Inquests (PFDs)

20/11/2024

2024-0642

Dorothy Nias

Cornwall and the Isles of Scilly

Secretary of State for Transport Great Minster House�� Horseferry Road�� London�� SW1P 4DR�� Chief Executive�� Driver and Vehicle Licensing Agency Longview Road�� Morriston�� Swansea

On 9 November 2023, I commenced an investigation into the death of� Dorothy Jennifer Nias aged 90. The investigation concluded at the end of the inquest on 20 November 2024.�� I recorded the cause of death as I a) Lower Respiratory Tract Infection I b) Multiple Injuries�� 1 c) Road Traffic Collision II Frailty�� My conclusion as to the death was as follows: Road Traffic Collision

On Wednesday 14 June 2023 Dorothy Nias was driving an automatic� transmission vehicle owned by her since April 2017. She was driving� downhill on a dual carriageway section of road on the A39 at Devoran,� Truro approaching a roundabout with a speed restriction of 50mph. On� approach she moved into lane 2 continuing at speed before mounting�the roundabout, travelling across to the other side where she hit a lamp� post causing her vehicle to rotate and land in the opposite direction of� travel. The lamp post then fell but did not cause any further injury or� incident.� Miss Nias later stated that she had confused her brake and� accelerator pedals and, in an attempt to prevent hitting the vehicles in� front of her in lane 1, she moved to lane 2. There was no evidence of�any vehicle defect. There were no other vehicles involved and no� evidence of any other feature that caused or contributed to the collision. It was a dry and fine day.� As a result of the collision she sustained� multiple injuries and did not regain her mobility with a gradual� deterioration in her condition. She died on 6 November 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� Miss Dorothy Nias� family. I have also sent it to: Chief Constable of Devon and Cornwall Police � Forensic Collision Department� I am also under a duty to send the Chief Coroner a copy of your� response and all interested person 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.

Road (Highways Safety) related deaths

Driver and Vehicle Licensing Agency | Department for Transport

05/10/2023

2023-0369

Jessica Baker

Liverpool and Wirral

Secretary of State for Transport The Rt Hon Mark Harper MP Secretary of State for Education The Rt Hon Gillian Keegan MP

INVESTIGATION � On 05 October 2023 I commenced an investigation into the death of Jessica Evie BAKER aged 15. The investigation has not yet concluded and the inquest has not been heard.

Jessica was a 15 year old pupil who was a passenger travelling on the school coach from her home address in Chester to West Kirby Grammar School when the bus was involved in a one vehicle road traffic collision. Jessica and the coach driver died in the incident. There were over 50 students on board. At approximately 08:03 hours a road traffic collision involving this bus has taken place on the northbound carriageway of the M53 motorway between junctions 5 and 4. This is in the Eastham area of Wirral, Merseyside. The motorway at this point is a generally straight stretch of road with three lanes and a hard shoulder in each direction that is separated by a corrugated metal barrier on the central reservation. The collision occurred on the northbound carriageway and this is bordered by a sloped embankment to the nearside that contains shrubbery, trees and general overgrowth. The coach was travelling in lane 2 of 3 (the central lane) and passing another vehicle to its nearside. Having completed this passing manoeuvre, the coach began to move back into lane 1 of 3 (the left hand lane). However, it continued to veer gradually towards the nearside. It has crossed the hard shoulder before leaving the carriageway altogether, where it has entered the embankment and into the overgrowth. It has continued forwards and up the embankment before striking a large tree which has then resulted in the vehicle lurching to its right before barrel rolling down the embankment and back onto the carriageway coming to rest predominantly in the hard shoulder. CCTV from within coach shows that prior to the collision, The driver slumps/falls to his left hand side prior to the vehicle leaving the motorway and the collision occurring. During the course of the vehicle rolling down the embankment, a passenger on the coach, Jessica Evie Baker, was partially ejected from the vehicle and become trapped underneath it. This has resulted in catastrophic instantly fatal injuries. Jessica was pronounced deceased at scene by attending paramedics at 09.01. The driver was also pronounced deceased at scene at 08:50. A Roads Policing investigation is ongoing � the court has directed evidence to be obtained and will review the investigation on 20th March 2024

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to 1.���� Carvers Coaches 2.���� Merseyside Police 3.���� Bereaved families who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

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

17/10/2024

2024-0560

Wilfred Fitchett, Jevon Hirst, Hugo Morris and Harvey Owen

North West Wales

Secretary of State for Transport, [REDACTED] The Department for Transport Project Manager, Environment Department, Cyngor Gwynedd Council Landowner Clough Williams-Ellis Trust

On 27 November 2023 I commenced an investigation into the deaths of Wilfred John Fitchett, Jevon Alexander Hirst, Hugo Oliver Morris and Harvey Graham Owen. The investigation concluded at the end of the inquest on 16 October 2024.� A Road Traffic Collision conclusion was recorded with deaths for all four young men resulting from drowning.

The circumstances of the death are as follows :- � Hugo Morris was aged 18 at the time of his death. On 19 November 2023 he was driving a motor vehicle and carrying three passengers who were aged 17 (Wilfred), 16 (Jevon) and 17 (Harvey), along the A4085 Garreg, Llanfrothen having been on a camping trip when the motor vehicle in question veered onto the nearside grass verge and entered into a water-filled drainage ditch which led to the deaths of all four young men, where the existing signage would not have given adequate warning of the upcoming bend. The motor vehicle with the four young men was not found until 21 November 2023.

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

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

Department for Transport | Cyngor Gwynedd Council Landowner | Clough Williams-Ellis Trust

26/01/2023

2023-0028

Matthew Dale

Liverpool and Wirral

Secretary of State for the Department of Health and Social Care, Mr S Barclay

On 07 January 2021 I commenced an investigation into the death of Matthew Harter DALE aged 43. The investigation concluded at the end of the inquest on 25 January 2023. The conclusion of the inquest was that: � Matthew was a 43 year old male with multifaceted and complex needs. He had significant learning disabilities, autism, visual impairment and bi-polar affective disorder. Matthew lacked capacity to make decisions for himself and was the subject of DOL (deprivation of liberty) safeguards. From an early age Matthew had a propensity to place non-food items into his mouth which presented as a choking risk, these risks continued throughout adulthood but were cyclical in presentation. Matthew resided in sheltered accommodation from 2008 which was deemed no longer able to meet his needs due to an escalation in behaviours which included in part, ingestion of non-food items on 4 separate occasions in short succession in 2010. In February 2011 Matthew moved to Vancouver House. Warrington borough council were the commissioning body for Matthews care and placement until September 2018 when he became eligible for Continuous Health Care funding and the Integrated care board took over that role. Matthew was known to Vancouver House managers on his transition of care to Vancouver House as posing a risk of ingesting non- food items with review in September 2011 noting that Matthew had settled in his placement and the risks associated with that were significantly reduced. Vancouver House changed ownership and with that a change of managers who at the time of Matthews death were not aware of any risks of Matthew ingesting non-food due to no ongoing identification of such risk or assessment of it since November 2011. There were no further incidents of Matthew ingesting non-food items from 2011 until 2020. As part of Matthews multifaceted and complex care plan, there was a system of reviewing Matthews care provision and a protocol for escalation of concerns around safeguarding or meeting his care needs to the agencies and professionals involved in his care. Regular and statutory reviews of Matthews care provision and placement were undertaken. No concerns were raised about risks to Matthew of the ingestion of non-food items or the provision of his care needs. There was a clear misunderstanding between commissioning authorities about Matthew�s care needs and the funding and provision of care, commissioners understanding Matthew requiring constant supervision with a provision for 1:1 care 8am-8pm and ongoing waking hours supervision outside of those hours as part of the funding package. The reality was Matthew was provided with 1:1 care 8am-8pm and after that time 1:1 care when eating and hourly observations thereafter that being the assumed regime of care by Vancouver House. On the 15/12/2020 and 26/12/2020 Matthew was noted to have accessed his incontinence pad and had on at least one occasion prior to death ingested part of it. Whilst some staff had an awareness of Matthews risk to put non-food items in his mouth, others did not. Whilst recorded in Matthews daily notes, these concerns were not properly escalated to senior management and this provided a missed opportunity for Matthew to have increased supervision levels on an urgent basis and until a multidisciplinary team meeting could be confirmed to reassess and consider his needs. Had the incidents on the 15 and 26 December have been properly escalated, Matthew would have been on 15 minute observations, he was in fact on hourly observations and when unsupervised Matthew placed a piece of his incontinence in his mouth and swallowed it. As a result, the piece of pad expanded with the saliva and became trapped in his airway. Staff at the home staff engaged backslaps which failed to dislodge the item in question, Matthew was then incontinent of faeces and concerns were turned to attending to his personal needs rather than the serious choking risk and Matthew was taken to his room during which no further attempts were made to dislodge the choking item until his personal care needs had been met. Thereafter abdominal thrusts were noted to be given but ineffective in part due to difficulties undertaking the manoeuvre due to Matthews size and also due it being unlikely that such actions would have in any event dislodged the item. Emergency services were contacted and upon Matthew becoming unconscious CPR was commenced, taken over by paramedics upon arrival. Paramedics were able to remove the piece of pad from Matthews throat by forceps. Matthew died from placing the piece of pad in his mouth during a period in which he was not supervised and in part contributed to by missed opportunity to increase supervision to meet Matthews identified needs.

Misadventure in part contributed to by a missed opportunity to increase supervision to meet Matthews needs

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

Care Home Health related deaths

Department of Health and Social Care

05/04/2024

2024-0186

Tracey Farndon

Birmingham and Solihull

Secretary of state for Health University Hospitals Birmingham NHS Foundation Trust

On 9 November 2023 I commenced an investigation into the death of Tracey Ann FARNDON. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Natural causes contributed to by a delay in diagnosis and treatment of sepsis. Her death was contributed to by neglect.

Tracey was admitted to the emergency department at the Queen Elizabeth Hospital at 02.17 on 25/04/23 with a 3 day history of diarrhoea and vomiting and severe lower back pain radiating down the buttock and right leg. Initial assessment was undertaken however her blood pressure could not be recorded due to it being very low and no NEWS2 score was calculated. It was not appreciated that Tracey likely had sepsis and no sepsis screen or treatment was given. Tracey was provided with pain relief but no further assessment or observations were undertaken until 07.20 when she was found to have a low blood pressure and a NEWS2 score of 6. She was moved to majors after 08.00 when she was noted to be very unwell. She was not reviewed by a doctor until 08.30 who suspected she was suffering from dehydration due to the diarrhoea and vomiting and fluids were administered but no sepsis screen was undertaken and no sepsis treatment was provided. She deteriorated rapidly with blood gases showing a severe metabolic acidosis. She went into cardiac arrest at 10.30 and sadly could not be saved. Post mortem showed evidence of severe pneumonia and a septic spleen. On balance she was likely suffering from severe sepsis when she was admitted to hospital and there were delays in diagnosing and treating this condition. The emergency department was overwhelmed with patients at the time of Tracey�s presentation which impacted on the care provided to her. � Following a post mortem the medical cause of death was determined to be: � 1a Septic shock � 1b Sepsis secondary to community acquired pneumonia

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

18/09/2024

2024-0501

Peter Jeffery

Somerset

Sedgemoor District Council Bridgwater House� King Square� Bridgwater� Somerset� TA6 3AR

On the 13th November 2023 I commenced an investigation into the death of Peter Ivor Jeffery. The investigation concluded at the end of the inquest on the 10th September� 2024. The conclusion of the inquest was death by Misadventure.� The medical cause of death was: Ia) Drowning.� I record that �Peter Ivor Jeffery, aged 68, jumped into the water by the jetty at� Burnham on Sea beach around 3.30pm on the afternoon of Sunday 29th October� 2023 to assist a stranger and her dog who were in distress in the water. He was fully clothed in jeans, trainers and a snug boiler suit, which negatively impacted on his� ability to swim. Peter got caught in a riptide and was unable to be rescued by those� on the beach. This section of water is known to be particularly treacherous.� Peter�s� body was discovered near to Stert Island on the 12th November 2023.�

Peter Ivor Jeffery (�Peter�) was a relatively strong, fit and healthy 68 year old man. On the afternoon of the 29th October 2023, Peter went to the jetty at Burnham-on-Sea,� somewhere that he�d been to previously and was reasonably familiar with, having� been there before at different times and so he had experienced that part of the coast� in different weather and seasonal conditions; although he had never been in the�water, only observing the tide from the shore, which was something that he liked to�do.� Whilst at the jetty on this occasion, Peter noticed a woman (a complete stranger to� him) and her dog who were in difficulty in the water; the dog had entered the water� and got into difficulty and so its owner had gone in after it, also finding herself in� difficulty. The lady had never been to this location before and was not familiar with it as she resides in another part of the country.� Peter, without hesitation, jumped into the water to try and help but was immediately� overcome by the water.� He went under. There were differing witness account as to whether or not he resurfaced shortly after entering the water but, if he did, it was not more than once.� �� An off-duty emergency service personnel and the specialist rescue service personnel (who by coincidence were at the scene) both declined to enter the water without� appropriate safety measures as they were aware of the dangers posed by the current and tip tides in this area and were aware that they would have been putting their own� lives at risk by doing so.�� The specialist rescue personnel gave evidence from his eighteen years of experience of this part of the coastline that the tide/under-current can sweep a grown man away� in seconds as the water has the power to drag them under and there is no time to do� anything about it, it doesn�t matter how strong an individual is or how competent they� are in the water.� Peter was not seen again and a coastal search was coordinated to try and locate his body. He was eventually located some two weeks later near to Stert Island.�� I admitted pictorial evidence showing the signage that is currently displayed on the walls and railings at the entrance to the Jetty. These showed or conveyed the� following messages:� (i) A warning about the potential risk posed by the sinking sand; (ii) A warning not to park a vehicle on the jetty; (iii) A warning that the gates to the jetty may be closed during high tide; (iv) Signs displaying varying warning triangles; this does include warnings about the� mud, sinking sand and risks posed by the tide. Evidence was admitted by the rescue personnel that this area of water is known to be notorious amongst locals.� I heard that signage and/or flags are displayed at the beach to advise against� swimming in certain stretches of that part of the coast, but that these are only� displayed in peak/summer season, and this incident happened out of season and so no flags or additional signage was in place.

