Inquests (PFDs)

20/03/2024

2024-0158 Deceased name: Jean Walker

Coroner name: Hannah Berry

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

The Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU � The West Yorkshire Integrated Care Board, White Rose House, West Parade, Wakefield, WF1 1LT Department of Health and Social Care | West Yorkshire Integrated Care Board

On 19 December 2023 I commenced an investigation into the death of Jean WALKER. The investigation concluded at the end of the inquest on 20 March 2024. The conclusion of the inquest was that; � Mrs Jean Walker died on 4 November 2022 having collapsed struggling to breathe at her home address [REDACTED] Sheffield. An ambulance was called but delays to its arrival resulted in a missed opportunity to give medical assistance. It cannot be said that if she had received earlier intervention that her death would have been prevented. � 1a�� Pulmonary Emboli 1b Deep vein thrombosis

On 4 November 2022 Mrs Walker called her daughter as she was feeling unwell. Her daughter attended her at her home address and at 0348 called 999 as she was struggling to breathe. The call was correctly coded as a Category 2 (expected response time of 40 minutes) and Mrs Walker�s daughter was told an ambulance would be with her within 40 minutes. � An ambulance was dispatched at 0526, arriving at 0542. At some point between the 999 call at 0348 and the ambulance arrival at 0542 Mrs Walker died. She was pronounced dead at 0551 by the attending paramedic.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; � Mrs Walker�s family � Yorkshire Ambulance Service, Brindley Way, Wakefield, WF2 0XQ � 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)

29/04/2024

2024-0231

Sophie Hindmarsh

South Yorkshire West

The Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU � NHS England, PO Box 16738, Redditch, B97 9PT � The West Yorkshire Integrated Care Board, White Rose House, West Parade, Wakefield, WF1 1LT

On 18 September 2023 I commenced an investigation into the death of Sophie HINDMARSH. The investigation concluded at the end of the inquest on 29 April 2024. The conclusion of the inquest was of natural causes.

Sophie had complex needs and required full time care. At 0245 on 21 July 2022 Sophie�s father called 999 as she was vomiting brown liquid, felt hot to touch and her percutaneous endoscopic gastronomy feeding tube was leaking. The call was initially coded as a Category 1, but at 0251 was correctly recoded as a Category 2 by the Senior Clinical Advisor. � An ambulance was dispatched at 0716, arriving at 0731. Within that 24 hour period 156 ambulance hours were lost to delays handing over patients to hospitals. � Sophie was conveyed to Northern General Hospital in Sheffield where she sadly died on 17 August 2024.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Sophie�s family � Yorkshire Ambulance Service, Brindley Way, Wakefield, WF2 0XQ � 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 of Social Care | NHS England | West Yorkshire Integrated Care Board

20/12/2023

2023-0538

Shaun Parks

South Yorkshire (Western)

The Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU, � The West Yorkshire Integrated Care Board, White Rose House, West Parade, Wakefield, WF1 1LT.

On 25 May 2023 I commenced an investigation into the death of Shaun PARKS. The investigation concluded at the end of the inquest on 15 December 2023. The conclusion of the inquest was that Mr Parks died on 13 December 2022 at the Northern General Hospital in Sheffield, there was a significant delay in Mr Parks receiving treatment and this may have affected the outcome. � His medical cause of death was recorded as: 1a Myocardial infarction (stented) 1b�� Ischaemic heart disease.

Mr Parks attended Doncaster Royal Infirmary�s Emergency Department on 12 December 2022 at roughly midnight, Mr Park�s waited in the emergency department for approximately 1-1.30 hours until an ECG was carried out and showed Mr Parks to be suffering a heart attack. Mr Parks was moved to the resuscitation area of the department and an interfacility transfer request to the Northern General Hospital�s primary percutaneous coronary intervention (PPCI) centre was made by a nurse at the hospital to Yorkshire Ambulance Service (YAS). � It was confirmed by YAS that the category 2 blue light ambulance was booked at 3.06am on 13 December 2022, the ambulance should have taken at the latest 40 minutes to arrive, YAS confirmed the ambulance was categorised correctly as a category 2. The ambulance arrived at Doncaster Royal Infirmary at 06.29 hours and left scene to transfer to Sheffield�s Northern General Hospital�s PPCI 06.44 and arrived at 07.15. � Mr Parks deteriorated during his time at Doncaster Royal Infirmary and his procedure at Sheffield�s PPCI unit commenced at 08.45. Mr Parks sadly died during the procedure at 10.17. � There was a delay in the ambulance arriving to collect Mr Parks of 3 hours 18 minutes and 41 seconds.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Mr Park�s family. � Yorkshire Ambulance Service, Brindley Way, Wakefield, WF2 0XG. � Doncaster Royal Infirmary, Thorne Rd, Doncaster DN2 5LT. � Sheffield Teaching Hospitals, Herries Road, Sheffield S5 7AU. �� I may also send a copy of your response to any person 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 | West Yorkshire Integrated Care System

07/06/2023

2023-0187

Anthony Smith

Lancashire and Blackburn with Darwen

The Director General of the Prison Service, 102 Petty France London SW1H 9AJ and I am sending a copy of the report to the Governor HMP Preston for information purposes

An investigation into the death of Anthony George Smith aged 34 was commenced on 16th May 2022. The investigation concluded at the end of the inquest on 7th June 2023. The conclusion of the inquest was that Mr Smith died as a result of self-suspension but his intention in doing so could not be determined

Mr Smith at the time of his death at HMP Preston was suffering an acute relapse in respect of his schizophrenia. He was delusional, hallucinating and hearing voices. On 4th May 2022 he was found hanging in his cell. He was cut down and officers commenced cardio-pulmonary resuscitation

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

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

03/10/2023

2023-0361

Manoel Santos

Inner South London

The Director at HMP Belmarsh, Western Way, Thamesmead, London, SE28 0EB. � The Head of Healthcare (Practice Plus Group) at HMP Belmarsh, Western Way, Thamesmead, London, SE28 0EB. � The Secretary of State for the Home Department, 2 Marsham Street, London SW1P 4DF. � Director General Chief Executive HM Prison and Probation Service (HMPPS), 102 Petty France, London, SW1H 9AJ. � Lord Chancellor and Secretary of State for the Ministry of Justice, 102 Petty France, London SW1H 9AJ, [REDACTED] Chief Executive Officer of Practice Plus Group, Hawker House, 5-6 Napier Court, Napier Road, Reading, Berkshire, RG1 8BW.

1.����� The death of Manoel Messias Santos (�Mr Santos�) was reported to the coroner by HMP Belmarsh on the date of his death, 2 November 2020.������������������������������������������������������������������������������������� . 2.����� A forensic post-mortem was conducted on 5 November 2020. The medical cause of death of MS was 1a: Hanging 3.����� On 24 February 2021 an Inquest was opened into the death of Mr Santos and an Article 2 Inquest was heard between 11 September 2023 and 25 September 2023 with a jury. The jury concluded with a narrative conclusion incorporating a conclusion of suicide. 4.����� I considered Prevention of Future Death (�PFD�) evidence (written and oral) on 27 September 2023.

1.������� Mr Santos was a Brazilian national who lived in the United Kingdom since 1997. He applied for indefinite leave to remain in 2004 but this was rejected in the same year. 2.������� He had a history of severe mental health issues. 3.������� Mr Santos was remanded to HMP Highdown on 29 October 2019, being transferred to HMP Belmarsh on 26 November 2019. On 6 May 2020, Mr Santos was sentenced to two years� imprisonment and was due to be released on 27 October 2020. 4.������� On 5 October 2020, the Immigration Service served an IS91 notice of a decision to detain on Mr Santos. This meant he would not be released from prison at the end of his sentence whilst his deportation was considered. A Stage 1 letter had been served on 28 December 2018 but a Stage 2 letter had not been served. There was also an outstanding appeal in the First-tier immigration Tribunal. 5.������� Mr Santos wrote a letter on a bail form outlining his concerns about returning to Brazil, referring to his sexuality and his health. This was sent by the prison to a charity assisting immigration detainees on 29 October 2020. 6.������� In the early hours of 2 November 2020, the night officer found Mr Santos hanging in his cell during a routine check. Staff tried to resuscitate him. Ambulance staff arrived. Mr Santos was declared dead at 3.30am. � In summary, the jury found as follows: � ������� That Mr Santos� understanding of his immigration position at the conclusion of his custodial sentence made a material contribution to his death. ������� There was a failure to notify Mr Santos of the incoming IS91 form and its significance. ������� The central issue was communication between Mr Santos and the various agencies involved with him. By 16 October 2020 Mr Santos understood he would be detained at the end of his sentence but was confident his bail application would lead to resolution. However in the days prior to his death he told a fellow prisoner he believed he was to be placed in immigration detention and deported within days. ������� Confusion amongst the agencies involved in communicating with Mr Santos is likely to have played a vital role in his change of understanding but it was difficult to pinpoint the role that information passed to Mr Santos played in changing his understanding of his position. There were no adequate notes of a meeting on 22 October 2020 with Mr Santos and his prison and community offender managers. However it was clear that his view of his circumstances changed and he decided to end his life and deliberately did not clearly communicate his intent to those around him.

I have sent a copy of my report to � [REDACTED] (Government Legal Department) representing the SSHD [REDACTED] (Government Legal Department) representing the MOJ [REDACTED] ([REDACTED]) representing Oxleas [REDACTED] representing Practice Plus Group (Change Grow Live) [REDACTED], Independent Chief Inspector of Borders and Immigration HM Inspectorate of Prisons Independent Advisory Panel on Deaths in Custody � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

State Custody related deaths | Suicide (from 2015) This report is being sent to: HMP Belmarsh | Practice Plus Group | Home Office | HM Prison and Probation Service | Ministry of Justice

24/10/2024

2024-0572

Aran Bradbury

Norfolk

The Emergency Call Prioritisation Group (ECPAG) Association Of Ambulance Chief Executives (AACE) National Ambulance Service Medical Directors (NASMeD)

On 29 August 2023 I commenced an investigation into the death of Aran Sean BRADBURY aged 34. The investigation concluded at the end of the inquest on 16 October 2024. The medical cause of death was: 1. Hypoxic Ischaemic Brain Injury 2. Cardiac Arrest 3. Hanging � The conclusion of the inquest was: On 21 August 2023, Mr Aran Sean Bradbury applied a ligature to his own neck.� His intention when he did so is unknown. As a result of applying the ligature, Mr Bradbury went into cardiac arrest. There was a delay of two hours between a call being made to 999 and an ambulance being despatched. Advance Life Support was provided by ambulance crews on arrival at the scene and Mr Bradbury was resuscitated and transferred to the Norfolk and Norwich University Hospital where scans identified the brain injury which caused Mr Bradbury�s death on 25 August 2023.

On 21st August 2023 at 13:07 a member of the local Drugs and Alcohol Service called 999 because of concerns about Mr Bradbury following a phone conversation with him and a separate call to the Service from his mother. The call expressed a concern that Mr Bradbury may intend to take his own life. Paramedics attended Mr Bradbury�s home, arriving at 15:15, and he was found with a ligature around his neck. Mr Bradbury was taken by Ambulance to the Norfolk and Norwich University Hospital, where he died on 25th August 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] � Mother [REDACTED], One Pump Court Chambers � Legal Representative for the Family East of England Ambulance Service Trust � I have also sent it to: Department of Health Care Quality Commission (CQC) Health Services Safety Investigations Body (HSSIB) 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.

Emergency services related deaths (2019 onwards)

NHS England | Association Of Ambulance Chief Executives | National Ambulance Service Medical Directors

21/12/2023

2023-0548

Denise Porter

West London

The Executive Director of Oxleas NHS Foundation Trust

On 23 February 2023 I commenced an investigation into the death of Denise Jane PORTER. The investigation concluded at the end of the inquest. The conclusion of the inquest was: Suicide. The medical cause of death was: 1a Decapitation.

On 19th February 2023, the deceased jumped on to the tracks of Platform 2 at Turnham Green Underground Station into the path of an oncoming train. She sustained multiple injuries incompatible with life. At the time she was under the care of Oxleas NHS Trust Adults� Community Mental Health Team. She believed she had early onset dementia which was being investigated. She had poor sleep and low mood in the months prior to her death but there was no formal diagnosis for her mental condition at the time of her death.

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

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

24/11/2023

2023-0512

Katie Williams

Plymouth, Torbay and South Devon

The Faculty of Intensive Care Medicine Churchill House 35 Red Lion Square London WC1R 4SG

On 11 June 2021 an inquest was opened touching the death of Katie Anne WILLIAMS (aged 45) who died at Derriford Hospital in Plymouth on 24 May 2021. She died having taken intentional overdose of [REDACTED] on 15 May 2021, and as a result of subsequent hospital care and treatment provided to her for that overdose and associated complications. � The inquest concluded on 23 November 2023 with the following narrative conclusion: � �Katie Anne Williams died on 24 May 2021 from serotonin toxicity caused by an overdose of [REDACTED] and hospital administered [REDACTED].� � In Box 3 of the record of inquest: � �Katie Anne Williams died on 24 May 2021 at Derriford Hospital. On 16 May 2021, she took an overdose of [REDACTED]. She was admitted to hospital where she was treated for this overdose and associated complications, including an aspiration pneumonia and paralytic ileus. [REDACTED] was initially withheld given the risk of serotonin toxicity, but re-introduced on day four of her ICU stay, as the period of risk for serotonin toxicity was felt to have passed. Sadly, as a result of the paralytic ileus Katie had developed, the absorption of modified release was delayed.� This, in combination with [REDACTED] administered in the ICU caused a re- precipitation of serotonin toxicity which was ultimately fatal.� The medical cause of death was recorded at the inquest as: � 1a) Circulatory failure 1b) Serotonin toxicity 1c) Drug overdose � As part of the inquest it was found as a matter of fact that the [REDACTED] administered by the ICU team in the hospital (as part of their standard procedure for sedating intubated patients) had caused a reprecipitation of the serotonin toxicity which was previously thought to have resolved. This was thought to have occurred because the patient had developed a paralytic ileus which had delayed the absorption of �the modified release [REDACTED] she had taken prior to her admission. This caused or contributed to Katie�s death. � Following this case the University Hospitals Plymouth NHS Trust (the �Trust�) has amended its sedation policy such that lower risk opiates (such as morphine) are recommended for sedating patients who are admitted following overdose of medications like venlafaxine, to reduce the risk of reprecipitating serotonin toxicity.

On 15 May 2021 Katie Anne WILLIAMS took an overdose of her prescribed [REDACTED].� She had taken [RED CTED] modified release tablets. Equivalent to 56 days� worth of this prescribed medication. � She was taken to Derriford Hospital by ambulance in the early hours of 16 May 2021 where she was reviewed in the emergency department and then shortly afterwards admitted to ICU. � On arrival at the emergency department, Katie was recognised to be extremely unwell. She was unconscious with a GCS of 3 as a result of her overdose. She had also had a number of seizures on her way to the hospital, and prior to the ambulance arrival. She required intubation and ventilation to protect her airway and stabilise her condition. � A chest x-ray was undertaken which demonstrated evidence of an aspiration. Katie also had a temperature of 40�c on admission to the emergency department; this, and the evidence of early muscle injury, led the treating ICU team to conclude that Kate was likely to be suffering with serotonin toxicity. � Given the ongoing risk of serotonin toxicity, and following Toxbase advice, no infusion of the opiate drug [REDACTED was administered to Katie during days 1, 2 or 3 of her ICU admission. At this stage, the venlafaxine was felt to still to be her system, and the plan was to support Katie whilst this cleared, and to treat her evolving aspiration pneumonia with antibiotics. Where additional sedation was required remifentanil was used. � On day 4 of Katie�s ICU admission (19 May 2021) a decision was made to switch the remifentanil infusion to a [REDACTED] infusion as per usual ICU practice. In the following days Katie�s kidney function continue to normalise. There was no recurrence of a hyperpyrexia, or any other clinical features to suggest a recurrence of the serotonin syndrome. The rationale for moving to [REDACTED] was that from day three onwards it was felt that the majority of the venlafaxine would have been metabolised by the body and therefore the risk of interaction with any other drugs such as fentanyl would not have been a significant concern. � [REDACTED] was infused on an hourly basis in accordance with usual practice and tolerance of the drug was monitored based on clinical effect, including considering a patient�s tolerance of the ET tube and interrupting the infusion on a regular basis to check for drug accumulation. � Sadly, over the next few days, Katie�s condition deteriorated. A CT scan confirmed the appearances of severe aspiration pneumonia and a paralytic ileus. � The concern at day five was the evolving severe aspiration pneumonia. Katie was now severely ill. As a result of this she required ventilating in the prone position. Prone ventilation required heavy sedation and as such the [REDACTED] infusion was increased to 5ml/hr. At this stage, it was felt that the [REDACTED] poisoning had passed. � Over the coming days Katie�s condition improved, and she was able to be managed once again in the standard supine position. The [REDACTED] infusion was reduced from 5 ml/hour to 3 ml/hour. She was having regular sedation breaks from which she was rousing quickly which meant that the infusion could not be further reduced. Again at this stage, the risk of an ongoing serotonin toxicity was not considered to be an issue. � Katie had also developed a paralytic ileus. In Katie�s case the paralytic ileus (it appears) delayed the absorption of the modified release [REDACTED]. This meant that the ICU team treating her at the time felt that the [REDACTED] had cleared from her system, and that it was therefore safe to introduce [REDACTED]. With the benefit of hindsight, and having seen the toxicology report, it appears that that was not the case; Katie still had a significant amount of [REDACTED] in her system. I am told there is no way of monitoring these levels in life. � In the morning of 24 May 2021 Katie appeared to be improving. She was reviewed on the ward round at 11am. She was haemodynamically stable, requiring no drugs to support her blood pressure. He abdomen remained distended, but there was no particular clinical concern for this at the time the plan was to continue with supportive care in the expectation she would continue to improve in the days ahead. � Very sadly however, and suddenly, Katie�s condition began to deteriorate at around 1pm that day. Her blood pressure began to drop and a noradrenaline infusion was commenced. Over the course of the afternoon her blood chemistry steadily deteriorated, reflecting her increasingly shocked state. Her oxygen requirement increased and she developed a severe refractory, circulatory failure and associated pulmonary oedema. Initially the team thought that Katy had become septic and that there might be an acute pathology such as a bowel ischemia or perforation. It was therefore decided to take Katie for a CT scan. However, sadly, whilst preparing Katy for transfer to the CT scanner she went into cardiac arrest. Attempts were made to resuscitate her over the following 40 minutes, but there was no reversible cause for the cardiac arrest that could be identified. Katy did not respond and resuscitation efforts ceased at 19:10 hours. Retrospectively, treating clinicians have considered the cause for Katie�s collapse on 24 May 2021. Having reviewed the toxicology report they are of the view that the paralytic ileus delayed the absorption of the modified release [REDACTED].�� This, combined with the[REDACTED] (that was used as a sedative drug in accordance with standard practice in the ICU setting) had reprecipitated a serotonin toxicity, which caused Katie to collapse on the 24 May 2021.� It is their view that Katie�s death was caused by a very unusual and rare presentation of a serotonin toxicity that occurred as a result of the delayed absorption of the [REDACTED], because of the paralytic ileus, and an idiosyncratic reaction between the [REDACTED] and the [REDACTED]. � Following Katie�s death, the ITU team has amended its sedation policy such that [REDACTED] would now be replaced with morphine in cases such as Katie�s, where patients presenting with a [REDACTED] (or similar) where there is an ongoing risk of serotonin toxicity.

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

Alcohol, drugs medication related deaths | Suicide (from 2015) This report is being sent to: Intensive Care Medicine

04/02/2023

2023-0043

Kirsty McKie

Manchester South

The Foreign Secretary

On 9th August 2022 I commenced an investigation into the death of Kirsty Margaret McKie. The investigation concluded on the 24th January 2023 and the conclusion was one of Narrative: Died from the complications of methanol poisoning after she had unknowingly consumed methanol believing it to be alcohol fit for human consumption. The medical cause of death was 1a) Methanol Toxicity

Kirsty Margaret McKie was a UK national who lived and worked in Bali. She ran a successful business as a talented ceramicist. On 22nd July 2022 she had consumed what she believed to be alcohol. The following day she felt unwell. She went to a hospital in Bali where she deteriorated and died on the 24th July 2022 despite treatment. Post-mortem examination included toxicology. It was found that she had methanol in her system which had caused her death. Methanol is not meant for human consumption. She had inadvertently consumed methanol believing she had consumed alcohol. The methanol had been sold as being alcohol fit for human consumption when it was not and caused her death.

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

Other related deaths

The Foreign Secretary

26/11/2022

2022-0410

John Lawler

North Yorkshire and City of York

The General Chiropractic Council

On 12/09/2017 I commenced an investigation into the death of John Thomas Lawler, 80. The investigation concluded at the end of the inquest on 18 November 2019. The conclusion of the inquest was that on 11 August 2017 John Thomas Lawler suffered a fractured neck and spinal cord damage whilst undergoing chiropractic spinal adjustment and subsequent mobilisation. The spinal cord damage led to respiratory depression from which he died at 20:00 hours on 12 August 2017.

Mr Lawler sought chiropractic treatment as he was suffering with an ache in his legs. On 11 August 2017 whist undergoing a spinal adjustment using a drop table he stated that he could not feel his arms. He was then moved from the prone position on the treatment table to being upright on a chair next to the table. He became less responsive, an ambulance was called and paramedics transported Mr Lawler down the stairs in a carry chair on stair tracks. He was fully immobilised on the ambulance. A CT scan at York District Hospital confirmed he had ankylosis of the cervical spine, a fracture at C4/C5 and dislocation of the facet joints at C4/C5. There was significant narrowing of the spinal canal. Mr Lawler was transferred to Leeds General Infirmary where he underwent an MRI scan on 12 August 2017 which confirmed significant spinal cord compression. Mr Lawler�s condition deteriorated and he died at 20.00 hrs that day. A post mortem examination confirmed the immediate cause of death as respiratory depression due to traumatic spinal cord injury and longitudinal ligament ossification with prominent vertebral body posterior osteophyte of C4/C5.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Stewarts Solicitors, DAC Beachcroft, General Chiropractic Council and Yorkshire 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 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

General Chiropractic Council

15/08/2023

2023-0385

Barry Lall

Central and South East Kent

The General Dental Council

On 18 May 2023 I commenced an investigation into the death of Barry Anthony LALL. The investigation concluded at the end of the inquest which was held on 14th August 2023 . The conclusion of the inquest was� Suicide � 1a� Suspension

Barry Lall was a dentist. I understand that concerns were raised with the General Dental Council (GDC) in relation to his dental work and fitness to practise as a dentist, and that such concerns were being investigated. � His case was referred to the Interim Orders Committee by the Registrar of the GDC on 4 August 2022. This led to a initial hearing taking place on 13th September 2022. The IOC decision was that interim conditions be placed on Mr Lall�s ability to practise for a period of 18 months, and a 7 page report being published on the GDC website. Within that report the complaints/concerns regarding Mr Lall�s working practices were set out in detail. � There was evidence provided by the Family that Mr Lall�s mental health, affected by the GDC investigation in the first instance, then deteriorated after the detail of the complaints/concerns of his work practices entered the public domain via the GDC Website. � In November 2022 Mr Lall was formally dismissed from his employment. In December 2022 he approached his GP reporting anxiety and depression with fleeting thoughts of suicide since the loss of his job and the fitness to practice enquiries. � On Friday 12th May and again on Monday 15th May 2023, Mr Lall received email notifications from his legal team regarding an upcoming meeting with the said team and the GDC scheduled for 18th May 2023. [REDACTED]. He died of suspension.

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

Other related deaths This report is being sent to: The General Dental Council

01/05/2024

2024-0235

Mohammed Azizi

Norfolk

The Governor of HM Prison Norwich Knox Road Norwich Norfolk NR1 4LU

On 23 May 2023 I commenced an investigation into the death of Mohammed Amin AZIZI aged 32. The investigation concluded at the end of the inquest on 25 April 2024. � The medical cause of death was: 1a)������ Cardiac Atrophy and Failure 1b)������ Malnutrition, Crohn�s Disease and Self-Neglect 1c) 2)�������� Pulmonary Thromboembolism and Infarction � The conclusion of the inquest was: Mr Azizi died of cardiac atrophy and failure with contributing factors of malnutrition, Crohn�s disease, self-neglect and a pulmonary thromboembolism and infarction due to his continued refusal of treatments.

