer Dorset & Wiltshire Fire & Rescue Service [REDACTED], Chief Executive Officer of South West Ambulance Service NHS FT

On the 11th August 2020, an investigation was commenced into the death of� Ivan Rumenov Ignatov, born on the 10th February 1996. � The investigation concluded at the end of the Inquest on the 26th May 2023. The Medical Cause of Death was: Ia Drowning � The conclusion of the Inquest was a narrative conclusion that Ivan� Rumenov Ignatov died as a consequence of drowning in� open� water,� in� circumstances where his intentions for entering the water remain unclear.

At around 21.15 hours on the 19th July 2020 Ivan Rumenov Ignatov was seen� to enter the driver�s seat of a motor vehicle parked on Easton Square, Portland attempting to take the vehicle. There was a tussle where Ivan received injuries and he fled on foot, knocking on the doors of residents nearby asking for help, displaying agitated behaviour. At approximately 22.00 hours he was seen by police officers, and he ran off from them on foot into a nearby quarry. At approximately 22.13 hours he was seen to enter and exit the water at Church Ope Cove, Portland fully clothed, displaying odd behaviour. At around 22.21 hours he was located walking on the cliffs and coastline of Portland, Dorset. He was acting erratically and seen stumbling along the rocky terrain. He was followed by the national police helicopter and police officers on the ground in an attempt to safeguard him. At 22.48 hours he entered the waters of the English Channel, north of Durdle pier and swam away from shore a distance of approximately 20 to 50 meters. At approximately 23.03 hours he went underneath the water and did not resurface. He was found deceased in the water south of Durdle Pier, Portland on the 31st July 2020.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � (1)� Ivan�s family (2)� DHUFT (3)�� Castle Rock Group Medical Services (4)� Chief Constable of Dorset Police (5)� HMCG (6)� NPAS (7)� RNLI � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person� who� he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response,� about the release� or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: College of Policing, National Police Chiefs Council, Niche Technology, Maritime and Coastguard Agency, National Police Air Service, RNLI, Association of Ambulance, National Fire Chiefs Council, NHS England, Dorset Police, Dorset & Wiltshire & Rescue Service and South West Ambulance Service NHS Foundation Trust

16/08/2023

2023-0296

Odichukwumma Igweani

Milton Keynes

[REDACTED] Chief Executive Officer � Central North West London NHS Foundation Trust [REDACTED] Chief Medical Director � BLMK Integrated Care Board [REDACTED] Practice Manager � Red House Surgery

On 01 July 2021 I commenced an investigation into the death of Odichukwumma Kelvin IGWEANI aged 24. The investigation concluded at the end of the inquest on 19 April 2023. The conclusion of the inquest was that he was lawfully killed.

At the time of the incident Kelvin Igweani was living at . Prior to the incident on the 26th June 2021 evidence shows Kelvin was suffering undiagnosed mental health problems, which were deteriorating over several months. Attempts by Kelvin�s mother to secure mental health assistance for him were unsuccessful, as no formal assessments were made. His mental health then spiralled significantly in the four days proceeding the incident. On the morning of 26th June 2021, Kelvin became extremely violent, firstly trying to forcefully baptise his partner�s children in the bath. His partner and her daughter were able to flee to knock on the neighbours flat ([REDACTED]) to seek assistance to call the police. His partner was then dragged back�[REDACTED]. Kelvin then forcefully regained control of her two year old son and began to progress into holding him under water causing him to become unconscious. On a second successful attempt to flee to the neighbours flat ([REDACTED]), his partner and her daughter asked the neighbours to help save her son as Kelvin was trying to kill him. The[REDACTED]neighbour then went into�[REDACTED] to try and save the two year old boy but was bludgeoned to death�[REDACTED]. The neighbours [REDACTED] called the police and gave shelter to Kelvin�s partner and her daughter. At this point, the first officer on scene attempted to gain entry after announcing she was police but was unsuccessful, so called for back-up assistance with method of entry equipment. � The police arrived and forced entry into the flat. Kelvin was tasered ineffectively at the front door of the flat and retreated into the bedroom where he barricaded himself in with the two year old boy. Armed police forced entry into the bedroom after repeated unsuccessful attempted to secure the childs release and on hearing sounds of someone being beaten in the bedroom. At no point did Kelvin engage or respond to the police requests to cooperate. Kelvin sprung out of the wardrobe and lunged forward once the bedroom door had been taken down by police. The police discharged four shots and two of them hit Kelvin in the chest. Kelvin died from gunshot wounds. The evidence shows Kelvin suffered from a severe mental health episode leading to and at the time of the incident for which he was unable to access adequate mental health care and attention. No mental health input or care received, as there was no engagement with A&E, crisis team or any other mental health services.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Mr Igweani Thames Valley Police � I have also sent it to the following who may find it useful or of interest: Midland Heart South Central Ambulance Service � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any 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: North West London NHS Foundation Trust | BLMK Integrated Care Board | Red House Surgery

22/02/2023

2023-0069

James Parsons

Cornwall and the Isles of Scilly

[REDACTED] Chief Executive Officer, Cornwall Council � [REDACTED] Director, Porthleven Harbour & Dock Company

On 10 May 2022, I commenced an investigation into the death of James Francis PARSONS. � The investigation concluded at the end of the inquest on 6 February 2023. The conclusion of the inquest was as follows. � Accidental Death The four statutory questions � who, when, where and how � were answered as follows James Francis PARSONS died at Porthleven Harbour on 23 April 2022 from drowning after falling off the harbour wall and into the harbour waters. � The medical cause of death was established on the evidence as 1a) � disease or condition directly leading to death Drowning 1b) � any other disease or condition leading to immediate Cause of Death Alcohol intoxication

On 24 April 2022 Mr Parsons was reported to police as a missing person by his wife,�[REDACTED]. Mr Parsons had spent the evening of Friday 22 April 2022 at the Porthleven Food Festival. He had been due to meet up with his wife at a rented holiday cottage in Porthleven on the morning of Saturday 23 April 2022. He failed to meet her as planned and was uncontactable. � The police search revealed that Mr Parsons was last seen just before midnight on 22 April 2022 by a witness in the in the big tent at the harbour. The witness stated that Mr Parsons did not seem to be drunk at the time that they were speaking. � On 4 May 2022 the fully clothed body of Mr Parsons was recovered from the sea, approximately 4 miles off the coast of the Isles of Scilly after being spotted by a fisherman. � The post-mortem revealed no injuries and gave the cause of death identified above. Toxicology shows raised urine ethanol (alcohol) at 291 mg / 100 ML. For comparison, the legal driving limit alcohol in urine is 107 mg / 100 ML urine. � The Inquest findings were as follows ������� Mr Parsons died after midnight, on 23 April 2023 after falling into the harbour waters and drowning. ������� Due to Mr Parsons body being located fully clothed, he fell into the water by accident and not through choice. That if Mr Parsons was still conscious and was able to shout for help, he is unlikely to have been heard by anyone due to the noise of the ongoing events. ������� The alcohol consumed by Mr Parsons made it more likely that when entering the water this would increase the risk of drowning due to impairment of cognition and motor skills. ������� Police evidence revealed that the sea off Porthleven features a notorious current that means it is not safe to swim in the harbour. ������� The pier and harbour walls raised safety issues discussed below under matters of concern. The police evidence was that these safety issues amounted to a failing to ensure the safety of members of the public. Responsibility for public safety rests with the Porthleven Harbour & Dock Company as the owners of the harbour, and with Cornwall Council as the licensing authority for the Food Festival.

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

Other related deaths | Alcohol, drugs medication related deaths

Cornwall Council, Porthleven Harbour & Dock Company

20/01/2023

2023-0022

Sophia Ayuk

East London

[REDACTED] Chief Executive Officer, East London Foundation Trust, 9 Alie Street, Goodmayes, Ilford, IG3 8XJ RT Honorable Therese Coffey, Secretary of State for Health & Social Care, 39 Victoria Street, Westminster, London, SW1H 0EU [REDACTED]

On 19th March 2022 I commenced an investigation into the death of Sophia Ayuk age 34 years. The investigation concluded at the end of an Article Two compliant inquest held on 18th and 19th January 2023. I arrived at a narrative conclusion. � �Sophia Abunaw Ayuk died in hospital on 18th March 2023 as the result of a pulmonary embolism. A deep vein thrombosis had developed in her left calf due to Sophia sitting motionless in her room on the day of her death. Sophia�s behaviour on 18th March 2022 was due to her mental illness. Ms Ayuk had not taken any food or drink for at least two days prior to her death. Dehydration may have contributed to the development of Ms Ayuk�s thrombosis.� � The medical cause of death was determined following a post-mortem examination; 1a Pulmonary embolus 1b Deep vein thrombosis II Schizophrenia (treated)

Ms Ayuk had been diagnosed with Hebephrenic Schizophrenia since 2013, her illness was treatment resistant and consequently, was treated with Clozapine. Ms Ayuk had been treated in the community and in hospital to manage her symptoms. In October 2021 Ms Ayuk suffered a relapse of psychosis and was admitted under S.2 of the Mental Health Act to a mental health ward for treatment. After a period of stabilisation Mrs Ayuk was discharged home but returned shortly thereafter when symptoms returned in January 2022. At the time of her death Ms Ayuk had yet to be successfully titrated back on to Clozapine and consequently, was experiencing symptoms of her illness. On 18th March 2022 Ms Ayuk was observed by staff to remain in her bedroom all day. Sophia sat, fully clothed and motionless on a chair for most of the day. Sophia would not respond to verbal prompts and declined food and drink. At 20.45.49 Ms Ayuk was seen to emerge from her bedroom and walk down a corridor to the main area of the ward. Moments later Sophia fell to the floor and a patient alerted staff. Staff made an emergency call for the rapid response team and went to Sophia� assistance. Ms Ayuk was breathing and conscious at that time. Sophia began to deteriorate and 999 was called at 21.04. Paramedics responded promptly and on arrival found Sophia unresponsive but breathing. No pulse could be found and CPR was commenced. Resuscitation continued for 90 minutes until Sophia was declared deceased.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; the family of Mrs Ayuk 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.

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

East London Foundation Trust | Department of Health and Social Care

19/12/2023

2023-0535

Amanda Hitch

Essex

[REDACTED] Chief Executive Officer, Essex Partnership NHS Foundation Trust, The Lodge, Lodge Approach, Runwell, Wickford, Essex SS117XX BRITISH TRANSPORT POLICE, 13 Selbie House, Allsop Place, London NW1 5LJ 3.

On 12th February 2022, the coroner commenced an investigation into the death of Amanda Susan Hitch, aged 59. The investigation concluded at the end of the inquest before me held between 13/12/2023- 15/12/2023. The conclusion of the inquest was a narrative conclusion. The deceased died of multiple injuries sustained deliberately jumping in front of a train with the intention to die. The care and treatment of the deceased�s mental health needs and risk of suicide were investigated at the inquest.

Amanda Hitch jumped onto railway tracks in front of a train, as I found, deliberately and intending to die, [REDACTED] on 12th February 2022. The risk that she would try to end her life at a station by this means was well known and chronic. She was receiving treatment in the community from a community mental health team under the Essex Partnership University Trust. This included out of hours support by ringing 111 and if thought appropriate, referral to a service called The Sanctuary, which was commissioned by EPUT but operated by people from Mind the mental health charity. The inquest considered the effectiveness of this treatment, and made findings about that in the narrative conclusion.

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

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

25/07/2024

2024-0405

Danny Anderson

East London

[REDACTED] Chief Executive Officer, Essex Partnership University NHS Foundation Trust [REDACTED]

On 12 April 2023 I commenced an investigation into the death of Danny Jay Anderson (aged 35). The investigation concluded at the end of the inquest on the 23 July 2024.� The conclusion was that Danny Anderson died as a result of suicide, contributed to by neglect.

Danny Anderson suffered from chronic mental health difficulties, which first developed around the age of 15. His past psychiatric history included serious incidents of self-harm and necessary admissions to hospital under the provisions of the Mental Health�Act. In 2022, Danny required a six-week admission to hospital in February/March 2022,� due to paranoid and delusional beliefs. In June 2022, Danny again required admission� under the Mental Health Act for paranoid and delusional beliefs. He received care and� assessment in hospital under Section 3 of the Mental Health Act. He received a number�of possible diagnoses during the course of the admission. Evidence is accepted from an� independent psychiatric expert, that Danny was likely to have been suffering from� paranoid schizophrenia in 2022. This is based upon his presenting condition, requiring� the admissions to hospital, and based upon his presentation throughout the six-month� period in hospital � June to December 2022. Danny�s condition was not correctly� diagnosed before discharge from hospital. Danny was entitled to Section 117 after-care� but no significant attention was given to his Section 117 after-care needs. Danny should have been assessed for supported accommodation. This was not done and supported� accommodation was not sought for him. Danny was discharged to grossly inadequate� hotel accommodation. Danny was discharged from hospital on the 14 December 2022.� There was no comprehensive assessment of risk prior to discharge. There was no� comprehensive safety plan put into place for him. Danny had stated his intention to� stop his anti-psychotic medication before he was discharged from hospital, but no plan�was put in place to address the clear risks of non-compliance with medication. The� community mental health team did not communicate to the housing team, the importance of Danny being placed within the area of the community mental health� team. Danny was placed out of area and was not seen face to face by his care co-ordinator before his discharge from the community team. Telephone contacts between� Danny and his care co-ordinator raised significant concerns about Danny�s mental�health and living circumstances. Despite this, he was discharged from the community� mental health team following telephone contact on the 18 January 2023. No� communication was sent to Danny�s GP to inform them of the discharge from mental� health services. On the 30 March 2023, Danny was found hanging inside his room at�[REDACTED]. Paramedics attended and pronounced his life extinct on scene.� Police attended and deemed the circumstances as non-suspicious. Danny took his own�life, whilst suffering from a mental illness, and whilst receiving absolutely no care from� the mental health services. Danny�s death was contributed to by cumulative failures, amounting to a gross failure, to provide mental health care to him

I have sent a copy of my report to the Chief Coroner, to the family of Danny Jay� Anderson, to the other interested persons to the inquest, to the Care Quality� Commission, 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.

Suicide (from 2015)�| Mental Health related deaths | Community health care and emergency services related deaths� � This report is being sent to: Essex Partnership University NHS Foundation Trust

26/01/2023

2023-0029

Zachary Klement

Surrey

[REDACTED] Chief Executive Officer, NHS England and NHS Improvement

The inquest into the death of Zachary KLEMENT was opened on 18th March 2021. Evidence was heard between 4th and 6th October 2022, and it was concluded on 2nd December 2022. � I found the medical cause of death to be: 1a. Suspension I determined that Zachary took his own life by suspension during a crisis of deteriorating mental health and increasing suicidal ideation. I recorded a narrative conclusion, detailing the following: On 2nd March 2021, Zachary Klement was found suspended in his bedroom at his supported living accommodation in Woking, Surrey, and was pronounced deceased by attending paramedics at 19:37. He had a long history of mental health issues from childhood and was diagnosed with Autistic Spectrum Disorder, Emotionally Unstable Personality Disorder, general anxiety disorder and Bipolar Affective Disorder. � On 26th January 2021, Zachary was admitted to Farnham Road Hospital as an informal patient following an escalation in his self-harm and suicidal ideation. He was discharged back to his supported living accommodation on 1st February 2021, initially under the care of� the Home Treatment Team and then the Community Mental Health Recovery Service. He continued to have fluctuating mood and episodes of self-harm, and he sought help from Safe Haven and the Psychiatric Liaison Service at St Peter�s Hospital on 4th, 22nd, 24th and 28th February. � On the last occasion, 28th February 2021, he expressed concern he could not keep himself safe. He requested inpatient admittance and then agreed to Home Treatment Team care before changing his mind. On this occasion his immediate risk was assessed as low and he was discharged back to the Community Mental Health Team. This was a missed opportunity to contain and manage his risk whilst exploring his needs. � The lack of availability of psychological therapies and resources tailored to the needs of patients with Autistic Spectrum Disorder which could be offered to Zachary by Surrey & Borders Partnership NHS Foundation Trust also represented a missed opportunity to provide therapeutic care. � On the afternoon of 2nd March, Zachary sent a text message to his Care Coordinator stating that he wanted to discharge himself from mental health services as he felt they were not helping him. A support worker found him suspended in his bedroom at around 18.45. Suicide.

Zachary was found suspended in the bedroom of his supported accommodation on 2nd March 2021, and was pronounced deceased by attending paramedics.

COPIES I have sent a copy of this report to the following: 1.���� See names in paragraph 1 above 2. [REDACTED] 3. Surrey and Borders Partnership NHS Foundation Trust, [REDACTED] 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.

Suicide (from 2015)

NHS England and NHS Improvement

25/04/2023

2023-0135

John Roberts

Cornwall and the Isles of Scilly

[REDACTED] Chief Executive Officer, Royal Cornwall Hospital Trust (RCHT) � ������������������������ [REDACTED] Chief Executive Officer, National Institute for Clinical Excellence (NICE)

On 22 July 2021 I commenced an investigation into the death of John Alfred Roberts. The investigation concluded at the end of the inquest on 14 April 2023. The conclusion of the inquest was as follows � Medical cause of death � 1a Peritonitis 1B Perforated sigmoid colon (inoperable) 1c Diverticular disease � II Diabetes mellitus type 2, chronic kidney disease, myasthenia gravis and coronary artery disease � The four questions � who, when, where and how � were answered as follows � � JOHN ALFRED ROBERTS died on 26 June 2021 at High Barn St. Buryan Penzance Cornwall from a perforated sigmoid colon due to diverticular disease, contributed to by multiple co-morbidities. My conclusion as to the death was a narrative conclusion John died from recognized complications of necessary medical treatment, namely steroid therapy for myasthenia gravis, contributed to by multiple co-morbidities.

John was a 78-years-old gentleman with a past medical history of ��diabetes (type 2) diagnosed 1999 ��chronic kidney disease, from 2012 ��diverticular disease from 2012 ��raised BMI, at times over 30, ��myasthenia gravis (MG), symptoms identified from around April 2020, � John was prescribed steroids from December 2020 for MG, escalating to the highest recommended dose of 100mg prednisolone, taken every other day. John received this high dose from 21 February 2021 until his death on 26 June 2021. That is with the exception of a period between 7 and 13 June 2021 following an inadvertent reduction in dosage to 25mg whilst an in-patient at RCHT. John was discharged on 15 June 2021 after this dosage error. I found that John was medically fit at the time of discharge and that the dosage error did not contribute to his cause of death. � John was re-admitted on 22 June with a history of vomiting and retching for 2 days before admission; I found on the evidence that this was the likely period when John suffered his perforated sigmoid colon. This was deemed inoperable. John did not respond to antibiotics and was discharged home on 25 June 2021 for palliative care. John died peacefully at home on 26 June 2021. � I found on the evidence of the histopathologist�[REDACTED], that steroid therapy was contributory to John�s cause of death, alongside John�s other conditions. I found on the evidence that it was not possible to distinguish between the multiple conditions contributing to, and causative of, the perforated bowel. � [REDACTED] stated in evidence as follows: � �steroid therapy increases the risks of gastrointestinal complications including ulceration and perforation of the stomach, duodenum and the colon and these are recognised complications documented in the literature. The mechanism is unclear but steroids are thought to impair the mucosal barrier which enables bacteria to penetrate. Steroid induced colonic perforation is more likely to occur in patients with diverticular disease and the deceased was noted at autopsy to suffer from diverticular disease. It is speculated that in diverticular disease there is a localised concentration of bacteria. Also, if the patient is treated by high dose steroids, the signs and symptoms of gastrointestinal and colonic complications may be masked by the anti-inflammatory effects of the drugs. This may potentially lead to delays in identification of the drug induced complications, so potentially resulting in the patient presenting with advanced complications such as viscus perforation.

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

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

27/11/2023

2023-0486

Luke Whitelaw

Inner North London

[REDACTED] Chief Executive Oxleas NHS Foundation Trust Pinewood House Pinewood Place Dartford Kent DA5 7WG

On 4 April 2023, an investigation was commenced into the death of LUKE MERVYN WHITELAW, then aged 46 years. The investigation concluded at the end of an inquest, heard by me, on 24 November 2023. The conclusion of the inquest was suicide, the medical cause of death being: 1a drowning

1) Mr Whitelaw had was known to mental health services at Oxleas NHS Foundation Trust prior to his death. 2) He was detained by police for his own safety, using their powers under section 136 of the Mental Health Act 1983, on 7 January 2023 having twice attempted suicide on that day. Having been treated in hospital (predominantly for his physical health as a result of the suicide attempts) between 7 � 12 January 2023, he was thereafter admitted to the Shrewsbury Ward in Oxleas House on an informal basis for care and support in relation to his mental health. He was discharged to the Greenwich Home Treatment Team, following an assessment by them on 25 January 2023. 3) His mood and mental health deteriorated significantly in late-January and early-February 2023. This deterioration was documented and noted by numerous individual clinicians, but they focussed on Mr Whitelaw�s presentation in the moment, without reference to past notes or full consideration of past risk factors. 4) On 2 February 2023, Mr Whitelaw was seen by a psychologist. During the appointment he disclosed that he would be willing to accept a further informal admission to hospital. At the conclusion of that appointment, the psychologist made a verbal referral of Mr Whitelaw to another clinician for urgent medical review by a psychiatrist. That referral was not acted on and, as such, Mr Whitelaw was not re- admitted to hospital on an informal basis, or otherwise. 5) On 14 February 2023, Mr Whitelaw�s wife reported to the police that Luke Whitelaw was missing. A missing person investigation was conducted. 6) On 17 March 2023, the Marine Policing Unit responded to reports of a body in the river Thames. They recovered a body, which was subsequently identified as Mr Luke Whitelaw.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] (Luke Whitelaw�s wife) [REDACTED] (Luke Whitelaw�s sister). � 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: Oxleas NHS Foundation Trust

13/11/2023

2023-0444

Bavaniammah Theiventhiran

Surrey

[REDACTED] Chief Executive Surrey and Sussex Healthcare NHS Trust Trust Headquarters East Surrey Hospital Canada Avenue Redhill RH1 5RH

INQUEST � An inquest into Ms Theiventhiran�s death was opened on 20 April 2023. The inquest was resumed and concluded on 9 November 2023. � The medical cause of Ms Theiventhiran�s death was: � 1a. Congestive Cardiac Failure 1b. Valvular Heart Disease, Ischaemic Heart Disease and Acute on Chronic Kidney Disease 2. Fracture Neck of Femur due to Fall on 26 February 2023 (Operated 2 March 2023) The inquest concluded with a narrative conclusion as follows: Ms Theiventhiran was 80 years old. Her past medical history included Ischaemic Heart Disease, Valvular Heart Disease and Chronic Kidney Disease. On 26 February 2023 Ms Theiventhiran tripped over a suitcase at her home address and was admitted to East Surrey Hospital on the same day and diagnosed with a fractured left neck of femur. On her admission to hospital Ms Theiventhiran was placed on the trauma list for surgery. However, the surgery did not place until 2 March 2023. There was no clinical reason to delay her surgery. Following the surgery Ms Theiventhiran developed an Acute Kidney Injury and on 6 March 2023 she died at East Surrey Hospital. Her death was due to Congestive Cardiac Failure caused by a combination of her Chronic Heart Disease and Acute on Chronic Kidney Disease. The fall and fracture, along with the amount of time that elapsed between the fracture and the surgery taking place, placed prolonged stress on Ms Theiventhiran�s already compromised heart, exacerbating her congestive cardiac failure and thereby contributing to her death.

The court heard that the NICE Guideline on the Management of Hip Fractures recommends that hip surgery take place on the day of the injury or the day thereafter on the basis that early surgery for hip fractures is the most appropriate form of pain relief, potentially quickening rehabilitation and reducing complications. � The Court heard evidence that Ms Theivanthiran was clinically fit for surgery following her admission to East Surrey Hospital on 26 February 2023. However, her surgery did not take place until 2 March 2023 because other trauma patients were prioritised ahead of her, either because they had been admitted on an earlier date, or because they had been assessed as having a higher clinical need. � The Court heard evidence that the most recently monthly figures recorded by East Surrey Hospital indicate that fewer than 50 per cent of its neck of femur patients had been operated upon with the timeframes set out in the NICE Guideline on the Management of Hip Fractures. CORONER�S CONCERNS The MATTER OF CONCERN is: The NICE Guideline on the Management of Hip Fractures recommends that hip surgery take place on the day of the injury or the day thereafter in order, amongst other things, to reduce complications. The most recent monthly figures indicate that East Surrey Hospital it is not meeting this timeframe for over half of patients who present to the hospital with a fractured neck of femur. The Coroner is concerned that in failing to comply with the NICE Guideline in this way, the Trust is placing such patients at risk of early death.

ANNA CRAWFORD Anna Crawford H.M Assistant Coroner for Surrey Dated this 13th day of November 2023

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

17/01/2023

2023-0014

Teegan Barnard

West Sussex

[REDACTED] Chief Executive U. Hospitals Sussex NHS Foundation Trust, [REDACTED] Medical Director, St Richards Hospital, Chichester, Chief Executive NHS England, Chief Executive Health Education England, Chief Executive CQC

On 7th January 2022 I resumed an investigation into the death of Teegan Marie Barnard. On 14th December 2022 I concluded the Investigation. � The medical cause of death given was: � 1a. Acute Bronchopneumonia 1b. Global Cerebral Hypoxia 1c. In Hospital Cardiac Arrest following Third Trimester Lower Segment Caesarean Section, Significant Post-Partum Haemorrhage and Perioperative Bilateral Tension Pneumothoraces I determined: On 7th October 2019 Teegan Marie Barnard died at her home address in Havant. She sustained an irrecoverable hypoxic brain injury following a prolonged pulseless electrical activity (PEA) cardiac arrest during emergence from a general anaesthetic after an emergency lower segment caesarean section (LSCS) on 9th September 2019 at St Richards Hospital, Chichester. The PEA cardiac arrest was due to bilateral tension pneumothoraces, the cause of which remains unclear, but in circumstances whereby a delay in the recognition and treatment thereof made a material contribution to Teegan�s death.

Teegan became pregnant in December 2018 and was admitted in the early stages of labour to the delivery suite at St Richard�s Hospital, Chichester on 8th September 2019. Labour did not progress and a category 2 LSCS was undertaken at or around 0300 on 9th September 2019 by way of general anaesthesia as the spinal anaesthetic was ineffective. � At LSCS, Teegan was found to have had an obstructed pregnancy with an atonic uterus, sustaining a significant post-partum haemorrhage of approximately four litres. This was treated with pharmacological and surgical interventions. � The surgery was concluded at or around 0430 hours. Teegan was clinically stable with all physiological parameters, including airway pressures, within normal limits. A decision was made to awaken Teegan from the anaesthetic. This included reversal of neuromuscular blockade, with transfer to ventilator pressure support mode with delivery of 100 % oxygen. At or around 0500 hours, Teegan remained intubated and had been transferred from the operating table onto her bed. After transfer and on turning Teegan to be cleaned, the ventilator high airway pressure alarm sounded, and Teegan�s oxygen saturation fell. Attempts to ventilate Teegan by the ventilator or by hand and with a separate breathing circuit were not successful. She was deeply cyanotic and had begun to swell, at first in and around her head and neck and thereafter throughout her whole body. No breath sounds were heard on auscultation and despite strenuous attempts at ventilation, her chest was not moving. Shortly thereafter, at or around 0510-0515 hours, Teegan had a pulseless electrical activity (PEA) cardiac arrest. � Teegan was thought to have developed anaphylaxis for which treatment was given but without resolution or improvement in her clinical condition. At or around 0545 with the enduring PEA cardiac arrest, an ongoing inability to ventilate by any means possible, and the continuing absence of chest movement and breath sounds on auscultation, the whole-body swelling was recognised to be due to surgical emphysema from a presumptive diagnosis of bilateral tension pneumothoraces. At or around 0548 hours bilateral thoracostomies were undertaken with return of spontaneous circulation. � Unfortunately, given the length of time of the cardiac arrest, Teegan sustained a non-survivable hypoxic brain injury and sadly died at home six weeks later, on 7th October 2019. She was 17 years of age at the time of her death.