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

Other related deaths

Sedgemoor District Council

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25/05/2022

2022-0418

Ryan Taylor

Cornwall and the Isles of Scilly

Service Director for Transport, Cornwall Council Project Manager for Safety, Cormac

On Monday 18th March 2019 I commenced an investigation into the death of Ryan Gareth TAYLOR. The investigation concluded at the end of the inquest on 6th May 2021. The conclusion of the inquest was as follows � Medical cause of death � 1(a): Multiple� Injuries. 1(b): Road Traffic Collision � The four questions � who, when, where and how � were answered as follows � � Ryan Gareth TAYLOR died on 16th March 2019 at A390, Coliza Hill, St Austell, Cornwall from trauma sustained in a road traffic collision after he lost control of his vehicle due to aquaplaning in heavy rain. � Conclusion � Road Traffic Collision

Ryan died when his Jaguar XF suddenly veered across the road and collided with another vehicle, a Mazda MX5, which was travelling in the other direction. Ryan was pronounced dead at the scene by attending Paramedics. The driver of the Mazda, sustained life changing injuries. � The collision occurred during the hours of daylight. Visibility was poor due to heavy rain and poor light conditions. The road surface was very wet. The sky was overcast with heavy cloud. The court heard the following evidence in connection with road drainage at the scene. Coliza Hill Slip Road There are gullies on the south-eastern side of the slip road. These were clear of debris at the time of inspection, but due to the steep hill, under conditions of exceptional rainfall, it is possible that a fast flow of water may overwhelm the existing gully grid capacity. A change of camber takes water falling on the lower end of the slip road onto the main carriageway, although this is always likely to be the minor flow. A recommendation has been made by Cormac to enhance the size of or provide additional gully grids for better capture of water above the changeover point, and to minimise surcharge at the lower end of the slip road. A390 Coliza Hill (eastbound description) The A390 drains to the north-western side of the road in accordance with standard super elevation of the carriageway for the left-hand bend, until a short distance above the entrance to the layby, when the changeover occurs and water begins to drain along the road and then to the south- eastern side. Gullies intended to capture this water before the changeover point were fleeced over with debris from adjacent trees at the time of site visit. It is not known if this was the case at the time of the collision. Drainage standards have altered since the design and construction of the original A390 improvement, since adopting higher inundation calculations due to anticipated climate change and other factors. Cormac & Cornwall Council are investigating the capacity of the underlying drainage system and outfalls with a view to increasing both the size and number of gullies to improve capture and system resilience. � The Inquest findings of fact were as follows � ������� There was no evidence of excessive speed or unsafe driving by Ryan at the time of the collision or in the period leading up to the collision. Indeed, there was evidence from other road users that Ryan was driving appropriately for the conditions. � ������� There was meteorological evidence a large band of heavy rain passing over the location of the collision and that just prior to the collision rainfall of 20 � 30 mm was recorded. Eyewitnesses referred to the driving conditions as being poor due to the heavy rain and excessive water. � ������� Examination of road drainage at this location revealed that during periods of heavy rainfall surface water from the adjoining road known as Coliza Hill is likely to converge with surface water on the A390 in the vicinity of where the Jaguar initially lost control. � ������� Ryan was driving a rear wheel drive car. The evidence of the forensic collision investigator was that a rear wheel drive car is more likely to aquaplane in these circumstances than a front wheel drive car. � ������� The manner in which Ryan�s car crossed the carriageway was found to be consistent with a rear wheel drive car aquaplaning in wet conditions. The forensic collision investigator�s evidence was that Ryan would have had little or no warning of this sudden loss of control. � From these findings of fact driver error was ruled out. The cause of the collision was found to be the surface water from Coliza Hill converging with surface water on the A390 following heavy rain just prior to the collision. The inquest found that Ryan lost control of his car as he was traversing the converging surface water which had inundated the road at this point. This caused the rear tyres of his vehicle to lose traction with the road surface, either causing it to rotate and suffer a sudden and catastrophic loss of control such as that witnessed by other road users, or causing Ryan to over steer in an attempt to regain control, which would have resulted in the same consequences.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons. � Ryan�s mother. � I have also sent it to������ 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

Cormac and Cornwall Council

04/10/2024

2024-0532

Bryan and Mary Andrews

South Yorkshire West

Sheffield Health and Social Care NHS Foundation Trust

On 28 November 2022 I commenced investigations into the deaths of Bryan Andrews aged 79, and Mary Andrews aged 76. The investigation concluded at the end of the� inquests on 2 October 2024. The conclusion of the inquests was unlawful killing. The� medical cause of death was:� 1a. Multiple stab wounds.

On 27 November 2022 Bryan and Mary Andrews died at their home address of [REDACTED] due to multiple stab wounds inflicted by their adult son. Their son had epilepsy caused by an area of abnormal brain development in the right frontal lobe. He continued to have regular seizures despite the medication he was� taking.� He had a documented history of postictal psychosis. The Court heard his frontal lobe epilepsy created a risk around how he responded to experiences of postictal�psychosis.� His mental health had deteriorated significantly in the two years before his parents�died. Seven months before his parents died, he reported thoughts of wanting to kill someone.� In police interview, he admitted to killing his parents and attempting to end his own life by inflicting a knife wound in his abdomen.� He pleaded guilty to murder on the grounds of diminished responsibly and was sentenced to an indefinite hospital order.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� The family of Bryan and Mary Andrews. Sheffield Teaching Hospitals NHS Foundations Trust. [REDACTED], Consultant neurologist. [REDACTED], Domestic Homicide review author. � 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 | Mental health related deaths

Sheffield Health and Social Care NHS Foundation Trust

26/04/2023

2023-0136

Janet Smith

Leicester City and South Leicestershire

Silver Birches Care Home

On 31 March 2022 I commenced an investigation into the death of Janet SMITH aged 81. The investigation concluded at the end of the inquest on 24 April 2023. The conclusion of the inquest was Accidental death with a medical cause of death being given as: � 1a) Pneumonia 1b) Multiple Spinal Vertebral Fractures 1c) Fall � 2) Advanced Dementia, Frailty, Ischaemic Heart Disease

Janet Smith was an 81-year-old woman with a history of advanced dementia and ischaemic heart disease, who was found by carers on the floor following an unwitnessed fall in an unsafe environment at around 20.00 hours on 15 March 2022, at the Silver Birches care home, Leicester, where she was a resident. Although Mrs. Smith sustained no obvious physical injury, she complained of head pain the same evening and was taken by ambulance to the Leicester Royal Infirmary in the early hours of 16 March 2022, where she was diagnosed with spinal fractures. On a balance of probabilities, the injuries were caused by a high energy fall and in keeping with having fallen down the stairs. At the hospital Mrs. Smith was treated conservatively due to her age and dementia; she deteriorated over the following days and, after discussions with family members on 21 March 2022, she was placed on palliative care and died the following day.

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

Care Home Health related deaths This report is being sent to: Silver Birches Care Home

17/01/2024

2024-0034

Kane Boyce

Nottingham and Nottinghamshire

Sodexo (via their General Counsel) His Majesty�s Prison and Probation Service, The Rt Hon Edward Argar MP

Kane Christopher Boyce died by ligature asphyxiation on 3 October 2021, at HMP Lowdham Grange, Nottinghamshire, where he was detained as a serving prisoner. A coronial inquest into his death was opened on 23 November 2021. An inquest was resumed before a jury on 6 November 2023, concluding on 22 November 2023.

CIRCUMSTANCES OF DEATH � The following represents the findings of fact returned by the jury: � Kane Christopher Boyce (aged 41) was discovered inside his locked cell at 0150 on 3rd October 2021 with a ligature around his neck. Emergency first aid was provided by wing officers and healthcare prior to the arrival of paramedics. Kane could not be resuscitated, and he was declared deceased at 0223 on 3rd October 2021. His death occurred sometime between the hours of 0013 and 0150 on 3rd October 2021, a period of time he was not subject to observations. Kane was under the influence of alcohol at the time of his death. Kane obtained the alcohol from an unknown source during the day of 2nd October 2021, which was consumed throughout the evening in celebrations of this recent birthday. The level of alcohol found in his body has caused significant impact on Kane�s judgement and mood. Kane was prescribed an anti-depressant, which was not present in his toxicology report, which indicates that Kane had not taken his prescribed medication for at least five days prior to his death. Both of these factors combined contributed to this death. � The jury returned a narrative conclusion determining that � Kane�s death was not intentional He was intoxicated with alcohol which contributed to his death Three separate members of staff suspected Kane to be acting under the influence of alcohol when they spoke to him at 23.14 hours, 23.29 hours and 00.08 hours, respectively. Those staff all failed to adequately share information about Kane�s intoxication with colleagues. They further failed to open an �under the influence log� contrary to the local prison policy. This failing contributed to the circumstances of his death because the opening of a log would have necessitated a medical review with regular monitoring of his condition by healthcare over the following hours. Instead of following the policy on the night of his death, staff isolated the electricity supply to the sockets inside his cell in order to prevent him from playing loud music. The decision to isolate his cell from the electricity supply was not an authorised and approved prison action, and it was not supported by training or guidance for staff. Staff failed to consider Kane�s level of risk of harm or his wellbeing when isolating the electricity supply. Staff actively ignored Kane�s cell bell for long periods of time. The action of ignoring cell bells was not an authorised and approved prison action, and staff were not supported to do so with training and guidance. Again, staff failed to consider how this might affect his level of risk of harm or his wellbeing. The above failings more than minimally contributed to his death.