The circumstances of Mr Azizi�s death are summarised in the finding of the jury that �Mr Azizi had a diagnosis of Crohn�s disease (2012) and Deep Vein Thrombosis (DVT) (May 2022) as a result he was transferred to the healthcare wing at His Majesty�s Prison, Norwich on the 11th August 2022 to have access to 24 hour healthcare. Whilst at His Majesty�s Prison, Norwich Mr Azizi was admitted on multiple occasions to the Norfolk and Norwich University Hospital for these conditions. Mr Azizi repeatedly refused food, monitoring, investigations and treatment. The risks to Mr Azizi�s physical health were known to him and he was judged to have capacity to understand that the outcome of his decisions could result in death. Mr Azizi was admitted to Norfolk and Norwich Hospital on the 24th April 2023 where he remained until his death on the 15th May 2023. He died of cardiac atrophy and failure�. � Mr Azizi was placed under an ACCT on two occasions while at HMP Norwich. The second of these was opened on 26.03.23. Prior to the Inquest, disclosure was provided by the prison, and this included an ACCT document dated 26.03.23 which was closed 27.03.23. However, during the course of the inquest, one of the Officers called to give evidence regarding that ACCT, indicated that she was not familiar with the ACCT document in the disclosure bundle, and that there was in fact a second ACCT document of the same date, with the same reference number, that had been opened by her. It then transpired that both the Coroner and the PPO (which had separately investigated this death) had only been provided with one of these two documents. � The copy of the second document was produced at Court, and in due course, the originals of both documents. � The Officer�s evidence was that, although the document originally disclosed bore what appeared to be her signature, this had not in fact been signed by her. She reported that when she was asked to prepare a witness statement for the purpose of the inquest in December 2023, she was provided with both copies of the document, and raised a concern that one was not completed or signed by her. Her evidence was that she was told not to refer to the second document. She also gave evidence that she thought the document not signed by her may have been a photocopy of her signature. Upon inspecting the two original documents, neither was a photocopy and both appear to have been completed in pen. � The prison were unable to provide any evidence of why they did not disclose both versions of the document, how there came to have been two documents, who had created the second one or details of the investigation carried out in to the concern of a signature being added by someone other than the Officer. � A Senior Officer who closed the ACCT then also gave evidence and he also advised that the document originally disclosed to the Court (and PPO) which appeared to bear his written and electronic signature, had not been signed by him.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Mr Azizi�s family HCRG Norfolk and Norwich University Hospitals NHS Foundation Trust Norfolk and Suffolk Foundation Trust [REDACTED] � I have also sent it to: � Ministry of Justice HM Inspectorate of Prisons HM Prison and Probation Service The Independent Advisory Panel on Deaths in Custody � who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

State Custody related deaths This report is being sent to: HMP Norwich

21/03/2024

2024-0160

Alan Davies

South Wales Central

The Governor of HMP Cardiff, The Chief Executive of the Cardiff and Vale University Health Board, the Chief Executive of the Swansea Bay University Health Board and the Secretary of State for Justice

A Coronial investigation was commenced on 23rd September 2021 into the death of Alan Richard Miles Davies. The Investigation concluded at the end of the inquest which I conducted with a jury on 26th February � 15th March 2024. The conclusion was a narrative conclusion and the medical cause of death was 1 (a) Cardiac arrest in a setting of starvation and dehydration

These were recorded as: Mr Davies was transferred to HMP Cardiff from Caswell Clinic on the 2nd September 2021. 10 days later on 12th September Mr Davies was found in a collapsed state in his cell and following CPR was transferred by ambulance to University Hospital of Wales where he later died. The narrative conclusion which the Jury returned was: Mr Davies died from an equal combination of misadventure, self neglect and neglect. Mr Davies contributed to his death by deliberately refusing food and fluid but he did not intend to end his life. It was an unintended consequence of such refusal. There were missed opportunities regarding the transfer of Mr Davies to hospital. The management, coordination and planning of Mr Davies� care including the handover of information within the prison and healthcare was unsatisfactory. The level and adequacy of observations was insufficient in noticing Mr Davies� signs of deterioration. The Inquest focused upon the following: 1. Mr Davies was transferred to HMP Cardiff from the Caswell Clinic following 16 days of food refusal in a state in which reception nursing staff felt he was unfit to be admitted to the prison, mobilising by wheelchair and requiring to be physically supported by escort staff. � 2. While Mr Davies refused to consent to formal observations, no assessment was made by Caswell Clinic of his physical condition prior to his transfer. � 3. No advanced notice was provided to HMP Cardiff that Mr Davies was being transferred to it in an impaired physical condition and refusing food, although the risk that he would refuse food had been communicated � 4. Mr Davies was transferred to HMP Cardiff by escort agency staff unfamiliar with his care or needs � 5. The majority of the Caswell Clinic discharge paperwork was provided to HMP Cardiff at the time of transfer rather the prior to it, in a format which did not easily identify the concerns related to his transfer � 6. At HMP Cardiff there was no systematic care plan put in place to address Mr Davies� food and fluid refusal or the risks of physical deterioration as a result of the same. � 7. No policy was in place to guide prison healthcare staff relating to food and fluid refusal. � 8. Mr Davies� capacity was not assessed on a planned or formal basis in prison. � 9. The prison GP reversed her decision to send Mr Davies to hospital on 10th September 2021 following discussion with a prison Governor, the product of which was that she received an erroneous understanding of the length of time for which he had been refusing food. � 10. No clear plan for escalation of care was put in place for the weekend. A GP was not asked to review Mr Davies over the weekend. � 11. The Health care assistant responsible for the care of Mr Davies on the night of his collapse had not been informed that he was refusing fluids and had not been observed to drink fluid since 3rd September 2021. � 12. The Nurse and Health care assistant responsible for the care of Mr Davies at the time of his collapse had not been informed that he was at risk of sudden collapse due to food and fluid refusal. 13. The number of healthcare staff working night shifts was insufficient to meet the demands upon them. 14. Despite being held in a camera call on the Healthcare wing, Mr Davies� focalised requests for �help� while lying on the floor of his cell were not recognised or heeded from 00.19 on 12th September 2021 until it was identified that he was in a collapsed state at about 02.54

I have sent a copy of my report to the following who may find it useful or of interest. Mr Davies�s family, HM Prison and Probation Service, the Governor of HMP Parc, the Medical Director of the Cardiff and Vale University Health Board, Medical Director of the Swansea Bay University Health Board. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

State Custody related deaths | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: HMP Cardiff | Cardiff and Vale University Health Board | Swansea Bay University Health Board | Ministry for Justice

25/10/2024

2024-0577

Mark Beresford

Nottingham City and Nottinghamshire

The Governor, HMP Ranby

Mark Stephen Beresford aged 39 died by hypoxic brain injury due to hanging on 7 July 2023. On 19 July 2023 I commenced an investigation into the death. An inquest was opened and later resumed before a jury on 7 October 2023, concluding on 15 October 2023.

CIRCUMSTANCES OF DEATH Mark Stephen Beresford died on the 7 July 2023 at Bassetlaw District General Hospital from hypoxic brain damage due to hanging. Mark was remanded at HMP Nottingham on 24 February 2023. He was later sentenced and was due for release on 25 August 2024. He transferred to HMP Ranby on 11 April 2023. Between 12:53 and 13:26 on 3 July 2023, while locked in his cell, Mark applied a ligature to his neck [REDACTED]. He was discovered unresponsive at 13:26. He was successfully resuscitated but remained in critical condition. He died following withdrawal of treatment 3 days later. Between 6 March 2023 and 29 April 2023, there were 15 risk related incidents, including 13 acts of self-harm nearly all involving the application of a ligature. After a period of apparent stability, there were further risk related incidents on 2 and 3 July 2023. He was subject to Assessment Care in Custody and Teamwork (ACCT) procedures at various points during his detention, with observations ranging from constant supervision to 1 at least every 3 hours. Mark attributed his actions to anxiety that he and his family would be under threat from a former cell mate upon his release on 25 August 2023. There was little evidence that Mark and his family were in fact under any significant threat. On several occasions he also expressed anxiety due to his belief that prisoners and staff were talking about him. There was no evidence to support this belief. Upon transfer to HMP Ranby Mark had disclosed to a member of the mental health team that he struggles with paranoia and hearing voices. The jury found that at the time of his death, Mark was suffering significant mental ill health. The jury returned a short form conclusion of misadventure within a narrative conclusion. i) They found the following failings contributed to Mark�s death: The decision by healthcare staff to discharge Mark from under the care of the Mental Health team and not refer him to the psychiatric MDT on 20 April 2023 was unreasonable in all the circumstances at that time. (Admitted by the Healthcare Trust) ii) A failure by healthcare staff at HMP Ranby to adequately assess the nature and extent of Mark�s mental health problems between 11 April 2023 and 3 July 2023. (Admitted by the Healthcare Trust) iii) When Mark�s ACCT was reopened on 2 July 2023, the decision by prison staff to set the observation levels at no more than 1 every 2 hours was unreasonable in all the circumstances. iv) Following a second self-harm incident on the 2 July 2023, there was an unreasonable failure to increase the level of observations. v) The assessment of Mark�s risk and the decision by healthcare and prison staff to close the ACCT at approximately 9:50am on the 3 July 2023 was unreasonable in all the circumstances. (Admitted by the Healthcare Trust) vi) When the ACCT was reopened again at around 12pm that day, the assessment of his risk by prison staff and the decision to leave the observation levels at no more than 1 every 2 hours was unreasonable in all the circumstances. vii) A failure by prison staff to complete an immediate action plan within the required 1 hour or at all. (Admitted by prison authorities) viii) A failure by prison staff to respond to the cell bell that Mark activated at approximately 12:53 on 3 July 2023 in a prompt manner, which went unheeded for approximately 33 minutes until Mark was discovered unresponsive at 13:26. (Admitted by prison authorities) ix) A failure by prison management to ensure there were sufficient staff on duty on House Block 3 to respond to cell bells over the lunch period. (Admitted by prison authorities)

I have sent a copy of my report to the Chief Coroner and to the following interested persons: Family � [REDACTED] and�[REDACTED] Nottinghamshire Healthcare (NHS) Foundation Trust who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner. 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 | Mental Health related deaths

HMP Ranby

08/09/2023

2023-0331 Deceased name: Kristopher Tilbury Coroner name: Jonathan Stevens Coroner Area: Hertfordshire Category: State Custody related deaths | Alcohol, drugs medication related deaths This report is being sent to: HMP The Mount | Ministry of Justice

The Governor, HMP The Mount, Molyneaux Avenue, Bovingdon, Hemel Hempstead, Hertfordshire The Secretary of State for Justice, Ministry of Justice, 102 Petty France, Westminster, London

On 24th September 2019 Senior Coroner Geoffrey Sullivan commenced an investigation into the death of KRISTOPHER COREY JAMIE LEE TILBURY [age 29). The investigation concluded at the end of a jury inquest on 31st August 2023. The conclusion of the jury at the inquest was that death was a consequence of smoking [REDACTED] and consuming alcohol whilst detained in prison, to which the availability illicit drugs within the Wellbeing Wing contributed.

The circumstances of death recorded by the jury at the inquest were that Kristopher Corey Jamie Lee Tilbury died of respirato sion as a consequence of smoking [REDACTED] and consuming alcohol whilst detained in his prison cell at HMP The Mount between the evening of 23rd September/early morning of 24th September. He was found with a mobile phone in his hand and drug paraphernalia nearby in his cell with the smell of�[REDACTED] in the air. The jury also recorded that despite Mr Tilbury�s known drug and alcohol issues and residing on the prison�s additionally supported Wellbeing Wing, drug paraphernalia was found in his cell including�[REDACTED] and evidence of �shamboiling�.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � (i)���� [REDACTED] (Mr Tilbury�s mother) (ii)���The Prison & Probation Ombudsman (iii)��The Forward Trust (iv)� Practice Plus Group � � 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.

01/10/2024

2024-0523

Brandon Johnson

Inner West London

The Governor, HMP Wandsworth, Heathfield Road, Wandsworth, London

Between 24th and 27th June 2024 evidence was heard touching the death of Brandon Valrick JOHNSON who died on 12th September 2019 aged 40 years. � Medical Cause of Death � I (a) Cardio-Respiratory Failure 1(b) Ischaemic Heart Disease 1(c) Coronary artery atheroma and left ventricular hypertrophy 1(d) Chronic cocaine misuse 2 Schizophrenia, chronic substance misuse � How, when, where Brandon Valrick JOHNSON came by his death: � On 12th September 2019, Brandon Valrick Johnson suffered cardio-respiratory failure at cell 29, HMP Wandsworth, Heathfield Road, Wandsworth, London. Conclusion of the Jury as to the death: He died from cardio-respiratory failure as a result of poor heart health. Chronic cocaine misuse more than minimally contributed to his poor heart health.

CIRCUMSTANCES OF 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: � I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12th�September 2019 despite a number of attendances at his cell by prison officers and other staff. Rigor mortis and pooling of the blood had been identified. I was told various checks had been undertaken since 0430. I heard evidence that whilst staff knew they needed to obtain positive responses from prisoners and should assess whether the person is alive and breathing, they had little time in which to do this when combined with other duties.

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

State Custody related deaths

HMP Wandsworth

17/11/2023

2023-0457

Raymond Eggleton

Wiltshire and Swindon

The Great Western Hospital Department of Health and Social Care

On the 13th February 2023 I commenced an investigation into the death of Raymond Lionel Eggleton and I opened an Inquest into his death on the same date.� On the 14th November 2023 I concluded Ray�s Inquest. I found the medical cause of death was as follows: � 1a.�Aspiration Pneumonia 1b. Dysphagia 1c.�Hospital Acquired Delirium and Immobility due to Osteoporotic Right Fractured Neck of Femur (Operated 19/01/2023) and Acute On-Chronic Subdural Haemorrhage and Subarachnoid Haemorrhage following a Fall on Ward � II.��Falls due to Orthostatic Hypotension and Frailty of Old Age � By way of a conclusion, I recorded not only the short form conclusion of Accident but also a Narrative Conclusion to explain when, where and how (by what means Ray came by his death). That Narrative Conclusion was as follows: �Raymond died on the afternoon of 25 January 2023 at the Great Western Hospital in Swindon having developed an aspiration pneumonia attributable to swallowing issues {dysphagia), having developed hospital acquired delirium and immobility following a fall on the Linnet Acute Medical Unit during the early hours on 18 January 2023. As a result of the fall Raymond sustained an osteoporotic right fractured neck of femur (repaired 19 January 2023) and an acute on chronic subdural haemorrhage and subarachnoid haemorrhage. Raymond was admitted to hospital the day before with a history of recent falls attributable to orthostatic hypotension and was frail by virtue of his age. The falls risk assessment, prior to the fall on the ward, did not accurately take into account this history and as a consequence� there� was� no assessment� in respect of his additional�care needs�which more likely� than� not� should�have�resulted�in�1:1�care which probably would have avoided the severity of the injury by managing the fall when he needed to urinate or avoided him having to get out of bed in the first place.

Having considered the evidence, I found the following facts in relation to the circumstances of Ray�s death. � Ray arrived late evening on the 16th January 2023 at the Emergency Department of the Great Western Hospital in Swindon. He had a history of 3 falls in the previous few days which following an examination was considered to be attributable to a condition called postural hypotension. This condition results in a sudden drop of blood pressure when somebody stands up and can cause dizziness even temporary unconsciousness. The treating clinicians view, in respect of which I agreed, was that the postural hypotension and general frailty likely caused Ray�s falls noted over the previous few days. � Ray was admitted the following day onto the Linnett Acute Medical Unit (LAMU) and a CT scan undertaken revealed evidence of chronic subdural haematomas, indicative of previous head trauma more likely than not attributable to earlier falls, not necessarily those falls in the last few days. In keeping with the hospital�s falls policy, following his arrival on LAMU, Charge Nurse [REDACTED] who was starting the night shift, carried out a falls risk assessment amongst other assessments. Relying on information that was passed to him verbally at the� shift handover before 8 o�clock that evening, he was however only told and therefore recorded as part of that falls risk assessment that Ray had had 1 fall in the last 12 months. Whilst recognising that there was a risk of a fall the assessment did not trigger any of the higher levels of monitoring over and above 1 hourly care rounding such as ensuring that Ray was within line of sight or more importantly was within arm�s reach of a care worker. � Whilst the plan was for hourly care rounding I noted that no such checks were made on Ray from 20:50 on 17th January 2023 until just after midnight on 18th January 2023, although it was not material in my view to the events that followed but was indicative as regards the working pressures faced by nursing staff on that shift. � At 00:45 on 18th� January� 2023, Nurse [REDACTED] was called by another patient in the same bay as Ray and saw him stood next to his bed passing urine into a bottle. She recalls the night light was on and she could see him clearly. She observed him suddenly falling to the right not putting his hands out to break his fall and he fell hitting his head on the chair leg as he collapsed to the floor. Due to the postural hypotension Ray was being given IV fluids and this equipment was connected to his arm. I was not of the view that the equipment contributed to the fall and found as a fact that the fall more likely than not was attributable to Ray�s postural hypotension. � As a consequence of the fall, Ray was found to have suffered head trauma and in addition had fractured his right neck of femur in respect of which it was noted more likely than not it was an osteoporotic fracture. The fracture was repaired the following day on the 19th January 2023, however, Ray as a result of immobility and trauma sustained deteriorated and he began to develop swallowing issues. He also became generally more confused and ultimately, he developed an aspiration pneumonia from which sadly he died in The Great Western Hospital on the 25th January 2023. � During� the Inquest� hearing I heard live� evidence� from� Charge �Nurse [REDACTED] who came across as a conscientious and caring Nurse. That having been said I did ask probing questions of Charge Nurse [REDACTED] �as regards the discrepancy between Ray�s pre-admission history and what was actually� recorded� as part of the falls risk assessment.�� By way of background,� I �was told that� LAMU� consisted� of a ward� with� 36 beds.�� Back� in January� 2023� those� beds �were occupied by elderly patients. I was told following the arrival of a new Chief Nurse there had been improvements in relation to staffing levels and at the time of Ray�s fall Charge Nurse [REDACTED] �told me that there was �1 Senior Nursing Sister in charge, 5 Registered Nurses of which he was one, 4 Health Care Assistants� and 2 enhanced Care Workers.��� There were no shortages in terms of their allotted numbers. Charge Nurse [REDACTED] �was assigned 8 patients of which Ray was one of those patients and they were split between 2 bays on the ward. As previously stated, Ray�s bed was not in direct eyesight of the nursing station. �When asked why Charge Nurse [REDACTED] �did not check the medical records where there were at least 4 entries referring to a number of previous falls� and� postural� hypotension, Charge Nurse [REDACTED] indicated that he relied on the verbal handover and that due to the volume of work he did not check either the electronic or paper records when completing� the falls risk assessment.��� Initially� when I challenged� Charge �Nurse [REDACTED] as� to whether� or not Ray� would� have� been a candidate� for 1:1 supervision/arm�s length supervision the response was that Ray would have had to have had a fall on ward before that would have been considered. I rejected that argument as of course in this particular instance it would have made no difference here and sometimes it only takes a single fall to be causative in relation to an individual�s death. My view and my finding was that the previous falls history and the presence of postural hypotension made Ray a prime candidate for arm�s length supervision and had that been in place then more likely than not his injuries as a result of the fall would have been avoided and given that his intention at the time was to pass urine, the need for him to get out of bed at all more likely than not could have been avoided. � I asked all the witnesses who gave live evidence in relation to the challenges as regards getting 1:1 supervision and I noted in particular that the answers were consistent that it was very difficult to secure 1:1 supervision during a night shift. There was no pool of people available. I also� noted� the� comments from [REDACTED] �a senior member of the nursing team, as regards the dynamic changes that can affect LAMU over a very short period of time in terms of the acuity of patients on the ward. LAMU is an assessment ward and therefore its patients are ultimately either transferred to another ward or other hospital or discharged into the community such that the patient constitution on the ward can change quite dramatically during a shift. From being Senior Coroner for a number of years now I am acutely aware that in dealing with� elderly patients it not only presents challenges in relation to addressing physical needs but often the elderly have additional mental health issues that only add to the level of the challenge to care for them. By that I mean conditions such as dementia, depression and Alzheimer�s and as a consequence I was told whilst on paper the ward may appear to be adequately staffed, the� reality is that does not necessarily translate, as I was of the view here, as was the case on the evening of the 17th and the morning of the 18th of January 2023, that there were not enough staff to meet the needs of the patients all of whom were vulnerable and to ensure that they were appropriately safeguarded. The inability to carry out hourly intentional� rounding in relation to Ray combined with the evidence from Charge Nurse [REDACTED] �was clear evidence to me� of� the� extreme pressure that the nursing team faced in managing the needs of 36 patients on that shift.

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

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

06/10/2023

2023-0372

Adam Stuyvesant

Wiltshire and Swindon

The Great Western Hospital, Marlborough Road, Swindon

On 2 September 2022 I commenced an investigation into the death of Adam Connelly STUYVESANT. The investigation concluded at the end of the inquest on the 6 October 2023. The conclusion of the inquest was: � Narrative Conclusion � On the 17 August 2022 Adam Connolly Stuyvesant was involved in a minor, single vehicle road traffic collision, on the Marlborough Road at Pewsey Wiltshire. He was admitted to The Great Western Hospital Emergency Department, Marlborough Road, Swindon, where in addition to minor injuries he was diagnosed with an avulsion fracture from the lateral malleolus in the left ankle. Adam was given a plastic boot to wear which immobilized the ankle. At that time, the DVT risk assessment had it been carried out would only have taken account of Adam�s size, not the ankle immobility, which carried a risk of deep vein thrombosis. On the 22 August 2022 Adam collapsed at Unit 31 Blackworth Industrial Estate, Highworth, Swindon and despite best efforts at resuscitation, died. The post mortem confirmed that death was due to the immobilisation of the left ankle allowing a deep vein thrombosis to develop which led to pulmonary embolus. � la�� Pulmonary Embolus � lb��� Deep Vein Thrombosis � le��������� Lower Limb Immobilisation Secondary to Injury after Road Traffic Accident

See Box 3 above

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

Road (Highways Safety) related deaths | Child Death (from 2015) This report is being sent to: The Great Western Hospital

26/02/2024

2024-0199

Deborah Cooper

Wiltshire and Swindon

The Head of Amazon Legal Department, Amazon UK The Rt Hon Kemi Badenoch MP, The Secretary of State for Business and Trade The Rt Hon Lucy Frazer KC MP, The Secretary of State for Culture, Media and Sport

Today (22nd February 2024), I received notification from Wiltshire Police as regards the sudden death of Deborah Jane Cooper whose body was found at her home in Melksham yesterday on the 21st February 2024. Deborah was aged 61 at the time of her death.� I have commenced as of today�s date a Coronial Investigation into Deborah�s death and will shortly be opening an Inquest into her death once the postmortem examination has taken place, and I am in a position to release her body back to the family.

From information provided by the police I have reason to suspect that her death is unnatural and given the cherry red complexion noted in relation to photographs that I have seen of Deborah�s body and the presence of apparatus, some of which was purchased on line from Amazon, it appears that she has put together an apparatus [REDACTED] died from carbon monoxide poisoning. Notes were left at the scene as regards her intention to end her life. �As part of the police report I received photographs taken from her computer of a publication [REDACTED]. My investigation will establish how she acquired that digital copy. The book essentially contains instructions on how to make a piece of apparatus [REDACTED] The book also covers other methods again with the aim of end an individual�s life. � I then Googled the said publication in order to see if the publication could be purchased here in the UK, which then led me to the Amazon UK site where I found that copies of this publication were freely available and supplied direct by Amazon UK. [REDACTED]there was also a similar publication [REDACTED] �was also marketed in both electronic and paperback formats. This second publication seems to also suggest that it may contain instructions as to how one goes about ending one�s life.

I have sent a copy of my report to the Chief Coroner and to the following Interested Person, Family of Mrs Cooper 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 Business and Trade | Amazon UK | Department for Culture, Media and Sport

16/05/2023

2023-0157

Carl Thompson

Manchester South

The Head of Patient Safety of Pennine Care NHS Foundation Trust

On 11th March 2022 an investigation was commenced into the death of Carl Garry Thompson. The investigation concluded on the 17th February 2023 and the conclusion was one of Drug-Related Death. The medical cause of death was 1a) Drug Toxicity; 2) Hypertensive Heart Disease

At the time of his death on the 9th March 2022, Carl was on s.17 Mental Health Act (MHA) leave from the Arden Ward, Stepping Hill Hospital where he was detained under s.3 MHA. Carl had been granted leave by his Responsible Clinician on the 4th March and his leave commenced on the 7th March. He was granted 5 days overnight leave and should have returned to the ward on the 11t March. The jury made the following findings in relation to the circumstances of Carl�s death: Carl Thompson was found unresponsive in the bedroom of his house at 01:00 by his daughter on 10th March 2022. Ambulance staff attended at 01:39 and declared him deceased as a result of a drug overdose. Mr Thompson had last been observed to be alive before 9:30pm on the evening of 9th March 2022, when he was thought to be in a deep sleep, observed by his daughter. Due to the post mortem condition of the deceased upon being found, it is likely that he died on the night of 9th March 2022. Mr Thompson�s death was probably contributed to by a failure of producing and regularly updating adequate risk assessments in relation to the planning of his section 17 leave and updating them following reported family concerns. In addition, it is possible that Carl�s death was contributed to by a failure of both the hospital ward staff and the Community Mental Health Team. The response and lack of escalation following family concerns by ward staff was inadequate. Further to this, it was a failure by the Community Mental Health Team practitioner who assessed Carl via telephone on 9th March 2022. when in fact this should have been carried out face to face.

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

Alcohol, drugs medication related deaths | Mental Health related deaths This report is being sent to: Pennine Care NHS Foundation Trust

02/12/2023

2023-0504

Steven Bowker

Manchester South

The Home Office 2 Marsham St, London SW1P 4DF Andrew Stephenson MP for the Department of Health and Social Care.

On 2nd December 2021, I commenced an investigation into the death of Steven Bowker. The investigation concluded on the 23rd June 2022 and the conclusion was one of Drug related death. The medical cause of death was 1a)[REDACTED] toxicity ([REDACTED]) and (II) Alcoholic hepatic cirrhosis, hepatitis C and hepatocellular carcinoma.

Steven Bowker fell from garden ladders in 2016 whilst gardening. He landed on his elbow and was in considerable pain which ultimately affected his work causing him, in part, to leave his job. He was prescribed [REDACTED] which is an opioid. He remained on [REDACTED] for several years and developed an addiction to his medication. He was taking a cocktail of pain relief and was unable to reduce his dependency on his medicationn, particularly [REDACTED]. His relationships suffered and he became withdrawn from friends and family. He was not responding to phone calls and ultimately the police were called to attend the property [REDACTED] Manchester Road where Mr Bowker was found unresponsive and pronounced dead at his home address [REDACTED] Manchester Road, Altrincham on 1st December 2021. The cause of death was [REDACTED] toxicity, confirmed following toxicological analysis of blood and urine samples.

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

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

27/11/2023

2023-0482

Barbara Rymell

Somerset

The Home Office 2 Marsham St, London SW1P 4DF Helen Whatley MP, MP for Department of Health and Social Care

On 9th August 2022 I commenced an investigation into the death of Barbara Jean Rymell, aged 91 (�Barbara�). The investigation concluded at the end of the inquest on the 21st of November 2023. The conclusion of the inquest was death by Misadventure. The medical cause of death was recorded as: Ia) mechanical obstruction of respiration Ib) presumed fall downstairs II) senile myocardial atrophy, dementia, general frailty. � I recorded in box 3 of the Record of Inquest that: Barbara Jean RYMELL, aged 91, was left unattended on a mechanical stair lift at her care home (Ashley House Residential Home) on the evening of the Eighth of August 2022. Risk assessments identified that Barbara was not permitted to use the stair lift unaccompanied or unattended due to her physical and cognitive limitations. Whilst left unattended, Barbara has left the mechanical chair and proceeded to try and ascend the stairs. She has fallen causing her head to become wedged in between the chair seat and the stairs at an awkward angle, meaning it was not possible for care home staff to free her, or administer first aid due to her body position. Barbara�s breathing was compromised as a result of her entrapment, and she was pronounced deceased on the arrival of the paramedics.