COPIES I have sent a copy of this report to the following: 1.���� See names in paragraph 1 above 2.����[REDACTED] (mother of Teegan Marie Barnard 3.���� Clinical Director, Anaesthetics, St Richards Hospital, Chichester 4.�����[REDACTED] ex- CEO, UHS NHS Foundation Trust 5.���� Chairman, Board of Governors, UHS NHS Foundation Trust 6.���� President, Royal College of Anaesthetists 7.���� President, Association of Anaesthetists Great Britain and Ireland 8.���� General Medical Council 9.���� HSIB � 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

University Hospitals Sussex NHS Foundation Trust | St Richards Hospital | NHS England | Care Quality Commission | Health Education England

4/6/2024

2024-0367

Andrew Naylor

Durham & Darlington� � Category: Alcohol, drug and medication related deaths � This report is being sent to: County Durham and Darlington NHS Foundation Trust | Tees, Esk and Wear Valleys NHS Foundation Trust

[REDACTED] Chief Executive of County Durham and Darlington NHS Foundation Trust. [REDACTED] Chief Executive of Tees, Esk and Wear Valleys NHS Foundation Trust County Durham and Darlington NHS Foundation Trust | Tees, Esk and Wear Valleys NHS Foundation Trust

On the 17th of October 2022 an investigation was commenced into the death of Andrew James Naylor, aged 37 years. The investigation concluded at the end of the inquest on the 3rd of June 2024. I gave a narrative conclusion as follows :- Andrew James Naylor was found deceased on the 11th of October 2022 at Drury Lane, Durham City. He died as a result of the combined central nervous system depressant actions of alcohol, [REDACTED] and [REDACTED]. The [REDACTED] had been administered to the deceased during his hospitalisation subsequent to an overdose, and to manage the symptoms and effects of alcohol withdrawal. He was not advised of the specific and potentially fatal risk of respiratory depression should he drink or misuse drugs in combination with the [REDACTED] or the [REDACTED] he had ingested, and no full consideration was given to the safety of the discharge, given the deceased was a chronic alcoholic likely to drink alcohol and or take drugs upon discharge, and was homeless having been evicted from his supported accommodation. In particular, the mental health team in the hospital did not inform the medical clinicians that the deceased was homeless, which would have delayed his discharge until a place of safety was identified. There was no consideration of contacting the deceased�s family or friends who may have provided an essential safety net in the absence of professional support, nor as to how he was to contact or be contacted by community support services such as community mental health or drug and alcohol services in the absence of a postal address or mobile phone. Poor communication between the various agencies involved led to a failure to ensure a robust safety plan was in place. These cumulative failures contributed more than minimally to the death. The medical cause of death was :- 1a) Acute Cardiorespiratory failure 1b) Central Nervous System Depressant Actions of Alcohol, [REDACTED], and [REDACTED]

Andrew James Naylor was found deceased on the ground in Drury Lane, Durham City on the morning of the 11th of October 2002 . He had been discharged from the University Hospital of North Durham the day before, subsequent to treatment for a drug overdose, which included the administration of drug [REDACTED] to treat his alcohol withdrawal.� He was known to have mental health, drug and alcohol issues. It was known, or ought to have been known that he was homeless having been evicted from his supported accommodation.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; 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, drug and medication related deaths �

21/12/2023

2023-0543

Amal Ahmed

Milton Keynes

[REDACTED] Chief Executive of Milton Keynes City Council [REDACTED] Chief Executive National Highways

INVESTIGATION � On 20 November 2023 I commenced an investigation into the death of Amal Mohamed AHMED aged 38. The investigation has not yet concluded and the inquest has not been heard.

Ms Amal Mohamed Ahmed died on the A5 southbound Little Brickhill at or adjacent to the point where the A5 joins the �off� slip road. She appears to have been using a satnav directing her to Queensway, Bletchley. She entered the exit to the off slip road and drove the wrong way down the slip road, ultimately colliding with a vehicle travelling at speed on the A5 head on. Ms Ahmed died at the scene. The driver of the other vehicle died later at the John Radcliffe Hospital. A passenger of one of the vehicles required critical care treatment and suffered life threatening and changing injuries.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Chief Executive of Milton Keynes City Council Chief Executive National Highways � I have also sent it to � The families of the deceased 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: �Milton Keynes City Council | National Highways | Apple | Google | TomTom

19/07/2023

2023-0268

Kenneth Rippon

County Durham and Darlington

[REDACTED] Chief Executive of Tees, Esk and Wear Valley NHS Foundation Trust Care Quality Commission.

On the 16th May 2022 an investigation was commenced into the death of Kenneth Rippon, aged 47 years. The investigation concluded at the end of the inquest on 18th July 2023. The conclusion of the inquest was that Kenneth died on the 5th of May 2022 when he jumped or fell from the viaduct at Durham Train station, sustaining fatal injuries.The medical cause of death was multiple injuries. I recorded a narrative conclusion which included my finding that mental health services inadequate response to escalating risks, which were known or ought to have been known, including the failure to include family in assessment and safety/discharge planning contributed, more than minimally, to the death.

The deceased had a history of mental health difficulties and he, and his family, had been actively seeking professional help for a significant deterioration in his mental heath in the days leading up to his death. These difficulties included self harm and suicidal ideation, as a result of command auditory hallucinations. � On the 2nd of May 2022 the deceased presented at hospital via ambulance with a mental health crisis and suicidal ideation, [REDACTED]. He was clear that what would help him would be �to not go home� and that he did not feel safe at home. He was discharged in the absence of any comprehensive assessment, and in the absence of liaison with his family. The clinician assessing him did not have all of the important information to be able to carry out a comprehensive risk assessment, including in relation to recent incidents of self harm. � The deceased was seen by his care co ordinator on the 3rd of May 2022. The de- ceased again confirmed that he had drunk bleach on the command of voices, and both he and family were asking for admission. There was no comprehensive assessment. Again the clinician was not aware of important information which should have been taken into account in any assessment of risk, including in relation to self harm. � On the 4th of May 2022 the deceased presented at hospital via ambulance [REDACTED]. He told Doctors in the Emergency Department he had done this at the command of voices, that he still felt suicidal, and if discharged he would attempt to take his life again. There was no comprehensive assessment by mental health services and the clinician was not in possession of all relevant information as to risk. The deceased was discharged on the basis that there was no indication of current suicidal ideation at the point of the assessment or objective evidence of psychosis, to his home address, where he had indicated he did not feel safe. Whilst awaiting transport the deceased left the hospital having discarded his mobile phone and was reported missing. He was assessed as medium risk by the Police in the light of information provided by mental health services which had not been up- dated and did not include all risk events. � Having left the hospital, the deceased fell or jumped�[REDACTED] on the 5th May 2023, despite the efforts of Police officers on the scene. Kenneth�s intention cannot be established although it is known that the deceased was suffering from a deterioration in his mental health in the days leading up to his death, including evidence of auditory command hallucinations to harm himself. � Mental health services involved with the deceased, did not carry out comprehensive mental state assessments despite the escalating risks which were known or ought to have been known, and did not fully involve family members in care, safety and dis- charge planning, who were crucial to his safety.

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

Mental Health related deaths This report is being sent to: Tees, Esk and Wear Valley NHS Foundation Trust | Care Quality Commission

15/09/2023

2023-0334

Eclipse Morrison Coroner name: Linda Lee Coroner Area: Warwickshire Category: Child Death (from 2015)� | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: George Eliot Hospital NHS Trust | Department of Health and Social Care� | The Royal College of Midwives | The Royal College of Obstetricians and Gynaecologists | The National Institute for Health and Care Excellence

[REDACTED] Chief Executive of the George Eliot Hospital NHS Trust, Nuneaton, Warwickshire The Secretary of State for Health and Social Care�� The Chief Executive of the Royal College of Midwives���������������������������������������������������������������������������������� The Chief Executive of the Royal College of Obstetricians and Gynaecologists� The Chief Executive of the National Institute for Health and Care Excellence (NICE)

INVESTIGATION AND INQUEST Eclipse Morrison died on 21 July 2021, the day after her birth on 20 July 2021. A referral was made to the coroner on 27 July 2021 and an investigation commenced into the death of Eclipse Morrison aged one day. The investigation concluded at the end of the inquest on 28 July 2023. The conclusion of the inquest was a narrative conclusion: Eclipse Morrison died from Perinatal Asphyxia. Her mother had been diagnosed with Gestational Diabetes Mellitus (GDM) after a blood test at 21 + 4 weeks. The mother�s blood glucose levels remained high throughout the pregnancy with the insulin dose being increased at each diabetic review. Serial growth ultrasound scans identified that Eclipse�s growth was above the 95th customised centile and at the last scan at 37 + 3 weeks showed increased growth velocity. The mother went into spontaneous labour at 38 + 1 weeks and there was a shoulder dystocia during which there was a fracture of the humerus. Eclipse weighed 5,800g at birth and showed no signs of life. Her Apgar scores were zero at 1, 5 and 10 minutes. Advanced resuscitation was carried out and Eclipse was transferred to the regional neonatal intensive care unit in Nottingham. Eclipse had cardiomegaly as a result of the GDM and her condition was unstable. Eclipse died a natural cause of death; however, the evidence leads me to find that the following three circumstances may have contributed to her death: 1.������ Missed appointments by the mother were not followed up and subsequent appointments were not arranged with the appropriate teams. She only had one appointment with a consultant at 28 weeks. 2.������ As the mother was not seen by a consultant at two-week intervals (as required) in the latter stages of her pregnancy, appropriate modes and timing of delivery, such as elective Caesarean Section were not considered and as a consequence, not discussed with the mother. 3.������ Once the mother was in labour, the triage midwife relied on the information given by the mother on the telephone and was not aware of the mother�s risk factors. As a consequence, she did not ask the mother to come to hospital immediately. Finally the CTG traces from 16.44 were of poor quality and a fetal scalp electrode (FSE) was not available in the delivery room to monitor Eclipse�s condition. Once an FSE had been obtained it was not properly attached. It is possible that Eclipse suffered the cerebral hypoxia-ischaemia either in the period after 16.44 before the shoulder dystocia occurred or after the shoulder dystocia occurred at around 17.10.

The deceased died at 28 hours and 12 minutes on 21 July 2021 at Nottingham City Hospital. She had been transferred from the George Eliot Hospital NHS Trust (GEH) following her birth on 20 July 2021. Prior to Eclipse�s birth, her mother had received ante-natal care at GEH and was receiving treatment for Gestational Diabetes Mellitus.

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

30/12/2022

2023-0005

Gavin Pedleham

Surrey

[REDACTED] Chief Executive of the National Institute for Health Care Excellence, [REDACTED] Chief Executive of the Medicines and Healthcare Products Regulatory Agency, The Right Honourable Suella Braverman KC MP Secretary of State for the Home Office

The inquest was opened on the 12th May 2022 and resumed and concluded before a Coroner on the 9th December 2022. The cause of death was Morphine and Ethanol Toxicity The Coroner found that Gavin Peter Pedleham inadvertently drank a dose of oramorph at a family Christmas event which, in combination with the alcohol he had consumed, led to his death at home at 45, Hurst Green Road, Oxted on the 26th December 2021. The Conclusion was that he met his death by Accident.

Alcohol, drug and medication related deaths

National Institute for Health Care Excellence | Medicines and Healthcare Products Regulatory Agency | Home Office

31/01/2023

2023-0037

Donald Brown

Gloucestershire

[REDACTED] Chief Executive, Gloucestershire Hospitals NHS Foundation Trust, Gloucester Royal Hospital, Great Western Road, Gloucester GL1 3NN

On the 8th March 2021 I commenced an investigation into the death of Donald Charles Brown. The investigation concluded at the end of the inquest on the 13th December 2022. The conclusion of the inquest was a narrative conclusion. The medical cause of death was 1A Aspiration pneumonia, 1B C1/C2 fracture dislocation.

Donald Charles Brown �Donald� was an 87 year old man who suffered a fall at home on the 31st January 2021. He was taken to hospital and underwent CT examination. No fractures were reported. Following further investigations he was discharged home. Following discharge Donald continued to experience neck pain and difficulty swallowing. He was readmitted to hospital on the 26th February 2021 and was treated for aspiration pneumonia. Further CT imaging demonstrated that he had suffered a displaced fracture of the C2 vertebra with spinal cord compression. This injury had been sustained in his fall on the 31st January. It was visible on the CT imaging taken on that day. However it was not reported. It is likely that the severity of this injury led to his swallowing difficulties and caused aspiration pneumonia. Neurosurgical opinion was sought and advised against operative intervention. Donald�s condition thereafter steadily deteriorated and he passed away at 08.15 hours on the 4th March 2021.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (1)��� Taynton�s Solicitors representing the family of Donald Brown, [REDACTED] (2)��� National Medical Director,[REDACTED] (3)��� Royal College of Radiologists, 63 Lincoln�s Inn Fields, London WC2 3JW. 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

Gloucestershire Hospital NHS Foundation Trust

25/09/2023

2023-0350

Shaun Houghton

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 5th of December 2022 I commenced an Investigation into the death of Shaun Daniel Houghton, 35 years, born 5th of October 1987. � The Investigation concluded at the end of the Inquest on the 26th of May 2023. � The Medical Cause of Death was: la Hanging The Conclusion of the Investigation was Shaun Daniel Houghton died as a consequence of self-suspension by Ligature but his intentions at the time remain unclear.

1.�Shaun Daniel Houghton (hereinafter referred to as the �Deceased�) was found dead in a rural area near Dukes Barn Farm, Hall Lane, Winstanley, Wigan on the 1st of December 2022. � 2. The Deceased suffered with diagnosed Emotionally Unstable Personality Disorder, Attention Deficit Hyperactive Disorder, Anxiety and Depression and Mental Health & Behaviour Disorder due to substance misuse. 3. On the 16th of November 2022 the Deceased was admitted to the Prospect Unit at Atherleigh Park Hospital, Atherleigh Way, Leigh, as a voluntary patient after his Partner contacted the Mental Health Crisis Team due to family concerns about his mental health and he received in patient treatment until he was discharged from the Hospital after a Multi-Disciplinary Team meeting on the 25th of November 2022. � 4. On the 28th of November 2022 a Senior Nurse Practitioner from Greater Manchester Mental Health Trust visited the Deceased at his home address, and he demonstrated overwhelming feelings of anxiety and low mood. He indicated that he felt that he was impulsively going to end his life. Impulsivity is a recognised symptom of Attention Deficit Hyperactive Disorder and the Deceased continued to express thoughts, plans and intent to end his life. The Senior Nurse Practitioner arranged for the Deceased to be readmitted to the Sovereign Unit at Atherleigh Park Hospital as a voluntary patient later the same day. � 5.�On the 29th of November 2022 the Deceased was seen by an Associate Specialist Doctor in Psychiatry at the Hospital and a plan was created whereby the Deceased would remain in the Hospital as a voluntary patient with appropriate medication and he would be further reviewed in a Multi-Disciplinary Meeting the following week. � 6.�On the 30th of November 2022 the Deceased indicated that he wished to take his self-discharge from the Hospital, which was against medical advice, and he stated that he was unhappy with the Sovereign Unit at the Hospital, referring to the lack of Television remote controls on the Unit and he wanted to be moved to the Prospect Unit at the Hospital but a bed in the Prospect Unit was not available at the time. � 7.�The Deceased�s wish to self-discharge was referred to the Doctor on call and he was seen by a Foundation Year 2 Doctor, a junior Doctor, who had only spent a period of 4 months in Psychiatry as part of his general training as a Doctor. The Doctor followed the training he had been given in relation to self-discharge patients and he conducted an assessment in relation to the capacity of the Deceased and a risk assessment in relation to the Deceased but he did not consult or refer the self-discharge to the Senior Doctor who had created the plan of treatment on the previous day or the Consultant, both of whom were in the Hospital at the time. It is unclear from the evidence whether a referral to the Senior Doctor or the Consultant would have changed the decision to allow the Deceased to self� discharge and leave the Hospital or whether a referral would have led � to his detention under the Mental Health Act. � 8.�The Deceased took his self-discharge from the Sovereign Unit at the Hospital on the 30th of November 2022 and his mother took him from the Hospital to his home address. 9. At 02.34 hours on the 1st of December 2022 the Deceased sent a message and a photograph of himself to his mother [REDACTED] 10. The Deceased was found in a collapsed and unresponsive condition suspended by a ligature [REDACTED] similar circumstances in 2017. His death was verified by a 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] Mother 2. [REDACTED], Partner I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Mental Health related deaths This report is being sent to: Greater Manchester Mental Health NHS Foundation Trust

13/03/2023

2023-0089

Charlotte Comer

Worcestershire

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

[the details below are fictional] � On 27 July 2021 I commenced an investigation and opened an inquest into the death of Charlotte Comer. The investigation concluded at the end of the inquest on 17 February 2023. � The conclusion of the inquest was as follows: � �Charlotte Comer died as the result of suicide. The following failings on the part of the Herefordshire and Worcestershire Health and Care NHS Trust ( �the Trust� ) probably caused or contributed to her death: (a) The erroneous decision at the beginning of 2021 to seek to pause Charlotte�s referral to the Priory Hospital for specialist treatment for Body Dysmorphic Disorder; (b) The high turnover of care coordinators for Charlotte whilst she was under the Trust�s care, together with a five month period when she was without a care coordinator at all, which led to a loss of awareness on the Trust�s part about the seriousness and complexity of Charlotte�s needs; and (c) The failure by the Trust to provide sufficient focus on the important issue of Charlotte�s Body Dysmorphic Disorder. Charlotte�s death was contributed to by neglect.�

In answer to the questions �when, where, how and in what circumstances did Charlotte come by her death?�, I recorded as follows: � �On 18.7.21 Charlotte Comer, who lived with a number of significant mental health disorders, including Body Dysmorphic Disorder, and had a known history of attempts at suicide and self-harm, left Worcestershire Royal Hospital before doctors there could treat a substantial, recently self-inflicted wound to her upper arm. She returned initially to her parents� home, before then making her way to her own address in Worcester, where she proceeded to take a substantial overdose of Propranolol and Amlodipine medication. She was taken by ambulance back to Worcestershire Royal Hospital where, despite treatment, she succumbed to the effects of the overdose and died on the morning of 20.7.21.�

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] (Charlotte�s parents); [REDACTED] Novum Law solicitors ( representing Charlotte�s family ); [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)

Herefordshire & Worcestershire Health and Care NHS Trust

27/06/2023

2023-0218

Rachel Garrett

West Sussex

[REDACTED] Chief Executive, NHS England, Wellington House 133-135 Waterloo Road, London, SE1 8UG. [REDACTED] Chair, Integrated Health Board NHS Sussex, Wicker House, High Street, Worthing, BN11 1DJ.

On 30th July 2020 Ms Hamilton-Deeley, the former Senior Coroner, commenced an investigation into the death of Rachel Kathleen Garrett aged 22 years. The investigation was concluded at the end of the Inquest on 2nd June 2023. The conclusion given was a narrative conclusion namely: � Rachel, who was suffering from a complex mental health disorder, took her own life having suffered a deterioration of her mental health in the preceding months. Despite the extensive support of her family and the care being provided by the Mental Health services they had been unable to keep her safe. There was a missed opportunity to prevent her from leaving the Royal Sussex County Hospital on the second occasion on the 29th July 2020.

Rachel had been struggling with her mental health for some time, but there had been a marked deterioration in July 2020. � She had, on a number of occasions, been found close to the cliff edge in and around Brighton. On each occasion she was either detained by the Police under Section 136 Mental Health Act 1983 or voluntarily agreed to attend A&E at the Royal County Sussex Hospital. � On 28th July 2020 Rachel had again been found on the cliff edge. She was detained under Section 136 Mental Health Act and was again taken to A&E in Brighton. Before a mental health assessment could be carried out, she absconded from the hospital and returned home. In the early hours of the 29th July her parents contacted the ambulance service as they felt unable to keep Rachel safe. She was returned to A&E where she was later seen by the Mental Health Liaison team. Throughout her time in A&E she was nursed by an HCA on a 1 to 1 basis. � Although Rachel was found not to be detainable under the Mental Health Act the Consultant Psychiatrist, who was part of the Mental Health Liaison Team, had recommended that if she decided to leave the Hospital again, that consideration should be given to the use of the Doctor�s holding power under Section 5(2) Mental Health Act. � Sadly, Rachel did leave the hospital for a second time and went back to the cliffs where she ended her life by falling from the cliff top.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � ������� The family of Rachel Garrett ������� University Sussex Hospital NHS Foundation Trust ������� Sussex Partnership Foundation Trust ������� Royal College of Psychiatrists ������� Secretary of State ������� Chief Executive 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 person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Mental Health related deaths This report is being sent to: NHS England | Integrated Health Board NHS Sussex

08/01/2024

2024-0009

Walter Faulder

Cumbria

[REDACTED] Chief Executive, National Highways, 3 Ridgeway, Quinton Business Park, Birmingham B32 1AF [REDACTED] Area Transport & Highways Manager, Lillyhall Depot, Workington (by email)

On 20 December 2022 I commenced an investigation into the death of Walter FAULDER. The investigation concluded at the end of the inquest . The conclusion of the inquest was Death due to Road Traffic Collision and the medical cause of death was 1a Multiple Injuries

Walter Faulder BEM was an 88 year old gentleman who lived alone in Wigton, Cumberland. He had recently been discharged from hospital. � On Saturday 10th December 2022, Walter�s daughter visited his address and there was a Cranston�s shopping bag next to his chair. He said he had got the bus to Orton Grange (where the shop is) and back which raised alarm bells to his daughter. She asked him not to do this journey again as it is unsafe. Walter stated that he believes there is a pelican crossing to assist him crossing the road (A595). This is not the case at Orton Grange. � On Tuesday 13th December 2022, Walter has got the 400 bus at 16:10 hours from Wigton and got off at Orton Grange. Walter has forgotten his wallet and crossed the road to the middle island and continued onto the South-West carriageway. He then collided with a vehicle, causing him to fall into the chevrons in the middle of the road. At the time of the collision it was nearly dark and the road was busy with a steady flow of traffic in both directions moving at normal speed. � Walter was given first aid at scene, however he was pronounced deceased at scene in the rear of the ambulance at 17:20 hours.

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

Road (Highways Safety) related deaths This report is being sent to: National Highways | Area Transport and Highways

01/05/2024

2024-0237

Lilly Proctor

West Yorkshire (Eastern)

[REDACTED] Chief Executive, National Institute for Health and Care Excellence [REDACTED] Chief Executive Officer, Royal College of Paediatrics and Chid Health

On 7th April 2022 I commenced an investigation into the death of Lilly Grace Proctor, 28/02/2009. The investigation concluded at the end of the Inquest on 25/04/2024. The conclusion of the Inquest was a narrative conclusion reflecting Lilly�s admission to and discharge from Pinderfields Hospital over the period 01-02/04/2022, her collapse at home on the early hours of 03/04/2022 and her death later that day in Pinderfields Hospital where she had been brought by ambulance.

Lilly Proctor died on 3rd April 2022 in Pinderfields Hospital, having collapsed at home in the early hours of the morning. She was 13. � A joint paediatric and forensic post mortem examination gave the cause of her death as 1a) Massive Pulmonary Thromboembolism 1b) Deep Vein Thrombosis 1c) Pathogenic PROS 1 Variant (said by the pathologists to have been causative of hereditary Protein S deficiency, a risk factor for venous thromboembolism). � The findings at post mortem were consistent with Lilly having developed a number of non-fatal pulmonary thromboembolisms prior to her final collapse, and in particular were suggestive of an old thromboembolism having developed around 6th March 2022 when she had sought out of hours advice for a pleuritic chest pain. � Lilly had a strong family history of thromboembolic disease, her mother having the Leiden Factor V mutation with a history of clots and anticoagulation from the age of 16, and her biological father having had a blood clot some two years before Lilly�s death. � On 1st April 2022 Lilly (with her mother) attended the Emergency Department at Pinderfields� Hospital with complaints of shortness� of breath and chest pains. Of the five doctors� who saw Lilly before� her� death,�only one of them�elicited the history�of Lilly�s mother�s Leiden Factor V mutation, and none obtained the history of blood clots in both of Lilly�s parents. Her presentation was variously thought to be cardiac in origin, symptomatic of hypothyroidism, suggestive of pneumonia, attributable to a viral upper respiratory infection, or related to anxiety. An independent expert paediatrician gave evidence to the Inquest that features of an ECG that were thought by treating clinicians to be attributable to Lilly�s age were potentially indicative of a number of conditions, including heart strain and pulmonary embolus. Lilly was discharged from hospital on 2nd April 2022 with no formal diagnosis and no prescribed treatment. She had been unable to complete an exercise test whereby she had been asked to walk a short distance around the department although her heart rate (which remained above 100 bpm throughout her admission) was recorded as the same at the beginning and the end of the test. The combination of Lilly�s ECG, a raised inflammatory marker and Lilly�s extreme breathlessness would have justified an echocardiogram and 24 hour ECG being performed. Proper consideration of the parental history (if obtained) would have justified consideration of a CTPA investigation to confirm or exclude a pulmonary embolism, although the risks associated with that procedure may have militated against it. It cannot be said on the balance of probabilities that any step taken as an alternative to discharging Lilly on 2nd April 2022 would have prevented the tragedy of her terminal collapse the following day.

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

Child Death (from 2015) This report is being sent to: National Institute for Health and Care Excellence | Royal College of Paediatrics and Child Health

01/11/2024

2024-0591

Phyllis Tromans

Birmingham and Solihull

University Hospitals Birmingham NHS Foundation Trust

On 13 June 2024 I commenced an investigation into the death of Phyllis TROMANS. The� investigation concluded at the end of the inquest . The conclusion of the inquest was: Mrs Tromans died as a result of an infected pressure ulcer to her right hip which developed when she was an inpatient in Queen Elizabeth Hospital, to which gaps in her pressure area care during that admission made a contribution.

Mrs Tromans was a long term resident at Cotteridge House Residential Home. She had� Parkinson�s disease and was in a frail condition. On 17 March 2024 she was admitted to Queen�Elizabeth Hospital where she was treated for pneumonia but where her condition did not improve and she was assessed as being for end of life care. Whilst in hospital, she developed a grade 4� pressure ulcer of her right hip, to which gaps in her pressure area care made a contribution. She died at Cotteridge House on 24 May 2024.� Following a post mortem performed by [REDACTED], the medical cause of death was determined to be:� 1a Infected Pressure Related Ulcer Right Hip 1b 1c 1d II��Frailty, End stage Parkinsonism with immobility

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] � (Mrs Tromans� daughter) � I have also sent it to the Medical Examiner, ICS, NHS England and CQC. 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

University Hospitals Birmingham NHS Foundation Trust

14/05/2024

2024-0266

James Pearson

Birmingham and Solihull

University Hospitals Birmingham NHS Foundation Trust

On 9 November 2023 I commenced an investigation into the death of James Patrick PEARSON. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Died as a result of complications of prolonged hospital admission, in combination with injuries sustained in a road traffic collision, and subsequent hypoxic brain injury, following cardiac arrest.