I have sent a copy of my report to the Chief Coroner and to the following: � The Interested Persons INQUEST Charity 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 | Alcohol, drug and medication related deaths This report is being sent to: Sodexo | HM Prison and Probation Service

26/06/2024

2024-0349

Michelle Moore

Somerset

Somerset Foundation Trust at Trust Management Office: Level 1, Yeovil District Hospital, Yeovil BA21 4AT National Institute for Healthcare and Clinical Excellence (NICE) at 2nd Floor, 2 Redman Place, London E20 1JQ and [REDACTED] NHS England [REDACTED]

On 31st October 2023 I commenced an investigation into the death of Michelle Patricia Moore. Michelle was 42 years old. The investigation concluded at the end of the inquest on 25th June 2024. The conclusion of the inquest was a short-form conclusion of Suicide. The medical cause of death was: Ia) Compression of the neck Ib) Suspension by a ligature

Mrs Moore had a lifelong history of anxiety and had difficulties in managing her emotions. She was unable to use distraction and de-escalation techniques taught to her by the mental health services as she was never able to �ground herself� to fully utilise them and any de-escalation was short lived. � In the 18 months prior to her death her mental health had noticeably declined. Mrs Moore herself could not identify any particular event, trigger or stressor for this when engaging with mental health professionals. � Mrs Moore had first contacted her GP back in November 2019 (aged 37) as she was concerned about the menopause. There were no further recorded consultations or investigations in this regard until Mrs Moore had a consultation with the GP on the 27thJanuary 2023 when she expressed further concern about menopausal/perimenopausal symptoms. There were multiple secondary investigations concerning gastro and blood hormone tests, but these all came back as normal. The results of multiple clinical investigations did not reveal that there was anything sinister going on. Blood hormone tests were also not indicative of hormone changes to indicate menopause, but Mrs Moore was insistent as to the severity of her symptoms and so was started on HRT, which appeared to be clinically appropriate to trial to see if this alleviated her symptoms at all. � Mrs Moore�s underlying anxiety pre-disposed her to being very suggestive as to the potential side-effects of medication, as she would research them online and then develop these symptoms very quickly after commencement. Consequently, she was unable to tolerate the HRT (either orally or in patch form) for long enough to give the medication a sufficient trial to ascertain whether it helped alleviate her menopausal symptoms. She stopped taking HRT on the 17th April 2023 and did not re-start. � Mrs Moore had multiple attendances and contacts with the GP, 111, Ambulance service, A&E departments and Secondary care between January 2023 and her death in October 2023; there were over 30 contacts, appointments and call-outs that related to physical symptoms. � Between the 7th May 2023 and the 5th August 2023, Mrs Moore was under the care of the Home Treatment Team. She had a second episode of being under their care between the 26th September and her death on the 31st October 2023, and during these periods she had almost daily contact (sometimes multiple times a day) with the mental health teams. This was in addition to the contacts above. � Mrs Moore had two acute voluntary admissions; one in a Step-Up setting (an alternative setting to an admission if there is no bed) and one to the Rydon Ward (an acute mental health ward). She was keen to avoid admissions in the future as she disliked the environment and those treating her appeared to agree that admissions had the potential to make Mrs Moore worse by increasing her anxiety and distress. � Mrs Moore met with a consultant psychiatrist from the Community Mental Health Team on the 30th October 2023 and did not present in any way that gave immediate concern for her welfare and safety (over and above her baseline presentation). She was due to see a consultant psychiatrist from the Home Treatment Team the following day as part of a fluid discharge from one service to another. � On the morning of the 31st October 2023, Mrs Moore was discovered deceased in her [REDACTED] home [REDACTED]. Whilst Mrs Moore had a long history of mental health anxiety, her mental health had declined acutely and severely in the 18 months prior to her death and there was no immediately identifiable life event (i.e. of a social, relationship or economic nature) that could account for her acute deterioration over this period. She had never before tried to harm herself to any significant extent and/or attempt to take her own life.

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

Suicide (from 2015) This report is being sent to: Somerset Foundation Trust | National Institute for Healthcare and Clinical Excellence | NHS England

15/11/2024

2024-0631

John Cogdon

Teesside & Hartlepool

South Tees Hospitals NHS Foundation Trust

INVESTIGATION On 09 August 2023, I commenced an investigation into the death of John COGDON, aged 62. The investigation and the inquest have not yet concluded. An initial inquest hearing occurred on 8 November 2024 and went part-heard, with a further hearing to be listed.

On 26 June 2023, Mr Cogdon had coronary artery bypass graft surgery at the James Cook University Hospital, Middlesbrough. He deteriorated following that surgery and died on 4 August 2023. The proposed medical cause of death has been offered as: 1a) Congestive Cardiac Failure; 1b) Coronary Artery Bypass Graft Surgery for Coronary Artery Atheroma on a background of Peripheral Vascular Disease.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1. The Deceased�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

South Tees Hospitals NHS Foundation Trust

15/03/2024

2024-0147

Romeo Esposito

Avon

South Western Ambulance Service Trust

I held an Inquest in the death of Romeo Miles Esposito on 14-15th March 2024. The conclusion of the inquest was � � Romeo was found unconscious in bed at home. Emergency staff attended but stopped resuscitation and assessed Romeo as having died. This proved incorrect � he continued to make respiratory effort and his heart beat returned for some time before resuscitation resumed. However, he died in hospital the next day from a brain injury consequent upon his cardiac arrest.

See below.

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.

Emergency services related deaths (2019 onwards) | Child Death (from 2015) This report is being sent to: South Western Ambulance Service Trust

02/05/2024

2024-0241

Evie Davies

Cheshire

Spider Project Cafe 71 Cheshire & Wirral Partnership NHS Foundation Trust (CWP) West Cheshire Clinical Commissioning Group

On 08 December 2021 an investigation was commenced into the death of Evie Jane DAVIES aged 25. The investigation concluded at the end of the inquest on 01 May 2024. The conclusion of the inquest was one of suicide.

Evie Jane Davies was found deceased [REDACTED] at home on 2 December 2021 having taken a significant overdose of medication which had not been prescribed to her. It is likely that this was a deliberate act with the intention to end her life, contributed to by a deterioration in her mental health which commenced in June 2021 following the unexpected death of her partner, and was compounded significantly over the following months by on- going family proceedings regarding her children, lack of regular contact with her children and a forthcoming criminal hearing which she perceived would also impact upon her ability to be with her children. � In the 6 month period prior to her death, Evie was being supported by the mental health team (part of CWP), had an allocated care co-ordinator until November 2021, and in the last few weeks before her death was under the home treatment team. The mental health team supporting her were aware of her on-going stressors and that 3 December was a key date for Evie, the anticipation of which was significantly affecting her mood. On 1 December Evie received some unwelcome news. It is described by the GP that she called the crisis line and was directed to the cafe71 service. There were no notes of this call available to the inquest as the pro forma supplied to the GP is blank but it is likely, given what we know of the background circumstances and the susbequent events, that she shared some distress during this call.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Evie�s family, specifically [REDACTED]Cheshire Constabulary Cheshire West & Chester Council � 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: Spider Project Caf� 71 | Cheshire and Wirral Partnership NHS Foundation Trust | West Cheshire Clinical Commissioning Group

29/09/2023

2023-0356

Steven Sanders

Birmingham and Solihull

St Andrew�s Healthcare The Care Quality Commission Chief Constable of West Midlands Police

On 6 December 2022 I commenced an investigation into the death of Steven Sanders. The investigation is ongoing and is currently listed for a Jury inquest to commence on the 5th February 2024.

Mr Steven Sanders was a detained patient under section 3 of the Mental Health Act at the Hawksley Medium secure ward of St Andrew�s Healthcare (�SAH�) in Birmingham. He required treatment for paranoid schizophrenia. On the 20th November 2022 Steven had appeared well and had been allowed authorised leave from the unit during the afternoon returning to the ward at 14:10. For the rest of the afternoon he appeared his normal self and had spent time around the ward and in his room. Records show him as being asleep during the early evening but when staff went to wake him for medication at 22:10 he was unresponsive, a nurse identified he wasn�t breathing and an ambulance was called. Despite resuscitation attempts Steven was pronounced deceased at 23:04. Following a post mortem examination a pathologist gave the cause of Steven�s death as arising from coronary artery disease. However, there has since come to light reason to suspect Mr Sanders might have taken [REDACTED] before his death calling into question the natural cause. This suspicion arises from: � 1. Mr Sanders had a history of drug dependence (this was not known to the Coroners or Pathologist at the time of the post mortem); 2. �[REDACTED] 3. [REDACTED] 4. there is evidence Mr Sanders made comments to other patients [REDACTED]

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

Alcohol, drugs medication related death This report is being sent to: St Andrew�s Healthcare | Care Quality Commission | West Midlands Police

01/11/2023

2023-0425

Sasha Mishabi

Birmingham and Solihull

St Andrew�s Healthcare, Birmingham

On 2 May 2023 I commenced an investigation into the death of Sasha Honey MISHABI. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Natural causes.

Mr Mishabi died at the Queen Elizabeth Hospital Birmingham on the 18th April 2023. He was a detained mental health patient under section 37/41 of the Mental Health Act at Lifford Ward, St Andrew�s Healthcare (�SAH�), Birmingham for the treatment of personality disorders and schizoaffective disorder of a severe and enduring nature. Mr. Mishabi�s physical health was also poor due to diabetes mellitus type 2, essential hypertension, end stage renal failure and heart failure, he also had poor nutrition and generally used a wheelchair. Mr. Mishabi�s personal hygiene was poor and due to his mental health condition he would often refuse assistance despite suffering episodes of incontinence. He had developed painful skin ulcers to his buttocks that were first identified at SAH on the 15th March 2023 and initially thought to be pressure sores. Dressings were applied. � Mr. Mishabi was admitted to the Queen Elizabeth Hospital on the 17th March 2023 for management of urinary retention. He was found to have a urinary tract infection and anaemia. He was treated and clinically stable when discharged back to SAH on the 2nd April 2023. On admission it was also identified that he had grade 2 ulcers to his left buttock that were thought to be pressure related and was managed accordingly. � Following discharge the ulcers proved difficult to manage and deteriorated. Therefore Mr. Mishabi was admitted to the Queen Elizabeth Hospital on the 6th April 2023 for input from the tissue viability team at which time signs of local infection were identified which were treated with antibiotics. He was reviewed by a tissue viability specialist on the 12th April 2023 who felt that the ulcers were not pressure ulcers. Consequently on the 14th April he underwent a surgical review, a pelvis CT with contrast and a dermatology opinion was obtained to consider what the nature of the ulcers was and how they should be managed. No abcesses or collections were identified and the appropriate management was advised to be ongoing antibiotics. Mr. Mishabi continued to be clinically stable with all observations within normal limites until the 16th April 2023 when he had an episode of pyrexia and tachycardia during the morning prompting investigations. The only other cause for concern on the 16th was a low blood sugar during the early evening but this responded to treatment. However at 22:35 on the 16th April 2023 Mr. Mishabi suddenly became unrousable and suffered a cardiac arrest. He was successfully resuscitated but subsequently developed an overwhelming bronchopneumonia which despite treatment lead to his death. � Based on evidence heard at the inquest from a variety of clinicians and [REDACTED], pathologist, the medical cause of death was determined to be: � 1a Bronchopneumonia 1b Cardiac Arrest 1c Local infection of unknown origin with diabetes mellitus; hypertension; end stage kidney failure; ischaemic heart disease and heart failure II��� Skin infection of the buttocks with superficial ulceration The skin ulcers were determined not to be pressure related and at post mortem were seen to be healing and uninfected, therefore it was concluded that they did not play a significant part in Mr. Mishabi�s death. � However, the inquest did examine the pressure area risk assessments, prevention management and ulcer care at the University Hospitals of Birmingham and St. Andrew�s Healthcare.

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

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

17/10/2023

2023-0392

Jason Bayley

Birmingham and Solihull

St. Andrew�s Healthcare

On 24 January 2023 I commenced an investigation into the death of Jason Mark BAYLEY. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Natural Causes.

Jason suffered from paranoid schizophrenia and was detained under section 3 of the Mental Health Act 1983 for treatment at St. Andrew�s Healthcare. He was prescribed clozapine on a long term basis, which carried a recognised risk of constipation which was treated with a regime of laxatives. Despite this, Jason had chronic constipation which was likely to have been developing over a period of many years. In December 2022 Jason�s severe and chronic constipation led to intestinal pseudo-obstruction as a result of which he died at Queen Elizabeth Hospital in Birmingham on 28 December 2022. � Following a post mortem/Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a Intestinal pseudo-obstruction (Megacolon) 1b Obstipation 1c � II��� Lower respiratory tract infection

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: St Andrew�s Healthcare

28/08/2024

2024-0480

Elizabeth Bury

Staffordshire

Staffordshire Moorlands District Council

On the 12 April 2024, I commenced an investigation into the death of Mrs Elizabeth Margaret Bury.�� The investigation concluded at the end of the inquest on 13 August 2024.� The� conclusion� of� the� inquest� was� a� narrative� conclusion� comprising� of �complications following a fall.� The cause of death was: 1a Bilateral haemothorax due to rib fractures and cardiac laceration 1b Fall 1c II Ischaemic heart disease

i) Mrs Bury was walking back to her care in Tape Street Carpark in Cheadle on the 15 February 2024.� She fell on a speed bump in the car park.� This caused bilateral haemothorax due to rib fractures and cardiac laceration. She passed away at the carpark.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Family of the deceased; � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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

Staffordshire Moorlands District Council

19/09/2023

2023-0438

Lauren Bridges

Manchester South

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

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

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

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, who may find it useful or of interest. 1.������ Lauren�s family 2.������ The Priory 3.������ Dorset Healthcare NHS Trust 4.������ Dorset ICB 5.������ Bournemouth, Christchurch & Poole Council � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner

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

19/01/2023

2023-0062

Lance Walker

West London

Steve Barclay, Secretary of State for health and social care Gillian Keegan, Secretary of State for Education Chief Executive London Borough of Ealing Chief Executive London Borough of Islington West London Alliance