Barbara became a resident of Ashley House Residential Home in Langport (�Ashley House�) on the 8th August 2022. She took up residency on discharge from hospital where she had had an inpatient stay as a result of a fall in the community. � On becoming a resident of Ashley House Barbara had a known diagnosis of dementia, which sometimes affected her memory. She was at a high risk of falling and had blurred vision. All in all, she was a relatively frail elderly woman with known risks around her mobility and she relied on others to keep her safe. � Barbara was the only resident with a bedroom on the first floor of Ashley House. This could only be accessed via the stairs (which Barbara was incapable of ascending or descending safely) or the mechanically operated stairlift (which Barbara was not permitted to use unattended or unsupervised.) � On the evening of the 8th of August 2022 two carers were on duty; neither of whom were native English speaking nationals; one was Romanian and the other was Indian. � I was told that in order to be able to work in the UK, those requiring a Visa (as the two carers on duty did) must prove that they can read, write, speak and understand English to at least Level B1�. [that they must demonstrate that they] can understand the main points of clear standard input on familiar matters regularly encountered in work�. Applicants for a Visa must have passed a Secure English Language Test (SELT). � It transpired during the Inquest that one of the workers on the evening of the 8th August 2022 had never passed the SELT, so was not qualified or permitted to work in the UK. � At 19:27 one of the carers called 999 to request an ambulance. It was clear, on the evidence, that Barbara had been left unattended on the mechanical chair for around five minutes. This was clearly contrary to the rules and procedures of Ashley House. During those five minutes she has left the seat of the mechanically operated stairlift (possibly unfastening the seat belt) and proceeded to climb the stairs; which she was unable to safely, due to do physical limitations and her underlying cognitive impairment. � She has fallen on the stairs, falling downwards. There were no witnesses to this incident but Barbara has been found, having fallen awkwardly, landing with her head trapped under the chair for the mechanically operated stairlift. Care staff were unable to free her because of the positioning and angle at which she was entrapped within the mechanics. � On calling 999 (copies of both recordings were played at the Inquest) it was obvious that neither of the care staff were sufficiently proficient in English to be able to: Explain clearly the nature of the medical emergency. An internal audit by the ambulance service revealed that the call-handler had selected an incorrect pathway. The correct pathway that should have been selected was �entrapment� but at no time during the call did the carer give any information that would have indicated that this was the presenting problem. The carer repeated used the word �blocked� which added no assistance, clarity of explanation of the events that were unfolding. � Understand the difference between �bleeding� and �breathing�. This made any meaningful triage of Barbara�s condition virtually impossible. The call handler followed the script to ask if the patient was conscious and breathing (i.e. to ascertain clinical emergency and determination of a priority response) but this assessment was severely hampered given the carer did not appear to know or understand the difference between bleeding and breathing. � Understand the difference between �alert� and �alive�, which presented all of the same problems as referred in in (ii) above. � Paramedics arrived on a category 2 response and, on arrival, it was clear that Barbara was beyond medical help. She was pronounced deceased at the scene.

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

Care Home Health related deaths This report is being sent to: Home Office | Department of Health and Social Care

05/11/2024

2024-0599

James Boland

Manchester South

The Home Secretary

On 20th June 2024 I commenced an investigation into the death of James�Patrick BOLAND .The investigation concluded on the 17th October 2024 and the conclusion was one of narrative: Died from the complications of� pyelonephritis probably contributed to by the complications of chronic� ketamine use. The medical cause of death was� 1a) Sepsis 1b) Acute� Pyelonephritis on a background of Chronic Ketamine use

On 19th June 2024 James Patrick Boland known as Jamie was a chronic user of ketamine. He had developed significant urological issues as a consequence from the ketamine use. He was found unresponsive at his home address�[REDACTED]. A post mortem examination was undertaken. He was found to have a non-fatal level of ketamine in his system, but to have died from sepsis� caused by acute pyelonephritis, a complication of long term use of ketamine.

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

Alcohol, drug and medication related deaths

Home Office

02/10/2024

2024-0524

Sean Heath

Manchester South

The Home Secretary� The Secretary of State for Health� The College of Policing� The Minister for Policing� Care Quality Commission� Greater Manchester Mental Health NHS Foundation Trust North West Ambulance Service� Greater Manchester Police� NHS England� Trafford Council

On 29th August 2023 an investigation was commenced into the death of Michael Sean Heath aged 35. The investigation concluded at the end of the inquest on� 30th September 2024. A jury made a determination that Michael Sean Heath�died by taking his own life by�[REDACTED] whilst suffering from an acute episode of a mental health crisis.

On 25th August 2023 Michael Sean Heath died in apartment [REDACTED]�Manchester as a result of a fatal�[REDACTED] which�penetrated his pericardial sac. He had been suffering with mental health issues� for several years. Having considered the evidence, on the balance of� probabilities we have identified the following contributing factors ��� 1) The decision to close the police log on the 25th August 2023 and the police�not attending Michael resulted in a missed opportunity for a welfare check,� 2) Poor inter agency communication and failures to follow up any outstanding� action points, in particular the failure of the Trafford North West Mental Health team to chase up the date when Michael was due to return from Gibraltar and� investigate the blank email with Michael�s identifier. In addition, the failure of� Trafford Council Adult Social Care to verify that police were attending on the� 25th August 2023.�� 3) The failure of mental health services in Gibraltar to notify Trafford Mental� Health Team of the exact date of Michael�s return to the United Kingdom. This� resulted in a lack of mental health support when he returned.� 4) The lack of probing by North West Ambulance Service mental health� practitioner during telephone triage on 23rd August 2023 resulted in a missed� opportunity for a face to face assessment.�� 5) Michael�s mental health condition and his reluctance to take his psychiatric�medication consistently and his reluctance to engage with mental health� services or General practitioner.

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

Suicide (from 2015) | Mental Health related deaths

Department of Health and Social Care | The College of Policing | Home Office | Care Quality Commission | Greater Manchester Mental Health NHS Foundation Trust | North West Ambulance Service | Greater Manchester Police | NHS England | Trafford Council

12/07/2024

2024-0490

Jason Holland

Rutland and North Leicestershire

The International Powered Access Federation (IPAF) The Road Transport Industry Training Board (RTITB) LANTRA (LANd and TRAining) Independent Training Standards Scheme and Register (ITSSAR) National Plant Operators Scheme (NPOS) National Open College Network (NOCN) as part of the Construction Plant Competence Construction Scheme (CPCS)

On 16 February 2023 I commenced an investigation into the death of Jason Vaughan HOLLAND aged 51.� The investigation concluded at the end of the inquest held before a Jury on 12th� July 2024.� The conclusion of the jury was that: Jason Vaughan Holland was an experienced self-employed electrician.� On the 10th� February 2023 he was working at the Mercia Park site when he was found entrapped between a scissor lift and ladder racking at a height of approximately 20 metres.� As a result of this he suffered a cardiac arrest which resulted� in� an� unsurvivable� brain� injury. Jason� passed� away� at� the� Queens� Medical� Centre, Nottingham. Jason unintentionally activated the platform raising function instead of the drive function. The Jury returned a conclusion of accidental death. The cause of death was established as: I a Hypoxic Brain Injury. I b Traumatic Cardiac Arrest I c II

Jason Holland had been sub contracted to work on a construction site at Mercia Park at the fit out stage for the purposes of installing cabling within containment.� 90% of the work to be carried out was working at height.� The height of the Unit was 20 metres high.� The Unit was 100,00 m2. Mr Holland was an experienced electrician of over 20 years.� He held his IPAF card.� On 10th February 2023, whilst working on a scissor lift at a height of 20 meters, undertaking tie wrapping of armoured cable in containment tray which had been laid in the roof space, he became trapped between the scissor lift railing and the containment tray. The scissor lift could not be lowered from ground level, as Mr Holland was positioned over the rail and any movement could have caused him to fall 20 meters to the floor.�Operatives from the principal contractor on site, and sub contractors had to carry out a basket to basket rescue of Mr Holland.� Not one of those had been practically trained on how to conduct this rescue before. It took approximately 20 minutes from Mr Holland being discovered to him being lowered to the ground safely on the scissor lift platform whilst being supported by an operative who, harnessed, had climbed from a cherry picker at a height of 20m on to the scissor lift platform. Paramedics were on the scene at the point Mr Holland was lowered on the scissor lift.�He was in cardiac arrest but paramedics were able to establish a return of spontaneous circulation.� Mr Holland went into cardiac arrest for a second time, and again paramedics were able to establish a return of spontaneous circulation. A secondary part of his rescue necessitated Mr Holland�s retrieval from the scissor lift platform which was 8ft high, before he could be conveyed on to the back of an ambulance and was taken to the Queens Medical Centre in Nottingham.

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

Accident at Work and Health and Safety related deaths

The International Powered Access Federation | The Road Transport Industry Training Board | LANTRA | Independent Training Standards Scheme and Register | National Plant Operators Scheme | National Open College Network as part of the Construction Plant Competence Construction Scheme

28/02/2024

2024-0122

Kerri Mothersole

Mid Kent and Medway

The Kent and Medway Integrated Care Board

On 2 September 2022 I commenced an investigation into the death of Kerri Louise MOTHERSOLE. The investigation concluded at the end of the inquest. The conclusion of the inquest was: � Narrative �She died as a consequence of endometrial cancer, the diagnosis of which was delayed due to a number of factors.� � 1a�Endometrial Cancer with Brain Metastases

Kerri Mothersole was a 44 year old woman who had a past medical history of asthma, labyrinthitis, depression and back pain. In May 2020 she was seen with symptoms of possible early menopause and blood tests requested. In October 2020 she was noted to be suffering from tiredness and had irregular periods and again blood tests were requested. Blood tests taken in January 2021 noted a low haemoglobin and ferritin so iron was prescribed as well as follow up in 2 months. In March 2021 she complained of having per vaginal bleeding for 6 weeks and she was referred for an ultrasound. Due to her underlying ill health she had difficulty in attending appointments and missed a number of different appointments. She was seen in the surgery on 21 June 2021 by her General Practitioner who noted abdominal tenderness and weight loss and he again referred her for an ultrasound. An ultrasound was undertaken by a private firm HEM Clinical Ultrasound on 28 June 2021 but the report was never sent to her General Practitioner. A second ultrasound on the 1 July 2021suggested a diagnosis of adenomyosis but noting that serious pathology could not be ruled out. Only the second report was sent to the General Practitioner which led to a routine gynaecology referral, she had however already been referred to the colorectal team on the urgent two week wait pathway. Had the earlier scan report been seen this would have led to an urgent referral to gynaecology. � There were a number of missed appointments and a colonoscopy took place on 20 October 2021. The procedure was negative but the endoscopist thought he could feel something in the pelvis and a CT scan was arranged. The CT scan on 28 October 2021 demonstrated a large pelvic mass and she was referred to the gynaecology team in early December and a multidisciplinary team meeting discussion on 17 December 2021 led to a request for an MRI scan. Appointments were made for 31 December 2021, 25 January 2022 and again in February but not attended and she eventually underwent an MRI on 1 May 2022 which revealed a large mass. She was again discussed at the multidisciplinary team meeting on 6 May 2022 and referred to the gynae-oncology surgeons at Maidstone hospital. She was seen on 1 June 2022 and booked for surgery on 27 June 2022. She was, however, far too unwell for surgery on 27 June 2022 and further investigations revealed brain metastases. She was admitted to hospital and treated with steroids and referred to the Oncologists as surgery was deemed no longer appropriate. She was prescribed hormone treatment but she was, by now, too unwell to receive even palliative radiotherapy. She was taken to Medway Maritime hospital on 19 August 2022 and was struggling as she had been so unwell at home. Whilst plans were being made to provide some care at home she remained overnight but sadly died on 20 August 2022 as she was so unwell she could not return home.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Kerri Mothersole�s son and her partner, Medway Maritime NHS Trust, Maidstone and Tunbridge Wells NHS Trust, HEM Clinical Ultrasound Ltd and Green Porch Medical Centre. � 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: Kent and Medway Integrated Care Board

06/09/2024

2024-0483

John Howlett

Manchester South

The Lakes Care Centre Secretary of State for Health and Social Care Care Quality Commission

On 6th February 2024 I commenced an investigation into the death of John� Francis HOWLETT. The investigation concluded on the 13th August 2024 and the� conclusion was one of Narrative: Died from exacerbation of chronic obstructive pulmonary disease contributed to by frailty due to dehydration and poor� nutritional status. The medical cause of death was 1a) Infective exacerbation� of chronic obstructive pulmonary disease II) Frailty

John Francis Howlett had severe chronic obstructive pulmonary disease. He was placed at The Lakes Care Home due to his severe chronic obstructive pulmonary disease. He required oxygen and was bedbound. He became increasingly frail�whilst at The Lakes with poor nutrition and fluid intake. He developed an� infection and was admitted to Tameside General Hospital. He was treated but� despite the treatment he continued to decline as a consequence of the� exacerbation of his underlying chronic obstructive pulmonary disease and� frailty. He died at Tameside General Hospital on 31st January 2024.

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

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

Department of Health and Social Care | Care Quality Commission | The Lakes Care Centre

18/03/2024

2024-0149

Darnell Smith

South Yorkshire West

The Legal Department The Royal Hallamshire Hospital Broomhill Glossop Rd Sheffield S10 2JF

On 7 July 2023 I commenced an investigation into the death of Darnell Errol Hugh Smith, aged 22. The investigation concluded at the end of the inquest on 8 March 2024. The conclusion of the inquest was a narrative conclusion as follows: � Darnell Errol Hugh Smith was admitted to the haematology ward at the Royal Hallamshire Hospital on 7 November 2022 with a one week history of a reduced appetite, cough and cold like symptoms and no bowel movements for five days. He was admitted to critical care later that day where he was intubated and ventilated. He remained in critical care until he died on 23 November 2022 � There were missed opportunities between the observations taken on admission to hospital and admission to critical care to take observations on an hourly basis for a minimum of six hours in line with his individualised care plan; to provide intravenous fluids; to monitor for pain; to consider Darnell�s health passport and his individualised care plan and to escalate any difficulties in obtaining observations or inserting a cannula. � This led to a missed opportunity to identify Darnell�s condition was deteriorating but it cannot be said that had an earlier review taken place, his death would have been prevented.

Darnell Errol Hugh Smith had a past medical history which included cerebral palsy, scoliosis, sickle cell disease and epilepsy. He was wheelchair dependent, non-verbal, and he required 2:1 care. � Darnell attended the haematology ward at the Royal Hallamshire Hospital at approximately 6pm on 6 November 2022 with a one week history of a reduced � appetite, cough and cold like symptoms and no bowel movements for five days. � His observations were taken and he was prescribed antibiotics. He returned home. � He returned to the Royal Hallamshire Hospital at 1am on 7 November 2022 and was admitted to the the haematology ward. � Between his admission at 2.16am and the critical care assessment at approximately twelve hours later, observations were not conducted on an hourly basis for a minimum of six hours in line with his individualised care plan, or every four hours as a minimum as a result or the NEWs 2 score calculated at 2.16am in line with Trust guidelines. � Between his admission at 2.16am and the critical care assessment at approximately twelve hours later there were no assessments of Darnell�s pain at thirty minute intervals in line with his individualised care plan. � Darnell was not provided with fluids in line with his individualised care plan � Darnell�s health passport was not in the records and was not available to staff until approximately 10.50am on 7 November 2022. � Darnell�s individualised care plan was in his records but staff were not aware of it. Darnell was admitted to critical care at 4.30pm on 7 November 2022 for sedation and treatment. � Darnell responded to treatment initially but by 8am on 8 November 2022 he required additional support to maintain his observations and he was therefore intubated and ventilated. � He initially improved from a respiratory perspective but by 16.11.22 he had developed ventilation associated pneumonia � By 22 November 2022 he was in type 2 respiratory failure He was extubated and died on 23 November 2022 There were missed opportunities between the observations taken on admission to hospital and admission to critical care to take observations on an hourly basis for a minimum of six hours in line with his individualised care plan; to provide intravenous fluids; to monitor for pain; to consider Darnell�s health passport and his individualised care plan and to escalate any difficulties in obtaining observations or inserting a cannula. � This led to a missed opportunity to identify Darnell�s condition was deteriorating but it cannot be said that had an earlier review taken place, his death would have been prevented.

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

Hospital Death (Clinical Procedures and medical management) related deaths

The Royal Hallamshire Hospital

16/04/2024

2024-0196

Edith Alden

Norfolk

The Limes Care Home 16A Drayton Wood Road Hellesdon Norwich Norfolk NR6 5BY

On 29 September 2021 I commenced an investigation into the death of Edith Jane ALDEN aged 89. The investigation concluded at the end of the inquest on 10 April 2024. � The medical cause of death was: 1a) Traumatic Subdural and Subarachnoid Haemorrhage with intraventricular extension 1b)�Fall 2)� Frailty, Type 2 Diabetes Mellitus � The conclusion of the inquest was: Mrs Alden was assessed at very high risk of falls and required supervision when mobilising outside. On 13 September 2021 Mrs Alden, unnoticed and unsupervised, got up from her chair, walked through the communal area, opened an unlocked door and stepped outside. There she fell. Mrs Alden suffered severe head injuries and died as a result. Mrs Alden�s death is contributed to by neglect.

Edith Alden had a history of falls and was admitted to The Limes Residential Home on 11 June 2021. Care Plan and Risk Assessments deemed Mrs Alden as being at a very high risk of falling and measures in place to control this risk included reference to staff monitoring her, supervision and mobilising with her frame plus the support of one carer. The evidence does not clearly reveal what the practical interpretation of these individual measures was. On 26 August 2021 Mrs Alden had an unwitnessed fall in her room. On 13 September 2021 Mrs Alden was sitting in a communal lounge. Four carers were present in the communal area carrying out handover. The door from the lounge area to the outside garden area was closed and unlocked. During handover, unnoticed and unsupervised and without the support of one carer, Mrs Alden got up from her chair, made her way out of the small lounge area, through the large lounge area, opened the patio doors and stepped out into the garden area. Mrs Alden was then heard to scream. Mrs Alden was found unresponsive lying on her back on the patio. Emergency services were called at 20.20 hours. Mrs Alden regained consciousness and was moved inside to keep her warm. On Mrs Alden�s condition deteriorating emergency services were called again at 22.04 and 22.25. Emergency services arrived at 22.45 and Mrs Alden was taken to Norfolk and Norwich University Hospital where CT scan showed a subdural and subarachnoid haemorrhage. Mrs Alden�s condition continued to deteriorate and she died on 25 September 2021.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED], Next of Kin [REDACTED], Next of Kin [REDACTED], Next of Kin [REDACTED], Fosters Solicitors, Norwich (family legal) I have also sent it to: Care Quality Commission 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 This report is being sent to: The Limes Care Home

31/07/2023

2023-0278

Eileen Walsh

Norfolk

The Manager Broadland View Care Home 147 Yarmouth Road Norwich Norfolk NR7 0SA

On 26 June 2020 I commenced an investigation into the death of Eileen Marguerite WALSH aged 97. The investigation concluded at the end of the inquest on 27 July 2023. � The medical cause of death was: 1a)�Frailty, Old Age 2)�Osteoporotic Neck Of Femur Fracture (operated on 02/03/2020), Dementia, Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Ischaemic Heart Disease � The conclusion of the inquest was: Mrs Walsh died following an unwitnessed fall in Broadland View Care Home. Required hourly checks were not completed during the night prior to her fall. Her bed was not in the lowered position as required. The PIR sensor and pressure mat alarms did not sound. Mrs Walsh�s death was contributed to by neglect.

Mrs Walsh had a significant medical history including dementia and general frailty. Mrs Walsh was admitted to Broadland View Care Home on 3 March 2019. Following falls on 5 November 2019 and 12 February 2020 Mrs Walsh�s Care Plan was updated to include steps to mitigate risks by 1. Leaving on hall light, 2. Providing a PIR sensor alarm, 3. Pressure mat alarm, 4. Hourly checks. Mrs Walsh was also provided with a bed which was to be lowered at night to prevent her being able to stand up to get out of bed. � The records show that Mrs Walsh was checked and found to be in bed and asleep at 20.31, 21.41, 22.33, 23.35, 00.33, 01.23, 02.33, 03.35, 04.34 and 05.36 on the night of 29 February/1 March 2020. � At about 6.15 am Mrs Walsh was heard to call for help and was found on the floor in her room, some 4 or 5 steps away from her bed. Emergency services were called and Mrs Walsh was taken to Norfolk and Norwich University Hospital where she underwent an operation to fix a fractured right neck of femur. Mrs Walsh�s condition continued to deteriorate and she died on 3 March 2020. � Evidence was heard that Mrs Walsh was not checked at 21.41 and 23.35 on 29 February 2020, nor at 01.23 or 03.35 or 05.36 on 1 March 2020 as recorded in the records. Evidence was heard that Management were aware that a carer regularly slept whilst on night duty. Mrs Walsh�s bed was not lowered. The PIR sensor and the pressure mat alarms did not sound. The evidence does not reveal whether this was because the alarms had not been set or whether the equipment was faulty. � The evidence does not reveal the exact time at which Mrs Walsh fell or for how long she was lying before she was found.

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

Care Home Health related deaths This report is being sent to: Broadlane View Care Home

18/11/2024

2024-0637

John Riley

Norfolk

The Manor House Care Home The Manor House Skeyton Road North Walsham Norfolk NR28 0LU

On 22 February 2024 I commenced an investigation into the death of John Edward RILEY aged 73. The investigation concluded at the end of the inquest on 15 November 2024. The medical cause of death was: 1a) Neck Fracture 1b) Fall 1c) 2) The conclusion of the inquest was: Accident

Mr Riley suffered life changing injuries in a road traffic collision in 1976 and was dependent on others for his care. Mr Riley entered Manor House Residential Home in 2017 and was provided with personal care. His mobility was severely limited. Risk Assessments found that Mr Riley was deemed at low risk of falling out of bed. His bed was to be placed at the lowest setting when unattended and he was subject to two hourly checks at night time. On 8 February 2024, Mr Riley was checked at 01.10 hours and 03.00 hours.� When checked at about 05.25 hours Mr Riley was lying on the floor with the bed frame under his neck. Emergency services were called and Mr Riley was declared dead at the scene. The evidence does not reveal the means by which Mr Riley came out of bed and onto the floor.� Mr Riley died from a fracture to his neck.

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

Care Home Health related deaths

The Manor House Care Home

06/06/2023

2023-0207

Alexander Blewitt

Milton Keynes

The Medical Director � Milton Keynes University Hospital � [REDACTED] � Chief Inspector of Hospitals at the Care Quality Commission [REDACTED] � Chief Medical Director, Bedfordshire, Luton, and Milton Keynes Integrated Care Board � The General Medical Council

On 20 July 2022 I commenced an investigation into the death of Alexander Shone BLEWITT aged 48. The investigation concluded at the end of the inquest on 21 March 2023. The conclusion of the inquest was that: � Alexander Shone Blewitt died at the Milton Keynes University Hospital on the 11th July 2022. He had attended on the 9th July 2022 after visiting the nearby Urgent Care Centre (UCC) and being referred to ED by the GP there. He was provided with a printout of his consultation with her. She was worried about him. That communication detailed his complaint of loose stools and abdominal pain. The triage nurse did not record the content of the UCC letter accurately and took that letter from Mr Blewitt. He later saw the ED doctor who did not see or read the UCC letter or attempt to source it. The ED doctor did not record any questions relating to bowel habit on his contemporaneous note, but sometime subsequent to Mr Blewitt�s death wrote a statement in which he identified that he had and that there were no bowel complaints. This was despite several days of being faecally incontinent at home and highlighting this to the UCC doctor. The ED doctor sent him home with a diagnosis of a possible resistant or recurrent urinary tract infection even though the MSU taken by his GP a few days earlier and available to the UCC doctor showed no growth. Mr Blewitt, even though he was sent home with a diagnosis of a possible resistant urinary tract infection on the 9th July 2022, was told to continue the original antibiotics his GP had started him on and then to start the new ones the next day. Mr Blewitt spent a difficult two days with faecal incontinence and abdominal pain before returning on the 11th July 2022 to the ED. At this visit a possible acute abdomen was diagnosed and CT scanning confirmed this. He was taken to theatre and suffered a cardiac arrest before surgery and died the next day on ITU. It emerged in evidence that there were no reliable records of any fluid resuscitation in the ED available for examination. This is because the computerised system records the prescription of IV fluids but unless the prescription is signed, that prescribed item is erased. The best information I received was that he had received two litres of an unknown fluid at some point during his time in the ED. It seems that doctors were not as a routine signing the prescriptions and so no reliable record was retained. I was told that doctors had been reminded on the need to sign prescriptions but no audit of this had been carried out since Mr Blewitt�s death.

Alexander Shone Blewitt died at the Milton Keynes University Hospital on the 11th July 2022. He had attended on the 9th July 2022 after visiting the nearby Urgent Care Centre (UCC) and being referred to ED by the GP there. He was provided with a printout of his consultation with her. She was worried about him. That communication detailed his complaint of loose stools and abdominal pain. The triage nurse did not record the content of the UCC letter accurately and took that letter from Mr Blewitt. He later saw the ED doctor who did not see or read the UCC letter or attempt to source it. The ED doctor did not record any questions relating to bowel habit on his contemporaneous note, but sometime subsequent to Mr Blewitt�s death wrote a statement in which he identified that he had and that there were no bowel complaints. This was despite several days of being faecally incontinent at home and highlighting this to the UCC doctor. The ED doctor sent him home with a diagnosis of a possible resistant or recurrent urinary tract infection even though the MSU taken by his GP a few days earlier and available to the UCC doctor showed no growth. Mr Blewitt, even though he was sent home with a diagnosis of a possible resistant urinary tract infection on the 9th July 2022, was told to continue the original antibiotics his GP had started him on and then to start the new ones the next day. Mr Blewitt spent a difficult two days with faecal incontinence and abdominal pain before returning on the 11th July 2022 to the ED. At this visit a possible acute abdomen was diagnosed and CT scanning confirmed this. He was taken to theatre and suffered a cardiac arrest before surgery and died the next day on ITU. It emerged in evidence that there were no reliable records of any fluid resuscitation in the ED available for examination. This is because the computerised system records the prescription of IV fluids but unless the prescription is signed, that prescribed item is erased. The best information I received was that he had received two litres of an unknown fluid at some point during his time in the ED. It seems that doctors were not as a routine signing the prescriptions and so no reliable record was retained. I was told that doctors had been reminded on the need to sign prescriptions but no audit of this had been carried out since Mr Blewitt�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 � 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: Milton Keynes University Hospital, Care Quality Commission, Bedfordshire, Luton, and Milton Keynes Integrated Care Board and The General Medical Council

18/08/2023

2023-0311

Louis Thorold

Cambridgeshire and Peterborough

THE SECRETARY OF STATE FOR THE DEPARTMENT OF TRANSPORT THE CHIEF EXECUTIVE OF CAMBRIDGESHIRE COUNTY COUNCIL

On 24.01.21 I commenced an investigation into the death of Louis Steven James THOROLD (age 5 months 18 days). The investigation concluded at the end of the inquest on 26.07.23. The conclusion of the inquest was that Louis died as the result of a �road traffic collision�. The medical cause of Louis� death was �multiple traumatic injuries�.

