Inquests (PFDs)

20/06/2023

2023-0197

Joan Corcoran

Manchester South

The Secretary of State for Health and Social Care

On 19th December 2022 I commenced an investigation into the death of Joan Mary Corcoran. The investigation concluded on the 15th May 2023 and the conclusion was one of Narrative: Died from complications of heart failure whilst being transported to hospital for treatment contributed to by the complications of an accidental fall. The medical cause of death was 1a) Myocardial Infarction 1b) Heart Failure 1c) Hypertension II) Neck of femur fracture (operated on)

Joan Mary Corcoran had an accidental fall. She was operated on for a fracture to the neck of femur. Post-operatively she developed pneumonia. Subsequently the wound became infected, and a wound wash and debridement took place. She became increasingly frail. She was discharged home with support from the discharge to assess team. She felt unwell on 13th December 2022 and called for an ambulance with chest pains. Her initial call was dealt with as a category 5 call, and she contacted her GP. Her GP visited her and was concerned about her presentation. A further call to the ambulance service resulted in her being classified as a category 2 call. The blood tests taken indicated she was in severe heart failure and at a risk of a myocardial infarction. The ambulance arrived significantly outside the target Department of Health response times. The ambulance crew identified she needed urgent cardiac treatment and she was for transfer to hospital. Enroute to hospital she deteriorated further and died in the ambulance from complications of heart failure.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1)�[REDACTED]; 2) [REDACTED] Solicitors on behalf of Stockport NHS Foundation Trust; 3) Weightmans LLP on behalf of North West Ambulance Service, who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

29/01/2025

2025-0050

Carla Smith

Norfolk

The Secretary of State for Health and Social Care

On 15 June 2023 I commenced an investigation into the death of Carla Marie SMITH aged 38, date of death 07 June 2023.� The investigation concluded at the end of the inquest on 24 January 2025. The medical cause of death was: 1a)������ Metastatic Endometrial Cancer 1b) 1c) 2) The conclusion of the inquest was: Died due to a naturally occurring condition, a rapidly progressing cancer, the diagnosis and treatment of which was delayed due to a number of missed opportunities.

Carla Smith had a history of excessive vaginal bleeding. She first attended her GP surgery in July 2022 and an ultrasound scan was arranged. The report received 23 August 2022 showed a thickened endometrium of 22 millimetres. This should have led to a referral to the gynaecology team. After a review by a different GP and a discussion with Carla on 27 September 2022, an urgent referral was made with an anticipated wait of 4-6 weeks. When triaged by specialists at the hospital, the referral should have been upgraded to a 2 week wait pathway. Carla was not seen until 31 January 2023. A biopsy on that day was marked as routine instead of 2 week wait. There was a delay in the sample being processed and this was chased after Carla attended hospital again as an emergency on 15 April 2023 due to ongoing heavy bleeding. A CT scan showed signs suggestive of advanced endometrial malignancy with disseminated metastasis. This prompted a report on the January biopsy, which was said to show grade 1 womb cancer at that time. After a further biopsy and investigations in April 2023 it was felt that Carla had stage 4 cancer. While an initial plan was made for surgery, due to the unusually aggressive nature of the cancer, Carla rapidly deteriorated and was sadly not suitable for surgery and palliative care commenced. She died on 7 June 2023. During the course of the Inquest, it was apparent that there were a number of missed opportunities to refer Carla for treatment and to use the correct pathway to do so and there were also significant delays in receiving results from the laboratory and due to lengthy waiting lists, even for urgent referrals.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Carla�s mother and partner Norfolk and Norwich University Hospitals NHS Foundation Trust The Queen Elizabeth Hospital King�s Lynn NHS Foundation Trust Heacham Group GP Practice I have also sent it to CQC, HSSIB, Healthwatch NHS England & NHS Improvement. who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care

04/02/2023

2023-0044

Patricia Green

Manchester South

The Secretary of State for Health and Social Care

On 4th July 2022 I commenced an investigation into the death of Patricia Grace Eileen Green. The investigation concluded on the 11th January 2023 and the conclusion was one of Narrative: Died from Covid 19 pneumonia contributed to by a fall with a prolonged long lie following the fall. The medical cause of death was 1a) COVID-19 Pneumonia on a background of a fall with a long lie; II) Chronic Obstructive Pulmonary Disease, Ischaemic Heart Disease, Frailty, Acute Renal Failure.

Patricia Grace Eileen Green had an accidental fall at her home address. She fell in such a way that she was left in a prone position on the floor. An ambulance was called. There was a 9 hour wait for the ambulance due to the demands on the ambulance service. She remained prone on the floor during the wait. She deteriorated particularly in relation to her breathing whilst waiting for an ambulance .She was unable to access toilet facilities whilst waiting for an ambulance On arrival at Tameside General Hospital, she was seen by a doctor after a 3 hour wait. She was found to have Covid 19 pneumonia. She continued to deteriorate and died at Tameside General Hospital on 30th June 2022.

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

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

Department of Health and Social Care

15/01/2025

2025-0025

Robert McGowan

Manchester South

The Secretary of State for Health and Social Care

On 18th October 2024, Christopher Murray, HM Assistant Coroner for Manchester South, opened an inquest into the death of Robert John McGowan who died on 13th August 2024 at Stepping Hill� Hospital, Stockport, aged 53 years. The investigation concluded with the inquest which I heard on� 6th January 2025.� The inquest determined Mr McGowan died as a consequence of:� 1) a) Cardiorenal failure;� 1) b) Acute myocardial infarction;� 1) c) Spontaneous bacterial endocarditis.� II. Autism� At the end of the inquest, I recorded the following Narrative Conclusion: �� �Mr McGowan died as a consequence of complications arising from partially treated spontaneous� bacterial endocarditis against a background of barriers to accessing treatment connected with� autism and complex mental health needs.�

Mr McGowan died on 13th August 2024 at Stepping Hill Hospital, Stockport as a consequence of complications arising from spontaneous bacterial endocarditis against a background of Autism.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care

04/02/2023

2023-0042

Benjamin Stanley

Manchester South

The Secretary of State for Health and Social Care

On 24th May 2022 I commenced an investigation into the death of Benjamin Paul Stanley. The investigation concluded on the 15th November 2022 and the conclusion was one of Narrative: Died as a consequence of malnutrition caused by chronic pancreatitis contributed by liver cirrhosis and the complications of necessary antibiotic therapy. The medical cause of death was 1a) Multi organ failure; 1b) Malnutrition; 1c) Chronic Pancreatitis; II) Clostridium Difficile Infection, Liver Cirrhosis, Sepsis

Benjamin Paul Stanley developed chronic pancreatitis. He became severely malnourished as a direct consequence of his chronic pancreatitis. He was admitted to Stepping Hill Hospital on 11th May 2022 and was very unwell. He had become severely malnourished. It was identified that he had liver cirrhosis in addition to the chronic pancreatitis. He was treated but continued to deteriorate. He developed sepsis and was treated further. He was found to have developed clostridium difficile probably as a consequence of antibiotic therapy. He died at Stepping Hill Hospital on 19th May 2022.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care

21/06/2024

2024-0336

Terrence Taylor

Cambridgeshire and Peterborough

The Secretary of State for Health and Social Care The Chief Executive, Care Quality Commission The Chief Executive, British Standards Institute

On 7 January 2021I commenced an investigation into the death of Terrence Roy Hubert Taylor, who died on 11 December 2020, aged 82. The investigation concluded at the end of the inquest before me and a jury on 20 June 2024.

Mr Taylor was a short term resident at a residential care home. He suffered from confusion and memory loss following a stroke. He had absconded from a previous care home on a number of occasions via a fire exit. In order to ensure his safety he was moved to another care home which was reasonably considered to be secure. He had a room on the first floor. The doors from the floor and to the outside were locked. The windows had window restrictors which complied with British Standard BS EN 14351-1 and BS EN 13126-5. These standards specify that window restrictors should be effective to withstand a static force of 350N for 60 seconds and restrict the window from opening more than 100mm. The window restrictors had been properly fitted and maintained. The jury concluded, in summary and in so far as relevant, that during the early hours of 11th December 2020, while alone, Mr Taylor overcame a window restrictor, climbed out of a first floor window and fell to the ground, sustaining injuries from which he died. The evidence was clear. An 82 year old man was able to apply sufficient force to detach the fixing which secured the window restrictor to the window frame. He was able to do so without the use of tools.

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

Care Home Health related deaths | Product related deaths This report is being sent to: Department of Health and Social Care | Care Quality Commission | British Standards Institute

28/05/2022

2022-0415

Hayley Smith

North East Kent

The Secretary of State for Health and Social Care The Department of Health and Social Care

On the 5th February 2020 an inquest was opened into the death of Hayley Smith. At the inquest, which was heard with a jury and lasted eight days we heard from many of those involved in Hayley�s short life. The jury concluded on 9th March 2022 with a narrative conclusion �The deceased died from complications of Anorexia Nervosa.�

(1) Hayley Smith developed severe and enduring Anorexia Nervosa at around the age of nine or ten and was resistant to treatment including several hospital admissions both voluntary, and at times compulsory treatment under the Mental Health Act. (2) Between 2015 and 2018 she was repeatedly admitted to the Priory hospital in Hayes but following each discharge her weight fell rapidly and she required readmission. She was discharged for a final time in October 2018 and subsequently admitted to the Bethlem hospital a couple of weeks later in the November. She was a resident of Kent and throughout her care the local Eating Disorder service were involved in her care (Kent and Medway Eating Disorder service managed by North East London Foundation Trust.) (3) By May 2019 it had become clear to the treating clinicians that Hayley had not gained weight and was managing to falsify her weight. Her illness was pervasive and her metabolism severely affected with a seizure in July 2019 likely as a consequence of hypoglycaemia and her liver function deteriorated showing signs of raised transaminases as a consequence of her malnutrition. She was subject to regular blood tests and her leave was restricted when her results were abnormal leading to some improvements. She was referred for a Hepatology opinion and investigations at Kings. (4) As she was unlikely to be able to cope in the community steps were taken to find a suitable rehabilitation placement, the nearest being Ipswich some considerable distance away from her family and any support network she had. There were no local units where Hayley could have been treated which may have led to improved communication and more involvement and support from her family. We heard evidence from Professor Consultant Psychiatrist from the Bethlem hospital and Dr.�� an independent Consultant Psychiatrist that her final placement was one of only two units in the country offering rehabilitation treatment for those suffering from Anorexia Nervosa. (5)�As she had been so resistant to treatment she was discharged with a Community Treatment Order (CTO) in place. On 22 December 2019 she travelled back to Kent to spend Christmas with her family. (6)�On 23rd December 2019 she had not eaten, became confused and unwell, and an ambulance was called. The correct emergency treatment was provided but Hayley responded quickly and regained consciousness and refused further treatment or admission to hospital. On 24th December she became unwell again and this time was taken to Queen Elizabeth the Queen Mother hospital where she again refused treatment and discharged herself against medical advice. The responsible medical officer from the Kent Eating disorder team gave evidence that had the team known of either of these episodes they would have taken steps to admit her and treat her. (7) On Christmas Day 2019 she collapsed for a final time and this time, had an out of hospital cardiac arrest, and was admitted to Queen Elizabeth the Queen Mother hospital and transferred to Intensive care where she was diagnosed as suffering from hypoxic brain damage as a result of her cardiac arrest due to severe hypoglycaemia as a consequence of her Anorexia Nervosa. She died on 29th�December 2019 at the age of twenty-seven.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the family, The White House, North East London NHS Foundation Trust, South London and the Maudsley NHS Foundation Trust, Kings College NHS Foundation Trust, East Kent hospitals NHS Trust and Hayley�s General Practitioner at the time. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths

Department of Health and Social Care

31/05/2024

2024-0294

Frazer Williams

Dorset

The Secretary of State for Health and Social Care The Minister of State for Prisons, Parole and Probation������������� [REDACTED], Director General of His Majesty�s Prison and Probation Service (HMPPS) [REDACTED], Chief Executive Officer for NHS England [REDACTED], Governor at HMP Guys Marsh���������������� [REDACTED], Chief Executive Officer of Unilink Software Ltd, provider of email a Prisoner

On the 10th March 2022, an investigation was commenced into the death of Frazer Charlie Williams, born on the 30th October 1993. � The investigation concluded at the end of the Inquest, before a jury, on the 17th May 2024. � The medical cause of death was: � Ia Ligature suspension � The conclusion of the Inquest was �Frazer Charlie Williams died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death�.

Frazer was found deceased on the 7th March 2022, in his cell at HMP Guys Marsh, Shaftesbury, Dorset, suspended by a ligature [REDACTED] I have attached to this report the Record of Inquest.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Leigh Day on behalf of Frazer�s Family Government Legal Department on behalf of the Ministry of Justice and HMP Guys Marsh Hill Dickinson LLP on behalf of Practice Plus Group and Oxleas NHS Foundation Trust DAC Beachcroft LLP on behalf of Southern Health NHS Foundation Trust EDP CGL (Change Grow Live) I am also under a duty to send the Chief Coroner a copy of your response. � I have also sent a copy of this report to the following persons for their awareness: � Prisons and Probation Ombudsmen [REDACTED], president of the Royal College of Psychiatrists � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

State Custody related deaths | Suicide (from 2015) This report is being sent to: Department of Health and Social Care | HM Prisons and Probation Service | NHS England | HMP Guys Marsh | Unilink Software Ltd

29/09/2023

2023-0357

John Winsworth

Norfolk

The Secretary of State for Health and Social Care, The Rt Hon Steve Barclay MP And The Department of Health and Social Care

On 24 February 2023 I commenced an investigation into the death of John Trevor WINSWORTH aged 92. The investigation concluded at the end of the inquest on 25 September 2023. � The medical cause of death was: la) Traumatic Intracranial Bleed lb) Fall le) 2) Atrial Fibrillation (on Warfarin) � The conclusion of the inquest was: Accident

Mr Winsworth was found on the floor at his home on 14 February 2023. Emergency services were called at 11.55 hours. An ambulance arrived at 09.30 on 15 February 2023 and Mr Winsworth was taken to Norfolk and Norwich University Hospital, arriving at 10.52 hours. He was admitted to Accident and Emergency Department� at 14.42 hours. A CT scan showed a small bleed in the brain and Mr Winsworth�s Warfarin medication was stopped and he was given Vitamin K to promote clotting. Mr Winsworth was not referred to the Haematology Department in accordance with internal protocol, when it is probable medication to promote blood clotting within a shorter space of time� would be prescribed.� Mr Winsworth� was assessed as fit to� be discharged following examination and assessment. He was unable to get into a motor car and� hospital� transport� was arranged.� Mr� Winsworth� was returned� to the ward. His condition suddenly deteriorated and he died on 21 February 2023 in hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ���� [REDACTED] �� son I have also sent it to: �������� East of England Ambulance Service Trust �������� Department of Health �������� Care Quality Commission �������� Healthwatch Norfolk �������� HSIB �������� NHS England and NHS Improvement 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: Department of Health and Social Care

18/01/2023

2023-0017

Lyn Brind

Norfolk

The Secretary of State for Health and Social Care: The Rt Hon Steve Barclay MP � The Department of Health and Social Care

On 07 June 2022 I commenced an investigation into the death of Lyn Mary BRIND aged 61. The investigation concluded at the end of the inquest on 05 January 2023. � The medical cause of death was: 1a)Congestive Cardiac Failure 1b)Ischaemic and Hypertensive Heart Disease 1c)Coronary Artery Atherosclerosis and Morbid Obesity 2)Diabetes Mellitus � The conclusion of the inquest was: Mrs Brind died from cardiac failure. Her condition was not diagnosed nor treated in a timely fashion.

On 24 May 2022, Mrs Brind went to see her GP and was taken to Queen Elizabeth Hospital arriving at 13.05 hours. The Emergency Department was busy and Mrs Brind remained on the ambulance. Physiological observations were undertaken at 12.50, 13.24 and 13.53 which showed an elevated NEWS2 score. Mrs Brind required increasing oxygen which was not escalated to the Ambulance Navigator at the hospital, no further physiological observations were undertaken and no ECG was undertaken. Mrs Brind was taken to the ward at 17.30 hours, when she became agitated and short of breath. Advanced life support was put into place but Mrs Brind�s condition continued to deteriorate and she died at 17.52 hours.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] Queen Elizabeth Hospital East of England Ambulance Service NHS Trust (EEAST) I have also sent it to Department of Health, Care Quality Commission (CQC), HSIB, Healthwatch Norfolk,NHS ENGLAND (NHS IMPROVEMENT) 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 | Emergency services related deaths (2019 onwards)

Department of Health and Social Care

25/07/2024

2024-0401

David Curry

Norfolk

The Secretary of State for Health and Social Care: [REDACTED] The Department of Health and Social [REDACTED]

On 05 October 2023 I commenced an investigation into the death of David Alfred CURRY aged 77. The investigation concluded at the end of the inquest on 19 July 2024. The medical cause of death was: 1a) Multi Organ Failure 1b) Urosepsis 1c) Ureteroscopy, Laser Lithotripsy and Insertion of Stent 20.09.2023 1d) Ureteric stent insertion for urosepsis due to an obstructing ureteric stone 07.04.2023 2)�Atrial Fibrillation, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease � The conclusion of the inquest was: Mr Curry died from recognised risks of an appropriate procedure

Mr Curry was admitted to Norfolk and Norwich University Hospital on 7 April 2023 when a stone was identified in the left lower ureter and a ureteric stent was placed as an emergency.� Mr Curry was referred for a ureteroscopy which was undertaken on 20 September 2023 at Spire Norwich Hospital.� Following the procedure Mr Curry showed signs of infection and was transferred to Norfolk and Norwich University Hospital where his condition deteriorated and he died on 1 October 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] Norfolk and Norwich University Hospital Legal Team [REDACTED] � Spire Counsel [REDACTED] � Spire Healthcare Centre Legal Team [REDACTED] � Spire Healthcare Centre Legal Team � I have also sent it to: Department of Health Care Quality Commission HSSIB (Health Services Safety Investigations Body) Healthwatch Norfolk NHS England (NHS Improvement) 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: The Secretary of State for Department of Health and Social Care

28/10/2024

2024-0588

Malcolm Taylor

Norfolk

The Secretary of State for Health and Social Care: [REDACTED] The Department of Health and Social Care Email: [REDACTED]

On 12 March 2024 I commenced an investigation into the death of Malcolm John TAYLOR aged 76. The investigation concluded at the end of the inquest on 25 October 2024. The medical cause of death was: 1a) Drowning 1b) 1c) 2) Ischemic Heart Disease, Cardiomegaly, Liver Fibrosis � The conclusion of the inquest was: Suicide while suffering from extreme distress

Mr Taylor was referred to Adult Social Services and Mental Health Team in December 2023. He was low in mood following the death of his wife. From February 2024 Mr Taylor�s mood worsened and he remained under the care of the Mental Health Team. He was not taking his medication and had psychotic episodes and following assessment it was agreed consideration should be given to his being admitted to a mental health hospital. Mr Taylor expressed thoughts of self harm and suicidal intent. It was deemed appropriate not to carry out a formal Mental Act Assessment until a bed was available due to his paranoid presentation around professionals and concern his risk of self harm would increase. There was an urgent request for a bed to be found in a mental health hospital. On 3 March 2024 Mr Taylor drove to Gorleston [REDACTED]. He probably entered the sea at some time between 22.21 and 8 minutes after midnight on 4 March 2024. Mr Taylor was found on the shoreline at Gorleston beach on 4 March 2024. Mr Taylor died from drowning. A bed in a mental health hospital had not been found prior to Mr Taylor�s death.

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

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

Department of Health and Social Care

17/7/2024

2024-0382

Pauline Spedding

Norfolk

The Secretary of State for Health and Social Care: [REDACTED] The Department of Health and Social Care [REDACTED]

On 28 March 2023 I commenced an investigation into the death of Pauline SPEDDING aged 69. The investigation concluded at the end of the inquest on 08 July 2024. The medical cause of death was: 1a) Acute Left Subdural Haematoma 1b) Fall 1c) 2)�Type 2 Diabetes Mellitus, Postural Hypotension, Chronic Kidney Disease, Aortic Stenosis, Frailty, Extended-Spectrum Beta-Lactamase Escherichia Coli Urinary Tract Infection The conclusion of the inquest was: Accident

Mrs Spedding had a complex medical history and a history of falls and was frequently admitted to hospital as a result. Mrs Spedding was admitted to Norfolk and Norwich University Hospital from 11 to 15 February 2023 and again from 18 February to 6 March 2023 due to falls. On 7 March 2023 Mrs Spedding had a further fall at home and was admitted to Norfolk and Norwich University Hospital. There were deemed to be multifactorial reasons for her falls and she was identified as at high risk of falls.� Consideration was being given to discharging Mrs Spedding when she had an unwitnessed fall in the bathroom on 13 March 2023. She was examined and no concerns were raised regarding injury.� On 17 March 2023 Mrs Spedding was found lying on the floor by the sink in the bay. She was examined and no significant injury was found. On 18 March 2023 Mrs Spedding was moved to Gunthorpe Home First Unit which cares for patients medically fit for discharge and awaiting input into care needs. It aims to encourage independence and encourages movement. On 20 March 2023 Mrs Spedding was positive for Escherichia coli and she was moved to a side room. The risk of infection was not documented alongside her high risk of falls. The Falls Response Team was not notified. On 24 March 2023 at 00.20 Mrs Spedding was found on the floor next to her bed and had a graze to her elbow. At 03.30 hours Mrs Spedding was found sitting on the floor next to her bed. She declined observations. Mrs Spedding was reviewed by a doctor at 04.55 and a CT scan was requested Mrs Spedding became increasingly unresponsive and she suffered a pericardiac arrest. The CT scan showed a large subdural haematoma. Mrs Spedding�s condition continued to deteriorate, and she died later that morning. Throughout her stay falls risk assessment documentation, care plan documentation and hot debrief documents were not completed or not completed in full. Mrs Spedding was not referred to the Falls Response Team.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] [REDACTED] Norfolk and Norwich University Hospital, Legal Department, [REDACTED] I have also sent it to: Department of Health Care Quality Commission HSIB Healthwatch NHS England (NHS Improvement) 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: Department for Health and Social Care

13/09/2023

2023-0330

Melissa Kerr

Norfolk

The Secretary of State for Health and Social Care: The Rt Hon Steve Barclay MP House of Commons London SW1A OAA � The Department of Health and Social Care 39 Victoria Street London SW1H 0EU

On 09 December 2019 I commenced an investigation into the death of Melissa Hannah KERR aged 31. The investigation concluded at the end of the inquest on 12 September 2023. � The medical cause of death was: la)��������� Pulmonary Thromboembolism and Fat Embolism lb)��� Elective Cosmetic Surgery (Gluteal Augmentation) le) 2) � The conclusion of the inquest was: Melissa Kerr died following cosmetic surgery to the thigh and buttock area on 19 November 2019. Ms Kerr was not seen by a surgeon or clinician prior to the date of the procedures. Ms Kerr underwent a limited assessment prior to the procedures. Ms Kerr was provided with limited information regarding the risks and mortality rate associated with the procedures. There is limited documentary evidence as to the procedures performed. Certain techniques used during the Brazilian Buttock Lift procedure increased the risk of fat embolus occurring, namely the choice of access incision for the augmentation cannula and the� decision to inject fat into the superficial muscle.

Melissa Kerr was admitted to Private Medicana Kadikoy Hospital, Istanbul on 19 November 2019 and underwent surgery to harvest fat from the abdomen,� thighs and the� jowl area of her face. Ms Kerr was not seen by a surgeon or clinician prior to the 19 November 2019. Evidence revealed that Ms Kerr underwent a limited assessment prior to the procedures. The evidence is that Ms Kerr was provided with limited information regarding the risks and mortality� rate associated� with the procedures.� The fat� was collected and processed� before it was injected into her buttocks; a liposuction procedure and a Brazilian Buttock Lift procedure. During surgery Ms Kerr became unwell. Her condition deteriorated and she was declared dead. There is limited documentary evidence as to the procedures performed. Expert evidence was heard that certain techniques used during the Brazilian Buttock Lift procedure increased the risk of fat embolus occurring, namely the choice of access incision for the augmentation cannula and the decision to inject fat into the superficial muscle.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � � [REDACTED] Mother. I have also sent it to Private Medicana Haznedar Hospital The British Association of Aesthetics and Plastic Surgeons � [REDACTED] Expert � 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. � Regulation 28 � After Inquest Document Template Updated 30/07/2021 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 int erest . � You may make 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

06/01/2023

2023-0007

Kyriacos Athanasis

Norfolk

The Secretary of State for Health and Social Care: The Rt Hon Steve Barclay MP � The Department of Health and Social Care The Norfolk and Waveney Integrated Care Board

On the 30th May 2022 an inquest was opened into the death of Kyriacos Athanais. At the inquest hearing on 4th January 2023, I concluded with the short form conclusion of accidental death.

Kyriacos Athanasis was an 88-year-old man who had a past medical history of asthma, chronic kidney disease stage 3, hypertension, orthostatic hypotension, type 2 diabetes mellitus and ulcerative colitis. At the beginning of 2022 he was becoming more frail and suffering from falls leading to hospitalisations. He fell down some stairs at home at some point on 16th May 2022 and was subsequently taken to the James Paget hospital arriving at around 21.30 on 17th May 2022. After some delay in offloading him from an ambulance he was diagnosed as suffering from an unstable cervical spine fracture. There was a delay in seeking senior clinical advice which in turn led to a delay in being able to sit him upright. During this period, he developed pneumonia which was in part due to aspiration whilst nursed immobile and flat in conjunction with his hiatus hernia, influenza A and chronic obstructive pulmonary disease. He was treated with intravenous antibiotics and oxygen therapy but deteriorated and died as a consequence of his multifactorial pneumonia predominately due to the consequences of his fall on a background of frailty and type 2 diabetes mellitus.

Emergency services related deaths (2019 onwards)

Department of Health and Social Care | The Norfolk and Waveney Integrated Care Board

07/11/2023

2023-0467

Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent

Derby and Derbyshire

The Secretary of State for Justice, Mr Alex Chalk MP � The Chief Probation Officer for England and Wales, [REDACTED] � Capita PLC (Electronic Monitoring Services), [REDACTED] Operations Director Derbyshire Healthcare NHS FT, [REDACTED] Chief Executive

On 23 September 2021 I commenced investigations into the deaths of Terri Liz Harris aged 35, her children John-Paul Bennett and Lacey Bennett, aged 13 and 11 respectively, and their friend Connie Gent aged 11. The investigations concluded at the end of the inquests on 23 October 2023. The four inquests were held concurrently. � The conclusions of all four inquests, with the inclusion and detailing of 57 contributory acts and omissions by the Probation Service and Capita PLC (Electronic Monitoring Services), were: � Unlawful killing, contributed to by acts and omissions by the designated statutory agency for offender management, and by the commissioned electronic monitoring tagging service, in the course of DB�s offender supervision and management. � I enclose copies of the Records of Inquest.