On 17 July 2017 I commenced an investigation into the death of Lance Scott Walker, age 18 . The investigation concluded at the end of the inquest on 21 November 2022. The conclusion of the inquest was � Medical cause of death 1a Shock and Haemorrhage 1b Stab Wounds to the back � Lance Scott Walker was killed by The Assailant in the afternoon of 15 August 2016 in Gledwood Drive, Hayes. The immediate cause of death was shock and haemorrhage, due to stab wounds to the back. Numerous circumstances both probably and possibly led to this death. � The jury Conclusion was as follows � (the questionnaire they responded to is attached for ease of reference):- � The jury is satisfied by unanimous decision that, on the balance of probability, Lance Scott Walker was unlawfully killed. � 1. In response to the questionnaire: regarding the West London NHS Trust, the jury finds by unanimous decision errors, omissions, and failures that probably caused Lance Scott Walker�s death, considering: � Insufficient planning for the transfer of The Assailant�s care from child and adolescent services to adult services;Inadequate management of The Assailant�s care following the transfer of his care from CAMHS to the Early � Intervention in Psychosis team when he turned 18, including the administration of his depot medication and the absence of any contact with The Assailant, including by way of home visit. � The grave lack of any assessment in order to determine whether the assailant should be detained under the Mental Health Act of 1983. � Unacceptable assessment, if any, of the risks The Assailant posed to others, including by way of violent offending, on and after 29 June 2016 �� The insufficient communication on the part of the Trust with Urban Youth Flex and the London Borough of Ealing, including informing them of The Assailant�s mental health, needs and risks and liaising with Urban Youth Flex and the London Borough of Ealing regarding the Assailant�s mental health, needs, or Risks. � 2. In response to the questionnaire: regarding the London Borough of Islington, the jury finds by unanimous decision errors, omissions, and failures probably caused or contributed to Lance Scott Walker�s death, considering: �� The unsatisfactory decision to commission Urban Youth Flex to provide unregulated accommodation to 23 Gledwood Gardens to Lance Scott Walker specifically regarding matters of financial due diligence and the absence of a contract, in particular detailing the expectations on the care provider � Urban Youth flex; �� Insufficient evidence to show suitable management of Lance Scott Walker during his placement in 23 Gledwood Gardens � 3. In response to the questionnaire: regarding the London Borough of Ealing, the jury finds by unanimous decision errors, omissions, and failures that probably caused or contributed to Lance Scott Walker�s death, considering: �� The inappropriate commissioning of Urban Youth Flex to provide unregulated accommodation at 23 Gledwood Gardens to The Assailant specifically regarding matters of financial due diligence and the absence of a contract, in particular detailing the expectations on the care provider- Urban Youth flex; �� The inappropriate placement of The Assailant in unregulated accommodation at 23 Gledwood Gardens managed by Urban Youth Flex; �� The grave omission of information regarding The Assailant by London Borough of Ealing with Urban Youth Flex when they placed The Assailant on 4 August 2016, including his forensic history, risk of offending, harming others and being bullied and details of his medication and medical regime; �� The grave lack of communication by London Borough of Ealing with the Trust and/or Urban Youth Flex after The Assailant�s placement on 4 August 2016; �� The inadequate system in place whereby Merlins are shared with the allocated social worker; �� The unacceptable lack of escalation of The Assailant�s specific case through the appropriate channels; �� The failing in proper internal communication between the various interested departments of the London Borough of Ealing with respect to The Assailant�s case. � 4. In response to the questionnaire: regarding Urban Youth Flex (also known as Choices Homes), the jury finds by majority decision (8-2) errors, omissions, and failures that possibly caused or contributed to Lance Scott Walker�s death, considering: �� The improper training, experience, staffing levels, and formal qualifications of the Urban Youth Flex staff working at 23 Gledwood Gardens; �� Urban Youth Flex�s inadequate ongoing management of their tenant�s suitability with one another, after (and only after) they were placed in 23 Gledwood Gardens; The failure to share information with the London Borough of Islington and London Borough of Ealing, including in particular the incidents on the 11th and 12th August 2016.

Lance Scott Walker was a �looked after� child who was entitled to be accommodated under the provisions of the Leaving Care Act. When his penultimate placement broke down, he was placed by London Borough of Islington in an unregulated residential home, 23 Gledwood Gardens run by Urban Youth Flex during 2016. He was 18 years of age. Several weeks later, another resident, referred to as �the assailant� also 18 years old was placed in the same accommodation as an emergency. 11 days after they were placed together, the assailant fatally stabbed Lance Scott Walker.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Lance Scott Walker Director of Urban Flex Metropolitan Police Commissioner London Borough of Ealing London Borough of Islington West London Mental Health Trust I may also send a copy of your response to any other person who I believe may find it useful or of interest, and will therefore send a copy to OFSTED. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me coroner at the release publication of our response.

Other related deaths

Department of Health and Social Care | Department for Education | London Borough of Ealing | London Borough of Islington | West London Alliance

20/06/2023

2023-0200

Michael Sullivan

Manchester South

Stockport Integrated Care Partnership

On 22nd December 2022 I commenced an investigation into the death of Michael Brian Sullivan. The investigation concluded on the 16th May 2023 and the conclusion was one of Narrative: Died of natural causes exacerbated by lithium toxicity. The medical cause of death was 1a) Bronchopneumonia; II) Bipolar disorder, Lithium toxicity, chronic obstructive pulmonary disease

Michael Brian Sullivan had schizophrenia and was bipolar. He took lithium medication. He deteriorated at his home address and was admitted to Stepping Hill Hospital after concerns were raised by his family. He was found to have pneumonia and lithium toxicity, a complication of his bronchopneumonia and related to his dehydration. He deteriorated despite treatment and died at Stepping Hill Hospital on 17th December 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1)�[REDACTED] and 2) 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.

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

01/10/2024

2024-0521

Scott Davies

Manchester South

Stockport Metropolitan Borough Council, Highways Department Secretary of State for Transport

On 29th August 2024 an inquest was opened into the death of Scott Bradley Davies aged 32. The inquest concluded on 19th September 2024. I made a� determination at inquest that Scott Bradley Davies died as a result of an� accident.

Scott Davies had collected his modified Sur-Ron Light Bee Motorcycle on the� evening of Friday 2nd February 2024 and returned home carrying the� unregistered motorcycle in a van. He proceeded to attend upon Alexandra Park� in Stockport to test out the vehicle. He collided with a steel barrier which was in� a closed position. He was dismounted from the vehicle and sustained serious� head injuries. He was not wearing a helmet at the time of his collision. He was� given first aid at the scene and taken to Salford Royal Hospital by ambulance. He was treated by way of sedation and ventilation but never regained� consciousness and died as a result of a traumatic brain injury on 8th March 2024� at Salford Royal Hospital.

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

Road (Highways Safety) related deaths

Stockport Metropolitan Borough Council | Department for Transport

14/12/2023

2023-0528

Olivia Russell

Cheshire

Stretton Medical Centre

On 23 September 2021 I commenced an investigation into the death of Olivia Amy RUSSELL aged 25. The investigation concluded at the end of the inquest on 6 December 2023. The conclusion of the inquest was one of suicide.

Olivia Russell had a history of anxiety which was initial managed without medication. In October 2020 she contacted your surgery and discussed options to treat her anxiety as this had worsened. She initially decided against anti-depressants but subsequently had another appointment on 2 November where she opted for a 10mg dose of citalopram. Following a period of apparent stability, Olivia stopped taking her medication in or around June 2021 without consulting a GP, subsequently suffering a relapse and re-starting her medication in August 2021. Sadly, Olivia took her own life on 19 September 2021.

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

Suicide (from 2015) This report is being sent to: Stretton Medical Centre

17/05/2024

2024-0273

Lily Jahany

Leicester City and South Leicestershire

Student Roost Leicestershire Partnership Trust

On 16 December 2022 I commenced an investigation into the death of Lily Precious JAHANY aged 18. The investigation concluded at the end of the inquest on 17 May 2024. The conclusion of the inquest was that: � Lily Precious Jahany was an 18 year old university student. She was a bright intelligent girl, who was studying to become a Doctor. She resided in student accommodation in Leicester and had been in the city for a period of only 3 months at the time of her death. � Lily had a diagnosis of bipolar affective disorder, but also was suffering from post traumatic stress disorder, depression and anxiety, had an underlying eating disorder and whilst not diagnosed with autistic spectrum disorder, demonstrated certain traits associated with the condition, such as rigid thinking and perfectionism. � Lily had a lengthy and complicated psychiatric history which was not fully appreciated by those clinicians whose care she came under during her time in Leicester due the lack of a single national medical record for patients, but also the fact that Lily was treated within the private sector. This had the impact of misleading those who treated Lily in the assessment of her risk. But conversely, placed upon them a greater duty and emphasis on ensuring they had at their disposal the relevant information to be able to properly and fully assess Lily�s risk, which they failed to do. At the time of her death Lily had been closed to the Crisis Team and was awaiting assessment by the Community Mental Health team for a medication review by a psychiatrist. � 3 weeks prior to her death Lily started to suffer manic episodes connected to her bipolar affective disorder. She took 3 overdoses and attempted to ligature on two occasions. Lily would decline hospital admission by the emergency services who attended on her, including on the 8th December 2022, when she was found to be ligating in her room in her student accommodation and paramedics and the police were called. On the 9th December 2022, Lily was found by accommodation staff in her room suspended by a ligature around her neck. Emergency services were called, but Lily was declared deceased at 12.35 hours. The cause of death was established as: I a Suspension by ligature

Lily Precious Jahany was an 18 year old medical student who had an extensive background history of mental health difficulties starting as early as the age of 7. She also had an extensive history of previous self harm. Lily was diagnosed with Bipolar Affective Disorder and was treated with Fluoxetine and Lurasidone and had input from a of counsellor. � Lily was a highly complex young lady and in addition to her diagnosis of Bipolar Affective Disorder had underlying diagnosis of post traumatic stress disorder caused by the childhood trauma, depression and anxiety. Although not positively on the autistic spectrum disorder, Lily also demonstrated autistic spectrum disorder traits and had an underlying eating disorder. � Lily started Leicester University in September 2022. By mid November 2022, Lily started to experience manic episodes connected to her bipolar symptoms and reported taking 3 overdoses on 15, 16 and 18 November. Lily refused to seek medical attention� and when she did present to A&E on the 18th discharged herself before being assessed by the Mental Health team. � Lily�s maladaptive behaviors escalated further and she ligated on 1st December 2022 and again on the 8th December 2022. In the week in between there were other episodes which could be construed as self harm through not eating necessitating ambulances to be called. � The extent of Lily�s mental health difficulties were not fully appreciated when she arrived in Leicester due to not only the absence of a national single electronic patient record but also because Lily was treated in the private sector and records held by private clinicians are not accessible within a national SystmOne record keeping system. � This in my judgment had the impact of misleading those who treated her in the assessment of Lily�s risk. But conversely, placed upon them a greater duty and emphasis on ensuring they had at their disposal the relevant information to be able to properly and fully assess Lily�s risk. There were failures to obtain the full extent of Lily�s mental health challenges and seek information which was pertinent to the assessment of her risk. However, whilst I find there were failures I cannot find on balance that those failures more than minimally trivially or negligibly contributed to Lily�s death. At a time unknown between 11pm 8th December 2022 and midday on the 9th December 2022 Lily took increased doses of Zopicone and Promethazine and tied a ligature around her neck and she did so intending to die as a result of her actions. Lily was pronounced deceased at 12.35 hours on the 9th December 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Lily University of Leicester [REDACTED] Girls Day School 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) This report is being sent to: Student Roost | Leicestershire Partnership Trust

23/11/2023

2023-0472

Kevin O�Hara

Surrey

Surrey County Council Executive Director of Adults, Wellbeing and Health Partnerships. � Surrey County Council Chief Fire Officer

INQUEST � An inquest into the death of Kevin Stephen O�HARA was opened on 7 March 2023, resumed on 2 November 2023 and concluded on 22 November 2023. � The medical cause of death was: � 1a. Inhalation of fire fumes and burns. � With respect to where, when and how Mr O�Hara came by his death it was recorded at Box 3 of the Record of Inquest as follows: � Kevin Stephen O�Hara died in a fire in the early morning of 7 February 2023 at his home in Frimley, Camberley. He lived on his own and was bedbound in his living room. He was known to smoke in bed and it is more likely than not that the fire started because a lit cigarette fell onto a mattress used as a crash mat next to Mr O�Hara�s bed. This resulted in a smouldering fire which created significant amounts of smoke. Mr O�Hara died from inhaling fire fumes and burns. The fire was only detected when a smoke alarm situated in the hallway of the flat detected smoke seeping through the living room door. Mr O�Hara�s death was recorded at 0420 hours that morning. � The inquest concluded with a short form conclusion of �Accident�.