Louis died at 1701hrs on 22.01.21 at Addenbrookes Hospital in Cambridge. Postmortem examination revealed that he died as a result of multiple severe traumatic injuries. At around 1551hrs earlier that day the driver of a car travelling north on the A10 Ely Road at Landbeach turned right across the southbound carriageway where it was struck by an approaching van. The van left the carriageway to the nearside as a result of the impact and struck Louis and his mother as she pushed him in his pushchair along the pavement. The van came to rest in a ditch on the far side of the pavement trapping Louis underneath. He was extricated by a passer-by and treated at the scene. Sadly, Louis went into cardiac arrest and despite prolonged attempts at resuscitation and transfer to hospital he died of his injuries. Louis died at 1701hrs on 22.01.21 at Addenbrookes Hospital in Cambridge. Postmortem examination revealed that he died as a result of multiple severe traumatic injuries. At around 1551hrs earlier that day the driver of a car travelling north on the A10 Ely Road at Landbeach turned right across the southbound carriageway where it was struck by an approaching van. The van left the carriageway to the nearside as a result of the impact and struck Louis and his mother as she pushed him in his pushchair along the pavement. The van came to rest in a ditch on the far side of the pavement trapping Louis underneath. He was extricated by a passer-by and treated at the scene. Sadly Louis went into cardiac arrest and despite prolonged attempts at resuscitation and transfer to hospital he died of his injuries.

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

Child Death (from 2015) | Road (Highways Safety) related deaths This report is being sent to: Department for Transport | Cambridge County Council

01/11/2022

2023-0365

Rowan Thompson

Manchester North

THIS REPORT 15 BEING SENT TO: [REDACTED] Chief Executive Greater Manchester Mental Health Trust [REDACTED] Chief Executive Officer of NHS England

On the 7th October 2020, I commenced an investigation into the death of Rowan Louis Thompson. Rowan died on the 3rd October 2020. The investigation concluded on the 31st Qctober 2022. The medical cause of death was confirmed as 1a) Cardiac Arrythmia 1b) Severe Hypokalaemia of unknown cause. A jury recorded a narrative conclusion which noted that that Rowans death was contributed to by neglect,. in that there was a failure to communicate the finding of blood tests analysed at Salford hospital on the 2nd October which showed a life-threatening severe hypokalaemia.

CIRCUMSTANCES OF DEATH Rowan was a detained patient in the Gardner Unit at Prestwich hospital. This is one of four national forensic medium secure units for adolescents (aged 11-18). Its patients are often high risk (either to themselves or others) and have been accused of some of the most serious criminal offences. On the 3rd October 2020 Rowan was found in his room and it was thought he was having a seizure. CPR was commenced and paramedics called. Rowan died shortly after his arrival at North Manchester General Hospital. During the course of the investigation it became apparent blood test results had been available at Salford Royal hospital 24 hours earlier which indicated Rowan was suffering from severe hypokalaemia a medical emergency. There had been a failure to communicate those results in part due to errors at Salford and also at GMMH. During the course of the evidence the court heard of the failure by at least four staff members to undertake observations on Rowan on the morning of the 3rd October 2020. In addition witnesses confirmed that records were falsified to show the observations had been undertaken. During this shift no deputy ward manager or ward manager were on duty. The court heard there is no commissioning for deputy or ward managers to work at weekends. Both nurses working that day were still in their preceptorship being newly qualified. At least one, likely both had never been in a situation where they were faced with a medical emergency and having to consider CPR. The Court heard evidence in respect of the calling and arrival of the ambulance. It was clear that there was a delay in the paramedics attending Rowan due to it being unclear on the Prestwich site where the Gardner unit was, a lack of persons looking out for the paramedics and then them not bein�� able to swiftly enter the locked unit.��� Following Rowans death a number of investigations were undertaken. There was no sufficient consideration of the emergency response following Rowan being located in his room. Finally the court heard evidence as to the audit of the observation sheets which were (and continue to be) undertaken by managers. An investigation following Rowan�s death highlighted a further 6 staff who in the three week period prior to the 3rd October 2020 failed to conduct observation checks. Despite this there is no ongoing audit of CCTV and the current audit of the observation logs will not highlight the falsifying of checks ahd documentation.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Greater Manchester Mental Health NHS Foundation Trust | NHS England

15/09/2023

2023-0351

Geoffrey Brooks

Exeter and Greater Devon

THIS REPORT DATED 15 SEPTEMBER 2023 IS BEING SENT TO: � [REDACTED] Interim Chief Executive Royal Devon University Healthcare Foundation Trust.

On 10 November 2020 an investigation was commenced into the death of Geoffrey Robin Brooks. The investigation concluded at the end of the inquest held on 14 September 2023. The conclusion of the inquest was as follows: � Geoffrey Robin Brooks died due to complications of nephrogenic diabetes insipidus on a background of poor fluid intake.

Geoffrey Robin Brooks suffered with nephrogenic diabetes insipidus diagnosed in 2013. In 2020 Mr Brooks�s health declined and he had multiple admissions to hospital. In August 2020 he was admitted to the Exmouth Community Hospital. Due to his diabetes insipidus Mr Brooks required monitoring of his blood sodium to ensure that he was maintaining the correct balance of fluid intake to remain stable. On admission his blood sodium was low, and he was on a restricted fluid intake; during his admission his condition improved, and he was moved from a restricted fluid intake to a daily target level of fluid intake of 2.5 to 3L per day. On 25 September 2020 Mr Brooks was discharged to the Barton Place Nursing Home. The discharge summary did not clearly set out Mr Brooks�s fluid requirements and the nursing home staff believed Mr Brooks was to be restricted to no more than 2.5 -3L per day rather than that figure being a target to aim for; the nursing home were advised it was a target on 9 October 2020 after Mr Brooks became unwell; the target level of 2.5 to 3L was not achieved during his stay in the nursing home. On 18 October 2020 Mr Brooks� health deteriorated and was admitted to hospital where despite treatment he sadly died on 12 November 2020.

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

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

19/09/2023

2023-0341

Stewart Stanley

Exeter and Greater Devon

THIS REPORT DATED 19 SEPTEMBER 2023 IS BEING SENT TO: � [REDACTED] Governor Exeter Prison ***by email only***

On 15 July 2020 an investigation was commenced into the death of Stewart Stanley.��������� The investigation concluded at the end of the inquest held on 17 -27 July 2023. The conclusion of the inquest was Suicide in addition the Jury answered a series of questions raised by me. � In summary, the Jury concluded that Mr Stanley�s death was probably caused or contributed to by a failure to follow the processes resulting in the staff best qualified to appreciate Stewart�s risk to himself being excluded from the decision to remove him from constant watch. In the addition the Jury concluded that the multi-disciplinary processes in place were adequate however they were not fully complied with in this case.

On 23 June 2020 Mr Stanley was remanded in custody to HMP Exeter. � On the night of 9 to 10 July, Mr Stanley�s cellmate found him [REDACTED] seemingly trying to hang himself. He alerted prison staff, who started Prison Service suicide and self-harm prevention procedures (known as ACCT). The staff placed Mr Stanley under constant supervision and moved him to a special cell that allowed an officer to observe him continuously. On 11 July, after a case review it was decided that constant supervision should end and directed that Mr Stanley should now be observed at least once every half an hour during the evening. At around 1.20am on 12 July, the night patrol officer, found Mr Stanley hanging. She called for staff assistance and, when it arrived, they opened the cell, removed the ligature and began chest compressions. Paramedics arrived and took Mr Stanley to hospital, where he died on 14 July.

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

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

31/01/2023

2023-0424

Eric Huber

Exeter and Greater Devon

THIS REPORT DATED 31 OCTOBER 2023 IS BEING SENT TO: Chief Executive � Devon County Council

On 15 April 2021 an investigation was commenced into the death of Eric Sebastian Huber. The investigation concluded at the end of the inquest held on 10 October 2023. The conclusion of the inquest was as follows: � Eric Sebastian Huber was known to suffer with his mental health and was considered to be vulnerable. On 1 April 2021 Mr Huber was discovered deceased hanging [REDACTED]. He died due to self-inflicted suspension Eric Sebastian Huber died as a consequence of his own actions.

Mr Huber had a long history of drug and alcohol use dating back to 2005. � he also had a long history of depression and anxiety. He had been managed intermittently by the community mental health services. Mr Huber was considered vulnerable and at risk of exploitation and harm from others � he was known to the safeguarding team at Devon County Council (DCC) and the safeguarding team at Devon and Cornwall Police. � His vulnerability was felt to be due to alcohol, chronic mental health problems general self-neglect and to his ongoing misuse of drugs and risk of �cuckooing� from convicted drug dealers. In October 2019 a safeguarding enquiry was commenced and allocated to a case worker at DCC to follow up with a visit to establish their views and risks and discuss with the police. The case worker spoke with police officer who had seen Mr Huber that day � the officer reported that Mr Huber was fine, he was attending AA meetings regularly and coping much better � the case worker did not follow up directly with Mr Huber and did not assess Mr Huber. In September 2020 there was a further safeguarding concern raised to DCC by the police as his flat was being used to sell drugs by two individuals staying there � an activity known as cuckooing. The police requested a review of Mr Huber�s care and support needs. � On 13 October 2020 this was allocated to the same caseworker as previously. On 18 October 2020 Further concerns were raised with DCC around 2 individuals intimidating Mr Huber. � There is no written record in the DCC care first record system of action taken by the case worker in response to these concerns. � From the records it appears that there is no evidence of a Care Act assessment, multi-agency discussion meeting or consideration or Mr Huber�s situation and how to manage the risk from drug dealers at this stage. On 24 November 2020 Mr Huber himself called the DCC Adult Social Care Direct via its call centre to ask for support � there is no record of this message being followed up by the team manager or the social worker. On 3 December 2020 a friend of Mr Huber rang DCC Adult Social Care Direct to raise concerns over cuckooing and bullying of Mr Huber and that he was struggling to cope. � The case worker called Mr Huber on 7 December 2020 and discussed help with his drug and alcohol use and enabler assist to help with household matters � the case worker noted that he would contact the police for an update. There is no record of a call to the police. � On 8 December 2020 the safeguarding enquiry was closed with the outcome that the immediate risks were adequately addressed and that it was a proportionate response to reallocate for a full assessment of needs. There is no record of that full assessment taking place. On 15 January 2021 a police report was received by Devon Adult Social Care Direct call-centre there are no records of any contacts or discussions arising from this police contact. The case was closed on 3 March 2021 � at this time there had been no assessment of his needs.

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

Suicide (from 2015) | Mental Health related deaths This report is being sent to: Devon County Council

13/06/2024

2024-0324

Harry Vass

Avon

THIS REPORT IS BEING SENT TO Royal College of Nursing 20 Cavendish Square London W1G 0RN

On 17/1/23 an investigation was commenced into the death of Harry Roland Ian Vass.� The investigation concluded at the end of the inquest 3-13 June 2024. The conclusion of the jury inquest was a narrative which read as follows:�� �On the basis of the evidence presented concerning the events of the morning of 26th December 2022, it is probable that the failure to act at that time contributed to the� death of Harry, by delaying his transfer to a hospital environment or place of safety.�� In relation to Harry�s medical treatment in the Emergency Department of Southmead� Hospital, prior to his transfer to the Mason Unit, the medical evidence deemed him to�be medically fit for discharge, at that time. However, it is probable that the failure to� take more physical observations, specifically after he had ingested more cocaine and� prescribed medication, significantly contributed to the death in that the evidence for his discharge was more likely than not to have been insufficient.� Given the evidence regarding his treatment in the Mason Unit, it is probable that the� failure to perform adequate observations, both physical and non-contact, contributed to Harry�s death as, by failing to prioritise the accurate monitoring of his physical condition and therefore identify it�s deterioration, an opportunity to transfer him promptly back� into the Emergency Department was missed.�� The medical cause of death was recorded as:� �� 1a) Sudden death, most likely as a result of terminal cardiac arrhythmia, on a� background of psychosis and recent cocaine use leading to an acute disturbance in behaviour and complex disturbance in normal physiology

Harry Vass was a 24yr old, he had a history of ADHD, poor mental health, psychosis, paranoia secondary to recreational drug use and illicit drug dependency including� cocaine.� Harry attended the A&E department of Southmead Hospital on 26th December 2022 at 16.42hrs, with the reason recorded as �mental health�, he was expressing paranoid� thoughts. He had a high heart rate and was sweating. He underwent a physical� assessment and was assessed by the Mental Health Team.�� At some point he took cocaine in the toilet of the hospital after which he became more� agitated and there were concerns being raised that others in the department felt� threatened. At one point he absconded from the unit but was brought back, a doctor in the emergency department gave him medication to calm him down. The police were� called but when they attended Harry was calm from the effects of the medication.� �� The police were called and attended again when Harry�s agitation increased. It was� during this discussion that the police officer raised the possibility of Harry having ABD� (acute behavioural disturbance). The police officer said that he�d seen close to a dozen cases, that Harry had similar symptoms.�� The two mental health practitioners said that they knew very little about ABD. After� some discussions with the police officer, the two mental health practitioners and the consultant in emergency medicine Harry was deemed medically fit and he was� admitted under s136 Mental Health Act to The Mason Unit (a place of safety) within� the hospital at around 23.00hrs.� Once on the Mason Unit Harry continued to be distressed and agitated, he was given� further medication to calm him. Harry remained disturbed but had periods of calm, he� became fearful of isolation, he became sleepy and at around 3.30hrs on 27th December 2022, he vomited. Observations were carried out confirming that Harry had low oxygen� saturations and a high temperature. At 4.45hrs his extremities were discolouring, and�he became unresponsive, an ambulance was called. He was transferred back to the�A&E department but died at 06.36hrs.� Dr Delaney a forensic pathologist assisted in determining the medical cause of death (noted above).

I have sent a copy of my report to the chief coroner and to the following interested persons:� Family of the Deceased� Avon & Wiltshire Mental Health NHs trust� North Bristol NHS Trust� Avon & Somerset Constabulary� I have also sent it to The Royal College of Psychiatrists 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

Royal College of Nursing

21/02/2024

2024-0098

Severine Kelly

Gloucestershire

THIS REPORT IS BEING SENT TO The Chief Executive Gloucestershire Health & Care NHS Foundation Trust

On 10 October 2022 I commenced an investigation into the death of Severine Alexia Kelly born on 30 July 1981. The investigation concluded at the end of the inquest on 21 February 2024. The conclusion of the inquest held with jury was that Severine died on 1 October 2022 at Wotton Lawn Hospital Gloucester of food inhalation.

Severine was detained at the time of her death under s.3 Mental Health Act 1983 and accommodated at Greyfriars Psychiatric Care Unit Wotton Lawn Hospital Gloucester. On 1 October 2022, she was provided with a sandwich by a member of the hospital staff. She choked on the sandwich. Various medical professionals attempted to assist, including nurses, paramedics and a doctor, but she died at the hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � the family of Severine Kelly. � 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: Gloucestershire Health and Care NHS Foundation Trust

07/09/2023

2023-0321

Sultana Choudhury

East London

THIS REPORT IS BEING SENT TO : [REDACTED], Chief Executive Officer, Barts Health NHS Foundation � � Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care

On 19th December 2022 this Court commenced an investigation into the death of Sultana Razia Choudhury aged 60 years. The investigation concluded at the end of the inquest on 24th August 2023. The court returned a short form conclusion of accident contributed to by neglect. � Mrs Choudhury�s medical cause of death was determined as; � Multi-organ Failure HypovolaemiaRenal Haemorrhage secondary to Renal Biopsy (7th December 2022)

Sultana Choudhury was diagnosed with Diabetes and chronic kidney disease, she agreed to take part in a research project related to these conditions. On 7th December 2022 she consented to undergo a renal biopsy to harvest sample material in furtherance of the research programme. The procedure was completed after two attempts to take tissue. � A week later Mrs Choudhury was admitted into hospital with abdominal pain, haematuria, rapidly worsening acute kidney injury and a positive for gram negative rods in blood cultures. � Following diagnostic testing and imaging, Mrs Choudhury was admitted for treatment of a queried diagnosis of pyelonephritis and was administered enoxaparin for VTE risk. � Mrs Choudhury was not adequately monitored whilst an inpatient. She died following a cardiac arrest in hospital on 17th December 2022. The cardiac arrest was caused by hypovolaemia which, in turn was caused by a undiagnosed renal haemorrhage the result of the renal biopsy 7 days earlier. The haemorrhage was exacerbated by contraindicated VTE prophylaxis.

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

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

04/10/2024

2024-0527

Marina Young

Lancashire and Blackburn with Darwen

THIS REPORT IS BEING SENT TO� [REDACTED], Director of Nursing at Lancashire Teaching Hospitals NHS Trust

On March 2023 I commenced an investigation into the death of Marina Sharon Young aged 46 the investigation concluded at the end of the inquest on Friday, 27 September 2024, the conclusion of the inquest was Marina Sharon Young died on 22 June 2022 after a 39 hour wait for a hospital bed in Royal Preston Hospital�s Accident & Emergency Department. Her death, due to asthma, was preventable and was caused by neglect characterised both by a gross failure to provide appropriate assessment and medical care and an inadequate escalation of her management to specialist physicians or ITU.� The cause of death was 1a Aspiration b asthma.

Marina was born with spina bifida and as a result had decreased sensation from the waist down and reduced motor power in her legs which resulted in the use of an adapted car. Had undergone a bladder transplant as a child and, due to a lack of sensation, needed to self-catheterise every 3-4 hours with a disposable catheter. However, when Marina was unwell, she required assistance with catheterisation, and she was unable to complete the task by herself. Marina also wore incontinence pads.� On the morning of 20 June 2024 Marina�s chest infection precipitated an asthma attack. Marina was admitted to Royal Preston Hospital Accident & Emergency Department (A & E) where she was initially appropriately assessed and treated by the A & E doctor. At this time, the hospital was full and during the remainder of Marina�s 39 hour stay A & E had a �bed block� preventing transfer of patients out of A & E was in place and would have been known to senior nursing staff. Such holding of patients in A & E was described around this time as �continuous�.� Marina, according to the British Thoracic Society predictive peak flow rates was throughout her stay in A & E in the �life-threatening� asthma category. Marina�s asthma attack had an 80% chance of survival but, due to the acute medical team�s substantial failures of medical management, inadequate treatment, insufficient direction of the nursing staff for observations and a lack of referral to either respiratory or ITU specialist teams, Marina died at approximately 10 AM on 22 June 2024. During this time Marina�s nursing needs were neither assessed nor met, despite it being known to the senior nursing staff that Marina, having complex nursing needs due to her spina bifida, would be spending an extended period of time in the A & E. During Marina�s 39 hour stay in A & E none of the six nurses involved with Marina undertook a nursing assessment of her toileting needs and failed to offer a catheter, assist with catheterisation or change the incontinence pad. The nursing staff made no assessment of Marina�s sensory deficits due to spina bifida and relied upon patient reports for pressure area care in an overweight and incontinent patient, who remained sat in a chair due to her breathing difficulties for almost all of the 39 hours. A falls risk assessment was completed, albeit with substantial errors. When Marina died, she was still wearing the shoes that she was wearing when she arrived in the Department 39 hours earlier and which she could not remove without assistance.� It was accepted that A & E is geared up for short-term stays dealing with acutely ill patients. Any patients remaining in A & E beyond the expected period are being nursed in an area that is not designed for their needs, without the benefit of specialist nursing staff and the risks they are exposed to are consequently increased.� Despite the Matron for A & E being on the Trust�s level 3 STEIS investigation, not a single concern regarding the nursing care provided was identified.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, the family. I have also sent it to Care Quality Commission who may find it useful or of interest.� I am also under a duty to send 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

Lancashire Teaching Hospitals NHS Trust

11/11/2024

2024-0619

Lisa Gale

Avon

THIS REPORT is BEING SENT TO: Royal College of Pathologists Royal College of Obstetricians and Gynaecologists Chief Midwife Southwest Regional Midwife University Hospitals Bristol and Weston NHS Foundation Trust

On 20th April 2023 1 commenced an investigation into the death of Lisa Gale. The investigation concluded at the end of the inquest on 12th November 2024. The conclusion of the inquest was Natural Causes.

Lisa developed a rare but serious condition of pregnancy Acute Fatty Liver of Pregnancy (AFLP). She attended hospital promptly and cooperated fully with the medical advice she received. Medical assessments and treatment were detailed and thorough. Despite this, and maximal therapy on intensive care, sadly she still died from this condition due to the rapid progression and severity of the AFLP and the added complication of acute pancreatitis.

I have sent a copy of my report to the chief coroner and to the following interested persons � a) Lisa�s family; b) University Hospitals Bristol and Weston NHS Foundation Trust. I have also sent it to [REDACTED] (Consultant Obstetrician) and [REDACTED] (Director of Midwifery and Nursing for Women�s Services) at University Hospitals Bristol and Weston 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

Royal College of Pathologists | Royal College of Obstetricians and Gynaecologists | Chief Midwife | South West Regional Midwife | University Hospitals Bristol and Weston NHS Foundation Trust

17/02/2023

2023-0067

Rachelle Ross

Newcastle upon Tyne and North Tyneside

TPP Group Limited Eglon Medical Information Systems Limited The Chief Executive for NHS Digital The Secretary of State for Health

On 20th December 2022 an inquest was opened into the death of Rachelle Naomi Ross. � On 17th February 2023 I resumed the inquest. � I concluded that Rachelle Ross died on 20.4.22 at her home address at 30 Haig Avenue, Whitley Bay, Tyne & Wear. She was diagnosed with Squamous Cell Carcinoma in November 2020. Despite treatment her cancer metastasised and she died on 20th April 2022. I recorded a conclusion of Natural Causes.

Rachelle Ross was a 34 year old female who had been invited to attend smear tests as part of the National Screening Programme since she was 25 years old. She did not have a smear test prior to diagnosis.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Rachelle Ross�s Family Collingwood Health Group 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

TPP Group Limited | Egton Medical Information Systems Limited | NHS Digital | Department of Health and Social Care

23/03/2023

2023-0101

Jade Revell

Derby and Derbyshire

TPP LTD

On 05 January 2022 I commenced an investigation into the death of Jade Paula REVELL aged 30. The investigation concluded at the end of the inquest on 22 March 2023. The conclusion of the inquest was that: � Jade Revell was taken to Chesterfield Royal Hospital on 25 December 2021 having suffered a sudden cardiac event at home. Despite extensive resuscitation she passed away in hospital the same day. � Jade suffered with an eating disorder and was under the care of the mental health team. Prior to making a change to her medication her bloods were tested. On 27 October 2021 the bloods were electronically sent to Jade�s GP practice. These showed a low potassium level which required further action. � There was a failure to notify Jade of this result. This caused a missed opportunity to medically treat the hypokalaemia and monitor the potassium levels which increased the risk of ventricular fibrillation and sudden cardiac death.

Jade Revell died from a sudden cardiac event. A missed opportunity to treat hypokalaemia shown in blood results on 27 October 2021 has more than minimally contributed to the cause of the sudden cardiac event.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to [REDACTED] (Miss Jade Revell�s mother) [REDACTED] (Miss Jade Revell�s father) [REDACTED] � Primary Health 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.

Other related deaths

TPP LTD

17/07/2023

2023-0251 Deceased name: Jane Wadsworth Coroner name: Alison Mutch Coroner Area: Manchester South Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Tameside and Glossop Integrated Care NHS Foundation Trust and NHS England

Tameside and Glossop Integrated Care NHS Foundation Trust NHS England

On 3rd January 2023 I commenced an investigation into the death of Jane Elizabeth Wadsworth .The investigation concluded on the 12th June 2023 and the conclusion was one of Narrative: Died from the complications of elective surgery where antibiotics were not always administered in accordance with her prescription and her deteriorating condition was not assessed by Intensive Care clinicians until 31st December despite her poor liver function, poor kidney function and worsening condition. The medical cause of death was 1a) Sepsis; 1b) Cellulitis; II) Elective Hip replacement performed on 13/11/22, Deep Vein Thrombosis, Adult Polycystic Kidney Disease with Liver Cyst, Acute Kidney Injury, Ulcer Left Foot

Jane Elizabeth Wadsworth had elective hip surgery. She returned to Tameside General Hospital with concerns over her wound. She subsequently developed a deep vein thrombosis and cellulitis. On 22nd November 2022 she became very unwell and was admitted to Intensive Care Unit with sepsis, acute kidney injury and liver failure. She was treated on the Intensive Care Unit until 26th November when she returned to the ward. She continued to be treated for her cellulitis and an ulcer of the left foot that had developed. She was stepped down to the Stamford Unit on 16th December 2022. On 22nd December 2022 she returned to Tameside General Hospital due to concerns about her raised NEWS 2 score, raised probably as a consequence of cellulitis. She was started on intravenous antibiotics. Her liver function was deranged and she had acute kidney injury. She had a catheter but her urine output was difficult to assess due to issues regarding possible catheter bypass. On 24th December, one dose of antibiotics was missed. On 25th December, two doses of antibiotics were missed. She continued to be unwell and on 27th December further antibiotics were prescribed. She was referred to the Critical Care Outreach Team who assessed and determined that Intensive Care Unit referral was not necessary. On 29th December the antibiotics were changed. There was a further referral to Critical Care Outreach that was unsuccessful as there were no staff available. There was no doctor to doctor assessment and no consultant review and no liver specialist advice sought or provided. She continued to deteriorate on 30th December with poor liver function and poor kidney function. On the morning of 31st December she deteriorated rapidly and was accepted by the Intensive Care Unit where despite aggressive treatment she deteriorated rapidly and died on 31st December 2022.

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

25/06/2024

2024-0338

Afolabi Ojerinde

Manchester City

Tesco Stores Limited � Copied for interest to: Chief Coroner Sainsbury�s Supermarkets Limited ASDA Stores Limited WM Morrison Supermarkets Limited [REDACTED] [REDACTED] Greater Manchester Fire and Rescue Service

INVESTIGATION � On 05 September 2023 I commenced an investigation into the death of Afolabi Oluwafemi OJERINDE aged 48. The Inquest was opened on 26th September 2023. The final hearing has not yet taken place. � However, following investigations by my office and Greater Manchester Fire and Rescue Service, there is concern that future deaths will occur, and I am of the opinion that action should be taken to reduce the risk of death. � I have been made aware of a Section 21 Improvement Notice pursuant to Health and Safety at Work Act 1974 from Greater Manchester Fire and Rescue Service.

Mr Afolabi Oluwafemi Ojerinde (�the Deceased�) died on 5th September 2023 at Wythenshawe Hospital. The medical cause of his death has been offered as 1a. Major Burns. � The circumstances of his death relate to him attending an unmanned Tesco petrol station and using of the petrol pumps to then douse himself in petrol, and thereafter set himself alight. The Deceased was able to pay for the petrol using the �pay at pump� function, and without having a motor vehicle or an authorised plastic or metal container. � The Deceased was allowed to proceed once payment had been made, and seemingly without any additional checks through CCTV/security cameras.

I have sent a copy of my report to the Chief Coroner and to Interested Persons. I have also sent it to organisations who may find 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: Tesco Stores Limited

04/07/2024

2024-0412

Harry Dunn

Northamptonshire

The Americas Section of the Foreign and Commonwealth and Development Office, � The Ministry of Defence Police, and � The Ministry of Defence.