Terri, John-Paul, Lacey, and Connie were discovered deceased by police officers on 19 September 2021, at Terri and her children�s home. They were murdered by Terri�s partner Damien Bendall, curfewed to the address under a suspended sentence order, who had inflicted severe head injuries on all four, and he had also raped Lacey. � The actions of Damien Bendall directly caused the deaths, but the deaths were contributed to by acts and omissions by the Probation Service, and Capita PLC (Electronic Monitoring Services), in the course of Damien Bendall�s offender supervision and management. In total there are 57 contributory acts and omissions which are detailed in the conclusions. The Probation Service accepted all the findings of the related Serious Further Offence report by HM Inspectorate of Probation, and the Probation Service made 51 admissions which are also detailed on the Records of Inquest. The inquests engaged Article 2 of the European Convention on Human Rights.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] (parents of Terri, grandparents of Lacey and John-Paul) � [REDACTED] (father of Lacey and John-Paul) � [REDACTED] (father of Connie) � [REDACTED] (mother of Connie) � National Probation Service � Derbyshire Healthcare NHS FT � Derbyshire County Council � Capita (EMS) � � �����[REDACTED] � � �����[REDACTED] � � I have also sent a copy of this report to HMI Probation 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: The Secretary of State for Justice | Chief Probation Officer for England and Wales | Capita PLC |Derbyshire Healthcare NHS Foundation Trust

30/12/2022

2023-0003

Jordan Pry

Surrey

The Secretary of State for Transport National Highways Limited Connect Plus (M25) Limited

I commenced an investigation into the death of Jordan Kevin Pry. The inquest concluded on the 22nd December 2022 when I found that the medical cause of death was : � Ia Multiple Injuries � and my Conclusion as to the death was that: � � In the early hours of the 2nd April 2018, Jordan Pry was driving his BMW-M3 motor car along the anti-clockwise carriageway of the M25 motorway, between junctions 6 and 5, and in an easterly direction. It was raining heavily and the road surface was wet. Jordan Pry was driving in the third of four lanes, at a speed of approximately 78 miles per hour, when he drove through an area of surface water on the road and the car began to aquaplane and rotate. Whilst still rotating, the vehicle travelled across the second and first lanes and then left the carriageway to the nearside in the vicinity of marker post B4348, which is approximately 200 metres before the start of the slip-road to the Clacket Lane Services. The car then moved down or over the verge and steep embankment to the nearside of the road and collided with a tree. As a result of the collision and its force, the tree intruded into the vehicle from its offside central pillar and through the driver�s compartment, causing Jordan Pry to suffer fatal injuries. The collision occurred at hours on the 2nd April 2018 and it is likely that Jordan Pry died shortly thereafter, although his death was formally pronounced, at the scene, at 02.52 hours, following the arrival of the emergency services. The probable causes of the collision and Jordan Pry�s death were : (i) The presence of excessive surface water on the road which resulted from (a) heavy rainfall, (b) blockage of a drain in the central reservation at a point approximately 65 metres south-west of the collision location which had been caused, unusually, by a large piece of plastic entering the drainage system and which resulted in there being a flow of water across the carriageway, and (c) the profile of the road on the approach to the collision location which included a flat spot where the surface water was able to settle, and (ii) The speed at which the BMW was being driven, namely a speed of approximately 78 miles per hour. Prior to the collision there was a long history of wet-road related incidents at the location, including many aquaplaning events and a previous fatality. The absence of any warning on the approach to the collision location of the risk of aquaplaning, which was known to arise when there was excessive surface water on the road, and the absence of any vehicle restraint system at the nearside of the carriageway, were both possible contributory causes of the Deceased�s death. Jordan Pry died as a result of a Road Traffic Collision.

Road (Highways Safety) related deaths

Department for Transport | National Highways Limited | Connect Plus (M25) Limited

24/07/2017

2023-0105

Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi

East Sussex

The Secretary of State for Transport The Health and Safety Executive The Chairman of the National Water Safety Forum The Operations Director RNLI [REDACTED] [REDACTED] Birnberg Peirce Solicitors Royal Society for the Prevention of Accidents Local Government Association The Chairman, Rother District Council Maritime and Coastguard Agency East Sussex Divisional Commander, Sussex Police

On 24th of July 2016 I commenced an investigation into the death of GUSTAVO SILVA DA CRUZ. On 29th of July 2016 I opened an investigation into the death of MOHIT DUPAR. On 25th of August 2016 I opened investigations into the deaths of INTHUSHAN SRISKANTHARASA, GURUSHANTH SRITHAVARAJAH, KENUGEN SATHTHIYANATHAN, KOBIKANTHAN SATHTHIYANATHAN and NITHARSAN RAVI. The investigations concluded at the inquest into all seven deaths on 30th June 2017. The conclusions of the inquests are summarised on the seven Record of Inquest forms, copies of each I have attached to this letter.

On 24th of June 2016 Mr. Da Cruz and Mr. Dupar went into the sea at Camber Sands, Rye. Mr. Da Cruz was seen to be in difficulties and his body was later washed up on the shore. Mr. Dupar was seen to be in difficulties and was brought to the beach unconscious. He had suffered from hypoxic brain damage and died at Ashford Hospital, Kent on the 28th of July. The other five deceased were all part of a party of five young Sri Lankan men who travelled together to Camber to enjoy a day at the beach on 24th of August 2016. They all went into the sea at a time when the tide had started to come in. It is not known how well any of them could swim. It is thought that they were all on a sand bar when they were overtaken and cut off by the incoming tide. All five bodies were recovered to the shore that day, or found after the tide had receded. The RNLI had recommended deploying lifeguards at the beach in 2013 but Rother District Council had not implemented that recommendation. It was accepted quite quickly after these deaths and lifeguards are now deployed. There was considerable evidence at the inquest on the question of whether that step, and others recommended, would have prevented any of the deaths. It should be noted that the length of the beach from which people can swim is about three miles and the distance between high water mark and low water mark is as much as a kilometre in some tides.

I have sent a copy of my report to the Chief Coroner and all those persons or organisations names at the head of it. 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

Department for Transport | Health and Safety Executive | National Water Safety Forum | Royal National Lifeboat Institution | REDACTED | REDACTED | Birnberg Peirce Solicitors | Royal Society for the Prevention of Accidents | Local Government Association | Rother District Council | Maritime and Coastguard Agency | Sussex Police

16/03/2023

2023-0095

Rachael Walker

Derby and Derbyshire

The University Hospitals of Derby and Burton NHS FT

On 9 August 2022 I commenced an investigation into the death of Rachael Chloe WALKER aged 36. The investigation concluded at the end of the inquest on 3 March 2023. Article 2 of the European Convention on Human Rights was engaged due to the relevance to Chloe�s death of hospital Trust policies and systems. The conclusion of the inquest was: Chloe died of the effects of placental haemorrhage and amniotic fluid embolism at week thirty- seven of her pregnancy due to diagnosed placenta praevia. It is probable that her death would have been avoided if a delivery plan made for her had been recorded in her notes and acted upon, and if the relevant Trust had incorporated national guidance issued in September 2018 which provided for consideration for earlier caesarean delivery.

Rachael Walker, known as Chloe, died in hospital on 19 June 2021 due to experiencing a placental haemorrhage and amniotic fluid embolism at the thirty seventh week of her pregnancy.� Chloe� had� been� diagnosed� with� placenta �previa� during� her� antenatal �care. � Chloe had antepartum haemorrhage at home on the early morning of 19 June 2021 and had to be taken to hospital by ambulance. At the maternity unit she experienced further haemorrhage and was taken for emergency caesarean section. Her baby was delivered but Chloe quickly went into the first of three cardiac arrests. On the evidence it is not apparent that there was a postpartum haemorrhage, but she did develop blood clotting disorder and disseminated bleeding, likely related to the placental haemorrhage and amniotic fluid embolism. Chloe sadly died in the operating theatre despite prolonged resuscitation attempts. � Chloe had recognised risk factors in her pregnancy and the consultant obstetrician with lead responsibility for her care decided at an appointment at week thirty-four of Chloe�s pregnancy on a plan to review Chloe at an appointment at week thirty-seven, with a view to offering hospital admission and planned caesarean section by week thirty-eight due to the placenta previa. That plan was not recorded in Chloe�s notes with the result that the obstetric registrar who saw Chloe at week thirty-seven was unaware of the plan. Furthermore, the relevant hospital Trust had not adopted national guidance issued in September 2018 for consideration of delivery by caesarean section between weeks thirty-six and thirty-seven in Chloe�s circumstances. Consequently, Chloe was booked for planned caesarean section at week thirty- eight as per Trust guidance. At inquest the Trust accepted these were missed opportunities to avoid Chloe�s death and had they not been missed it is likely that Chloe would not have died because delivery would have occurred well before 19 June, or, if antepartum haemorrhage had occurred during admission, it would have been successfully managed. Although not clearly causal or contributory to Chloe�s death, I identified the following serious issues from the evidence: The maternity unit did not have a system or proforma to note down and pass on to clinicians information provided by the ambulance service via the dedicated phone line to the unit. Blood for urgent use in maternity unit surgery was not kept on or near to the maternity unit. There was delay in calling for the on-call consultant anaesthetist to attend once the emergency caesarean section had been called. There was no robust system in place for a major obstetric haemorrhage to be called and acted upon with resulting delay in the provision and use of blood products. There was insufficient co-ordination and oversight of the emergency team and roles and tasks in the surgical theatre, in particular in oversight of obtaining and use of blood products. Certain key equipment was not available for the maternity unit theatre: A blood storage fridge Warming equipment for women during surgery Point of care testing anticoagulation equipment

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- ���[REDACTED] (partner of Rachael Chloe Walker) ���University Hospitals of Derby and Burton NHS FT ���East Midlands Ambulance Service � I have also sent it to: ���Health Service Investigation Branch (maternal deaths) ���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

The University Hospitals of Derby and Burton NHS FT

31/01/2023

2023-0035

Nathan Forrester

Inner South London

This REPORT IS BEING SENT TO: 1.�[REDACTED] Director General Chief Executive HM Prison & Probation Service (HMPPS), 70 Petty France, London, SW1H 9AJ 2. [REDACTED] Lead Commissioner for Secure & Detained Estate, NHS England, Wellington House, 133-135 Waterloo Road, London, SE1 8UG

INQUEST On 2nd� July 2019 death of Mr Nathan Forrester ([REDACTED] was reported to the coroner by HMP Thameside. A forensic autopsy was conducted and on 3rd September 2019, an inquest was opened. The listing was delayed by the pandemic. An inquest was part heard and jury dismissed in January 2022 and a fresh inquest heard from 9th until 19th January 2023, before a jury. The medical cause of death was 1a Acute toxic effects of Heroin, Cocaine and Methadone and the jury concluded he died of a drug related death.

He was well known as drug dependent with a history of concealing drugs. He had been released from prison on licence and was recalled and detained again, under the influence of drugs. The intoxication wore off. He was later found dead in his shared cell, having consumed illicit drugs there, after his cell mate alerted officers. Although emergency measures were instigated, at inquest it was determined that he had been beyond resuscitation, when found by officers. A substantial number of actions were taken both by the prison service and local provider of health care to the prison, to prevent future deaths, including installation of a scanner to detect drugs hidden in orifices, training in CPR and increases in night nurse staffing.

I have sent a copy of my report to the following interested persons: [REDACTED] for the family [REDACTED] Turning Point� [REDACTED] Capsticks for Oxleas [REDACTED] of DWF Law LLP for Serco [REDACTED] for MPS I am also copying it to Royal College of Nursing and the PPO, who may have interest in the matter. I am also under a duty to send the Chief Coroner a copy of your response. He may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related deaths | State Custody related deaths

HM Prison and Probation Service, NHS England

10/07/2023

2023-0239

Christian Tuvi

Inner South London

This REPORT IS BEING SENT TO: 1.��� The Rt. Hon Mark Harper, The Secretary of State for Transport, Department of Transport, Zone 1/18 Great Minister House, 33 Horseferry Road, London, SW1P 4DR 2. [REDACTED], Chief Executive of Office for Road & Rail, 25 Cabot Square, London, E14 4QZ

INQUEST � On 18th September 2019 the death of Mr Christian Kwame Tuvi [REDACTED], an escalator cleaner aged 44, in Waterloo Station was reported to the coroner by the British Transport Police. A forensic autopsy was conducted. An inquest was opened on 30th September 2019, and was suspended under CJA schedule 1(1). It was extended, due to the ongoing criminal investigation. On 1st March 2022, BTP informed the coroner that there were to be no charges and that the matter was then referred to the Office for Road and Rail. The senior coroner resumed his investigation. The inquest did not engage Article 2 ECHR. On 16th June 2023, the jury returned a narrative Record of Inquest The medical cause of death was 1a blunt force (crash) trauma to the chest 1b Movement of the travellator while Mr Tuvi was in the gap.

The jury concluded that there was an inadequate briefing to the cleaners, omitting the form of communication to be used, a failure to complete a site specific risk assessment, and a failure to give an audible warning that the travellator was about to be moved. The jury found that two other matters contributed to the death: failure of the person in charge to plug the inching pendant into the closest port to the gap being cleaned and an acceptance of variation and non- compliance with the established method statement not being corrected.

The report is copied to Transport for London (TfL), Cleshar Cleaning Services Ltd (Cleshar) and Kone Plc. as these organizations need to know of the report to the Department and Regulator seeking review of the contractual process or directions to resolve the impasse between them, to ensure that a permanent solution is found that secures the minimization of risks of deaths in cleaning moving walkways and escalators. It is also sent to the other interested persons: [REDACTED] representing family from Simpson Millar Solicitors. [REDACTED] representing�[REDACTED] from Keoghs Solicitors. I have sent a copy of my report to the following interested persons: [REDACTED] for Transport for London. [REDACTED] for Cleshar of BCL Solicitors LLP. [REDACTED] for Kone Plc from Walker Morris Solicitors. for Office of Road and Rail. � I will also be sending a copy of my report to British Transport Police for information. I am also under a duty to send the Chief Coroner a copy of your response. He may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 for Transport | Road & Rail

14/10/2024

2024-0542

Jennifer Chalkley

Surrey

This report is being sent to: 1. [REDACTED], Secretary of State for Education, The Department for Education (in relation to Concerns 1 and 2)� 2. [REDACTED], The Chief Executive Officer of Surrey County Council (in relation to Concern 1)

I commenced an investigation into the death of Jennifer Sharren Chalkley. The inquest concluded on the 1st May 2024 when I found that the medical cause of� death was:� �� Ia Suspension and my conclusion as to the death was that: Jennifer Chalkley died as a result of Suicide. Her death was more than minimally contributed to by : � (i) A failure by Surrey and Borders Partnership NHS Foundation� Trust�s Child and Adolescent Mental Health Service properly to� assess, diagnose and treat Jennifer following referrals made in May 2018 and January 2021 in order to manage her conditions and� minimise her risk of suicide,� (ii) A failure by Surrey County Council�s Special Educational Needs� Department to ensure that Jennifer�s Education, Health and Care� Plan contained sufficient and updated information about her mental and emotional health needs and her risk of suicide, such as to�enable the college she attended from September 2021 to understand and meet her consequential needs and manage the consequential� risk, and� (iii) A multi-agency failure to share information and work together to ensure that Jennifer was supported effectively to manage her� neurodevelopmental and mental and emotional health needs, and her risk of suicide, especially from June 2021 onwards.� � I subsequently held a hearing to receive evidence relating to the prevention of� future deaths and this was concluded on the 26th July 2024. I then allowed time for submissions by Interested Persons.

When she died, aged 17 years, Jennifer Chalkley was a girl with complex special� needs. She had been diagnosed with Attention Deficit Hyperactivity Disorder� when she was 10 years of age and Autistic Spectrum Disorder when she was aged 11 years.�� These two neurodevelopmental conditions, together with associated excessive anxiety, low mood, and emotional dysregulation from which she suffered� periodically, resulted in a persisting but fluctuating risk of suicide.� Jennifer was known to the Child and Adolescent Mental Health Service and to� Children�s Services, having been the subject of a number of referrals arising from� her suicidal ideation and behaviour and her other vulnerabilities. She was also� monitored under the Paediatric Team at a local hospital. An Education, Health and Care Plan was issued to Jennifer by the Special Educational Needs Department of� her local authority when she was 15 years old, but she struggled to cope in� mainstream school and experienced the breakdown of school and college� placements. Jennifer also struggled to cope with personal relationships.� In September 2021, Jennifer enrolled in a course at a new college. Within weeks� she experienced low mood and was expressing suicidal ideation. Late on the� evening of the 11th October 2021, Jennifer returned to her mother�s home, having separated from the boyfriend with whom she had been living.�� On the 12th October 2021, Jennifer�s mother feared that she was suffering a� mental health crisis and arranged an emergency telephone consultation with the� General Practitioner for later that day. However, at 16.20 hours, Jennifer was�found hanging [REDACTED] in her bedroom. Despite resuscitation efforts from�attending paramedics, she could not be revived and her death was pronounced at 16.40 hours on the 12th October 2021.� Full details of the events and failings which lead to Jennifer Chalkley�s death are� set out in my �Findings and Conclusions� document, a copy of which is sent with this report.

I have sent a copy of my report to the Chief Coroner and to the following: � (i) [REDACTED] (ii) [REDACTED]� (iii) Surrey and Borders Partnership NHS Foundation Trust (iv) Guildford College (v) Nescot College (vi) Howard of Effingham School and the Howard Partnership. � I am also under a duty to send a copy of your response to the Chief Coroner. I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or� summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the� coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Suicide (from 2015)

Department for Education | Surrey County Council

8/7/2024

2024-0375

Michael Huggon

Cumbria

To: [REDACTED] Chief Executive Cumbria Health [formerly CHOC] [REDACTED] Practice Manager Carlisle Healthcare

On 8th February 2024 I commenced an investigation into the death of Michael HUGGON who died in Cumberland Infirmary, Carlisle on 7th February 2024 aged 75. The investigation concluded at the end of the inquest on 4th July 2024. The conclusion of the� inquest was� Death from natural causes. The medical cause being registered as: 1a Cardiac Arrest 1b Hypovolaemia 1c Spontaneous Gastrointestinal Haemorrhage II������ Atrial Fibrillation

Michael Huggon had been in declining health following a stroke some 9�months before he died, he was found to be in atrial fibrillation at that time and was�anticoagulated with Edoxaban to try to prevent a recurrence. He had also been� newly diagnosed with interstitial lung disease. On 6th February he was very unwell and his wife rang her GP surgery -Carlisle Healthcare at 14.15 to request a home� visit and was told a doctor would ring her back. I was told that after receiving this�request her call was reviewed by a triaging doctor who then passed it to another� doctor to call her back. The call back took place at 18.06 when Mr and Mrs Huggon� were told that it was too late to have a visit and that they should call the after hours service -Cumbria Health by way of the 111 service after 18.30. �� 111 was contacted and an automated voice told the Huggons there would be a 40 minute wait -they took it in turns to hold the telephone awaiting a reply.� Eventually 111 spoke and said an ambulance would be sent. Shortly after this� Cumbria Health rang to let the couple know there would be yet another call to see if� an ambulance was required, this call was prompt and they were told a doctor would� visit. The duty doctor arrived at about 21.00 and immediately saw that Michael was� extremely anaemic and required emergency admission to hospital -however despite repeated advice he declined and was deemed to have capacity to do so. A nursing� call the following day was therefore promised to take a blood count.� Sadly Michael collapsed on the toilet shortly after midnight in cardiac�arrest, despite prompt and extensive attempts to resuscitate him my his wife, a�neighbour, ambulance staff and in the hospital emergency department he was� pronounced deceased. A blood test on arrival at hospital indicated a haemoglobin level of just 48 g/L -profound anaemia.

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

Community health care and emergency services related deaths� � � � This report is being sent to: Cumbria Health | Carlisle Healthcare

28/02/2024

2024-0113

Adrian Green

Plymouth and South Devon

Torbay and South Devon NHS Trust The Disclosure and Barring Service

On 12th November 2021 I commenced an investigation into the death of Adrian Stuart Green age 55 . The investigation concluded at the end of the inquest on 23rd February 2024. The conclusion of the inquest was a narrative one in that Mr Green died at Torbay hospital on 1st November 2021 from alcoholic liver disease where opportunities to prevent his medical deterioration were not taken . Mr Green lived at Whitley court from 4th November 2019 to 26th October 2021 . Mr Green was supposed to be having assistance by way of a care package with medication , support and care , meals and shopping . Although this case was originally reported to the CQC they declined to prepare a report because they said that this was not a case that fell under their jurisdiction because Mr Green did not receive �personal care�. [REDACTED} Manager from Care First disputed that at inquest . Concerns were raised by a neighbour who had not seen activity in Mr Green�s flat for a while and the housing provider notified Care support who ran the accommodation at their time of this incident . Care Support had won the contract for Devon during the pandemic and [REDACTED] had been asking the Devon service from London whether or not there were any issues with staffing or them coping during the pandemic and she was being told that there was not . On 15th October 2021 the previous manager of Whitley court and a number of staff members left the employment of Care support in an unplanned way , deleting records and electronic information as they went . This left the service in chaos and Mr Green was not receiving any sort of appropriate care or visits from about 1.10.21 . Many visits were carried out by intercom calls only which were against company policy. The service was run by agency workers who had no direction and guidance and Mr Green was left lying in squalid and unhygienic conditions in an almost unresponsive state from 23rd October 2021 to 26th� October 2021 when [REDACTED] found him having arrived from London the previous day and called paramedics. Mr Green was conveyed to Torbay hospital but sadly passed away on 1st November 2021 with his family being told that if he had received medical attention sooner he would have had a 50 % chance of surviving [REDACTED] raised a safeguarding alert to the Police and the Trust and made a referral to the Disclosure and Barring service

CORONER�S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. � The MATTERS OF CONCERN are as follows. Despite there being a safeguarding meeting following Mr. Green�s death on 22nd January 2022 there appeared to be no review of whether the local authority ought to be have had policies in place to ensure that independent providers were adequately carrying out their contractual duties towards vulnerable individuals especially if the CQC were correct and there was no role for them in this case � [REDACTED] gave evidence to the inquest that she believed that there was a role for the CQC here as she believed that Mr Green had been in receipt of a personal care package � [REDACTED] made a referral to the Disclosure and Barring service in respect of the former manager�s actions and received no response as to what action if any the service were taking or an acknowledgement of her concerns .

28th�February 2024������ Deborah Archer

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Torbay and South Devon NHS Trust | The Disclosure and Barring Service

03/12/2024

2024-0666

Gary Dunn

East Riding of Yorkshire and City of Kingston Upon Hull

Traffic Services, Hull City Council National Highways � For area of Kingston Upon Hull

On 19th December 2023 I commenced an investigation into the death of Gary Stephen DUNN, aged 47 years. The investigation concluded at the end of the inquest on 2nd December, 2024. � The conclusion of the inquest was: Road Traffic Incident � The following findings of fact were made: Lorry White Volvo LGV registration H4 LGE Mr Dunn was riding a bicycle. Neither vehicle had any defects. No weather conditions were contributory to the incident. There was no defect in the road that was contributory to the incident. I do acknowledge that the road had changed it markings, this was a relatively recent change. I acknowledge that there was an alternative route for Mr Dunn to navigate the busy roundabout, however Mr Dunn was within his rights to use the road. The issue of whether Mr DUNN was visible at any time was an issue at inquest.� The driver of the LGV could not recall specifics about his mirror checks but stated a number of times that it was instinctive, constant thing, something that he does all the time.� He was open about the fact that he did not see Mr DUNN at any time.� I do find his evidence credible. When Mr Dunn is in a position where he could be started to be regarded as visible, he is approximately 70 metres from the roundabout.� I accept there was an opportunity for the LGV to see Mr Dunn and recognise him as a road user, but I also recognise that for the majority of the time Mr DUNN was in the inside lane, there were other vehicles on the road and the driver of the LGV would have also been looking to negotiate the roundabout.� Mr Dunn did have lights on his bike but he was not wearing any clothing that would make him more visible.� As stated previously, the driver of the LGV reported that at no time did he see him.� At the time that the presence of Mr DUNN would have indicated a risk, he would have been in the blind spot of the LGV, high visibility clothing at that stage not have made a difference. This is relevant when at the give way line, albeit for a short period of time, Mr Dunn was positioned in the LGV driver�s blind spot before both move to negotiate the roundabout. The 1st lane of the roundabout is marked for those to leave the roundabout at the first junction.� The 2nd lane of the roundabout allows users to both leave the roundabout at the 1st junction and also continue travelling forward on the roundabout. As the vehicles leave the give way line, the LGV is indicating to take the first junction.� Mr Dunn was positioned very close to the cab.� It would not be possible to say whether he noticed the indicator. As both the LGV and Mr Dunn leave the roundabout, they are both positioned in lanes that allow exit via the first junction.� Mr Dunn is, however, not visible to the LGV driver.� Mr Dunn is straddling both the 1st and 2nd lane and is going to travel straight over the roundabout. CCTV shows that as the LGV manoeuvres to take it�s exit, Mr Dunn rides across its front directly in its path.� I note that the lorry does not cross the bicycles path, it does not leave it�s lane.� It is evident that Mr Dunn does not appreciate that the vehicle was indicating to turn left at the 1st junction.� At the time that the LGV takes its junction Mr Dunn may have been trying either to cycle quickly to out-manoeuvre the vehicle, or attempting to cut across the front of the LGV to reach the next junction, however the CCTV seems to indicate he simply does not appreciate the lorry is turning left and he carries on his route which takes him in front of the LGV.� It was a quick misjudgement, with very tragic consequences. At the time the bicycle crosses his path, there was nothing that the driver of the LGV could do to avoid the collision. I find the LGV stopped appropriately.� For the avoidance of doubt, I accept the evidence that the tachograph did not show that this slowing was in an attempt to avoid the accident. I do note that Mr DUNN was not wearing a cycling helmet, however given the gravity of his injuries, this piece of equipment would not have saved his life. Mr DUNN�s death was instantaneous. Toxicology revealed previous exposure to cocaine and tramadol in his system, but no evidence of acute toxicity. I note that the dashcam was not seized immediately, and then there was a discrepancy over who seized it.� I accept that one officer seized the LGV and the dashcam together but another then seized the dashcam itself.� I note that the override on the dashcam was continuous even when the engine was running, and as such there was no dashcam footage.� I appreciate that when officers attend these scenes there are many tasks and priorities, but it is regrettable that this footage was not seized immediately.� This is something that could have given comfort to the family.� However we do have the CCTV footage and while it does not give a view from the cab it does provide a record of the incident. I will be making a RPFD to highlight the officers concerns over signage. Box 3 of the record of inquest read: On 8th December 2023 Gary Stephen DUNN was riding his pedal cycle to college.� At the Stoneferry Road/Ferry Lane roundabout, Kingston Upon Hull Mr DUNN�s bicycle collided with a Light Goods Vehicle.� Mr DUNN was killed instantly. � His medical cause of death was recorded as: 1a Severe Head Injuries 1b Road Traffic Incident

Gary Stephen DUNN, aged 47 years, was cycling to college.� En route he had to negotiate the Stoneferry Road/Ferry Lane roundabout in Kingston Upon Hull.� Evidence was heard that the layout of the road had changed recently, whereby the centre lane could now also be utilised to turn left.� An LGV was in this lane and indicating to turn left.� Mr DUNN was intending to travel over the roundabout and was on the nearside of the LGV.� The driver of the LGV said at no time did he see Mr DUNN.� Mr DUNN attempted to travel towards his exit but rode into the path of the LGV as it turned left.� He died instantly.

I have sent a copy of my report to: The family of Mr Gary Stephen DUNN via counsel [REDACTED] Counsel for 2nd Driver � [REDACTED] Serious Collision Investigation Unit � Humberside Police � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Road (Highways Safety) related deaths

Hull City Council | National Highways

29/06/2023

2023-0286

Clinton Fear

Avon

UK Health Security Agency

On 26th July 2022 an investigation into the death of Mr. Clinton Peter Fear was commenced. The investigation concluded at the end of the inquest 29th June 2023. The conclusion of the inquest was � � Mr Fear died from a Mycobacterium Chimaera infection acquired from a Liva Nova heater cooler unit during open heart surgery. � The cause of death was � � 1a) Hospital acquired pneumonia; b) Disseminated Mycobacterium Chimaera infection following a composite aortic root replacement (November 2012).

Mr Fear underwent cardiac valve replacement surgery in November 2012 and during surgery he contracted Mycobacterium Chimaera infection from a Liva Nova heater cooler unit (part of the heart bypass machine). He developed symptoms of Mycobacterium Chimaera in the form of night sweats in 2017/2018, was diagnosed and started on treatment in October 2019, suffered a protracted disabling illness for 3 years and died from the infection in July 2022. He was not notified of the risk of Mycobacterium Chimaera infection from the operation when this risk became known in 2015 because his operation was before January 2013 � the date from which patients were then considered to be at risk and adopted in guidance from Public Health England. Mr Fear contracted his Mycobacterium Chimaera infection at surgery before January 2013 and other cases have been reported from surgery dating back to at least 2008.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: UK Health Security Agency

24/10/2024

2024-0574

Patricia Lines

Durham and Darlington

UK Health Security Agency Department of Health and Social Care NHS England

On 6 November 2023 an investigation into the death of Patricia Heather Lines, aged 77, was commenced. The investigation concluded at the end of the inquest before a jury on 22 October 2024.� The medical cause of death was: I a Septicaemic Shock I b Necrotising Fasciitis, Right Shoulder I c Invasive Group A Streptococcus Pyogenes Infection II Type 2 Diabetes Mellitus; Ischaemic, Hypertensive and Valvular Heart Disease The conclusion of the jury was �Accident�.