Mr O�Hara was aged 63 at his death. He lived in a one bedroom flat on the ground floor of a two storey Independent Living Scheme in Frimley, Surrey. He was bedbound in his living room. He lived alone but carers came in four times a day. He misused alcohol and was known to smoke in bed. Concerns about fire risks from his smoking had been reported to both Surrey Fire and Rescue Service (SFRS), Surrey Adult Social Care (ASC) and the landlords. It was known that he could not self-rescue in the event of fire. � Mr O�Hara died in a fire on 7 February 2023 which resulted from a lit cigarette igniting debris on a mattress being used as a crash mat next to his bed. The resulting fire created a significant amount of smoke. The smoke detectors (one linked to a careline operator) and the intercom box were in the hallway. The door to the hallway from the living room was shut. As a result the fire was not detected until sufficient smoke had built up to seep through the top of the living room door into the hallway to then trigger the alarm. Once SFRS became aware that the alarm had activated they deployed quickly but Mr O�Hara died from the effects of the fire before they could reach him. � It is not known how long the fire had been burning before the smoke activated the alarm.

COPIES I have sent a copy of this report to the following: � Chief Coroner Mr O�Hara�s family

Other related deaths This report is being sent to: Surrey County Council

23/07/2024

2024-0414

Neil Woodley

South London

Surrey Police Metropolitan Police Service

On 11 March 2024 an investigation was commenced into the death of Neil John Woodley.� The investigation concluded at the end of the inquest on 17 July 2024. The conclusion of the ����inquest was suicide.

Neil Woodley was found [REDACTED] at 7.25 am on 4 January 2024.� Evidence from suicide notes suggest he killed himself some time overnight.

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

Suicide (from 2015)� � This report is being sent to: Surrey Police | Metropolitan Police Service

8/7/2024

2024-0363

Alan Kinsbury

West Sussex, Brighton & Hove� � Category: Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to:�Sussex Community Dermatology Service | British Society for Dermatological Surgery

Sussex Community Dermatology Service British Society of Dermatological Surgery�Sussex Community Dermatology Service | British Society for Dermatological Surgery

On 21st February 2024 I concluded an investigation into the death of Dr Alan William Kingsbury. The medical cause of death recorded was:- 1a Pneumonia 1b Fractured right neck of femur (repaired surgically 21/10.23) 1c Fall secondary to anaemia, secondary to bleeding chest wall lesion (excised squamous cell cancer 19.10.23) 3 Severe frailty of Old Age I returned a narrative conclusion: Dr Alan William Kingsbury was extremely frail with poor physiological reserve. On the 19th October 2023 he was admitted into Worthing Hospital, Worthing as an emergency for excessive bleeding secondary to an excision of a left cutaneous chest lesion (squamous cell carcinoma in situ) earlier that day whilst anticoagulated with aspirin and clopidogrel. In the early hours of 21st October 2023 Dr Kingsbury had a fall in the hospital in circumstances whereby neither a sitting and lying blood pressure or a falls assessment had not been undertaken.� He sustained a right neck of femur fracture requiring surgical repair later that day alongside further surgical revision of the chest wound for dehiscence and ongoing bleeding. The combination of frailty, ongoing bleeding from the chest wound and complications of the fall all contributed to his death at the hospital on 29th October 2023

The conclusion reflects the circumstances of Dr Kingsbury�s death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � �[REDACTED] � [REDACTED] Consultant Dermatologist, Worthing Skin and Laser Clinic � [REDACTED] Orthopaedic Surgeon. University Hospitals Sussex NHS Foundation Trust I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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� �

15/02/2024

2024-0086

Thomas Loxton

Birmingham and Solihull

THE CHIEF EXECUTIVE OF DUDLEY INTEGRATED HEALTH AND CARE NHS TRUST THE CHIEF EXECUTIVE BLACK COUNTRY HEALTHCARE NHS FOUNDATION TRUST

On 2 October 2023 I commenced an investigation into the death of Thomas Peter LOXTON. The investigation concluded at the end of the inquest. The conclusion of the inquest was: Suicide

At 16:30 on 21/09/2023 paramedics attended Thomas� home after he was discovered by family members lying unresponsive on his sofa, with empty packets of medication and a hand-written note nearby, and Thomas was subsequently declared deceased. Post-mortem examination confirmed that death was due to an overdose of multiple prescription medications. Thomas had a long history of mental health illness and was under the care of two separate secondary mental health service providers at the time of his death. Investigations post-death revealed incidental areas of learning but none of which were directly causative of his death, and none of which would have prevented his death. Following a post mortem the medical cause of death was determined to be: � 1a�� [REDACTED] OVERDOSE

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

Suicide (from 2015) This report is being sent to: Dudley Integrated Health and Care NHS Trust | Black Country Healthcare NHS Foundation Trust

07/09/2023

2023-0323

Graham Smith

Birmingham and Solihull

THE CHIEF EXECUTIVE, NHS ENGLAND

On 13 March 2023 I commenced an investigation into the death of Graham Thomas John SMITH. The investigation concluded at the end of the inquest on 24th August 2023. The conclusion of the inquest was; � Died from natural causes likely contributed to by a combination of the delay in him being prescribed his normal medication for the condition Myasthenia Gravis from which he suffered as well as him being prescribed on admission a dose of an antibiotic medication for sepsis that was contraindicated in his case. � � The medical cause of his death was: 1(a) Respiratory Failure. Chest Infection 1(b) Myasthenia Gravis II Biliary Sepsis. Type 2 Diabetes

Graham Smith suffered from Myasthenia Gravis, a rare long-term condition that causes muscle weakness and for which he was prescribed Pyridostigmine by his GP. On 1st March 2023 he was admitted to the Emergency Department of the Queen Elizabeth Hospital in Birmingham with suspected biliary sepsis/ascending cholangitis due to an obstructing bile gall stone as well as a bilateral basal consolidation which was revealed by a chest x ray. � Whilst in the ED, he was initially prescribed Tazocin for treatment of the sepsis but was then given a dose of Gentamicin which is in fact contraindicated in patients suffering from Myasthenia Gravis. He was not prescribed his normal Pyridostigmine. � On 2nd March he was transferred to a Liver ward for further treatment and arrangements were made for him to undergo an Endoscopic Retrograde Cholangiopancreatography Procedure (�ERCP�) which could not be done until 3rd March. In the early hours of 3rd March he deteriorated suddenly and was seen by the Critical Care Outreach Team who noted that he had not been prescribed his normal medication since admission and that he had received a dose of the Gentamicin. He was found to be suffering from a myasthenic crisis causing respiratory failure. He was restarted on the Pyridostigmine and treatment and management of his sepsis continued on ICU. Following a successful ERCP procedure later on 3rd March, his inflammatory markers were improving and his cholangitis was noted to be resolving over the next few days. However, he continued to have multi organ dysfunction with increasing respiratory failure and following a further significant deterioration passed away on 7th March

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

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

18/08/2023

2023-0301

Juanita Nti

Inner South London

THE REPORT IS BEING SENT TO: [REDACTED] Chief Executive of NHS England, Skipton House, London, SE1 6LH

INQUEST � On 9th September 2020 Miss Juanita Boate Nti (ref 9210617), died aged 4 months, in a Paediatric Intensive Care Unit. A post mortem examination was conducted, indicating an overdose of morphine. An inquest was opened on 10th March 2021 and concluded on 27th July 2023. The medical cause of death was found to be 1a Townes-Brocks syndrome with tracheal stenosis and complex congenital heart disease, following accidental morphine overdose.

Juanita was born on 12th May 2020 and investigations determined that her complex congenital diseases were not treatable. She received palliative care from 1st July and was tenderly cared for by her parents at home with a symptom management plan devised by specialists, which included Morphine solution via her naso-gastric tube as needed. � On 3rd September her condition suddenly deteriorated after a dose of morphine and she suffered a respiratory arrest on the way to hospital. She improved with urgent medication to reverse the effect of morphine intoxication, but went on to require intubation. She breathed regularly on pressure support but could not sustain spontaneous ventilation after extubation. Neither the Symptom Control Plan nor prescription written by the GP, just before a Bank Holiday during the pandemic, stipulated the volume of morphine solution to be administered and although the correct dose was stated, in error two concentrations were on the prescription. The pharmacist did not notice the error and failed to write the volume of the solution to be administered. � She died of a combination of natural disease and accident. The failures of both the GP and pharmacist to make further enquiries to ensure the medication administration was safe related in part to the workload pressures of the pandemic. But they contributed to the death, as the child was given twenty times the intended dose. Juanita was very fragile with limited life expectancy, but would not have died when she did, without the overdose, naturally having less reserve to recover from the intoxication.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] for Clapham Law Solicitors representing the family [REDACTED] for Clyde & Co representing [REDACTED] for Gordon Solicitors representing Millennium Pharmacy [REDACTED] Senior Safeguarding manager of Lambeth Child Safeguarding Board. � I have also sent it to: [REDACTED], consultant paediatrician, The Royal College of Paediatrics and Child Health, The Royal College of General Practitioners and The Royal Pharmaceutical Society, who may find it useful. The Department of Health � 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: NHS England

12/09/2023

2023-0326

Isabela Suciu

Inner South London

THE REPORT IS BEING SENT TO: [REDACTED], Chief Executive of Royal College of Paediatrics and Child Health 5-11, Theobalds Road, London, WC1X 8SH � [REDACTED],� Chief Executive of the British Association Perinatal Medicine 5-11, Theobalds Road, London, WC1X 8SH � [REDACTED], Chief Executive of NHS England, Skipton House, London, SE1 6LH � [REDACTED], Chief Executive of Queen Elizabeth Hospital Trust Stadium Road, London, SE18 4QH

INQUEST � The inquest touching the death of Baby Isabela Suciu, was opened on 19 April 2022 and heard on 23rd and 24th August 2023 by the Senior Coroner. The coroner�s reasons for his judgment were handed down and the Record of Inquest was signed on 31st August 2023, recording thus: The medical cause of death was 1a Sudden unexpected neonatal death. Isabela died from a sudden unexpected neonatal death. In the absence of any identifiable cause, such as airway occlusion, research evidence suggests there is often an underlying infection, but although maternal sepsis was a risk factor for neonatal infection, there is insufficient evidence to conclude the underlying cause here.

Isabela was born in hospital at 41 weeks gestation by forceps, weighing 4.3 kg on 2nd November 2020. She received some resuscitation to achieve an Apgar score of 10 at 5 minutes. Her mother was treated for maternal sepsis and Isabella initially had a temperature of 38. This was monitored and she had two low readings of 36.3 at 02.00 and 36.2 at 06.20. These were not escalated for paediatric review and antibiotics were not given. Her temperature stabilised, and she showed no signs of infection before discharge at 12.51 on 4th December. She suffered a cardiac arrest at home about 35 minutes after a 15 minute breast feed. She never recovered consciousness, despite resuscitation by prompt ambulance officers and she died at 16.10 in hospital.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � � [REDACTED] for Novum Law representing the family [REDACTED] for Clyde&Co representing Queen Elizabeth Hospital � � I have also sent it to: [REDACTED], Consultant Neonatologist, Northwest Neonatal Ltd [REDACTED], Consultant Neonatologist, Lewisham and Greenwich Trust [REDACTED], Consultant Microbiologist, Lewisham and Greenwich Trust [REDACTED], Consultant Microbiologist, UK Health Security Agency and University College London Hospital NHS Foundation Trust (now retired) � 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)� | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Royal College of Paediatrics and Child Health | British Association Perinatal Medicine | NHS England | Queen Elizabeth Hospital Trust

12/06/2024

2024-0322

Louise Jones

Cornwall and the Isles of Scilly

Petroc GP Group Practice, St Columb Cornwall

On 21 November 2023 I commenced an investigation into the death of Louise Helen Jones. The investigation concluded at the end of the inquest on 11 June 2024. � The medical cause of death was found as follows: � 1a Respiratory Depression and Opiate Drug Use II Obesity The four questions � who, when, where and how � were answered as follows: � Louise Helen JONES died on 1 October 2023 at no2 Mosquito Crescent St. Eval Wadebridge Cornwall following an unintentional overdose of morphine and bromazolam, and therapeutic use of codeine, diazepam, zopiclone and quetiapine. In combination, all of the aforementioned central nervous system depressant drugs are likely to have enhanced the overall effects on cardio-respiratory function which resulted in fatal respiratory depression. � The conclusion of the inquest was Drug Related Death.