On 04 September 2019 I commenced an investigation into the death of Harry Peter DUNN aged 19.� The investigation concluded at the end of the inquest on 13 June 2024.� The conclusion of the inquest was: � Road Traffic Collision

The circumstances of the death are as follows: � � On 27 August 2019 at about 2030 hours there was a head on collision between a car driven by [REDACTED] an employee of the US Government who had not long been in the UK and whose husband worked out of the nearby RAF Croughton, and a motorcycle ridden by Mr Harry Dunn. The cause of the collision was that on exiting RAF Croughton [REDACTED] inadvertently moved onto the incorrect side of the B4301 rural road and travelled about 350 meters on the wrong side of the road prior to the head on collision with Mr Dunn, who was on the correct side of the road travelling out of the village of Croughton. � Mr Dunn suffered catastrophic injuries including fractures to all four limbs, some of which were open in nature and a fracture to his pelvis with the concomitant severe internal blood loss commonly associated with such serious injuries. � He was attended to by an advanced medical team including a Consultant Anaesthetist and Critical Care paramedics and then conveyed to hospital where he died shortly after arrival.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this report to West Northamptonshire Council, Northamptonshire Police, to the Chief Executive of East Midlands Ambulance Service and the solicitors on behalf of [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� �� � This report is being sent to: Foreign, Commonwealth & Development Office | The Ministry of Defence Police | The Ministry of Defence

14/02/2023

2023-0060

Stephen Preston

West Yorkshire (Western)

The Association of Conservative Clubs LTD 1 Norfolk Row London SE1 7JP

On 22/3/22 I opened an inquest into the death of Stephen Geoffrey Preston who, at the date of his death was aged 68 years old. The inquest was resumed and concluded on 7/2/23 I found that the cause of death to be: 1a Haemorrhage from face and neck injuries II Hypertensive Heart Disease � I arrived at a conclusion of Accident.

I heard that Mr Stephen Preston had previously served the Earlsheaton Conservative Club in Dewsbury for many years in the capacity as Secretary and Trustee. On 6/5/22 Stephen was in the company of several friends in the Club whilst he was overseeing in a voluntary capacity the entertainment that had been previously booked to appear. � During the afternoon he had been drinking alcohol, although he was not thought to be unduly intoxicated when he left the club for a taxi to take him home. It was as Stephen made his way down the stairs, with the assistance of a walking stick, that he took a fall on the lower steps, causing his head to make direct contact with the glazing in the double doors at the bottom of the stair case, such that his head became lodged between the broken glass. � Although paramedics arrived very quickly, Stephen was found to have passed away. � In considering the evidence, I noted the contents of an experts� report who had conducted a site visit at the club, in which he expressed the view that the glazing that Stephen made contact with was not safety glass and as such was a major contributor to his demise. � He also confirmed that the double doors were too near the bottom step and do not comply with legislation governing the spatial requirements. During the inquest representatives of the Club informed me that they were to immediately take remedial steps to prevent a further recurrence and that they would write to me in due course to confirm that they have been implemented.

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

Other related deaths

The Association of Conservative Clubs LTD

14/11/2024

2024-0629

Kumaran Chetty

Greater Manchester South

The Brinnington Surgery, Brinnington Road, Stockport SK5 8BS

On the 14th August 2024, I commenced an investigation into the death of Mr. Kumaran Chetty. At the inquest into his death on the 11th� November 2024 I found that he died from an acute cardiac episode, contributed to by fentanyl and morphine toxicity.

My findings at the inquest were as follows � The deceased was 51 years old at the time of his death. He had a� number of chronic health conditions including ischaemic heart disease� and cardiomyopathy. On the 19th April 2024 an ECG indicated that his� left ventricular function was less than 25% ejection. He also suffered� from chronic pain as a result of long standing colorectal issues and was under the care of a consultant. He was prescribed fentanyl by his GP in the dose of 1 25mg patch per 72 hours. He was also prescribed� morphine sulphate.� On the morning of the 9th May 2024, the deceased was found� unresponsive in the kitchen at his home address. Paramedics attended and pronounced life to be extinct. Autopsy confirmed the presence of� an acute left ventricular failure. Examination revealed the presence of 4 fentanyl patches on the upper back of the deceased, which was in�excess of the amount he was prescribed. Toxicology reported the� presence of fentanyl and morphine in levels associated with fatalities. There is no evidence that the deceased intended to take his own life. It is not clear whether his application of the patches was a mistake or a� response to the level of pain he was experiencing. However, I find the� excessive, even if accidental use of these strong opiates would have� had a consequent effect on his already failing heart and is likely to� contributed to his death from acute left ventricular failure.

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

Alcohol, drug and medication related deaths | Community health care and emergency services related deaths

The Brinnington Surgery

21/01/2025

2025-0037

Reginald Smith

Dorset

The British Orthopaedic Association Managing Director of Stryker (UK) Ltd

On the 14th December 2023, an investigation was commenced into the death of�Reginal Victor Smith, born on the 11th June 1933. � The investigation concluded at the end of the Inquest on the 10th January 2025.�� � The Medical Cause of Death was: � 1a ��Hypovolemic Shock � 1b�� Re operation of fractured neck of femur � 1c��� Fractured neck of femur � II � The conclusion of the Inquest recorded that Reginald Victor Smith died as a consequence of a rare but recognised complication of a surgical procedure.

On 9/10/23 Mr Smith had a witnessed fall at his care home. He was admitted to Poole Hospital where he underwent surgery to repair a right extra capsular neck of femur fracture on 12/10/23. The surgery involved Mr Smith being laid on a traction table and a jig was used to align the fracture for screws to be inserted into a titanium nail which is placed into the femur. On 24/10/23� he was discharged from hospital. On 5/12/23 he attended Poole Hospital for a review appointment when X rays disclosed a failure of metalwork inserted on 12/10/23 and he was readmitted to hospital. On 7/12/23 Mr Smith underwent revision surgery. It was apparent that the hip screw was slightly off centre and being approximately 1mm-2mm off centre did not make proper contact with the nail. Following surgery his health deteriorated. Mr Smith received palliative care and he died in hospital on 7/12/23.

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

Hospital Death (Clinical Procedures and medical management) related deaths

The British Orthopaedic Association | Stryker (UK) Ltd

06/02/2024

2024-0063

Mark Pryor

Derby and Derbyshire

The CEO, HCRG Care Services Ltd, The Health Business and technical Park Heath Road Runcorn WA7 4QX � Rt Hon Alex Chalk MP, the Secretary of State for Justice Ministry of Justice 102 Petty France London SW1H 9AJ � Rt Hon Victoria Atkins MP, the Secretary of State for Health and Social Care, Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU

On 07 September 2020 I commenced an investigation into the death of Mark PRYOR aged 46. The investigation concluded at the end of the inquest on 01 February 2024.� The conclusion of the jury was: Mr Pryor suffered an alcohol withdrawal related seizure whilst detained in police custody which caused cardiorespiratory arrest and death. There were deficiencies in the health care professionals� assessment and treatment of Mr Pryor�s alcohol withdrawal which probably made a more than minimal contribution to his death.

Mr Pryor died at the emergency department of the Royal Derby Hospital on 5th September 2020, shortly after being taken there from police custody where he had gone into cardiorespiratory arrest due to alcohol withdrawal. He had a long-term history of drug and alcohol misuse and was alcohol dependent. He had been arrested and detained in police custody on 4th September. � Mr Pryor was seen in police custody by Health Care Professionals (HCP�s) due to his documented opiate misuse, methadone usage and alcohol dependency. Mr Pryor was attended on four separate occasions by two different HCP�s whilst in custody. He was recognised to be dependent on alcohol and when he began to exhibit symptoms of withdrawal a HCP began a course of alcohol withdrawal medication to reduce the symptoms and guard against possible alcohol withdrawal related seizure. � The inquest jury returned the following conclusion: � � �Mr Pryor suffered an alcohol withdrawal related seizure whilst detained in police custody which caused cardiorespiratory arrest and death. There were deficiencies in the health care professionals� assessment and treatment of Mr Pryor�s alcohol withdrawal which probably made a more than minimal contribution to his death�. � The jury recorded the following findings: � � �The HCP assessments were not of a reasonable standard due to the following reasons: � Assessments provided were substantially shorter than the recognised accepted practice and consistently shorter than would have been required to properly assess Mr Pryor effectively. In addition to this the time between assessments was too long, particularly after the critical dose of the withdrawal medication was administered, to ascertain the effectiveness. � Assessments were lacking in consistent information i.e. BP, pulse, heart rate and history. Previous assessments were not referenced prior to each visit, changes in vital signs were not acted upon. � Assessment records were inadequate and lacking in detail. � There was a point at which an increase in the withdrawal medication dose should have been considered when Mr Pryor�s BP and pulse were not taken and found to be elevated. �.. � Although not demonstrably contributory to Mr Pryor�s death, the jury records the following matters: � There were inadequacies in the training and induction provided to the lesser experienced HCP who attended Mr Pryor. � It is also clear that the lesser experienced HCP did not have suitable experience and skills to work as an HCP�. � The lesser experienced HCP had previously worked as a mental health nurse.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED](son) Derbyshire Police� Constabulary Independent Office of Police Conduct (IOPC) [REDACTED] � I have also sent it to: � � Chief Cons [REDACTED], Chair, National Police Chiefs� Council, 50 Broadway, London, SW1H 0BL � [REDACTED], President, The Faculty of Forensic & Legal Medicine 11 St Andrews Place London NW1 4LE � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

State Custody related deaths This report is being sent to: HCRG Care Services Ltd | Department of Health and Social Care | Ministry of Justice

27/11/2023

2023-0479

Gracie Spinks

Derby and Derbyshire

The Chief Constable of Derbyshire Constabulary The Rt Hon James Cleverly MP, Secretary of State for the Home Department

On 21 June 2021 I commenced an investigation into the death of Gracie Elizabeth Spinks (�Gracie�) who was 23 years old when she died on 18 June 2021. The investigation concluded on 16 November 2023 at the end of the inquest heard with a jury. The jury concluded that Gracie was unlawfully killed by a former work colleague on 18 June 2021.

Gracie was born in 1997. In 2020 Gracie started working for a company in Chesterfield called Xbite. Whilst working at Xbite, Gracie met up on a number of occasions outside of work with a male colleague who was employed as a supervisor at Xbite. Gracie decided that she did not want to have any sort of relationship with the supervisor and made this clear to him in December 2020. The supervisor failed to accept Gracie�s decision and became obsessed and fixated with her. Gracie reported the supervisor�s behaviour to Xbite in January 2021 and he was subsequently dismissed from Xbite in February 2021. � Gracie also reported the supervisor�s stalking behaviour to Derbyshire Constabulary in February 2021. A police investigation was carried out which resulted in no action being taken against the supervisor. The supervisor was given �words of advice� by the investigating police officer. � In May 2021 a member of the public found a rucksack containing multiple weapons on a public footpath near to the field where Gracie kept her horse. The member of the public was concerned about the contents of the rucksack and reported this to Derbyshire Constabulary. The attending police officers treated the rucksack as if were simply an item of found property and failed to carry out any form of investigation into the rucksack and its contents. On 18 June 2021 Gracie was unlawfully killed by the supervisor who she had reported to Derbyshire Constabulary in February 2021. Gracie died as a result of a stab wound to the neck. It was established after Gracie�s death that the rucksack found by the member of the public in May 2021 containing weapons belonged to the supervisor who killed Gracie. � At the inquest into Gracie�s death Derbyshire Constabulary accepted that there were multiple serious police failings in respect of the stalking investigation in February 2021 and the rucksack incident in May 2021. Those failings were recorded by the jury on the Record of Inquest but it could not be determined that those failings contributed to Gracie�s death on 18 June 2021.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Gracie�s family Derbyshire Constabulary I have also sent it to the following individuals who may find it useful or of interest: [REDACTED] , National Police Chief Council Lead for Stalking and Harassment [REDACTED], Police and Crime Commissioner for Derbyshire [REDACTED], MP for Chesterfield 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: Derbyshire Constabulary | Home Office

12/02/2024

2024-0079

Mouayed Bashir

Gwent

The Chief Constable of Gwent Police.

INVESTIGATION AND INQUEST � On 25/02/2021, an investigation was opened touching upon the death of Mouayed Mamoun Bashir. � The investigation concluded at the end of the inquest on 02/02/2024. � The conclusion of the inquest was recorded as a narrative conclusion in the following terms: � On the 17th February 2021, Mouayed Mamoun Bashir took an unknown quantity of cocaine. This resulted in him developing symptoms in keeping with Acute Behavioural Disturbance (ABD). Mouayed barricaded himself in his bedroom and was heard banging, shouting and breaking objects. � At 08:50, Mouayed�s family were concerned for his welfare and proceeded to contact emergency services. At 09:01 the first police officer arrived and informed the control room that the ambulance was required. � Gaining entry Mouayed was agitated, police officers restrained him for his own safety and for the safety of others. � We believe from the evidence we heard that there was insufficient knowledge and understanding around identifying some of the signs of Acute Behavioural Disturbance. � Throughout, Mouayed�s condition was deteriorating, police officers and family continued to update the ambulance service. An ambulance arrived at 10:04. � The priority was to transfer Mouayed to hospital, but it was difficult to manoeuvre him out of the house. Shortly after he was transferred into the ambulance at 10:37, Mouayed went into cardiac arrest. Police and paramedics commenced cardiopulmonary resuscitation (CPR) and conveyed Mouayed to the Grange University Hospital, Llanfrechfa, where the clinicians continued to attempt to revive Mouayed. Sadly, they were unsuccessful and Mouayed died at 11:41 on 17/02/2021. � In conclusion, Mouayed�s death was caused by cocaine intoxication, this was contributed to by the effects of ABD following a period of restraint. � The medical cause of death was: � 1a) Intoxication with cocaine and the effects of cocaine, following a period of restraint.

The circumstances of Mouayed�s death are best described in the narrative conclusion. As you can see the jury have referenced the police�s knowledge of ABD in their conclusion.

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

Alcohol, drug and medication related deaths | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Gwent Police

23/10/2024

2024-0568

John Hurst

Sunderland

The Chief Constable of Northumbria Police and their Solicitors and Counsel The Chief Executive of Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and their Solicitors

On 29th September 2021 I opened and adjourned an Inquest into the death of Mr John Paul Hurst, who was born on 19th May 1972 and who died [REDACTED] on 15th September 2021 aged 49 years. The Inquest was heard on 9th October 2024 and concluded on 11th October 2024. The conclusion of the Inquest was �John Paul Hurst had a diagnosis of paranoid� schizophrenia with a long history of mental health difficulties and was the main carer for� his father. Having initially been arrested in connection with the death of his father and� subsequently de-arrested and then re-arrested on suspicion of an offence of possession of a controlled substance he was released from custody under investigation and then died�[REDACTED] on 15th September 2021 from the� effects of bleeding from trauma consistent with the amputation of the lower half of his� right leg which is consistent with impact with a passing train in circumstances which� cannot be explained.�� The medical cause of death was: � Ia Right Lower Limb Injury

John Paul Hurst had a medical history of a diagnosis of paranoid schizophrenia. He had� previously attempted to take his own life on three occasions between 2000 and 2002, and had been sectioned under the Mental Health Act during the same period.� John lived with his father and was his main carer. His father sadly passed away on 12th� September 2021. Due to concerns around the length of time before John had sought� assistance from emergency services, his demeanour upon police arrival and notes� containing disturbing content within the premises, John was initially arrested on suspicion of involuntary manslaughter. He was quickly de-arrested for that offence and re-arrested� on suspicion of possession of a controlled substance.� Concerns were raised by police officers involved in the investigation about his mental� health due to John�s demeanour, the volume and content of the notes found at the scene� and detailed concerns expressed by his sister regarding a risk of him ending his own life upon release.� John was assessed by Criminal Justice Liaison and Diversion Service (CJLD) and deemed fit for interview and release from custody.� Following his interview, John was released from custody at around 4pm on 13th� September 2021. He last spoke to his sister at around 9.44pm on 13th September 2021. On the afternoon of 15th September 2021, John was found by a passer-by in undergrowth near to the train tracks�[REDACTED]. John died due to the effects of haemorrhage from the tearing and loss of the� lower half of his right leg consistent with impact with a train moving at high speed.

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

Mental Health related deaths | Police related deaths | Suicide (from 2015)

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust | Northumbria Police

29/09/2024

2024-0522

Leighton Dickens

South Wales Central

The Chief Constable of South Wales Police

A Coronial investigation was commenced on 27th October 2020 into the death of Leighton Alan Dickens.� The Investigation concluded at the end of the inquest which I conducted with a jury on 18th � 28th September 2023. The conclusion was a narrative conclusion and the medical cause of death was 1 (a) pressure on the neck (incomplete or atypical hanging)

These were recorded as: � � Leighton Dickens died by incomplete atypical hanging alone in his home address on 14th October 2020. � The narrative conclusion which the Jury returned was: � Leighton Dickens died by hanging himself in circumstances where his intention could not be ascertained. It is the juries understanding, that it was a missed opportunity on the part of the police not to detain Leighton Dickens at hospital until he had been assessed by a Mental Health Professional. � � The Inquest focused upon: � � a) Mr Dickens� mental health condition and behaviour on the night of his death. � b) The fact that police officers came upon him by the side of the road in an undressed state in the presence of his partner who was trying to convey him to hospital. � c) His presentation and behaviour towards the officers before during and after arrival at hospital � d) The decision by officers not to invoke their powers under s. 136 Mental Health Act and to leave Mr Dickens at hospital in circumstances in which they knew that he had not been subject to medical assessment and intended to leave. � e) The limited sources of support available to assist or guide the officers.

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

Police related deaths | Mental Health related deaths

South Wales Police

29/09/2023

2023-0367

Leighton Dickens

South Wales Central

The Chief Constable of South Wales Police

A Coronial investigation was commenced on 27th October 2020 into the death of Leighton Alan Dickens. The Investigation concluded at the end of the inquest which I conducted with a jury on 18th � 28th September 2023. The conclusion was a narrative conclusion and the medical cause of death was 1 (a) pressure on the neck (incomplete or atypical hanging)

These were recorded as: � Leighton Dickens died by incomplete atypical hanging alone in his home address on 14th October 2020. The narrative conclusion which the Jury returned was: � Leighton Dickens died by hanging himself in circumstances where his intention could not be ascertained. It is the juries understanding, that it was a missed opportunity on the part of the police not to detain Leighton Dickens at hospital until he had been assessed by a Mental Health Professional. � The Inquest focused upon: � a.���� Mr Dickens� mental health condition and behaviour on the night of his death. � b.���� The fact that police officers came upon him by the side of the road in an undressed state in the presence of his partner who was trying to convey him to hospital. � c.���� His presentation and behaviour towards the officers before during and after arrival at hospital � d.���� The decision by officers not to invoke their powers under s. 136 Mental Health Act and to leave Mr Dickens at hospital in circumstances in which they knew that he had not been subject to medical assessment and intended to leave. � e.���� The limited sources of support available to assist or guide the officers.

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

Mental Health related deaths | Child Death (from 2015) This report is being sent to: South Wales Police

8/8/2024

2024-0438

Emma, Ellette and George Pattison

Surrey

The Chief Constable of Surrey Police, [REDACTED] (in respect of paragraphs 5.1,2 & 3) [REDACTED} as the National Police Chiefs� Council�s Lead on Firearms Licensing (in respect of paragraphs 5.1,2 & 3) [REDACTED], The Secretary of State for the Home Department (in respect of paragraphs 5.1,2 & 3) [REDACTED], The Secretary of State for Health and Social Care (in respect of paragraphs 5.1 & 2) [REDACTED] as Chair of the General Practitioners Committee UK of the British Medical Association (in respect of paragraphs 5.1 & 2)

The inquests into the deaths of Emma and Ellette Pattison were opened on the 2nd March 2023 and the inquest into the death of George Pattison was opened on the 28th February 2023. All three inquests were resumed and concluded on 30th July 2024.� The causes of death were:� Emma Pattison:� 1.a: Shock and Haemorrhage� 1.b: Shotgun wounds to chest and abdomen Ellette Pattison:� 1.a: Shotgun Wound to the Head George Pattison:� 1.a: Shotgun Wound to the Head The conclusions were:� Emma Pattison:� Unlawfully killed Ellette Pattison:� Unlawfully killed George Pattison: Suicide

At a time, unknown between 22:49 hours on the 4th February 2023 and� 00:40 hours on 5th February 2023 George Pattison shot and killed his� wife Emma Pattison aged 45 years and his daughter Ellette Pattison� aged 7 years. Thereafter he shot himself intra-orally. At the time of her� death, Emma Pattison was the headteacher at Epsom College, Epsom,� Surrey and she lived with her family at the head teacher�s house which was situated within the College park.� The firearm which George Pattison used was a shotgun lawfully held� by him under Shotgun Certificate Number [REDACTED]. That� certificate was originally issued by Surrey Police in 2012. In 2016, the� police were notified of a domestic violence incident, whereby it was�alleged that Emma Pattison had assaulted George Pattison. The matter� was investigated and, although the certificate was removed� temporarily, it was later returned. There was a renewal application in� December 2016 which was granted and a further application for�renewal in 2022, which was also granted.�� The last renewal application required completion of a new form by the� applicant, providing details of the applicant�s GP and answers by him� to medical questions, which included, have you ever been diagnosed or treated for any of a number of medical conditions, which included� �Depression or anxiety�, to which the applicant responded �No�. The� inclusion of the GP�s details and medical questions is a safeguard to� ensure that the Licensing Officer is aware of an applicant�s medical� history. (Please see my earlier PFD Report dated 15th July 2019 relating� to the inquests touching the deaths of Christine and Lucy Lee.)� However, George Pattison had consulted an on-line GP and, over the� course of 2019 to 2021, had been prescribed a significant amount of� Propanolol, the purpose of which was to assist with the symptoms of� anxiety. It is unknown whether knowledge of that medical history on� the part of the Licensing Officer would have affected the renewal of the shotgun certificate to Mr Pattison.� Further, as set out above, in 2016 there was an allegation of assault� made by Mr Pattison against Mrs Pattison. It would appear that, at the� time, no consideration was given as to whether this might have been an example of coercive controlling behaviour on the part of Mr Pattison.� However, there was evidence within the papers of subsequent�domestic abuse / coercive controlling behaviour on the part of Mr� Pattison towards Mrs Pattison. That evidence does not appear to have� come to attention of the Licensing Officer at the time of Mr Pattison�s� most recent application for renewal of the licence.

COPIES I have sent a copy of this report to the following Interested Persons in the Inquest and to the Chief Coroner.� 1. [REDACTED] 2. [REDACTED] 3. [REDACTED] � DWF on behalf of Epsom College

Suicide (from 2015) | Other related deaths� � This report is being sent to: Surrey Police | National Police Chiefs� Council | The Home Office | Department of Health and Social Care | The General Practitioners Committee

21/12/2022

2022-0412

Angeline Phillips

Manchester West

The Chief Constable, Greater Manchester Police Headquarters Central Park 1 Northampton Road Manchester M40 5BP

On the 2nd February 2021 I commenced an investigation into the death of Angeline Marie Phillips, 35 years, born on the 20th December 1985. The investigation concluded at the end of the inquest on the 5th December 2022. The medical cause of death of Angeline Marie Phillips was: 1a) ��Toxicity The conclusion of the investigation at the Inquest was Misadventure.

1)� Angeline Marie Phillips (hereinafter referred to as �the� Deceased�) died on the 30th January 2021 at her home address at 2 Wilbraham Road, Walkden, Manchester. 2)��� The Deceased was found having died at her home address at 03.48 hours on�the 30th January 2021, having had no contact with family or friends after 19.44 hours on the 28th January 2021. � 3)��� On the 29th of January 2021at 18.09 hours a friend of the Deceased�contacted Greater Manchester Police by telephone and reported a concern for the welfare of the Deceased. The friend confirmed that the Deceased had been in and out of Hospital (both Salford Royal Hospital and the Royal Bolton Hospital) in the previous week following on from numerous suicide attempts. The home address of the Deceased was given to the Police as 2 Wilbraham Road, Walkden, Manchester. � 4)��� The Call Handler graded the priority response to the reported incident under�the Greater Manchester Response Policy, which was last amended to Version 1.4 on the 24th June 2019. The response was graded as Grade 2 Priority Response, which requires the radio operator to allocate the incident within 20 minutes and attendance within 1 hour from the creation of the Incident Log. � 5) A police officer did not attend 2 Wilbraham Road, Walkden, Manchester and at 20.28 hours on the 29th of January 2021 a Sargent, who was the Command and Control Supervisor, made a decision that the incident was a medical matter and the North West Ambulance Service (hereinafter referred to as �NWAS�) needed to deal with the incident. The incident was reported to NWAS at 20.32 hours. � 6)��� NWAS attended the Deceased�s home address at 23.06 hours and confirmed�that there was no answer at the address or from any contact numbers and the Ambulance crew had left the address to attend another incident. � 7)��� At 00.03 hours on the 30th January 2021 th�e Command and Control�Supervisor noted the Incident Log �For Allocation� but a Police officer still did not attend the address at 2 Wilbraham Road, Walkden, Manchester until entry to the address was forced at 03.48 hours by police officers and the deceased was found having died in the property.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1.��� Sister of the Deceased 2.�� Independent Office of Police Conduct 3.�� Greater Manchester Mental Health Trust � DAC Beachcroft Solicitors � I am also under a duty to send a copy of your response to the Chief Coroner, and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

�Emergency services related deaths (2019 onwards)

Greater Manchester Police

15/11/2023

2023-0455

Ocean-Leigh Hayes

South Wales Central

The Chief Executive Cardiff & Vale University Health Board

On 29 December 2021 I commenced an investigation into the death of Ocean-Leigh Pauline Jean Hayes. The investigation concluded at the end of the inquest on 15th November 2023. The conclusion of the inquest was Sudden Unexplained Death in Infancy, as there was insufficient evidence of any other natural or unnatural factor. � 1a Sudden Unexplained Death in Infancy

These were recorded as : Ocean-Leigh Pauline Jean Hayes was aged 4 months when on 22nd December 2021, she died at her home address of 58 Snowden Road, Ely, Cardiff. Ocean had been co-sleeping with her mother in the hours and minutes before she died. � The Inquest focused upon:� a. The arrangements for sleeping with a newborn infant and the pathology evidence.

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

Child Death (from 2015) This report is being sent to: Cardiff and Vale University Health Board

14/10/2024

2024-0547

John Follon

South Wales Central.