On 14th June 2023, James Pearson was hit by a vehicle on A4540 Birmingham. He was assessed at the scene and his injuries did not appear to be serious. He was taken to Birmingham Heartlands Hospital where a CT scan showed an axonal brain injury, small bleed to the brain, and severe pelvic injuries with suspicion of an active bleed. Observations taken at 03.16 indicated that he was maintaining his blood pressure and the Consultant at the time did not feel he was actively bleeding. James went into peri-arrest, and subsequently suffered a cardiac arrest. After 12 minutes of CPR, a return of spontaneous circulation was achieved, however, James had suffered hypoxic brain injury as a result of the cardiac arrest. This, alongside the traumatic brain injury sustained in the road traffic collision resulted in a prolonged stay in hospital for James, who continued to decline, and developed hospital acquired pneumonia. He was transferred to St Catherine�s Hospice in Preston on 12th October 2023 for end of life care, and he passed away there on 22nd October 2023. Whilst at Birmingham Heartlands Hospital an opportunity to provide fluids to James was missed, which, on the balance of probabilities would have prevented his cardiac arrest and subsequent hypoxic brain injury. � Following a post mortem, the medical cause of death was determined to be: 1a Pneumonia 1b Diffuse axonal injury and hypoxic brain injury 1c Road traffic collision II�Malnutrition

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

Road (Highways Safety) related deaths | Child Deaths (from 2015) This report is being sent to: University Hospitals Birmingham NHS Foundation

22/10/2024

2024-0566

Joan Knight

Birmingham and Solihull

University Hospitals Birmingham NHS Foundation Trust

On 11 June 2024 I commenced an investigation into the death of Joan Margaret KNIGHT. The� investigation concluded at the end of the Inquest . The conclusion of the inquest was; Died from the consequences of a recognised complication following treatment for severe coronary artery� stenosis

Mrs Knight suffered an acute inferior wall myocardial infarction on 16/05/24 and had treatment by� way of angioplasty to her right coronary artery with a stent being fitted. The procedure was� complicated as she was found to have significant calcium build up in the coronary artery. It was� also noted that the left anterior descending artery had severe narrowing. Initially after the�procedure she was pain free; however she began to experience further chest pain on 18/05/24� which was treated with medication. The chest pain recurred on 20/05/24 and a further procedure to insert a stent into the left anterior descending artery was undertaken on 21/05/24. During the� procedure access was difficult and significant calcification was noted. During ballooning the� coronary artery ruptured and was successfully treated with a stent. Whilst initially stable after the� procedure her condition deteriorated, and she presented with an unrecordable blood pressure. A� bedside echocardiogram confirmed a collection of blood around the heart and an emergency� pericardial aspiration was undertaken and she was taken back to the cardiac catheter lab where a� covered stent was fitted to try to treat the bleeding at the site of the previous perforation. The� bleeding was difficult to control and arrangements were made to transfer her to the Queen� Elizabeth Hospital where a CT scan confirmed bleeding in the abdomen. She was taken to theatre� where no site for bleeding was found in the abdomen; however a small perforation in the right� ventricle was identified and repaired which was likely caused when the emergency aspiration� procedure was undertaken. Sadly, she developed multi organ failure in the post operative period� and passed away on 25/05/24.� Based on information from the Deceased�s treating clinicians, the medical cause of death was determined to be:� Multiple organ failure � 1b�� intrabdominal bleeding from chest compressions and ventricular bleeding secondary to emergency pericardial aspiration (operated)� 1c�� cardiac tamponade� 1d treatment for severe stenosis of the left anterior descending coronary artery leading to�perforation and bleeding� �II��� Myocardial infarction (treated)

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mrs Knight. I have also sent it to the Medical Examiner, ICS, NHS England, CQC. 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

University Hospitals Birmingham NHS Foundation Trust

22/10/2024

2024-0567

Robert Taylor

Birmingham and Solihull

University Hospitals Birmingham NHS Foundation Trust

On 4 July 2024 I commenced an investigation into the death of Robert TAYLOR. The investigation concluded at the end of the Inquest. The conclusion of the inquest was; Natural causes contributed to by injuries sustained in a fall when he was not receiving enhanced nursing observations.

Mr Taylor suffered from prostate cancer was frail and had chronic liver disease. On 29/05/24 he� fell in the bathroom at his home address after his leg gave way. He was admitted to Birmingham� Heartlands Hospital where he was investigated and treated for pancytopenia, possible infection�and dropping HB. He was being nursed in a side room due to the increased risk of infection. In the� morning on 11/06/24 he was noted to be very confused and agitated and it was recognised that he� required enhanced 1:1 observations. No enhanced observations were put in place. He did have�non slip socks and the bed rails were down to reduce the risk of him falling. He received lorazepam to enable a CT scan to be undertaken at 11.06. At around 18.13 he was found face down in his�side room with an obvious head injury. A CT scan confirmed bilateral subdural haematomas and a� small subarachnoid haemorrhage which were treated conservatively. A bone marrow biopsy� confirmed he was sadly suffering from high grade acute myeloid leukaemia and inflammatory� markers showed this disease was progressing. He continued to deteriorate and sadly passed away on 21/06/24.� Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be:� 1a High grade Acute Myeloid Leukaemia 1b 1c 1d II Acute subdural and subarachnoid haemorrhage (traumatic)

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr Taylor�s Family I have also sent it to the Medical Examiner, ICS, NHS England, CQC. 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

University Hospitals Birmingham NHS Foundation Trust

23/04/2024

2024-0217

Ronald Spencer

Birmingham and Solihull

University Hospitals Birmingham NHS Foundation Trust NHS Birmingham and Solihull Integrated Care Board NHS England Ms Victoria Atkins � Secretary of State for Health and Social Care

On 14 December 2023 I commenced an investigation into the death of Ronald Henry SPENCER. The investigation concluded at the end of the inquest. The conclusion of the inquest was that he died from a recognised complication of a medical procedure

On 13 November 2023, Ronald had an oesophageal stent placed at the Queen Elizabeth Hospital to treat a symptomatic and reoccurring benign oesophageal stricture. He previously suffered an oesophageal perforation in March 2023 following dilatation procedure, but this had healed. Following the stent procedure, he subsequently became ill with a suspected bowel perforation caused by the stent migrating from his oesophagus into the mid jejunum, which is a recognised risk. He underwent laparotomy on 27 November where the stent was removed and the bowel repaired. Initially, he recovered well but began to deteriorate on 1 December, and he sadly died at 07:48 on 2 December 2023. � Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a Gastro-intestinal ischaemia � 1b Oesophageal stent migration to small bowel (operated) II�� Oesophageal stricture, Iatrogenic � Presented with this 3/2023 to Sandwell hospital due to dysphagia and impassable scope ; Atrial Fibrillation

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

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

26/02/2024

2024-0108

Alissa Norton

West Sussex, Brighton and Hove Category: Child Death (from 2015) This report is being sent to: University Hospitals Sussex NHS Foundation

University Hospitals Sussex NHS Foundation Trust University Hospitals Sussex NHS Foundation

On 13 July 2022 I commenced an investigation into the death of Alissa Claire NORTON aged 4 Days. The investigation concluded at the end of the inquest on 22 February 2024. The conclusion of the inquest was that: � Alissa Claire Norton died on 22 April 2022 at the Royal Sussex County Hospital, Eastern Road, Brighton from a hypoxic ischaemic encephalopathy caused by chorioamnionitis which she was exposed to prior to her birth on 18 April 2022.

Alissa Claire Norton died on 22 April 2022 at the Royal Sussex County Hospital, Eastern Road, Brighton from a hypoxic ischaemic encephalopathy caused by chorioamnionitis which she was exposed to prior to her birth on 18 April 2022 at Worthing Hospital, West Sussex.

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

Child Death (from 2015)

30/06/2023

2023-0228

Sinon Masha

Birmingham and Solihull

University Hospitals of Birmingham NHS Foundation Trust

On 30 December 2021 I commenced an investigation into the death of Sinon MASHA. The investigation concluded at the end of the inquest. The conclusion of the inquest was: � Natural causes.

Sinon Masha was born following a home birth at 13:41 on the 17th December 2021. For a variety of reasons, a home birth was against medical advice, this had been explained on a number of occasions throughout the pregnancy. On the 17th December 2021 advice to transfer to hospital had been given by midwives during early labour due to concerns that Sinon�s mother was showing signs of pre-eclampsia and due to findings of light meconium staining on rupture of membranes which could indicate fetal distress. This advice was not accepted. At 12:47 it was identified that Sinon maybe an undiagnosed breech presentation, transfer to hospital was recommended and declined. Up to that time presentation based on abdominal palpitation and vaginal examinations had been assessed as cephalic. A frank breech presentation was confirmed during a 999 call commencing at 13:00. Paramedics arrived at scene at 13:07 and transfer to hospital was again advised and not accepted. The presenting part delivered at 13:14, there was then a 27 minute period before delivery of Sinon�s head causing a catastrophic hypoxic brain injury. He received resuscitation and was transferred to Birmingham Heartlands Hospital arriving at 49 minutes of age. At 57 minutes Sinon was found to have a heartbeat, he was ventilated and cooled but remained comatose and subsequently developed signs of encephalopathy and multi organ failure, a decision was made to provide palliative care on the 20th December and Sinon died at 05:15 on the 21st December 2021. � Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a Hypoxic ischaemic encephalopathy � 1b Undiagnosed breech presentation during home delivery

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

Child Death (from 2015) This report is being sent to: University Hospitals of Birmingham NHS Foundation Trust

09/06/2023

2023-0188

Alice Fox

Derby and Derbyshire

University Hospitals of Derby and Burton NHS FT Derbyshire Community Health Services NHS FT East Midlands Ambulance Service

On 05 July 2021 I commenced an investigation into the death of Alice Jean FOX aged 90. The investigation concluded at the end of the inquest on 26 May 2023. The conclusion of the inquest was that: � Mrs Alice Jean Fox, known as Jean, died in hospital on 1 July 2021 due to the effects of severe infection resulting from bacterial infection of her surgical site in relation to a partial hip replacement for fracture following a fall at home.

Jean was admitted to Royal Derby Hospital on 7 June 2021 following her fall, and surgery was performed on 9 June. There were no complications during the surgery nor in her post- operative care leading to discharge to Ripley Rehabilitation Hospital where she arrived at about 23:00 on 22 June. Because she arrived so late and out of core hours, she did not have the benefit of the full and usual assessments and she had also been waiting for the transfer for some significant time at the general hospital in its discharge lounge. � The rehabilitation hospital nurse who examined Jean on her arrival noticed the wound site to be red and hot to touch and considered there was a possibility of infection and it was thereafter kept under visual observation. The following morning an advanced nurse practitioner requested routine blood samples be taken as part of the clinical assessment and the blood samples were taken the next day, 24 June, and were available for clinical review that afternoon but were not reviewed until the next day, 25 June, when raised inflammatory markers were noted and Jean was then transferred back to the general hospital (Royal Derby Hospital) due to infection. � At the general hospital antibiotic treatment was started but Jean was not considered fit to undergo major surgery to remove the partial hip replacement and wash out the wound and end of life care was agreed with her family. � Although the court considered that there had been opportunity to refer Jean back to the general hospital earlier, on the evidence this would not have prevented her death, as even at that earlier point surgery would not have been appropriate due to the high risk of mortality given her comorbidities and frailty.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] (daughter of Jean Fox) [REDACTED] (son of Jean Fox) University Hospitals of Derby and Burton NHS FT Derbyshire Community Health Services NHS FT � 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 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 of Derby and Burton NHS Foundation Trust, Derbyshire Community Health Services NHS Foundation Trust and East Midlands Ambulance Service

27/06/2024

2024-0347

John Parry

Leicester City and South Leicestershire

University Hospitals of Leicester NHS Trust

On 16 November 2023 I commenced an investigation into the death of John Kenneth PARRY aged 72. The investigation concluded at the end of the inquest on 26 June 2024. The conclusion of the inquest was that: � Following the falls on the 6th July 2023 Mr Parry was commenced on neurological observations. However, they were not carried out in accordance with the hospital trust policy. In addition, the calculations were inaccurate. As a result, no reliance could be placed on the observation recordings. Medical evidence also makes it clear that Mr Parry should have had a CT head scan within one hour of his fall. Had this been carried out, on a balance of probabilities, the intracranial bleed could have been detected sooner and there would have been a chance of reducing the mortality risk and achieving a better outcome. The cause of death was established as: � I a Spontaneous Intracerebral Haemorrhage II Mitral Valve Disease (On Anticoagulation)

John Parry was a 72-year-old male who was admitted to the Leicester Royal Infirmary via the Emergency Department on the 4th July 2023. He presented with feeling unwell for six weeks, a headache for one month, weight loss and an increased urinary frequency for a few days prior to admission. He was appropriately investigated but no conclusive diagnosis was made regarding the cause. On the 6th July 2023 Mr Parry had two unwitnessed falls. Later that day his condition deteriorated and following a CT scan of his head a spontaneous bleed was diagnosed. In consultation with the neurosurgeons at the Queens Medical Centre, Nottingham it was decided that Mr Parry was not suitable for surgical intervention and the decision was made to commence Mr Parry on palliative care. He died on the 7th July 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] [REDACTED] [REDACTED] [REDACTED] Browne Jacobson Solicitors (representing the hospital trust) � I have also sent it to:� NHS England 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: University Hospitals of Leicester NHS Trust

05/12/2023

2023-0500

Patricia Walton

Leicester City and South Leicestershire

University Hospitals of Leicester NHS Trust and NHS England

On 30 January 2023 I commenced an investigation into the death of Patricia Ann WALTON aged 80. The investigation concluded at the end of the inquest on 28 November 2023. The conclusion of the inquest was: � �Accidental death contributed to by natural causes and an error in the administration of her dual anticoagulation which led to a haemorrhage into her chest and abdominal wall.� � The cause of death was established as: � I a Bilateral Pneumonia � b Immobility due to Fractured Right Fibula, Chronic Obstructive Pulmonary Disease and Anaemia secondary to Right Chest and Abdominal Wall Haematoma Diabetes Mellitus Type 2, Severe Coronary Artery Atherosclerosis, Obesity, Hyperlipidaemia, Old Age and Frailty

Mrs Walton had a fall at her grand-daughter�s address whilst she was visiting on Christmas Day 2022. Initially it was thought that she was not badly injured, but her immobility developed leading to an ambulance being called on the 28 December 2022. There was a delay in the ambulance arriving but when it did, she was conveyed to the Leicester Royal infirmary on the 29 December 2022. She was diagnosed with a fractured right ankle and shoulder injury. A boot was put on her right leg for conservative treatment of the fracture, and she was admitted. A doctor reviewed her on the 30 December 2022 and noted that she was taking warfarin to treat atrial fibrillation and decided to put her on dalteparin as they considered her International Normalized Ratio (INR) was too low. No plan was made at that time as to when to review the situation or when to stop the dalteparin. She was not seen by a Consultant Medical Physician until the 03 January 2023. He did not appreciate that she was taking warfarin and dalteparin. The INR was being measured but not considered or reviewed and by the 02 January 2023 it was above 2 which should have initiated stopping the dalteparin. However, it was not stopped at that time. Mrs Walton�s haemoglobin suddenly dropped on the 04 January 2023. On the 05 January 2023 the medical staff noticed that she was on dual anticoagulation therapy and the dalteparin was stopped and Vitamin K and blood was given. She was commenced on antibiotics for a chest infection and taken to radiology for a pelvic x-ray as it was thought that a pelvic fracture may be the source of the blood loss. It was thought that the x-ray showed a fractured pelvis, but this was later confirmed not to be the case. Further investigations were not undertaken to confirm a fracture as Mrs Walton�s condition deteriorated in the radiology department. She returned� to the ward and was treated for pneumonia with antibiotics. Sadly, her condition continued to deteriorate, and she was taken off medications. She died at Leicester General Hospital on the 09 January 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (daughter) on behalf of the family of Mrs Walton. 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 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 of Leicester NHS Trust | NHS England

14/06/2024

2024-0320

Amina Ismail

Manchester South

Victoria Aitkins, Secretary of State for Health and Social Care, Department of Health and Social Care, 39 Victoria Street, London SW1H 0EU. � �������������������������� [REDACTED], Chief Executive, NHS England, PO Box 16738, Redditch B97 9PT

On 18.09.23 an investigation commenced into the death of Amina Ahmed Ismail who died on 15.09.23 at Pankhurst Ward, Priory Hospital Cheadle, aged 19 years having been born on 08.06.03. Amina had self-ligatured. Pankhurst Ward is a PICU � where Amina had been a patient from August 2022. � Interested Persons In addition to Amina�s family the Interested Persons were The Priory Hospital, Cheadle Birmingham Women and Children Hospitals NHS FT � otherwise known as Forward Thinking Birmingham (�FTB�) Birmingham and Solihull Integrated Care Board (�the ICB�). � The inquest was held as an Article 2 inquest with a jury; Amina was a detained patient. The inquest concluded on 16.05.24. The medical cause of death was: 1a) Ligature Strangulation 2���Emotionally Unstable Personality Disorder, Post Traumatic Stress Disorder � The conclusion of the jury was: Misadventure � In answer to the question how Amina came by her death the jury recorded: [REDACTED] . Amina was ready for step-down in September 2022, but was subject to a prolonged stay on the PICU ward due to the shortage of appropriate, specialist care beds. Amina�s mental health deteriorated during her long PICU stay. These factors contributed to the circumstances of Amina�s death.

Amina lived in Birmingham. At the age of 15 years Amina was admitted to Orchard Ward, Priory Hospital Cheadle (adolescent acute ward) on 02.01.19, under section 2 of the MHA 1983, following an overdose, and then section 3 of the Act. From� there Amina�s journey was to Mulberry Unit, Priory Hospital Woodbourne (adolescent acute ward) in February 2019, from there to Meadows Unit, Priory Hospital Cheadle (adolescent PICU) with discharge back into the community in September 2019. � Amina was admitted to Pegasus Ward, Cygnet Sheffield (adolescent acute ward) on 18.06.20, aged 17 years, following an overdose of her medications under section 2 of the Act From then until her death, some 2 years 3 months later, Amima was a detained patient on mental health units distant from her home, family and friends. � On 23.07.20 Amina was transferred from Pegasus Ward to Unicorn, Cygnet Sheffield, A PICU, where she remained for 5 months. � In December 2020 Amina was transferred to a low secure unit in Ebbw Vale, South Wales, where she stabilised. � On 22.11.21 Amina was transferred to a specialist Personality Disorder Unit at Cygnet Nield House, Crewe to commence Dialectical Behavioural Therapy (DBT). � In mid-June 2020 Amina�s mental health deteriorated and her incidents of self-harm worsened. Nield House advised FTB (�the home team�) that it could no longer keep Amina safe and that a PICU was required. � It took until 01.08.22 for FTB to locate a PICU that was able to, and would, accept Amina. � On 02.08.22 Amina was transferred to The Priory Hospital, Cheadle. � Other than her brief time at The Priory Hospital, Woodbourne all of Amina�s placements were out-of-area. � Amina was ready for step-down from the PICU, at The Priory Cheadle, in early September 2022. Nield House would not re-admit Amina without a further assessment, and in any event, had Amina then been accepted FTB would have needed to re-apply to the ICB for funding of her placement at Nield House. � FTB decided to carry out a PACT assessment to re-determine Amina�s needs in order to ensure that the next placement would be the most appropriate. Failure of another rehabilitation placement would be devastating for Amina. � That assessment was commenced in October 2022 and was complete by early January 2023. � There was consideration of Fern Unit, a specialist Personality Disorder Unit at Priory Cheadle but it was felt that its DBT programme was too rigid for Amina�s needs. � Following completion of the assessment FTB sought a suitable rehabilitation placement. At the time only two independent providers had capacity to take Amina. One of those, Cygnet Alders Ward turned Amina down as it did not think Amina was sufficiently stable. The other one, Equilibrium Eleanor House in Manchester. was prepared to accept Amina after carrying out its own assessment. On 15.03.23 the FTB applied to the ICB for funding to transfer Amina to Eleanor House, which at the time had voluntarily closed itself to patients following a CQC rating of overall inadequate, and was appealing a Notice of Decision, to be heard in June 2023. The application was turned down by the ICB on 04.05.23. The ICB provided the FTB with 3 other potential placements, Cygnet Kewstoke: Weston-Super-Mare Elysium Gateway: Widnes Priory Middleton St George: Durham. None of these units were prepared to consider Amina because of the acuity of their current patients. Upon being told that funding for Eleanor House had been declined there was a significant downturn in Amina�s mental stability evidenced by a re-emergence of ligaturing as a coping mechanism, and for the following 10 weeks was monitored on enhanced level observations. By mid-July Amina had stabilised. � During that period the option of transferring Amina to a local PICU, with input from the local mental health in-reach team was explored, but there were no local PICU female beds available. There being only 6 such beds locally, commissioned exclusively by FTB at The Priory, Barnt Green. � In July 2023 The Priory (the treating team) and FTB (the home team) and Amina felt that she was stuck. � Further consideration was given to Fern Unit. Following assessment, and with some flexibility introduced into the DBT programme, Amina was accepted by Fern Unit on 31.08.23. At a Ward Round on 06.09.23 both the Pankhurst Ward team and FTB felt that the transfer would be appropriate. Amima was noted to be looking forwards to the� move. A peer from Pankhurst Ward had already been transferred. � Although a bed was immediately available FTB needed to complete an application for funding the Fern Unit to the ICB. That had not been commenced at the time of Amina�s death but had it been it is unlikely, even if commenced on 06.09, that funding would have been approved in time to allow transfer before her death. � The evidence of the Responsible Clinician at The Priory, Cheadle and the Court appointed expert was that there was an overall deterioration in Amina�s mental health during her prolonged admission on the PICU; it was not an appropriate environment, she was not able to have the necessary therapy, although Amina received psychological input it was limited (by the fact of being in PICU) and by July/August Amina had stopped learning and was not using coping mechanisms that she had developed in her psychology sessions.

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. Amina�s family The Priory Cheadle Birmingham Women and Children Hospitals NHS FT � otherwise known as Forward Thinking Birmingham Birmingham and Solihull Integrated Care Board. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

07/02/2024

2024-0064

Brian James

South Wales Central

WELSH AMBULANCE SERVICE NHS TRUST

On 5 November 2021 I commenced an investigation into the death of Brian JAMES . The investigation concluded at the end of the inquest on 11/01/2024. The conclusion of the inquest was Mr James died following a fall at his home. A delay in ambulance response and admission may have affected the treatment available to Mr James. � Medical Cause of Death: 1a Cerebral Haemorrhage Following Fall

These were recorded as : Brian JAMES aged 91 years suffered a Cerebral haemorrhage following fall at home. He lived at home with his brother. He got up in the night to pass water due to his overactive bladder and fell out of bed. He hit his head ( suffered abrasion) he did not lose consciousness and was alert and talking when police and fire came to assist as his brother could not get him back into bed. Ambulance was contacted however there was a delay of around 9 hours until their arrival. Ambulance crew came to do a courtesy visit the following morning and he was found in bed GCS 3 and covered in his own vomit. CT head showed cerebral haemorrhage. CT head findings discussed with neurosurgeons who said this man would not be for surgical intervention He sadly passed away in hospital on 1st November 2021. The Inquest focused upon:- The events of 30 October 2021 and leading to admission � whether any delay in admission to hospital and medical treatment was causative (more than minimally contributory) to death.

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

Emergency services related deaths (2019 onwards) | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Welsh Ambulance Service NHS Trust

7/5/2024

2024-0419

David Riley

Warwickshire

Warwick Hospital Department of Health/Secretary of State NHS England and NHS Improvement NICE Copies to Family and [REDACTED]

On 17 June 2022, I commenced an investigation into the death of David RILEY (aged 72 years). The investigation concluded at the end of the inquest on 26th April 2024 at Warwick Coroners Court. The medical cause of death was confirmed as: 1a Multiple Cerebral Infarcts 1b Resolving Haemopericardium 1c Ablation for Atrial Fibrillation

David Riley had symptomatic atrial fibrillation. A DC cardioversion had been performed but Mr Riley relapsed to atrial fibrillation after a few days. After considering the treatment alternatives, Mr Riley opted for lifestyle modification and AF ablation. The ablation was performed at the BMI Priory Hospital Edgbaston on 3 May 2023 without incident. Mr Riley was discharged with a sinus rhythm. Due to the increased risk of clots due to the ablation procedure, it was recommended that Mr Riley take Apixaban, a direct oral anticoagulant (DOAC) for at least 6 weeks following the AF ablation. Mr Riley developed chest pain and shortness of breath. Initially it was thought that this was an expected side effect of the procedure, and no other cause was found. An echocardiogram performed on 24 May 2023, whilst Mr Riley was on holiday in Montenegro, did not show a pericardial effusion but this was present after his admission on 31 May 2023 to the Warwick hospital. Initial investigations at the Warwick hospital did not reveal the cause of the pericardial effusion or Mr Riley�s symptoms of pain in the chest and back (unaffected by breathing in or out). The CHA2DS2-VASc score is a means of assessing the risk of stroke in a patient with atrial fibrillation.� Evidence was given that whilst he was an inpatient at Warwick, Mr Riley�s score was four. Evidence was given that DOACs have a reduced risk of bleeding compared to Warfarin and that DOACs can be discontinued for a shorter period of time, if at all. An assessment as to the need for pausing or the period of pausing the DOAC has to be made on a case-by-case basis, depending on the clinical assessment of the patient and the procedure under consideration. Evidence was given that there is an inconsistency in decisions taken to pause DOACs not only from hospital to hospital but within different teams within the same hospital and much depended on consultant �confidence� in the ability to pause DOACs. A decision was taken to perform a pericardiocentesis to drain the extra fluid from the pericardial cavity. The pericardiocentesis took place on 2 June 2023. It was not performed as an emergency procedure but primarily for the purpose of diagnostic testing and to a lesser extent as a means of relieving Mr Riley�s symptoms. In the event no fluid was obtained during the procedure, but no untoward event occurred. Evidence was given that in Mr Riley�s case, consideration could have been given to not pausing the Apixaban or to pausing it for only a short period of time before and after the pericardiocentesis.� However, the decision to pause the Apixaban had already been taken by someone other than the Consultant who was to perform the pericardiocentesis. The instruction given by the Consultant once he had performed the pericardiocentesis to restart the Apixaban was not acted on promptly. The Apixaban was eventually restarted and then again paused for reasons that are not clear. The clinical records do not indicate who took the decisions to pause the Apixaban and what consideration was given as to the duration of the pause. The precise duration of the pausing of the Apixaban is not clearly recorded, but it appeared to have been paused for longer than was required. Mr Riley was under the care of three consultants and numerous middle grade doctors during his time as an inpatient at Warwick hospital. Concern was expressed in evidence as to the continuity of care Mr Riley received and the efficiency of communication between the medical staff engaged in his care. Evidence was also given that staff had difficulty in entering information on the computerised record and accessing that information, due to lack of familiarity with the system. The postmortem examination and the subsequent review did not reveal a definitive cause of the clotting which led to the stroke suffered by Mr Riley on the 9June 2023, and his death on 10 June 2023. The pausing of the Apixaban may have increased the risk of Mr Riley suffering a stroke but it cannot be said to have caused it.