The deceased underwent an intramuscular Vitamin B12 injection into her right shoulder on 17 October 2023. The following day she became unwell and was admitted to hospital.� Blood tests revealed that the deceased was suffering with an Invasive Group A Streptococcus Infection. Despite receiving hospital treatment, the deceased�s condition deteriorated and she died on the 23rd October 2023. The post mortem pathology evidence indicated that the most likely source of the Invasive Group A Streptococcus Infection was the intramuscular injection; it was likely that streptococcus bacteria was present on the skin of the shoulder at the time of the injection and it was introduced into the deeper tissues of the shoulder when the injection was administered.

I have sent a copy of my report to the Chief Coroner and to the following Interested Person, [REDACTED]. I have also sent it to the GP surgery where the injection was administered, 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

UK Health Security Agency | Department of Health and Social Care | NHS England

25/04/2024

2024-0219

Ash Bannister

Leicester City and South Leicestershire

United Children�s Services via their legal representative.

On 12 August 2021 I commenced an investigation into the death of Ash BANNISTER aged 16. The investigation concluded at the end of the inquest on . The conclusion of the inquest was: � Suicide � The cause of death was established as: � I a Hanging (suspension by a ligature around the neck)

Ash Bannister was a 16 year old who was assigned female at birth but became gender neutral, Ash wanted to be referred to as �they� or �their�. �Ash was born in Croydon in 2004 and had a very difficult start to life. Ash first became known to social services in 2005 after concerns were raised about Ash being exposed to drug use in the family home, [REDACTED] and physical abuse. Ash was subject to a Child Protection Plan and ultimately placed into foster care in 2006 due to concerns about neglect and the misuse of drugs at home. Ash remained looked after until 2007 when Ash returned to her father�s care. Social care became involved again when Ash was around 10 or 11 years old. In January 2018 Ash�s family confirmed they were no longer able to manage Ash at home and keep the rest of the family safe, Ash was therefore to move into a residential placement. Ash remained in residential care until she died on 7 August 2021. � Ash was involved with multiple agencies throughout life and was a child with complex needs. Ash had multiple vulnerabilities including early neglect, a difficult childhood, the fact Ash was a looked after child, a history of exposure to Child Sexual Exploitation, mental health difficulties and a diagnosis of Autism Spectrum Disorder along with some potential difficulties around eating and exploration of their gender identity. � Ash was first referred to Child and Adolescent Mental Health Services (�CAMHS�) in around 2009 or 2010 at the age of 5 or 6 whilst living in Croydon. � Ash had a long history of self-harming, this started at a very early age (9 years old) and was a theme throughout Ash�s short life. � Ash experienced both auditory and visual hallucinations. Ash would hear a male voice which told Ash that they were worthless, the voice would belittle Ash and encouraged self-harming. � Ash� was found hanging [REDACTED] at the residential care home (which was run by United Children�s Services) where they lived on 7 August 2021. Ash was confirmed dead at 0922hrs by East Midlands Ambulance Service.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED], father and step-mother of Ash [REDACTED], mother of Ash The London Borough of Croydon Leicestershire County Council Leicester City Council Leicestershire Partnership NHS Trust I have also sent it to: OFSTED � 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) | Suicide (from 2015) This report is being sent to: United Children�s Services

13 /02/2024

2024-0077

Joshua Burgess

Staffordshire and Stoke on Trent

University Hospital of North Midlands NHS Trust Brook Medical Centre Godfrey Care

On 25 November 2022 I commenced an investigation into the death of Joshua Ethan BURGESS aged 27. The investigation concluded at the end of the inquest on 31 January 2024. The conclusion of the inquest was that: � On 19th November 2022 Joshua Ethan Burgess passed away at his home address after vomiting and aspirating during an epileptic seizure. He was diagnosed with Lennox-Gastaut Syndrome for which he was under the care of a consultant neurologist and medicated with Brivaracetam. � Natural causes

Joshua Burgess was a 27-year-old male who had severe acquired brain injuries, communication difficulties, impaired executive functioning and severe learning difficulties. He developed epilepsy from the age of 6 years and had a diagnosis of Lennox-Gestaut syndrome for which he was under the care of the Department of Neurology at Royal Stoke University Hospital. In 2019 the Department of Neurology commenced Mr Burgess on 2.5ml twice daily Brivaracetam to control his seizure activity. The dosage was increased to 10ml twice a day in 2020 and responsibility for prescribing the medication was transferred to Mr. Burgess� General Practitioner at the Brook Medical Centre, Bradeley, Stoke-On- Trent. The reason for the change in prescriber was for the sake of convenience as the GP were the prescriber for other medications. � Although the Brook Medical Centre were responsible for prescribing Brivaracetam there were no consultations between the surgery and Mr. Burgess or his mother regarding the management of his seizures or a review of medication, these continued to be undertaken by the Department of Neurology at the Royal Stoke University Hospital. � In July 2020 the Consultant Neurologist agreed with Mr. Burgess� mother that the dosage of Brivaracetam should be reduced by 2ml every 2 weeks and to be reviewed in 4 months. A letter was sent from the Department of Neurology at Royal Stoke University Hospital to the Brook Medical Centre advising of this planned reduction. No amendment to the prescription was requested and no changes were made following the letter. The remained as Brivaracetam 10ml twice daily. � In November 2020 a letter was sent from the Department of Neurology at Royal Stoke University Hospital to the Brook Medical Centre advising that the dose of Brivaracetam had been reduced to 3ml twice daily but then back up to 5ml twice daily. No amendment to the prescription was requested and no changes were made following the letter. � In January 2021 a letter was sent from the Department of Neurology to the Brook Medical Centre advising that the dose of Brivaracetam was at 4ml twice daily and the deceased�s seizures were �relatively stable�. No amendment to the prescription was requested and no changes were made following the letter. The prescription remained as Brivaracetam 10ml twice daily. � On 22 July 2022 Mr. Burgess was moved out of his parent�s care by Stoke-on-Trent social services into a supportive living placement in Leicestershire run by Godfey Care. This was undertaken on an emergency basis. When Mr. Burgess arrived at the placement it was reported by staff that the medication bottles were unlabeled and so could not be given to Mr Burgess until confirmation of the prescription was received in writing by the prescriber. The evidence at inquest was that this was a Care Quality Commission requirement. � The deceased did not receive any Brivaracetam between 22 July 2022 and 26 July 2022. � On 25 July 2022 a �Best Interests Meeting� was undertaken involving Mr Burgess� mother, Godfrey care and social services during which the Mr Burgess� mother advised that the correct dosage of Brivaracetam was 4ml twice daily and not 10ml twice daily. The same information was provided by the Department of Neurology to Godfrey Care however the medication was not provided as the information regarding the correct dose had not been provided by the prescriber. � On 26 July 2022 the deceased was given Brivaracetam 10ml twice daily. The evidence at inquest was that this was likely due to a manager from Godfrey Care being given the prescription details during a call to the 111 service. � On 27 July 2022 a letter was sent from the Department of Neurology to the Brook Medical Centre explaining that Mr Burgess had been moved to a care organisation on an urgent basis and there was confusion over what medication he should be taking. A request was made to forward a list of his medication but also included information from his last review within the Department of Neurology that Brivaracetam at 4ml twice daily was the appropriate dose. � On 28 July 2022 the Brook Medical Centre sent a list of prescribed medication to Godfrey Care. As there had been no changes to prescription since July 2020 the recorded prescribed dose of Brivaracetam was 10ml twice daily although the dose that he has been given during the preceding 2 years was 4ml twice daily. � Mr Burgess continued to receive Brivaracetam at dose of 10ml twice daily until 5 September 2022 when he was seen in a clinic at Department of Neurology at Leicester Glenfield Hospital and established that there had been a sudden increase in the Brivaracetam dose from 4ml twice daily to 10ml twice daily. The plan was for the medication to be reduced to 9ml twice daily and then to continue to reduce by 1ml twice daily at weekly intervals until he was back to the �well tolerated� dose of 4ml twice daily. � Prior to 22 July 2022 whilst being given Brivaracetam at 4ml twice daily Mr Burgess experienced 5-6 seizures per week. Following the cessation of medication between 22-26 July 2022 and the increase in Brivaracetam to 10ml twice daily he was experiencing about 5 seizures per day and of longer duration. � The medication was reduced as per the instruction from Department of Neurology at Leicester Glenfield Hospital. On 23 September 2022 Mr Burgess was taken back into care of his mother. Although there had been a hospital attendance on the on 15 November 2022 the seizures had stablised to a similar frequency as before the sudden interruption and increase in medication. � On 19 November 2022 Mr. Burgess was sadly found unresponsive at his home address with death being verified by attending paramedic. He had passed away after vomiting and aspirating during an epileptic seizure.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � I have also sent it to � NHS England Care Quality Commission Stoke-on-Trent, Adult Social Care � 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 North Midlands NHS Trust | Brook Medical Centre | Godfrey Care

19/08/2024

2024-0458

Alan Fallows

Birmingham and Solihull

University Hospitals Birmingham

On 11 April 2024 I commenced an investigation into the death of Alan Stanley FALLOWS. The� investigation concluded at the end of the inquest . The conclusion of the inquest was; Death due to natural causes, contributed to by injuries sustained from an in-patient fall whilst in hospital

Mr Fallows was admitted into Good Hope Hospital in Birmingham on 08/02/2024 following a fall at home and was diagnosed as having sustained a suspected broken elbow as well as� having postural hypotension. He was initially discharged but readmitted on 09/02/2024 due� to a CT scan showing a chronic subdural haematoma. On 10/02/2024 a falls assessment� was incorrectly completed but which still deemed him to be at high risk of falls, and on� 12/02/2024 bed rails were put in place following an assessment. Later that day he had an� unwitnessed fall but did not sustain injuries. His falls risk assessment was not updated� following this fall, although his bed rails assessment was updated three days later on� 15/02/2024. On 16/02/2024, he had a further unwitnessed fall and suffered a minor head� injury and a fracture to his right neck of femur. On 17/02/2024 he was transported to� Birmingham Heartlands Hospital for surgery which was uneventful. On 02/03/2024, he was� transferred to Solihull Hospital for physiotherapy, but subsequently developed severe� bilateral aspiration pneumonia. Despite optimal treatment, his condition deteriorated over� the course of three weeks, and he sadly died on 28/03/2024. Although gaps in care were� identified, it is impossible to say whether his falls could have been prevented.� � Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be:� 1a Aspiration pneumonia 1b Frailty of old age 1c � II��� Fracture right neck of femur (operated), Chronic obstructive pulmonary disease

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

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

University Hospitals Birmingham

19/05/2023

2023-0165

Norma Bruton

Birmingham and Solihull

University Hospitals Birmingham NHS Foundation Trust

On 3 November 2022 I commenced an investigation into the death of Norma Winifred BRUTON. 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.

The deceased was admitted to Birmingham Heartlands Hospital on 13 October 2022 for treatment of a pneumothorax with a background of pulmonary mycobacterium infection and chronic obstructive lung disease. An assessment of her risk of falling did not take into account the presence of a chest drain and an intravenous drip and Mrs Bruton was assessed as being able to mobilise independently. She had an unwitnessed fall on the morning of 15 October 2022 when trying to walk the short distance to her bathroom and sustained a right fractured neck of femur for which she underwent surgery on 20 October 2022. Mrs Bruton�s condition deteriorated after the surgery and she died in hospital on 22 October 2022. � Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a Sepsis � 1b Hospital acquired pneumonia 1c II���Chronic Obstructive Lung Disease, Frailty, Neck of femur fracture (operated), Pneumothorax

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

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

15/11/2024

2024-0632

Rachael Ryan

Birmingham and Solihull

University Hospitals Birmingham NHS Foundation Trust

On 11 July 2024 I commenced an investigation into the death of Rachael Alicia Elizabeth RYAN. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Natural causes

Miss Ryan was discharged from Birmingham Heartlands Hospital on 27th February 24� following a period of treatment after a fall at her home against a background of� osteoarthritis. On discharge she was cared for at home in bed with a package of care� provision and was also receiving district nursing input for some moisture associated skin� damage to her buttocks which had developed post discharge from hospital. She was also� receiving treatment from her GP for suspected cellulitis in her legs. On 25th March 2024 she was readmitted to Heartlands Hospital because she was in great pain. When assessed after� her admission to A and E, it was found that she now had a Category 3 pressure ulcer on her buttocks/sacral area. On 26th March tests revealed she had a deep vein thrombosis in her� left leg and a scan on 27th March revealed a pulmonary embolism. Subsequently, on 5th� April it was suspected that her pressure ulcer may be infected so she was started on� antibiotics. A scan on 9th April revealed that she now had contracted osteomyelitis. Advice� was subsequently received on 23rd April from the infectious diseases consultant that Miss� Ryan needed a deep tissue biopsy in order to best inform the correct anti-biotic therapy.� Despite a number of different specialities being contacted to facilitate this, the biopsy could not be carried out until 21st May at which point the most appropriate anti-biotic therapy for� the particular type of infection she had was then identified and started. Although her skin� began to heal, she deteriorated on 11th June and despite continuing ongoing treatment she� passed away on 21st June 2024.� Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be:� 1a Osteomyelitis 1b Infected Sacral Pressure Sore 1c 1d II��� Frailty of Old Age

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: FAMILY OF MISS RYAN 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

University Hospitals Birmingham NHS Foundation Trust

10/11/2023

2023-0448

Claire Homer

Inner North London

The Medical Director, CEO and Legal Department of: Camden and Islington NHS Foundation Trust St Pancras Hospital 4 St Pancras Way London NW1 OPE

On 23 My 2023 an investigation was commenced into the death of Claire Homer aged 46 years. The investigation concluded at the end of the inquest held on 2nd and 11th November 2023. � The Inquest found that Claire Elizabeth Homer suffered from a debilitating constellation of physical, psychiatric and somatic illnesses, with a complex interplay between them. She was found dead in her home on 5 May 2023. Despite Post Mortem examination and toxicology, no cause of death was identified. � The medical cause of death was Unascertained. I returned an Open Conclusion.

Please see attached Findings of Fact.

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

Other related deaths This report is being sent to: Camden and Islington NHS Foundation Trust

17/08/2023

2023-0297

Shirley Ashelford

Inner South London

The Medicine Healthcare products Regulatory Agency (MHRA) London Borough of Southwark (Occupational Therapy Service and Asset Management Team). Prism Medical UK Ltd.Bureau Veritas UK Ltd. His Honour Judge Thomas Teague KC, The Chief Coroner for England, and Wales

On the 27th July 2021 an investigation commenced into the death of Shirley Frances Ashelford, born 30th June 1961, and who died on 20th July 2021. The investigation concluded at the end of the inquest on 9th August 2023. The medical cause of death was: 1(a) Asphyxia 1(b) Chest compression with suspension from Mobility Body Hoist Harness II Multiple Sclerosis. I recorded the following factual findings in Box 3 of the Record of Inquest: At the time of her death Shirley had secondary progressive multiple sclerosis, diagnosed in 2000, which severely restricted her mobility. Despite her condition, preventing her from standing up and walking, she was determined to live as independently as possible sharing a home with her husband. Her daily routine was to wake at 06:00 am, and call her husband between 07:00 and 07:30 am, to assist her getting dressed. On the morning of the 20/7/21 whilst she was transferring from her bed to a mobility scooter, using a mechanical ceiling hoist, the lowering mechanism failed leaving her suspended with her feet off the floor in the hoist chest harness. The harness tightened causing compression of the chest which, in combination with respiratory weakness caused by multiple sclerosis, led to fatal asphyxia. Her husband awoke at about 08:00 am, when he did not hear his usual alarm call, and discovered her unresponsive in the hoist harness. Despite attempts at resuscitation she was pronounced dead after the arrival of the ambulance service. Based on those factual findings my Conclusion in Box 4 of the Record of Inquest was: Misadventure

Shirley was aged 60 at the time of her death. Following a diagnosis of multiple sclerosis, in 2000, her mobility slowly declined, eventually losing the ability to stand and walk and becoming reliant on a mobility scooter. In February 2003 she referred herself to the London Borough of Southwark Occupational Therapy (OT) Services who over the years arranged adaptations to her home to assist with her declining mobility. She was provided with a powered transverse hoist to transfer her from her bed to a mobility scooter. The hoist was a Freeway Transactive Xtra, serial No. TXD23090, Manufactured by Prism Medical UK. It consisted of a motor which moved along an H-track frame, installed in the ceiling, above the bed. Attached to the motor was a harness consisting of 2 lines which attached to the front and back of a sling which fitted around the chest area. The sling was a Liko Mastervest MOD 64. The sling/harness was designed to tighten around the chest when put under weight to prevent a user sliding through it. When the hoist was working correctly Shirley would only be suspended for a matter of seconds before her feet encountered the floor when transferring to the scooter. She operated the hoist using a handheld control which had 6 buttons for movements in every direction, up/down, left/right, and forwards/backwards. The local authority employed an independent contractor, Higher Elevation Ltd to maintain the working of the hoist. The contractor�s attendance was organised by the local authority Asset Management Team (AMT). Higher elevation produced visit report sheets which they sent to the AMT. The AMT in turn did not provide the visit reports to the OT department. In the months leading up to her death Shirley reported problems with the hoist getting stuck when trying to lower it and causing her to be suspended in mid-air. This was documented in emails to her Occupational Therapist (OT). On the 25/3/21 she described being trapped in the hoist for 5 minutes and stating �� the pain all this is causing me is immense and the damage to my condition is noticeable�� . On the 9/4/21 she emailed her OT describing the hoist lowering problem as being occasional and that it worked normally most of the time. On the same day Higher Elevation advised the AMT that the hoist should be replaced. This was not communicated to the OT team by the AMT. On the 30/6/21 Bureau Veritas UK Ltd, a private company, commissioned by the London Borough of Southwark, performed a 6 monthly inspection of the hoist, and reported no defects, which could become a danger to persons, were present. That report was made to the AMT but not to the OT department. The report does not indicate that Bureau Veritas was aware of the reports Shirley had made to the OT, and the Higher Elevation report of 9/4/23. On the morning of 20/7/21 Shirley�s husband found her suspended in the hoist halfway between the bed and mobility scooter in an upright position with her feet about 2 inches off the floor. He manoeuvred her above the scooter using the hoist handheld control, which although unable to lower, was still operating in the horizontal plane. He then used a knife and scissors from the kitchen to cut the harness lines to lower her onto the scooter and called the ambulance. It is significant that he did not use a red emergency cord, located on the hoist unit underside, to lower her. He revealed at the inquest that he had not received training on its use. He then attempted to perform CPR whilst she was on the scooter because he could not move her onto the floor by himself. The ambulance service attended about 10 minutes later and pronounced life extinct. Rigor-mortis was noted. An initial Post-Mortem report, 3/11/21, considered that positional asphyxia was possible due to the presence of petechial haemorrhages of the sclera but the pathologist, [REDACTED], was only able to offer the cause of death as 1(a) Unascertained. A neuropathologist had also been unable to identify a cause of death. A second pathologist,[REDACTED], was provided with a diagram and description of the position in which Shirley was suspended in the hoist and concluded in a report 2/5/23 that the harness tightened causing compression of the chest which, in combination with respiratory weakness, from multiple sclerosis, led to the fatal asphyxia. When submitting his report�[REDACTED] provided me with several medical publications of studies of deaths caused by straps and harnesses in different settings to illustrate his finding as to the cause of death. The Pathology Report and medical publications are attached. Based on the pathology findings I ruled out �natural cause� on the basis that chest compression from a mobility hoist harness was not a natural event but the failure of a piece of manufactured equipment. I recorded a conclusion of Misadventure because death resulted from an unintended mechanical failure of the hoist to lower and the unforeseen increasing pressure on the chest area caused by the sling restricting Shirley�s breathing movements.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons who may find it useful or of interest: 1.����Solicitors representing the London Borough of Southwark. 2.���Higher Elevation Ltd. 3.���[REDACTED] next-of-kin. 4.���[REDACTED] pathologist. 5.���[REDACTED] pathologist. � 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: Medicine Healthcare products Regulatory Agency | London Borough of Southwark | Prism Medical UK Ltd | Bureau Veritas UK Ltd

05/06/2023

2023-0186

Jonathan Cole

Derby and Derbyshire

The Ministry of Defence [care [REDACTED] of GLD Defence Private Law and Inquests Team] for the attention of: a. The Rt Hon Dr Andrew Murrison MP, Parliamentary Under Secretary of State (Minister for Defence People, Veterans and Service Families) b. The Rt Hon Johnny Mercer MP. The Minister for Veterans� Affairs c. The Rt Hon James Heappey MP, Minister for Armed Forces d. The Rt Hon Ben Wallace MP, Secretary of State for Defence Nottinghamshire Healthcare NHS Foundation Trust [for the attention of [REDACTED], Chief Executive; � Executive Director of Mental Health; [REDACTED] Newham- Deputy Chief Executive; [REDACTED] � Executive Director of Community Mental Health Services; [REDACTED] Executive Director of People and Culture] [care of {REDACTED]]

In 2018 an investigation was commenced into the death of Jonathan �Jonny� Philip Cole [JC], aged 39. The investigation concluded at the end of the Inquest on 25 April 2023. The conclusion of the Inquest was a Narrative Conclusion namely: Narrative Conclusion a. JC developed Post Traumatic Stress Disorder as a result of at least three traumatic experiences whilst serving in the British Army in Afghanistan on operational tour in 2009 one of which represented a direct threat to his life (where he also suffered physical injuries including hearing loss and tinnitus, shrapnel injuries following a Rocket-Propelled Grenade attack (RPG); [Note: This service had been with 2 Rifles as part of Operation Herrick 10.] b. JC had made multiple attempts at suicide and self-harm beginning in January 2010 which were caused or materially contributed to by his unresolved symptoms of PTSD, culminating in a final and successful suicide attempt in August 2018; c. JC did not receive Eye Movement Desensitisation and Reprocessing [EMDR] for those symptoms of Post Traumatic Stress before the summer of 2012, it consisted of no more than 8 sessions of EMDR, which on balance of probability proved latterly to be insufficient albeit the EMDR did provide JC with temporary improvement and some alleviation of symptoms of PTSD in 2012/2013; d. JC�s intrusive memories of the RPG incident were not verified as having been fully processed in the presence of JC�s treating CPN before EMDR was discontinued in 2012 albeit JC had confirmed his belief in 2012 that he had managed to self-process that memory; e. JC received no psychological trauma therapy from 2013 onward up until the time of his death other than the EMDR provided whilst still in the British Army; f. JC left the Army in 2013 without a formal diagnosis of having had PTSD as a result of operational trauma. This was a failure and a diagnosis of PTSD was appropriate at that time; g. JC��s unresolved symptoms of PTSD caused or contributed to episodic periods of profound mental health crisis, often preceded, and accompanied by, thoughts and attempts to end his life by way of overdose, and latterly hanging. His unresolved symptoms of PTSD also contributed to use of alcohol and drugs to manage the symptoms which in turn led to marital and relationship problems and financial problems; h. JC�s PTSD was accompanied by alcohol and drug use, exacerbating the severity of the underlying condition; i. The continued lack of any official recognition, acknowledgment, or diagnosis on the part of the MOD of his PTSD in the context of JC�s attempts to access financial compensation for his condition, was a failure and materially contributed to a deterioration in his mental health state in the period following his discharge from the Army up until his death and resulted in JC making contact again on 8th June 2018 which was not responded to before his death; j. The Risk assessment and Care Plan completed on 28th January 2018 was inadequate and under estimated the risk of suicide for JC; k. There was a failure to conduct a psychiatric review in January 2018 despite a referral for psychiatric review this failure also caused unnecessary delay before a medication review took place; l. The Risk assessment and Care Plan completed on 14th May 2018 was inadequate and underestimated the risk of suicide; m. JC�s mental health had deteriorated significantly in 2018 and deterioration continued whilst under care of local mental health team and with knowledge that no psychological trauma therapy was being provided; n. By the beginning of 2018 JC�s medication was no longer proving effective as he became increasingly depressed, as well as socially, and occupationally isolated. This led to a change in medication in June 2018, which whilst appropriately indicated was not effectively managed and documented as ineffective on 28th July 2018 when consideration should have been given to appropriately increasing the dose of Paroxetine to assist JC�s low mood; o. Further risk assessments and Care plans should have been completed when Fluoxetine was reduced and removed and Paroxetine introduced; p. A further risk assessment and care plan should have been completed on 26th July 2018 in light of having elicited JC�s recent arrest and changes in his psycho social position4 including issues of accommodation and financial pressures. This consultation underestimated the risk of suicide. There was a failure of the treating mental health professional to identify that JC was to appear in court 8.8.18. There was a lost opportunity therefore to make contact with the police/ CPS and to liaise with the criminal justice liaison and divergence with relevant information as to the medication review underway and relevant factors of JC�s mental health. There was an under estimation of the risk of suicide on 26.7.18 by not identifying the upcoming court date of 8.8.18 and offering support to JC; q. There was a missed opportunity throughout 2018 to refer JC to the Transition Intervention and Liaison Service [TILS] and the Centre for Trauma Resilience and Growth.

On the 9th August 2018 at a location of Old Stone Bridge, Butterley Park, Codnor Park, Ironville, Derbyshire Jonny Cole was found hanging [REDACTED] having acted with the intention to end his life. Jonny had PTSD, anxiety, suicidal ideation and was under the care of his local mental health trust. Jonny had not been seen since leaving his home on the afternoon of 7th August 2018 and was due in court on 8th August 2018 to face charges of criminal damage but did not attend.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] � Jonny�s wife. [REDACTED] � Jonny�s partner. [REDACTED] � Jonny�s father. Ministry of Defence Nottinghamshire Health Care Foundation Trust Derbyshire Constabulary Derbyshire Healthcare NHS Foundation Trust I have also sent it to: Op Courage Midlands Lincolnshire Partnership NHS Foundation Trust [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.

Other related deaths This report is being sent to: Ministry of Defence | Nottinghamshire Healthcare NHS Foundation Trust

16/02/2024

2024-0088

Sobhia Khan

Derby and Derbyshire

The Ministry of Justice � Cygnet Health Care � Derbyshire Constabulary � Derbyshire NHS Foundation Trust � Derby City Council

On 28 May 2017 an investigation was commenced into the death of Sobhia Tabasim Khan, aged 37. � The investigation concluded at the end of the inquest on 16 February 2024. � The conclusion of the inquest was unlawful killing. I found that there were numerous failures by the various state agencies involved with Sobhia, including one that was causative of her death, namely the failure of Derbyshire Police to act on information received indicating that Sobhia�s killer was in a relationship with a woman in Bradford and was planning to marry her in February 2017.

Sobhia formed a relationship with a man named [REDACTED]��who was subject to conditional discharged from a s.37 hospital order with s.41 restrictions following violent and sexual offences against his former wife. His discharge conditions included that he should notify the authorities of any developing relationships. He failed to notify the authorities that he had begun a relationship with Sobhia, and after the relationship had been ongoing for around a year he persuaded her to move from Bradford to Derby. Within little more than 5 weeks of her doing so he brutally murdered her. He ran a defence of diminished responsibility but was convicted of her murder. At the time of the murder [REDACTED] was being supervised by numerous agencies: the police, social services, the community mental health team, MAPPA, and the Ministry of Justice. That he was nonetheless able to form a relationship with Sobhia in secret, and to murder her, was surprising and concerning. This formed the focus on my inquest.

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

Other related deaths This report is being sent to: The Ministry of Justice | Cygnet Health Care | Derbyshire Constabulary | Derbyshire NHS Foundation Trust | Derby City Council

07/01/2025

2025-0007

Thomas Kingston

Gloucestershire

The National Institute for Health and Care Excellence (NICE) 3rd Floor, 3 Piccadilly Place, Manchester, M1 3BN Emailed address: [REDACTED] The Medicines and Healthcare Products Regulatory Agency (MHRA) 10 South Colonnade, London E14 4PU Email address: [REDACTED] The Royal College of General Practitioners (RCGP) 30 Euston Square, London NW1 2FB Email address: [REDACTED]

On the �26th February 2024 I commenced an investigation into the death of Thomas Henry Robin Kingston. The investigation concluded at the end of the inquest on the 3rd December 2024. The conclusion of the inquest was a narrative conclusion; see below � Mr Kingston took his own life using a shotgun which a caused a severe traumatic wound to the head. Intent remains unclear as the deceased was suffering from adverse effects of medications he had recently been prescribed. � The medical cause of death was 1A Traumatic wound to head.