The Chief Executive Cardiff & Vale University Health Board

On 5 December 2022�I commenced an investigation into the death of John Austin�FOLLON�. The investigation concluded at the end of the inquest �08/10/2024 . The conclusion of the inquest was �Mr John Follon, a 78 year old gentleman was admitted to hospital from the GP surgery having suffered a MI. He underwent successful stenting to remove the blockage. Four days later, he suffered a cardiac arrest from which he did not recover. Prior to the cardiac event, a lead from the monitor had become disconnected, the alarm was silenced by a staff member who did not then check on Mr Follon leading to a period of an hour and three quarters during which he was not monitored. The cause of the cardiac arrest cannot be established and it is not possible to determine whether the lack of monitoring more than minimally contributed to his death.. � 1a���Inferior ST Elevation Myocardial Infarction 1b��� 1c��� �II����Hypertension, Chronic Smoker

Mr John Follon, a 78 year old gentleman attended his GP surgery with chest pains and breathlessness on 17 Nov 2022. Following an ECG, which showed he had suffered an inferior myocardial infarction, he was transported by emergency ambulance from the surgery directly to the catheter laboratory at The University Hospital of Wales where he underwent a stenting procedure to unblock the right coronary artery. He made good progress following the procedure to the point of independently caring for himself on the ward. However, the monitor showed intermittent 1st degree and complete heart block and a decision on whether he required a permanent pacemaker depended upon the extent of his recovery. While awaiting this decision, he was being monitored on CCU by telemetry. On 21 Nov 2022 at 06:57, one of the leads became disconnected triggering an alarm at the nurses station which was acknowledged at 07:04 and silenced by a staff member. The evidence suggests that person did not check on Mr Follon at that time. Mr Follon was last spoken to on or around 07:30hours before being found unresponsive in a state of cardiac arrest in his bed at 08:45hrs. Resuscitation was commenced, however, it was not successful and he passed away at 09:06. Neither the cause nor time of the cardiac arrest can be established as he there was no monitoring during the period from when the lead became detached until his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Chief Executive Officer, [REDACTED], Cardiff and Vale University Local Health Board� 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)

Cardiff & Vale University Health Board

17/09/2024

2024-0497

Sara Grinnell

South Wales Central

The Chief Executive Cwm Taf Morgannwg University Health Board

On 22 April 2022�I commenced an investigation into the death of Sara�GRINNELL�. The investigation concluded at the end of the inquest �17/09/2024 . The conclusion of the inquest was �Ms Grinnell died as a result of the progression of endometrial cancer. There were delays in investigating her symptoms which may have identified potential treatment options at an earlier stage. 1a���Metastatic Endometrial Cancer 1b��� 1c��� �II

These were recorded as :- Mrs Grinnell had been suffering with excessive vaginal bleeding since 2015. She suffered with significant menorrhagia from around 2018 and had a cervical poly removed in 2018. She was referred to the Gynaecology Department in 2019 due to the ongoing menorrhagia. An ultrasound scan performed in June 2019 resulted in an Urgent referral to the Gynaecology Department. She was sent 2 letters by the gynaecology department approx. 22 weeks after the Urgent referral, however it appears that Sara Grinnell did not receive the letters. She was referred again in Aug 2020, Jan 2021, and in May 2021 she was referred under the Urgent Suspected Cancer pathway. In June 2021, Ms Grinnell was diagnosed with endometrial cancer. A planned hysterectomy on 10 September 2021 was postponed due to insufficient theatre time. Her treatment options were limited to palliative.� She sadly died on 11 April 2022 at Princess of Wales Hospital. She deteriorated, and passed away on 11/4/22� The Inquest focused upon:- The timeline of referrals to and appointments with the Gynaecology Department and investigations that took place The treatment received by Mrs Grinnell

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

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

Cwm Taf Morgannwg University Health Board

27/10/2023

2023-0502

Kai Takagi

Inner West London

The Chief Executive NHS England The Chief Executive Chelsea and Westminster Hospital [REDACTED], Medical Director, Chelsea and Westminster Hospital

On the 30th and 31st August and 1st September 2023 evidence was heard touching the death of Kai TAKAGI. He died on 14th June 2021 aged 27 years. � � Medical Cause of Death � I (a) Acute Peritonitis I (b) Perforated Gastric Ulcer � How, when, where Kai TAKAGI came by his death: � On 11th June 2021 Kai Takagi presented at Chelsea and Westminster Hospital Emergency Department with stomach ache and pain. Bloods were taken at the hospital and he was treated for gastritis and discharged home at about 2102. At 2106 shortly after discharge a blood result was received in the hospital emergency department indicating a high amylase level suggestive of acute pancreatitis. The plan was to contact Kai in the morning of 12th June 2021 with the result. This plan was handed over to the night shift and then to the morning shift doctors. Kai was not contacted by the hospital with the result as planned. No-one from the hospital asked him to return to the hospital for further examination or tests. On 14th June 2021 Kai was discovered by a work colleague at Kai�s Apartment [REDACTED] passed away in his apartment sometime between 2026 on 12th June 2021 and his discovery at 0938 on 14th June 2021� as a result of acute peritonitis from a perforated ulcer. � Conclusion of the Coroner as to the death: � Natural Causes

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

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

22/08/2023

2023-0312

Audrey King

Cornwall and the Isles of Scilly

The Chief Executive Officer Royal Cornwall Hospital Trust (RCHT)

On 21 November 2022 I commenced an investigation into the death of Audrey King. The investigation concluded at the end of the inquest on 7 August 2023. � The medical cause of death was found as follows � 1a Ischaemic stroke 1b Atrial Fibrillation II Femoral Hernia repair (Operated) � The four questions � who, when, where and how � were answered as follows � � Audrey KING died on 15 November 2022 at Royal Cornwall Hospital Truro Cornwall from a stroke following an operation, against a background of atrial fibrillation in which anti-coagulant medication was not re-started which likely contributed to the stroke. � The conclusion was as follows � Audrey died from complications following necessary surgery contributed to by not re-starting anti-coagulant medication after the operation.

Audrey had a previous medical history which included Atrial Fibrillation (AF), which was medicated by an anti-coagulant, apixaban, to reduce the risk of a stroke. � On 6 November 2022, Audrey was admitted to RCHT with abdominal pain secondary to femoral hernia obstruction. The apixaban was suspended pending surgery. Audrey underwent surgery for femoral hernia repair, that same day, 6 November 2022. The operation was uneventful. � On 9 November 2022 the eldercare consultant reviewed Audrey. The review notes were handwritten on paper medical notes. The eldercare consultant recommended that the surgical team restart Apixaban as soon as safe post operatively. � The court heard evidence that the NICE guidance on this subject states � Stroke risk associated with atrial fibrillation; Post procedure with immediate and complete haemostasis NOACs can generally be resumed 6�8?h after the end of the intervention. Some surgical interventions carry increased bleeding risk in which case resume anticoagulation 48�72?h post procedure but at the earliest opportunity � The apixaban was not restarted. � On 11 November 2022 Audrey had a severe stroke secondary to AF. Audrey died as a result of this complication four days later. � The court found that whether and when to re-start the apixaban was a decision for the surgical team. The court heard that on the consultant surgeon�s ward round his junior doctor colleague was briefing him, this included reference to the eldercare review paper notes. The junior doctor went through a number of aspects regarding care and treatment but did not refer to the recommendation to re-start apixaban. As a result, the consultant surgeon did not consider whether or not to re-start the apixaban. � The court heard that the eldercare team use paper medical notes whilst the surgical team use a digital system, known as NerveCentre. The consultant surgeon stated that the digital system is easier for the surgical team to read because the consultant surgeons can look at the detail on their phone or iPad. The consultant surgeon considered that the different recording platforms contributed to the error of omission in Audrey�s case. � Where an �important clinical note� has been handwritten in the handwritten record there is facility for highlighting this on the �ward round� function on Nerve centre. There was no alert that clinical notes had been handwritten in the written notes following the review by the eldercare consultant on 9th November. � The court found that apixaban was prescribed on admission and correctly suspended due to bleeding risk in light of pending surgery. There is no evidence of review of this suspension in either medicines reconciliation (10th November) or in the medical records. The court heard that there is no automatic flag on the Electronic Prescribing Medication Administration (EPMA) requiring review of the ongoing suspension of prescribed medication.

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

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

04/11/2024

2024-0597

Darren Hope

Coventry and Warwickshire

The Chief Executive Officer of the Coventry and Warwickshire Partnership Trust

INVESTIGATION AND INQUEST: On 14 July 2023, an investigation was commenced into the death of Darren Joseph Hope, who died on the 3July 2023 aged 53. The investigation concluded at the end of the inquest before me and a jury on 24 October 2024. The conclusion of the Jury was: Medical cause of death: 1a Multiple Injuries Darren Joseph Hope died as a result of suicide. Some factors that contributed to this were him being allowed to leave after being assessed as low risk despite threats to himself and others, and him being unaccompanied despite having been assessed already that he should be accompanied.

: Darren Joseph Hope had a background of increasing mental health problems and ��prior involvement with the police. On 29 May 2023, he was taken to the Caludon Centre (the Centre) by the police and admitted under Section 2 of the Mental Health Act. Due to an administrative error, he was initially treated as a voluntary patient for several days before being formally detained under Section 3 of the Mental Health Act. He had a diagnosis of schizoaffective disorder. Darren was deemed suitable for unescorted Section 17 leave, against a history of absconding, using alcohol and cannabis while on unescorted leave, and expressing suicidal thoughts while on unescorted leave at home. It does not appear that the Responsible Clinician was given this information. Darren was granted six hours of unescorted leave. However, the Section 17 leave form signed by the Responsible Clinician indicated that he was to be accompanied by family members. The Responsible Clinician later reported this was an error, as he had intended to grant unescorted leave. The Responsible Clinician also stated that even if all of the events had been drawn to his attention, he would still have granted unescorted leave. On the morning of 3 July 2023, Darren appeared happy and optimistic about the future when he utilised his six-hour unescorted leave at approximately 11:15 am. He returned to his home address at around 2:15 pm. Darren lived in a 10th-floor flat. At approximately 3:20 pm, he was found at the base of the building and was pronounced dead. The cause of death was determined to be multiple injuries due to a fall from height. At the time of his leave, Darren did not have a mobile phone, as it had been retained by the police on his arrest, prior to admission to the Centre. He did not have a landline, and it appears he did not have means of accessing his bank accounts, and no cash was found on his person. The evidence suggests that Darren had no means of contacting the Centre or anyone else if he had concerns, nor could the Centre contact him during his leave. His inability to contact or be contacted was not considered when granting his leave or when signing him out of the ward on 3 July 2023. A subsequent investigation and Patient Safety Incident Investigation Report (the Report), dated 18 January 2024, did not �identify a requirement for the implementation of any safety actions.� The Report noted that on 3 July 2023 Darren had been granted over the six hours permitted, as he left at 10:15 am [sic] and was not required to return until 6 pm. The Report also noted that on 3 June 2023, Section 17 leave would have been permitted even though there was no Section 17 leave form in place on that date. Leave did not take place due to misplaced keys. The Report did not note that the Section 17 leave form in place on 3 July 2023 only permitted unescorted leave. The Report did not note that Darren�s method of communicating with the Centre had not been considered at any point. The inquest received evidence that the investigating officer was not required to inform the oversight team who sign off the Report�the Significant Incident Group (the SIG)�of any issues that had arisen during the investigation and subsequently disregarded. The evidence did not explain how the SIG was able to provide meaningful oversight on the basis of reviewing the draft report only. Although the inquest received evidence regarding proposed changes around Section 17 leave, this was not reflected in the evidence of staff members directly involved in patient care. The Report states that, �The investigation team follow the Duty of Candour and the Engaging and Involving Patients, Families and Staff after a Patient Safety Guidance in their collaboration with those affected, to help them identify what happened and how this resulted in a patient safety incident.� The inquest received evidence that Darren�s mother had been contacted once by telephone call and once by text message, but she and the wider family were not given the opportunity to participate or raise issues. They were not provided with any information about Darren�s care or any other information which would have enabled them to participate in any significant way.

COPIES AND PUBLICATION: I have sent a copy of my report to the following interested persons: Darren�s family West Midlands Police I am also under a duty to send a copy of this report to the Chief Coroner and to publish it on the Judiciary website but may redact the report before publication if appropriate

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

Coventry and Warwickshire Partnership Trust

26/11/2024

2024-0647

Susan Paley

Manchester South

The Chief Executive Officer, Harbour Healthcare Ltd., Lodge House,� Dodge Hill, Stockport, SK4 1RD

On 18th October 2024, I opened an inquest into the death of Susan Paley who died on 11th May 2024� at Hilltop Court Nursing Home, Dodge Hill, Stockport, aged 65 years. The investigation concluded� with the inquest which I heard on 22nd November 2024.� A post mortem examination determined Ms Paley died as a consequence of:� 1) a) Asphyxia;� 1) b) Food bolus obstruction At the end of the inquest, I recorded a conclusion of Accident.

Ms Paley was a resident at Hilltop Court Nursing Home who was significantly dependent on the care� of others as a consequence of complex neurological problems which left her with tremors,� contractures and very limited mobility. Whilst Ms Paley had previously reported swallowing� problems, the outcome of her most recent Speech and Language Therapy Assessment was normal� meaning no modification was required to her diet.� On 11th May 2024, a Healthcare Assistant had left Ms Paley with a sandwich to eat in bed in her� room. When around an hour later the same staff member returned to check on Ms Paley, she found her unresponsive. Whilst staff sought to assist Ms Paley and an ambulance was called, an attending� paramedic confirmed she had died.�� Ms Paley died having choked on food whilst eating in her bed.

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

Care Home Health related deaths

Harbour Healthcare Ltd

02/01/2025

2025-0003

Peter Good

Manchester South

The Chief Executive Officer, Harbour Healthcare Ltd., Lodge House,� Dodge Hill, Stockport, SK4 1RD

On 28th June 2024, I opened an inquest into the death of Peter Good who died on 9th January 2024 at Stepping Hill Hospital, Stockport, aged 64 years. The investigation concluded with the inquest which� I heard on 17th December 2024.�� A post mortem examination undertaken by a consultant forensic pathologist on the Home Office� Register determined Mr Good died as a consequence of:� 1) a) Pneumonia;� 1) b) Cerebral infarction, Parkinson�s disease and skin ulceration.� At the end of the inquest, I recorded a narrative conclusion to the effect that Mr Good died as a� consequence of complications arising from a previous cerebral infarction, Parkinson�s disease and� skin ulceration which had significantly deteriorated whilst at the nursing home from which he was� admitted to hospital for the final time.

Mr Good was a resident at Hilltop Hall Nursing Home who was nursed in bed as a result of complex� care needs particularly arising from a previous cerebral infarction. On 26th December 2023, Mr Good was admitted to Stepping Hill Hospital, Stockport with a blocked gastrostomy tube.�� On admission, Mr Good was noted to be in poor condition exhibiting what clinical staff perceived as� signs of prolonged neglect, leading to a safeguarding alert being raised.�� Despite treatment with antibiotics, Mr Good deteriorated further whilst in hospital and died on 9th� January 2024.

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

Care Home Health related deaths

Harbour Healthcare Ltd

10/01/2025

2025-0015

Mark-Anthony Summersett

West Sussex, Brighton and Hove

The Chief Executive University Hospitals Sussex NHS Foundation Trust

On 16 February 2024 I commenced an investigation into the death of Mark-Anthony SUMMERSETT aged 58. The investigation concluded at the end of the inquest on 09 January 2025. The conclusion of the inquest was that: On 5 February 2024 Mark-Anthony Summersett attended the Emergency Department at Worthing Hospital in the company of a Police Officer.� Suicidal thoughts were reported and recorded by reception staff but Mr Summersett left around an hour later before being triaged or assessed for treatment.� Over thirty six hours later he was sadly found deceased in his car in the Crown Car Park, Arundel on 7 February 2024, with self-inflicted wounds to his neck; Police ruled out any 3rd party involvement.

Mr Summersett was known to local Mental Health Services (ATS), although he had cancelled multiple appointments for a full clinical assessment.� He approached Police on 5 February 2024, at the station in Littlehampton trying to hand himself in for fraud.� He stated that he felt he should be punished and everyone would be better off if he was dead. He said a decline in his mental health had led to him self-harming a number of times, but he didn�t think he could actually end his life and had thrown away a razor blade just before coming to the police. Officers took him to Worthing General Hospital Emergency Department to receive help. They helped him sign in at 1840 and he told reception that he was experiencing suicidal thoughts.� Officers left him in the care of hospital staff. He was seen around an hour later appearing calm.� He was not called for triage until 1946 but did not respond.�ED staff notified the MHLT who confirmed he was known to their service.� They were only told he was experiencing suicidal thoughts and made internal notification to his lead practitioner. Both teams attempted contact by telephone to Mr Summersett�s mobile, to no avail.� MHLT were unaware that he had been brought to hospital by Police, who were not informed he had left the ED. Nor were his former partner or GP informed. Neither Police nor his partner therefore attempted contact. On 7th February Police and SECAMB were called at 1415 to report that a male had been found deceased in his car in Arundel, subsequently identified as Mr Summersett.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (former partner) Sussex Police Sussex Partnership 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)

University Hospitals Sussex NHS Foundation Trust

21/04/2023

2023-0205

Maria Shafighian

Gwent

The Chief Executive of Aneurin Bevan University Health Board.

INVESTIGATION AND INQUEST � On 10/12/2020 an investigation was opened into the death of Maria Christine Shafighian. � The investigation concluded at the end of the inquest on: 6/4/2023 The conclusion of the inquest was recorded as: Death from Natural Causes � The medical cause of death was: 1a. Metastatic oesophageal cancer.

Maria Shafighian was a 59-year-old woman who was referred to the ENT department at Aneurin Bevan University Health Board by her GP on 27/1/2020 with symptoms of persistent hoarseness. Ms Shafighian was assessed by a specialist ENT trainee on 3/2/2020 who ordered a CT scan, which found no evidence of laryngeal cancer. Maria was diagnosed with vocal cord palsy and referred to the Speech and Language Therapists (SALT). � On 4/5/2020 the SALT team noted that Maria was suffering from dysphagia which I heard was a worrying development which may need urgent assessment. I heard that the SALT team referred Maria back to the ENT team and notified them of this development. � After further assessment, Maria was diagnosed with oesophageal cancer. She was not a candidate for surgical intervention and received palliative chemotherapy and radiotherapy. � Maria Shafighian died from the effects of oesophageal cancer at Ysbyty Ystrad Fawr on 24/11/2020 � In the inquest I determined that there had been opportunities missed to identify and treat Maria�s tumour earlier but I could not determine on balance that this would have altered the outcome and hence the conclusion was death by natural causes.

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

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

20/03/2024

2024-0153

Neil Edwards

Gwent

The Chief Executive of Aneurin Bevan University Health Board.

INVESTIGATION AND INQUEST � On 12/05/2023, an investigation was opened touching upon the death of: Neil Francis Edwards The investigation concluded at the end of the inquest on 08/03/2024. � The conclusion of the inquest was recorded as a narrative conclusion in the following terms: � Neil Francis Edwards was admitted to the Grange University Hospital in Llanfrechfa on 12/04/2023 in respiratory failure. He was at a high risk of falling and required 1:1 observation throughout the entirely of his admission. � Mr Edwards was transferred to Ysbyty Aneurin Bevan where he suffered a fall on 01/05/2023 and fractured his hip. He was not being observed at the time. Mr Edwards underwent surgery to repair his hip on 03/05/23 at the Grange University Hospital. � Postoperatively Mr Edwards suffered a gastrointestinal bleed contributed to by the stress of the fracture and the necessary surgery. He did not have the physiological reserve to withstand the effects of the haemorrhage and he died at Nevill Hall Hospital 09/05/2023. � His death was contributed to by neglect. The medical cause of death was: 1a) Upper gastrointestinal bleed � 2) Fractured neck of Femur (Operated). Chronic Obstructive Pulmonary disease

It was determined that Neil Francis Edwards should have been under 1:1 observation from the time of his admission until at least the time he fell and sustained the hip fracture on 01/05/23. Mr Francis suffered 4 falls whilst in hospital and was not being observed on any of these occasions. The trauma associated with his final fall and the requirement for surgery resulted in a stress-related gastrointestinal haemorrhage and his death.

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

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

30/06/2023

2023-0221

Kaye McCoy

Gwent

The Chief Executive of Aneurin Bevan University Health Board.

INVESTIGATION AND INQUEST � On 3/10/2022, an investigation was opened into the death of Kaye McCoy. The investigation concluded at the end of the inquest on 27/6/2023. The conclusion of the inquest was recorded as: Suicide The medical cause of death was: � la. Suspension by ligature lb. Unstable Affective Disorder.

Kaye McCoy suffered from depression and anxiety and was diagnosed with Unstable Affective disorder. Kaye had been under the care of the Older Adults Mental Health Team since 2017 and prior to that under the care of the Adult Psychiatric Services. � On 1/9/2022, Kaye had an outpatient appointment with her consultant psychiatrist who advised admission to hospital, but Kaye declined. On 5/9/2022, Kaye took an overdose of prescribed� medication� with an intention to end her life, she was assessed in hospital and discharged back to the care of her care co-ordinator. Kaye was followed up daily by her care coordinator who, on Friday 9/9/2022, again offered Kaye admission to hospital. At the inquest I determined that by this stage Kaye was in crisis and her main protective factor, which were her family, had been diluted. Kaye was expressing anger towards and was emotionally distanced from family members. � The inquest found that there was no strategy developed for the involvement of Kaye�s family in her care, and that engagement with the family by the mental health teams had been poor. � After seeing Kaye on 9/9/2022, the next follow up was scheduled for the Monday after the weekend; 12/9/22. I was informed that follow-up and support from a Crisis or Home Treatment team was not available for Older Adults at the weekends, or indeed out of hours. Kaye was told that if her condition deteriorated she should phone the Samaritans. � Kaye McCoy [REDACTED]�taken her own life by hanging on Sunday 11/9/2022. � I determined that her death was contributed to by a failure of the mental health service to adequately respond to a severe downturn in Kaye�s mental health.

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

Suicide (from 2015) | Mental Health related deaths This report is being sent to: Aneurin Bevan University Health Board

04/12/2023

2023-0501

Catriona Martin

Gwent

The Chief Executive of Aneurin Bevan University Health Board.

INVESTIGATION AND INQUEST � On 19/01/2021, an investigation was opened into the death of Catriona Ellen Martin The investigation concluded at the end of the inquest on 23/11/2023. The conclusion of the inquest was recorded as a narrative conclusion in the following terms: � Catriona Ellen Martin was admitted to hospital on 05/12/2020 with autoimmune encephalitis. The treatment plan was not adhered to because Catriona was not provided with adequate nursing care which resulted in a failure to observe her, failure to administer medication and caused her to develop dehydration, acute kidney injury and uncontrolled seizures. This resulted in Catriona�s death at the Grange University Hospital, Llanfrechfa on 25/12/2020. Catriona Ellen Martin died from the effects of autoimmune encephalitis contributed to by neglect. � � The medical cause of death was: 1a) Autoimmune encephalitis

The circumstances of Catriona�s death are best described in the narrative conclusion. Throughout her admission Catriona required 1:1 nursing care which, apart from a short admission to ITU between 08/12/2020 and 15/12/2020, Catriona did not receive. The nursing staff relied on Catriona�s mother to ensure that Catriona received the fluid and medication she required. Catriona�s mother continuously advised the nursing staff that she was unable to ensure that Catriona was receiving fluid and medication, however no assistance was given, and Catriona went into a fatal decline. � I found that Catriona�s death would have been prevented if 1:1 nursing care had been provided.

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

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

20/05/2024

2024-0275

Sylvia Evans

Gwent

The Chief Executive of Aneurin Bevan University Health Board.

INVESTIGATION AND INQUEST � On 18/09/2023, an investigation was opened touching upon the death of: Sylvia Eileen Evans The investigation concluded at the end of the inquest on 14/05/2024 The conclusion of the inquest was recorded as: Death by Accident. � � The medical cause of death was: � 1a) Ischaemic heart disease 1b) Coronary Artery Disease 1c) 2 Blood loss from leg wound. Atrial Fibrillation (on anticoagulants)

On 05/09/2023, Sylvia Eileen Evans sustained an accidental wound to her leg at home, which caused a severe haemorrhage. This in turn put pressure on her heart, the function of which was already compromised by extensive ischaemic heart disease. The effects were overwhelming and resulted in Sylvia�s death on 06/09/2023 at her home address.

COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) � The family of Sylvia Eileen Evans Health Inspectorate Wales Welsh Ambulance Service NHS Trust Minister of Health for Wales � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Emergency services related deaths (2019 onwards) | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Aneurin Bevan University Health Board

17/01/2023

2023-0025

John Henderson

Mid Kent and Medway

The Chief Executive of HM Prison and Probation Service; The Governing Governor of HMP Rochester; The Chief Executive of OXLEAS NHS Foundation Trust.

On 7 June 2021 I commenced an investigation into the death of John Allen Martin HENDERSON. The investigation concluded at the end of the inquest . The conclusion of the inquest was Natural causes 1a Ischaemic Heart Disease

Mr Henderson was found dead on his bunk in the morning by other HMP Rochester inmates. His cell mate was concerned that Mr Henderson had not moved and asked another inmate to check on him. When this was done, the deceased was discovered to be cold to the touch and no pulse could be detected. Staff were informed upon this discovery. The Ambulance Service attended and confirmed that Mr Henderson had died. � Following a post mortem it was confirmed that Mr Henderson had died of ischaemic heart disease. � Throughout the inquest, various evidence was heard as to how Mr Henderson had previous acute medical episodes which had required hospitalisation. Mr Henderson was undergoing neurological investigations at the time of his death and was receiving treatment for hypertension. � I recorded on the record of inquest that: � John Henderson was a serving prisoner at HMP Rochester. He had physical health problems which were subject of ongoing treatment and investigation. Those investigations were continuing at the time of his death but had been delayed by administrative issues. At some point late in the evening of 26 May 2021 or early 27 May 2021, Mr Henderson had a sudden and fatal haemorrhage into the wall of the left circumflex artery which caused him to die. Mr Henderson was found in his cell at HMP Rochester on 27 May 2021 having died.