I have sent a copy of my report to the following:� HHJ Teague QC the Chief Coroner of England & Wales The family of David RILEY 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: Warwick Hospital | Department of Health/Secretary of State | NHS England and NHS Improvement | NICE

20/02/2023

2023-0065

David Strachan

North Wales (East and Central)

Welsh Ambulance NHS Trust Betsi Cadwaladr University Local Health Board

On 24 March 2022, an investigation was commenced into the death of David Colin Strachan. � The investigation concluded at the end of an Inquest on 14 February 2023. The conclusion of the inquest was a narrative conclusion. The cause of death was recorded as: 1a. Acute myocardial infarction 1b. Coronary artery atheroma

David Strachan was aged 76 years when he died on 16th March 2022 at his home address in Uangollen, Denbighshire. At 23.20 hours on 15 March 2022, he experienced a sudden onset of chest pain, vomiting and became clammy with shortness of breath. A number of 999 calls were made to the Welsh Ambulance Service but it was not until 9.10am, some 9 hours and 52 hours from the initial call that an ambulance and paramedics arrived. An ECG by paramedics indicated that Mr Strachan had suffered an ST elevation myocardial infarction. He was conveyed directly to the North Wales Cardiac Centre at Ysbyty Gian Clwyd and following investigations he was transferred to the Coronary Care Unit. On arrival his breathing weakened and he died at 12.27pm on 16 March 2022 in hospital.

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

Wales prevention of future deaths reports (2019 onwards) | Emergency services related deaths (2019 onwards)

Betsi Cadwaladr University Health Board, Welsh Ambulance NHS Trust

12/09/2023

2023-0325

Rashdah Bhatti

North Wales East and Central

Welsh Ambulance Services NHS Trust, Ty Elwy, Unit 7 Richard Davies Road St Asaph Business Park, St Asaph, Denbighshire LL17 0LJ

On the 16th of June 2022 an investigation was commenced into the death of Rashdah Waseem Begum Bhatti (DOB 19/05/45) who died at her home in Prestatyn on the 14th of June 2022. The conclusion of the inquest on the 11th of September 2023 was by way of a narrative conclusion in the following terms : � �On the 14th of June 2022 at her home, the deceased began haemorrhaging from her varicose veins and although ambulance assistance was requested, there were no resources available to respond for some hours. This resulted in a delay which denied Mrs Bhatti timely and potentially life preserving treatment and she was pronounced dead at the scene at 21.15 hours�

As detailed in the narrative conclusion the deceased began bleeding from varicose veins and the extent of the haemorrhage was exacerbated by her being on anticoagulants. An initial 999 call was made at 18.25 and over the course of the next two hours there were a further six calls made before a response was allocated, with the first ambulance arrival on scene at 20.36.

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

Wales prevention of future deaths reports (2019 onwards) | Emergency services related deaths (2019 onwards) This report is being sent to: Welsh Ambulance Services NHS Trust

28/10/2024

2024-0584

Shirley Hughes

North Wales (East and Central)

Welsh Ambulance Services University NHS Trust�� Ty Elwy, Unit 7 Ffordd Richard Davies, St Asaph Business Park, St Asaph, Denbighshire LL15 2NG

On the 7th of June 2024 I commenced an investigation into the death of Shirley Ann Hughes (DOB 22.1.42 DOD 6.6.24). The investigation concluded at the end of the inquest on the 23rd of October 2024. The cause of death was recorded as being due to 1(a) Sepsis of Unknown� Aetiology 2. Rhabdomyolysis, Diabetes Mellitus and Lymphoedema and the conclusion of the inquest was that the death was due to natural causes.

The circumstances of the death are that Mrs Hughes collapsed at her home on the 1st of June� 2024 and that a 999 call was made to WAST at 17.13 at which time this was allocated an amber� 2 response. Due to resource issues, no ambulance was able to attend at that time and at 04.13� the response was upgraded to amber 1, due to the amount of time Mrs Hughes had been� awaiting a response.� Despite this upgrade there were still no ambulances available to attend�until 07.48 on the 2nd of June, as a result of which Mrs Hughes had spent more than fifteen hours lying on the floor before being treated and admitted to hospital.

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

Wales prevention of future deaths reports (2019 onwards) | Emergency services related deaths (2019 onwards)

Welsh Ambulance Services University NHS Trust

12/02/2024

2024-0075

Natalie Mountford

Dorset

Wessex Water Services Limited, Claverton Down Road, Bath Dorset Council, County Hall, Colliton Park, Dorchester

On the 22nd December 2022, an investigation was commenced into the death of Natalie Christina Mountford, born on the 9th March 1977. � The investigation concluded at the end of the Inquest on the 5th February 2024. The Medical Cause of Death was: 1a Multiple Injuries Consistent with a Road Traffic Collision 1b 1c 2 � The conclusion of the Inquest recorded that Natalie Christina Mountford died as a consequence of a Road Traffic Collision.

Shortly after midnight on 18th December 2022, Natalie Chistina Mountford was travelling from Shaftesbury to Sturminster Newton on the B3019 in her Vauxhall Astra, when she came across a single vehicle road traffic collision in the St James� Common area: a Vauxhall Corsa, driven by [REDACTED], had lost control on ice that was present on the B3091 and collided with one or both verges, coming to rest in the opposing lane, with the front of the vehicle pointing into the verge. Ms Mountford came to [REDACTED] assistance, and invited her to sit in the rear of her Astra to keep warm while they awaited the Emergency Services. Ms Mountford remained outside of the vehicle. Shortly thereafter, [REDACTED], driving a Citreon Berlingo, again travelling from Shaftesbury in the direction of Sturminster Newton, tried to stop at the scene, but lost control of his vehicle on the ice that was present on the road. He elected to mount the verge to drive around the passenger side of Astra. As he died so, Ms Mountord walked around the front of her vehicle and she was struck by the Berlingo. Ms Mountford died at the scene as a consequence of the injuries she sustained. Witnesses describe water flowing down the hill, with ice having formed as a consequence of the sub-zero temperatures that prevailed that night.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Meesons� &� Spurlings �Solicitors, �representing [READCTED] , Natalie Mountford�s daughter; [REDACTED], Natalie Mountford�s father; [READCTED], the father of Natalie Mountford�s children; Horwich Farrelly Solicitors, representing on behalf of Ageas Insurance. 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: Wessex Water Services Limited | Dorset Council

15/11/2023

2023-0454

Lauren Smith

Black Country

West Midlands Ambulance Service University NHS Foundation Trust Health & Care Professions Council Wolverhampton University Quality Care Commission (Chief Inspector of Hospitals) HSIB

On 27/1/23 I commenced an investigation into the death of Lauren Page Smith aged 29. The investigation concluded at the end of the inquest on 1/11/23. The medical cause of Lauren�s death was; 1a) Acute Myocardial Infarction 1b) Coronary Artery Thrombosis 1c) Ruptured Coronary Artery Atherosclerosis � The inquest concluded with a narrative conclusion as follows; Lauren Smith died from an acute myocardial infarction. The ecg reading that was taken at 08:56 am on the morning of her death was abnormal and was incorrectly interpreted. The ecg was likely consistent with a cardiac event in progress at the time which was clearly identified on the auto diagnostic monitor and consistent with the clinical symptoms reported by the deceased. At inquest I found the failure to interpret the ecg correctly was a GROSS FAILURE.

On 6/1/23 Miss Lauren Page Smith passed away at her home address of 142 Essington Way, Wolverhampton. Earlier that day, paramedics had responded to a Category 2 ambulance call whereby Miss Smith reported vomiting, chest and arm pain. Her observations were normal. An ecg showed evidence of pathological q waves in V1, V2 and V3, an isolated ST elevation in V2 and a positive AVR deflection. The ecg was abnormal. The auto diagnostic monitor clearly recorded the ecg as abnormal and reported an anterior infarct. Both the attending paramedic and technician interpreted the ecg as normal and reported it as normal to Miss Smith who based on that information declined to attend hospital. Evidence was heard that the ecg indicated a likely cardiac event in progress at the time the paramedics were in attendance. Miss Smith was found in cardiac arrest several hours later and confirmed as deceased. A post mortem revealed evidence of a blood clot in the left anterior descending artery leading to an acute Myocardial Infarction.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (parents of Lauren Smith). 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.

Emergency services related deaths (2019 onwards) This report is being sent to: West Midlands Ambulance Service University NHS Foundation Trust | Health & Care Professions Council | Wolverhampton University | Quality Care Commission | HSIB

30/10/2024

2024-0589

Sebastian �Benji��Oliver

Birmingham and Solihull

West Midlands Police

On 19 August 2024 I commenced an investigation into the death of Sebastian Benjamin OLIVER. The investigation concluded at the end of the inquest. The conclusion of the inquest was: �Died�after suffering an accidental injury to his hand from climbing a fence whilst under the influence of� drugs�.

At 06:21 on 29/11/23, Benji was found unresponsive by a member of the public outside [REDACTED], Sutton Coldfield, and was suffering significant blood loss from an incised wound to his left hand, together with hypothermia. Paramedics duly attended and conveyed him to Good Hope Hospital where sadly he could not be resuscitated, and he was� pronounced deceased at 07:56. The evidence indicates that there was no third party� involvement, and instead Benji had impaled his left hand after trying to climb a spiked metal fence, for reasons unknown, on Harrison Road off Erdington High Street at about 22:00 on� 28/11/23 whilst under the influence of drugs. He was attended to and treated by paramedics� twice during the evening of 28/11/23 but refused treatment in hospital and subsequently� absconded. It is not possible to say whether he would have been found following� absconding from hospital. There were missed opportunities for emergency services to� provide instructions on bystander life support and provide defibrillation in a timelier�fashion, but on the balance of probabilities these delays did not minimally, trivially or� negligibly contribute to his death. � Following a post mortem the medical cause of death was determined to be: 1a Incised wounds to the left hand with hypothermia 1b 1c 1d II Mixed drugs intoxication ([REDACTED])

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Next of kin I have also sent it to West Midlands Ambulance Service and the Medical Examiner 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 | Police related deaths

West Midlands Police

14/11/2023

2023-0451

Gerard Goodwin

Cumbria

Westmorland and Furness Council

On��� 16��� November��� 2022 I��� commenced��� an��� investigation��� into��� the��� death����� of Gerald GOODWIN. The investigation concluded at the end of the inquest . The conclusion of the inquest was � Accidental death. 1a��Multiple injuries consistent with being struck by a train

Gerald Goodwin was 64 years old. He lived in Barrow-in-Furness, Cumbria. Mr Goodwin had been diagnosed with Alzheimer�s Dementia in 2016 and observed to be unable to assess risk to his own safety in 2022. He also had a history of depression and anxiety. On 10th November 2022 Mr Goodwin was struck by a train whilst walking along the railway track in the vicinity of Dalton-in-Furness Station. His death was confirmed at 00:17 on 11th November 2022. A post mortem examination has confirmed that Mr Goodwin had ingested a significant amount of alcohol prior to his death. It is more likely than not that he happened on to the railway track as a result of his dementia and alcohol consumption.

I have sent a copy of my report to the Chief Coroner and to the family of Mr Goodwin. � 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 This report is being sent to: Westmorland and Furness Council

25/01/2023

2023-0026

Rita Taylor

Milton Keynes

Will Quince M.P. Minister of state for Health.

On 07 October 2022 I commenced an investigation into the death of Rita Maureen TAYLOR aged 84. The investigation concluded at the end of the inquest on 17 January 2023. The conclusion of the inquest was that: � The deceased suffered an unwitnessed fall at her home, 43 Dodkin, Beanhill, Milton Keynes and suffered a head injury. An ambulance was called at 10.28 but due to lack of resources did not arrive until 17.17. When she arrived at Milton Keynes University Hospital at 17.58 her Glasgow Comma Score was 3. A CT scan revealed a large intracerebral bleed. She died the same day at the hospital. The delays in sending an ambulance resulted in a number of lost opportunities to admit her to hospital and begin her treatment.

As outlined above and in Coroner�s concerns

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � South Central Ambulance Service � I have also sent it to MK Together 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)

Department of Health and Social Care

01/09/2023

2023-0316

Harold Pedley

Blackpool & Fylde

Will Quince MP � Minister of State for Health and Secondary Care Department of Health & Social Care C/O Ministerial Correspondence Public Enquiries Unit Department of Health and Social Care 39 Victoria Street London SW1H 0EU [REDACTED]� � Chief Medical Director Lancashire & South Cumbria Integrated Care Board [REDACTED]

The death of Harold Derek PEDLEY Otherwise known as Derek PEDLEY on 21.12.22 at Blackpool Victoria Hospital was reported to me and I opened an investigation, which concluded by way of an inquest held on 17th August 2023. � I determined that the medical cause of Mr. Pedley�s death was: 1 a Small bowel ischaemia 1 b Severe Superior mesenteric artery atheroma � II��� Left ventricular hypertrophy; severe coronary artery atheroma In box 3 of the Record of Inquest I recorded as follows: � Harold Pedley, known as Derek, attended his GP surgery during the late afternoon on 21.12.22 and after spending most of that day feeling unwell with symptoms including abdominal pain and vomiting. He was appropriately referred to the hospital and travelled there with his� Friend after his GP had discussed his� case with� doctors. Due to a lack of available beds in the assessment unit, Derek needed to remain in the emergency department. Following� his arrival at� 20.07 hours, doctors were not notified of his attendance. He remained in the emergency department waiting area�� for almost two hours during which time due to significant pressures faced by the department he was not assessed or spoken to by a medical professional. At 21.59 hours a triage nurse called for him. By then, Derek had been unresponsive for some time and had died, his death confirmed at 22.26 hours. A subsequent post mortem examination revealed he died from the effects of non � survivable extensive small bowel ischaemia caused by a significantly narrowed mesenteric artery. His death was contributed to by heart disease. � The conclusion of the Coroner was Natural causes

In addition to the contents of section 3 above, the following is of note: � ������ This inquest was about a man who, aged 90, died whilst waiting to be seen by� a medical professional in hospital. He did not simply arrive at hospital,� but�� had been assessed and then sent there by his GP, who felt, rightly as it turned out, that Derek may have developed an obstruction. He was anticipating�� Derek would be seen quickly. � ������ He arrived at the Emergency Department, and handed in some paperwork at reception and understandably expected he would not have to wait long to be assessed by doctors who he knew were expecting him. � ������ No-one called for him for almost two hours by which time he had died. � ������ It is correct to say that once a post mortem examination was performed, it was clear that even if he had been assessed immediately upon arrival at hospital his condition was such that surgical intervention was not a realistic possibility and the condition was going to prove terminal. � ������ At the time Derek arrived, as the Hospital Trust�s own internal review of this death explained, such were the pressures on the hospital Trust posed by patient numbers that it was operating at OPEL [Operations Pressure Escalation Level] 4. This is a method used by the NHS to measure the stress, demands, and pressure a hospital is under. OPEL 4 represents the highest level, when a hospital is �unable to deliver comprehensive care, and patient safety is at risk�. � ������ At the time of Derek�s death, there was a �Streaming� Nurse working on the Emergency Department whose role it was to undertake initial basic observations and assess the risk of the patients waiting and to prioritise them. However, due to the pressures on the department she was unable to perform that role. Had she had the time to carry out her role as expected, it is likely Derek would have been seen much earlier. � ������ The Emergency Department staff were also under such pressure they did not have the time to notify the doctors who were expecting Derek�s arrival at hospital that he had arrived. Those doctors were under similar pressures and had not had the opportunity to check whether Derek had arrived. � ������ Staffing levels had been reduced suddenly for that shift due to staff illness and no additional staff could be made available as a replacement. � ������ Even though a GP had referred Derek on the basis he would not have to spend time in the Emergency Department before being seen on the surgical assessment unit, in reality this was not going to be the case because as the author of the Trust�s internal review told the court, due to a lack of beds on�� the Surgical Assessment Unit, a patient arriving at the Emergency Department such as Derek will almost always� have to� remain� in the Emergency Department for some time waiting for a bed to become available. � ������ The author of the Trust�s review, an impressive and candid witness, acknowledged that although on the day on which Derek died was particularly busy, the Emergency Department is regularly subject to these levels of pressure and they are by no means limited to the winter months. � ������ The author also explained how the situation may be eased to some degree were perhaps two surgical beds to remain free for when patients such as Derek arrive in the Emergency Department, but this has not been possible to date. � ������ Finally, it is relevant to point out that Derek had not moved for some time before a medical professional called for Derek. I formed the view that there had been an understandable reluctance on his Friend�s part to request assistance due to the pressures staff were clearly under, but also because he had already handed in Derek�s paperwork and was expecting some assistance imminently which did not arrive.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department of Health and Social Care | Lancashire and South Cumbria Integrated Care Board

13/02/2023

2023-0057

Michael Poulton

Wiltshire and Swindon

Wiltshire Police

On 25 June 2019 the Senior Coroner Mr David Ridley commenced an investigation into the death of Michael POULTON then aged 60. The investigation concluded at the end of the inquest. The conclusion of the inquest was suicide, the medical cause of death being � 1a��Hanging

Deceased had been in police custody following a domestic matter. He was released following enquiries on 22/6/19 and due to concern for his welfare, arrangements were made, for him to be taken by police transport to a family members home. There was a delay in the transport attending, which he was not made aware of. Some 2 hours after being released, he left the custody suite and was seen walking on the A350. The following day he was found suspended by a ligature in a field by the A350 at Yarnbrook. The police have submitted an OIPC referral regarding this matter.

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

Suicide (from 2015)

Wiltshire Police

20/11/2023

2023-0485

Susan Gladstone

Hertfordshire

XXX

INVESTIGATION AND INQUEST On 11 January 2021 I commenced an investigation into the death of Susan Ann GLADSTONE. The investigation concluded at the end of the inquest on 20 November 2023. The conclusion of the inquest was She died as a result of a generally unknown interaction between warfarin and tramadol which caused exceptional thinning of her blood � 1a Intraparenchymal and Subarachnoid Haemorrhage

CIRCUMSTANCES OF DEATH Mrs Gladstone was admitted to Lister Hospital on 06/01/2021 presenting with a history of feeling increasingly unwell over the preceding few days. On admission Mrs Gladstone was found to have pyelonephritis and was treated with IV antibiotics. Mrs Gladstone was on warfarin, and had recently been prescribed tramadol. Her INR was found to be extremely elevated at 11.6. Reversal medication was prescribed. Mrs Gladstone�s condition deteriorated and she died at 22.58 hrs on 08/01/2021

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

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

01/02/2024

2024-0053

Peter Stajic

West Yorkshire (Western)

Yorkshire Ambulance Service

On 21 March 2022 I commenced an investigation into the death of Peter STAJIC aged 60. The investigation concluded at the end of the inquest on 01 February 2024. The conclusion of the inquest was that: He died from a complication following a medical procedure to which a missed opportunity to provide medical intervention contributed.

Peter was pronounced dead at 04.50 on 27 February 2022 at Calderdale Royal Hospital, Halifax. He was aged 60, fit and well save that he had required a carotid endarterectomy � undertaken on 12 January 2022. Due to a post operative haematoma, he was discharged on 16 January 2022. He developed an infection at the suture site. He was prescribed antibiotics by his GP. On 25 February he attended the Emergency Department at Calderdale Royal Hospital. This was an opportunity to discuss his case with a vascular consultant. It did not happen. On 26 February paramedics attended Peter at home at 10.42. There was evidence available of a herald bleed indicating that a major haemorrhage was likely to happen. This was not appreciated at the time and an opportunity was missed to admit Peter to the specialist Vascular Unit at the Bradford Royal Infirmary where, on the balance of probability, a procedure necessary to save his life could have been undertaken. In fact Peter was admitted to Calderdale Royal Hospital Emergency Department following a second attendance on his at home at 20.32 on 26 February. The concern at that stage was in relation sepsis, not the risk of haemorrhage. He was triaged to level 3. At 22.56 a nurse noted bleeding at the suture site. She reported this to a consultant of the Department, who was not equipped to appreciate its significance. Its is not available to conclude on a balance of probability that at that stage there would have been sufficient time to intervene to save Peter�s life. Peter suffered a catastrophic haemorrhage shortly after 01.05 and consequently died.

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 � Bradford Teaching Hospitals NHS Foundation Trust Calderdale Royal Hospital Mortuary � 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: Yorkshire Ambulance Service

28/10/2024

2024-0586

Susan Shipley

North Yorkshire and York

Yorkshire Ambulance Service NHS trust

On 07 February 2024 I commenced an investigation into the death of Susan Patricia SHIPLEY aged 68. The investigation concluded at the end of the inquest on 22 October 2024. The conclusion of the inquest was that: Susan Patricia Shipley died as a consequence of naturally occurring disease contributed to by injuries sustained while being inappropriately transported in a hospital wheelchair, and on a background of further naturally occurring disease.

On the 28th of January 2024 Susan Patricia Shipley, who had critical limb ischaemia and a right below knee amputation, was taken by ambulance to the Emergency Department of Scarborough General Hospital. She was inappropriately deemed fit to sit in a hospital-issue wheelchair. Mrs Shipley required transfer to York District Hospital for specialist vascular assessment. In the process of transfer, Mrs Shipley suffered an accidental fall from the hospital wheelchair, fracturing her right neck of femur. On eventual transfer to York District Hospital, Mrs Shipley consented to high risk surgery to amputate her left leg above the knee and revise her right leg amputation to above the knee, which took place on the 31st of January 2024. Her hip fracture was managed conservatively following orthopaedic assessment. Mrs Shipley developed pneumonia and her condition continued to deteriorate. She died at the hospital on the 4th of February 2024.

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

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

Yorkshire Ambulance Service NHS trust

26/01/2024

2024-0306

Michael Pegg

Worcestershire

[REDACTED ]Chief Executive, Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester WR5 1DD; [REDACTED], National Medical Director, NHS England;

On 28 July 2023 I commenced an investigation and opened an inquest into the death of Michael Leslie PEGG. The investigation concluded at the end of the inquest on 23 January 2024 � The conclusion of the inquest was that Mr. Pegg �died from natural causes.�

In answer to the questions �when, where and how did Mr. Pegg come by his death?�, I recorded as follows: � �On 13.1.23 Michael Pegg, who lived with congenital adrenal insufficiency and epilepsy, was admitted to Worcestershire Royal Hospital after suffering two significant seizures at home earlier that morning. Early the following morning he suffered a significant deterioration in his condition and developed pneumonia. Despite treatment, he continued to decline and died in hospital on 15.1.23.�

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

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

06/07/2023

2023-0232

Elizabeth Agbejimi

Lincolnshire

[REDACTED]

On 06 July 2021 I commenced an investigation into the death of Elizabeth Oluwatofunmi AGBEJIMI aged 22. The investigation concluded at the end of the inquest on 13 June 2023. The conclusion of the inquest was that: � The deceased died on 27th June 2021 at Lincoln County Hospital, Greetwell Road, Lincoln following a multiple falls that the pathologist identified as a direct cause of death.

CORONER�S CONCERNS � During the course of the investigation my inquiries 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: (brief summary of matters of concern) � [REDACTED] gave evidence that following a venous blood gas sample undertaken on 12th June 2021 which showed a significant respiratory abnormal acidosis reading but no further investigation was undertaken. The deceased died 2 weeks later of a respiratory condition. Is this a training/communication issue?

06/07/2023 Paul COOPER, HM Assistant Coroner for Lincolnshire

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

29/09/2023

2023-0359

John Wrigley

Derby and Derbyshire

[REDACTED]

INVESTIGATION � On 06 May 2021 I commenced an investigation into the death of John Frederick WRIGLEY aged 60. The investigation has not yet concluded and the inquest has not as yet been concluded.

John Wrigley was an experienced Superkart racer who had been involved in motor sport for over 20 years. On 3rd May 2021 he attended an event at Darley Moor Kart Circuit. During a qualifying session, his kart left the track� (reason� unknown),� travelled� across� wet grass� and the left front wing of the kart impacted with a lorry tyre wall at between� 66 and� 71� mph, The kart rotated 360 degrees, then impacted on the left rear side wing and came to rest on the opposite side of the track. He was subject to huge forces and was flung out of the kart and landed on the track. There was no contact with any other Kart. A Marshall and another Kart racer witnessed the collision. Mr Wrigley received immediate medical care for his severe head injury and was taken to Derby Royal by land ambulance where he was pronounced deceased. His injuries were consistent with a high-speed impact. Police were not contacted initially. Following police involvement, police were in touch with the Motor sport association who had primacy to investigate the circumstances� with police assistance. Following the post mortem the medical cause of death was determined to be: la. Head Injury

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] [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 our response b the Chief Coroner.

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

10/11/2023

2023-0440

Graham Coombe

East Sussex

[REDACTED]

On 11 May 2022 I commenced an investigation into the death of Graham Ian COOMBE aged 56. The investigation concluded at the end of the inquest on 13 October 2023. The conclusion of the inquest was that: � Mr G Coombe was seen sitting below Eastbourne Pier when at approximately 7.20pm on 1st May 2022 he was seen to fall in. It was possible that he was suffering from the effects of alcohol. Attempts were made to find a life saving ring on the pier and than climb over a high locked gate to access the lower pier to try to save Mr Coombes. The lifeboat arrived at 1950hrs and removed Mr Coombe to the beach were CPR was continued. Mr Coombe died on 4th May 2022 as a result of drowning.

On 1st May 2022 at approximately 7.20pm Mr Coombe was seen to enter the water and then could be heard calling for help by those on the lower level of Eastbourne Pier which is not open to the public. � Police were called who tried to gain access to the lower level of the pier but were obstructed by a locked gate. Eventually police were able to climb over it and made their way down to the lower level. They asked for a life saving ring which was not easily accessible nor visible. When this was eventually located and taken to the pier�s lower level it was thrown to Mr Coombe but the rope was too short to reach the water as the tide was going out. � The life boat was called and on arrival rescued Mr Coombe from the sea and commenced CPR which was continued on the beach. He was later taken to Royal Sussex County Hospital Brighton where he died on 4th May 2022 as a result of drowning.

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

Other related deaths This report is being sent to: REDACTED

6/12/2023

2024-0368

Margaret Heal

Durham & Darlington� � Category: Other related deaths � This report is being sent to: REDACTED

[REDACTED] REDACTED

On 25/07/2022 14:17an investigation was commenced into the death of Margaret HEAL 30/07/1935 00:00:00. The investigation concluded at the end of the inquest on 06/12/2023 00:00.� The conclusion of the inquest was that Margaret Heal died on 12th July at her home, [REDACTED] from a massive pulmonary thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti-coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication.

Margaret Heal died on 12th July at her home,�[REDACTED] from a massive pulmonary thromboembolism which had caused by a deep venous thrombosis. This is a natural disease running its full course and resulting in her death. She had stopped taking her anti-coagulant medication on medical advice 10 days prior to her death to undergo surgery. She did not resume this medication after it. It is unclear on the evidence if she was unaware of the need to resume the medication or she chose not to resume the medication.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] I am also under a duty to send 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 �

02/05/2024

2024-0243

Michael Dalkin

Teesside and Hartlepool

[REDACTED]

On 18 February 2020 I commenced an investigation into the death of Michael Lee DALKIN aged 22. The investigation concluded at the end of the inquest on 30 April 2024. The conclusion of the inquest was that: � Michael Lee DALKIN Suffered with hypoplastic left heart syndrome. On the evening of 26/12/2019, he was socialising in Stockton town centre. He consumed alcohol and illicit substances. In the early hours of 27/12/2019, he was inside Goldie�s Bar. Two off duty door supervisors believed he was going to cause injuries with a glass. One of the off duty door supervisors removed the glass from him and moved him to the floor. They transported him outside the bar by carrying him by his limbs. They placed him on the floor outside the bar. Their actions were inconsistent with SIA training but reasonable and proportionate in the circumstances. Michael Lee DALKIN died in an Ambulance on Stockton High Street on 27/12/2019 due to a combination of his congenital heart defect, ingestion of alcohol and drugs and stress caused by the interaction with the off duty door supervisors.