The deceased was a 45 year old man who was visiting his parents in Kemble Gloucestershire for the weekend. He had recently been experiencing anxiety, but had not expressed any suicidal ideation. On Sunday 25th February 2024 after lunch he began to unload his car, and prepared to return to London. Between approximately� 1700-1800 hours he removed a shotgun from his vehicle which he had recently borrowed from his father for a shoot. He then accessed an annex attached to his parent�s property. Within a locked bathroom he self inflicted a gun shot to the head, and sustained injuries incompatible with life. He was subsequently found by his father. He was pronounced deceased at 1854 hours by attending police, who confirmed there were no suspicious circumstances surrounding his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. [REDACTED], counsel for the family of Thomas Kingston, 2. [REDACTED] counsel for the GP, [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)

National Institute for Health and Care Excellence | Medicines and Healthcare Products Regulatory Agency | Royal College of General Practitioners

30/08/2022

2023-0084

Glenn Barton

Somerset

The National Institute for Health and Care Excellence 2nd Floor, 2 Redman Place London E20 1JQ

On the 26th August 2020 the then-Senior Coroner, Mr Tony Williams, commenced an investigation into the death of Glenn Barton, aged 71. The investigation concluded at the end of the inquest, heard before me, on the 16th August 2022. The conclusion of the inquest was Accidental death, including medical cause of death being Ia) Traumatic subdural haematoma II) Myelodysplasia (Chronic Myelomonocytic Leukaemia) � With a finding in box 3 that: On the 19th August 2020, Glen BARTON tripped on garden steps at his home address consequently falling and striking his head on the door of the garage. Glen had an existing diagnosis of myelodysplasia (chronic myelomonocytic leukaemia). This meant he had a low platelet count which is a form of blood clotting disorder. � The day after this fall, on the 20th August 2020 Glen drove himself to the Minor Injuries Unit at Bridgwater hospital where he was triaged by a trainee emergency nurse practitioner and assessed by an emergency care practitioner in accordance with NICE guidelines. As part of this assessment there was a telephone discussion with a staff grade clinician at Musgrove Park Hospital. Glen was then discharged home with written and verbal head injury advice as at that time he did not present with any clinical features that would indicate a CT scan was required. It was not appreciated at the time of triage nor assessment that a diagnosis of leukaemia may have increased Glen�s risk of suffering a significant intracranial bleed following a relatively minor head trauma and the operative clinical guidance was ambiguous on whether a CT scan would be required. � On the 21st August 2022 Glen developed severe headaches and vomiting following his fall 2 days previously. He attended Musgrove Park Hospital Emergency Department where a CT scan was requested. This was not performed until 21:50 due to other patients presenting with a more urgent clinical need. There was no record of any neurological observations but nursing staff became concerned about his cognitive abilities. The CT scan revealed a catastrophic subdural haematoma which was unsurvivable. Glen was not a candidate for surgical intervention. He died on the Twenty-second of August 2020 as a result of the subdural haematoma sustained at the time of the original fall. There has been no evidence that an earlier scan would have changed the tragic outcome.

Glenn had his left arm amputated when he was 17, back in 1966. He was diagnosed with myelodysplasia (chronic myelomonocytic leukaemia) on the 31st December 2019, following a bone marrow biopsy. On the 19th August 2020 Glenn suffered a mechanical fall up some garden steps at his home. Due to only having one arm he wasn�t able to fully break his fall, hitting his head on the garage side door and sustaining a graze on his head. He didn�t lose consciousness. He elected not to seek medical attention on the day. The following day, 20th August 2020, he attended the Minor Injuries Unit (�MIU�) at Bridgwater Community Hospital where the underwent a full and thorough triage at 11.03 by a trainee emergency nurse practitioner who noted his diagnosis of leukaemia. This took place 4 minutes after his arrival. He was then assessed by an emergency care practitioner (�ECP�) 20 minutes later who, again, conducted a full and comprehensive neurological assessment. The ECP contacted a Senior Doctor at Musgrove Park Hospital to discuss Glenn, given his diagnosis of Leukaemia. The consensus of medical opinion at the time was that in the absence of any clinical features and/or concerns within the neurological assessment, then Glenn was suitable to be discharged home with appropriate head injury advice. At 18:27 on the 21st August 2020 Glenn attended the Emergency Department at Musgrove Park Hospital with a headache. This is the first time he had experienced that symptom since his fall two days previously. A CT scan was organised which revealed a major brain haemorrhage. Discussions with had with the Neurological Department at Southmead Hospital and Glenn was not a surgical candidate. He died the following day.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (i)��[REDACTED] (Glenn�s wife); and (ii)�Somerset Foundation Trust who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any 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

The National Institute for Health and Care Excellence

04/09/2023

2023-0318

Talia Phillips

Cornwall and the Isles of Scilly

The National Institute for Health and Care Excellence and the British National Formulary, Level 1A, City Tower, Piccadilly Plaza, Manchester, Mi 4BT

On 4 August 2022 I commenced an investigation into the death of Talia Evania Phillips. The investigation concluded at the end of the inquest on 9 March 2023. The conclusion of the inquest was a narrative conclusion; � �Talia Evania Phillips died at 19.55 on 6 March 2022 on the B3266 opposite the main entrance to the Colquite Estate near Washaway Bodmin as a result of catastrophic head and neck injuries sustained when the vehicle she was driving was in head on collision with an oncoming vehicle. The Deceased had been driving in the direction of Washaway when it crossed over the white line into the Camelford bound lane. It is likely that the Deceased lost control of her vehicle when she suffered a cardiac event caused by a significantly elevated level of the drug Fluoxetine in her blood which had been prescribed to her. There is insufficient evidence evidence to establish why the drug was at such a high level . There is no evidence that the Deceased had any intention to harm herself� � The medical cause of death was 1a Head and neck injuries 1b Fluoxetine toxicity.

Talia Phillips died as a result of injuries sustained in a head on road traffic collision with an oncoming vehicle. It is likely that she lost control of her vehicle having suffered a cardiac event caused by a significantly elevated level of Fluoxetine in her blood. � Evidence from a toxicologist indicated that a chronically high level of fluoxetine may have led to arrhythmia in life and contributed to a collapse at the wheel. � Talia was prescribed Fluoxetine by her general practitioner on 22 December 2021 for anxiety. On 31 January 2022 Talia experienced an episode of palpitations and contacted her general practitioner who organised routine blood tests and an ECG. The tests and the ECG were reported as normal, save for slightly low iron levels. The routine tests did not test Fluoxetine levels.

I have sent a copy of my report to the following; Talia�s Family Wadebridge & Camel Estuary Practice � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 | Alcohol, drugs medication related deaths This report is being sent to: The National Institute for Health and Care Excellence | The British National Formulary

10/06/2024

2024-0434

Sailor Court

South London

The National Medical Director, NHS England Secretary of State for Health and Social Care, the Rt Hon Victoria Atkins MP

On 8 December 2021 an investigation into the death of Sailor (previously known as Sara) COURT, who died following an overdose of [REDACTED] aged 14 years on 17 September 2021. � Sailor was non-binary and chose to be referred to by the pronouns �they / them�. � The investigation concluded at the end of the inquest on 7 June 2024. The conclusion of the inquest was that Sailor took their life by suicide. At the time of their death, Sailor was on the waiting list for treatment under the Community Child and Adolescent Mental Health Service, which is operated by the South London and Maudsley NHS Foundation Trust (�CAMHS�).

Sailor was first referred to the CAMHS in October 2020 aged 13 due to low mood and self-harm. � The referral was accepted in November 2020. Sailor was advised that the waiting time for the mental health assessment appointment would approximately one year, in November 2021. In fact, after an episode of self-harm in mid 2021 and the intervention of the CAMHS crisis team, the assessment due to take place in around November 2021 was superseded by an earlier assessment in mid 2021, and on 20 August 2021 Sailor and their parents were advised that Sailor had been added to the list for and treatment which at that time was approximately 10 months. � Sailor took their life some four weeks later on 17 September 2021 when they were found deceased in their bedroom at home by their parents. Toxicology and circumstantial evidence showed that Sailor had taken an overdose of [REDACTED] which had been prescribed by their GP. I concluded that the overdose was an intentional act amounting to a suicide.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Sailor�s parents; The Chief Executive of the South London and Maudsley NHS Foundation Trust. � I have also sent copies to the following who may find it useful or of interest: � The local safeguarding school (since Sailor was a minor under the age of 18); The Head Teacher at Sailor�s school; Sailor�s GP. � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

03/07/2023

2023-0348

Andre Moura

Manchester South

The National Police Chiefs Council and the College of Policing

On 7th July 2018 I commenced an investigation into the death of Andre Felipe Mendes Moura. The investigation concluded on the 15th December 2022 and the conclusion of the jury was one of Narrative: Andre Moura had taken cocaine in the hours leading up to his death. There was a significant struggle with Greater Manchester Police Officers as he was restrained, during which an episode of acute behavioural disturbance developed. He was put in the back of a police van for transportation. He suffered a cardiac arrest in the back of the van and died after attempts to resuscitate him were unsuccessful. The medical cause of death was 1a) Cocaine toxicity resulting in hyperthermia and acute behaviour disturbance in association with obesity and struggling against restraint.

On the 7th July 2018 Andre Moura was declared dead at Tameside General Hospital. He had a cardiac arrest in a police vehicle whilst under police arrest to prevent a breach of the peace. Attempts to resuscitate him were unsuccessful. He had high levels of cocaine in his system, resulting in cocaine toxicity. Acute behavioural disturbance in association with hyperthermia, obesity and a prolonged, high stressing and physical struggle were all contributory factors.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely; � 1) Southerns Solicitors on behalf of the Family; 2) Greater Manchester Police; 3) the Independent Office for Police Conduct; 4) RJW Legal and 5) Precedence Law who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drugs medication related death This report is being sent to: The National Police Chiefs Council |�The College of Policing

18/08/2023

2023-0308

William Nichols

Gateshead and South Tyneside

The Newcastle Upon Tyne Hospitals NHS Foundation Trust Gateshead Health NHS Foundation Trust

On 07/01/20 an investigation was commenced into the death of William Nichols age 66 years. The investigation concluded at the end of the inquest on 20/04/23. � The conclusion of the inquest was: Mr Nichols suffered a catastrophic haemorrhage from the site of a right femoral endarterectomy due to deep patch infection. The significance of blood in the wound discharge at 5 weeks post-surgery having not been acted upon, the opportunity to prevent a fatal outcome was lost. � The medical cause of death was: 1a) Hypovolaemic shock, 1b) Dehiscence of right femoral endarterectomy, 1c) Post-operative deep patch infection, 2) Type 2 diabetes mellitus, rheumatoid arthritis (on Toclizumab), hypertension, ischaemic heart disease and atherosclerosis.

Mr Nichols underwent surgery, a femoral endarterectomy, on 20/11/19, and developed a lymphatic leak and a post-operative infection, from which he was at an increased risk of developing. � A week prior to his death, Mr Nicholas suffered a herald bleed due to deep patch infection, and on the evening of 02/01/21 Mr Nichols suffered a fatal catastrophic haemorrhage from the site of the right femoral artery. The blood in Mr Nichol�s wound discharge observed on 26/12/19 is likely to have been a herald bleed, and from then Mr Nichols was at a significant risk of catastrophic haemorrhage. On 26/12/19 Mr Nichols should have been instructed to attend hospital immediately where the management would have included an urgent CT scan or CT angiogram before urgent surgery to eliminate the deep patch infection. � On 27/12/19 Mr Nichols should have been admitted to hospital. At that point management would have been an urgent CT scan or CT angiogram before urgent surgery to eliminate the deep patch infection. � If surgery had been undertaken on 26/12/19 or 27/12/19, or at any time prior to the catastrophic bleed on 02/01/20, the deep patch infection would have been eliminated and it is likely that Mr Nichols would have survived

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, the Family of Mr Nichols, and Sunniside Medical Practice. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: The Newcastle Upon Tyne Hospitals NHS Foundation Trust | Gateshead Health NHS Foundation Trust

27/02/2023

2023-0076

Peter Seaby

Norfolk

The Oaks and Woodcroft Care Home 2a Dereham Road, Matishall Dereham, NR20 3AA � The Priory Group (Owner)

On 06 July 2022 I commenced an investigation into the death of Peter Gary SEABY aged 63. The investigation concluded at the end of the inquest on 24 February 2023. � The medical cause of death was: 1a) Aspiration Pneumonia 2)�Down�s Syndrome, Cirrhosis of the Liver, Cerebral Infarction. � The conclusion of the inquest was: Mr Seaby died of aspiration pneumonia. Inadequate preparation of his lunchtime meal and inadequate supervision at his lunchtime meal possibly contributed to his death

Peter Seaby was a resident at The Oaks and Woodcroft Care Home. Mr Seaby was assessed by a Speech and Language Therapist [�SALT�]. A SALT Care Plan was in place with regard to his nutrition which included specific requirements that he be given only soft, moist and mashed food, with two specific exceptions and that he was to be supervised throughout meals on a one-to-one basis with a ten minute gap between food and drink and for ten minutes afterwards. The Care Plan stated it was �essential� the Plan was adhered to and specifically provided that if the requirements were not adhered to, Mr Seaby was at risk of aspiration and asphyxiation �which are potentially life threatening�. Evidence was heard that Mr Seaby was not always given food which complied with the Care Plan and he was not always provided with supervision in compliance with his Care Plan. On 21 May 2018, Mr Seaby�s food at lunchtime was not prepared in accordance with the SALT Care Plan.� Mr Seaby was not provided with the required one to one supervision during the lunchtime meal. During lunch Mr Seaby coughed while eating and brought some food back up. He cleared his throat and then appeared fine and finished the rest of his meal. At afternoon snack Mr Seaby brought up large amounts of phlegm and then coughed up anything he ate or drank. Mr Seaby was taken to see the General Practitioner by a member of staff who had not been with Mr Seaby during that day. No copy of Mr Seaby�s Daily Record was shown to the General Practitioner. Mr Seaby was given a working diagnosis of gastric reflux and his medication was changed. At teatime, Mr Seaby coughed/vomited his medication and yoghurt and drink. Mr Seaby vomited phlegm on two more occasions. The 111 service was called at 20.53 hours. The out of hours Doctor was spoken to at 22.45 hours following which emergency services were contacted and Mr Seaby was taken to Norfolk and Norwich University Hospital where he died on 22 May 2018. Following post mortem examination a slice of carrot was found in Mr Seaby�s throat.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] represented by Hodge Jones & Allen, solicitor, Serjeants Inn, counsel NCC represented [REDACTED] CQC represented [REDACTED] � I have also sent it to 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.

Care Home Health related deaths

The Oaks and Woodcroft Care Home

09/10/2023

2023-0377

Mark McKessy

Manchester South

The One Stockport Health and Care Board

On 24th February 2023 I commenced an investigation into the death of Mark Anthony McKessy. The investigation concluded on the11th July 2023 and the conclusion was one of Narrative: Died from the complications of decompensated alcoholic liver disease when agencies had not effectively shared information or recognised his needs until shortly before his death. The medical cause of death was 1a) Multi- Organ Failure; 1b) Pneumonia on a background of Decompensated Alcoholic Liver Disease; and II) Malnutrition.

Mark Anthony McKessy had learning disabilities and care needs. He lived in the community. His regular and prolonged use of alcohol led to him developing alcoholic liver disease. He had limited capacity to understand the risks that this presented to him due to his learning disabilities. The significant threat his lifestyle and health issues posed to his life was not recognised by agencies. There was limited information sharing by agencies and no understanding of how his learning disability was impacting his health. As a consequence his health continued to deteriorate. He was admitted to Stepping Hill Hospital and was diagnosed with decompensated alcoholic liver disease. He deteriorated and died at Stepping Hill Hospital on 18th February 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1)�[REDACTED]� on behalf of the Family; 2) Stockport Metropolitan Borough Council; and 3) Stockport 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.

Alcohol, drugs medication related death | Mental Health related deaths | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: The One Stockport Health and Care Board

12/10/2023

2023-0382

David Hall

Manchester South

The One Stockport Health and Care Board

On 16th March 2023 I commenced an investigation into the death of David Hall. The investigation concluded on the 2nd August 2023 and the conclusion was one of Narrative: Died from the complications of poor swallow which developed whilst an inpatient where admission had been due to a shortage of a suitable community placement and discharge was delayed due to a shortage of a suitable social care placement. The medical cause of death was 1a) Aspiration Pneumonia and COVID-19; II) Dementia

David Hall had dementia and was admitted to Stepping Hill Hospital as a consequence of there being no safe and suitable place for him to reside when his usual care arrangement could not continue. He was fit and ready for discharge and was awaiting a placement in a suitable care facility. Whilst in the acute hospital setting, he deteriorated rapidly. His nutritional requirements were not fully met and his swallow deteriorated, which led to further weight loss and ultimately to him developing aspiration pneumonia. Whilst an in-patient he contracted covid 19 which impacted his overall health further. He continued to deteriorate and died at Stepping Hill Hospital on 14th March 2023.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: The One Stockport Health and Care Board

22/03/2024

2024-0162

Finlay Finlayson

East Sussex

The Phoenix Partnership EMIS Health

On 04 February 2019 I commenced an investigation into the death of Finlay Stuart Ian FINLAYSON aged 54. The investigation concluded at the end of the inquest on 19 March 2024. The conclusion of the jury was that: � Narrative: we the jury consider that Vinney�s care was affected by the following issues, the absence of which may have delayed or changed the circumstances of his death. There was confusion and uncertainty about his medical conditions caused by information sharing and permissions issues with SystmOne, leading to an over reliance on Vinney�s own statements. Some poor record keeping on SystmOne and confusion over when to reference the system. This affected both plans and reporting of interactions. Failures in communication between agencies and shifts, not helped by the numbers of different staff and agencies involved, high demand and challenging workloads and associated delays in accessing healthcare. This was particularly relevant between 21 and 24 January 19. In particular we note: a lack of quantifiable evidence, e.g. NEWS scores or notes of proportionate follow-ups and recorded observations between 21 and 24/1/19 which may have allowed any deterioration in Vinney�s condition to be missed. On 25/1/19, there was a grave and unacceptable failure in communications with two or three emergency radios switched off in contravention of prison rules and protocols. This was then compounded by a delay in timely response, i.e. the proposal of a phone call rather than an in-person response, which may have been longer had it not been for decisive intervention from comms. This was followed by unacceptable indecision on calling an ambulance, in which perceptions of Vinney�s mental health were a factor, and should have been automatic on account of his head injury.

Vinney died of the causes in section 2 (pulmonary thromboemboli due to deep vein thrombosis with a background of metastatic carcinoma of the base of the tongue) following cardiac arrest on 25/1/2019 at HMP Lewes (Cell 216 on C-Wing), whilst on remand. He was pronounced dead at 9.16am.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Mr Finlayson�s family HMP LEWES Sussex Partnership NHS Foundation Trust Med-Co Secure Healthcare Services Ltd � I have also sent it to � NHS England Practice Plus Group � 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: The Phoenix Partnership | EMIS Health

30/07/2024

2024-0421

Derryck Crocker

Norfolk

The President, The Royal College of Emergency Medicine The President, The Royal Society of Medicine The President, The Royal College of Physicians The President, The Royal College of Surgeons The President, The Royal College of Anaesthetists

On 12 May 2023 I commenced an investigation into the death of Derryck Lynn CROCKER aged 77. The investigation concluded at the end of the inquest on 30 July 2024. The medical cause of death was: 1a) Iatrogenic Cerebral Gas Embolism 1b) Lung biopsy under computed tomography (CT) guidance 1c) 2)�Lung lesion, suspected cancer The conclusion of the inquest was: Died due to the delayed recognition and treatment of a rare, but recognised complication of a lung biopsy.

On 3 May 2023 Derryck Crocker attended hospital for a lung biopsy after previous investigations had shown a suspicious mass.� As part of the consent process the risks identified were bleeding/haemoptysis, infection, pneumonia, pneumothorax, insertion of chest drain & inadequate sampling.� Air embolism was not a risk consented for at that time. The procedure started at 13.00 hours & biopsies were taken at 13.18 hours.� Immediately after the samples were taken, Mr Crocker developed a cough.� He then became semi- unresponsive.� The resuscitation team were called and his blood pressure and oxygen saturations were said to be normal.� A CT scan was done at 13.29 hours and was said not to demonstrate any significant abnormality, especially no evidence of an air embolism in the chest. A CT head scan was also done which demonstrated some low-density areas in the brain and the possibility of a fat embolism was suggested, or an air embolism in the cerebro-vascular fluid.�� The CT scan was reported at 1606 hours with these possible diagnoses mentioned. This led to a discussion with the neurosurgical unit at Addenbrookes who advised that this was not a surgical issue, but that a Neuro-Radiologist should be consulted if local Radiologists needed further advice.� Care was then handed over to the resuscitation team. Mr Crocker�s family gave details of him being significantly unwell after he was taken to the Emergency Department.� On the balance of probabilities this was due to a cerebral air embolism caused by the biopsy, a rare but recognised complication of any invasive procedure. At 2004 hours a CT chest scan was ordered due to haemoptysis.� Mr Crocker collapsed in the CT department and had a brief seizure and then respiratory/cardiac arrest.� After 2 cycles of CPR, return of spontaneous circulation was achieved and he was transferred to ICU. After his condition had been appropriately stablised, the Trust�s Lead Consultant in the Hyperbaric Unit was contacted to discuss the possible benefit of delayed hypobaric treatment for the cerebral air embolism (evidence was that treatment is most effective if it is commenced within 4-6 hours of the embolism occurring).� It was agreed to commence such treatment and this took place on 3, 4 and 5 May 2023 but did not lead to an improvement in his condition.� On 7 May 2023 a diagnosis of a vegetive state was made and he was provided comfort care and end of life support and died at James Paget University Hospital on 10 May 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr Crocker�s Next of Kin James Paget University Hospitals NHS Foundation Trust For interest I am also sending a copy to the Royal College of Radiologists.� I am aware that they are already undertaking work with REAL and working on a training module. A copy will also be sent to: Department of Health Healthcare Safety Investigation Branch Healthwatch Norfolk NHS England and NHS Improvement 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: Royal College of Emergency Medicine | Royal Society of Medicine | Royal College of Physicians | Royal College of Surgeons | Royal College of Anaesthetists

13/03/2023

2023-0090

Lugh Baker

Cornwall and the Isles of Scilly

The Registered Manager, Bowden Derra Park Ltd, Launceston

On 13/3/23, I concluded an inquest into the death of Lugh Baker. The medical cause of death was recorded as: 1a) Unascertained II) � I recorded an Open Conclusion.

Lugh was a 24-year-old man with a diagnosis of Angelman�s syndrome. He suffered with epileptic seizures for which he was prescribed medication, and he had difficulty swallowing. At the time of his death, he was a resident at Rosewood House in Launceston which provided supported living for individuals with physical and/or mental disadvantages. � On 21/4/21, he was given prescribed medication with a chocolate milkshake at about 20:00. He was checked upon subsequently before being found unresponsive at about 23:30. CPR was initiated during the course of which an unsealed, partly-consumed chocolate bar was seen under or near his bed. � Lugh had a care plan that mandated he should not eat unsupervised and should eat sitting up. It is not known how the chocolate bar came to be found where it was. It is further not known if Lugh had been eating it immediately prior to his death. � Lugh could not be resuscitated. A post-mortem examination did not reveal evidence of airway obstruction. The evidence did not further or fully explain the means whereby the cause of death arose.

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

Care Home Health related deaths

Bowden Derra Park Ltd

13/02/2024

2024-0078

Blanche Knowles

West Yorkshire (Eastern)

The Registered Manager, Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, Leeds HC-One healthcare company Care Quality Commission

On 31st January 2024 I resumed an inquest into the death of Blanche Audrey Knowles, aged 91 years, which had been opened on 13th of September 2023. The investigation which has commenced on 7th September 2023 concluded at the end of the Inquest on 31st January 2024. A narrative conclusion was recorded after the conclusion of the evidence. � The medical cause of death was as follows: � 1a) Frailty of old age 2) Burns, multiple sclerosis, lschaemic heart disease, hypertension, previous stroke The Narrative conclusion was recorded as follows: �Blanche Audrey Knowles died of frailty of old age contributed to by the effects of long� standing medical conditions and the effects of burns suffered as a result of a hot drink being accidently spilled into her lap the temperature of which had not been adequately checked�.

Blanche Audrey Knowles had a number of health conditions and was admitted for general nursing care within Whitkirk House, Colton Lodges Nursing Home, 2 Northwood Gardens, Colton, Leeds on 7th November 2022. � On 15th July 2023 she was served a drink in a beaker cup the temperature of which had not been adequately checked by a staff member. � The evidence heard at the inquest was that a �warm drink� would be comprised of �aired water� topped by cold water and that a member of staff would check the temperature of the cup/beaker by way of applying their wrist to the same. � Blanche was not assisted with the beaker and it spilled causing her to suffer burns which upon assessment by a General Practitioner led to admission to hospital in the early hours of 16th July 2023. It was wholly apparent from the injuries that Blanche suffered that the temperature of the drink had not been checked in an adequate manner. � The paramedics who attended Blanche on 16th July 2023 recorded that: � �The injury occurred on 1517/2023 17.30. Mechanism of injury: Burn: thermal. Pt was given hot water to drink which pt spilt between her legs. Pt had cold compress/towels applied but no active cooling by running water for 20 mins. Pt was given Paracetamol at the time. GP OOH visit arranged-Ambulance called ppst GP assessment �� � Blanche was admitted to hospital in the early hours of 16/7/2023 and discharged on the same day. Thereafter she was treated and monitored accordingly. � On 14th August 2023 paramedics were called as she was presenting with unresponsive episodes, weakness to her right side and difficulty with speech. Upon General Practitioner attendance she was prescribed antibiotics for a chest infection. Thereafter Blanche remained frail and on 29th August 2023 palliative care and anticipatory medication was discussed. � On 1st September 2023 her condition deteriorated and she passed away her death being confirmed at 0930 hours.

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

Care Home Health related deaths This report is being sent to: Colton Lodges Nursing Home | HC-One Healthcare Company | Care Quality Commission

24/04/2020

2023-0122

Russell Curwen

Lancashire and Blackburn with Darwen

The Right Honourable Grant Shapps � Secretary of State for Transport Great Minster House 33 Horseferry Road London SW1P4DR

On the 15th May 20181 commenced an investigation into the death of Russell Curwen aged 49. An inquest has yet to be concluded.

CIRCUMSTANCES� OF THE DEATH � On Saturday 5th May 2018 Mr Curwen, a volunteer with the North West Blood Bikes, was transporting blood samples from 5 patients at the Westmoreland General Hospital to the out-of� hours biochemistry unit at the Royal Lancaster Infirmary. He was riding a BMW red and yellow liveried blood bike R1200, equipped with blue flashing lights and sirens. At around 19:45 he was riding his bike along the A6 Caton Road, Lancaster, �using the fitted sirens and lights. Whilst travelling through the junction of the A683 and A589 he travelled through a traffic light, against the lights, colliding with a vehicle travelling through the lights, causing injuries that proved fatal later at the Royal Lancaster Infirmary.

I have sent a copy of my report to the Chief Coroner and I have also sent it to: Lancashire Constabulary; Nationwide Association of Blood Bikes; North West Blood Bikes; Police Commissioner for Devon and Cornwall; 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�your response by the Chief Coroner.

Other related deaths | Road (Highways Safety) related deaths This report is being sent to: Department for Transport

12/04/2024

2024-0194

James Baxter

Berkshire

The Right Honourable Mark Harper MP, Secretary of State for Transport

On 5th September 2022 I commenced an investigation into the death James Ferris Baxter aged 78. The investigation was discontinued by the issue of coronial Form B on 31st January 2023, without inquest.