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

State Custody related deaths

HM Prison and Probation Service, HMP Rochester and OXLEAS NHS Foundation Trust

19/12/2022

2022-0408

Mollie Stansfield

East Riding and Hull

The Chief Executive of NHS England The Chief Coroner The President of the Royal College of Psychiatrists The President of the Royal College of Nursing All Interested Persons The Chief Executive of NHS Scotland The Chief Executive of NHS Northern Ireland

On 12th July 2019 I commenced an investigation into the death of Mollie Rose Stansfield, age 22 years. The investigation concluded at the end of the inquest on 9th December 2022. The conclusion of the inquest was: �NARRATIVE Mollie Rose Stansfield was born on 6th January 1997 in Hull and died on 10th July 2019 on Princes Quay, Hull after falling. She suffered multiple injuries as a result of this fall which resulted in her rapid death. She had an underlying diagnosis of Emotionally Unstable Personality Disorder, as well as a history of drug and alcohol abuse. She was admitted to the Avondale Unit on 27th June 2019 as an informal patient, after being transferred there following presentation to Hull Royal Infirmary with a self-inflicted neck wound which was appropriately treated. Whilst there she absconded and purchased a number of tablets, which she took, but did not tell the nursing staff who discovered it later that day. She was transferred back to Hull Royal Infirmary and treated for this overdose. Upon her return to the Avondale unit she became physically unwell and was sent back to Hull Royal Infirmary for investigation of what was thought to be a cardiorespiratory problem. This was refuted and it is likely that her physical symptoms were due to the systemic toxic effects of cocaine. She absconded from the ward on a number of other occasions and sourced������������������ whilst absent, which she took. She suffered a fit as a result of taking����������������������� but recovered. A Section 5.2 Mental Health Act order was put in place, but was probably not valid at material times. She was discharged to step down accommodation following being declared medically fit and following assessment by a psychiatrist. She was evicted from the step down accommodation on 10th July following an altercation the previous evening, and went to a high rise block of flats with the intention of jumping off. Her friend however intervened, called the police who attended the flats and removed her to a place of safety, Miranda House, under Section 136 of the Mental Health Act 1983. Following a mental health assessment at 13:00 on 10th July she was found neither to be psychotic nor intoxicated with. She subsequently took following her discharge and went to Princes Quay and fell to her death. The effects may have clouded her judgment but equally the text message exchanges prior to her assessment at the Section 136 suite and after her release suggested that she intended to take her own life.

See section 3

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:�� (Clyde & Co � represented Humber) (Williamsons � represented the Family) and�� (Capsticks � represented NHS Teaching Hospitals Trust). I have also sent it to: (Chief Executive of NHS England) (President of the Royal College of Psychiatrists) (President of the Royal College of Nursing) (Chief Executive of NHS Scotland) and������������������������������������������������������������������������������������������ (Chief Executive of NHS Northern Ireland) 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)

NHS England, Chief Coroner, Royal College of Psychiatrists, Royal College of Nursing, NHS Scotland and NHS Northern Ireland

26/11/2024

2024-0646

Emma Sanders

Dorset

The Chief Executive of NHS England The Chief Executive of NHS Dorset

On the 4th April 2023, an investigation was commenced into the death of Emma Victoria Sanders, aged 34 years. � The investigation concluded at the end of the Inquest on the 18th November 2024. � The medical cause of death was: � Ia Hypoxic Brain Encephalopathy Ib Asphyxia � The conclusion of the Inquest was a narrative conclusion that Emma Victoria Sanders died as a consequence of the self-application of a ligature to her neck, in circumstances where her intention remains unclear.

Emma had a complex mental health history with confirmed diagnoses of Emotionally Unstable Personality Disorder (EUPD) and complex Post Traumatic Stress Disorder (PTSD) and was known to regularly self harm by a variety of means. Emma had a history of opiate dependence and on the 22nd February 2023, she began a period in a detoxification and rehabilitation placement in Cornwall in order to become abstinent from methadone so she could progress to therapy treatment for her mental health diagnoses. Prior to this she had experienced a period of relative stability with her mental health. During this placement the methadone prescription was reduced more quickly than she had experienced before, and she became emotionally dysregulated. Her mental health deteriorated, and her acts of self harm increased as a result of which she was taken to the local hospital in Cornwall. The placement was ended on the 7th March as it was felt her risks were too high to be managed in that setting. On the 14th March 2023 Emma was taken to the Emergency Department at the Royal Bournemouth Hospital, Bournemouth after she disclosed that she had taken an overdose of her prescribed medication. At this time the hospital was experiencing extreme capacity pressures and Emma was placed in the cohorting corridor which was being staffed by paramedics due to the capacity pressures. At 18.58 hours, when for a very short period of time there were no staff in the corridor, Emma can be seen on the CCTV of the corridor to secret upon her person a nasal canula with plastic tubing from an equipment trolley. At 19.53 hours Emma went to the toilet in the Emergency Department. At 20.03 hours, Emma was found in a collapsed and unresponsive condition on the floor of the toilet with a ligature fashioned from nasal canula tubing around her neck. Following attempts at cardiopulmonary resuscitation there was a return of spontaneous circulation, and she was admitted to the critical care unit at the hospital where she continued to receive care, however her condition deteriorated, and she died on the 19th March 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Emma�s family Dorset Healthcare University NHS Foundation Trust University Hospitals Dorset NHS Foundation Trust South West Ambulance Service NHS Foundation Trust We Are With You � 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: � BCP Council, as they were involved in the Inquest Chief Executive of Dorset County Hospital, Dorset [REDACTED], Service Manager, St Mungo�s � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

NHS England | NHS Dorset

17/03/2023

2023-0096

Benjamin Teague

Northamptonshire

The Chief Executive of National Highways, National Highways Bridgehouse, 1 Walnut Tree Close Guilford Surry GU1 4LZ

On 11 August 2021 I commenced an investigation into the death of Benjamin James TEAGUE aged 26. The investigation concluded at the end of the inquest on 08 March 2023. The conclusion of the inquest was: 1a Head Injury

On the evening of 2nd August 2021, Benjamin Teague drove his BMW car on the A5 between Potterspury and Paulerspury. He overtook a vehicle, crossed to his incorrect side of the road where he collided head on with an approaching car. He was confirmed deceased at the scene. � My conclusion was Road Traffic Collision

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � The family of Benjamin Teague � 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

The Chief Executive of National Highways

22/06/2023

2023-0206

Lucy Walles

Berkshire

The Chief Executive of Reading Borough Council Chief Executive of Berkshire Healthcare NHS Foundation Trust

I conducted an inquest into the death of Lucy Anne Walles, which concluded on 16th June 2023. I recorded a conclusion of suicide. I concluded that her cause of death was : 1a Traumatic brain injury 2 Polytrauma

Lucy was born on 17th November 1997. She was 24 at the time of her death. Her death in hospital on 23 February 2022 happened after she jumped [REDACTED] on 16 February 2022. � The key facts for the purposes of this report are as follows: � Lucy had mild learning disabilities but had capacity to make her own decisions and go out alone. She needed support with everyday tasks and remembering to do things.Lucy lived in supported accommodation in Reading, funded by Wokingham Borough Council. A support worker was provided by a care provider (Dimensions). � Mental Health Support: � Lucy had some interactions with mental health services over the years, and we focused on her most recent contacts. Lucy was under the care of the Crisis Home Resolution and Treatment Team (CRHTT, hereafter referred to as �the crisis team�) between 11th January and 2nd February 2022, after an overdose. She was discharged from mental health services with a recommendation to refer herself to a group called SUN (Service Users Network). She had been told at that point that she did not meet the criteria for the learning disabilities team and was advised to speak to her GP herself from that point.She saw a mental health practitioner based at her GP surgery on 15th�February, indicating that she had thoughts of jumping from a particular bridge in Reading. The crisis team was contacted. Their advice was that, Lucy had been discharged recently from the service, and that she did not meet the criteria for being taken on by them. The recommendation for Lucy to refer herself to the SUN group remained. They did not speak to Lucy at that point. They did not offer her support from other mental health teams. � Safeguarding referrals � There was at least one earlier safeguarding referral, but we focused on those in the last 12 months of Lucy�s life. ��A safeguarding referral was sent to Reading Borough Council in May 2021 following an incident where Lucy took too many sleeping tablets. This report referenced Lucy�s past history of deliberate self-harm. The evidence suggests that this was not reviewed by Reading Borough Council for almost 3 months � in August 2021 � when it was deemed to be an inappropriate referral on the basis that it did not describe abuse or neglect. ��Between 10th and 20th January 2022, 3 separate safeguarding concerns were raised with Reading Borough Council. These are referred to below. ��On the 10th January 2022, a safeguarding referral was made regarding an overdose of Nurofen tablets. ��On the 18th January, there was an update on the above referral, but this related to additional incidents, including ingestion of bleach. When this was followed up by telephone (with the person who had made the referral) RBC�s record of this conversation includes the following: Lucy has allegedly done a few more self-harm attempts�she is making several threats of suicide ([REDACTED]). Today she tried to�[REDACTED] � her mental health seems to be deteriorating�Dimensions believe she needs more support than what they can provide as they are not mental health skilled professionals. ��Subsequent to the referrals on 10th and 18th January, a social worker recorded that she did not think that Section 42 [of the Care Act] criteria were met. She also concluded that there was �robust support from agencies involved and appropriate measures have been taken to address risks posed by her threats of self-harm. No serious harm has occurred to Miss Walles�. �� On 20th January, South Central Ambulance Service Centre made a safeguarding referral. This referral relates to a previous overdose, and mental health deterioration. The report said that Lucy had told them she did not want to be here anymore. ��During all of these safeguarding referrals, Lucy was not contacted at all. It appears that the only information taken into account in reaching conclusions was the initial safeguarding report itself and information on Reading Borough Council�s computer system (Mosaic). These would have included earlier safeguarding reports. After the third safeguarding concern was raised by the ambulance service, no review or action took place before the tragic events of 16th February 2022.

I have sent a copy of my report to the Chief Coroner and to Lucy�s family. � I have also sent this report to the following recipients, who have an interest in this matter: 1.���� Legal representative for Wokingham Borough Council. 2.���� Legal representative for Dimensions. � 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: Reading Borough Council, Berkshire Healthcare NHS Foundation Trust

18/05/2023

2023-0163

Samuel Morgan

Swansea Neath Port Talbot

The Chief Executive of Swansea Bay University Health Board (Mark Hackett), One Port Talbot Gateway, Baglan Energy Park, Port Talbot, Sa12 7BR

On 13th May 2019 an investigation was commenced into the death of Samuel Alexander Morgan who was found deceased in his parents� house on the 9th May 2019 after having tied a ligature around his neck. He was 29 years of age at the time of his death. The investigation concluded at the end of the inquest on 6th March 2023. � The medical cause of death was: 1a Hanging

The deceased was Samuel Alexander Morgan. At the time of his death Samuel was suffering from alcohol addiction and had a diagnosis of ADHD and social anxiety. Prior to his death Samuel had received treatment from the Community Drug and Alcohol Treatment (�CDAT�) team and primary mental health services. Samuel was discharged from CDAT fifteen months prior to his death. CDAT had information on their system (including from their own risk assessment) to indicate that Samuel had been assessed as a significant risk of suicide. There was other valuable information about Samuel�s risk factors on the CDAT system. At the time when Samuel was under CDAT the GP had also referred Samuel to the community mental health team raising his concerns about Samuel�s risk of suicide. It is not clear is CDAT had access to this letter. When the primary mental health services consultant began treating Samuel for his ADHD � which continued up to Samuel�s death � he received a referral from CDAT but he did not have access to the detailed information on the CDAT electronic system. The consultant could not and did not see the CDAT risk assessment, the outcome and assessment from the individual CDAT sessions and other vital historical information of potential relevance to Samuel�s risk factors and triggers for suicide.

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

Suicide (from 2015) This report is being sent to: Swansea Bay University Health Board

16/05/2023

2023-0158

Roger Southwick

Manchester South

The Chief Executive of Tameside and Glossop Integrated Care NHS Foundation Trust

On 10th November 2022 an investigation was commenced into the death of Roger Southwick. The investigation concluded at the end of the inquest on 10th March 2023. The conclusion of the inquest was that the medical cause of death was: 1a) Subdural Haemorrhage; 1b) Accidental Fall; II) Myocardial infarction, Lower respiratory tract infection, anticoagulation medication My conclusion was that this was an accidental death.

Roger Southwick had a stent inserted in his chest following a heart attack in October 2022. On 5th November 2022 he was feeling breathless and admitted to Tameside General Hospital where a chest infection was diagnosed and low sodium levels detected secondary to his heart failure and he was admitted for treatment. A falls risk assessment was inaccurately completed and concerns raised about his mobility were not actioned. On 7th November Roger was found outside his cubicle having fallen and hit his head. CT scanning revealed a significant subdural haemorrhage which was not amenable to surgical intervention and he died at Tameside General Hospital on 9th November 2022.

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

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

25/01/2024

2024-0039

Christopher Kapessa

South Wales Central

The Chief Executive of the Coal Authority

A Coronial investigation was commenced on 8th July 2019 into the death of Christopher Grace Kapessa. The Investigation concluded at the end of the inquest which I conducted on 8th � 22nd January 2024. The conclusion was a narrative conclusion and the medical cause of death was 1 (a) submersion

These were recorded as: � Christopher Kapessa, aged 13, attended the Red Bridge at Abercwmboi in the afternoon of 1st July 2019, meeting a group of school friends of largely the same age, some of whom intended to jump into the water. Christopher took with him clothes in which he could swim, undressed to his shorts and approached the water side. He had not decided whether to enter the water and was expressing both a desire to swim and concern due to his limited ability to swim. At about 17.25, while he was standing by the water side looking in to the river, he was deliberately pushed in to the water by another child, falling 2.5 metres to the water surface. �There was a current. �The water was cold and too deep for him to touch the bottom and keep his head above the surface. Christopher was swiftly in difficulty, thrashing ineffectively with his arms.� Children, including the boy who had pushed him, jumped in to the water to try to save him, but were unable to do so. He became submerged. Some of the children sought help and the emergency services attended and carried out a search, finding Christopher underwater at about 19.25. Resuscitation attempts took place but after so long a period submerged, Christopher could not be saved. � The narrative conclusion which I returned was: � Christopher Kapessa, aged 13, died by submersion when intentionally pushed by another child into the river Cynon. The push was a dangerous prank. However, the child responsible for it did not intend to cause Christopher�s death and himself jumped into the water with other children in an unsuccessful attempt at rescue. The Inquest focused upon: � The circumstances in which Christopher came to enter the water at the �Red Bridge�, Abercwmboi � The response of the emergency services to reports of the incident � What was known by the Coal Authority, being the occupier of the bridge from the vicinity of which Christopher entered the water, and the authorities responsible for public safety, as to whether the site was used for swimming by children, and whether any steps were or ought to have been taken to prevent such activity or warn or safeguard those undertaking them.

I have sent a copy of my report to family who may find it useful or of interest. � Welsh Government, the National Water Safety Forum, Rhonda Cynon Taf County Borough Council � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Other related deaths | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Coal Authority

17/01/2025

2025-0032

Jackson Yeow

South Wales Central

The Chief Executive of the Cwm Taf Morgannwg University Health Board

A Coronial investigation was commenced on 20th April 2022 into the death of Jackson Yeow, aged 16.� The investigation concluded at the end of the inquest which I conducted on 15th -16th January 2025. The conclusion was a narrative conclusion and the medical cause of death was 1 (a) cerebral oedema, 1(b) diabetic ketoacidosis; 2 recent covid 19 infection; pancreatitis

These were recorded as: � � Jackson Yeow, aged 16 years, suffered autistic spectrum disorder and obesity.� On 28th March 2022 he was assessed by a general practitioner following a history of abdominal pain and vomiting, diagnosed with suspected gastritis, and treated.� On 4th April 2022 his mother became concerned that his symptoms had worsened and sought the assistance of the general practice by telephone.� Jackson was unable to mobilise to attend GP consultation in person and his mother� phoned 999 at 12.13.� Despite subsequent clinical support desk review and further 999 calls, an ambulance service resource was not allocated until after Jackson became unconscious at about 19.30, attending at 20.00.� Jackson was subject to a prolonged extrication from his house with fire service and EMERTS assistance, was intubated and taken to the University Hospital of Wales where he was diagnosed to be suffering diabetic ketoacidosis, pancreatitis, cerebral oedema, renal compromise and severe acidosis.� Despite intensive treatment over the subsequent days his condition deteriorated and he died on 9th April 2022. � The narrative conclusion which I returned was: � Jackson Yeow, aged 16, died of diabetic ketoacidosis following a wait for an ambulance of approximately 9 � hours. � The Inquest focused upon: � � a. The fact that Jackson Yeow�s condition deteriorated on 4th April 2022.� His family contacted his GP and was offered a face to face appointment which he became physically unable to attend. � b. His family telephoned 999 at 12.13 on 4th April 2022. � c. The ambulance service categorised the call as an amber 1 response, which it characterised as a life threatening call requiring an urgent response. � d. The evidence of the ambulance service was that its ability to respond to the call was substantially impaired by the fact that a significant number of its resources were delayed at hospitals awaiting hand over of patients. � e. An ambulance did not attend until 20.00 on 4th April 2022, by which time Jackson Yeow had suffered a substantial metabolic derangement, cardiovascular collapse and renal impairment.� He was severely acidotic. � f. The first language of the family was not English.�Although some clinicians were able to use the services of an interpreter, this was not always employed.

I have sent a copy of my report to the following who may find it useful or of interest. � The Welsh Government, the Chief Executive of the Welsh Ambulance Services NHS Trust, the Chief Executive of the Cardiff and Vale University Health Board; The family; The General Practitioners who were recognised as 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.

Child Death (from 2015) | Emergency services related deaths (2019 onwards) | Hospital Death (Clinical Procedures and medical management) related deaths | Wales prevention of future deaths reports (2019 onwards)

Cwm Taf Morgannwg University Health Board

25/06/2024

2024-0341

Isobel Stapleton

South Wales Central

The Chief Executive of the Cwm Taf Morgannwg University Health Board and the Welsh Government

A Coronial investigation was commenced on 19th July 2022 into the death of Isobel Lilian Stapleton. The Investigation concluded at the end of the inquest which I conducted on 19th June 2024. The conclusion was that Ms Stapleton died from suicide. The medical cause of death was 1 (a) lncisional Injury to Right Femoral Artery and Vein.

These were recorded as: Isobel Stapleton, aged 32, suffered depression. She was admitted to the Royal Glamorgan hospital as a voluntary inpatient on 18th June 2022 for assessment and was reviewed by a consultant psychiatrist. She was discharged on 24th June 2022, returned to reside with her father and received treatment from the home treatment team.� On Saturday 9th July 2022 Ms Stapleton was at home and appeared to give no cause for concern until her father heard her call from upstairs. He found her on the floor of her bedroom with significant bleeding [REDACTED]. He summoned help and comforted her as she lost consciousness.� Paramedics were deployed at 14.49 and attended at 14.54 but her life could not be saved.� It is likely that her injuries were self inflicted. Ms Stapleton expressed a clear intention to end her life in a hand written note found at the scene. � The Inquest focused upon the following: The assessment and management of the risk posed by Ms Stapleton to herself. � The information available to medical professionals and information sharing between professionals and agencies. � The availability of psychological assessment and treatment resources to the inpatient team at the Royal Glamorgan hospital and the home treatment team covering Merthyr Tydfil. � The involvement of Ms Stapleton�s family in discharge planning.

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

Suicide (from 2015) | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Cwm Taf Morgannwg University Health Board | Welsh Government

19/07/2023

2023-0256

Thelma Radmore Coroner name: Alison Mutch Coroner Area: Manchester South Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department of Health and Social Care

Secretary of State for Health and Social Care

On 30th December 2022 I commenced an investigation into the death of Thelma Mary Radmore. The investigation concluded on the 22nd May 2023 and the conclusion was one of Narrative: Died from a combination of Influenza A and Covid Pneumonitis contracted whilst an in-patient contributed to by an unstageable sacral pressure ulcer that was exacerbated by a prolonged wait for an ambulance and a prolonged wait for treatment and a bed in the Emergency Department. The medical cause of death was 1a) Influenza A and Covid Pneumonitis; II) Ungradable Sacral Pressure Ulcer, Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease

Thelma Mary Radmore had a complex medical history. She was taken to Stepping Hill Hospital on 11th December 2022 at 18:20 via ambulance following a prolonged delay waiting for an ambulance to become available. Due to the volume of patients at the Emergency Department Mrs Radmore waited for over an hour with the ambulance crew in a corridor on an ambulance trolley. She was then moved to a hospital trolley in a cubicle. She was in the Emergency Department for in excess 26 hours before being transferred to a ward this was due to demand for and availability of beds. On the balance of probabilities the prolonged wait for a hospital bed and delayed transfer to hospital contributed to a significant deterioration in her skin integrity. Her sacral pressure ulcer was found to be unstageable on assessment by the tissue viability nurse on 16th December 2022. On 20th December 2022 she was swabbed for Covid-19 and Influenza A. Both on balance of probabilities contracted in hospital. She was initially stable. On 22nd December 2022 she began to deteriorate rapidly with Covid Pneumonitis and Influenza A. She died at Stepping Hill Hospital on 23rd December 2022.

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

04/08/2022

2024-0281

Malcolm Garrett

Manchester South

Secretary of State for Health and Social Care

On 30th September 2021 I commenced an investigation into the death of Malcolm John Garrett. The investigation concluded on the 16th June 2022 and the conclusion was one of Narrative: Died from Covid-19 acquired whilst an inpatient contributed to by the complications of a lung transplant. The medical cause of death was 1a) Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia; II) Chronic immunosuppression (lung transplant 2013), chronic allograft dysfunction/bronchiolitis obliterans, non-traumatic thoracic vertebra wedge fracture, ischaemic heart disease, chronic kidney disease.

Malcolm John Garrett had a bilateral lung transplant in 2013. He was placed on long term medications to avoid rejection of the transplant. He was immunosuppressed as a consequence. He also developed chronic allograft dysfunction and chronic kidney disease and ischaemic heart disease that are recognised long term complications in transplant patients. � He developed severe back pain and was admitted to Stepping Hill Hospital on 2nd August 2021. A MR of the spine showed a traumatic wedge fracture of the vertebra at T9. He was given pain relief and subsequently fitted with a brace. On 7th August 2021 he had symptoms of opiate toxicity and was treated with opiate reversing medications. The toxicity was probably as a consequence of an acute kidney injury. � He was found to have developed pneumonia and was treated for it. He was placed on NIV due to ongoing acidosis. Subsequently he was stabilised and was weaned off NIV. On 8th September he deteriorated significantly and was again started on NIV and intravenous antibiotics. He stabilised again. � Subsequently on 17th September 2021 he began to deteriorate again. Antibiotics were restarted as he showed signs of infection. On 19th September 2021 he was confirmed to be Covid-19 positive having acquired it whilst in the hospital. He was moved to a Covid ward and treated. He subsequently deteriorated further and died at Stepping Hill Hospital on 23rd September 2021. Post-mortem examination confirmed the direct cause of his death was a combination of Covid pneumonitis and pseudomonas aeruginosa bronchopneumonia.

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

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

31/01/2024

2024-0046

Shahzadi Khan

Manchester South

Secretary of State for Health and Social Care

On 15th February 2023 I commenced an investigation into the death of Shahzadi Khan. The investigation concluded on the 23rd November 2023 and the conclusion was one of Narrative: Suicide contributed to by a failure to effectively and appropriately manage her care in the community following discharge from hospital. The medical cause of death was 1a) Drug Toxicity.

On 29th December 2022, Shahzadi Khan was detained under section 2 of the Mental Health Act due to her mental state and the risks she presented. She was found to have had a manic episode with psychotic symptoms. Due to a lack of beds, she was placed in a privately-run mental health hospital in Norfolk. She remained there until her discharge to the family home on 26th January 2023. She was commenced on Olanzapine and Zopiclone for her mental health whilst an inpatient. � Her diagnosis on discharge was mania with psychotic symptoms. She was to remain on olanzapine in the community. Her placement out of area contributed to disjointed and inadequate discharge planning to support her in the community and was exacerbated by poor communication between the team managing out of area placements and the local team. As a consequence, the aftercare planning did not take place in accordance with S117 Mental Health Act. � This was exacerbated by a failure by all health professionals involved in her care within the mental health trust to recognise that she needed to be referred on to the Trafford Shared Care pathway. A referral would have ensured she received support and care for at least 12 weeks when she returned to the community. There is no clear reason for this failure. � She was seen by the Home-Based Treatment Team (HBTT) on 28th January and 2nd February, then discharged back to her GP. Within a week of that discharge from HBTT, which meant she had been left with no mental health support, she had deteriorated significantly. On 9th February her GP sent her to hospital for emergency assessment due to her presentation. She was discharged home to be seen by the Home- Based Treatment Team on 11th February. She was seen by that team on 11th, 12th, and 13th February. � There was still no recognition of the fact that the Trafford policy was not being followed. She had indicated her lack of compliance with olanzapine, suicidal thoughts and her behaviour on 13th February was erratic. On 14th February 203 she took a fatal overdose of prescribed zopiclone at her home address.

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) Greater Manchester Mental Health NHS Foundation Trust and; 3) Southern Hill Hospital, who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Alcohol, drug and medication related deaths This report is being sent to: Department of Health and Social Care

04/07/2024

2024-0411

Harry Dunn

Northamptonshire

Secretary of State for Health and Social Care

On 04 September 2019 I commenced an investigation into the death of Harry Peter DUNN aged 19.� The investigation concluded at the end of the inquest on 13 June 2024.� The conclusion of the inquest was: � Road Traffic Collision

The circumstances of the death are as follows: � � On 27 August 2019 at about 2030 hours there was a head on collision between a car driven by [REDACTED] an employee of the US Government who had not long been in the UK and whose husband worked out of the nearby RAF Croughton, and a motorcycle ridden by Mr Harry Dunn. The cause of the collision was that on exiting RAF Croughton [REDACTED] inadvertently moved onto the incorrect side of the B4301 rural road and travelled about 350 meters on the wrong side of the road prior to the head on collision with Mr Dunn, who was on the correct side of the road travelling out of the village of Croughton. � Mr Dunn suffered catastrophic injuries including fractures to all four limbs, some of which were open in nature and a fracture to his pelvis with the concomitant severe internal blood loss commonly associated with such serious injuries. � He was attended to by an advanced medical team including a Consultant Anaesthetist and Critical Care paramedics and then conveyed to hospital where he died shortly after arrival.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this report to West Northamptonshire Council, Northamptonshire Police, to the Chief Executive of East Midlands Ambulance Service and the solicitors on behalf of [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�| Hospital Death (Clinical Procedures and medical management) related deaths�� � This report is being sent to: Department of Health and Social Care

14/02/2023

2023-0058

John Abrahams

Manchester North

Secretary of State for Health and Social Care

On� 31� August� 2021� an� Investigation� into� the� death� of� John� Abrahams� (Jack) was commenced. The investigation concluded at the end of the inquest on 10 February 2023. I recorded a conclusion of Suicide.

CIRCUMSTANCES OF DEATH Jack Abrahams was 20 years old when he took his own life by means of self-ligature. J heard evidence that when Jack was 17 years old, he had received a six month course of lsotretinoin (brand name Roaccutane) for treatment of acne. The available evidence did not meet the standard required to show a causative link between the course of treatment and Jack�s suicide.