Mr Dalkin was socialising in Goldies bar, Stockton High Street in the late hours of 26.12.19 and early hours of 27.12.19. Two off-duty door supervisors were in the venue. They observed Mr Dalkin in a group of people who were arguing between themselves. They saw him walk to the bar and pick up an empty glass. Mr Dalkin placed the empty glass behind his back and started to walk back to the group with whom he had been arguing. Both off-duty door supervisors formed the impression that he was going to use the glass as a weapon. One of the men removed the glass from him. Mr Dalkin threatened the man with injury, so he was moved to the floor and escorted out of the premises. Outside of the venue Mr Dalkin collapsed and was attended to by the emergency services. He died in the ambulance. Evidence was given at the Inquest about the door supervisors employed and in used at Goldies bar on 26/27 December 2019. Evidence was given by the owner and designated premises supervisor [REDACTED] as to improvements made however his evidence lacked credibility. Evidence was provided by other witnesses who were former door supervisors at Goldies and Che Bar (adjacent bars both owned by [REDACTED]). I determined that on 26/27 December 2019 the door supervisors were made up of one SIA registered door supervisor who was acting as a door supervisor, an unlicensed door supervisor acting as a door supervisor, the SIA registered designated premises supervisor who said he left the premises at approx. 21:00 on 26.12.19 and another man who was SIA registered but carried out the role of the manager and did not act as a door supervisor.

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

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

22/11/2024

2024-0643

Muhammad & Naemat Esmael

Swansea Neath and Port Talbot

[REDACTED] Cabinet Secretary for Housing and Local Government Welsh Government� 5th Floor� T? Hywel� Cardiff Bay� CF99 1SN� Email: [REDACTED] [REDACTED] Head of Mid and West Wales Fire and Rescue Service Service Headquarters,� Lime Grove Avenue,� Carmarthen,� SA31 1SP� Email:�[REDACTED]

On 1 July 2023 a fire started in an upstairs bedroom of�[REDACTED]. When the fire started the door to the bedroom was shut and inside the bedroom was Muhammad Esmael, who was three years of age.� Muhammad�s father, Naemat Esmael, was in the adjacent bathroom having a� shower.� Muhammed�s mother, Sharmeen Ahmed, had left Muhammad with his� father in the parents� bedroom and had gone downstairs. After being downstairs� for a very short period of time, Mrs Ahmed heard what sounded like a ball being� kicked on a wall and she went to look up the stairs. Mrs Ahmed also heard a� couple of beeps from the fire- alarm. On looking up the stairs Mrs. Ahmed saw in the upstairs hall mirror a fire on the ceiling of the bedroom in which Muhammed� was located (although she did not know that he was in there). The door to the� room was closed.� Mrs. Ahmed shouted to alert Naemat and her daughter and her� daughter ran out of the property. Naemat came straight out of the shower and ran� into the bedroom where Muhammad was located, and the door banged shut�behind him. Mrs Ahmed went to ring for help. Naemat was unable to save� Muhammad and was forced to jump out of the bedroom window. Tragically both� Naemat and Muhammad died because of the fire. The property was leased to the� family by Swansea Council. Swansea Council carried out all the appropriate� inspections, including electrical inspections, prior to leasing the property to the� family. The property contained two smoke alarms, one in the downstairs hallway� and one in the upstairs hallways, as required by Welsh Government legislation.� The smoke alarms had been replaced in 2020 and were not due to be replaced�until 2025. Swansea Council had tested the smoke alarms, and I am satisfied that� the smoke alarms were in good working order when the property was leased.�� The smoke alarms were appropriately hard wired into the mains electricity and�the lighting circuit. I therefore find that the smoke alarms were working at the� time of the fire but that they did not sound either because the fire had started in a� sealed room behind a door closed which meant that no smoke could get to and� activate the upstairs fire alarm or that the electricity circuit had tripped and� deactivated the fire alarms where those alarms possibly had insufficient battery� power.� During the investigation, there were only two possible causes for the fire� found at the property and these were smoking and electrical. I find that smoking� did not cause the fire as there was no evidence that anyone smoked within the� property. There was evidence within the property (including within the bedroom� where the fire started) that someone had carried out unauthorised electrical works that fell below the standards of a competent electrician. Some unauthorised� electrical alterations had been carried out in the property by Naemat Esmael.� Swansea Council did not know about these electrical works and so had not� authorised them. In the front bedroom where the fire started a two-way extension�lead had been directly wired into a double electrical socket behind a wardrobe.� Plugged into this extension lead were a games console and a six-way extender� lead. A TV was plugged into the six-way extender lead. The cable of the�extension lead was fed into the rear of a console unit through an area that had�been cut out. The extension leads were housed within a drawer in the console�unit and the TV was sat on the console unit. When the drawer was inspected�there was evidence of uneven burn patterns within the drawer. There was also�evidence of a circular burn pattern that was below the surface where the TV sat� and charring to the underside of the console where the TV sat. The console unit�and electrics were removed before they could be fully inspected by all the�investigators instructed to investigate, including the Chartered Electrical� Engineer. The charring and burn pattern around the console unit indicates that� something had been on fire within the drawer. The two-way socket, the extension leads, the TV and games console were forensically examined after the fire and� there was no evidence of any electrical fault with these electrical items. I� therefore find that the fire was not caused by an electrical fault from these items.� However, I do find that the fire probably started in or around the console unit.� I� also find that the fire was probably electrical in origin because there is no other� explanation for the fire but also because Mrs Ahmed heard a thud which may� have been a switch tripping in the electrical console unit which was downstairs. I am unable to determine the precise electrical fault that caused the fire.

The deceased died following a house fire in a property leased to them by the� Council. The property contained two working smoke alarms but they were not activated by the fire, which started in a bedroom where the door was closed.

I have sent a copy of my report to the Chief Coroner and to both Interested� Parties, namely, the family of the deceased and the City and County of Swansea. 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.

Wales prevention of future deaths reports (2019 onwards) | Product related deaths

Mid and West Wales Fire and Rescue Service | Welsh Government

21/09/2023

2023-0343

Alison Ross

West Sussex, Brighton and Hove

[REDACTED] Chief Executive University Hospitals Sussex NHS Foundation Trust

On 17 November 2022 I commenced an investigation into the death of Alison Mary ROSS aged 55. The investigation concluded at the end of the inquest on 20 September 2023. The conclusion of the inquest was that: � Alison Mary Ross died on 11 November 2022 at the Princess Royal Hospital, Lewes Road, Haywards Heath, West Sussex from an intraabdominal haemorrhage caused by an ascitic drain procedure on 10 November 2022 to treat ascites resulting from decompensated chronic alcoholic liver disease.

Mrs Ross was admitted to hospital on 3 November 2022 and was found during admission to have abdominal ascites. � On 9 November 2022 Mrs Ross was prescribed treatment doses of apixaban commencing on 10 November. This replaced the prophylactic dose of enoxaparin given previously. At the time of the prescription of apixaban she had been diagnosed with a DVT. � She had an ascites drain inserted on 10 November 2022. At the time of the procedure Mrs Ross� platelets were within normal range and she had an INR of 1.3 which was slightly above the normal range. � Mrs Ross reported to the clinician during the morning ward round that she had not taken her oral medications that morning as she was too unwell. These were charted as including apixaban. There was also a Nurse present at that time. The clinician advised the Nurse and Mrs Ross that the anticoagulation would be stopped for 48 hours due to the procedure and charted this accordingly. � The clinician inserted the drain at 13:30 without any reported complications. � At 15:30 the clinician reviewed Mrs Ross with the drain still in situ. The Nurse who had been at the ward round was also present. At that time Mrs Ross reported relief from her symptoms and that she had since the start of the procedure taken her morning medications. There was no evidence that apixaban was omitted. There was no evidence as to what had happened to the medications that were not taken when dispensed. � The clinician administered Tranexamic acid (TXA) and Vitamin K as preventative medications to mitigate the effects of the apixaban. At that time there were no clinical indications of bleeding. � Around 30 minutes after the drain had been removed Mrs Ross started to demonstrate symptoms which may have been indicative of a bleed having occurred. � Despite treatment to try and increase Mrs Ross� clotting due to the location of the bleed she said died from the haemorrhage.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [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

25/10/2024

2024-0576

Sylvia Prichard

Surrey

[REDACTED] Chief Executive Officer Avery Healthcare Group 3 Cygnet Drive Swan Valley Northampton NN4 9BS

INQUEST An inquest into Mrs Prichard�s death was opened on 11 April 2024.� The inquest was resumed on 26 September 2024 and concluded on 27 September 2024. The medical cause of Mrs Prichard�s death was: 1a. Traumatic Acute Subdural Haemorrhage With respect to where, when and how Mrs Prichard came by her death it was recorded at Box 3 of the Record of Inquest as follows: Mrs Prichard was 91 years old and frail due to her age. On 28 March 2024 she had an unwitnessed fall at her care home as a result of which she sustained a head injury, resulting in her death at the Royal Surrey County Hospital on 3 April 2024. The inquest concluded with a short form conclusion of �Accidental Death�.

Mrs Prichard had been assessed as being at high risk of falls.� Some falls minimisation measures were recorded in her mobility care plan, however, she did not have a falls minimisation plan in place. Mrs Prichard had her own apartment at Moorlands Lodge Care Home.� She had emergency buttons on the walls of her sitting room and her bedroom which could be used to attract immediate attention in the event of a medical emergency.� She also had a call button on a pendant around her neck which could be used to alert staff that she needed routine assistance of any kind. At 10:11 on the morning of 28 March 2024 Mrs Prichard pressed her call button.� The call button was responded to at 10:28, at which time Mrs Prichard was found on the floor.� It is not known whether she pressed the call button before of after the fall.� Following her fall she was unable to move so would have been unable to use the emergency button on the wall. Previously Moorlands Lodge Care Home was owned by a company called Signature, during which time there was a ten minute response time for call bells.� However, in Summer 2023, Avery Healthcare acquired Moorlands Lodge Care Home, at which time a response time of two to five minutes should have been introduced in accordance with Avery Healthcare�s policy. However, at the time of Mrs Prichard�s death, the Manager of Moorlands Lodge Care Home was not aware of the Avery Healthcare policy and the home was continuing to aim to respond to call bells within ten minutes. It took seventeen minutes to respond to Mrs Prichard�s call bell on the day of her fall, which was a twelve minute delay. The court found that this was not an isolated delay but was part of a broader pattern of delayed response times to call bells, including for Mrs Prichard but also other residents at Moorlands Lodge Care Home.

COPIES I have sent a copy of this report to the following: Chief Coroner Mrs Prichard�s family Care Quality Commission

Care Home Health related deaths

Avery Healthcare Group

31/01/2024

2024-0048

Michael Waite

Essex

[REDACTED] Chief Executive Officer of Peabody, Peabody, 45 Westminster Bridge Road London, SE1 7JB CQC The Inspecting Officer for Location [REDACTED] Care Quality Commission National Customer Service Centre Citygate Gallowgate Newcastle upon Tyne, NE1 4PA � Skills For Care [REDACTED] Information Service Manager Skills for Care West Gate, 6 Grace Street Leeds, LS1 2RP

On 2nd September 2022 I commenced an investigation into the death of Michael Brian Waite, aged 63 years. The investigation concluded at the end of the inquest on the 8th December 2023. � � Following a Post Mortem Examination the medical cause of death was confirmed as: �1a Sudden Cardiac Event, 1b Hypertensive Heart Disease; 2 Diabetes Mellitus�. I concluded that the this was a Natural Causes death.

Mr Waite had recognised learning difficulties and was a resident, together with two others with learning disabilities, in supported living accommodation provided by Peabody. The three residents were provided with 24-hour support by a sole Support Worker (SW), working shifts. On the late afternoon of the 19th August, 2022 at some point after 17.30 hours, Mr Waite was seen by his SW to be vomiting heavily at the kitchen sink and drinking a significant amount of water. The SW urged him to stop drinking the water and to go into the back garden for some fresh air. � The SW accompanied Mr Waite to the garden and returned to the house to clean the kitchen sink and to check on the other two residents. Whilst in the kitchen the SW witnessed Mr Waite collapse in the garden and ran out to him. Mr Waite collapsed in the rear garden of the property and, having relocated Mr Waite from the flower bed into which he had partly fallen to the lawn, he provided some initial CPR before returning to the house to locate his work mobile phone to call for an ambulance. The SW confirmed in evidence that there was delay in his making the call as he had struggled to locate the phone, and then once he found it he returned to Mr Waite but had difficulty accessing the phone as he could not, in the pressure of the moment, recall the passcode. He eventually made contact with the emergency services at 18.14 hours before resuming his attempts at resuscitation. An experienced East of England Ambulance Service Trust (EEAST) paramedic in a Rapid Response Vehicle arrived at around 18.20 hours and, identifying that Mr Waite�s cardiac output was asystole and that hypostasis was present (subsequently confirmed by the EEAST Leading Operations Manager attending within minutes), confirmed life extinct. No further CPR was initiated. � In my findings and determinations, I recorded that it was likely that time elapsed between Mr Waite�s witnessed collapse and the call being made to summon the EEAST was significantly longer that the SW had (honestly) recalled. I made this finding in accordance with the agreed pathology evidence that signs of hypostasis unambiguously confirming death (and upon the basis of which, together with other features, the RRV paramedic did not initiate further CPR) would have required a minimum of 20 to 30 minutes following death to be apparent. I was satisfied that the SW had provided honest though mistaken evidence about the length of time that had elapsed between the collapse and the 999 call, arising in the circumstances and context of the SW�s first experience of such a challenging event and the provision of CPR by him.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED], Sister-in-Law of the deceased; � Hill Dickinson Solicitors, representing the EEAST; [REDACTED], EEAST Paramedic represented by � 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: Peabody | Care Quality Commission | Skills for Care

02/12/2024

2024-0660

Elton Deutekom

Inner West London

[REDACTED] Chief Executive Officer, Chelsea and Westminster NHS Foundation Trust, Chelsea and Westminster Hospital, 369, Fulham Road, London. SW10 9NH [REDACTED], Medical Director NHS England By email: [REDACTED] [REDACTED], Chief Medical Examiner for England and Wales, By email: [REDACTED]

On the 18th, 19th and 20th November 2024, evidence was heard touching the death of Master Elton Michael Deutekom. He had died on the 12th January 2022, thirty seven minutes after he had been born on labour ward at Chelsea and Westminster Hospital. Medical Cause of Death 1 a. Acute perinatal hypoxia/ischaemia (�perinatal asphyxia�) �� b. Placental abruption II Placental delayed chorionic villous maturation How, when, where the deceased came by his death: Elton�s mother was transferred to labour ward at Chelsea and Westminster Hospital from the community at 01:25 on 12th January 2022. Her labour initially progressed well. At approximately 0320- 0330 she suffered an abrupted placenta. As a result, Elton suffered an acute hypoxic ischaemic injury. This was undiagnosed by those caring for Elton�s mother despite a sharp change in her clinical presentation manifesting as severe pain, strong contractions and rapid progression to push and CTG (Cardiotachograph) changes consistent with hypoxia from 0334, when his mother was reattached to the monitor. Elton�s baseline heart rate had gone up significantly, increasing by 30 beats per minute, followed by decelerations. There was no heart rate detected after 0414. This change in base rate followed by decelerations was unrecognised by the obstetric registrar, despite her being in the room with Elton�s mother from about 0335 to at least 0348. The registrar relied on the historic CTG trace, rather than the trace at the time of her assessment. This was a serious failure that contributed to Elton�s death. The midwife caring for Elton and his mother did not seek assistance from the obstetric team nor the senior midwifery team, despite recognising that the CTG trace was abnormal from 0355 hours at the latest. This was against training and guidance. This was a gross failure that contributed to Elton�s death. The labour ward co-ordinator responded to hearing Elton�s mother screaming at approximately 0420 and allocated a senior midwife to assist. Neither recognised how long Elton had had an abnormal CTG. The emergency bell was not activated until 0430. The emergency team responded promptly, and Elton was delivered by forceps at 04:35. Despite resuscitation his life could not be saved, and he was recognised as life extinct at 05:12. If Elton had been recognised as suffering with hypoxia and delivered before 04:05 on the balance of probabilities, he would have survived. Conclusion of the Coroner as to the death: Natural Causes contributed to by neglect.

Evidence relevant to the matters of concern. Extensive evidence was taken and exhibited and some potential regulation 28 matters explored. Of relevance to this report: 1. The midwife caring for Elton�s mother who took over from the community midwife was very newly qualified and had only been managing women in labour independently for a couple of weeks. This midwife appeared to be distracted by administration tasks and TED stockings when she should have been prioritising the abnormal CTG. She made no contemporaneous notes in the medical records and entered information into the notes retrospectively some four- five hours later with the help of a midwife supervisor advising her. The supernumery time spent by a newly qualified mid-wife has not changed since this incident, but there is more training provided now post qualification than at the time of Elton�s death. 2. A finding of fact was made that had the community midwife remained to care for Elton�s mother whilst in labour, it is likely that she would have recognised the abnormal CTG and acute change in Elton�s mother in terms of pain and summoned help appropriately and Elton would have had an expedited delivery and survived. 3. The labour ward has nine rooms all of which were full, but only 8 midwives including the Labour Ward Co-ordinator who should be just assisting not managing women in labour on a 1:1 basis. This was and is currently the usual number. The labour ward was busy with all rooms occupied. This meant that some midwives were caring for 2 women even without covering breaks. It was so busy that the community midwife who had accompanied Elton�s mother to the ward was asked to remain with her until 0315. It was so busy that no practitioner picked up on Elton having an abnormal CTG at the CTG central monitoring station, nor was able to provide ad hoc support to the newly qualified midwife caring for Elton�s mother until the Labour Ward Co-ordinator responded after hearing Elton�s mother screaming. The evidence was that this level of business is usual on the labour ward. The labour ward was effectively 2 midwives short. This may have contributed to his death. 4. Elton�s death occurred on 12th January 2022 but was not referred to the coroner until 17th June 2022, and then the evidence presented suggested a still birth since he had only had a heart rate for a couple of minutes after 23 minutes of resuscitation, and did not highlight labour management issues. This understanding of the court came from information supplied by the hospital and resulted in a PIRH on 12th July 2022 to determine whether Elton was a stillbirth. He had never been treated as such by the hospital and had been treated as a neonatal death. Following this hearing, and review of the HSIB report, the court opened an inquest. Elton had been subject to a consented PM, but evidence in relation to the management of labour and the abrupted placenta was not given to the pathologist. When further evidence gathered as part of the inquest was passed to the pathologist, he changed the medical cause of death. 5. Issues in relation to management of labour that may have contributed to the death and thus render the death as reportable to the coroner under the Notification of Deaths Regulations (the Regulations) were noted on 17th January 2022 on a Datix report, in statements gathered in January and February 2022 and at the Perinatal Mortality Review meeting in early March 2022. On 11th April 2022, HSIB advised Chelsea and Westminster to report the death to the coroner based on issues they identified in relation to management of Elton�s mother�s labour. Despite this the death went unreported until 17th June 2022. 6. Explanation from the hospital was sought as to why the death was not reported in line with Regulations and a letter was received from the Lead for Neonatal mortality. This provided no clear explanation to many of the questions raised and demonstrated a lack of understanding of the Regulations and the obligation they place upon doctors to report deaths to coroners, and that these legal obligations continue after the death may have been registered as natural. 7. Statements that had been requested at PIRHs on multiple occasions were not produced until after the hearing had started. Notes given by the Labour Ward Co-ordinator to the Hospital legal team that were relevant to the inquest were not disclosed until the Labour Ward Co-ordinator referred to them in evidence, and the court asked for them to be produced. Handwritten notes apparently written contemporaneously by the midwife caring for Elton�s mother on the labour ward were destroyed by that midwife after she updated the electronic medical record with the assistance of a midwife supervisor. 8. This court also has heard a recent jury inquest into two baby deaths at Chelsea and Westminster where the full medical records were not received until two thirds the way through the evidence. 9. The court was also informed that the apparent confusion as to when to report neonatal deaths to the coroner is not confined to Chelsea and Westminster. 10. That in some hospitals medical examiners do not routinely have access to obstetric records when assessing neonatal deaths. In Chelsea and Westminster, they do.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Parents of Elton Deutekom: [REDACTED] Via their legal representative�s email. [REDACTED] [REDACTED] Consultant neonatologist and lead for Neonatal Mortality, Chelsea and Westminster NHS Foundation Trust Via Trust legal team email [REDACTED] Lead Medical Examiner, Chelsea and Westminster Hospital NHS Foundation Trust Via Trust legal team 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.

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

Chelsea and Westminster NHS Foundation Trust | NHS England�| National Medical Examiner

04/09/2024

2024-0575

Charles Daniels

Cheshire

[REDACTED] Chief Executive Stepping Hill hospital Oak House Poplar Grove Hazel Grove Cheshire SK2 7JE

On 25 March 2024 I commenced an investigation into the death of Charles Henry DANIELS aged 81. The investigation concluded at the end of the inquest on 29 August 2024. The conclusion of the inquest was that: Natural causes

81 year old Charles Daniels was taken from home to Stepping Hill Hospital arriving at 04:00 hours on 26 January 2024. Family members had noticed a decline in his mobility and responsiveness. He had a significant previous medical history which included rheumatoid arthritis, an active stroke and subarachnoid haemorrhage diagnosed in March 2023. He suffered various falls resulting from that condition over the last year. He had previously attended Stepping Hill with what appeared to be a seizure in August 2023 and had been referred to a Neurologist who tested for motor neurone disease, which was negative. He was due an MRI scan to rule out causes for his confusion at the point at which he was admitted to Stepping Hill Hospital. The complaint on admission was lethargy and bruise to the right side of the head following a fall at home. A CT scan revealed a bilateral new subdural collection due to a malignant process. Given the diagnosis of a bleed the expectation was that it would stop, and it did. His confusion improved. Consequently, in March 2024 he was thought to be optimised for discharge. He did not see a doctor immediately prior to discharge. The records incorrectly indicated that Mr Daniels was completely mobile despite telephone reports to the family that he was deteriorating. He was sent home by ambulance on 6 March 2024 due to being unfit to be transported by car. He was clearly unwell and returned by ambulance to Macclesfield Hospital on 9 March 2024 where a CT scan revealed an acute on chronic subdural bleed. He was transferred to Salford Hospital into the care of the neurosurgical team. His condition was not survivable at any point from 26 January 2024 and he sadly passed away on 21 March 2024. His condition fluctuated in keeping with a rare diagnosis of intracranial hypotension which was not known until a specialist neuroradiologist independently reviewed the scans at Stepping Hill following his death.

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 Browne Jacobson solicitors 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

Stepping Hill Hospital

16/09/2024

2024-0496

Laura Farmer

Inner North London

[REDACTED] Chief Executive� UK Health Security Agency (UKHSA) Wellington House� 133-155 Waterloo Road� London� SE1 8UG� [REDACTED} Medical Director� Medicine Board� University College London Hospitals NHS Trust (UCLH) University College Hospital� 2nd Floor Central� 250 Euston Road� London NW1 2PG

On 9 May 2024, one of my assistant coroners, Melanie Lee, commenced an investigation into the death of Laura Farmer aged 46 years. The investigation concluded at the end of the inquest on 11 September 2024. The jury made a determination at inquest that Laura Farmer died from a stroke caused by an E coli infection.� Her medical cause of death was: 1a) left middle cerebral artery infarction 1b) thrombotic microangiopathy (TMA) haemolytic uraemic syndrome (HUS)� 1c) Shiga toxin-producing Escherichia coli infection

Following a diarrhoeal illness about ten days earlier, Ms Farmer was admitted to University College Hospital on 20 April 2024.�She was diagnosed with HUS caused by Shiga toxin producing E coli. When she was thought to be in the recovery phase, she suffered an unexpected stroke and, despite best efforts, died as a consequence.

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

Other related deaths

UK Health Security Agency | University College London Hospitals NHS Trust

06/07/2023

2023-0231

Oleg Khala

Inner West London

[REDACTED] Clinical Director- CARMHS, West London NHS Tmst, Trust Headquarters, 1, Armstrong Way, Southall, Middlesex. UB2 4SD.