Mr Baxter was a qualified and lawfully licensed passenger carrying coach driver. He held a valid Category D licence authorising him to drive a PCV, issued on 3rd December 2021. He died on 4th September 2022 at Junction 15 of the M25 motorway, while driving a single deck Mercedes Benz coach. It has been determined by post mortem that he died from an acute right coronary artery thrombosis secondary to plaque rupture, due to severe ischaemic heart disease.� This was a natural cause of death. He was at the wheel and actually driving, with 25 passengers on board, when he suffered this medical episode causing the coach to crash. A passenger managed to take over control of the moving coach which was brought to a stop by collision with a safety barrier, causing some minor injury to some passengers and minor damage to the vehicle.

I have sent a copy of my report to the Chief Coroner and to [REDACTED} (next of kin), Thames Valley Police Roads Policing, Ryminster Medical Services Limited (trading as D4Drivers UK), and Westbus Coach Services Ltd I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: Department for Transport

30/12/2022

Category: Accident at Work and Health and Safety related deaths This report is being sent to: Department for Work and Pensions | Health and Safety Executive 2023-0004

Malcolm Basten

Surrey

The Right Honourable Mel Stride Secretary of State for Work and Pensions [REDACTED], Chief Executive of the Health and Safety Executive

The inquest was opened on the 14th March 2016 and resumed and concluded before a Coroner sitting with a jury on the 19th October 2022. The cause of death was: 1a. Cerebral Oedema 1b. Acute and Subdural Haematoma (Operated) 1c. Head and Chest Injuries The jury found that: Mr Basten died on 28th February 2016 at St George�s Hospital, Tooting while in care for head and chest injuries sustained on 25th February 2016. These injuries were sustained during a fall which took place while working at a height on a construction site in Chaldon. Following the incident, Mr Basten was airlifted to St George�s Hospital, where he was diagnosed with an acute subdural haematoma. Mr Basten was operated on for the acute subdural haematoma but following the operation he suffered a cerebral oedema to which he succumbed. Mr Basten had been engaged as a carpenter to work on the roof and started work before the end of January 2016. On the morning of 25th February 2016 Mr Basten was working on the first-floor dormer at the rear of the property at a height of at least 2.5m. This first-floor area was comprised of open wooden joists and an RSJ suspended at least 2.5m above concrete and wooden board. There was no safe internal access to the first floor. This area did not have edge protection and was not completely boarded out. On the day in question, this area was access via an unsecured scaffold ladder. There is no material evidence of planning for the first-floor timberwork regarding health and safety. There was no site supervisor at the time of the incident. The Conclusion was Unlawful Killing

27/03/2023

2023-0106

Kayleigh Burns

Warwickshire

The Right Honourable Mr Dominic Raab � Secretary of State for Justice.

On 17 June 2022, I commenced an investigation into the death of Miss Kayleigh Burns. The investigation concluded at the end of the inquest on 24th March 2023 at Warwick Coroners Court. The medical cause of death was confirmed as 1a inhalation of Nitrous Oxide compounding Asthma.

Miss Burns was 16 years old and suffered from asthma. On the 3rd June 2022, Kayleigh visited a friend�s flat in Stratford upon Avon. Whilst there she ingested the contents of a number of nitrous oxide cannisters. She started to wheeze and used her blue inhaler. She declined an ambulance and collapsed as she was going outside to get air. An ambulance was called and her friend performed CPR. She was resuscitated but died the next day at University Hospital Coventry & Warwickshire. The medical cause of death was inhalation of Nitrous Oxide compounding Asthma. I concluded that her death was drug related (ie inhalation of Nitrous Oxide) in the context of Asthma.

I have sent a copy of my report to the following: 1.��HHJ Teague QC the Chief Coroner of England & Wales Chief Coroner�s Office. chiefcoronersoffice@judiciary.gsi.gov.uk 2.�The family of Miss Kayleigh Burns I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Child Death (from 2015) | Alcohol, drugs medication related deaths

Ministry for Justice

20/04/2023

2023-0128

Joseph Maunick

Suffolk

The Right Honourable Steve Barclay MP Secretary of State for Health and Social Care 39 Victoria Street London SW1H 0EU � Mrs Amanda Pritchard Chief Executive for NHS England PO Box 16738 Redditch B97 9PT

On 18th March 2022 an investigation was commenced into the death of Joseph Willy Maunick. � The investigation concluded at the end of the inquest on 18th April 2023. The narrative conclusion of the inquest was that: � Joseph Willy Maunick (Will) died on 15th March 2022 as a result of a severe head injury that he suffered in a fall in the Emergency Department of West Suffolk Hospital on 4th March 2022. He was in the Emergency Department as a social admission, while his wife was going through unplanned emergency major surgery. � Will was not safe to be left alone at home and required care around the clock. Exhaustive efforts to find appropriate care while his wife was in hospital were unsuccessful, so he had been admitted to a hospital Emergency Department as a last resort. This was not the most suitable environment for a gentleman with dementia who was a falls risk and required constant supervision. The situation was exacerbated by pre-existing severe pressures on the Emergency Department on that day due to high demand for beds, without the availability of beds to meet the demand, and a severe deficiency of staff. The scarcity of resource, relative to demand, at the hospital also contributed to Will not being transferred to a ward sooner. While there was no specific failure by an individual that contributed to the death, Will�s death was contributed to by the lack of availability of more appropriate care. � The medical cause of death was confirmed as: � 1(a) Subdural Haematoma 1(b) Fall 2 Dementia, Complete Heart Block, Frailty

Joseph Willy Maunick (Will) was an intelligent man, gifted with communication skills, who worked as a teacher and spoke multiple languages. In his later years he developed cognitive impairment, which in turn led to him being at very high risk of falls. This risk, in relation to which he needed constant supervision, was known to those caring for him and to those responsible for looking after him when he was admitted to the Emergency Department of the West Suffolk Hospital on 4th March 2022. He was admitted to the hospital Emergency Department not because he himself was experiencing a medical emergency, but as a last resort after exhaustive efforts to explore all options before Will was admitted to hospital: it proved not to be possible to find suitable alternative care for him in residential care placements while his wife, and main carer, underwent unplanned emergency major surgery. � The inquest heard evidence that, prior to his admission to hospital, at least eight social care providers were contacted plus further residential homes, but none of them could provide emergency care for Will. The inquest heard undisputed evidence that this was an instance of a national care shortage. � The inquest heard evidence that in an Emergency Department where many patients are suffering medical emergencies constant one-to-one supervision will not always be possible. I found as a fact that it was not possible on this occasion and that Will�s fall in the Emergency Department took place when the nursing assistant who was trying to maintain constant one-to-one supervision of Will insofar as possible had their attention momentarily diverted to another patient experiencing a medical emergency. I judged that it would not be just to describe this as a failure on the part of the nursing assistant or the Emergency Department staff. � The reason why it was not an individual failure included that the inquest heard evidence that the hospital, and in particular the Emergency Department, was experiencing significant pressures associated with high demand and an internal critical incident had been declared. There was a high demand for beds within the hospital without the availability of beds to meet the demand. This included the facts that there were, at the time of Will�s arrival in the Emergency Department, 50 patients in the Emergency Department, of whom 32 were waiting for bed placement. Moreover, staffing was at a �black status� (the worst level) across the hospital, with a deficiency of staff of around 60 nurses and nursing assistants. � I found as a fact that those severe pressures � the high demand levels and the deficiency of staff and scarcity of resource � contributed to the death. Firstly, if it had been possible to care for and supervise Will on a constant basis as he needed, then on the balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged. � Secondly, on the balance of probabilities, the scarcity of resource relative to demand contributed to Will not being transferred to a ward � or other more appropriate environment � sooner. � Apart from the inherent particular difficulties in providing constant supervision in an Emergency Department referred to above, the inquest also received undisputed evidence that the environment of a busy, noisy Emergency Department, with lights on at all hours of the day and night would be overly stimulating and not the most suitable environment for someone with cognitive impairment who was experiencing confusion and agitation. I found that such an environment probably contributed to Will�s inclination to wander and so to his fall. � If it had been possible to transfer Will to a more suitable environment sooner, then on the balance of probabilities the fall that led directly to his passing would have been prevented and his life would have been prolonged. � I found as a fact that, on the balance of probabilities, the lack of availability of more appropriate care contributed to the death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] �������� West Suffolk NHS Foundation Trust �������� Norfolk County Council �������� Norfolk & Suffolk 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 | NHS England

09/11/2023

2023-0453

Christopher Hart

Suffolk

The Right Honourable Steve Barclay MP Secretary of State for Health and Social Care House of Commons London SW1A 0AA

On 11 November 2022 I commenced an investigation into the death of Christopher Ivan HART aged 50. The investigation concluded at the end of the inquest on 27 October 2023. The conclusion of the inquest was that: � Narrative Conclusion The medical cause of death was confirmed as: 1a Coronary Artery Atherosclerosis

On the 25th October 2022 Christopher Hart was declared deceased at his home address of 30 Old Barrack Lane, Woodbridge in Suffolk. � Christopher had become unwell at approximately 01:00 on 25th October 2022, and an ambulance was requested via a 999 call. � Due to high service demand, and ambulances waiting to off-load their patients at the local hospitals, no ambulance was immediately available. The 999 call had been coded at Category 2 , with an average expected response time of 40 minutes, and a target attendance time of 18 minutes. � At approximately 09:30 a family member visited Christopher�s home, finding him unresponsive and not breathing on the lounge floor. East of England Ambulance Service attended, but Christopher could not be resuscitated. His death was recognised at 09:35 on the 25th October 2023. � A subsequent post-mortem examination identified that cardiac condition was responsible for Christopher�s death. The delay in an ambulance attending meant that potentially life saving treatment could not be given, so that delay directly contributed to Christopher�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] � I have also sent it to � East of England Ambulance Service NHS 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.

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

07/11/2023

2023-0435

Gina Bywater

Suffolk

The Right Honourable Steve Barclay MP Secretary of State for Health and Social Care House of Commons London SW1A 0AA

On 16 December 2022 I commenced an investigation into the death of Gina Marie BYWATER aged 36. The investigation concluded at the end of the inquest on 01 November 2023. The conclusion of the inquest was that: � Narrative Conclusion � Natural causes due to an untreated cardiac condition, the death being contributed to by a delay in attendance of an ambulance, that delay being caused by extreme resource pressures on the ambulance service at the time. � The medical cause of death was confirmed as: � 1a Acute Myocardial Infarction 2 Fatty Liver, Pancreatic Cyst and Fibrosis

On the 13th December 2022 Gina Bywater was declared deceased at her home address [REDACTED] in Suffolk. � Gina had become unwell at approximately 22:00 on 12th December 2022, with vomiting and shortness of breath. � An ambulance was requested via a 999 call at 00:01 hours on the 13th December 2022, but due to high service demand, and ambulances waiting to off-load their patients at the local hospitals, no ambulance was immediately available. � A second 999 call was made at 01:08 stating that Gina was now suffering chest pains, and a third was made at 04:07, but again no resources were available. � All of the 999 calls had been coded at Category 2 , with an average expected response time of 40 minutes, and a target attendance time of 18 minutes. The East of England Ambulance service made a welfare call at 09:36, and during this call it was identified that Gina had gone into cardiac arrest. � A Category 1 response was therefore initiated and an ambulance arrived with Gina at 09:45. A subsequent post-mortem examination identified that she had died as the result of a heart attack. � The delay in an ambulance attending meant that lifesaving treatment could not be given, so that delay directly contributed to Gina�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1.�Gina�s next of kin. 2. East of England 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 form. He may send a 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.

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

22/05/2023

2024-0238

Michael Bray

Suffolk

The Right Honourable Steve Barclay MP Secretary of State for Health and Social Care � [The East of England Ambulance Service NHS Trust]

On 15th October 2021 an investigation was commenced into the death of Michael James Francis Bray. � The investigation concluded at the end of the inquest on 16th February 2023. The Jury�s narrative conclusion of the inquest was that: Michael Bray died by way of misadventure. � Points that possibly contributed to Michael�s death include: � The Fast Action Response Plan, and whether it should have been updated to include risks arising from the near-miss on 23 September 2021 and PC Cook�s view by 4th October 2021 that the risks of suicide / misadventure had risen to high. � Whether the Police should have deployed resources upon learning, at about 2.02am on 10th October 2021, that Michael was no longer on the telephone to the mental health professionals together with the knowledge that an ambulance could take up to 120 minutes to arrive. � Whether the Ambulance Service should have asked Police to deploy a resource because of delays in sourcing an available ambulance. � The Ambulance Service omission to bring the Police declining to attend, at about 3.18am, to the attention of the Ambulance dispatcher, leading to a one- hour delay in the dispatcher becoming aware that Police would not attend. � The appropriateness of the ambulance crew�s dynamic risk assessment on arrival at Michael�s home address and their decision not to approach his house and check his door and check welfare. � The period of time taken for the ambulance crew to chase for the whereabouts of Police attendance. � The timing of any escalation of the Ambulance Service request for Police attendance. � Shortcomings in software and communication systems, amongst agencies � Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned. The sharing and agreement of actions, at times lacked urgency. � The police failing to complete a welfare check after an initial call from the Crisis Team. � The medical cause of death was confirmed as: 1(a) Hanging

The Jury�s answer to how, when, where and in what circumstances the deceased came by his death was: � Michael Bray was at home on 9th and 10th October 2021 He had been drinking alcohol and called the Crisis Helpline stating [REDACTED] considering hanging himself. After the call, he proceeded, resulting in his death sometime between 1:55-5:53, 10th October 2021 � After the conclusion of the evidence, I ruled that on the evidence the Jury could not safely make any finding of fact on the balance of probabilities on the precise time of death other than that death occurred between about 1.50am and 5.53am on 10th October 2021. The Jury were directed to, and did, answer the question of when the deceased died accordingly. � A notable feature of this case was a lack of availability or provision of an ambulance to respond in a timely manner to the deceased�s Category 2 call, which contributed to a considerable delay. � On the evidence, the national ambulance target response time for a Category 2 call is an average of 18 minutes, with 90% of calls to be responded to within 40 minutes. In this case, the ambulance response took a period of time in the hours, considerably greater than the target response time.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The Bray Family (in particular [REDACTED], the deceased�s son, and [ REDACTED], the deceased�s wife) [REDACTED] The Chief Constable of Suffolk Constabulary Norfolk & Suffolk NHS Foundation Trust � I am under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards) | Suicide (from 2015) This report is being sent to: Department of Health and Social Care | The East of England Ambulance Service NHS Trust

13/11/2023

2023-0446

Roger Stevenson

Mid Kent and Medway

The Right Honourable Steve Barclay MP, Secretary of State for Health and Social Care [REDACTED], Chief Executive NHS England

On 18th October 2022 I commenced an investigation into the death of Roger Adrian Stevenson, age 28. � The investigation concluded at the end of the inquest on 29th September 2023. The conclusion of the inquest was a narrative stating: � �Roger Adrian Stevenson was found deceased in room [REDACTED] which is accommodation in which he had been staying. He was found deceased on the 2nd of May 2022 having last been seen alive on CCTV on the 30th of April 2022. Post-mortem evidence indicates that he had a morphine blood level [REDACTED] which in a range that could have been fatal to him. He had a lengthy history of mental health issues and had been lost to the mental health services in the months leading to his death.� � The medical cause of death was recorded as: 1(a) Fatal toxic morphine intoxication

Roger Stevenson was found deceased in his room at [REDACTED] (being state funded supported accommodation) during the early hours of the 2nd of May 2022, he was last known to be alive (from CCTV footage) on the afternoon of Friday 30th April 2022. The post mortem evidence including toxicology has established that the medical cause of death was fatal toxic morphine intoxication. � While Roger�s death was initially not treated as suspicious a later disclosure by another resident led to police investigation [REDACTED] . � It was believed that Roger had been abstinent of drugs for some time prior to this. No evidence, beyond the account of the other resident (who failed to attend court to give evidence), was identified from which any intention by Roger to self-harm could be inferred. � The evidence indicated that Roger had become lost to mental health services through the local NHS Trust, namely Kent and Medway NHS and Social care Partnership Trust (�KMPT�). Roger had last been formally assessed under the Mental Health Act in July 2021 although on that occasion he was not assessed to be detainable. No 72 hour follow up, after Roger was discharged, was carried out. No consideration appears to have been had to the provision of depot type injections to help Roger to comply with his Quetiapine regime. � Roger had engaged with other community services including Kent Enablement Recovery Service. However family concerns were highlighted that Roger would go through a cyclical pattern of illness in which he would have placid periods and in which he would be told to engage with community services but there were not arrangements in place to ensure that he did so. It was then felt that only when Roger had manic periods of crisis would mental health services become significantly engaged with him. � The family highlighted concerns about a lack of communication and multidisciplinary approach between agencies (including Kent County Council and KMPT) to assist Roger into maintaining a stable lifestyle rather than a position where the cyclical pattern of mental health issues would continue (depot injections being one example). � It was identified that Roger had been transferred between Community Mental Health Team in Medway and Maidstone, delays in these transfers occurred and it was shown that transfer policies were not followed so far as written and ,as bets practice face to face, handovers were concerned. It was also identified that Roger was among 149 individuals awaiting allocation of a care co-ordinator owing to KMPT resourcing issues.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the family and Kent and Medway NHS and Social care Partnership 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.

Alcohol, drugs medication related deaths | Mental Health related deaths This report is being sent to: Department of Health and Social Care | NHS England

30/06/2023

2023-0222

Victoria Storey

Surrey

The Right Honourable Suella Braverman KC MP, Secretary of State for the Home Department The Right Honourable Alex Chalk KC MP, Lord Chancellor and Secretary of State for Justice, Ministry of Justice,

The inquest into the death of Victoria STOREY was opened on 24th January 2023. Evidence was heard and the inquest was concluded on 26th June 2023. � I found the medical cause of death to be: 1a. [REDACTED] Toxicity I determined that Victoria took an accidental overdose of [REDACTED], a potent synthetic opioid not licensed for medicinal use. Victoria had a history of opioid dependency, exacerbated by historic necessary medicinal use and to alleviate Post Traumatic Stress Disorder following a traumatic assault aged 18. I did not find any evidence she had intended to take her own life. The source of the [REDACTED] could not be traced despite Police interrogation of her electronic devices. � I recorded a short form conclusion of Drug Related.

Victoria was found deceased in her bedroom on the evening of 3rd September 2022. Toxicology found she had low therapeutic levels of prescribed drugs; a higher level of Venlafaxine �consistent �with �chronic �(not �acute) �dosage �and [REDACTED] of [REDACTED]in her post mortem blood; which the Toxicologist stated �contributed more than minimally, and possibly substantially, to the cause of Ms �Storey�s death�.�[REDACTED] containing [REDACTED]were found in Victoria�s bedroom. The Pathologist recorded a cause of death of 1a) Mixed drug (mainly [REDACTED]) toxicity). Having considered the Toxicology evidence in respect of the other drugs being at low levels, save for Venlafaxine which was stated to be at a level consistent with chronic dosage, I amended the cause of death to 1a) [REDACTED]Toxicity. I heard evidence from a Drug Expert with Surrey Police that [REDACTED]is not sold under that name, but is often marketed as one of the common pharmaceutical opiates, so the danger of taking this illegal substitute would not be known to the end user.

COPIES I have sent a copy of this report to the following: 1.��See names in paragraph 1 above 2. [REDACTED] 3. 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.

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

16/09/2023

2023-0344

Sienna Monterio

Blackpool & Fylde

The Royal College of Obstetricians and Gynaecologists 10-18 Union Street, London Bridge, SE1 1SZ � The Royal College of Paediatrics and Child Health 5-11 Theobald�s Road London WC1X 8SH � NICE � National Institute for Health and Care Excellence � �National Institute for Health and Care Excellence �Level 1A, City Tower �Piccadilly Plaza �Manchester �M1 4BT

The death of Sienna Scarlett Monterio, on 6th April 2022 at Blackpool Victoria Hospital was reported to me and I opened an investigation, which concluded by way of an inquest on 15th September 2023. � I determined that the medical cause of Sienna�s death was 1 a Fetal-maternal haemorrhage � In box 3 of the Record of Inquest I recorded as follows: � Sienna Monteiro was born in hospital in Blackpool on 6th April 2022. Earlier that morning, her Mother rang the hospital to report a lack of fetal movements and was appropriately asked to attend the maternity day unit, arriving within 30 minutes. There had been no noticeable fetal movements since the previous evening. It is likely that a fetal-maternal haemorrhage had occurred during the previous afternoon or early evening, and at around the time her Mother was admitted to hospital Sienna would have been experiencing some mild hypoxia. Upon being triaged, and with a concerning CTG trace, plans were made for Natalie to go the delivery suite for continued observations. Sienna was delivered by way of an emergency caesarean section at 10.18 hours. Sienna was pale and was handed to the neonatal team and she was given ventilation breaths. A Consultant Paediatrician attended when Sienna was four minutes old. Sienna remained on the delivery unit so she could be stabilised prior to her transfer to the neonatal unit for ongoing care, which would have included establishing IV access through an umbilical cord catheter. There were difficulties in trying to intubate Sienna. At around 77 minutes of age, there was no detectable heart rate. CPR was commenced but after 20 minutes of resuscitation with no cardiac output, this was stopped when there were no apparent signs of life and death was confirmed at 11.59 hours that morning. A subsequent paediatric post � mortem report revealed Sienna died due to a severe fetal � maternal haemorrhage, which occurs when there is a passage of fetal blood into the maternal circulation. Prior to Sienna being born, there had been no clear indication of a fetal maternal haemorrhage. In part due to what appeared to be effective lung inflation, and a reassuring heart rate, the extent of fetal compromise was not fully appreciated. Sienna suffered a delayed collapse from which she could not be resuscitated, caused by significant blood loss and hypoxia. The blood loss needed to be replaced if she was to respond to ventilation. This fetal � maternal haemorrhage was a very rare occurrence as there had been incomplete haemodynamic recovery by the time Sienna was born. Given the circumstances at the time, there was nothing the clinical team could have done to avoid the fatal outcome. � In addition to the above, I wish to note that I made the following findings: That investigation revealed no significant failings in the antenatal care received, nor in relation to the obstetric care provided;That earlier attendance at the hospital once a reduction in felt movement was suspected would not have altered the outcome; � In box 4 of the Record of Inquest I determined that Sienna died due to: � Natural causes

In addition to the contents of section 3 above, the following is of note: � In advance of the inquest, the court received a maternity investigation report from the Healthcare Safety Investigation Branch [HSIB] which included the following finding: �Paired cord blood gas samples were taken at the time of birth of the Baby. The blood gas analyser was not set to analyse the haemoglobin. This prevented other possible causes for the Baby�s condition being considered and possibly corrected.� � At the end of that report, this recommendation was made: �The Trust to ensure a blood gas analyser with an Hb (haemoglobin) measurement facility is available in all neonatal resuscitation settings to support the provision of clinical information, and to optimise decision making processes and clinical care.� � Despite the fact that in Sienna�s case I found that it did not contribute to her death, nevertheless, having considered the evidence received at inquest, I have a concern that this issue may pose a risk in future. Haemoglobin is the protein in red blood cells that carries oxygen to the body�s organs and tissues. If a blood test reveals that haemoglobin levels are lower than normal this is known as anaemia. � [REDACTED] [independent Obstetrics & Gynaecology witness] told the court that although in his experience the blood gas analyser facility is usually turned on, he had recently been involved in a significant piece of work analysing maternity incidents within another hospital trust and found that it is variable whether this function is turned on or not; � [REDACTED] [independent Consultant Neonatologist] echoed [REDACTED] comments, and said he that rather than having to rely on clinical observation only, were clinicians to have this blood gas analyser data in the event of a low haemoglobin level in the blood cord gas, this may provide additional insight. He went on to say that personally, he could see no potential disadvantage in having the Hb measurement being readily available in the cord blood gas from a clinical perspective; � The court also received some helpful information from Blackpool Teaching Hospitals NHS Foundation Trust on this issue which included the following: � ������� that cord blood haemoglobin analysis is not a standard requirement and does not form part of the Newborn Life Support (NLS) process; � ������� that according to guidance from The British Journal of Haematology, the current position is that cord blood testing is not regulated or included in the Newborn Life Support (NLS) process at a national level and that there remain concerns regarding the reliability of samples tested by the blood gas analyser; � ������� that against this background nationally, from a local perspective the Trust in Blackpool are considering whether there may be steps that can be taken locally, despite there being no national requirement for the same, to use cord blood sampling as a screening tool to assist in ongoing treatment. The Trust add they are acutely conscious that no snap decision should be made and that careful consideration is given to the matter such that the Trust can be reassured that any changes made locally are both safe and appropriate in the clinical setting. As Senior Coroner for this coroner area, I regard that approach as reassuring. � However, having considered all of the above, I have determined that I have a duty to write this report.

8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � ������� [REDACTED] [Parents of Sienna] ������� The Director of North West Neonatal Operational Delivery Network ������� Medical Director of 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.

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

23/11/2023

2023-0465

Charlotte Burton

Cambridgeshire and Peterborough

The Royal College of Physicians Department of Health NHS England

On 7 October 2021 an inquest in to the death of Charlotte Burton was opened. Charlotte died on 28 November 2020. The investigation concluded at the end of the inquest on 15 November 2023. The conclusion of the inquest was: � Medical Cause of Death: � 1a. Acute left ventricular failure � 2. Morbid obesity and pre-eclampsia associated with cardiomyopathy � Conclusion � Died from a naturally occurring condition, the treatment for which did not commence in time to avoid death.

1. Charlotte Burton was aged 40 when she became pregnant with her second child. She had a BMI of 45 and was using methadone as part of her treatment plan. As a result, she was under regular surveillance during her pregnancy and had regular growth scans as her age, BMI and methadone use all placed her in the high-risk category. � 2. While some concerns were raised regarding care during pregnancy, labour and immediately after delivery, which were investigated by the HSIB and reviewed by an independent expert Obstetrician, none of these were causative of Charlotte�s death. � 3. Charlotte returned to hospital on 27 November 2020. While speaking to a neonatal nurse, she was increasingly short of breath, she coughed up blood and was transferred to the emergency department. � 4. In considering the care provided to Charlotte at this stage, expert evidence in the fields of Obstetrics, Intensive Care Medicine & Anaesthesia and Cardiology. � 5. Based on the expert evidence it was found that from the time Charlotte arrived in the ED, she had a number of signs and symptoms which pointed towards a likely respiratory and/or cardiac pathology which included shortness of breath, coughing up blood, fast respiratory rate requiring supplemental oxygen, bilateral lung crepitations and hypertension. � 6. The initial medical review was reasonably comprehensive and the differential diagnosis and management plan appropriate, and appropriate blood tests and investigations were requested. The junior doctor quite appropriately included cardiomyopathy in the differential diagnosis. � 7. Charlotte was given Frusemide due to concerns about heart failure and pulmonary oedema. As heart failure was being considered, the high blood pressure should also have been addressed. Expert evidence was that Frusemide should have been given twice a day, so a further dose should have been given around 1900 hours. � 8. Charlotte had a raised NT-proBNP level and this is a test for heart failure, but can also be raised with pre-eclampsia. A chest x-ray was said to be difficult to interpret, but did have signs of significant pulmonary oedema. � 9. A history of Charlotte having to sit on the side of her bed to catch her breath when she got up in the morning, was also said to be consistent with signs of heart failure. 10. Witness evidence from two of the Consultants (in Obstetric Anaesthesia and Nephrology) who reviewed Charlotte was that there had been some consideration of cardiac issues, which is supported by the medication prescribed, the undertaking of an echo and a decision to transfer to the coronary care team. However, neither was aware of whether or not there had been a review by a Cardiologist and the Trust�s representative checked the records and confirmed that the echo was performed by a suitably qualified technician, but that there had been no cardiology input. � 11. The expert Cardiologist was of the view that the treating Consultants had been falsely reassured by the echo showing a preserved ejection fracture and that this distracted everyone from understanding that the ventricle was having to work very hard, didn�t relax properly and that the heart was backing up and causing the pulmonary oedema. � 12. The expert accepted that it is much more common in older women and that to find it post pregnancy in a woman in her 40s was unusual. She stated that she would not expect them to have a full knowledge, but would expect an understanding that the NT proBNP and pulmonary oedema could be related to heart failure. � 13. In light of the findings of the various examinations, the treating team should have considered diastolic heart failure as a likely cause of the pulmonary oedema which should have led to IV frusemide, glyceryl trinitrate (or a suitable alternative), oxygen and treatment of the hypertension. � 14. There were operational issues that delayed a transfer to the coronary care team. The inquest also heard evidence from the treating clinicians that the Trust does not have any Cardiology cover, not even on call, after 5pm weekdays or at the weekend. It was stated that this was not an issue unique to this Trust and that there is a nationwide shortage of trained Cardiologists. The Trust does have the option to call Cardiologists at other hospitals, but there is no provision for on site assessment by a Cardiologist out of hours and transfer is often not possible due to severity of illness or the timescales involved. � 15. It was found that had the nature of Charlotte�s condition been recognised, she should have been prioritised for a bed on either the coronary care unit or ICU. Had Charlotte been under the care of ICU or specialist cardiac nurses, they may have recognised the need for cardiology input and discussed this with the on call Physicians to consider seeking advice. It was accepted that that this would not have led to a transfer in Charlotte�s case, but on the balance of probabilities would have led to the Cardiologists or ICU clinicians giving the advice that experts recommended for appropriate treatment. 16. Although Charlotte�s condition did improve by around 1745 hours, she remained short of breath on minimal exertion and by 1930 hours was again requiring oxygen. From 2025 hours her respiratory rate and blood pressure were significantly elevated and oxygen saturations were persistently low. There should have been urgent escalation when Charlotte began to deteriorate again by 1930 hours. � 17. By the time the deterioration was recognised at 2245 hours, and intubation occurred at 2315 hours, this was sadly too late and was shortly followed by a cardiac arrest. Had the appropriate treatment, under the advice of a cardiology or intensive care specialist commenced between 1900 and 2100 hours, Charlotte would not have died when she did.