At approximately 15.50 hours on 1 October 2023 Louise was found deceased in her home, kneeling on the kitchen floor with her head on the floor. � Louise was 40 years old at the date of her death. � Louise had suffered a complex medical history of physical and mental health conditions including anxiety and depression, and chronic pain due to fibromyalgia and back problems. For these conditions Louise was prescribed a variety of CNS depressant drugs including codeine, diazepam, zopiclone and quetiapine. � In February 2023 Louise was admitted to Royal Cornwall Hospital with leg swelling and non-malignant leg pain. Investigations did not reveal a cause. Louise was prescribed oramorph by the hospital. At Louise�s request this prescription was continued by Petroc GP Practice together with other CNS depressant drugs referred to above. � The family view was that Louise had become addicted to morphine. The GP had raised the issue of addiction with Louise. Significant weight was attached by the GP to Louise�s assurance that she was not addicted to morphine. � The court found that there had been no attempt (or exit strategy formulated) to try and incrementally reduce and remove Louise�s prescription of opiate-based drugs, or to adjust the co-prescription of opioids and benzodiazepines. At the time of Louise�s death, the intention was for those prescriptions to continue. � The court noted guidance referred to by NICE in connection with using opioid drugs for non-malignant pain: � � Long term use of opioids in non-malignant pain (longer than 3 months) carries an increased risk of dependence and addiction, even at therapeutic doses�. � MHRA/CHM advice: Opioids: risk of dependence and addiction (September 2020) New safety recommendations have been issued following a review of the risks of dependence and addiction associated with prolonged use (longer than 3 months) of opioids for non-malignant pain. Healthcare professionals are advised to: discuss with patients that prolonged use of opioids, even at therapeutic doses, may lead to dependence and addiction; agree a treatment strategy and plan for end of treatment with the patient before starting opioids; � � The court noted guidance referred to by NICE in connection with co-prescription of morphine and drugs such as diazepam, zopiclone and quetiapine. � MHRA/CHM advice: Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression (March 2020) The MHRA reminds healthcare professionals that opioids co-prescribed with benzodiazepines and benzodiazepine-like drugs can produce additive CNS depressant effects, thereby increasing the risk of sedation, respiratory depression, coma, and death. Healthcare professionals are advised to only co-prescribe if there is no alternative and, if necessary, the lowest possible doses should be given for the shortest duration.

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

Alcohol, drug and medication related deaths This report is being sent to: Petroc GP Group Practice

28/03/2023

2023-0108

Louis Rogers

Surrey

President, Royal College of Paediatricians JRCALC N.I.C.E Royal College of General Practice Royal College of Emergency Medicine NHS England

On 8th February 2022 I recommenced an investigation into the death of Louis James Rogers. On 2nd February 2023 I concluded the Investigation. � The medical cause of death given was: � 1a. Cardio-respiratory arrest 1b. Tonic-clonic seizure 2. Dravet�s syndrome � I determined: � � Box 3 & Box 4 Louis James Rogers was a fit and well baby who had a self-limiting febrile seizure on the 29th September 2020 at 13 months of age. Louis had a further two seizures on the 11th February 2021. He was found in his bed at his home address on 20.47 hours on the 18th June 2021. There were no signs of life. He was transferred to St Peter�s hospital, Chertsey but despite further attempts at resuscitation death was certified at 21.53 hours on 18th June 2021 at SPH, Chertsey. Genetic analysis after death confirmed Dravet�s syndrome. Louis died by way of natural causes.

1. Louis was born fit and well on 1st August 2019. On the 20th September 2020 he had a short self-limiting seizure whilst having a mild cold like illness. He was admitted to St Peters Hospital, Chertsey (SPH) for further assessment and discharged later that day having fully recovered. � 2. Louis remained well until the morning of 11th February 2021 when he had a second self-limiting seizure. He was again taken to St Peters Hospital, Chertsey for observation and discharged later that day after being reviewed by a consultant paediatrician. � 3. However, shortly after discharge, Louis had a further seizure in the early evening 17.00 hours of 11th February 2021. The emergency services attended and after a period of observation, Louis remained at home. � 4. On 1st May 2021 Louis attended the Emergency Department at St Peters Hospital accompanied by his father over concerns of a 1 day history of being lethargic, clingy and wobbly on his feet following a minor head injury 5 days prior. Louis was discharged after observations were normal and no abnormalities, including neurological deficits, were found. 5. On the 13th May 2021, Louis�s parents visited and were reassured by the GP following concern over a further seizure whilst Louis was at nursery on a background of concerns over Louis�s developmental regression. � 6. On 18th June 2021 Louis had been clinically unwell and was laid down to sleep for the night. Louis was found unresponsive a short time later. Emergency services attended and Louis was taken to SPH with ongoing resuscitation but to no avail and Louis was recognised to have died at 21.53 hours on 18th June 2021 at SPH, Chertsey at 22 months of age. � 7. Autopsy confirmed Louis had a viral infection at the time of his death and genetic studies confirmed a diagnosis of Dravet�s Syndrome, a condition associated with developmental regression and delay, autism and epilepsy which can be triggered by pyrexia and may be resistant to treatment with antiepileptic agents.

I have sent a copy of this report to the following:1.���� See names in paragraph 1 above2.���� Mr and Mrs Rogers3.���� Chief Executive, St Peters Hospital, Chertsey 4. [REDACTED]5. [REDACTED]In addition to this report, I am under a duty to send the Chief Coroner a copy of your response.�The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who, he believes, may find it useful or of interest. You may make representations to me at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015)

Royal College of Paediatricians | Joint Royal Colleges Ambulance Liaison Committee | National Institute for Health and Care Excellence | Royal College of General Practice | Royal College of Emergency Medicine | NHS England

16/01/2024

2024-0022

Charles Harper

Birmingham and Solihull

President, The Pipeline Industries Guild.Chair, British Drilling Association.

On 22 May 2023 I commenced an investigation into the death of Charles Harper. The investigation concluded at the end of the inquest on 11 January 2024.

Mr Harper was involved in horizontal directional drilling and associated works, forming part of the HS2 high-speed railway construction project on land known as Sublot 5 Site, Land North of Hollywell Brook, Middle Lane, Birmingham. On 27 April 2023 ducting made from rigid 180mm poly- ethylene coiled pipe was being dispensed from a coil trailer through a pre-drilled 100 meter hole. Mr Harper was stood sufficiently close to the trailer, that at the end of dispensing when the stored energy was released, it caused the unsecured tail end of the coiled pipe to spring and strike Mr Harper causing serious abdominal and chest injuries, and he died the following day. The coil trailer was supplied with a restraining clamp and strap. The operating manual for the coil trailer, and method statement and risk assessment for the work, all identified the risk of the tail end of coiled pipe springing as a consequence of stored energy, and that it should be secured to the trailer. No such securing mechanism was utilised on 27 April 2023 and this contributed to Mr Harper�s death.

I have sent a copy of my report to the Chief Coroner of England & Wales, and to the following Interested Persons: � Harper Services Limited. The Harper family. Morrison Water Services Limited. Balfour Beatty Vinci Joint Venture. Steve Vick International Limited. Aviva Insurance. Health and Safety Executive. West Midlands Police. � I have also sent it to the following who may find it useful or of interest: � ATE (UK) Ltd (The evidence was that alongside Steve Vick Internation Limited they are the other major manufacturer of coil trailers). � 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 Pipeline Industries Guild | British Drilling Association

01/08/2024

2024-0418

Lee Purkis

West Sussex Brighton & Hove

Probation Service

On 14 March 2023 I commenced an investigation into the death of Lee Spencer PURKIS aged 54. The investigation concluded at the end of the inquest on 25 June 2024. The conclusion of the inquest was that: Lee Purkis was aged 54 at the time of his death. He was found in a state of advanced decomposition on the floor of his home on 9 March 2023, having been there for up to two months. The cause is unascertainable; he not been seen since 6.1.23.

Lee Purkis was aged 54 at the time of his death. He was found in a state of advanced decomposition on the floor of his home on 9 March 2023, having been there for up to two months. The cause is unascertainable; he not been seen since 6.1.23.

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

Other related deaths� � This report is being sent to: HM Prison and Probation Service

29/03/2023

2023-0110

Rebecca Kirby

East Riding and Hull

Public Transport Department Local Authority for City of Kingston Upon Hull and Hackney Carriage Association for the area of Kingston Upon Hull

On 2nd September 2021 I commenced an investigation into the death of Rebecca Lisa KIRBY, aged 31 years. The investigation concluded at the end of the inquest on 29th March 2023. The conclusion of the inquest was Road Traffic Incident. � Box 3 of the record of inquest read: � On the evening of 27th August 2021 Rebecca Lisa KIRBY was out socialising. She misjudged the traffic on Lowgate, Hull and ran in to the path of an oncoming vehicle. The vehicle was travelling at 23 miles per hour however the way Ms Kirby landed resulted in significant head injuries, causing her to become immediate unresponsive. Despite many people coming to her aid to offer advanced life support, she remained in cardiac arrest. She was transported to Hull Royal Infirmary where she was declared deceased. � One of the findings of fact stated: Miss Kirby had crossed behind a passing car which would obscure any oncoming vehicles view of her. In addition to lights, taxis and other pedestrians in the vicinity. � � His medical cause of death was recorded as: 1a Intracranial Haemorrhage 1b�Road Traffic Incident

Miss Kirby was out socialising with friends. She had consumed alcohol and was in an area of Hull known for its night time economy. She became separated from her friends and after looking in one location crossed a road. She misjudged the crossing and despite seeing the vehicle still attempted to cross the road. When struck by the car she landed on her head causing catastrophic injuries. Police witnessed the incident and were immediately on scene. Throughout the advanced life support she remained in cardiac arrest, without a pulse or signs of breathing. She was conveyed to Hull Royal Infirmary where CPR was ceased and she was declared dead.

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

Road (Highways Safety) related deaths

Department for Transport | Kingston Upon Hull Council | Hackney Carriage Association for the area of Kingston Upon Hull

16/09/2024

2024-0492

Philip Ross

Surrey

REDACTED Chief Executive�� South East Coast Ambulance Service NHS Foundation Trust�� Nexus House� 4 Gatwick Road� Crawley� RH10 9BG

INQUEST An inquest into Mr Ross�s death was opened on 4 January 2024.� The inquest was resumed and concluded on 23 August 2024.���� The medical cause of Mr Ross�s death was: 1a. Multiple Organ Failure Ib. Bronchopneumonia and Rhabdomyolysis Ic. Fall 2. Myocardial Fibrosis With respect to where, when and how Mr Ross came by his death it was recorded at Box 3 of the Record of Inquest as follows:� Philip Gordon Ross had a fall at his home injuring his shoulder� sometime before 2325 hours on the evening of 3 December 2023. He was unable to move until extracted by paramedics and he was� taken by ambulance to the Royal Surrey County Hospital�Guildford and admitted to the Emergency Department at around� 0416 hours. Within a day or so of admission he was found to have� acute kidney injury secondary to rhabdomyolysis, symptoms of� myocardial injury and pneumonia. He did not respond to� treatment and his condition continued to deteriorate. Mr Ross died� on 19 December 2023 at the Royal Surrey County Hospital of� multiple organ failure caused by rhabdomyolysis and� bronchopneumonia precipitated by his fall on a background of� myocardial fibrosis.� The inquest concluded with a short form conclusion of �Accident�:

On 3 December 2023, Mr Ross suffered a fall at his home and was unable� to move. His wife called for an ambulance at 23:25 hours. At that point his case was categorised by South East Coast Ambulance Service (SECAMB)� as a Category 3 case. Category 3 calls have a response time of 120 minutes. Mrs Ross then made a number of increasingly anxious calls to the� ambulance service about the need to help her husband, these included a� call at 00:48 hours. It was accepted in evidence that Mr Ross should have been re-triaged at this point as his condition had deteriorated. The court� heard he was not triaged again until 01:42 hours, when a nurse clinical� supervisor upgraded the call to Category 2 with a response time of 18� minutes. The ambulance did not arrive until around 02:30 hours.� SECAMB have adopted the NHS England protocol for validating�Category 3 and Category 4 ambulance calls. They therefore aim to�validate such cases within 90 minutes of the call. That was not achieved in Mr Ross�s case. The evidence showed that no form of clinical validation of the calls took place until approximately 2 hours and 20 minutes after the�initial call.�� The court heard that the delay in an ambulance attending Mr Ross was� because there had been a high demand for ambulance/paramedic� assistance over that period. And that no clinical validation of the calls� took place until well over 2 hours from the initial call because of a lack of available clinical staff or clinical hours to deal with the level of surge in� calls that night.