On the 4th July 2023 evidence was heard touching the death of Mr Oleg Khala. He had been found deceased on the 151 January 2022, aged 56 years. � Medical Cause of Death � 1 (a) Hanging � � How, when, where the deceased came by his death: � Mr Khala suffered with severe and enduring mental and neurodevelopmental illnesses which together made his needs complex and him vulnerable. He had a past history of non-engagement with services in part due to autistic spectrum disorder. From autumn of 2021 his mood began to fall. On the 17th December 2021 and 28th December 2021 he attended Chelsea and Westminster Hospital requesting admission due to suicidality and sleeplessness. On both occasions informal admission was recommended by the psychiatric liaison services, but he was discharged for community care by the Crisis Assessment and Treatment Team (CATT), without consultant advice. Given his known vulnerability, lack of engagement, complexity and risk he should have been admitted, particularly after community treatment had failed due to his non� engagement between 18th December 2021 and 28th December 2021. On 1st January 2022 at approximately 0940, he was found deceased hanging [REDACTED] by Parks Police. There were no suspicious circumstances. If he had been admitted on 28th December 2021, he would probably would not have died at this time, � Conclusion of the Coroner as to the death: Suicide

Extensive evidence was taken during this inquest from many live witnesses and multiple statements and reports were read and exhibited. Of relevance to this report: � Mr Khala lived alone, socially isolated in temporary accommodation. The difficulties that he experienced with interpersonal relationships with neighbours and officials rendered him very vulnerable. His main support and advocate was a social worker of Glasshouse homeless charity. He had moved multiple times and had had come under the care of different Mental Health Services. He had diagnoses of autistic spectrum disorder, ADHD, schizoaffective disorder and an historic diagnosis of bipolar disorder. He was on long term medication of sodium valproate as a mood stabiliser and risperidone as an antipsychotic. � He came under the care of West London Mental Health Services in February of 2021, referred from Croydon. He was allocated to the Mental Health Integrated Network Team (MINT). He did not have a care-coordinator despite his severe and enduring mental health issues, and ongoing symptomatology. He was placed on a list for a care- coordinator in July 2021, but had not been allocated one prior to his death, due to a shortage of and waiting list for care-coordinator provision. � In the past he had been admitted on several occasions, some under section, and had a history of overdose, and throwing himself in front of a bus and talked of possibly jumping off a building in around July 2021. His psychiatrist noted that his conditions would put him at risk of impulsive behaviour, including self-harm. � In around October of 2021, his prescriptions for his mood stabiliser and antipsychotic were stopped due his non engagement with his GP for about three weeks. These were restarted, but he experienced side effects as they were recommenced. At the time of his death toxicology revealed that he had stopped taking his medication. This was not appreciated by the clinicians caring for him. � The Glasshouse social worker, from around October noticed a real change n his mood and behaviour- mood falling and becoming anergic and attempted to support him and accompany him to appointments and assist with social issues. � On the 6th December 2021 he was seen for assessment by his psychiatrist through MINT. He presented as capacitous, with some insight, complex, and intelligent. He was able to give a good account of his past experiences and issues. His diagnoses were considered, and further assessment was required. Follow up appointments were offered but sadly he had died before these occurred. � On the 17th December 2021 he attended Earl�s Court Station with a plan to jump in front of a train, but asked for help of staff. He was taken by police to Chelsea and Westminster Hospital where he was assessed by liaison psychiatry and requested admission. He gave a history of intrusive suicidal thoughts, sleeplessness due to issues with a neighbour and to be at risk of suicide. Sleeplessness was a relapse indicator for him, and his social isolation was recognised. Admission was recommended by psychiatric liaison. He was referred to the CATT who found him not to be suicidal and discharged him with a tablet of diazepam and for follow up with MINT without discussion with a consultant nor psychiatric liaison. Whilst the records taken by psychiatric liaison were full and descriptive and gave a thorough impression of appearance and behaviour, presentation and assessment of his presenting complaints, the assessment by CATT was generic in style. Evidence taken live from CATT was that Mr Khala was underplaying his suicidality to CATT, but never the less he was discharged. � The court heard that more than half of patients assessed by CATT for informal admission are discharged for community follow up, and that one of the roles of CATT is specifically to explore alternatives to admission. Patients discharged without admission by MINT are not discussed with the on-call psychiatrists, whilst patients to be admitted are. � There is an on-call consultant psychiatrist at all times for patients to be discussed. Attempts were made to follow up Mr Khala by MINT but these were unsuccessful. On 28th December 2021, Mr Khala re-presented at Chelsea and Westminster with suicidality and reassessed by a different psychiatric liaison nurse. Again, a thorough assessment was undertaken. He was found to be suicidal, avoiding eye contact , intermittently covering his face with his face mask when distressed, to have slept only one night since he was last seen, and to have been wandering the streets at night rather than go home, and he requested and required admission to keep him safe due to his suicidality, to review his medication and care needs. � He was again seen by CATT. The notes recorded were again generic, and tick box in style. In live evidence it was accepted that he did have on going suicidal thoughts but no plans nor intent, his complexity appeared underappreciated and many questions put to the CATT witness based upon the assessment by psychiatric liaison centring on his demeanour and sleeplessness, which had taken place just a few hours previously, were not answered clearly by the CATT witness. The witness claimed that admission had been discussed with Mr Khala but declined and follow up by MINT agreed with him, despite its previous failure. The discussion which the CATT witness stated to have taken place about admission was not recorded in the notes. � The court had some questions of credibility of evidence of the CATT witness who saw Mr Khala on 28th December 2021. � Mr Khala was discharged with two tablets of zopiclone for MINT follow up. This occurred despite two admissions being requested in a short time, the differing views of psychiatric liaison on both the attendances, the recent failure of the same plan, his risks including social isolation, age, sex, impulsivity, complexity and on-going suicidal ideation, his demeanor and the recurrence of his relapse indicator of sleeplessness. His case was also not discussed with the on-call psychiatrist. � The psychiatrist from MINT stated that such cases should and could have been discussed with the on-call psychiatrist, especially given the differing views of psychiatric liaison and CATT, and his complexity, risk and vulnerability. � The view of the psychiatrist was that Mr Khala should have been admitted and would have benefited from admission with the opportunities that admission would have afforded to Mr Khala to keep him safe and review his treatment and care plan. This was especially so on the 28th December 2021 after the previous plan had failed and vet was tried aqain. The evidence was that all cases whether discharged or admitted should be discussed with the on-call psychiatrist, that there was a shortage of care-coordinators and Mr Khala should have had one, and that MINT has no access to specialist advice or assessment for ASD or ADHD within MINT which if this was available would also have been of potential benefit to patients such as Mr Khala.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] sister of Mr Khala, and his two children. [REDACTED] Consultant Psychiatrist, MINT, Claybrook Road, London. W68NF � [REDACTED] Team Manager, Hammersmith and Fulham Crisis Assessment Team Claybrook Road, London. W6 8NF. [REDACTED] Glass Door Homeless Charity, Argon, Argon Mews, London. SW6 1BJ � 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: West London NHS Trust

22/02/2024

2024-0103

Mia Janin

North London

[REDACTED] Headteacher of The Jewish Free School Sent by post and e-mail

Mia Janin was born on 7 June 2006. On 12 March 2021 Mia was found deceased at home aged 14 years old. On the 18 March 2021 an investigation was opened into her death and an inquest was opened on 31 March 2021. Following a lengthy police investigation a final inquest hearing concluded before me on 26 January 2024 as follows: � �Mia Janin took her life while still a child and while still in the process of maturing into adulthood�.

Mia was last seen alive around 10pm on 11 March 2021 when saying goodnight to her parents in their family home. Mia was found deceased at home by her parents around 6.50am on 12 March 2021 suspended from from a ligature. � Two undated notes in Mia�s handwriting were found on her bed on 12 March 2021 addressed to her family and friends, which explained that Mia had decided to end her life. Mia�s death was entirely unexpected by her family, friends and teachers. She had felt low self-esteem at times but had not been diagnosed with any mental illness nor presented a risk of taking her own life. � Mia had close friends including at her secondary school but she also experienced bullying behaviour from some male students. Neither Mia�s family nor teachers was aware of that behaviour before her death. � On 10 March 2021 Mia posted a video on social media asking two of these male students not to mock her and criticising their music and fashion. This video received a large number of hostile responses, which Mia found stressful. On the evening of 1 1 March 2021 Mia said to her parents that she had had a difficult week and asked to move to a different secondary school, which they agreed to explore. � Toxicological examination confirmed the absence of any illicit substances in Mia�s system. The post-mortem examination found marks of self-harm (recent and old) of which Mia�s family was not aware. Mia is much missed by her loving family, friends and wider community who describe her as creative, kind, entrepreneurial and highly intelligent, amongst many other things. � The current head teacher of Mia�s secondary school � the Jewish Free School (JFS) � gave evidence at the final inquest hearing concerning systemic changes introduced at JFS following Mia�s death. This included a complete overhaul of safeguarding practices, increased behaviour management, improved information, staff surveys and externally delivered sessions by charities including Norwood, Streetwise, Jewish Women�s Aid and Keshet. � Evidence provided by some JFS students after Mia�s death to the police and Ofsted described regular incidents of gender based bullying by some male JFS students of some female JFS students. Some of those child witnesses had not experienced a change in culture at JFS since Mia�s death and did not describe being consulted or surveyed about the changes introduced by JFS.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons via-email: [REDACTED] (via his solicitors) [REDACTED] (ibid) [REDACTED] (ibid) [REDACTED], Child Death Overview Panel, North Central London

Child Death (from 2015) | Suicide (from 2015) This report is being sent to: The Jewish Free School

17/7/2024

2024-0380

Barry Howard

Norfolk

[REDACTED] Lead Director Infrastructure Norfolk County Council Martineau Lane Norwich NR1 2DH

On 21 December 2023, I commenced an investigation into the death of Barry John HOWARD aged 75. The investigation concluded at the end of the inquest on 16 July 2024. The medical cause of death was: 1a)������ Drowning 1b) 1c) 2) The conclusion of the inquest was: Accident contributed to by lack of visible warning signs of flooding and road closure.

On 13 December 2023, Barry Howard was travelling along Mill Lane towards Shotesham Ford, an unbridged Ford, after 10pm.� He was not familiar with the road which had previously been closed at the request of police due to flooding.� The temporary signs indicating that the road was closed and impassable were not visible and the signs warning of the Ford and the depth of water, were beyond the flooded section of road, and on the balance of probabilities were not visible to Mr Howard before he entered the water. After entering the water his car was swept away into the river and he was found deceased in his car, which was almost completely submerged, at the Unbridged Ford, Mill Lane, Shotesham, Norfolk on 14 December 2023. The findings at Inquest were that: Based on the evidence of the police and the fact that they found road closed signs on the side of the road and face down the morning after the collision, on the night of 13 December 2023, while Barry was travelling home after 10pm in the dark, on the balance of probabilities, there were no appropriate, visible signs or barriers, leading to the Ford at Shotesham, to tell him that the road was closed and impassable. Anyone unfamiliar with the road, or unaware of the flooding, would not therefore have known that the road was closed. There are no warning signs that the road is liable to flooding.� I heard evidence that there are many Fords across the county, many of which may not significantly flood, but this Ford is prone to deep flooding.� Without a sign warning that the Ford may also flood, it is unclear how anyone unfamiliar with that particular Ford would be aware of the level of risk. The road surface was completely submerged around 40m prior to the sign for a Ford.� The sign for the Ford was beyond the area that was flooded so anyone unfamiliar with the road had no notice of the close proximity of the upcoming Ford before entering the area of flood water. The road slopes in the direction towards the Ford, so initially when entering the water it would not have been deep. It is not clear at what point it became so deep it was impassable or if there was a sudden change in depth. There was evidence in from reports from the Parish Counsil to Norfolk County Council that the surface of the road was very slippery.� It is not possible to say whether Barry would have been able to brake and reverse easily after he entered the water and approached the Ford. I did not accept evidence that there is a gauge depth clearly visible from both approaches when the road is heavily flooded.� Based on the police report & photographs the day after the accident, the gauge showing the depth of the flooded area was some way from the unflooded area of road and the road did not have street lights, and the gauge was on a bend � which, on the balance of probabilities, means that it would not have been clearly visible to Barry as he drove towards the flood, especially at night, so he had no way of knowing how deep the water was until he was some way in to the water. NCC Highways Dept were aware of difficulties with the Ford and that the signs and barriers, indicating that the road was closed were often moved and therefore not visible. They were also aware that the hinged sign to the east was damaged and inoperable. In accordance with the Traffic Signs and Regulations and General Directions 2016, when it became apparent that the road closure requested by police in October 2023 would be long lasting, there should have been an appropriate review and more permanent measures put in place including permanent and less mobile road closure signs, sufficient early warnings and a diversion.� This would have prevented the issue of Barry driving down a closed and impassable road with no warning signs. It was my finding therefore on the evidence, that on the night of 13 December 2023 there was a lack of visible warning signs, before entering the flood water, of the proximity of the upcoming Ford, the impassable flooding and road closure.

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

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

12/7/2024

2024-0371

Ryleigh Hillcoat-Bee

Blackpool & Fylde� � Category: Child Death (from 2015)� � This report is being sent to: Secretary of State for Health and Social Care

[REDACTED] Secretary of State for Health & Social Care� Department of Health & Social Care� C/O Ministerial Correspondence and Public Enquiries Unit Department of Health and Social Care� 39 Victoria Street� London� SW1H 0EU Secretary of State for Health and Social Care

The death of Ryleigh Hillcoat � Bee was reported to me and I opened an investigation, which concluded by way of an inquest commencing 19th June 2024.�� I determined that the medical cause of Ryleigh�s death was: 1a Cardiac arrhythmia�� 1b Hyperkalaemia�� 1c Rhabdomyolysis secondary to Lipin � 1 deficiency II Lower respiratory tract infection In box 3 of the Record of Inquest I recorded as follows: Ryleigh Hillcoat � Bee was three years of age. On 9th August 2021 she was admitted to� hospital where it was felt she had developed a respiratory infection. After further� investigations, including some concerning blood test results reporting raised liver enzymes� and very high levels of creatine kinase, treating clinicians sought some input from a liver� specialist at a tertiary centre in Leeds who, by 12th August 2021, had advised that a� neuromuscular cause be considered. With Ryleigh�s blood tests results improving but still� elevated, this advice was not pursued, and at a time when her mobility ought to have been� raising concern she was discharged home with a view to further assessment in the� community. It was felt that Ryleigh had myositis and hepatitis secondary to infection which had been treated with antibiotic therapy. The reason for her admission to hospital had in� fact been an episode of rhabdomyolysis, a potentially serious clinical syndrome which is� known to occur in young children, but only rarely. There was a missed opportunity to� scrutinise what may have been affecting Ryleigh�s mobility before discharge, which could� have led to more awareness that her deterioration may have been associated with a� neuromuscular problem, although from the available evidence it cannot be established�that such enhanced awareness would have prevented her later death. Over the course of� the following weeks, her condition was reassuring to the extent that by the time she� attended a paediatric clinic on 28th September 2021 she was described as back to her� normal self. However, by the early hours of 8th November 2021 she needed to be urgently� taken to hospital. She went into cardio-respiratory arrest, and despite life-saving efforts�she could not be revived and her death was confirmed at 7.33 am that morning. A� subsequent post � mortem examination established that, unknown to medical�professionals, Ryleigh had an inherited deficiency. A significant proportion of episodes of� rhabdomyolysis prove to be fatal, causing high potassium levels in the blood leaving a child vulnerable to cardiac arrhythmia. Ryleigh had suffered a more significant episode of� rhabdomyolysis than had been the case in August 2021, and had been susceptible to such� an episode after recently developing a lower respiratory tract infection.� In box 4 of the Record of Inquest I determined that: Ryleigh Hillcoat � Bee died as a result of complications arising from rhabdomyolysis, a� potentially fatal clinical syndrome associated with the breakdown of skeletal muscle fibres. It was not appreciated until after her death that Ryleigh had an inherited deficiency known to be a cause of early � onset acute rhabdomyolysis in childhood.

In addition to the contents of section 3 above, the following is of note: As recorded in the conclusion above, rhabdomyolysis in rare in young children, but potentially fatal.� Ryleigh was admitted to hospital on two occasions, once in August 2021 and then in November 2021, and on both occasions the possibility she may be experiencing an� episode of rhabdomyolysis was not appreciated.� The senior, experienced paediatricians based at Blackpool Victoria Hospital had no prior experience of dealing with a rhabdomyolysis case.��Evidence was given at the inquest by�[REDACTED], a Consultant Paediatrician and Lead Clinician in metabolic medicine.�[REDACTED] had ultimately overseen some genetic�testing performed after Ryleigh died which resulted in a LIPIN � 1 deficiency being� identified. He expressed the view that there have been cases of rhabdomyolysis in the�past which have probably been missed by clinicians. [REDACTED] is a contributor to a guideline produced by BIMDG (British Inherited Metabolic Disease Group) entitled� �Rhabdomyolysis in young children� (copy attached, although the court was informed a revised version is in the process of being finalised.). It is a guideline which highlights how rhabdomyolysis can lead to complications including hyperkalaemia [which can� cause cardiac arrhythmias] and acute renal failure. The guideline includes guidance on� management of this condition in young children.� � It was evident at the inquest there was a lack of awareness of the guideline, and of� rhabdomyolysis in young children generally, and I was left with the impression that the only way a paediatrician may have any appreciation of this condition would be if that� paediatrician has come across a similar case previously.�� The court also heard from an independent witness, a Consultant Paediatrician, who� provided expert opinion. He too works in a general paediatric department at another� hospital Trust. He too had no experience of dealing with a case of rhabdomyolysis in a young child before. When preparing his report, he had located just the one NHS� guideline from another NHS Trust, a helpful document, which provides advice to� clinicians regarding when rhabdomyolysis ought to be considered.�� What guidance is available to clinicians regarding rhabdomyolysis appears to be scarce. 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 Ryleigh Hillcoat � Bee.�� [REDACTED], Chief Executive, Blackpool Teaching Hospitals NHS Foundation Trust� � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief� Coroner.� I also send a copy of this report to the following organisations: BIMDG [British Inherited Metabolic Disease Group]� [REDACTED], Chief Executive Officer, Royal College of Paediatrics & Child Health

Child Death (from 2015)� �

04/06/2024

2024-0312

Nigel Dixon

Rutland and North Leicestershire

[REDACTED] The Right Hon. Lucy Frazer KC MP, the Secretary of State for Digital Culture, Media and Sport The Right Hon. Victoria Atkins MP, the Secretary of State for Health and Social Care

On 20 February 2023 I commenced an investigation into the death of Nigel Walter DIXON aged 64. The investigation concluded at the end of the inquest on 4 June 2024. � The conclusion of the inquest was: Drug related death The cause of death was established as: � I a Morphine and Zopiclone Toxicity

Mr Dixon was a 64 year old male who lived alone. A visitor to his property was unable to rouse him on Monday 13 February 2023. Entry was gained by the Fire Service and Mr Dixon was found dead inside.

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

Alcohol, drug and medication related deaths | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department for Digital Culture, Media and Sport | Department of Health and Social Care

05/02/2024

2024-0060

Paz Ogbe-Millar

North London

[REDACTED] West Hertfordshire Hospitals NHS Trust

On the 3rd of December 2021 an investigation was opened into the death of Mr Paz Ogbe-Millar. On the 4th January 2022 an inquest was opened, which concluded at a final hearing before me on 21 October 2022. The conclusion of the inquest was that Mr Ogbe-Millar intentionally took his own life by jumping in front of a moving train while suffering from a relapse in cannabis induced psychosis and that this outcome was contributed to by the following factors: a. the decision by the community mental health team to discharge Mr Ogbe-Millar from its service on 30 November 201. b. The adsence of an adequate system at the emergency department to record information provided by the police to the hospital staff regarding Mr Ogbe-Millar�s risk of self-harm. c. The decision by the emergency department not to allow Mr Ogbe-Millar�s mother to remain with him in the hospital, pending the arrival of the mental health liaison team d. Problems surrounding the system for making referrals to the mental health liaison team e. The decision of the emergency department not to go outside with Mr Ogbe-Millar when he said he was going outside to smoke after his mother was required to leave.

CIRCUMSTANCES Of THE DEATH Mr Ogbe-Millar died on� 2 December� 2021.� He� was� 30� years� old a11d� described by his� mother� as� highly� intelligent,� articulate, charming a11d well� read. Fm� much of his life Mr Ogbe-Millar was a heavy cannabis user, which led to his diagnosis with cannabis induced psychosis in 2020. � Mr Ogbe-Millar received treatment from community and in-patient mental health teams at various stages, including two hospital admissions under the Mental Health Act 1933 in late 2020 and in early 2021. � On being discharged from hospital in March 2021 he enjoyed a period free of cannabis and psychosis. He was able to work, attend Narcotics Anonymous and come off his medication _ This led to his discharge from the community mental health team in June 2021. � In November 2021 Mr Ogbe-Millar gave up his job and resumed using cannabis on a daily basis leading to a relapse of h is mental illness. His mother sought help from the community mental health team who spoke to Mr Ogbe-Millar by telephone on 26 November 2021 and referred him to a substance abuse organisation, which did 11ot specialise in psychosis. He was discharged by the community health team on 30� November� 2021,� without� the� team� having obtained any information regarding his relapse from his mother. � In the early� hours of 2 December 2021, Mr Ogbe-Millar sent a text message to his mother saying:� �I�m sorry for my actions and I hope you all find peace�. His mother immediately telephoned the police who found Mr Ogbe-Millar at home [REDACTED].� � The police took Mr Ogbe-Millar to the Emergency Department of Watford General Hospital, which is operated by West Hertfordshire Teaching Hospitals NHS Trust (�WHTHN T�) where there� was� all� inadequate� system� for� recording the information provided by the police to the hospital concerning his risk of self� harm. � Mr Ogbe-Millar was assessed by hospital staff later that morning as a moderate risk of self-harm and told to await the arrival of the local Mental Health Liaison Team, which is operated by the Hertfordshire Partnership University NHS Foundation Trust (�HPUNFT�) � Despite Mr Ogbe-Millar�s risk of self-harm and the protective factor provided by the presence of his mother, she was not allowed to stay with him at the Emergrency Department while he waited for the Mental Health Liaison Team. Instead, she was required to leave, by staff in breach of hospital policy � The Mental Health Liaison Team had not arrived to assess Mr Ogbe-Millar by the time his mother was required to leave the hospital due to problems surrounding the referral system. � Soon after his mother had been required to leave, Mr Ogbe-Millar left the Emergency Department unaccompanied saying he was� going outside� to� smoke a cigarette. � He never returned and instead �travelled to London, where he died after jumping in front of a high speed train at Harrow and� Wealdstone train� station at 10.09pm on 2 December 2021.

I have sent a copy o my report to the solicitors of the Interested Persons in the inquest proceedings [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.

Railway related deaths This report is being sent to: West Hertfordshire Hospitals NHS Trust

15/07/2024

2024-0374

Owen Gardner

Suffolk

[REDACTED] [REDACTED] NSFT � Norfolk and Suffolk Foundation Trust (Legal Services) Chief Coroner�s Office

On 22 May 2023 I commenced an investigation into the death of Owen Donal GARDNER aged 29. The investigation concluded at the end of the inquest on 03 July 2024. The conclusion of the inquest was that: Road Traffic Collision The medical cause of death was confirmed as: 1a Multiple Injuries 1b 1c

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons NSFT � Norfolk and Suffolk Foundation Trust (Legal Services) I have also sent it to [REDACTED] � [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 related deaths� � � This report is being sent to: REDACTED | REDACTED | Norfolk and Suffolk Foundation Trust

13/02/2023

2023-0055

Hannah Warren

Swansea Neath Port Talbot

[REDACTED] (COMMISSIONER OF THE POLICE OF THE METROPOLIS) THE Rt HON SUELLA BRAVERMAN KC MP (SECRETARY OF STATE FOR THE HOME DEPARTMENT) [REDACTED] (CHIEF EXECUTIVE, COLLEGE OF POLICING) [REDACTED] (CHAIR, NATIONAL POLICE CHIEF�S COUNCIL)

On 15 FEBRUARY 2016 the Senior Coroner commenced an investigation into the death of HANNAH WARREN aged 28 (hereafter �Hannah�). The investigation concluded at the end of the inquest held between 16-26 JANUARY 2023. The conclusion of the inquest jury was that Hannah died as a result of 1(a) drowning 1(b) head injury, and they returned a narrative conclusion in the following terms:

(1) In the evening of 3 February 2016 Hannah was reported missing by her flat mate and fianc�. The report was made to the MPS. It appeared Hannah had left London in her motorcar shortly after 11am that morning and had not been spoken to since around 10.30am. (2) It was reported that she had been acting out of character expressing delusional thoughts and ideas, specifically that she �hacked into a computer� and the �government were after her�. (3) Hannah�s case was considered by the Duty Inspector at Brixton police station towards the end of his shift that evening. He assessed Hannah as �medium risk� using the COMPACT risk assessment tool. (4)�A LOW stop ACT was placed on Hannah�s vehicle on the Police National Computer by the investigating Police Constable. There was no specific instruction to place a Low ACT (as opposed to a Medium / High stop ACT) and no discussion about which priority to place on the said ACT. The available evidence established that �LOW� would probably have been placed on the ACT by default. (5)�� Meanwhile Hannah had travelled in her vehicle down to Brighton, along the south coast as far as Exeter, and then north towards Weston Super Mare, before rejoining the M5. (6)�� A call from Avon and Somerset Police into the MPS shortly after 10.00pm notified them of an ANPR activation for Hannah�s vehicle inbound to Weston Super Mare. Avon and Somerset requested further details from the MPS. (7)�� A second call just over one hour later notified the MPS that the vehicle was heading back out towards the motorway and again requested further details from the MPS. (8)�� A third call from Gwent Police into the MPS shortly before 02.45am on 4 February 2016 made a similar request information in relation to the ACT instruction. (9)�� Hannah�s journey generated no fewer than 27 activations on the ANPR system, the last at about 03.25am in Margam, Port Talbot. (10) The ANPR Bureau were not contacted by the MPS during this time. (11) At around 03.25am Hannah entered the Port Talbot harbour site via a private road. Her body was found in the lock entrance to the harbour shortly after 9am on 4 February 2016 and her car located underwater in the harbour itself by South Wales Police divers. (12) During the inquest the MPS accepted five shortcomings with respect to the missing person investigation for Hannah. These shortcomings were recorded in Box 3 of the Record of Inquest. They were: �(1) On the overnight response team shift, which received the handover from Inspector [REDACTED], there was a lack of action taken to progress the missing person investigation. (2)�There was insufficient and insufficiently timely use of the ANPR Bureau by officers investigating the missing person investigation. (3)�There was a failure to contact Hannah�s family, in particular to check whether Hannah had any known family or friends in the West of England. (4)�There was shortcoming in the flow of communication from the calls received into the Metropolitan Police made by regional Police forces to the response team investigating the missing person investigation. (5)�The ACT placed on the Police National Computer directing a stop of the vehicle driven by Hannah was marked as a Low grade, when it could have been marked as a Medium grade.�

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (1)���� Hannah�s Family (2)���� Metropolitan Police Service (3)���� OKTRA (4)���� Associated British Ports 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 | Wales prevention of future deaths reports (2019 onwards)

Metropolitan Police Service | Home Office | College of Policing | National Police Chiefs� Council

13/03/2023

2023-0088

Kelly Dunne

County Durham and Darlington

[REDACTED] (Chief Executive Officer) Durham County Council

On 12/07/2022 an investigation was commenced into the death of Kelly Nicola DUNNE. The investigation concluded at the end of the inquest on 20/02/2023. The conclusion of the inquest was one of Road Traffic Collision. The medical cause of death was: 1a) Subdural Bleed, Diffuse Axonal Injury and Brain Swelling (Craniectomy on 02/07/2022) 1b) Road Traffic Accident Causing Severe Head Injury

The deceased died at the Royal Victoria Infirmary in Newcastle on the 4th of July 2022 as a result of fatal head injuries sustained in a road traffic collision on the 2nd July 2022. The collision occurred when the deceased pulled out of a side road, Pittington Road, into the path of a vehicle travelling in the outside lane of the A690.

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

Road (Highways Safety) related deaths

Durham County Council

08/06/2023

2023-0198

Hilary Guedalla

Inner North London

[REDACTED] (Chief Executive) East London NHS Foundation Trust

On the 11th November 2021 I commenced an investigation into the death of Hilary Clare (Billy) Guedalla who died aged 46 on the 30th October 2021�[REDACTED]. � The investigation resulted in an inquest, which was conducted by myself over a period of 5 days and concluded on 19th May 2023. � I made a determination at inquest that the deceased died as a result of suicide and returned a narrative conclusion as follows: � 1. The deceased suffered from long standing psychiatric conditions of a Recurrent Depressive Disorder and complex Post Traumatic Stress Disorder. � 2. On occasions, the deceased�s psychiatric conditions led to psychiatric in-patient admission to hospital, usually as a voluntary patient, on a number of occasions between 2013 and 2021. Those admissions were associated with the deceased exhibiting suicidal ideation and sometimes involved attempts to take their own life. � 3.�On the 26th October 2021, the deceased was admitted to Gardener Ward, Homerton Hospital, London E9 as a voluntary patient suffering a worsening of their psychiatric condition. � 4.�At a ward round at that hospital on the 28th October 2021, at around 11am, the deceased indicated to staff that they had tried to take her own life the night before in hospital and that they had equipment at home for the purposes of ending their life. � 5.�The deceased�s condition worsened thereafter and staff at the hospital considered that the deceased should not be allowed out of the ward alone, for her own safety because, in effect they were a high risk of suicide. That decision was made in the morning of the 29th October 2021 but not communicated to all staff on the ward. � 6.�The deceased asked a member of the clinical staff to leave the ward, at around 6pm on the 29th October 2021. That member of staff was unaware of the decision that had been made that the deceased should not be allowed out alone. The member of staff carried out a brief assessment of the deceased, largely based on their appearance, but did not refer to any medical notes and records. The deceased was then allowed to leave the ward. � 7.�Sometime between leaving the ward and around 3pm on the 30th October 2021, the deceased took their own life by hanging themselves [REDACTED]. No-one else was involved. The deceased was found by members of the London Fire Brigade between 3 and 4pm, on that day. � 8. After the deceased had left the ward, night staff found the deceased to be missing at around 8pm on the 29th October 2021. Staff first contacted the police 2.10am and again at 2.46am on the 30th October, 2021 and requested that the police carry out a welfare check. They did not inform the police that the deceased was a serious suicide risk. They were advised to contact the London Ambulance Service but did not do this until 3pm on the 30th October 2021 and in any event, that request did not generate attendance at the deceased�s home address. � 9.� At around 2pm on the 30th October 2021, the deceased�s mother attended the ward having made a pre-arranged booking to visit the deceased. She was shocked to be informed that the deceased had left the ward. She enlisted support from family and friends which led to the attendance of emergency services at the deceased�s home address, between 3-4pm on the 30th October 2021. � 10.�The deceased should not have been permitted to leave the ward alone. Had clinical staff observed the decision not to allow the deceased out without a staff member, the deceased would not have taken their own life when they did. � 11.�The decision that the deceased should not be permitted unescorted leave failed to be communicated to all staff members on the ward. � 12.�The information that the deceased had tried to end their own life on the ward on the evening of the 27th October 2021 was also not properly communicated to all staff on the ward or added to any document which concerned a proper risk of assessment of them. Also, the hospital staff did not fully comply with the patient admission policy when the deceased was admitted on the 26th October 2021 as records were not properly updated and no physical health assessment was made of the deceased within 24 hours. � 13.�The decision that the deceased was to receive 1:1 support following the ward round of the 28th October 2021 could not realistically be met because of staff shortages on the ward. There was a failure to recognise that this plan would could not realistically be achieved because of those staffing issues. � 14.�The assessment made of the deceased before the deceased was allowed to leave the ward at 6pm on the 29th October 2021 by that member of staff was inadequate as a risk assessment of the deceased�s mental state for the purposes of assessing their safety. That member of staff relied solely on the deceased�s presentation at that moment and did not consider any written record about the deceased or ask any other member of staff about how the deceased was. � 15.�There was a complete failure to appreciate the urgency of locating the deceased once the night staff found them to be missing at about 8pm on the 29th October 2021 and to follow the hospital policy which applied to missing patients. � 16. Night shift staff took far too long to contact the emergency services and failed to contact the ambulance service as advised by the police in the early hours of the 30th October 2021. � 17.� When the police were contacted, staff completely failed to state the urgent and serious suicide risk which the deceased presented to themselves. � 18. Hospital staff also failed to properly contact Billy�s family and friends after they went missing from the ward or leave messages for them which could have enabled them to be located. � 19.�Staffing levels on both the 29th and 30th October 2021 were not adequate and this contributed to the failings set out above. � 20.� The failure set out above which relates to the staff member being unaware that the deceased should not leave the ward unaccompanied, amounts to a serious failure which directly caused or contributed to the deceased�s death. � 21. The other failures set out above amount to missed opportunities which may directly or indirectly, have prevented the deceased�s death.