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

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

24/10/2023

2023-0405

Tracy Gambrill

South Yorkshire (Western)

The Royal College of Surgeons of England The General Medical Council NHS England The Society of British Neurological Surgeons

On the 29th of November 2016 I commenced an investigation into the death of Tracy Gambrill. The investigation concluded at the end of the inquest on 20th October 2023. � The conclusion of the inquest was On the 7th of November 2016 Tracy Gambrill underwent a neurosurgical operation at the Royal Hallamshire Hospital, intended to ameliorate her seizure symptoms of epilepsy. An incision made from the insular and intended to find the temporal horn was made at the wrong trajectory. Prior to that incision it is probable that her head position, previously fixed, had moved, a matter of which the surgeon remained unaware. The incision made was excessively deep and caused significant damage to Tracy�s brain. Two further attempts were made at different trajectories to locate the temporal horn with the last utilising a neuro-navigation system to assist. Both were excessively deep. On being woken from the anaesthetic it was immediately apparent that Tracy had sustained serious brain injury. She died in hospital on the 19th of November 2016. On the balance of probability, it is likely that Tracy would have died as a result of the damage caused by the first incision. � The cause of death was recorded as: 1a Cerebral oedema and focal infarction 1b Iatrogenic damage to diencephalic and brain stem structures 1c Refractory epilepsy (operated 7th November 2016)

On the 7th of November 2016 Tracy Gambrill underwent an amygdalohippocampectomy using the Trans-Sylvian approach. The Sylvian fissure was opened without incident. From there the surgeon made three incisions from the insular, intending to find the Temporal Horn. The first incision was measured from post-mortem images as being 5- 6cm in length. Having not found the Temporal Horn a second incision was made at a different trajectory. This again failed to find the Temporal Horn and was measured (post- mortem) at 6-7cm. The third trajectory was made with the assistance of a neuronavigational system and measured (post-mortem) 5cm. Tracy died following the operation. From the evidence it is likely that Tracy would have died following the first incision. Prior to that incision it is probable that her head position, previously fixed, had moved, a matter of which the surgeon remained unaware.

I have sent a copy of my report to the Chief Coroner and to the following Interested Person: Tracy Gambrill�s family [REDACTED] Sheffield Teaching Hospitals 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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: The Royal College of Surgeons of England | The General Medical Council | NHS England | The Society of British Neurological Surgeons

27/11/2023

2023-0477

Jennifer Whinney

Inner North London

The Royal London Hospital Queens Hospital

On 17 November 2022 an investigation was commenced into the death of Jennifer Ruth Whinney aged 68. The investigation concluded at the end of the inquest on 17 November 2023. I made a determination at inquest that Jennifer died of multi-organ failure following septicaemia from infective PICC lines and following successful surgery to repair a bowel fistula. The medical cause of death was 1a. multi-organ failure, 1b. septicaemia, 1c. recurrent line sepsis, enterocutaneous fistula repair, 2. ischaemic heart disease, hypertensive heart disease.

In 2017 Jennifer underwent an emergency resection of her left colon and a stoma formation at Queens Hospital due to an ischaemic bowel. A small area of the wound failed to heal and she was reviewed at Queens Hospital on several occasions in 2021 and 2022. She then presented to Queens Hospital as an emergency on 19 April 2022 when a large wound had opened up and was discharging fluid and bowel contents. A scan revealed a fistula. She was managed conservatively to see if the fistula would heal by itself and this included inserting a PICC line to administer nutrition so that the bowel could be rested. She had no problems with her PICC line whilst at Queens Hospital. � She referred to the Colorectal Specialist Team at the Royal London Hospital and seen in late May. At her initial appointment, her medical records were not sent with her and the surgeon reviewing her only had a referral letter. � Jennifer was admitted to the Royal London Hospital on 12 July 2022 in preparation for surgery. She developed numerous infections to her PICC lines which led to sepsis. � Jennifer underwent surgery to repair her bowel on 7 October 2022. The operation was uneventful and she recovered well. She then developed a further infection to her PICC line and died from multi-organ failure caused by septicaemia.

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

Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: The Royal London Hospital | Queens Hospital

05/05/2023

2023-0147

Joshua Asprey

East Sussex

The Royal Pharmaceutical Society The National Institute for Health and Care and Excellence

On 18 June 2021 I commenced an investigation into the death of Joshua Fynn ASPREY aged 19. The investigation concluded at the end of the inquest on 15 March 2023. � I determined that the medical cause of Joshua�s death was: � 1a Multiple injuries. � In box 3 of the record of inquest I recorded as follows: � Joshua Asprey died on 14th June 2021 from multiple injuries after deliberately jumping from a cliff � In box 4 of the Record of Inquest, I recorded a conclusion of: � SUICIDE

1.���� Joshua Asprey was 19 years old at the time of his death. He had a history of anxiety. � 2.���� On 27 May 2021, Joshua attended a telephone consultation with his GP reporting that he was feeling depressed. He was commenced on sertraline, [REDACTED] � 3.���� On 11 June 2021, Joshua attended a further telephone consultation with his GP and his dose of Sertraline was raised to [REDACTED] � 4.���� The GP did not discuss with Joshua in either consultation any risk of suicidal ideation associated with commencing or increasing the dose of Sertraline. The GP relied on the British National Formulary (�BNF�) which does not identify suicidal ideation as a risk of prescribing Sertraline. � 5.���� Following the increase of his dose of Sertraline, Joshua began to have thoughts contemplating suicide. 6. On 14 June 2021, Joshua took his own life by deliberately jumping from a cliff [REDACTED] 7.���� Joshua left a suicide note on his computer in which he wrote: �The reason for my current state of thoughts and plans is probably due to suicidal thoughts caused by a side effect of changing from�[REDACTED] dosage of sertraline. However, while this is the trigger in the short term, these thoughts have existed and persisted within me for many years now and to blame solely the medication would be unjust.� � 8.There was insufficient evidence on which to conclude that there was a causative link between the increased prescription of sertraline and Joshua�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � 1.����[REDACTED] (Joshua�s parents) 2.��� The GP. 3.��� Sussex Police. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any 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: The Royal Pharmaceutical Society | The National Institute for Health and Care and Excellence

20/06/2024

2024-0330

Yasmin Adams

Derby and Derbyshire

The Rt Hon Alex Chalk KC MP, Secretary of State for Justice 102 Petty France London SW1H 9AJ United Kingdom

On 14 November 2016 I commenced an investigation into the death of Yasmin Louise ADAMS aged 25. The investigation concluded at the end of the inquest on 19 April 2024.� The inquest was an Article 2 inquest. � The jury made the following findings: Although not found to be contributory to Yasmin�s death the jury recorded the following omissions: During Yasmin�s second prison term the majority of prison staff were not aware of her mental health and learning disability diagnoses but should have been informed of these by prison healthcare. � There should have been consideration for Yasmin�s care to be managed as an enhanced or complex case under the ACCT arrangements. � The duty governor should have considered whether to terminate cellular confinement having been updated about Yasmin on 12 November 2016. � Healthcare should have been informed of and attended all post self-harm incidents. � There should have been documented consideration for involvement of Yasmin�s family in the ACCT process. � All prison staff should have been provided with basic mental health awareness training. Basic first aid training to prison staff should have included instruction in CPR. Assessment of risk for prisoners who self-harmed should have included a clear documented environmental risk assessment of cells. There should have been clarity as to the availability of safer anti-tear clothing at the prison. � The jury returned the following conclusion: Misadventure. Contributed to by: Prison mental health care were not always invited to Yasmin�s ACCT reviews during Yasmin�s second prison term, did not attend any ACCT reviews, and only contributed to two reviews out of sixty-four by telephone consultation. This omission possibly contributed because healthcare could have provided a fuller picture of Yasmin�s current mental health state, which may have informed the decision-making process. � On 11 November 2016, Yasmin was placed on cellular confinement in a cell with a fixed shower rail despite it being known that fixed shower rails were generally a ligature risk of self-harming and suicidal prisoners, particularly in the context of the bathroom areas being out of sight during prison staff observation checks, [REDACTED] This omission probably contributed �[REDACTED]. � There should not have been a gap of 29 minutes in observations between 15:10 and 15:39 on 12 November. This omission possibly contributed because it provided Yasmin a greater opportunity to ligature, and not be discovered and not receive medical attention sooner.

Yasmin had learning difficulties and behavioural problems from a young age. As an adult she was diagnosed with emotionally unstable personality disorder. After the death of her grandmother in April 2015, her mental health declined, which resulted in multiple episodes of self-harm, in which she became known to police and the mental health team. � Yasmin�s first prison sentence at HMP Foston Hall commenced on 7 April 2016 after being found with a bladed article in a public place. Yasmin was placed on an ACCT after initial assessment. During her second screening, she was found to have superficial self-harm scratches and expressing a wish to die. During her 1st prison sentence, she continued to struggle with her mental health. � Yasmin�s second prison sentence at HMP Foston Hall commenced on 29 August 2016 due to carrying a bladed article in a public place. On the initial screening, she was placed on an ACCT and referred to primary mental health care during her prison sentence. Self-harm incidents were frequent due to Yasmin hearing voices telling her to self-harm and telling her to kill herself. � Yasmin self-harmed frequently [REDACTED] in her cell. � Yasmin was referred to a psychiatrist for an initial assessment, which resulted in a gatekeeping assessment for a secure mental health placement. However, she did not meet the criteria. � Yasmin remained on observations during her second prison sentence, which averaged at 4 times per hour. She was subjected to multiple sanctions under the adjudication scheme for noncompliance. Yasmin was placed on cellular confinement on 11 November 2016 after an adjudication for refusing to return to her cell. � Yasmin ligatured twice within a short period of time on the morning of 12 November 2016. She appeared unsettled after the removal of her television and table from her cell. Yasmin was repeatedly pressing the call bell in her cell. Later in the day, she was found suspended and unconscious [REDACTED] . Yasmin was cut down and prison staff commenced CPR until paramedics arrived. Yasmin was transported to hospital where she passed away the next day on 13 November 2016.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] (mother of the Yasmin), via her solicitors. � Practice Plus Group. � Midlands Partnership University NHS Foundation Trust. Birmingham and Solihull Mental Health NHS Foundation Trust. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

State Custody related deaths This report is being sent to: Ministry of Justice

10/05/2024

2024-0274

Paul Day

Derby and Derbyshire

The Rt Hon Alex Chalk KC MP, Secretary of State for Justice 102 Petty France London SW1H 9AJ United Kingdom

On 23 March 2017 I commenced an investigation into the death of Paul Edward DAY aged 55. The investigation concluded at the end of the inquest on 9 May 2024. Mr Day was a prisoner at HMP Sudbury at the time of his death and as his death appeared unnatural his inquest was a jury inquest. The inquest also examined whether there were any acts or omissions by prison staff that contributed to the death. The inquest engaged Art. 2 ECHR. The jury reached a short- form conclusion of drug related death but made a finding of omission which, on the evidence, could not be established as contributory to death.

I will only detail those circumstances which are relevant and assist understanding of my concerns. � On the night of 22 March 2017 Mr Day was discovered collapsed in a cubicle in the toilet block of the prison wing where he was placed. There was cold water gushing over him from a broken pipe to the toilet cistern which had likely broken during his collapse. The attending prison officers could not detect a pulse or breathing. The senior officer also believed him to be in a state of rigor mortis and considered he was dead. Factors cited by the officer for the belief that rigor mortis was present were: cold body temperature; pallor; the neck and wrist appearing firm when a pulse was felt for. However, it is not apparent that those were good reasons to consider rigor mortis was present as Mr Day was not moved and had been exposed to cold running water, and it was very unlikely that there had been sufficient time for this to have occurred. � No CPR was attempted, and Mr Day was left in-situ, without being moved at all until an attending paramedic, who had arrived approximately 15 minutes after the officers first attended Mr Day, pulled him into the corridor and began CPR and subsequent advanced life � support, after which there was a return of spontaneous circulation. Mr Day was taken to hospital but went into a further cardiac arrest and died in the early hours of the morning of 23 March. On the post-mortem and circumstantial evidence Mr Day�s cause of death was found to be 1a Toxic Effects of Synthetic Cannabinoids.[REDACTED] The jury found and recorded that: � Prison staff who attended Mr Day on the night of 22 March 2017 when he was found collapsed in the toilet cubicle should have performed CPR on him because: � � CPR should be attempted in all situations excluding certain extreme circumstances. � Staff were unqualified to recognise the signs of rigour mortis which was one of the exclusions. � Preservation of life should always be the primary goal. � Although the jury finds that the prison staff should have performed CPR, the jury does not find on the evidence that this omission contributed to Mr Day�s death. � The first bullet-pointed reason given by the jury relates to the HMP Sudbury Staff Information Notice at the time (the current Notice is the same), Guidance to support the decision-making process of whether to perform CPR in prisons. The guidance stated that: Resuscitation MUST be started on all people who are found not breathing and/or pulseless unless one of the following reasons/circumstances applies: Hypostasis/Lividity; Rigor Mortis; Decapitation; Massive Cranial and Cerebral Destruction; Incineration; Traumatic Hemicorporectomy; Decomposition/Putrefaction. � Three of the four prison staff who attended Mr Day were first aid trained, this included training in performing CPR. The training did not and still does not include assessing for and identifying rigor mortis, or verification of death. � HMP Sudbury is an open prison and does not have seven day a week 24-hour healthcare staff presence. � On the evidence it was quite possible that Mr Day had reached a point, by the time the prison officers attended him, where CPR would not have prevented his death, notwithstanding the clear opportunity for this to have been attempted.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � The Governor HMP Sudbury [REDACTED], partner � I have also sent it to � Practice Plus Group, healthcare provider at HMP Sudbury 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 | State Custody related deaths This report is being sent to: Ministry of Justice

05/01/2023

2023-0006

Floyd Carruthers

Birmingham and Solihull

The Rt Hon Damian Hinds, Minister of State [REDACTED] Director General Chief Executive � HM Prison and Probation Service (formerly known as The National Offender Management Service)

On 21 June 2021 I commenced an investigation into the death of Floyd Everton CARRUTHERS. The investigation concluded at the end of the inquest. The conclusion of the inquest was; � Conclusion of the Jury as to the death � These are the points that the Jury have discussed and reached a unanimous decision based on the following: The fact the Mr Carruthers died of an infected heart valve and this was from a natural condition.The fact that Mr Carruthers had probably had the infection for weeks if not months.Based upon the evidence heard in court, on the balance of probabilities the source of infection was not contributed to by the pressure sores found on Mr Carruthers body.A blood test was ordered on 15/05/2021 but was not carried out. Based upon the evidence heard in court a blood test may have shown markers of inflammation and possibly infection which could have prompted earlier intervention.The Prison staff involved in delivering the regime on Lima Wing in relation to Mr Carruthers from 10/05/2021 � 29/5/2021 had 10 weeks basic training at the start of their service but had insufficient ongoing mandatory training and understanding of the matters contained in the National Offender Management Service, Adult Safeguarding in Prison Policy, PIS 16/2015 dated 31/3/19, to enable them to undertake their role in compliance with that policy. As per evidence heard in court there was no safeguarding training in place during the period of Mr Carruthers incarceration. The Prison staff on Lima Wing and the HMP Birmingham Healthcare staff took insufficient steps to safeguard Mr Carruthers throughout the period 10/5/2021 � 29/5/2021. This includes insufficient record keeping, handover and escalation of events, such as missed meals and not leaving his cell.There were failures of Prison staff to make a referral to healthcare in response to Mr Carruthers condition, as reflected in his overall pattern of behaviour and his presentation, between 25/5/2021- 29/5/2021 As a result the Jury have reached a conclusion that death was contributed to by neglect.

Mr Carruthers was diagnosed with paranoid schizophrenia in 2003.Mr Carruthers was under the care of the Mental Health Team and on the whole had a good rapport, however could become irritable if challenged on his mental health by mental health professionals. Mr Carruthers was self aware of his condition and learnt to manage it, it is noted that he heard voices as part of his paranoid schizophrenia diagnosis even when stable. Whilst compliant to taking his medication, Mr Carruthers was stable. Mr Carruthers compliance with medication over time decreased and he subsequently stopped taking his medication. Mr Carruthers was not on medication at the time of arrest and subsequent transfer to HMP Birmingham. Mr Carruthers was arrested on the 09/04/21 and was taken to Perry Barr Police Station.Whilst in custody at Perry Barr Police Station, Mr Carruthers underwent a Mental Health Act Assessment on the 10/04/21 which determined he was fit to be interviewed and did not meet the criteria for detention under the Mental Health Act 1983.Mr Carruthers arrived on remand at HMP Birmingham on 12/4/2021. He was sentenced to 66 days imprisonment on 6/5/2021.Mr Carruthers underwent a reception medical screening at HMP Birmingham identifying his pacemaker. The resulting HMP Birmingham procedure is to raise a task, for a follow up on the pacemaker, this was not done. The reception medical screening did not identify Mr Carruthers mental health history or the Mental Health Act Assessment completed on the 10/4/2021. The HMP Birmingham procedure is a mental Health Nurse Review within 48 hours, this was not done. A mental health nurse attended Mr Carruthers cell on the 7/5/2021, this was triggered by concerns raised by Mr Carruthers family, to conduct an assessment. The assessment was completed from outside Mr Carruthers cell and was around one minute long. Mr Carruthers declined to input, he was polite but abrupt and the Nurse deemed Mr Carruthers had capacity to refuse mental health input.Mr Carruthers was moved to Lima Wing on 10/05/2021 to a double cell. At the time of his transfer to hospital he was a single occupant of this double cell. It is noted that Mr Carruthers had multiple cell mates during his time on Lima Wing. From evidence heard in court, having multiple cell mates does not trigger a Health Care review.A blood test was ordered on the 15/5/2021, it is unclear why it was ordered and why it was not undertaken. There is a general agreement that during Mr Carruthers time on the Lima Wing he presented as reserved, shy and polite; he kept himself to himself. The regime on Lima Wing changed regularly due to Covid restrictions and government regulations. It is generally accepted that the regime included a morning meal, delivered to Mr Carruthers cell, a hot meal to be collected from the servery and association and medicine collection.A summary of interaction between Prison staff and Mr Carruthers between the 25/5/2021 � 29/5/2021 based on limited CCTV and Prison Officer statements, shown during the inquest is as follows. Between the days of 25/5/21 and 29/5/2021, Mr Carruthers had multiple interactions with Prison Officers summarised as including food deliveries, unlocking of his cell and officers entering and leaving Mr Carruthers cell. The most notable event was when we last saw Mr Carruthers leave and return to his cell on the 25/5/21 having collected his hot meal. Following this we did not see Mr Carruthers leave his cell again. With regards to meals � we saw Mr Carruthers collect food once on the 25/05/21, had food delivered as customary between the 25/5/21 and 28/05/2021. Mr Carruthers did not have a hot meal on the 26/05/21 or 27/05/21 and his hot meals bought to him on the 28/05/21 and 29/05/21. Multiple statements show evidence of Mr Carruthers not wanting meals or association time. Evidence from Prison Officer statements show no concerns or observations raised or logged for Mr Carruthers during his time on Lima Wing up until 29/05/2021. Evidence shows that Prison Officers failed to notice a pattern due to no written log of observations or events. A Prison Officer raised concerns regarding Mr Carruthers� health on the 19/05/2021 based on his presentation and appropriately escalated to his Custodial Manager. A Hotel 2, high est escalation, call was made to Prison Healthcare staff, to attend which occurred. The Prison Nurse attended and conducted initial observations which promoted a 999 call.Paramedics attended and followed appropriate care, allocating roles to facilitate transfer to hospital and highlighting to Prison Officers that Mr Carruthers required a time critical transfer to City Hospital to gain essential input from the cardiac team. Following treatment in his cell, Mr Carruthers was transferred to an ambulance for transfer to City hospital. Significant delays occurred in the Sterile Area of HMP Birmingham whilst paperwork, personnel and handcuff procedure were complete � it did not contribute to the death of Mr Carruthers Upon presentation at City Hospital Mr Carruthers was extreamly unwell and was reviewed by the cardiac team. An ultrasound of the heart was used to quickly diagnose Mr Carruthers endocarditis and start treatment.When Mr Carruthers was admitted to the Acute Medical Unit he was at the point of multiple organ failure with septic shock, acute renal failure, hepatic failure, and delirium probably related to sepsis and cerebral hypoperfusion.Evidence suggests Mr Carruthers had staphylococcal endocarditus for weeks or potentially months prior to his hospital admission. Evidence suggests Mr Carruthers is likely to have developed sepsis in the 1-3 days prior to his hospital admission, leading to septic shock and multi-organ failure on admission to hospital. Mr Carruthers acute medical review led to a plan to take Mr Carruthers to New Cross Hospital, Wolverhampton on 3/6/2021 with a view to open heart surgery. There he was reviewed by 2 Consultant Cardiac Surgeons who felt that with multiorgan failure he was very unlikely to survive open heart surgery at that point and he was therefore transferred back to City Hospital. During this time, Mr Carruthers was in a critical condition, it was noted that Mr Carruthers was hand cuffed during the transfer from City Hospital to New Cross Hospital, at the recommendation of the Govenor) despite multiple conversations with the Prison Officers present. This showed a lack of consideration to Mr Carruthers medical condition and the true risk to Hospital staff and the public. Following his return to City Hospital, he became more drowsy and less responsive over the following days. He passed away peacefully on the morning of 14/6/2021. � Following a post mortem, the medical cause of death was determined to be: � 1a Cardiac tamponade. Hypostatic pneumonia 1b Haemorrhagic pericarditis 1c Infective endocarditis (implanted electronic cardiac pacemaker for 2nd degree atrio- ventricular block).

Other related deaths | State Custody related deaths

Minister of State, HM Prison and Probation Services

20/01/2023

2023-0023

Michael Holmes

West Yorkshire (Eastern)

The Rt Hon Dr Therese Coffey MP, Secretary of State for Environment Food and Rural Affairs J A Mitchell & Sons, Wakefield Council [REDACTED] Health and Safety Executive � [REDACTED] Principal Inspector

On 1 October 2020 I commenced an investigation into the death of Michael John Holmes, aged 57. The investigation concluded at the end of the Inquest on 18 January 2023. The conclusion of the Inquest was Accidental Death.

On Tuesday 29 September 2020, Michael John Holmes and his wife were walking dogs belonging to other family members on leads in a field at Hollinghurst Farm, Netherton, Wakefield. Cattle in the field approached them, knocked them down and trampled them, causing serious injuries. Emergency treatment was provided by a doctor who arrived by helicopter. Mr Holmes could not be revived and was pronounced dead at 12:56 that day at the scene of the incident.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] via CFG Law Solicitors�I have also sent it to:The Ramblers� Association National Farmers UnionCountry Land Owners AssociationThe Access and Rights of Byways and Bridleways Trust Open Spaces SocietyRights of Way Review Committee� ITV Reporter� BBC Reporter 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

Department for Environment, Food and Rural Affairs | J A Mitchell & Sons | Wakefield Council | Health and Safety Executive

19/12/2023

2024-0171

Martin Willis

Shropshire, Telford and Wrekin

The Rt Hon Edward Argar MP Minister of State for Prisons, Parole and Probation � [REDACTED]� Chief Executive (Interim) North Staffordshire Combined Healthcare NHS Trust � [REDACTED]� Chief Executive Midlands Partnership NHS Foundation Trust (if appropriate)

On 22nd September 2022, I commenced an investigation into the death of Martin Samuel WILLIS, aged 55 years. The investigation concluded at the end of the inquest with a jury on the 13th to 17th day of November 2023. The conclusion of the inquest was Mr Willis died from hanging and the narrative conclusion was that: �Mr Martin Willis took his own life, in part because the risk of him doing so was not reported, communicated and the precautions in place were insufficient to prevent him doing so whilst the balance of his mind was disturbed�.

Mr Willis was a serving prisoner at HMP Stoke Heath when at 8:37 am on the 15th September 2022 he was found hanging in his cell. He was on the suicide and self-harm prevention scheme (ACCT).

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Leigh Day Solicitors Shropshire Community Health NHS Trust Browne Jacobson Clyde & Co LLP Prisons and Probation Ombudsman�s Office Government Legal Department � 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: HM Prison and Probation Service | North Staffordshire Combined Healthcare NHS Trust | Midlands Partnership NHS Foundation Trust

05/12/2023

2023-0499

Samuel Jones

Dorset

The Rt Hon Edward Argar MP, Minister of State for Prisons, Parole and Probation [REDACTED], Director General Chief Executive of His Majesty�s Prison and Probation Service (HMPPS [REDACTED], Chief Executive of NHS England

On the 11th May 2021 an investigation was commenced into the death� of Samuel Lewis Jones, born on the 24th November 1998. � The investigation concluded at the end of the Inquest on the 28th November 2023. � The Medical Cause of Death was: � la Ligature Suspension � The conclusion of the Inquest heard before a jury was a narrative conclusion that �Sam suspended himself by a ligature, there is insufficient evidence� that has been presented to the jury to show that Sam had or had not intended� to take his own life.�

The deceased died on the 30th April 2021 after he suspended himself by a ligature in his cell at HMP Portland, Portland, Dorset.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Sam�s family The Ministry of Justice/HMP Portland Practice Plus Group Oxleas NHS Foundation Trust Change Grow Live � I am also under a duty to send the Chief Coroner a copy of your response. � I have also forwarded the report to the following who may find the report of interest: � [REDACTED], Director General of the Department of Health and Social Care [REDACTED]. Chief Executive Officer, Public Health England � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who� he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response,� about the release� or the publication of your response by the Chief Coroner.

State Custody related deaths This report is being sent to: HM Prison and Probation Service | NHS England

02/09/2022

2023-0010

Jennifer Wong

Oxfordshire

The Rt Hon Grant Shapps MP, Secretary of State for Transport Oxfordshire County Council

INVESTIGATION AND INQUEST � On 02 August 2022 I concluded the inquest into the death of Jennifer Wong with a hearing at Oxford Coroners Court. Ms Wong was 32 years old when she died at the scene of a road traffic accident on 26 September 2021 on Headington Road, Oxford at the junction with Headley Way. � The conclusion was Road Traffic Collision with the following factual findings: � At approximately 09:55 hours on 26th September 2021 Jennifer Wong cycled along Headington Road towards traffic lights at the junction with Headley Way and cycled on the nearside of a stationery mobile crane. She was positioned on the nearside in a cycle lane intending to cycle straight on. The mobile crane was positioned in the nearside lane for vehicles turning left. On the lights changing Jennifer Wong and the mobile crane moved forwards and when the crane began to turn left into Headley Way it caused Jennifer Wong to be knocked to the ground and be run over, resulting in her instant death due to crush injuries. � I heard evidence from a number of witnesses at inquest along with other written statements and reports. I enclose the following documents for your information: � 1. Police Report � 02/07/2022 2. Collision Investigators Report ([REDACTED]) � 19/04/2022 3.Report of�[REDACTED] (Traffic Management Post Collision Report) � 22/10/2021 4. Statement of�[REDACTED] of Oxfordshire County Council 01/08/2022 5. Record of Inquest � I heard oral evidence from the driver of the mobile crane and from [REDACTED].