COPIES� I have sent a copy of this report to the following: 1. Chief Coroner�� 2. Mr Ross�s family

Emergency services related deaths (2019 onwards)

South East Coast Ambulance Service

13/08/2024

2024-0446

Angela Mittal

Berkshire

REGULATION 28 REPORT TO PREVENT DEATHS Chief Constable for Thames Valley Police, [REDACTED] Chair of National Police Chiefs� Council, [REDACTED]

The family requested me to refer to the deceased as Angela. I will reflect that in this report. I conducted an inquest into the death of Angela Mittal which concluded on 26th of July 2024. The conclusion of the jury was as follows: Angela was unlawfully killed. The following Thames Valley Police findings have been admitted: a.� The officers who spoke to Angela on 29th of November 2018 did not recognise that she was reporting the crime of coercive control. b.� The officers who spoke to Angela on 29th of November 2018 did not record the crimes she reported, either of assault or coercive control. c.�� The officers who spoke to Angela on 29th of November 2018 accepted that the risk grading on the DOM-5 risk assessment form should have been medium rather than standard. d.� The senior officer who saw Angela on 29th November 2018 accepted that he did not fully review the DOM-5 risk assessment form before signing it. e.� The officers who spoke to Angela on 29th November 2018 did not take information available to them (on the command and control system used then, from a call Angela had made to the police earlier that morning) into account in their assessment of risk. This was despite the call handler identifying domestic violence and coercive control in the course of that 16 minute telephone call. f.�� The officers who spoke to Angela on 29th November 2018 did not investigate the crimes Angela reported to them that day. Based on all the evidence heard in court, we the jury conclude that the admitted failings of Thames Valley Police, on the balance of probabilities, did not contribute to Angela�s death.

Angela was murdered at her home address by her husband on 26th of December 2018. She was 41 years old at the time of her death. We heard in evidence that Angela had spoken to Thames Valley Police by telephone and in person on the 29th of November 2018. She reported an allegation of assault around a month prior to that, and also many of the elements of coercive control. She also reported an assault on her young child to the call handler, but this was not recorded as a crime, nor handed over to the police officers who saw her that day. Because of the involvement of a child in the family home, a referral was made to the Multi- Agency Safeguarding Hub within Wokingham Borough Council Children�s Services. A decision was made to carry out a Child and Family Assessment under Section 17 of the Children Act of 1989. Angela had moved out of the marital home whilst she was in contact with the social worker at Wokingham Borough Council. Although she had discussed the possibility of returning to the marital home, she did not tell the social worker of a definite plan to do so. Tragically, and against her family�s advice, Angela returned home on the evening of 25th of December 2018. Her husband rang Thames Valley Police the following morning to tell them that he had murdered his wife. Before this inquest took place, a criminal trial and a domestic homicide review had been undertaken. It is important to acknowledge, in relation to the concerns listed below, that the death occurred some five and a half years ago.

I have sent a copy of my report to the Chief Coroner and to Angela�s family, via their legal representative. I have also sent this report to the following recipients, who have an interest in this matter: Legal representatives for Thames Valley Police. Legal representative for Wokingham Borough Council. College of Policing. � who may find it useful or of interest. The above recipients are not expected to respond to this report. 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

Thames Valley Police | National Police Chiefs� Council

21/03/2024

2024-0159

Mary Jones

Cheshire

REGULATION 28 REPORT TO PREVENT DEATHS � 1��� amazon UK

INVESTIGATION � On 14 November 2023 I commenced an investigation into the death of Mary JONES aged 86. The investigation has not yet concluded and the inquest has not been heard.

Mary Jones was found dead at her home address on 7 November 2023. She had last been spoken to on 6 November. She died as a result of a deliberate overdose of medication, taken with the intent to end her own life. As part of calculating what a fatal dose would be, she consulted a well known book advising on suicide methods.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to � who may find it useful or of interest. � I am also under a duty to send 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: Amazon UK

18/11/2024

2024-0638

Richard Brookes

Greater Manchester South

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS The Department for Work and Pensions

On the 23rd February 2024, I commenced an investigation into the� death of Richard William Brookes, known to his family as Rick. I heard an inquest touching on Rick�s death at Stockport Coroner�s Court on� the 14th November 2024.

At the Inquest on the 14th November 2024, I returned a conclusion of� suicide. In respect of the circumstances of the death I found that on the 25th January 2024, the deceased accessed the railway by the�[REDACTED]. He intentionally stepped in the path of an approaching train and was struck, causing catastrophic and fatal� injuries.�� In the days prior to his death, the deceased had been experiencing a� crisis period in his mental health. He had been diagnosed with possible paranoid schizophrenia in 2011 and was taking anti-psychotic� medication. In the days prior to his death he had been expressing� paranoid thoughts to his family and was anxious and distressed. His� deliberate actions combined with his expressions to his family prior to� his death that he thought something would happen that day, led me to� conclude that it is likely that he intended to end his own life.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Greater Manchester Police, Pennine Care�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.

Suicide (from 2015)

Department of Work and Pensions

08/11/2024

2024-0612

Lacey Brookman

London Inner (South)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS � [REDACTED], President Royal, Royal College of General Practitioners, 30 Euston Square, London, NW1 2FB [REDACTED], President of the Royal College of Paediatricians and Child Health, 5-11 Theobalds Road, London, WC1H 8SH [REDACTED], President of the Royal College of Surgeons, 35-43 Lincoln�s Inn Fields, London WC2A 3PE [REDACTED], President of the Royal College of Radiologists, 63 Lincoln�s Inn Fields, London WC2A 3JW

On 18.6.2021 I commenced an investigation into the death of Lacey May Brookman, aged 11. �The investigation concluded at the end of the inquest on 11.10.2024. The conclusion of the inquest was a narrative conclusion.

That narrative conclusion summarises the events as follows: � Lacey was 11 when she had suffered over a week of varying abdominal pains associated with nausea, vomiting, constipation and low-grade fever. After approx. 10 days her mother had a telephone consultation with her GP. Some of her symptoms appeared to be settling and it was determined she had been/was suffering from a viral illness. She was given safety netting advice. � Three days later she re-presented to another GP at the same practice who considered she had appendicitis; she was transferred to hospital. There she was seen by A&E and surgical doctors. The registrar did not consider she had appendicitis but perhaps another diagnosis and arranged for her to be reviewed on the ward later the same day. She went home in the interim at about 0200 (24/4//2021). The consultant reviewed her later that day and considered she was unwell but could not reach a diagnosis. He arranged for an urgent abdominal ultrasound, +/- CT scan. Those investigations revealed a retrocaecal, perforated appendix with abscess formation and right sided hydronephrosis. The evidence was that the appendix had likely perforated before the original GP telephone review (20/4/2021). � Lacey was transferred to a specialist paediatric unit for operation the following day (25/4/2021) but developed a duodenal ulcer and coagulopathy as a result of her condition. The appendix was removed but Lacey had an extremely stormy post-operative period. That post operative period included further operations, leaving her abdomen open, on-going coagulopathy, disseminated intravascular coagulation and ultimately widespread multiorgan failure. Despite the input of 2 further hospitals, she did not survive and died on 4/6/2021 at 17.25hrs � The Inquest also heard expert evidence from a Consultant Paediatric Surgeon who explained that (1) Acute Retrocaecal appendicitis occurs in about one-third of acute appendicitis presentations (2) that it is difficult to determine as its presentation is not �classical� in terms of right sided abdominal pain and presenting symptoms (3) it therefore often presents late and following perforation and with complications already present, and (4) the availability of abdominal ultrasound +/- CT scan is therefore critical in diagnosing its presentation. � The court also heard about the Surgical Abdominal Pathway and �Getting It Right First Time� (re appendicitis) and the NICE guidelines (about which there is a brief reference to retrocaecal appendicitis). � However, from the evidence I heard in court, I do not consider there is sufficient knowledge and awareness and therefore consideration from junior staff in relation to this particular type of presentation of acute appendicitis.� In addition, the importance of carrying out an abdominal ultrasound (+/- CT) was highlighted.� The evidence was that this could only be provided by the on-call radiologist, which therefore restricted its availability and assistance in making the diagnosis.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] [REDACTED] [REDACTED] James Paget Hospital King�s College Hospital Addenbrooks � [and to the to all safeguarding boards in Norfolk, Cambridge and covering Kings (where the deceased was under 18)]. � 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) | �Hospital Death (Clinical Procedures and medical management) related deaths

Royal College of General Practitioners | Royal College of Paediatricians and Child Health | Royal College of Surgeons | Royal College of Radiologists

20/12/2024

2024-0702

Susan Karakoc

Nottingham and Nottinghamshire

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS � � The Secretary of State for Health and Social Care The Secretary of State for the Department for Science, Innovation and Technology The Medical and Healthcare Regulatory Authority The Financial Conduct Authority The Chief Coroner

On 7 March 2024, I commenced an investigation into the death of Susan Marie Karakoc. � The investigation concluded at the end of the inquest on 28 November 2024. � The conclusion of the inquest was a narrative conclusion: � Susan Marie Karakoc sought to treat her symptoms of fibromyalgia with [REDACTED] and [REDACTED] which she obtained from websites selling prescription medication off-label. Susan had levels of [REDACTED] associated with fatalities and [REDACTED] at a potentially toxic level. Those medications taken together acted synergistically to depress Susan�s cardiorespiratory system which led to her suffering hypoxic brain injury which in turn caused her to suffer multiple organ failure which led to her death.

On 1 December 2023, Ms Karakoc collapsed at her home address. She was found by a family member and transported to hospital by ambulance. Investigations at hospital found Ms Karakoc had suffered a hypoxic brain injury which was not survivable. Ms Karakoc died on 2 December 2023. � Following Ms Karakoc�s death, toxicological examination revealed that the catalyst for the chain of events leading to Ms Karakoc�s death was [REDACTED] and [REDACTED] toxicity. Ms Karakoc was not prescribed either of these medications by her General Practitioner and the General Practitioner was unaware of Ms Karakoc taking those medications. � Ms Karakoc�s family provided evidence which proved that Ms Karakoc obtained these medications from online sources via websites set up to sell prescription medication off-label. Ms Karakoc made over 100 purchases of [REDACTED] and [REDACTED] in a period of a little over a year. The ready availability of medications such as these to purchase from websites circumvents the patient safety measures in place and places vulnerable persons at risk of death. This represents a real and ongoing risk of future deaths occurring.

I have sent a copy of my report to the following Interested Persons: � Susan Karakoc�s family I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I will send a copy of my report to the following: � 1. The Secretary of State for Health and Social Care 2. The Secretary of State for the Department for Science, Innovation and Technology 3. The Medical and Healthcare Regulatory Authority 4. The Financial Conduct Authority � 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.

Alcohol, drug and medication related deaths

Department of Health and Social Care | Department for Science, Innovation and Technology | The Medical and Healthcare Regulatory Authority | The Financial Conduct Authority

22/08/2023

2023-0335

Lawson Bond

Worcestershire

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS [REDACTED], Chief Executive, Wychavon District Council, Civic Centre, Queen Elizabeth Drive, Pershore, Worcestershire WR10 1PT

On 22 April 2022 I commenced an investigation and opened an inquest into the death of Lawson Bond, a child of 2� years of age. The investigation concluded at the end of the inquest on 21 August 2023. The conclusion of the inquest was that Lawson died as the result of misadventure.

In answer to the questions �when, where and how did Lawson come by his death?�, I recorded as follows: �On 28.3.22 Lawson Bond was attacked and mauled by an adult Rottweiler at his home in Egdon. The Rottweiler was in a field at the address, to which Lawson had gained access from his garden by climbing a gate and unhitching a security chain. He was taken to Worcestershire Royal Hospital, and then to Birmingham Children�s Hospital, where he died from his injuries on the morning of 30.3.22.� The Rottweiler which mauled Lawson was one of eight adult Rottweilers kept by Lawson�s grandmother [REDACTED]. For many years,������������������������������������������ had been running a business breeding Rottweilers and advertising Rottweiler puppies for sale. She ought to have obtained a licence to carry out these activities, as per The Animal Welfare (Licensing of Activities Involving Animals) (England) Regulations 2018, but had never had one.