The circumstances surrounding the death are set out in Box 3 above.

I have sent a copy of my report to the following. � ������� HHJ Thomes Teague KC, the Chief Coroner of England & Wales. ������� The Care Quality Commission for England. ������� The parents of the deceased. � I am also under a duty to send the Chief Coroner a copy of your response and all interested persons who in my opinion should receive it. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: East London NHS Foundation Trust

24/05/2023

2023-0171

Peter Camp

Hampshire, Portsmouth and Southampton

[REDACTED] (Executor of estate of ) cc: [REDACTED] of Churchers Solicitors, 12 High Street Fareham, Hampshire (Solicitors)

INVESTIGATION � On 17 February 2023 I commenced an investigation into the death of Peter John CAMP aged 76. The investigation has not yet concluded and the inquest has not been heard.

Police officers attended the address of 2, The Haven, Gosport, Hampshire, PO12 2BD following a concern for welfare raised by the deceased�s friend. The deceased had complained of feeling unwell the previous morning. Police entered the property and noted the heating in the property was on. They found the deceased (Peter John CAMP) in his bedroom. There were no signs of forced entry, and the death was reported to the coroner as a non-suspicious category 3 death.

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

Other related deaths This report is being sent to: Churchers Solicitors

14/07/2023

2023-0244

Peter Fleming

Birmingham and Solihull

The Rt Hon Steve Barclay MP, Secretary of State for Health and Social Care, Department for Health. NHS England. NHS Digital. NHS Birmingham and Solihull Integrated Care Board. Chief Executive, Birmingham and Solihull Mental Health NHS Trust. Chief Executive, Birmingham City Council.

On 3 January 2023 I commenced an investigation into the death of PETER MARTIN AARON FLEMING. The investigation concluded at the end of the inquest on 4 July 2023.

Peter had a long history of depression, anxiety, and reported suicide attempts. He had acknowledged his reluctance to always engage fully with the treatment offered. On 3/08/22 he was referred to the home treatment team for crisis intervention. After poor engagement he was transferred back to the community mental health team. On 14/10 he was detained by police under section 136 mental health act after expressing suicidal ideation. He told a psychiatric liaison service nurse he had no ongoing suicidal ideation and was referred to the community mental health team and his GP. He contacted the crisis team on 30/10. He was telephoned by a mental health nurse on 31/10, and Peter reported upset about personal issues but no suicidal ideation. On 31/10 he also contacted RELATE and had a telephone consultation with his GP, reporting worsening mental health in part because of a delay in his medication being prescribed, but reported no suicidal ideation. On 8/11 he called the crisis team reporting upset but no suicidal ideation. This prompted a community mental health team nurse on the 9/11 to try without success contacting Peter on the telephone. On 10/11/22 Peter was found deceased in his flat having taken a deliberate overdose of his prescribed medication. At the time of his death he was on the waiting list to be allocated a mental health care co-ordinator and there had been no multi-disciplinary meeting with all teams involved to agree how best to work with Peter. His cause of death was confirmed at post-mortem: 1a Carbamazepine toxicity. The conclusion reached was death was a consequence of suicide.

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

Suicide (from 2015) | Other related deaths This report is being sent to: Department of Health and Social Care | NHS England | NHS Digital | Birmingham and Solihull Integrated Care Board | Birmingham and Solihull Mental Health NHS Trust | Birmingham City Council

17/08/2023

2024-0326

Luke Brooks

Manchester North

The Rt Hon Steve Barclay Secretary of State for Health The Rt Hon Michael Gove, Secretary of State for Levelling up, Housing and Communities

On the 16th February 2023, I commenced an investigation into the death of Luke Matthew Brooks, date of birth 17th November 1994 who died on the 25th October 2022 at his home address [REDACTED] Street, Oldham. The medical cause of her death was confirmed as 1a) Acute respiratory distress syndrome due to 1b) Aspergillus Pneumonia.

CIRCUMSTANCES OF DEATH Luke died unexpectedly at his home address. He had been unwell with cold/flu like symptoms for approximately one week. Luke lived at his home address together with his parents, brother, cousin and another family friend. The property was rented from a private landlord. The family had lived in the property since 2014. Over the years they had numerous concerns as to the condition of the property which was cold and damp. In 2021 concerns had been raised to both the landlord and the environmental health department at Oldham Council by both the family and an early help service Positive steps. Whilst the Inquest considered whether the aspergillus (fungi/mould) was linked to the property the evidence did not support this. The source of the aspergillus could not be determined. Over the weekend prior to Lukes death he had had several discussions with out of hours medical providers via the NHS 111 call line. This is a commissioned service run by North West Ambulance (�NWAS�). Whilst the outcome of the calls had on two occasions suggested that Luke required a category three ambulance (attendance to be within 2 hours) the court heard over the weekend the wait time was 6-8 hours. Luke declined the same. On one occasion Luke did ask whether he could take himself to A&E but was advised not to. This was in line with a local NWAS policy that people who had described chest pain should not make their own way to A&E.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:� The family of Luke Brooks Oldham Borough Council North West Ambulance Service � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary 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.

Other related deaths This report is being sent to: Department of Health and Social Care | Ministry of Housing, Communities & Local Government

16/06/2023

2023-0195

Girmaye Guyo

Manchester City

The Rt Hon Steve Barclay, MP, Secretary of State for Health and Social Care Mr Alex Chalk KC, MP, Lord Chancellor and Secretary of State for Justice � Copied for interest to: Chief Coroner Parents of the Deceased Greater Manchester Mental Health NHS Foundation Trust Royal College of Psychiatrists

INQUEST � I concluded the inquest into the death of Girmaye Guyo Liban on 17th May 2023 and recorded that he died from: � 1a Drowning � I returned an Open conclusion following investigations.

The Deceased had a long history of mental health illness and substance abuse. Between 4th June 2020 and 15th September 2020 he was detained pursuant to the provisions of Mental Health Act 1983 at Eagleton Ward, Meadowbrook Unit. � The Deceased�s discharge from Eagleton Ward was authorised via his mother using her Nearest Relative Powers pursuant to the provisions of Mental Health Act 1983, and its associated Code of Practice. The Deceased then returned to the family home. � The evidence that I heard at the Inquest was such that the Deceased was still liable to be held under Section 3 Mental Health Act 1983; however, due to the difference in the test being applied for consideration of an application by a Nearest Relative, there was no choice but to discharge the Deceased Further evidence alluded to the concerns from clinicians about this power, and although the evidence was that it is seldomly used, it presents an opportunity for patients and families to deviate from the clinical course prescribed by clinicians. � There was no consideration for a Community Treatment Order for the Deceased as the provisions of the legislation refer to discharge from detention. � The Deceased remained unwell in the community, and on 10th November 2020 he went missing. His body was found in a local reservoir on 26th November 2020. There was insufficient evidence to determine how he came to enter the water.

I have sent a copy of my report to the Chief Coroner and to Interested Persons. I have also sent it to organisations who may find 1t 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 1t useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

03/05/2023

2024-0062

Sienna Barber

Manchester North

The Rt Hon Steve Barclay, Secretary of State for Health and Social Care, President of the Royal College of Paediatrics and Child Health, Chief Executive of National Institute for Health and Care Excellence

On the 30th January 2022, I commenced an investigation into the death of Sienna Daisy Barber, date of birth 27th�May 2019 who died on the 29th January 2022 at the Royal Oldham hospital aged 2 years and 8 months old. The medical cause of her death was confirmed as 1a) Acute necrotising bronchopneumonia due to 1b) Group A Streptococcus.

CIRCUMSTANCES OF DEATH Sienna was a healthy child with no underlying medical conditions. On Sunday 23rd January she developed a high temperature. There were no specific concerns although it was noted she was eating less. The following day she was taken by her parents to her GP practice where she was examined and a suspicion of a viral infection was diagnosed. Parents were advised to continue with Calpol and to re� attend if there were any concerns. The next day Tuesday 25th January Sienna awoke and was more unwell, she had vomited and her temperature was 40.2. Parents sought advice from 111 who advised them to take her to A&E. Sienna was then taken to North Manchester General Hospital where she was triaged and examined. It was suspected Sienna had a viral respiratory tract infection, her throat was inflamed and whilst her temperature remained high, the advice was to take her home and continue with Calpol and ibuprofen. Over the next few days Sienna�s temperature fluctuated.� Whilst at times her temperature decreased, Sienna remained tired and lethargic and had a sore throat. On Saturday 29th January 2022, Sienna began to be very agitated, flinging her arms and legs around. She was taken immediately to Rochdale Urgent Care Centre. Upon arrival she began to present with. mottling. She was immediately treated and transferred to Royal Oldham hospital where she died later that day.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:� The parents of Sienna Barber Manchester Foundation NHS Trust Greater Manchester Integrated Care Board � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted 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.

Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department of Health and Social Care | Royal College of Paediatrics and Child Health | National Institute for Health and Care Excellence

15/11/2023

2023-0452

Madeleine Savory

Suffolk

The Rt Hon Victoria ATKINS MP [REDACTED], Chief Executive NHS England

On 12th August 2022 I commenced an investigation into the death of Madeleine Eve SAVORY. The investigation concluded at the end of the inquest on 7th August 2023. The inquest was heard without a Jury. � Madeleine died of: 1a. Hypoxic Ischaemic Encephalopathy 1b. Asphyxiation by Hanging � I returned the following narrative conclusion: � Madeleine Savory died as a result of Suicide whilst suffering from the effects of a mental health illness. Madeleine�s death probably was more than minimally contributed to by the failure of East Suffolk and North Essex NHS Foundation Trust to implement relevant policies which specifically dealt with the management of children such as Madeleine. This led to; � a. Staff on Bergholt Ward not having the necessary understanding of Madeleine�s risk and how to manage this. b. Ongoing failures to conduct risk assessments for Madeleine. During the time of Madeleine�s admission there were only three risk assessments conducted and these were conducted on an ad hoc basis. c. Ongoing failure to ensure relevant information about Madeleine�s level of risk and the management of this was communicated to all staff involved in Madeleine�s care. This included the recognition and communication of the fact that the bathroom posed a particular risk for Madeleine. � There was a failure on the part of Northgate High School to effectively implement the safety plan for Madeleine which was designed to keep Madeleine safe during school hours. The result of this failure meant Madeleine was able to leave school undetected and engage in a self-harm act which resulted in their admission to hospital. This failure possibly more than minimally contributed to Madeleine�s death. � The lack of resources available to enable the timely allocation to Madeleine of a Tier 4 bed in a paediatric mental health facility possibly more than minimally contributed to Madeleine�s death.

Madeleine Savory was 15 years old when they died. Although not formally diagnosed with a mental health illness, at the time of their death clinicians were considering a working diagnosis of mood disorder depression of a severe nature. Madeleine had a very significant history of periodic suicidal ideation and a history of self-harm, the risk of both becoming acute in early February 2022. Madeleine was known to the Child and Young Persons Mental Health Service and to the Paediatric Ward at Ipswich Hospital. All organisations concerned with Madeleine�s care had knowledge of their history of suicidal ideation. � On the 3rd February 2022 Madeleine absconded undetected from their school and carried out an act of self-harm which resulted in their hospitalisation. They were subsequently identified as needing a Tier 4 Bed admission on a paediatric mental health ward. Measures were put in place for such a bed to be sourced. At the time of Madeleine�s death a bed was neither identified nor allocated to Madeleine. � During Madeleines admission on Bergholt Ward at Ipswich Hospital they were assessed as being a high risk of self-harm. Their mood fluctuated and on occasions Madeleine presented with no indication of either suffering from low mood or suicidal ideation. Throughout this period of time Madeleine�s presentation was complex and reflected the working diagnosis of mood disorder depression of a severe nature. A risk assessment on the 12th February 2022 identified the need for additional measures in managing Madeleine�s risk which included mental health observations. These measures were ceased on or around the 14th February 2022. The rationale behind why these measures were ceased is unclear. � On the 19th February 2022, during the evening Bergholt Ward shift, Madeleine appeared settled and an earlier episode of distress during the day seemed to have no further impact on them. At around 22:05 pm Madeleine made their way to the bathroom securing the door behind them. They were not observed by ward staff entering the bathroom and there was a period of up to ten minutes during which Madeleine�s precise whereabouts was unknown. At around 22:20 pm the evening shift Nurse-in-Charge on Bergholt Ward was informed that Madeleine had been in the bathroom for at least ten minutes and was concerned that this period of time was longer than expected. Measures taken to rouse Madeleine by knocking on the door or calling out to them produced no response. Staff subsequently entered the bathroom and found that Madeleine had ligatured themself. Resuscitation efforts resulted in a return of spontaneous circulation and Madeleine was transferred to the Intensive Treatment Unit at Ipswich Hospital. However, Madeleine had suffered a fatal hypoxic brain injury and they sadly passed away on the 26th February 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Family of Madeleine Eve SAVORY East Suffolk and North Essex NHS Foundation Trust (ESNEFT) Norfolk and Suffolk Foundation Trust (NSFT) Suffolk County Council (SCC) (Children�s Services and Madeleine Eve SAVORY�s School) East of England Provider Collaborative � I have also sent it to � [REDACTED] (Legal rep. SCC) (Legal rep. NSFT) [REDACTED] (Legal rep. ESNEFT) (Legal Rep. Family) [REDACTED] (Legal rep. EofEPC) [REDACTED] (Family Solicitor) � who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Suicide (from 2015) | Mental Health related deaths This report is being sent to: NHS England

15/04/2024

2024-0195

Axel Price

West Sussex, Brighton and Hove

The Rt Hon Victoria Atkins MP Secretary of State for Health and Social Care 39 Victoria Street London SW1H 0EU

On 29th April 2021 I commenced an investigation into the death of Axel Price aged 18. The investigation concluded at the end of the inquest on 9th October 2023. The overall conclusion of the inquest was a narrative conclusion which stated that: �At some time between the 15th April and 23rd April 2021 Axel, who had recently turned 18 years old tied a ligature [REDACTED]. It cannot be determined if at the time he had intended to end his own life. On 22nd February 2021 Axel had an unplanned discharged from Hospital, following his arrest by Police, at a time when he was showing signs of a decline in his mental health. The agencies failed him in that:- � The Mental Health services failed to arrange a coherent planned discharge on 22nd February 2021 and provide a clear risk, crisis, and care plan on discharge.Adult Social Care failed to arrange a capacity assessment upon his discharge on 22nd February 2021 or anytime thereafter.There was lack of consideration by all agencies involved with Axel as to whether the accommodation provided to him was suitable for a young person, whose capacity fluctuated when in crisis, and who in those circumstances became unsafe to live alone.Axel�s lead Practitioner failed to assertively engage with Axel after discharge and meet with him in person. She was therefore not able to assess his ongoing risk or recognise his mental health deterioration.On 6th April 2021 following an obvious decline in Axel�s mental health presentation there was a failure by Adult Social Care staff to arrange a full risk assessment and mental health review.There was a lack of support and active engagement for Axel provided by the Adult Assessment and Treatment Service in Crawley pending his transfer to Adult Assessment and Treatment Service in Brighton. Axel�s death was contributed to by neglect�

At some time between the 15th April and 23rd April 2021 Axel, who had recently turned 18 years old tied a ligature [REDACTED}. Axel had recently been detained under Section 2 Mental Health Act 1983 but discharged following a violent incident in the hospital when he was taken into Police custody. He was released from Police custody into temporary accommodation in Brighton provided by Adult Social Care.

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

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

25/04/2024

2024-0221

Richard Carpenter

Wiltshire and Swindon

The Rt Hon Victoria Atkins MP The Secretary of State for Health & Social Care 39 Victoria Street London SW1H OEU

On the 15 December 2021 I opened an Inquest into the death of Richard Carpenter who was born on the 18 February 1950 and who died at his home address during the early hours on the 1 December 2021 aged 71. His Inquest was finally concluded today (23 April 2024). At the final hearing Inquest, I found that the medical cause of death was: 1a. Haemothorax 1b. Bleeding from Site of Cardiac Surgery 1c. Mitral Valve Replacement (November 2021) for Severe Mitral Regurgitation � In relation to the when, where and how Richard came by his death, I recorded as follows: � �Richard underwent elective complex heart surgery on 19 November 2021 that included a Mitra/ Valve repair and also a single vessel Coronary Artery Bypass Graft. He was discharged home on 28 November 2021. Late evening on 30 November 2021 he developed pains down his left side. He became unresponsive during the early hours on 1 December 2021 and was confirmed dead at home at 0500 the same day. He died as a consequence of a complication following surgery when he developed a bleed more likely than not from the surgical site.� � My conclusion as to Richard�s death was that it was an ACCIDENT.

As you will see from what I recorded on the Record of Inquest, Richard underwent elective major cardiac surgery in Bristol on 19 November 2021 and was discharged home on the 28 November 2021. Late evening on the 30 November 2021 he developed increasing pain down his left side and shortly after 22:30 that evening his wife made the first of a number of calls to the ambulance service.��� Although� Richard�was�categorised�as a�CAT�2 response� records�show� that �an ambulance� did� not arrive�at Richard�s�home�address until 04:11�on the 1 December,�some 5 hours 34 minutes and 36 seconds from the time of the first call by which time Richard was unresponsive and despite advanced life support his death was confirmed at 05:00 the same morning. You will of course be aware that the target response time for a Category 2, I understand, is 18 minutes. � At the final hearing I admitted evidence under Rule 23 of Coroners� (Inquests) Rules� 2013� from [REDACTED] who undertook the cardiac surgery on Richard in November 2021 and his evidence was that even if Richard had been got to hospital within say an hour of the original call the outcome would only have possibly been more favourable and the use of the word possibly does not meet the level of certainty that is required to establish causation which works on a balance of probabilities.

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

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

22/01/2024

2024-0037

Donna Smith

Teesside and Hartlepool

The Rt Hon Victoria Atkins MP the Secretary of State for Health & Social Care, House of Commons, London SW1A 0AA � [REDACTED], Chief Executive of North East Ambulance Service Foundation Trust, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle upon Tyne NE15 8NY

Donna Georgina Smith died at James Cook University Hospital, Middlesbrough on 17 July 2021. On 20 July 2021 I commenced an investigation into the death of Donna Georgina SMITH aged 51. The investigation concluded at the end of the inquest on 08 January 2024. � The Medical Cause of her death is: � 1a. Acute Left Ventricular Failure 1b. Diabetic Ketoacidosis and Coronary Artery Disease and Ischaemic Heart Disease I left a narrative conclusion as follows Donna suffered chest pains at home on 17.07.21. The emergency services were contacted. She suffered a myocardial infarction which deteriorated into cardiac arrest. There were missed opportunities on behalf of the ambulance service to recognise that Donna was peri arrest and in turn upgrade the call category. The failure to upgrade the call category and the delay in the ambulance contributed to Donna�s death.

Donna Georgina smith�s past medical history included two heart attacks, ischaemic heart disease, hypertension, and Type 2 Diabetes Mellitus. On 17.07.21 in the afternoon she described feeling lightheaded and went for a lie down. Approximately ten minutes later she told her husband she was having a heart attack. She was holding her chest in pain and collapsed to the floor. Her husband called for an ambulance at approx. 1500. The call was disconnected and a call handler from the North- East Ambulance Service (NEAS) returned the call at 1501. Donna was unable to talk properly because of her chest pain. A Category 2 disposition was allocated. This aims for an average ambulance response within 18 minutes, with a 95th percentile of 40 minutes. At 1526 the family called NEAS describing worsening symptoms. Donna was unconscious and breathing slowly. The call was received by a call handler and remained as a category 2 disposition. The family made further chasing calls to NEAS. They contacted the police and fire brigade for assistance, both of whom contacted NEAS and were told an ambulance would be attending. Due to the number of calls received a clinician telephoned the family at 1537. NEAS accept that the questions and probing undertaken by the call handler were insufficient to ascertain Donna�s position. The call handler asked the family if they could take her to hospital. The case was not re-categorised but was prioritised within the list of Category 2 dispatches. � A Dual Crew Ambulance arrived at 1606, one hour and six minutes following the first call. By that time the Fire Brigade had helped Donnas family place her on a stretcher and she was being transported to hospital in a family member�s car. The Fire Brigade flagged down the ambulance which was not travelling under sirens or at speed. Donna was transferred to the ambulance. She stopped breathing and deteriorated into a state of cardiac arrest. CPR was provided and an ECG identified Ventricular Fibrillation. Following defibrillation, a return of spontaneous circulation was achieved. In line with NEAS protocol the crew awaited the arrival of a second ambulance. Enroute to the hospital Donna sustained a further cardiac arrest and resuscitation was provided. She arrived at hospital at 1714. She was sadly pronounced Deceased shortly after her arrival. � NEAS undertook an SI report. Oral evidence was provided by a Patient Safety Manager. It was clear that a comprehensive investigation had been undertaken and learning implemented. The Patient Safety Manager (�PSM�) explained that if Donna was in peri-arrest when the Clinician called the family the call should have been categorised to a Category 1 call. This would have resulted in an average response time of 7 minutes, with the 95th percentile being 15 minutes. The escalation is because the peri-arrest is recognised as a life- threatening event. � I instructed an independent expert who determined that the delay in the ambulance arrival contributed to Donna�s death. He also told me that Donna was peri-arrest at 1526, when the family called and described Donna�s worsening condition to the call handler. She continued to be in peri-arrest when the clinician called at 1537.The failure to recognise this deterioration and act accordingly also contributed to Donna�s death. � The PSM explained that NEAS now employ a dispatch clinician, who monitors the category 2 calls to see if they should be escalated in status. It is not guaranteed that they will spot each call that needs to be escalated. The other way a category 2 case is re-considered is if, as in this case, there are a high number of calls. If there are a high number of calls a clinician will consider the case and ring the family. This happened in Donna�s case. My concern is that neither the call handler nor the computer recognised the significant change in Donna�s health when the family called at 1526. She was in peri-arrest and the call should have been re- categorised as a Category 1 dispatch. � A further concern is that the category 2 call was not responded to in a timely fashion. It took one hour and six minutes for the ambulance to arrive to an emergency call.

I have sent a copy of my report to [REDACTED] , Donna�s husband 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: Department of Health & Social Care | North East Ambulance Service Foundation Trust

15/01/2024

2024-0020

Dennis King

Suffolk

The Rt Hon Victoria Atkins, Secretary of State for Health and Social Care [REDACTED], Chief Executive of NHS England [REDACTED], Chief Executive of the East of England Ambulance Service

On 20 December 2022 I commenced an investigation into the death of Dennis John William KING aged 84. The investigation concluded at the end of the inquest on 29 November 2023. The inquest was heard without a Jury. � I returned the following narrative conclusion: � Dennis John William KING died as a result of recognised complications following necessary, life-saving emergency treatment for a myocardial infarction. � The medical cause of death was confirmed as: � 1a Multi Organ Failure 1b Post myocardial infarction left ventricular free wall rupture (operated on)

On the evening of 9th December 2022, Dennis John William KING suffered sudden chest pain which extended down his arm. At 22.51PM Mr. KING�s wife called 999 and spoke with an ambulance service call handler. Following triage of the call, the response to Mr. KING�s call was graded as a Category 3 (a potentially urgent condition which is not life threatening with a target response of 120 minutes). This call was subsequently re-graded following review in the call centre at 23.18PM to a Category 2 (a potentially serious condition requiring rapid assessment, urgent on scene intervention or transport to hospital, with a response within 40 minutes and a target of 18 minutes). � At 23.53PM Mrs. KING called again to enquire after the estimated time of arrival for the ambulance and was advised that due to high demand in the West Suffolk area that evening, the waiting time for an ambulance could be as long as six hours. On receiving this information Mr. and Mrs. KING decided to make their own way to the West Suffolk Hospital arriving there at 00.58AM on the 10th December 2022. The ambulance service were advised and the response stood down. � Within 40 minutes of arrival Mr. KING had been diagnosed as suffering an ST segment elevation myocardial infarction (STEMI) and arrangements made for him to be received as a patient at the regional specialist centre at the Royal Papworth Hospital for an urgent angioplasty procedure to be performed. The time was 01.44AM, 10th December 2022. Mr. KING�s condition at this point was stabilised and he was being closely monitored in a resuscitation room. Treating clinicians assessed his condition as necessitating an urgent transfer to the Royal Papworth and for the angioplasty procedure to be conducted forthwith. � The ambulance call centre was contacted by the hospital emergency department at 01.37AM with a request for an urgent transfer to the Royal Papworth. Emergency department staff were advised that there would be a 5 hour delay for an ambulance to attend. The call from the hospital emergency department to the ambulance service was graded by the ambulance call handler as a category 2 response. When the response timing was challenged the emergency department matron was advised that the hospital was a place of safety. The ambulance call handler assessment did not seem to take into account the clinical assessment of accident and emergency department staff who, in consultation with the regional cardiac intervention hospital, had determined Mr. KING�s further treatment at the regional cardiac centre was a matter of urgency. � An ambulance subsequently arrived at West Suffolk Hospital Accident and Emergency Department at 04.36AM and then transferred Mr. KING to the Royal Papworth Hospital, arriving at 05.56AM on the 10th December 2022. Mr. KING underwent treatment for what was identified as an occluded left anterior descending artery. The procedure was completed without incident and Mr. KING was placed on a cardiac ward. � About 1 hour after the procedure, Mr. KING�s condition deteriorated and he suffered a left ventricular wall rupture, a recognised complication of either the myocardial infarction he had suffered or the surgical procedure to correct the occluded artery, or both. Mr. KING received emergency surgery to repair the rupture by way of a patch which was successful. However, Mr. KING�s condition deteriorated and he died on the 13th December 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Family of Dennis John William KING � I have also sent a copy to: � Royal Papworth Hospital NHS Foundation Trust West Suffolk Hospital NHS Foundation Trust � as other persons who I believe may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

22/09/2024

2024-0508

Dennis Harry

Cornwall and Isles of Scilly

The Rt Hon Wes Streeting MP, Secretary of State for Health and Social care

On 13 February 2023 I commenced an investigation into the death of Dennis Richard Harry. The investigation concluded at the end of the inquest on 12 September 2024.�� The medical cause of death was found as follows: 1a. Hypertensive heart disease and SARS-CoV-2 infection�� (1a being the disease or conditions directly leading to death) The four statutory questions � who, when, where and how � were answered as follows: Dennis Richard Harry died on 10 January 2023 at Royal Cornwall Hospital Truro� from heart disease and Covid-19 infection following a grossly excessive� ambulance delay attributable to a systemic failure related to the whole system of� health and social care.��� There was a response delay of 15 hours and 35 minutes from the original 999 call on a category 2 priority requirement*, and then a delay in the handover between� the ambulance and the hospital of three hours and 14 minutes.� �� The total ambulance delay of 18 hours and 50 minutes led to a significant delay in the commencement of treatment.� Dennis subsequently made a partial recovery and was being considered for� discharge when he contracted an infection which delayed his discharge and then� contracted covid 19 which caused his death.�� Were it not for the significant delays in treatment it is possible that Dennis may�have had a speedier recovery and been discharged before contracting covid 19, or alternatively Dennis might have acquired greater resilience to withstand the covid� 19 infection which led to his death.� [*Category 2 identifies those patients who have a potentially serious condition that may require rapid assessment, urgent on scene clinical intervention and/or urgent transport to hospital.]�� The narrative conclusion of the inquest was as follows: Dennis died from Covid 19 and heart disease following a grossly excessive�ambulance delay of 18 hour and 50 minutes, this delay being attributable to a� systemic failure related to the whole system of health and social care, which was possibly causative of death.