Ms Wong was riding her pedal cycle on the morning of Sunday 26 September 2021 along Headington Road in Oxford and was intending to cycle straight across the junction. She was on the near side of a mobile crane intending to turn left into Headley Way. She was knocked off her pedal cycle by the crane and run over. � There were significant blind spots for the crane driver to the nearside. This is apparent from the report of [REDACTED] and the photographs therein. In addition to the issue of the blind spots,�[REDACTED] also stated that an overarching issue is the cycle lane and the left turn at the traffic light junction which results in vulnerable road users coming into direct conflict with vehicles intending to turn left into Headley Way.

ACTION SHOULD BE TAKEN � In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

Road (Highways Safety) related deaths

Department for Transport | Oxfordshire County Council

30/08/2022

2023-0098

Jennifer Davies

West Sussex

The Rt Hon Grant Shapps The Secretary of State for Transport Great Minister House 33 Horseferry Road London SW1P 4DR

On 26th May 2020, the then Senior Coroner Veronica HAMILTON-DEELEY commenced an investigation into the death of Jennifer Lilian Davies aged sixty-nine. The investigation was concluded by me Penelope SCHOFIELD at the end of the Inquest on 21st June 2021. The overall conclusion of the inquest was a short form conclusion of ROAD TRAFFIC COLLISION.

On 21st May 2020 Mrs Davies was struck by a parcel delivery service vehicle when crossing the road in front of the junction with Dyke Road at the Seven Dials Roundabout in Brighton. She was knocked to the ground and sustained a serious head injury. She was taken to Hospital but despite treatment she did not recover from her injuries, and she sadly died on 23rd May 2020. The driver of the vehicle has since admitted to causing her death by driving without due care and attention. He received a sentence of 3 years and 6 months imprisonment.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � � a)��� The family of Jennifer Davies b)��� DPD Group UK c)��� Precise Couriers Ltd d) [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.

Road (Highways Safety) related deaths

Department for Transport

19/12/2023

2023-0534

Chloe Macdermott

Inner West London

The Rt Hon James Cleverley MP, Secretary of State for the Home Office (Border Force) The Rt Hon Victoria Atkins MP, The Secretary of State Department of Health and Social Care The Rt Hon Lucy Fraser KC MP, The Secretary of State for Culture, Media and Sport OFCOM [REDACTED], Vice President and Managing Director, Google UK & Ireland [REDACTED], Vice President and UK & Ireland Manager Amazon UK Assistant Chief Constable [REDACTED], British Transport Police, National lead for suicide prevention at The National Police Chiefs Council

On the 5th December 2023 evidence was heard touching the death of Chloe Elizabeth MACDERMOTT. She died on 23rd May 2021 aged 43 years. � Medical Cause of Death � I (a)� [REDACTED] toxicity � How, when, where Chloe Elizabeth MACDERMOTT came by her death: Chloe Elizabeth Macdermott had been struggling with her mental health for some years prior to her death. She became increasingly suicidal and researched ways to end her life [REDACTED]. On or about 21st May 2021 she formed an association with two other persons with whom she planned to end her life. She had purchased [REDACTED], using Amazon US. On 22nd May 2021 whilst her husband was away from home, she contacted the persons she had discussed committing suicide with and an agreement was made to act that night. Chloe and one other person in a different part of the UK ingested [REDACTED], around midnight between 22nd and 23rd May 2021. Chloe died in the early hours of 23rd May 2021 from the effects of [REDACTED] toxicity on her bed in her home [REDACTED]. Conclusion of the Coroner as to the death: Suicide

Circumstances of the death: Extensive evidence was heard by the court in the form of written and oral evidence, including expert evidence. � Of particular significance for the purpose of this report are the following matters: � Chloe was able to purchase the product used over the internet and have it delivered to her home in the UK. Enquiries showed the product was purchased using Amazon in the United States. [REDACTED], and other such forums encourage suicide, assist it by provision of information about suicide methods, counsel suicide by providing information about it and thereby potentially facilitate the commission of a criminal offence in the United Kingdom.

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

Suicide (from 2015) This report is being sent to: Home Office | Department of Health and Social Care | Department for Culture, Media and Sport | Ofcom | Google | Amazon | British Transport Police | The National Police Chiefs� Council

25/10/2023

2023-0409

Bronwen Morgan

South Wales Central

The Rt Hon Lucy Frazer KC MP, Secretary of State for Digital, Culture, Media and Sport Ofcom Eluned Morgan, Welsh Health Minister

On 10 September 2020 I commenced an investigation into the death of Bronwen Grace MORGAN (BM). The investigation concluded at the end of the inquest 20/10/2023. The conclusion of the inquest was Suicide. 1a� Toxicity

Bronwen Morgan had a diagnosis of Emotionally Unstable Personality Disorder. This manifested itself in fluctuating symptoms including acute periods of distress and anxiety leading to acts of deliberate self-harm. She was under the care and treatment of local mental health services. She was engaging in dialectical behaviour therapy the indicated treatment for Emotionally Unstable Personality Disorder. On 27.8.20 she has travelled to a hotel possessing a toxic substance that she had purchased�[REDACTED] . � She was located in the hotel by the emergency services and conveyed to the University Hospital of Wales, Heath. Despite resuscitation attempts she did not regain consciousness and died from the toxic consequences of the substance. Material located on her mobile phone and at the scene demonstrated that she likely intended the consequences of her deliberate actions to be her own death.

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

Suicide (from 2015) This report is being sent to: Department for Digital, Culture, Media and Sport | Ofcom | Welsh Health Minister

14/05/2024

2024-0262

Charlie Hopkins and William Robinson

Surrey

The Rt Hon Mark Harper Department for Transport Great Minster House 33 Horseferry Road London SW1P 4DR � � Chief Executive Driver and Vehicle and Standards Agency Croydon Street Bristol BS5 0DA � � Chief Ombudsman The Motor Ombudsman 71 Great Peter Street London SW1P 2BN

INQUEST An inquest into the death of Charlie Hopkins was opened on 19 October 2021 and an inquest into the death of William Robinson was opened on 30 December 2021. Their inquests were resumed and evidence was heard from 26-28 April 2023. Thereafter, a referral was made to the Director of Public Prosecutions pursuant to rule 25 (4) of The Coroners (Inquest) Rules 2013. The inquests were resumed and concluded on 30 April 2024. � William Robinson The medical cause of William Robinson�s death was: 1a. Hypoxic Brain Injury 1b. Traumatic Cardiac Arrest 1c. Multiple Traumatic Injuries (26.9.21) � The inquest concluded with the following findings of fact and conclusion in Box 3 and Box 4 of the Record of Inquest: � Box 3 William Robinson was 17 years old. On 26 September 2021 at approximately 00:55 hours he was a front seat passenger in a Volkswagen Polo travelling northbound on the Oxenden Road, Tongham. As the car approached the roundabout connecting to the A331 and the A323, it made contact with the nearside curb prior to travelling into the opposing southbound lane, where it collided with an oncoming Ford Tourneo. As a result of the collision Mr Robinson sustained serious traumatic injuries, leading to a traumatic cardiac arrest, which in turn led to hypoxic brain injury, resulting in his death at St. George�s Hospital in Tooting on 4 December 2021. � Box 4 Road Traffic Collision. The Volkswagen Polo was travelling in excess of the speed limit of 30 mph and the driver was under the influence of alcohol, both of which contributed to the collision. � Charlie Hopkins The medical cause of Charlie Hopkins� death was: � 1a. Blunt Head Trauma The inquest concluded with a narrative conclusion as follows: Road Traffic Collision. Charlie Hopkins was 18 years old. On 26 September 2021 at approximately 00:55 hours Mr Hopkins was driving his VW Polo travelling northbound on the Oxenden Road, Tongham. As he approached the roundabout connecting to the A331 and the A323, he made contact with the nearside curb prior to travelling into the opposing southbound lane, where it collided with an oncoming Ford Tourneo. As a result of the collision Mr Hopkins sustained a fatal traumatic head injury and died at the scene. Mr Hopkins was travelling in excess of the speed limit of 30 mph and was under the influence of alcohol which contributed to the collision. The Hopkins family purchased the VW Polo for Charlie in January 2021. The VW Polo was fitted with airbags which did not deploy at the time of the collision. There was a fault with the VW Polo�s airbag system which had occurred on 9 August 2013. As a result, the airbag system had been automatically disabled to prevent the risk of it deploying whilst the car was being driven in normal conditions. Accordingly, from 9 August 2013 onwards the VW Polo did not have functioning airbags and the airbag warning light on the car�s dashboard was permanently illuminated from that time onwards. The owners of the vehicle in August 2013 were aware that the airbag warning light was illuminated, indicating a fault with the airbag system. At some point during the period from 9 August 2013 and the onward sale of the car on 1 March 2014 an unidentified individual removed the instrument cluster from the dashboard and deliberately concealed the airbag warning light with a piece of paper before returning the instrument cluster to the dashboard. As a result, the illuminated warning light was obscured and not visible to future drivers of the car. INQUEST An inquest into the death of Charlie Hopkins was opened on 19 October 2021 and an inquest into the death of William Robinson was opened on 30 December 2021. Their inquests were resumed and evidence was heard from 26-28 April 2023. Thereafter, a referral was made to the Director of Public Prosecutions pursuant to rule 25 (4) of The Coroners (Inquest) Rules 2013. The inquests were resumed and concluded on 30 April 2024. � William Robinson The medical cause of William Robinson�s death was: 1a. Hypoxic Brain Injury 1b. Traumatic Cardiac Arrest 1c. Multiple Traumatic Injuries (26.9.21) � The inquest concluded with the following findings of fact and conclusion in Box 3 and Box 4 of the Record of Inquest: � Box 3 William Robinson was 17 years old. On 26 September 2021 at approximately 00:55 hours he was a front seat passenger in a Volkswagen Polo travelling northbound on the Oxenden Road, Tongham. As the car approached the roundabout connecting to the A331 and the A323, it made contact with the nearside curb prior to travelling into the opposing southbound lane, where it collided with an oncoming Ford Tourneo. As a result of the collision Mr Robinson sustained serious traumatic injuries, leading to a traumatic cardiac arrest, which in turn led to hypoxic brain injury, resulting in his death at St. George�s Hospital in Tooting on 4 December 2021. � Box 4 Road Traffic Collision. The Volkswagen Polo was travelling in excess of the speed limit of 30 mph and the driver was under the influence of alcohol, both of which contributed to the collision. � Charlie Hopkins The medical cause of Charlie Hopkins� death was: � 1a. Blunt Head Trauma The inquest concluded with a narrative conclusion as follows: Road Traffic Collision. Charlie Hopkins was 18 years old. On 26 September 2021 at approximately 00:55 hours Mr Hopkins was driving his VW Polo travelling northbound on the Oxenden Road, Tongham. As he approached the roundabout connecting to the A331 and the A323, he made contact with the nearside curb prior to travelling into the opposing southbound lane, where it collided with an oncoming Ford Tourneo. As a result of the collision Mr Hopkins sustained a fatal traumatic head injury and died at the scene. Mr Hopkins was travelling in excess of the speed limit of 30 mph and was under the influence of alcohol which contributed to the collision. The Hopkins family purchased the VW Polo for Charlie in January 2021. The VW Polo was fitted with airbags which did not deploy at the time of the collision. There was a fault with the VW Polo�s airbag system which had occurred on 9 August 2013. As a result, the airbag system had been automatically disabled to prevent the risk of it deploying whilst the car was being driven in normal conditions. Accordingly, from 9 August 2013 onwards the VW Polo did not have functioning airbags and the airbag warning light on the car�s dashboard was permanently illuminated from that time onwards. The owners of the vehicle in August 2013 were aware that the airbag warning light was illuminated, indicating a fault with the airbag system. At some point during the period from 9 August 2013 and the onward sale of the car on 1 March 2014 an unidentified individual removed the instrument cluster from the dashboard and deliberately concealed the airbag warning light with a piece of paper before returning the instrument cluster to the dashboard. As a result, the illuminated warning light was obscured and not visible to future drivers of the car. If the airbag warning light had not been concealed the airbag fault would have been identified and remedied prior to the collision on 26 September 2021. In May 2014 and July 2015 the new owner of the vehicle took it to a Volkswagen garage where diagnostic tests were carried out on the car�s engine control unit. The tests identified a fault with the airbag module with no corresponding warning light and the owner was advised to carry out further investigations, which was declined. Had further investigations been carried out at that time the faulty airbag and concealed warning light would have been identified and remedied prior to the collision on 26 September 2021. In the event that the airbags had deployed, Charlie�s injuries would have been less severe and he would have survived the collision.

The circumstances of the deaths of William Robinson and Charlie Hopkins are set out above. � In addition, to the matters set out above, the court heard evidence that: � Charlie Hopkins had passed his driving test on 11 September 2021, shortly before the collision on 26 September 2021. The Court found that it was possible that Charlie being a new driver, who had only recently passed his test, contributed to the collision. � At the time of the collision, in addition to Charlie Hopkins and William Robinson, there were six other passengers in the car, five on the back seat and one in the boot of the car, making a total of eight people in the car. The court found that it was possible that Charlie Hopkins had been distracted by the other passengers in the car, thereby contributing to the collision. � The VW Polo involved in the collision underwent an annual MOT and regular services at both VW and non-VW affiliated garages. The airbag fault and non-functioning warning light was not identified during any of the MOTs and at only two of the services the car underwent prior to the collision.

COPIES I have sent a copy of this report to the following: � 1. Chief Coroner 2. William Robinson�s family 3. Charlie Hopkins� family 4. [REDACTED] 5. [REDACTED] 6. [REDACTED] 7. Glyn Hopkins Limited 8. British Car Auctions 9. Goodman Retail Limited (Slough Audi) 10. Allens of Chobham 11. Chobham Motor Company 12. Marshall Motor Group 13. Volkswagen Group

Road (Highways Safety) related deaths | Child Death (from 2015) This report is being sent to: Department for Transport | Driver and Vehicle and Standards Agency | The Motor Ombudsman

02/03/2023

2023-0081

Kathleen Fancourt

West Sussex

The Rt Hon Mark Harper MP Secretary of State for Transport Great Minster House Horseferry Road London SW1P 4DR � [REDACTED], Chief Executive Driver and Vehicle Licensing Agency Longview Road Morriston Swansea SA67JL

On 22 September 2021 I commenced an investigation into the death of Kathleen Grace FANCOURT aged 89. The investigation concluded at the end of the inquest on 01 March 2023. The conclusion of the inquest was that Mrs Fancourt died an Accidental Death.

On Thursday 16th September 2021 on Broyle Road in Chichester, West Sussex, Kathleen Fancourt was on her mobility scooter waiting at a pedestrian crossing. The crossing light was green for pedestrians and red for traffic. As Mrs Fancourt commernced to cross the road she was hit by a Peugeot car driving over the crossing. The driver of the car was 95 years old and has since this incident pleaded guilty to an offence of dangerous driving.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Kathleen Fancourt I have also sent it to Chief Constable of Sussex Police � Forensic Collison Department. West Sussex County Council � Highways department Gillian Keegan, MP for Chichester 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

Department for Transport | Driver and Vehicle Licensing Agency

21/12/2022

2022-0409

Donald Hooker

East Riding and Hull

The Rt Hon Mark Harper MP Secretary of State for Transport Great Minster House, 33 Horseferry Road, London. S1P 4DR and Transport Research Laboratory, Crawthorne House, Wokingham, Berkshire. RG40 3GA.

On 2nd September 2021 I commenced an investigation into the death of Donald Frederick HOOKER, aged 70 years. The investigation concluded at the end of the inquest on 20th December 2022. The conclusion of the inquest was Road Traffic Incident. � Box 3 of the record of inquest read: � On 26th August 2021, Donald Frederick HOOKER aged 70 years, was travelling on the Humber Bridge when the drive chain of his motorcycle broke. He collided with a vehicle as he drifted to the left causing him to fall off his motorcycle. His crash helmet came off during the incident and he sustained head injuries. Dr Hooker was transported to Hull Royal Infirmary where he died on 28th August 2021. His medical cause of death was recorded as: 1a��������� Multiple Traumatic Injuries 1b�������� Road Traffic Incident

Dr Hooker was an experienced motorcycle user. On 26th August 2021 he was travelling home from work via the Humber Bridge. When the road conditions permitted Dr Hooker began to accelerate appropriately (he had been travelling at approximately 30 mph). He was in 4th gear. As he accelerated the drive chain on his motorcycle broke, and Dr Hooker appeared to drift into a vehicle travelling on his nearside. The collision cause Dr Hooker to fall from his motorcycle but as the incident occurred Dr Hooker�s crash helmet came off. He sustained severe head and facial injuries. He was conveyed to Hull Royal Infirmary where he died on 28th August 2021. There were issues with the drive chain of the bike that were causative of the accident, however I had additional concerns regarding the loss of his motor cycle crash helmet.

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

Road (Highways Safety) related deaths

Department for Transport | Transport Research Laboratory

20/03/2024

2024-0157

Ellie Hunt

York and North Yorkshire

The Rt Hon Mark Harper MP, Department for Transport

On 31 August 2021 I commenced an investigation into the death of Ellie Louise Frances HUNT aged 9. The investigation concluded at the end of the inquest on 08 March 2024. The conclusion of the inquest was that: � On the 24th August 2021, Ellie Louise Frances Hunt was a travelling in the rear of a motorhome on the A64, Barton Hill. The front near side tyre unexpectedly deflated and the motorhome collided with a stationery vehicle. Ellie Louise Frances Hunt suffered multiple injuries. Her injuries were not survivable. Her death was confirmed at the scene of the collision, namely the A64, Barton Hill, at 20.08 on the 24th August 2021.

On the 24th August 2021, Ellie Louise Frances Hunt was a travelling in the rear living area of a motorhome vehicle, on the A64 Barton Hill, when the front near side tyre of the vehicle deflated, leading to a collision with a stationery vehicle. Ellie Louise Frances Hunt died instantaneously due to her multiple injuries. The vehicle had been converted into a motorhome, having originally been a works van. There were no seatbelts in the rear of the vehicle.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � �[REDACTED] �[REDACTED] �[REDACTED] �[REDACTED] �[REDACTED] �[REDACTED] �[REDACTED] �[REDACTED] � I have also sent it to � Chief Constable for North Yorkshire, [REDACTED] �[REDACTED] Rotherham LSCB � 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) | Road (Highways Safety) related deaths This report is being sent to: Department for Transport

20/03/2024

2024-0156

Shirley Hunt

York and North Yorkshire

The Rt Hon Mark Harper MP, Department for Transport

On 31 August 2021 I commenced an investigation into the death of Shirley Ann HUNT aged 44. The investigation concluded at the end of the inquest on 08 March 2024. The conclusion of the inquest was that: � On the 24th August 2021, Shirley Ann Hunt was a travelling in the rear of a motorhome on the A64, Barton Hill. The front near side tyre unexpectedly deflated and the motorhome collided with a stationery vehicle. Shirley Ann Hunt suffered multiple injuries. Her injuries were not survivable. Her death was confirmed at the scene of the collision, namely the A64, Barton Hill, at 20.08 on the 24th August 2021.

On the 24th August 2021, Shirley Ann Hunt was travelling in the rear living area of a motorhome vehicle, on the A64 Barton Hill, when the front near side tyre of the vehicle deflated, leading to a collision with a stationery vehicle. Shirley Ann Hunt died instantaneously due to her multiple injuries. The vehicle had been converted into a motorhome, having originally been a works van. There were no seatbelts in the rear of the vehicle.

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

Road (Highways Safety) related deaths This report is being sent to: Department for Transport

08/02/2023

2023-0047

Stephen Wood

Dorset

The Rt Hon Mark Harper MP, Secretary of State for Transport [REDACTED] Chief Executive Officer of National Highways Agency [REDACTED] Chief Constable of Dorset Police [REDACTED] Chief Executive of Dorset Council [REDACTED] Chief Executive of BCP Council

On the 10th June 2021, an investigation was commenced into the death of Stephen Robert Wood, born on the 18th March 1962. The investigation concluded at the end of the Inquest on the 07th February 2023. The Medical Cause of Death was: Ia Multiple injuries. � The conclusion of the Inquest was road traffic collision.

At approximately 19.13 hours on the 30th May 2021, the deceased was riding his Harley Davidson XL1200 motorcycle in a northerly direction along Coombe Road, Winterbourne Steepleton, Dorchester which has a speed limit of 60mph. He was travelling at a speed of no more than 44mph when he had just driven over the brow of a hill and his bike entered a 60 metre stretch of grass in the carriageway, which covered the entire width of the carriageway and had been there from at least approximately 18.00 hours that day. His motorcycle slipped on the grass, and he became separated from the motorcycle. He travelled into the pathway of an oncoming Ford Focus Titanium TDCI in the southbound carriageway of the road, which passed over him. He came to rest under the vehicle and sustained numerous significant and unsurvivable injuries.

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.

Road (Highways Safety) related deaths

Department for Transport | National Highways Agency | Dorset Police | Dorset council | BCP Council

11/07/2023

2023-0237

Mustafa Nadeem

Birmingham and Solihull

The Rt Hon Mark Harper MP, Secretary of State for Transport � Department For Transport [REDACTED] Mayor of the West Midlands, Chair � West Midlands Combined Authority [REDACTED] Chief Executive � Collaborative Mobility UK.

On 12 December 2022 I commenced an investigation into the death of MUSTAFA NADEEM. The investigation concluded at the end of the inquest.

On 6/12/22 Mustafa was riding an e-scooter to school on the pavement on the B4128, approaching the traffic island with Belchers Lane, Bordesley Green when at 7:58am he inadvertently collided with a pedestrian and fell into the path of a bus that was travelling at slow speed. He suffered fatal injuries and was confirmed deceased at the scene. The e-scooter was authorised for use in Birmingham as part of a national pilot scheme and users were required to have a valid motor-vehicle driving licence and be aged over 18. The e-scooter being used by Mustafa had been unlocked by a 14-year-old friend via an �app� on his mobile phone. � The medical cause of death was conformed at post-mortem examination: Multiple injuries. The formal conclusion as to the death: Death was a consequence of a road traffic collision.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1)� Mustafa Nadeem�s family. (2)�[REDACTED] , Chief Constable, West Midlands Police. (3)� Voi Technology Ltd ([REDACTED], General Manager for the UK). (4)��[REDACTED] (driver of the bus). (5)� Saltley Academy ([REDACTED] Headteacher). (6)� Washwood Heath Academy (�[REDACTED] Headteacher) and to the Local Safeguarding Board as the deceased was under 18 years of age. 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) | Road (Highways Safety) related deaths This report is being sent to: Department for Transport | West Midlands Combined Authority | Collaborative Mobility UK

16/03/2023

2023-0092

Brian Harfield

West Sussex

The Rt Hon Michael Gove Secretary of State for Levelling up, Housing and Communities 2 Marsham Street London SW1P 4DF

On 14th June 2022 I commenced an investigation into the death of Brian George Harfield aged 85. The investigation concluded at the end of the inquest on 3rd March 2023. The overall conclusion of the inquest was a short form conclusion of Misadventure.

On 3rd May 2022 a fire started in the living room of Mr Harfield�s flat in the proximity of his recliner chair. It is unclear how the fire started but it was more likely than not caused by the wiring of a lamp which was located close by. Sadly Mr Harfield was overcome by the smoke and was found unconscious in his kitchen. Despite medical intervention by the Fire Brigade he sadly did not recover and was pronounced deceased at the scene.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- � a)�� The family of Brian Harfield b)�� West Sussex Fire 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.

Other related deaths

Ministry of Housing, Communities & Local Government

17/01/2025

2025-0042

Donald Mitchell

South Wales Central

The Chief Executive, Bridgend County Borough Council� Welsh Government, Cathays Park, Cardiff

On 31 December 2020 I commenced an investigation into the death of Donald John� Drummond MITCHELL . The investigation concluded at the end of the inquest 17/01/2025 . The conclusion of the inquest was Road Traffic Collision.� The medical Cause of Death was:-� 1a�� Blunt Head Injury, including Transection of both Internal Carotid Arteries� 1b � 1c � �II

These were recorded as :-� Donald John Drummond Mitchell was cycling from his place of work to his home on 17� December 2020. Whilst cycling along the A48 road in an eastbound direction, between the Laleston roundabout and the junction of Well Street, Mr Mitchell was struck by a vehicle� travelling in the same direction. Mr Michell suffered catastrophic head injuries as a� consequence of the collision and was sadly pronounced deceased at the scene.� Conclusion: Road Traffic Collision

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.

Road (Highways Safety) related deaths | Wales prevention of future deaths reports (2019 onwards)

Bridgend County Borough Council�| Welsh Government

01/10/2018

2024-0090

Joan Blaber

West Sussex, Brighton and Hove

The Chief Executive, Brighton & Sussex University NHS Hospital Trust Director of Safety-Assistant� Director of SNurse Director,Chief Nurse, Clinical Director, for Facilities and Estates

On 14th November 2017 I commenced an investigation into the death of Mrs. Joan Catherine BLASER. The investigation concluded at the end of the inquest on 20th September 2018. The conclusion of the inquest was as per the attached NARRATIVE CONCLUSION

See Record of Inquest

I have sent a copy of my report to the Chief Coroner and to the following lnterested Persons � 1. [REDACTED] 2. [REDACTED] [REDACTED], Sussex Police [REDACTED], Sussex Police [REDACTED], Healy�s Solicitors [REDACTED], Medico-Legal Head, Care Quality Commission Secretary of State for Health, Department of Health [REDACTED], Chief Executive, NHS England National Patient Safety Agency Clinical Commissioning Group � [REDACTED] � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me, the coroner, at� the time of your response, about the release or the publication of your response by the Chief Coroner.

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

28/05/2024

2024-0289

Clara Winter

South Wales Central

The Chief Executive, Cwm Taf Morgannwg University Health Board

On 12th. December 2022, I commenced an investigation into the death of Clara Novella Winter, aged 77. The investigation concluded at the end of the inquest on 17th. May 2024. At the conclusion of the inquest, the medical cause of death was established as � 1a Perforated incarcerated ischaemic bowel 1b Intra abdominal adhesions in the setting of elective cholecystectomy (operated on 14/11/2022) and previous pelvic surgery � My conclusions were that Clara Novella Winter died at Prince Charles Hospital on 19th. November 2022 as a result of a perforated incarcerated ischaemic bowel. � I reached a narrative conclusion that following routine and uneventful surgery to remove her gall bladder, Mrs. Winter�s bowel became inflamed and resulted in complications with her existing hernia, including further adhesions, incarceration of the bowel, ischaemia and a bowel perforation. Emergency surgery was carried out to repair this but sadly Mrs. Winter was unable to recover.

Mrs. Winter was admitted to hospital on 14th. November 2022 for an elective laparoscopic cholecystectomy. She had undergone surgery some years ago which had resulted in complications, including an irreducible hernia and adhesions. Her condition deteriorated the following day, reaching crisis point at around 23:00. Subsequent emergency surgery revealed that whilst the upper abdomen area was normal, the existing hernia had changed, an ischaemic patch had developed along with a bowel perforation. A right hemi colectomy with side to side anastomosis was necessary. Mrs. Winter survived the surgery but later died.

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.

Hospital Death (Clinical Procedures and medical management) related deaths | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Cwm Taf Morgannwg University Health Board

03/07/2024

2024-0358

Sonny Farrier

Durham and Darlington

The Chief Executive, Durham County Council

On 08-Dec-23, I commenced an investigation into the death of � Sonny James FARRIER , 18 years old. � The investigation concluded at the end of the inquest on 03-Jul-24. I concluded that death resulted from head injuries sustained in a road traffic collision, as described below.