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

Suicide (from 2015)

Department of Health and Social Care

06/09/2024

2024-0482

Emilia Allsopp

South Manchester

Secretary of State for Health and Social Care

On 17th January 2024 I commenced an investigation into the death of Emilia� ALLSOPP. The investigation concluded on the 29th July 2024 and the conclusion was one of Narrative: Died from natural causes exacerbated by the� complications of an accidental fall. The medical cause of death was 1a) Lower Respiratory Tract Infection on the background of Left Acetabular fracture II)� Dementia, Frailty, Ischaemic heart disease, Congestive cardiac failure.

Emilia Allsopp had dementia, congestive cardiac failure and ischaemic heart� disease. She had an accidental fall at the care home where she lived. Initially a� fracture was not diagnosed from the x rays. However the following day her pain resulted in her returning to hospital and the fracture being identified. Surgical� intervention was deemed inappropriate with her comorbidities. She was�treated conservatively. Due to her limited mobility she developed a lower� respiratory tract infection when in conjunction with congestive cardiac failure� led to her respiratory function being significantly compromised. Her cardiac� function was also further compromised by the stress of the fall, fracture and� pain. She deteriorated and died at Tameside General Hospital on 15th January 2024.

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

Community health care and emergency services related deaths

Department of Health and Social Care

26/03/2023

2023-0104

Jordan Clare

Manchester South

Secretary of State for Health and Social Care

On 1st September 2020, an investigation was commenced into the death of Jordan Peter Clare, aged 22 years. The investigation concluded at the end of the Inquest on 14th October 2022. The conclusion of the inquest was misadventure in that that he died of hypoxic brain injury as a result of suspension by a ligature in a state of distress at an unresolved housing issue.

Mr Clare had diagnoses of ADHD, attachment and conduct disorder and suffered from anxiety and depression. He had historically been addicted to Class A drugs and this led him into conflict with the criminal law and with his family which had resulted in a restraining order which restricted contact with his family and periods in custody. He had significant support from a number of sources: he was supervised by the probation service and the police �Spotlight� team; he was working with Mosaic � an organisation who assist with drug misuse; the local authority Leaving Care team provided assistance on a voluntary basis as he was over 21 years old. The local authority housing organisation provided him with the tenancy of a flat in Marple and as part of that tenancy, he had an Offender Support Worker who assisted him. He had regular contact with his General Practitioner. � Notwithstanding the involvement of the various agencies there was no single individual or agency responsible for the co-ordination of the package of care, support and resources. Whilst there was sharing of information between some individuals involved, it was not structured, formalised or supervised. In practice, the Housing Offender Support worker, whose role did not require any formal social work or mental health care qualifications became the person upon whom Mr Clare relied. � An issue between Mr Clare and a neighbour developed over a period between June 2020 and his death on 26th August 2020, during the latter stages of which, he began to voice intentions to take his own life. On 26th August 2020, in a series of calls and messages to the police, Housing Officer and the Offender Support Worker, Mr Clare expressed extreme distress about the apparent lack of progress about the dispute with his neighbour and progressively, made threats to take his own life, which he did during a final call to the Housing Offender Support Officer by suspending himself by a ligature at his home.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:�[REDACTED] (on behalf of the family of Jordan Clare) via Leigh Day Solicitors and Stockport Homes Limited. I have also sent it to Head of Service for Safeguarding and Learning for Stockport Metropolitan Borough Council who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Other related deaths

Department of Health and Social Care

12/03/2024

2024-0138

Peter Beresford

Manchester South

Secretary of State for Health and Social Care

On 23rd October 2023 I commenced an investigation into the death of Peter Beresford, then aged 65 years. The investigation concluded at the end of the inquest on 23rd February 2024. The conclusion of the inquest was a narrative conclusion that Mr Beresford died as a result of acute myocardial ischaemia precipitated by coronary thrombosis as a consequence of atherosclerosis against a background of high blood pressure and high cholesterol. The medical cause of death being: 1 (a) Acute myocardial ischaemia Coronary thrombosis Coronary atherosclerosis

Peter Beresford suffered from high cholesterol and high blood pressure which both increase the risk of ischaemic heart disease. On 25th September 2023, Mr Beresford contacted the North West Ambulance Service complaining of chest pain at 05:38. His call was prioritised appropriately as a Category 2 call. When an ambulance arrived at his home address at 07:14 he was already deceased. The average response standard for Category 2 calls is within 18 minutes and attendance is within 40 minutes nine out of ten times. A post-mortem examination revealed that Mr Beresford died as a result of acute myocardial ischaemia precipitated by coronary thrombosis as a consequence of coronary atherosclerosis. � The Inquest heard that the North West Ambulance Service was unable to meet average response standards due to resourcing levels and the fact that ambulances were unable to clear the region�s hospitals because of the long waiting times there. A level 2 incident plan was commenced as a result. � A number of measures have been undertaken by the North West Ambulance Service to address emergency response times including: Ongoing recruitment, The introduction of a Clinical assessment of category 3 cases rather than automatic ambulance allocation, Introduction of Hospital Ambulance Liaison Offers to assist ambulances to clear hospitals and reduce waiting time. � The inquest heard that waiting times across the North West region are still impacted by peaks in demand and problems clearing the regions hospitals despite the above measures.

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) 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

14/03/2024

2024-0143

Tobias Mannering-Jones

Manchester South

Secretary of State for Health and Social Care Secretary of State for Local Government Greater Manchester Integrated Care

On 22nd February 2023 I commenced an investigation into the death of Tobias Ryse Mannering-Jones. The investigation concluded on the 29th January 2023 and the conclusion was one of Suicide. The medical cause of death was 1a) Hanging.

Tobias Mannering-Jones was very vulnerable. He became homeless at the end of December 2022. He had no support network. He generally slept at the Hostel for homeless people in Tameside where he was exposed to abuse due to his sexuality, felt unsafe, and was in the company of people who were significantly greater users of hard drugs. � He had mental health issues dating back to his childhood trauma that were greatly exacerbated by his homelessness. He increased his use of drugs to cope with his deteriorating situation, he was also sexually exploited. � After he became homeless, he sought help for his spiralling situation. On 6th January he saw the mental health worker attached to his GP practice. Concerns regarding his vulnerability in the homeless accommodation were expressed. He spoke to that worker again on the 9th February at an appointment. His contacts with other agencies in the interim were not known of. � He was also seen by Pennine Care Mental Health Liaison after he went to A&E on 15th January, 17th January and 14th February 2023. He indicated thoughts of self-harm with a key issue being his homelessness and the consequential impact on his mental health, drug use and support network exacerbated by the fact he had no telephone or address. � He contacted CGL for help on 6th February 2023 to try and obtain help for substance misuse. Attempts to contact him for assessment were unsuccessful given his lack of a telephone. � He was under the care of the neighbourhood mental health team and had been offered support from the Big Life Group previously. He was still awaiting assessment for therapy. Contact ceased with them, and they were not involved in planning how his discharges from the acute hospital would be managed in the community. � Adult Social Care were contacted, by Tobias, asking for help on 8th February 2023. He was allocated a Social Worker on 14th February. Attempts to contact Tobias were unsuccessful due to his lack of telephone and homelessness. On 21st� February 2023 Tobias was found [REDACTED] at Portland Basin Marina. Police found no suspicious circumstances. Post-mortem examination included toxicology. He was found to have evidence of limited cocaine use and alcohol use in the hours prior to his death. He had last been seen alive the afternoon before. No concerns for welfare had been raised following him last being seen. � It is probable that had Tobias not been homeless, isolated and vulnerable and had there been a co-ordinated approach to supporting him he would not have taken his own life on 21st 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) Tameside Metropolitan Borough Council; 2) Pennine Care NHS Foundation Trust and 4) CGL (Change, Grow, Live), 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 of Health and Social Care | Department for Local Government | Greater Manchester Integrated Care

04/07/2024

2024-0413

Harry Dunn

Northamptonshire

Secretary of State for Health and Social Care � The Medicines and Healthcare Products Regulatory Agency

On 04 September 2019 I commenced an investigation into the death of Harry Peter DUNN aged 19.� The investigation concluded at the end of the inquest on 13 June 2024.� The conclusion of the inquest was: � Road Traffic Collision

The circumstances of the death are as follows: � � On 27 August 2019 at about 2030 hours there was a head on collision between a car driven by [REDACTED] an employee of the US Government who had not long been in the UK and whose husband worked out of the nearby RAF Croughton, and a motorcycle ridden by Mr Harry Dunn. The cause of the collision was that on exiting RAF Croughton [REDACTED] inadvertently moved onto the incorrect side of the B4301 rural road and travelled about 350 meters on the wrong side of the road prior to the head on collision with Mr Dunn, who was on the correct side of the road travelling out of the village of Croughton. � Mr Dunn suffered catastrophic injuries including fractures to all four limbs, some of which were open in nature and a fracture to his pelvis with the concomitant severe internal blood loss commonly associated with such serious injuries. � He was attended to by an advanced medical team including a Consultant Anaesthetist and Critical Care paramedics and then conveyed to hospital where he died shortly after arrival.

I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy of this report to West Northamptonshire Council, Northamptonshire Police, to the Chief Executive of East Midlands Ambulance Service and the solicitors on behalf of [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 | Hospital Death (Clinical Procedures and medical management) related deaths � This report is being sent to: Department of Health and Social Care | The Medicines and Healthcare products Regulatory Agency

28/06/2023

2023-0216

Hilary Thomas

Birmingham and Solihull

Secretary of State for Health and Social Care University Hospitals Birmingham NHS Foundation Trust

On 10 November 2022 I commenced an investigation into the death of Hilary THOMAS. The investigation concluded at the end of the inquest . The conclusion of the inquest was: � Died from an ischaemic bowel which went undiagnosed when she attended hospital for a second time on 29/10/22.

The deceased attended Birmingham Heartlands Hospital emergency department on 28/10/22 with intermittent abdominal pain for 24 hrs. She was known to suffer from constipation and diverticulitis, hypertension, arthritis and had a previous hysterectomy. All tests were normal and she was reviewed by the OPAL team at 12.15 when she was noted to be pain free so she was discharged home at 15.15. She reattended the emergency department on 29/10/22 and was referred to the surgical team who reviewed her at 11.30. She complained of colicky abdominal pain and was passing wind but had not had bowels open for 4 days. She was complaining of severe pain but had normal observations and the initial diagnosis was acute diverticulitis. However the doctor was contemplating CT scan but incorrectly decided to wait for blood test results before proceeding. Due to workload the doctor came to review blood tests results at 20.00 but which time she had self discharged. These showed a slightly raised white cell count however the clinical decision at time was that she did not need to be recalled. During this attendance no clear plan was set out in the records about how to proceed with her care and the extent of her pain coupled with reattendance was not identified as indicating she was a high risk patient and her case was not escalated for consultant review. On balance a CT scan should have been arranged at this time which would have identified the condition and provided an opportunity for earlier surgery. She represented on 30/10/22 shocked and profoundly unwell with suspicion of an ischaemic bowel which was confirmed on CT scan and found to be due to adhesions constricting the bowel from previous hysterectomy surgery. She was rushed to theatre where the ischaemic bowel was resected; however, she failed to recover and sadly passed away on 31/10/22. Had her condition been identified as it should have been on 29/10/22 she would have likely survived emergency surgery. � Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a Sepsis and Multiorgan Failure 1b Ischaemic bowel, Small bowel volvulus secondary to adhesions (operated)

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mrs Thomas�s family 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 This report is being sent to: Department of Health and Social Care | University Hospitals Birmingham NHS Foundation Trust

10/02/2023

2023-0052

Celia Sanderson

Manchester South

Secretary of State for Health and Social Care and NHS England

On 12th July 2022 I commenced an investigation into the death of Celia Sanderson. The investigation concluded on the 12th January 2023 and the conclusion was one of Narrative: Died from injuries sustained in a road traffic collision where there was a delay in identifying the severity of the injuries sustained. The medical cause of death was 1a) Acute Myocardial Infarction; 1b) Multiple Injury, Acute Bilateral Subdural Haematomas; 1c) Road Traffic Collision

Celia Sanderson was involved in a Road Traffic Collision. She was then taken to Wythenshawe Hospital. There was a delay in triage due to demands on the Emergency Department. Triage did not pick up on her being a potential silver trauma case. A CT scan was not ordered at that time. She was triaged to be seen within 1 hour. Due to demands on the Emergency Department she was not seen by a clinician until approximately 6 hours after triage. This was not a senior clinician assessment due to staffing levels and demands on the department. The junior doctor found no significant injuries but asked for a more senior review. This was delayed due to the workload demands on the middle grade doctor. On assessment the middle grade doctor identified a CT scan was required. The CT scan was requested at 04.21. The scan was reviewed by a clinician at 7am before the radiology report itself was available. The actual report was delayed due to workload demands on the radiology registrar. It was identified that she had severe injuries from the road traffic collision and a transfer to a major trauma centre was required. Celia Sanderson began to deteriorate whilst further tests were undertaken and awaiting transfer. The further tests identified she had also sustained significant neurological damage from the road traffic collision. She continued to deteriorate and had an acute myocardial infarction. She died at Wythenshawe Hospital before she could be transferred.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely�[REDACTED] on behalf of the Family and [REDACTED] on behalf of Manchester University 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.

Road (Highways Safety) related deaths | Hospital Death (Clinical Procedures and medical management) related deaths

Department of Health and Social Care

06/04/2023

2023-0117

Alexandra Briess

Berkshire

Secretary of State for Health and Social Care, 39 Victoria Street, London, SW1H 0EU.UK Fatal Anaphylaxis Registry. Medicines and Healthcare Products Regulatory Agency, 10 South Colonnade, London E14.

CIRCUMSTANCES OF THE DEATH Alexandra was born on 3rd January 2004. She was 17 at the time of her death. The key facts in this case are as follows: ������� Alexandra had no significant past medical history. ������� She underwent an uneventful tonsillectomy on 22nd May 2021. ������� After returning home, she suffered post-operative bleeding and required further surgery. ������� The second operation was carried out on 30th May. ������� When the anaesthetic was administered on 30th May, Alexandra deteriorated suddenly and suffered a cardiac arrest. ������� A large number of clinicians were involved in trying to assist Alexandra, but tragically, she died at the Royal Berkshire Hospital in Reading on 31st May 2021. ������� There are no concerns about her clinical management. The most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium, a drug which she had not had before.

CORONER�S CONCERNS Background This is not new territory. Several coroners have raised concerns similar to mine. Those listed below are simply the cases where coroners have sent Regulation 28 reports. There may well be others. � Previous cases include : � 1.��� In the case of Shante Turay-Thomas (who I believe was 18 at the time of her death), the Senior Coroner for Inner North London stated: � �The issues within this Prevention of Future Deaths report are predominantly national issues, but I heard at inquest that there is no person with named accountability for allergy services and allergy provision at NHS England, or the Department of Health as a whole.� 2.����� In the case of Robin Bousquet (who I believe was 14 at the time of death), the Coroner for Inner South London stated in a Regulation 28 Report to Prevent Future Deaths: � �In my opinion action should be taken to consider establishing a national reporting system which includes timely reporting to local authority and FSA and maintenance of a register of fatalities and their investigations, and consideration be given to investigating the feasibility of wider access to AAIs. I believe that the organizations would wish to learn of the circumstances of this death and are in a position to facilitate a collaborative process to mitigate or prevent future deaths.� � 3.����� In the case of Ms Celia Marsh (who I believe was 42 at the time of her death), the coroner touched on many of the issues I will refer to in this report. She stated the following: � �Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this, changes are required. � In relation to the Food Standards Agency, the UK Health Security Agency, and the Department of Health and Social Care: ������� To establish a robust system of capturing and recording cases of anaphylaxes, and specifically, fatal and near-fatal anaphylaxis� ������� Such a system could involve, mandatory reporting of anaphylaxis presenting to hospital analogous to the current system for notifiable diseases� by registered medical practitioners have a statutory duty to notify the �proper officer� at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the State of Victoria in Australia, and allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate public health risk.� � Alexandra�s case It seems clear to all coroners in these cases, and those involved in this area of medical expertise, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research. � Appropriate organisations already exist, and there is a lot of goodwill towards improving understanding in this area. It does however require national leadership and �joining up� of these organisations. � The matters of concern are as follows: � 1.��� I have tried to make my list of issues clear and succinct. Paragraph 2 below sets out the crux of this ongoing risk. � 2.��� There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding. In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach. � 3.��� As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases. UKFAR has indicated that they would be prepared� to take on the role of receiving these reports (to avoid duplication for� reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the MHRA, where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider. 4.��� Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed. 5.��� Information sharing amongst the organisations referred to in this report should be straightforward. Confidentiality constraints are important, but not the same in the case of a deceased person as they are for a living person. I believe that a confidential advisory group has already started to consider this matter. 6.��� Consideration of including contact details for the UKFAR in algorithms used by doctors attempting to resuscitate patients � so that there is a clear requirement for referral to UKFAR in the event of an unsuccessful resuscitation. This is currently being considered by the Resuscitation Council UK. � For my part, I have taken the following steps to increase awareness in the work that I do : � 1.��� I have taken responsibility for making my fellow coroners aware of the existence of UKFAR and circulated guidance to them to use in anaphylaxis cases. � 2.��� The Royal College of Pathologists is reviewing their guidance, and I intend to circulate interim guidance which coroners can send to their pathologists, pending this more official guidance. � I will also send all coroners nationally a guidance note to use for their local police forces in gathering appropriate evidence at the scene of a likely anaphylaxis case.

6 April 2023 Mrs Heidi J Connor, HM Senior Coroner for Berkshire

Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department of Health and Social Care | UK Fatal Anaphylaxis Registry | Medicine and Healthcare Products Regulatory Agency

26/02/2023

2023-0041

Katie Wilkins

Liverpool and Wirral

Secretary of State for Health and Social Care, Mr S Javid

On 01 July 2021 I commenced an investigation into the death of Katie Julia WILKINS aged 14. The investigation concluded at the end of the inquest on 26 May 2022. The conclusion of the inquest was that: � Katie was a 14 year old girl with a diagnosis of Acute Promyelocytic Leukaemia (APML) which is known to have an associated and serious coagulopathy. Management and the treatment of the APML must also include treatment and management of the associated coagulopathy, that being a critical and basic element of the treatment of the condition. Katie initially presented at Warrington Hospital for concerns around pain and soreness in her vaginal area.� She was diagnosed with a suspected labial abscess.� Katie had no medical history of note and was not sexually active, this being an unusual presentation. Katie presented to the hospital initially on the 1/7/20 and subsequently on 5 further and separate occasions on the 2/7/20, 7/7/20, 14/7/20 and 15/7/20 and on the 21/7/20, each time relating to the unresolved labial abscess, pain and with tachycardia, including latterly with spiking temperatures. Despite the presentation on the 14/7/20 being the 4th occasion in which she was noted to be tachycardic, that increasing severity in the abscess was noted and there was an identified need for surgery the following day, no clinical review was undertaken or pre-operative blood tests directed. Those investigations were a basic part of the medical attention and treatment Katie required at that time. On the 26/7/20 Katie collapsed at home and was presented again to Warrington Hospital, at this time blood tests were instigated. Katie had a suspected diagnosis of APML and once stabilised, was transferred to Alder Hey Children�s Hospital where she received a formal diagnosis and treatment for the APML and also the associated coagulopathy. The associated coagulopathy poses a significant risk of bleeding in APML patients and as such Katie�s treatment plan was complex and multifaceted and involved the use of fibrinogen concentrate amongst other blood products, with regular blood testing to monitor the blood levels.� Katie suffered a drop in fibrinogen levels on the 28/7/20 at 10pm and further falling levels were noted in the early hours of 29/7/20. Katie�s plan of treatment for her coagulopathy was for treatment with fibrinogen concentrate when her levels fell below 1. Despite her initial falling levels from 28/7/20, the fibrinogen concentrate was not administered in accordance with treatment plan once the blood results were known. Further on the 29/7/20 at around 9:30am Katie was urgently prescribed further fibrinogen concentrate to be given immediately.� Also on or around 9:30am, she also complained of a mild headache which was more likely than not evidence of the commencement of a intracerebral haemorrhage when taken with her low fibrinogen levels. Despite fibrinogen concentrate having been part of Katie�s treatment plan when fibrinogen levels fell below 1, and the same being advised for immediate administration at 9:30am that day, that being a basic part of the medical treatment Katie required to manage her condition, it was not administered and Katie suffered a catastrophic intracerebral haemorrhage. Katie was taken urgently for a decompressive craniectomy surgery with evacuation of the intracerebral haemorrhage. Despite the surgery on the 29 July 2020 Katie did not recover. Having been assessed and undergoing an MRI scan, Katie was found to have no brain activity and deemed brain stem dead, she was subsequently extubated and passed away on the 31/7/20.

CORONER�S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. � The MATTERS OF CONCERN are as follows: The inquest has highlighted an ongoing concern that Oncology Consultants will continue to be the lead Consultants for care of APML patients at Alder Hey Trust. The most significant risk of death in such patients is due to the risk of serious bleeding due to the associated and significant coagulopathy. Coagulopathy management should be led by a Haematologist to prevent future deaths due to this issue, that was recognised by a Consultant Haematologist who gave evidence to the inquest as a expert witness and as supported by a leading Haematologist at the Trust. There is nationally a shortage of Haematologists which leaves Alder Hey Trust without resources available to them to address this matter of concern or to recruit.

Dated: 26 May 2022 Kate AINGE Assistant Coroner for Liverpool and Wirral

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

Department of Health and Social Care

29/05/2024

2024-0297

Christopher MacGillivray

Newcastle and North Tyneside

Secretary of State for Justice [REDACTED]

On 19 October 2021 I commenced an investigation into the death of Christopher Alistair MACGILLIVRAY. The investigation concluded at the end of the inquest . The jury reached the following conclusion: � Christopher MacGillivray hanged himself by a ligature whilst under the influence of a 3 combination of Cocaine and alcohol. 1a Pressure on the neck 1b Hanging

Christopher Alistair MacGillivray had a long history of Drug and Alcohol issues and attempted suicide and self-harm complicated by the impact of a brain injury sustained in an assault in 2018. He was charged with criminal offences for which he was granted conditional bail and subject to a curfew. He was also managed by Probation Service under the terms of a Probation Order for an earlier offence. � On 9th October 2021 he was remanded in custody to HMP Durham for breach of his curfew. His arrest was precipitated by a member of the public who contacted police raising concerns for his welfare having seen him standing on the edge of a bridge. � On 10th October Christopher Alistair MacGillivray reported thoughts of self-harm to prison staff. � Suicide and self-harm prevention procedures known as ACCT (Assessment Care in Custody and Teamwork) were implemented. � He was placed on hourly observations. � On 12th October Christopher Alistair MacGillivray was released on bail by Magistrates following a hearing via remote link. The ACCT was then closed. � There was no direct communication from Prison to his Probation Officer/Manager in respect of his release and his risk of self-harm. � On 14th October Christopher Alistair MacGillivray was found hanging in his home where his death was confirmed.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Christopher Alistair MacGillivray, Sodexo, Probation Service and Cumbria, Northumberland Tyne & Wear Trust (CNTW). � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) | Alcohol, drug and medication related deaths This report is being sent to: Ministry of Justice

07/05/2024

2024-0248

Colin Waterhouse

Manchester South

Secretary of State for Levelling Up, Housing and Communities

On 12th September 2023 I commenced an investigation into the death of Colin Waterhouse. The investigation concluded on the 2nd April 2024 and the conclusion was one of suicide. The medical cause of death was 1a) Hanging.

Colin Waterhouse was diagnosed with pancreatic cancer and given indication that the average survival time was 8 � 10 months. Palliative treatment was offered. He was referred to cancer support services. He found his accommodation in social housing difficult and it impacted his mental health significantly whilst he was also struggling to deal with his cancer diagnosis. He became eligible to bid for alternative properties as a consequence of his health. He struggled to make bids and navigate the complex system. This was exacerbated by a shortage of social housing. On 11th September 2023 he was found suspended by a ligature [REDACTED].

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

Suicide (from 2015) This report is being sent to: Ministry of Housing, Communities & Local Government

24/12/2024

2024-0709

Daniel Isaacs

Nottingham and Nottinghamshire

Secretary of State for Transport

On 16th October 2024 an inquest was opened into the death of Daniel Isaacs, aged 41. The inquest concluded on 16th�December 2024. I made a determination at inquest that he died as a result of a road traffic collision.

Daniel Isaacs was travelling along Carlton Road, Nottingham, when he lost control of his electric scooter. He was dismounted from the vehicle and collided with the road surface causing a serious head injury. He was not wearing a helmet at the time of his collision. He received first aid and treatment at hospital but died as a result of the head injury on 24th May 2024�at the Queen�s Medical Centre in Nottingham.

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

Road (Highways Safety) related deaths

Department for Transport

20/12/2024

2024-0698

David Haw

Dorset

Secretary of State for Transport Chief Executive Officer of the Royal Yachting Association (RYA)

On 16th May 2022 I commenced an investigation into the death of David John Haw, born on the 9th September 1997 who was, therefore, aged 24 years at the time of his death. The investigation concluded at the end of the inquest on 17th December 2024. The medical cause of death was: � Ia Drowning � The conclusion of the Inquest was unlawful killing.

On the evening of the 1st May 2022, David attended a prize giving event at Poole Yacht Club, Poole as part of Poole Regatta having been a member of crew for the vessel Off Beat. At just after midnight on the 2nd May 2022 having left the event, David as a passenger with others, boarded on a ridged hull inflatable boat (RHIB) called Fargo, which was a support boat being used for another boat at Poole Regatta. The RHIB travelled to Poole Quay Boat Haven, dropped 3 people off and left there at 0.15 hours at which point David was sat in the bow of the deck of the vessel. At 0.18 hours RHIB Fargo collided with Diver Buoy in Poole Harbour, Poole causing David to be thrown out of the vessel into the water. He disappeared and was later recovered from the water on the 14th May 2022, about 100 metres from Diver Buoy. At the point of the collision the RHIB was being helmed at excessive speed, approximately 30 knots, which is 3 times the speed limit for the waters, which was not a safe speed. The helm of the vessel did not hold appropriate qualifications to helm the boat at night and was under the influence of alcohol at the point of the collision. There was no pilotage plan for the journey, nor was there a safety briefing or offer to passengers to use lifejackets. There was no challenge by the helm to David about his position sitting in the bow of the deck. The helm used a navigation app on a phone which is not an approved method of navigation and would negatively impact on night vision. The helm failed to keep a proper look out.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: David�s Family Morgan Smith The Maritime and Coastguard agency � � I have also sent it to the following who may find it useful or of interest: � The UK Harbour Masters Association The British Ports Association UK Major Ports Group The National Water Safety Forum The Royal Life Saving Society Local Government Association � 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 | Royal Yachting Association