The findings of fact on how Dennis died are set out above in the answers to the four statutory questions.� Systemic failure and Dennis� death � 2.�� The court made findings of fact upon the wider circumstances, namely the� systemic failure that was possibly causative of Dennis� death.� 3.�� On the day the ambulance call was made (20th December 2022) there were� considerable ambulance delays. At approximately the time the ambulance call was made, 15:42 hours, there were between 13 and 18 ambulances waiting outside the Emergency Department (ED) at Royal Cornwall Hospital (RCHT).� 4.�� At approximately 08:00 on 21st December when Dennis arrived at ED there were� 56 patients in the ED and 11 ambulances waiting outside the ED. The ED is built to house 44 patients.� 5.�� In December 2022, the total amount of time waiting for beds or transport after� decisions to discharge from ED totalled 20,144 hours which is the equivalent of 27� cubicles being closed to ED.� This amounts to more than half the available space� in ED taken throughout December 2022 by patients waiting for beds to become� available on acute wards or for discharge for alternative care arrangements.� 6.�� The court found that the hospital regularly failed to meet the 4-hour target for� moving patients out of ED at the time of Dennis� death and since.� It was noted that there is a recent major study which shows that the standardised mortality rate� starts to rise from 5 hours after the patient�s time of arrival at the ED and they� concluded that after 6�8 hours, there is one extra death for every 82 patients� delayed.� 7.�� The court found insufficient bed availability on acute wards which was attributed to� an increase in patients with no reason to reside (NCTR), these being patients who� are medically optimised but cannot be discharged due to lack of onward care� support.� 8.�� Approximately 80% of NCTR patients are of that status for external reasons� beyond the control of RCHT.� The main causes of external NCTR numbers were� found to be as follows:� Social care provision (whether commissioned by social services or NHS)� namely packages of care in the community, beds in nursing homes or� residential care homes�� NHS primary healthcare support for discharge (in the home)� NHS community hospital provision� 9.�� On the day of Dennis� 999 call 20 December 2022 the externally delayed NCTR� was approximately 120 patients. This is over 20% of RCHT bed capacity.� 10. The court found significant correlation between delayed discharges, handover� delays and delays in response times. On this basis, the court found there was a� direct connection between the ambulance delay experienced by Dennis and�inadequate social care provision, community hospital provision and primary� healthcare support leading to delayed discharges from hospital.� 11. The connection between delayed discharges and ambulance delays and the associated risks has been referred to in reports from Southwest Ambulance� Service Trust (SWAST) and the Health Services Safety Investigations Body� (HSSIB). The court found that the state knew or ought to know of the risks.�� Current circumstances of systemic failure 12. The findings of fact upon current circumstances in relation to the systemic failure� were as follows.� 13. There was found to be a direct connection between current ambulance delays and� inadequate social care provision, community hospital provision and primary� healthcare support on discharge. This is because inadequacies in those services� lead to delayed discharges from hospital which lead to shortages of acute beds,� impeded patient flow, crowding in ED and the inability of ambulances to handover� patients to ED.� 14. Significant average handover delays at RCHT were recorded for every month of� 2024. This is a picture reflected across the SW and indeed nationally.�� 15. The average handover delays conceal spikes such as that which led to the long� delay as in this case. Such long delays increase the risk of mortality. �� 16. There are continuing delays of patients from ED which is evidenced by the ongoing failure to regularly meet the 4-hour standard.� These delays increase the risk of� mortality.� 17. Over the last year up to 16% of patients in RCHT have been of external NCTR� status, patients who meet the criteria for discharge but cannot be discharged for� reasons external to RCHT.� 18. The court found that if the external NCTR numbers could be reduced, this would� significantly address current issues of ambulance delays, ED crowding, and the� shortage of acute beds.�� 19. The main drivers of external NCTR patients are inadequate social care provision,� community hospital provision and primary healthcare support on discharge.� 20. Approximately 10% of social care posts in Cornwall are currently vacant� notwithstanding Cornwall Council securing the agreement of social care providers� to pay the living wage.� This reflects the national picture of 165,000 vacant social� care posts.�� 21. The NHS and Cornwall Council generally do not employ social care staff and rely� upon social care providers.�� 22. In connection with care homes there are no Cornwall Council owned care homes,� the Council does not directly run any homes and does not plan to build any new� care homes.� 23. The Council does have a ���development framework which will support local and� national developers to build new care homes in Cornwall.��� 24. The extent of the obligation on local authorities is set out in the Care Act s5� A local authority must promote the efficient and effective operation of a� market in services for meeting care and support needs with a view to� ensuring [inter alia] �. a variety of high quality services to choose from�� 25. The NHS does not carry responsibility for the recruitment and retention of social� care staff or any broad obligation to promote the social care market.� 26. The organisations immediately required to deal with ambulance delays are� ambulance trusts and acute hospitals, In Cornwall that is SWAST and RCHT.� These organisations do not have control over the services primarily responsible for� ambulance delays, namely social care provision, primary healthcare provision and� community hospital provision. They are unable to influence the whole-system and� therefore carry risks that they cannot wholly mitigate or manage.� 27. The court noted the HSSIB report which states that delayed discharges (and� consequent ambulance delays) are a national issue which is attributed to a whole� system failure of health and social care. The court noted the HSSIB investigation�s� first safety recommendation is an urgent �whole system� response to reduce patient harm.

I have sent a copy of my report to the Chief Coroner and to the following Interested� Persons: Dennis� family, RCHT, SWAST, Cornwall Council, NHS Integrated Care Board for Cornwall,� I have also sent it to other bereaved families who have experienced ambulance delays and 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�| Emergency services related deaths (2019 onwards)

Department of Health and Social Care

28/07/2023

2023-0285

Benjamin McQueen

London City

The Rt Hon. Ben Wallace MP, Secretary of State for Defence

On 26 November 2018 the Senior Coroner for Dorset commenced an investigation into the death of BENJAMIN DAVID MCQUEEN, aged 26. The investigation concluded at the end of the inquest held by me as nominated Judge Coroner from 10 to 28 July 2023. The conclusion of the inquest was as follows: � Medical Cause of Death la Drowning � How, when, and where, and for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by his or her death. � On 14 November 2018, Benjamin McQueen drowned during a military diving exercise in Portland Harbour, Dorset. He experienced complications during the dive. He carried out one or more authorised emergency drills which would have rapidly depleted the supply from his breathing apparatus. He was recovered from the sea bed from a depth of about 18 metres, but despite appropriate attempts at Cardio Pulmonary Resuscitation he could not be revived and his death was declared at 19.17. � Conclusion of the Coroner as to the death � Short form conclusion: Accident during arduous military training for operations with an elite unit. � Additional narrative conclusion: Ben�s Unit collectively took diver safety seriously and conscientiously. However, his death was contributed to by the following failures: Not topping up breathable gas levels between the two dives;The lack of a training requirement for all signals to be acknowledged;Inadequate risk assessment for the combined use of the equipment on the exercise which failed to identify mitigating measures for the risks arising 1 (insistence on careful progression;� shallower� water and ensuring� breathable� gas was topped up); A marked and inappropriate increase in the rate of training progression in the second phase of the exercise;Insufficiently firm instruction on when student divers should surface. It is also possible (but cannot be said to be probable) that his death was contributed to by: (1)�Limitations in training in the Emergency Ascent Drill, including the lack of reference to the use of the Buoyancy Control Jacket to ascend; (2) Not specifically training dive students to check their cylinder pressure after the trouble drill and not specifically warning about the use of breathable gas it could use up; (3)�Inadequate consideration of the risk of a lost diver in selecting the most appropriate cylinder for the stand-by diver; (4)�Failing to ensure a full and rapid de-brief of all of the surviving divers who surfaced in choosing where to deploy the stand-by diver; (5)�The lack of formal authorisation from Headquarters for some of the equipment to be used on the exercise because following the correct procedure may have highlighted the deficiencies in the risk assessments; (6) The resource limitations leading to a relative lack of proactive engagement in the Chain of Command between the levels of the Dive Cell Co-ordinator and the head of the training department.

The circumstances of the death are briefly summarised in the text above. Detailed factual findings in Security Sensitive form are held by MOD and I request that you should have regard to the full Security Sensitive factual findings.

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

Other related deaths | Accident at Work and Health and Safety related deaths | Service Personnel related deaths This report is being sent to: Ministry of Defence

13/03/2024

2024-0137

Jane Walker

North West Wales

The Rt Honourable James Cleverly, Secretary of State for the Home Office

On 11 August 2020 an investigation was commenced into the death of Jane Walker (DOB 3 April 1968) who died on 8 August 2020. The investigation concluded at the end of the inquest on 13 March 2024. The conclusion of the inquest was accident.

The circumstances of the death are as follows : On 8 August 2020 Jane Walker was a passenger on a rigid inflatable boat on the Menai Straits when a collision occurred between the rigid inflatable boat and a jet ski. Jane suffered significant internal injuries, was attended to by paramedics at the slip way and then conveyed to hospital, where she later died. The circumstances were investigated by the Marine Accident Investigation Branch.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this Report to the Chief Executive of the Welsh Ambulance Service Trust for his information. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 | Alcohol, drug and medication related deaths | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Home Office

04/12/2023

2023-0497

Fraser Moore

Inner South London

The Rt. Hon Mark Harper MP, Secretary of State for Transport, The Department of Transport (DfT) Great Minster House, 33 Horseferry Road, London SW1P 4DR�������������������������� [REDACTED], Chief Executive, Network Rail, Waterloo General Office, London SE1 8SW

On 4 May 2020 an investigation into the death of Fraser William Moore, aged 25, was opened. The investigation concluded at the end of the inquest on 15 December 2022. The conclusion of the inquest, heard before a jury was the �inappropriate handcuffing, his unnecessary arrest, inadequate supervision of his arrest and the failing to prevent his escape.�� He escaped firstly onto the station concourse and then onto the railway lines at London Bridge Station. � The medical cause of death was 1a. Electrocution, 1b. Contact with live rail.

On 25 March 2020 Mr Moore had been arrested, handcuffed and was present in a carriage. He managed to exit one of the carriage doors, which was unattended and fled onto the platform. After running for a short period of time firstly up and then down the platform by moving down one side of the concourse to the other, he was running towards the country end at London Bridge Hospital. He proceeded to jump onto the track whilst still within the platform area before continuing out of the platform area towards the country. He was followed by a BTP officer. The rails were still live. The calling for the lines to be isolated occurring about the same time that maters were picked up by the signalman. Sadly, he made contact with the live rail before power could be severed. Subsequently, after the power switched off and assistance to move to his location, some distance from the platforms, he was pronounced dead at the scene.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] of Taylor-Rose UK for the family of Kennedys Law for Network Rail [REDACTED] of Kennedys Law for Network Rail [REDACTED] of Weightmans for British Transport Police [REDACTED] , IOPC [REDACTED] for MPS for MPS [REDACTED], Lead Investigator for Police Conduct � 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 This report is being sent to: Department for Transport | Network Rail

21/12/2023

2023-0544

Kimberley Liu

Inner North London

The Rt. Hon. Lucy Frazer KC MP Secretary of State for Digital, Culture, Media and Sport Department of Digital, Culture, Media and Sport 100 Parliament Street London SW1A 2BQ

On 17 February 2023, an investigation was commenced into the death of KIMBERLY ANNA LIU, then aged 40 years. The investigation concluded at the end of an inquest, heard by me, on 14 December 2023. � The conclusion of the inquest was drug-related death, the medical cause of death being: � 1a mixed drug toxicity.

Dr Kimberly Anna Liu had become addicted to sleeping to sleeping tablets, painkilling medication, and other medications with a sedative effect in the years prior to her death. � On 7 February 2023, Kimberly Liu was found unresponsive at home by her husband and an ambulance was called. Paramedics verified her death at home. � Post-mortem toxicological analysis revealed numerous prescription-only medications in Dr Liu�s blood at the time of her death. Some of these medications had been prescribed by Dr Liu�s general practitioner and were at or about therapeutic levels; whereas other medications ([REDACTED]), which had not been prescribed by her GP, were found at levels suggestive of excessive use. � (For the avoidance of doubt and any confusion, Dr Kimberly Liu was not a medical doctor).

I have sent a copy of my report to the Chief Coroner and to the following Interested Person: � [REDACTED] (husband of Dr Kimberly Liu). � 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: Department for Culture, Media and Sport

08/05/2024

2024-0348

Oliver Barnett

Cheshire

The Rt. Hon. Victoria Atkins MP, Secretary of State for Health and Social Care NHS England

INVESTIGATION � On 14 December 2022 I commenced an investigation into the death of Oliver Walter John Stephen BARNETT, aged 17. The investigation has not yet concluded, and the inquest is part-heard.

Oliver Barnett was aged 17 years when he died and had, since the age of 14, experimented with drugs. Oliver became dependent upon Benzodiazepines in particular, and was admitted to hospital on several occasions in 2022 following overdoses. Following hospital treatment, Oliver was discharged to substance misuse services in the community (with a prescription for�[REDACTED] diazepam daily, a very high dose). During the inquest, evidence was given that there are no (publicly-funded) residential substance misuse treatment facilities in England for minors. On 8th December 2022, Oliver died from an overdose of illicitly obtained drugs.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] Cheshire and Wirral Partnership NHS Foundation Trust Mid-Cheshire Hospitals NHS Foundation Trust Change Grow Live Cheshire East Council North Staffordshire Combined Healthcare NHS Trust � � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Alcohol, drug and medication related deaths This report is being sent to: Department of Health and Social Care | NHS England

20/12/2024

2024-0700

Antony Williamson

Manchester South

The SECRETARY OF STATE FOR HEALTH AND SOCIAL CARE

On� 28th� March� 2024� an� investigation� was� commenced� into� the� death� of� Antony Williamson, aged 63. The investigation concluded at the end of the inquest on 17th December 2024. The conclusion of the inquest was that Mr Williamson died from dry drowning and took his own life whilst experiencing hopelessness in the investigation and treatment of pelvic pain.

Mr Williamson began to suffer from lower urinary tract symptoms towards the end of 2022. Until that time, he had been fit and healthy and was working full time. Specialist urological investigations began in January 2023 and by March 2023 a diagnosis of chronic prostatitis was made. The condition adversely affected his life, his business and his mental health such that he was diagnosed by his GP with anxiety in April 2023.�� Further urological investigations in May 2023 did not reveal any sinister cause of the symptoms� and� he� was� started� on� antidepressant� medication� by� his� GP.� He� had repeated consultations with his GP arising from the stress and pain associated with his condition and was diagnosed by the endocrinology team in July 2023 with syndrome of inappropriate� antidiuretic� hormone� (SIADH),� but� subsequent� tests� did� not� identify� a cause.�� He began to experience suicidal thoughts in early July 2023 and continued to consult his GP through August 2023 with increasing suicidal thoughts arising from the physical symptoms and pain. He attended A&E on 21st August 2023, where the symptoms were attributed to chronic prostatitis and he was referred back to GP in relation to his mental health. At the instigation of his GP, Mr Williamson attended A&E for an urgent mental health assessment by the Mental Health Liaison Team in light of his increasing suicidal thoughts which resulted in follow up by the Home Based Treatment Team (HBTT) and a referral for talking therapy.� On 1st September 2023, as a result of a follow-up consultation with the urology team, Mr Williamson was referred to the Pain Service. The urology team had not further plans to see him again, having exhausted their investigations.� On 4th September 2023, Mr Williamson was reported to the police by his family to be missing from home. He had by that time ceased his business due to the medical and mental health issues and on that day, he took the car keys from home, which his wife had been keeping from him in order to keep him safe. . He presented himself to hospital some hours later and told the police that he had been unable to kill himself because he could not think of a way to do so without involving a third party. He expressed the view that� his� physical� health� problems� were� not� being� taken� seriously� and� that� he� had previously tried to jump from a moving car. The mental health assessment resulted in an overnight admission to a mental health ward. On discharge, he came under the care of the HBTT and remained so until 19th December 2023.�� The physical symptoms, pain and an increasing sense of futility were the theme of the following weeks with suicidal ideation resulting. Mr Williamson�s wife obtained an urgent appointment with the Pain Service on 7th November 2023 for chronic pelvic pain. That consultation resulted in a referral to the specialist pelvic physiotherapist for assessment and a change of medication. The physiotherapy appointment did not take place before 19th December 2023. However, the following day, the HBTT adjusted the antidepressant medication again without liaison with the Pain Service.�� On 13th November 2023, Mr Williamson told his GP that he had threatened to slash his wrists with a knife the previous evening and that the change in his medication was adversely affecting him.� On 19th November 2023, Mr Williamson was taken to A&E by his family because they feared he was about to jump from a window at home. He was assessed and admitted to a mental health ward for the second time as a voluntary patient remaining there until he discharged himself against advice on 24th November 2023 due to the conditions on the ward, which has since been closed.� Immediately after his discharge, he absconded and was found by the police and his family at a local water park where he had intended to drown himself. He was seen by the HBTT two days later but was not made the subject of daily monitoring. He was assessed by the consultant psychiatrist from the HBTT on 30th November 2023 and by this time, Mr Williamson�s family were keeping him locked in the house for his own safety.� Mr Williamson was catheterised at A&E due to urine retention on 8th December 2023. On 12th December 2023, Mr Williamson and his wife told the HBTT member visiting him that they perceived a disconnection between the medical and mental health teams in relation to his care and requested liaison between the HBTT and urology to achieve coordination. That request was raised within the HBTT and a further request made by the HBTT member on 17th December 2023 to the medical doctor attached to the HBTT but no such liaison took place.�� The� evidence� at� the inquest was that the HBTT largely relied upon Mr� Williamson himself� and� his� family� for� their� understanding� of� the� involvement,� investigation� and treatment by the medical teams. The medical specialties relied on the GP being a �hub� for communication by way of discharge and clinic letters, which were copied to Mr Williamson. The inquest found that the absence� of a collaborative and coordinated approach� between� medical� and� mental� health� teams� contributed� to� a� feeling� of hopelessness in Mr Williamson.� Mr Williamson left his home on foot having climbed through a window on 19th December 2023 and the finding� of the� inquest was that� he entered an� unidentified stretch� of extremely cold water some time afterwards. The medical cause of his death was dry drowning due to a laryngeal spasm caused by the effect of immersion in cold water. His body was found on 17th March 2024 in the River Mersey some miles from his home.

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

Mental Health related deaths | Suicide (from 2015)

Department of Health and Social Care

22/02/2024

2024-0106

Benjamin Leonard

North Wales (East and Central)

The Scouts Association, England, [REDACTED] � Unity Insurance Services: Scouting and Scout Groups Insurance Secretary of State for Education, Gillian Keegan MP Minister of State for Children and Families, David Johnston MP Minister for Education, Wales, Jeremy Miles MS Children�s Commissioner for England, [REDACTED] Children�s Commissioner for Wales,[REDACTED] Charity Commission for England and Wales,[REDACTED] � Health and Safety Executive, [REDACTED] .

On the 28.8.18 the Court commenced an investigation into the death of Benjamin David Leonard (DOB 01.11.01). Ben died on 26.8.18. The investigation continued with a 5-day jury inquest from 3.2.20-7.2.20. Whilst the jury were in jury retirement, on hearing the PFD evidence it became apparent that the Court had been misled, resulting in the jury being discharged on 7.2.20. On 7.2.20, I issued a Report to Prevent Future Deaths (�PFD�) with the following 20 points: The arranging of the trip did not adhere to the Scouts Association�s own safety policies. Such policies were not adequately understood at grass roots level. Safety policies exist but are not implemented. There was no written risk assessment. There was no dynamic risk assessment. There is not a full understanding of what a risk assessment is. There is not a full understanding on when to do written and/or dynamic risk assessments. There had been no approval sought for the trip as required from the District Commissioner. There was an absence of a permanent District Commissioner to give oversight to the leadership of the group. There was no meaningful discussion between the scout leaders as to the plan for trip on the Great Orme. The leaders did not have a participant list nor list of phone numbers for the boys. There was no route planned for the Great Orme trip. No instruction or briefing was given to the boys. Each of the 3 leaders assumed the 3 boys were with one of the leaders when in fact they were not. They were on their own. There was no effective leadership for the group. The Scouts Association failed to provide the Court with full information about the action it had in fact taken concerning its leaders on the trip, post death. The Scouts Association created a misleading impression in the evidence concerning its actions regarding its leaders on the trip post death. The Scouts Association is distant from its membership through its federated branches of 8,000 charities and layers of hierarchy meaning that it cannot know how health and safety is executed at ground level. The health and safety training intervals for leaders are said to be every 3 years with no way of assessing their competencies. The lives of young people are being put at risk by The Scouts Association�s failure to recognise the inadequacies of their operational practice and the part this has played in the death of Ben. � Responses to this PFD Report were provided from The Scouts Association dated 1.4.20 and then an updated response dated 12.2.21. � The Second jury inquest was fixed for 4 weeks and was due to proceed on 02.11.22 but had to be aborted due to material non-disclosure to the court. The Third jury inquest began on 4.1.24 and concluded on 22.2.24. The Jury recorded their ultimate Conclusion in Section 4 was: � � Unlawful killing by the Explorer Scout Leader and Assistant Explorer Scout Leader contributed to by the Neglect of the Scouts Association.

Ben (aged 16) was on a 3-day Explorer Scout trip in North Wales with 3 leaders and 8 other Explorer Scouts. Prior to the trip, Ben had undergone a circumcision. On the day of arrival, the Assistant Explorer Scout Leader took all the Explorer Scouts on a 3-hour unplanned hike without the other leaders. The next day�s plan of going up Snowdon was rearranged due to poor weather conditions. They instead went to Llandudno. After breakfast, the Explorer Scout Leader and his son left to move his car. The two other leaders and remaining Scouts walked through the town towards the Great Orme. There was no brief, instructions or written risk assessment was done. The group then proceeded up the Orme led by the Assistant Explorer Scout Leader, with the Assistant Scout Leader at the rear. Ben and two of the other Explorer Scouts split off from the main group, taking a different path up the Orme. Part way up the Orme, the Assistant Scout Leader paused and broke away from the group. Near the top of the Orme, the Assistant Explorer Scout Leader saw Ben and the two other Scouts on the grassy tops. The Assistant Explorer Scout Leader did not give any instructions to regroup, or to stay on the safe path. Ben and the two other Scouts were left unsupervised and proceeded to walk to the cliff edge. Ben complained of discomfort due to circumcision. Ben thought he could see a quicker way down the Orme and attempted to follow animal tracks down the cliff edge. During his descent, Ben slipped and fell from the cliff. Paramedics attended the scene and performed medical interventions and CPR. Ben was pronounced dead at 14:45 on the 26th August 2018 due to head injury.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. � I am also under a duty to send the Chief Coroner a copy of your response. � � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. � Regulation 28(4) of the Coroners (Investigations) Regulations 2013, requires that a copy of this Report be sent to the Local Child Safeguarding Board as Ben was under 18 years of age when he died. It will be sent to the Board for the area where Ben lived as well as to the Board for the area where he died. � Copies of this Report will be sent to: � � Child Death Overview Panel (Tameside, Trafford and Stockport); Child Death Review Team (Wales) Scouts Scotland, Chair, [REDACTED] Scouts Northern Ireland, [REDACTED] World Organisation of Scout Movement, [REDACTED] Mountain Rescue for England and Wales All Tracks Academy, Whistler, Canada Conwy Centres, Wales HM Senior Coroner for North West Wales, Ms Kate Robertson HM Senior Coroner for Lancashire and Blackburn with Darwen, Dr James Adeley

Child Death (from 2015) | Other related deaths | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: The Scouts Association | Unity Insurance Services: Scouting and Scout Groups Insurance | Secretary of State for Education | Minister of State for Children and Families | Minister for Education, Wales | Children�s Commissioner for England | Children�s Commissioner for Wales | Charity Commission for England and Wales | Health and Safety Executive

01/10/2024

2024-0519

Ryan Campbell

Manchester South

The Secretary of State for Health NHS England� Stepping Hill Hospital

On 29th August 2023 an inquest was opened into the death of Ryan James� Richard Campbell aged 33. At the inquest I concluded that Ryan Campbell died as a result of an acute myocardial infarction due to severe coronary artery� atheroma that had not been identified for surgical intervention, which was� likely to have resulted in survival, during medical investigation as imaging� measures were still awaited at the time of his death.

Ryan Campbell had been suffering with chest pain which prompted him to visit� his GP on 15th December 2023. His GP referred him immediately to Stepping� Hill Hospital she underwent a series of tests. He was discharged on 16th� December 2023 and arrangements were made for follow up tests, namely echo cardiogram, a CT angiogram and a 24 hr heart monitor. The subsequent� echocardiogram and 24hr heart monitor did not provide any further diagnostic� outcome but his symptoms persisted and he consulted his GP again on 19th� January 2024 resulting in a expedite letter sent the same day to the bookings� team in the imaging section of the cardiology department. It was not until the� 22nd February 2024 that the cardiology team requested an urgent stress�echocardiogram which was then scheduled for 3rd April 2024

I have sent a copy of my report to the following: Ryan�s family. HHJ Alexia Durran, the Chief Coroner of England & Wales The Chief Coroner may publish either or both in a complete or redacted or� summary form. She may send a copy of this report to any person who�she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the� publication of your response.

Hospital Death (Clinical Procedures and medical management) related deaths

Stepping Hill Hospital | NHS England | Department of Health and Social Care