At around 1300 hrs on 2nd December 2023, the deceased was a passenger in a van travelling north-east along Butsfield Lane in Consett, when driving control was lost as the van slid downhill on ice and collided with a tree at the bottom of the hill, where the road changes direction. � Having disembarked from the van, the deceased was struck by a car travelling in the same direction, a few minutes after the van; at the point of collision, the car was also out of control due to slippery conditions on the same stretch of Butsfield Lane. � On the same day, at least two further independent incidents of loss of vehicular control were caused by slippery conditions on the same stretch of Butsfield Lane.

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

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

19/12/2023

2023-0546

Richard Hedges

North West Kent

The Chief Executive, Gravesham Borough Council. The Chief Coroner [REDACTED]

On 6 October 2023 I commenced an investigation into the death of Richard HEDGES. The investigation concluded at the end of the inquest . The conclusion of the inquest was � Accident � 1a Hypoxic Brain Injury � 1b�� Out of Hospital Cardiac Arrest � 1c�� Fall with Traumatic Cervical Spine Fracture � Chronic Obstructive Pulmonary Disease, Previous Pulmonary Embolism

Mr Hedges was admitted to the critical care unit following an unwitnessed fall at his residence. He fell in some short stairs leading to a bin, and was found at the bottom of the stairs with his head down, already looking hypoxic was unresponsive, and a pulse was not detectable. Immediate cardio-pulmonary resuscitation (CPR) was started by a grand-daughter. London Ambulance service arrived and confirmed PEA arrest; further 22 minutes of CPR to obtain ROSC. An iGel was inserted for ventilation. Initially Mr Hedges was very unstable, requiring Adrenaline infusion to maintain blood pressure. On arrival to A&E Mr Hedges was intubated and ventilated. Trauma CT scan revealed an unstable C6 and C7 fracture and bilateral rib fractures (no flail segment).The spine was immobilized and the fracture managed conservatively. The initial CT head showed no signs of intracranial injury except for a superficial haematoma on the scalp. A superficial laceration was sutured in A&E. Mr Hedges was admitted to critical care and stabilised. He was neuro-protected for 48 hours, with full sedation. Initial haemodynamic instability resolved, and he was almost off Noradrenaline. Sedation (Propofol and Fentanyl) was stopped on 24/09 in the morning, but Mr Hedges remained with a GCS E1VtM1, and absent reflexes on triggering of the ventilator. A repeat head CT head was done at 72 hours of admission; this revealed widespread hypoxic brain damage with bilateral uncal herniation, crowding of the foramen magnum, and bilateral extensive infarcts. The overall outcome looked very poor given the prolonged out of hospital cardiac arrest, extensive hypoxic brain injury with uncal herniation and no improvement in neurology. A decision was made to move to comfort care and extubate Mr Hedges, after discussions with the family members. The family mentioned multiple times that Mr Hedges had been deteriorating over the last 6 months prior to admission. He was having memory problems, and had some panic attacks (long-standing problems). Mr Hedges sadly passed away on 26/09/23 @ 15:48

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

Other related deaths This report is being sent to: Gravesham Borough Council

02/06/2023

2023-0179

Nigel Harper

Worcestershire

The Chief Executive, Herefordshire & Worcestershire Health and Care NHS Trust, 2 Kings Court, Charles Hastings Way, Worcester WR5 1JR; � The Chief Executive, Gloucestershire Health & Care NHS Foundation Trust, Edward Jenner Court, 1010 Pioneer Avenue, Gloucester Business Park, Brockworth, Gloucester, GL3 4AW.

[the details below are fictional] � On 27 July 2022 I commenced an investigation and opened an inquest into the death of Nigel Harper. The investigation concluded at the end of the inquest on 15 May 2023. � The conclusion of the inquest was that Mr. Harper died as the result of suicide.

In answer to the questions �when, where and how did Mr. Harper come by his death?�, I recorded as follows: � �On 8.7.22 Nigel Harper, who had over the previous month been experiencing severe depression and anxiety, and living with thoughts of self-harm, took an intentional overdose of prescribed sedative and hypnotic medications. He was taken to Worcestershire Royal Hospital where, despite treatment, he continued to decline, and died on 23.7.22.� � Mr. Harper lived in Scotland, but in the period leading up to his death had been staying with his sister near Malvern. He had a lengthy mental health history, which included a recent inpatient admission to a psychiatric hospital in Edinburgh.

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

Suicide (from 2015) This report is being sent to: Herefordshire and Worcestershire Healthy and Care NHS Trust and Gloucestershire Health and Care NHS Foundation Trust

13/06/2024

2024-0318

Christopher Larsen

Rutland and North Leicestershire

The Chief Executive, Leicestershire Partnership NHS Trust via their legal representatives

On 17 January 2023 I commenced an investigation into the death of Christopher Henrik LARSEN aged 52. The investigation concluded at the end of the inquest on.� The conclusion of the inquest was�that: The cause of death was established as: I a Hanging by Ligature

Mr Larsen was a 52 year old white male who, on 6 January 2023, was found hanging at his home in Leicestershire.

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

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

7/8/2024

2024-0435

Mavis Dewey

South Yorkshire West

The Chief Executive, Monarch Health Care C/O Heeley Bank Care Home, [REDACTED}

On 8 April 2024 I commenced an investigation into the death� of Mavis DEWEY. The investigation concluded at the end of the inquest on 07.08.24 The conclusion of the inquest was a narrative, namely:� Mavis Dewey died on 29.03.24 at the Northern General Hospital Sheffield� following a fall at the Heeley Bank Care Home Sheffield on the 23.03.24 when staff used incorrect equipment to help her stand in breach of her care plan.� Her death was contributed to by neglect from Heeley Bank Care home.� The Medical Cause of Death was: 1a Multiorgan failure 1b Covid 19 infection and open fracture of right proximal tibia and fibula 1c II Alzheimer�s Disease, Heart Failure

On 07.08.24 I heard the inquest touching the death of Mavis Dewey. Mavis�was 89 years old and becoming frailer with a number of underlying health� conditions. Her level of need was such that she required residential care which was provided by Heeley Bank Care Home in Sheffield. Mavis� needs were set� out in her care plan and there was no dispute that, to be moved or mobilised,� she required two members of staff to help her stand together with a standing�aid and sling. �� On 23.03.24 Mavis was being assisted to stand by two members of staff in her own room. A stand aid was present in her room but so also was a Zimmer� frame. It was not possible to establish how the Zimmer frame got there.� Ms Davison for Monarch and Heeley Bank accepted that it was entirely inappropriate for the two members of staff to use the Zimmer frame to help� Mavis stand, but this is what they did. As she was being helped to stand,� Mavis asked to use the toilet. One member of staff left her with her colleague and supported on the Zimmer frame. Mavis legs gave way and she fell to the floor sustaining a severe gash to her right leg. �� An ambulance was called, and she was taken to the Northern General� Hospital Sheffield where a fracture to the right proximal tibia and fibula was identified together with a diagnosis of Covid 19.� Despite appropriate care in hospital, Mavis did not recover and she died there� on 29.03.23� It remained unclear after evidence why the carers failed to comply with the�care plan. I was taken to the care plan which was clear about how moving and handling should take place. The evidence from�[REDACTED] was that no full�reason was established as to why this happened. Rather, the fact was that the carers simply used the Zimmer frame which was to hand. She said that the� carers had sufficient time to work with Mavis. I found that there was no good� reason for what they did. This failure led directly to Mavis eventual death.� In evidence it was stated by [REDACTED]�that agency staff continued to fail to�read care plans on occasion. This concerned me. The care plan sets out the� essential requirements to ensure that a resident is safely cared for. I consider�that if agency staff are not reading care plans then they may place residents at risk of harm or death just as Mavis was.

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

Care Home Health related deaths� � This report is being sent to: Monarch Health Care C/O Heeley Bank Care Home

8/8/2024

2024-0437

Mary Horgan

Greater Manchester South

The Chief Executive, Northern Care Alliance NHS Foundation Trust, Mayo Building, Salford Royal, Stott Lane, Salford, M6 8HD

On 13th June 2023 an investigation was commenced into the death of Mary Margaret Horgan, aged 80 years. The investigation concluded at the end of the inquest on 6th August 2024. The inquest found that the medical cause of Mrs Horgan�s death was:� 1a) Severe Compressive Spinal Cord Injury� 1b)� Traumatic� Cervical� Spinal� Injury� with� Fracture� Dislocation� of� the� Cervical Spine.� The conclusion of the inquest was that she died from complications arising from a significant spinal injury sustained in an accidental fall.

Mrs� Horgan� fell� at� home� on� 5th� May� 2023.� She� was� taken� by� ambulance� to Wythenshawe hospital where a CT scan revealed no evidence of trauma to her neck or spine. However, she continued to experience pain to her neck and an MRI scan was attempted on 8th May to investigate further. Unfortunately, Mrs Horgan was unable to tolerate the procedure due to claustrophobia and anxiety on a background of bipolar affective� disorder. No further attempt was made thereafter to mobilise Mrs� Horgan, pending� the� MRI� scan.������� By� 11th� May� 2023,� there� were� indications� of� spinal� cord compromise, but these were subtle signs for which there were other possible credible alternative causes and the CT scan had shown no bony trauma. Although the plan was to continue to attempt to undertake an MRI scan, with sedation if necessary, due to pressures on the scanning equipment, no slot became available over the coming days. By 14th May, Mrs Horgan�s breathing had become laboured, with hindsight, indicating a progression of spinal cord compression. The MRI scan was successfully achieved on 15th May. The radiological report failed to identify a dislocated fracture at C5/6 with spinal cord compression. In the light of the misleading report of the MRI scan, and weakness noted in Mrs Horgan�s left arm, a referral was made via Patient Pass to the spinal team at Salford Royal Hospital at 19.10 hours. The Patient Pass system notified the on-call Registrar at the spinal unit of the new referral by text message and the Registrar triaged the referral, replying via Patient Pass to Wythenshawe hospital at 19.44 hours. Two minutes later, the Registrar contacted the on-call spinal Consultant. The evidence was that there is no alert generated by Patient Pass to the referrer to indicate that a reply has been generated. The spinal Consultant accessed the referral and the radiological scans, immediately identifying� the C5/6 dislocated fracture and significant compromise of the spinal cord.� By 20.36, there had been no response from Wythenshawe Hospital and the spinal Consultant posted another message on Patient Pass raising a number of questions seeking background information, highlighting the seriousness of Mrs Horgan�s condition and advising that she be transferred as soon as possible to Salford Royal Hospital with and Aspen collar and spinal precautions.� Further attempts by the on-call Registrar at Salford Royal Hospital to gain information from Wythenshawe Hospital by telephone were unsuccessful, in all likelihood because of a recent change of shift on the ward. � Arrangements were made by the Wythenshawe Night Manager and the Salford Bed managers to transfer Mrs Horgan to Salford Royal by ambulance, but no collar or spinal precautions were deployed. By the time of the transfer, Patient Pass had not been accessed by the medical staff at Wythenshawe Hospital. The Patient Pass system was next checked at around 22.30 hours, by which time, Mrs Horgan had been taken to Salford Royal Hospital.� The inquest heard that Patient Pass can only be accessed by medical staff with a General Medical Council registration number. The inquest also heard that the spinal unit at Salford Royal Hospital usually respond to new referrals within 30-40 minutes and in any event, a response can certainly be expected within an hour of the referral. The spinal unit regard all referrals via Patient Pass as urgent, hence the speed of the triage and� initial� response� times.� By� contrast,� the� understanding� of� the� medical� staff� at Wythenshawe is that Patient Pass is the only and routine method of referral for in- patients� and� there� is� no� mechanism� to� indicate� the� receipt� of� a� response� or,� if necessary, to differentiate between urgent and non-urgent referrals. On the part of the spinal unit at Salford Royal Hospital, from the evidence, it is anticipated that referrers would� anticipate� the�� swift� response�� to� a� new� referral,� whereas� there� was� no corresponding anticipation on the part of the medical staff at Wythenshawe Hospital of a need to expect a response within that timescale. Identifying and reading a response requires the referrer regularly to log in to Patient Pass to look for a response. The inquest heard that it may be possible for staff such as bed managers to obtain some information from the Patient Pass system, it was not directly accessible to them. The inquest also heard that it is possible to make bespoke amendments to the Patient Pass operations so as, for example, to give additional information about anticipated response times and contact numbers. It was also clear from the evidence that Patient Pass is widely used by a number of specialty units, whose working practices and utilisation of the Patient Pass system may differ. The inquest also heard that there is no specific induction training for junior doctors nor any refresher training for established doctors relating to the Patient Pass system within the established training programs.�� Once� Mrs� Horgan� arrived� at� Salford� Royal� Hospital,� it� was� clear� that� she� was quadriplegic and that there was severe spinal compression. A further CT scan confirmed the� dislocated� C5/6� fracture.� She� was� admitted� to� the� Critical� Care� Unit.� It� was necessary to address low blood pressure in particular and having regard to her frailty and the poor response to blood pressure support, the decision was made, with Mrs Horgan and her family, that the risks outweighed any potential benefit of spinal surgery and palliative care was adopted. She was placed on end of life care and died on 5th June 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED], on behalf of Mrs Horgan�s family and the Chief Executive, Manchester�University NHS�� Foundation�Trust,�Cobbett�House,�Oxford�Road, Manchester, M13 9WL. I have also sent a copy of my report to the Chair of the Greater Manchester Integrated Care Partnership, 4th Floor, 3 Piccadilly Place, Manchester M1 3BN� and� The� Directors,� Patient� Pass� Limited,� Tomorrow� Building,� Media� City� UK, Salford, Greater Manchester, M50 2AB 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: Northern Care Alliance NHS Foundation Trust

24/11/2023

2023-0475

Michael Daft

Nottinghamshire

The Chief Executive, Nottingham University Hospitals NHS Trust (NUH)

On the 23rd of November 2022, I commenced an investigation into the death of Michael David Daft. The investigation concluded at the end of the inquest on the 22nd of November 2023. The conclusion of the inquest was natural causes.

Michael was diagnosed with rectal cancer on the 30th of July 2021. A left renal mass was also identified, and further tests had to be undertaken to identify its cause. There were delays in establishing the renal diagnosis and the colorectal surgery was postponed until the outcome of that was known. A diagnosis of renal cell carcinoma was confirmed on the 5th of November 2021 and the necessary surgery for both conditions was planned for the 3rd of December 2021 but was cancelled due to no HDU bed. � Further scans identified a progression of the rectal cancer and Michael was referred to Oncology for treatment, which commenced in January 2022. Michael�s cancer did not respond to treatment, and he was admitted to hospital on the 8th of November. He deteriorated rapidly and died on the 10th of November 2022, at City Hospital, Nottingham, from a perforated bowel, secondary to tumour progression. Detailed findings as to how he came by his death are described within a written Determination dated 22nd of November 2023, appended to this report.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED], Michael�s wife. The Nottingham University Hospital Trust (NUH). 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: Nottingham University Hospitals NHS Trust

04/10/2024

2024-0529

James Southern

Nottingham

The Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust

On the 6th of June 2023, I commenced an investigation into the death of James Southern. The investigation concluded at the end of the inquest on the 2nd of October 2024.� The conclusion of the inquest was drug related death.

Jimmy died on the 31st of May 2023. He was found unresponsive by his father at his home address in Nottinghamshire. Jimmy suffered with pain and anxiety since his motorbike� accident in 2002, and at times in order to cope, was known to self-medicate. There was�an elevated reading of [REDACTED] and [REDACTED] at the time of death, which was the direct cause of death. Jimmy died from a polydrug toxicity.�� He was receiving care from Nottinghamshire Healthcare Trust following a discharge from Highbury Hospital, Nottingham. However, he wasn�t seen by the services in the months� leading up to his death.�� The investigation and inquest identified there were errors in his records which misled� medical practitioners and Jimmy into thinking a care coordinator had been allocated.� There was also evidence that the records had not been uploaded in a timely manner and� at times after death. There was also evidence that records were amended after death.�� Jimmy�s case was not transferred to another care coordinator when his care coordinator� was absent. This meant Jimmy was left without care in the months leading up to his� death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� 1. [REDACTED], Jimmy�s mother�� 2. The Nottinghamshire Healthcare NHS Foundation Trust 3.�[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.

Alcohol, drug and medication related deaths

Nottinghamshire Healthcare NHS Foundation Trust

22/07/2024

2024-0392

Theo Bradley

Nottinghamshire

The Chief Executive, Sherwood Forest Hospitals NHS Foundation Trust

On the 16th September 2023, I commenced an investigation into the death of Theodore Riley Bradley The investigation concluded at the end of the inquest on the 5th July 2024 The conclusion of the inquest was a narrative as follows: Theodore Bradley died from hypoxic ischaemic encephalopathy, caused by a placental abruption, secondary to sub clinical acute chorioamnionitis. The abruption led to a major antepartum haemorrhage, which was not recognised as an obstetric� emergency� that� required� immediate� assessment� of� maternal� and� foetal wellbeing. Theo�s mother�[REDACTED] was not seen for 37 minutes on arrival at the Triage unit, at Kings Mill Hospital at 01.05 hours, when she was in pain and with significant vaginal bleeding, Had she been seen on arrival as she should have been, Theo would have been delivered by an emergency Category 1 caesarean section, likely by 01.25, certainly by 01.35, instead of at 02.02 hours as occurred. Had he been delivered at either of these earlier times, he would on balance have survived. The� delay� in� Triage� assessment� made� a� more� than� minimal,� negligible� or� trivial contribution to Theos death. Theo�s death was contributed to by neglect

Theo was born at 02.02 hours on 14.9.23 with no heart rate, and no breathing effort or movement. He had suffered a period of prolonged intra uterine hypoxia, due to a partial placental abruption. His mother, [REDACTED], reported vaginal bleeding at 41 plus weeks gestation, the severity of which was not recognised during the telephone Triage call, at 00.37 hours on 14.9.23. On arrival at the triage unit at 01.05 on that day,�[REDACTED] was not seen as she should have been on arrival, nor thereafter until 00.42 hours, meaning there was a delay of some 37 minutes before she was seen. Whilst delivery thereafter was achieved in 20 minutes, by this time Theo simply could not recover from the acute hypoxic injury caused by the continuing interruption to his blood and oxygen supply, caused by the abruption, evidenced at the time of delivery. Both the Trusts Maternity Triage policy and the Antepartum Haemorrhage policy were not followed Detailed Findings as to how he came by his death are provided in a written Determination dated 5.7.24

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. Theo�s family 2. The Regional Lead Obstetrician for the Midlands (NHS England)- [REDACTED] 3. The National Clinical Director for Maternity- [REDACTED] 4. The Care Quality Commission I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths | Child Death (from 2015)� � This report is being sent to: Sherwood Forest Hospitals NHS Foundation Trust

22/07/2022

2023-0053

Christopher Ryan

West London

The Chief Executive, South West London and St George�s Mental Health NHS Trust

On 31 December 2020 I commenced an investigation into the death of Christopher Thomas Ace RYAN. The investigation concluded at the end of the inquest . The conclusion of the inquest was Mr Christopher Thomas Ace Ryan was detained under section 3 of the mental health act in laurel ward of Queen Mary�s Hospital, Roehampton. In the days leading up to Mr Ryan�s death hospital notes documented he was well, compliant in taking prescribed medication and following hospital regulations on escorted leave, returning on two prior occasions on the 21st and 22nd December 2020. No apparent concerns in needing to change his risk assessment for future escorted leave. On 23rd December 2020 Mr Ryan absconded from escorted leave and was reported missing to the police at 13.51 by the hospital staff. He was assessed as medium risk by the police. � Conclusion � Drugs related death Cause of death � 1a�� Aspiration of stomach contents 1b Central nervous system depression 1c Combined drug intoxication

Deceased was a S3. Mental health patient absconder and missing person from St Marys Hospital. Deceased has absconded from the ward and met with a friend (previous patient on the same ward) at New Malden railway station. Friend has agreed to let the deceased stay at his flat in Kingston. Deceased has bought heroin and smoked it, deceased underwent laboured breathing and lost consciousness. Friend of the deceased called LAS who arrived and carried out CPR to no avail.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family Probation 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 form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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

South West London and St George�s Mental Health NHS Trust

19/09/2023

2023-0456

Mark Bennett

South Yorkshire (Western)

The Chief Executive, Yorkshire Ambulance Service (YAS) Trust Headquarters Brindley Way Wakefield 41 Business Park Wakefield WF20XQ � The Chief Executive, Association of Ambulance Chief Executives (AACE) 25 Farringdon Street London EC4A4AB

On 12.12.22, I commenced an investigation into the death of Mark Bennett aged 38 The investigation concluded at the end of the inquest on 19.09.23 The conclusion of the inquest as to the medical cause of death was: � 1a Pulmonary Embolism 1b Deep Vein Thrombosis 1c Immobility in relation to leg injury � I answered the statutory questions as follows: � Mark Bennett died on 14.04.22 at Meadowhall Shopping Centre Sheffield from a pulmonary embolism following a sprained ankle sustained in a trip on stairs in the London Underground on 05.04.22. There was a delay in the ambulance attending Mark caused by pressures on the ambulance service and an error in ambulance allocation. � I recorded a short form conclusion of accidental death

Mark tripped in the London underground on 05.04.22 causing damage to his ligaments in his right ankle. He was initially treated in the Royal Free Hospital, London and then had an outpatient appointment at his local hospital of Diana Princess of Wales Hospital in Grimsby, near to� where he lived, on 11.04.22. � Mark collapsed with a suspected pulmonary embolism causing a cardiac arrest in the Meadowhall Shopping Centre Sheffield on 14.04.22. � During evidence of [REDACTED] for the Yorkshire Ambulance Service (YAS) in the inquest on 19.09.23, it emerged that paramedics attempted resuscitation of Mark for only 21 minutes. This was just within their then applicable protocol. Rather than transport Mark to the nearby accident and Emergency Department of the Northern General Hospital Sheffield, they declared ROLE and no further attempts a resuscitation took place. � Concern was expressed that this meant that there was no opportunity for thrombolysis to be attempted by hospital staff . [REDACTED] of YAS gave evidence that the guidance and protocols available for ambulance staff/paramedics on when to stop resuscitation and/or take to hospital for attempts at thrombolysis in these circumstances were unclear. � I was concerned that this lack of clarity on what constituted best practice on this issue for paramedics and/or ambulance staff might place future patients at risk in similar situations

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

Emergency services related deaths (2019 onwards) This report is being sent to: Yorkshire Ambulance Service | Association of Ambulance Chief Executives

26/03/2024

2024-0181

Craig Burfield

South Yorkshire West

The Chief Executives of the Sheffield Teaching Hospital Trusts NHS Foundation Trust and the Sheffield Children�s NHS Foundation Trust

On 18 September 2023 I commenced an investigation into the death of Craig John BURFIELD. The investigation concluded at the end of the inquest on 26.03.24. The conclusion of the inquest was � Craig Burfield died on 24.02.23 at the Northern General Hospital Sheffield from the consequences of clots which formed in his hydrocephaly shunt and cerebral sinus during surgery related to his spina bifida. This caused his brain to swell in an unsurvivable event. The cause of the blood clots could not be established on the evidence. � 1a�� Cerebral oedema and Coning � 1b�� Cerebral Sinus and Ventriculo-Cardiac Shunt Thrombosis 1c�� Spina-Bifida (Previously treated)

Craig Burfield suffered from spina bifida and had shunts fitted as a child. He had complicated medical needs as a result of his condition. He was admitted for surgery for bladder stones at the spinal injury unit at the Northern General Hospital on 20.02.23, undergoing surgery on 23.02.23. He failed to come round from the anaesthetic and died from swelling in the brain as set out above. The cause of the thrombosis could not be established.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Sheffield Teaching Hospital Trust NHS Foundation Trust | Sheffield Children�s NHS Foundation Trust

20/06/2024

2024-0461

Susan Williams

Pembrokeshire & Carmarthenshire

The Clinical Director, Hywel Dda University Local Health Board, Ystwyth Building, Hafan Derwen, St David�s Park, Jobswell Road, Carmarthen, SA31 3BB The Chief Executive NHS Wales, Welsh Assembly, Cathays Park, Cardiff, CF10 3NQ

On the 14th February 2020 I commenced an investigation into the death of Susan Margaret Williams aged 73. The investigation concluded at the end of the inquest on 19th June 2024. The conclusion of the inquest was a natural causes one with the medical cause of death recorded as: 1a. Cardiorespiratory failure. 1b. Lung Fibrosis. Cor Pulmonale.

Susan Margaret Williams had been admitted as an emergency patient at 4.23am on the� morning of the 14th July 2019 into the Accident and Emergency Unit of Withybush� Hospital, Haverfordwest with a suspected diagnosis of sepsis, complaining of abdominal pain. She underwent care and treatment consistent with that diagnosis.� Despite appropriate measures being taken, Mrs Williams deteriorated and died from Cardiorespiratory failure due to lung fibrosis and Cor Pulmonale

I have sent a copy of my report to the Chief Coroner and to the following Interested�Persons �[REDACTED]�and [REDACTED], the family of Mrs Susan Margaret Williams.� 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 | Wales prevention of future deaths reports (2019 onwards)

Hywel Dda University Local Health Board | NHS Wales

08/11/2024

2024-0624

Alexander Rogers

Oxfordshire

The Department for Education

INVESTIGATION AND INQUEST On the 30 January 2024 an Inquest was opened into the death of Alexander Rogers, a student at Corpus Christi College, Oxford.� On 6 November 2024 I� concluded an Inquest into his death after a 2-day hearing.

Alexander took his own life when he jumped from [REDACTED], Oxford into the River Thames suffering a fatal head injury.� In the preceding� days, he had been ostracised, which included what was described as �name�calling�, �targeted behaviour� and exclusion and rejection following allegations made against him about his conduct.� I reached a formal conclusion of� Suicide.

I confirm that a copy of this report and your response will be sent all� interested persons, including the family of Alexander Rogers, Corpus Christi� College, Oxford, and the University of Oxford. The Chief Coroner will also� receive a copy and may publish the report, in whole or in part, as well as any response received.� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015)

Department for Education

01/12/2023

2023-0506

David Briggs

South Yorkshire (Western)

The Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU � The South Yorkshire Integrated Care Board, 722 Prince of Wales Road, Sheffield, S9 4EU

On 20 June 2023 I commenced an investigation into the death of David John BRIGGS. The investigation concluded at the end of the inquest on 30 November 2023. The conclusion of the inquest was that Mr David Briggs, died on 15 November 2022 at the Northern General Hospital, Sheffield from an infection resulting from catheterisation. � The medical cause of death was: 1a. Urosepsis 1b. Urinary tract obstruction � 1c. Spina bifida

Mr Briggs had spina bifida with paralysis from the waist downwards and resided in supported living where he relied heavily on support staff for everyday living. He had a long term supra pubic catheter and colostomy and in early November 22 Mr Briggs�s carers became concerned that his catheter wasn�t draining properly and with engagement with primary care Mr Briggs was prescribed antibiotics for a possible urinary tract infection on 12 November 2023. � At 2049 on 14 November Mr Briggs�s carers called 999 as he was struggling to breath. The call was routed to Yorkshire Ambulance Service (YAS) who coded the call as a Category 2 (expected response within 40 minutes). � At 2145 a second 999 call was made which was answered by East Midlands Ambulance Service (EMAS) having been routed by BT. This call was also coded as a Category 2 and passed to YAS. � At 2219 a third 999 call was made and answered by YAS as Mr Briggs�s breathing was worse and he was struggling to breath in-between talking. This call was again coded as a Category 2 � At 2339 a fourth 999 call was made which was again answered by EMAS. This call was incorrectly coded as a Category 2 by EMAS, instead of a Category 1 and passed to YAS. � At 0027 the final 999 call was made. Mr Briggs was unresponsive and not breathing. The call was coded as a Category 1 and carers advised to start CPR. The YAS ambulance arrived at 0044 and after initial treatment David was transferred to the Northern General Hospital in Sheffield where he was pronounced dead at 0231.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; � Mr Briggs�s family � Yorkshire Ambulance Service, Brindley Way Wakefield 41 Business Park Wakefield WF2 0XQ � East Midland Ambulance Service, 1 Horizon Place, Mellors Way Nottingham Business Park Nottingham, NG8 6PY � 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: South Yorkshire Integrated Care Board | Department of Health and Social Care