I have sent a copy of my report to the Chief Coroner and to the following: (a)�� [REDACTED], Lawson�s mother; (b)�� [REDACTED], Lawson�s father; (c)���[REDACTED], Lawson�s grandmother, who had Interested Person status for the purposes of the inquest. � 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

Wychavon District Council

04/01/2023

2023-0009

Sylvia Price

Suffolk

RH Thomas Pursglove MP Minister of State for Disabled People, Health and Work. House of Commons London SW1A 0AA � RH Nusrat Ghani MP Minister of State for Business, Energy and Industrial Strategy House of Commons London SW1A 0AA

On 9th December 2021 I commenced an investigation into the tragic death of� Sylvia Frances PRICE.� The investigation concluded at the end of the inquest on 8th December 2022. The conclusion of the inquest was that:� Sylvia Price, died as the result of an accidental death � The medical cause of death was confirmed as: � 1a Aspiration pneumonia 1b Intracerebral, subdural and extradural haemorrhages � 2 Cervical and thoracic spine fractures

Sylvia Frances Price died on the 4th December 2021 at 0915 am, at Ipswich Hospital, Heath Road, Ipswich. � Sylvia attended Ufford Park Hotel and Spa on the 30th November 2021 for a meal. Prior to leaving the hotel, Sylvia went to use the toilet facilities. The closest toilet facilities were located down a flight of stairs. Sylvia fell down this flight of stairs. � No signage was in place in the vicinity, that would have indicated the availability of an accessible toilet on the same level as an alternative option. The injuries she sustained as a result of the fall were extensive, and led to Sylvia being admitted to Ipswich Hospital. Whilst being treated for her injuries at Ipswich Hospital, Sylvia developed aspiration pneumonia which was the medical cause of her death. The injuries sustained in the fall, cerebral haemorrhages and spinal injuries, were contributing factors to her death.

Other related deaths

Minister of State for Disabled People, Health and Work and Minister of State for Business, Energy and Industrial Strategy

10/7/2024

2024-0365

Benjamin Faux

Berkshire� � Category: Suicide (from 2015)� � � This report is being sent to: Reading University | Universities UK

Reading University Universities UK Reading University | Universities UK

On 3 October 2023 I opened an inquest into the death of Benjamin Faux on 5 August 2023, aged 21. The inquest concluded on 26 June 2024. The conclusion of the inquest was suicide, and the medical cause of death was 1a Hanging. The family requested that I refer to Benjamin as Ben, I will reflect that in this report.

Ben graduated from Cambridge University in Summer 2022 and started a taught research Masters in the Chemistry School at Reading University in the autumn term of 2022. From October 2022 Ben had a diagnosis of mixed anxiety and depressive disorder on a background of chronic social anxiety since the Covid pandemic. Ben�s attendance fell drastically from Christmas 2022. From then on Ben missed lectures, hardly attended labs and missed deadlines repeatedly. In early 2023 he developed acute mental health issues probably triggered by the stress of managing academic work and deadlines and he reported suicidal thoughts to student welfare counsellors, his GP and NHS secondary mental health services. Ben had capacity and was adamant he did not want his parents to know about his mental health problems, or his difficulties with his studies. Ben�s academic tutor and department director of academic tutoring (DDAT) were unaware of Ben�s difficulties until he wrote to them in March 2023 explaining that he had severe mental health problems that were interfering with his work. They met with him twice and at the second and last meeting on 24 April 2023 proposed that he formally indefinitely suspend his studies and concentrate on his health. Ben was provided with paperwork to formally take this step. Ben�s academic tutor thought that Ben was going to do it. Ben in fact did not. On 17 May 2023 Ben told a member of staff at the Student Support Centre who contacted him that he no longer wanted to suspend and would contact his academic school to produce an academic plan of action. However he did not contact his school and they did not contact him. Academic staff became aware that Ben had not suspended his studies in late June 2023. No-one from the University took any other steps to contact or check on Ben, or to ask anyone else to contact or check on him. Ben did not re-engage with any academic work but continued living in his student accommodation where he took his own life on or around 5 August 2023.

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

Suicide (from 2015)� � �

08/02/2024

2024-0070

Dayle Bates

Cumbria

Recovery Steps Cumbria

On 8 September 2023 I commenced an investigation into the death of Dayle BATES. The investigation concluded at the end of the inquest . The conclusion of the inquest was � Drug related death. 1a������ Drug Intoxication

Dayle Bates was 39 years old. He lived in Workington, Cumbria. Mr Bates had a past medical history of drug misuse. On 31st August 2023 Mr Bates� body was discovered at�his home. Ambulance staff were unable to revive Mr Bates and his death was confirmed at 11:50. A post mortem examination has confirmed that his death was caused by the combined effect of heroin, bromazolam, protonitazene, xylazine and alcohol.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of Mr Bates. � I have also sent it to of J H Sandham Chemists, 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: Recovery Steps Cumbria

25/08/2023

2023-0309

Miss C

Northamptonshire

Resuscitation Council UK Northampton General Hospital Trust

On 13 October 2021 I commenced an investigation into the death of Miss C, aged 36. The investigation concluded at the end of the inquest on 24 August 2023. The conclusion of the inquest was that: � Miss C died at Northampton General Hospital on 5th October 2021. The primary underlying causes are recent weight loss with nutritional deficiencies and interstitial pneumonia. On 4th October 2021 during her deterioration, a doctor should have reviewed but did not do so until later. A review before the cardiac arrest would have provided a chance for enhanced supportive care and an early peri-arrest call might have been activated which could have had a favourable effect on the outcome. There was therefore a missed opportunity in the medical care.

Miss C died at Northampton General Hospital on 5th October 2021. The primary underlying causes are recent weight loss with nutritional deficiencies and interstitial pneumonia. On 4th October 2021 during her deterioration, a doctor should have reviewed but did not do so until later. A review before the cardiac arrest would have provided a chance for enhanced supportive care and an early peri-arrest call might have been activated which could have had a favourable effect on the outcome. There was therefore a missed opportunity in the medical care. � Although ultimately determined to be non-causative of the death, the management of the cardiac arrest which occurred around 7 hours before Miss C passed away was scrutinised. During the cardiac arrest, an arterial blood gas showed metabolic acidosis, hyperkalaemia, increased lactate, hyponatraemia, and hypoglycaemia. Calcium gluconate (dose not known) and 20% glucose were administered. Administering calcium gluconate (medication used to manage hypocalcaemia) is not the Hospital Trust�s policy for the treatment of hyperkalaemia in cardiac arrest. � There were conflicting amounts of dextrose recorded as given in the clinical notes compared to what was signed on the drug chart. The drug chart states that only 500mls of 5% glucose was commenced at 17:20 hours, however the clinical notes state that the following was given: � 20% 100mls, 3 bags of 5% Dextrose. Insulin was not given. The Hospital Investigation Panel concluded that dextrose and insulin would be administered to treat hyperkalaemia however, as Miss C was hypoglycaemic (blood sugar of 0.9mmol/l) and this would have further reduced her blood sugar, this was the rationale for not administering insulin at that time. � Return of spontaneous circulation was achieved after ten minutes.

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 � The family of Miss C. � 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: Resuscitation Council UK | Northampton General Hospital Trust

22/06/2023

2023-0208

Mason French

Sunderland

Road Safety Manager, South Tyneside Council

On 31st October 2022 I commenced an Investigation into the death of Master Mason French, who was born on 2nd January 2011 and who died at Lizard Lane, Whitburn, Sunderland on 25th October 2022 aged 11 years. The Investigation concluded at the end of an Inquest on 22nd June 2023. The conclusion of the Inquest was �Road traffic collision�. The medical cause of death was: Ia Blunt Head Injury

Mason French died on 25th October 2022 at a concealed junction on Lizard Lane, Whitburn., when his bicycle collided with a passenger bus.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ������ 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: South Tyneside Council

13 /02/2024

2024-0082

Michael Nye

Berkshire

Royal Berkshire Hospital Berkshire and Surrey Pathology Services

On 18 November 2022 I commenced an investigation into the death of Michael James NYE aged 48. The investigation concluded at the end of the inquest on 07 February 2024. The conclusion of the inquest was that: � On advice from his General Practitioner Mr Nye attended the Emergency Department of the Royal Berkshire Hospital at 18.33 on 14th November 2022 suffering from sepsis due to a Streptococcus A skin and soft tissue infection. A single working diagnosis of an upper arm DVT was made by the Emergency Department consultant on call. The Emergency Department was exceptionally busy that night and there were delays in obtaining blood test results, CT scans, escalating Mr Nye�s case to the Intensive Care Unit team and prescribing antibiotics or any other treatment to target sepsis from skin and soft tissue infection. Mr Nye�s condition was observed to deteriorate at about 23.45 and he went into cardiac arrest at about 01.20am on 15th November 2022. A return of spontaneous circulation was achieved after about 3 minutes, but after a CT scan at about 03.00 Mr Nye suffered a further cardiac arrest and resuscitation attempts were unsuccessful. His death was verified at 04.05 on 15th November 2022. On the balance of probability Mr Nye�s death was more than minimally contributed to by: over-crowding in the Emergency Department, lack of a resus bed and pressure on clinical resources;delay in considering a differential diagnosis of sepsis from skin and soft tissue infection;delay in obtaining blood test results;delay in organising and undertaking CT scanning;delay in prescribing antibiotics to target sepsis from skin and soft tissue infection;delay in escalating his case to the Intensive Care Team.

On advice from his General Practitioner Mr Nye attended the Emergency Department of the Royal Berkshire Hospital at 18.33 on 14th November 2022 suffering from sepsis due to a Streptococcus A skin and soft tissue infection. A single working diagnosis of an upper arm DVT was made by the Emergency Department consultant on call. The Emergency Department was exceptionally busy that night and there were delays in obtaining blood test results, CT scans, escalating Mr Nye�s case to the Intensive Care Unit team and prescribing antibiotics or any other treatment to target sepsis from skin and soft tissue infection. Mr Nye�s condition was observed to deteriorate at about 23.45 and he went into cardiac arrest at about 01.20am on 15th November 2022. A return of spontaneous circulation was achieved after about 3 minutes, but after a CT scan at about 03.00 Mr Nye suffered a further cardiac arrest and resuscitation attempts were unsuccessful. His death was verified at 04.05 on 15th November 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Michael Nye�s family 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: Royal Berkshire Hospital | Berkshire and Surrey Pathology Services

19/07/2024

2024-0389

Joseph Parker

Avon

Royal College of Anaesthetists (RCOA)�� Faculty of Intensive Care Medicine (FICM)� Royal College of Emergency Medicine (RCEM) NHS England

On 21/4/22 an investigation into the death of Joseph Lawrence Parker was commenced. The� investigation concluded at the end of the inquest on 4/5/24. The conclusion of the inquest was a narrative, recorded as follows:�� �The deceased Joseph Lawrence PARKER died on 16 April 2022 at Southmead Hospital. On 17th February 2022 he had taken an overdose of medication which caused his collapse. He was taken to hospital and required intubation. During the procedure the tube was accidentally positioned in the oesophagus, this accidental misplacement should have been identified due to the volume of vomit coming from the tube and the lack of a recognisable capnograph at that time. Once accidental osophageal intubation was recognised he was correctly intubated. The incorrect placement caused him to suffer a cardiac arrest, which led to hypoxic encephalopathy and his death.�

On 17th February 2022 Joe�s parents couldn�t wake him, so called 999. The first paramedic was on scene at 07.16hrs. Joe was unconscious, but not in cardiac arrest, his oxygen levels were low at 12, he could see evidence of vomit, an oropharyngeal airway was put in and his� oxygen levels went up to 48%. Joe vomited and they had to suction his airway. �� Joe was taken to Southmead Hospital. During the journey Joe confirmed he had taken�and an unidentified tablet.�� �� The Consultant in Emergency Medicine, [REDACTED], confirmed that after Joe arrived, and following a rapid assessment of him, colleagues from the Intensive care unit were called as Joe needed to be intubated.� � �� [REDACTED], attended from the intensive care unit to carry out the intubation, he called his colleague�[REDACTED]�to assist and to supervise the intubation. Joe was pre-oxgenated. Intubation began at around�9.37am.�� �� Video laryngoscope was used to view the chords, both [REDACTED]�and�[REDACTED]�said that the chords�could be viewed. [REDACTED] then inserted the bougie into the airway, both doctors said that they� saw the bougie enter the windpipe, [REDACTED] then inserted the breathing tube, by railroading it�over the bougie, as he did this it became stuck on cartilage which meant that he had to rotate the tube, the bougie was then taken out, and the cuff was inflated. The tube was not tied in and he accepted that�it should have been done immediately.� �� �� It appears from the evidence that both�[REDACTED] and [REDACTED] checked the capnograph at this point to check for an end tidal trace.� � [REDACTED]�said he didn�t know how many, but that he had confirmed�tube placement, he added that he didn�t think he would ever have confirmed without seeing at least 3;�[REDACTED] said we saw 3 breaths on the monitor.��� [REDACTED] also referenced the other indicators which were: chest wall movement, breath sounds in the� chest, fogging in the tube. He accepted that on their own they are unreliable but that they supported the view that the tube was in the right place.�[REDACTED] said that she would have been looking at the monitor�as well and she thinks she saw a few end tidal carbon dioxide traces 2 or 3.� �� �� What is clear from the evidence is that at the time there was no standard guidance on what the� requirement was in relation to the capnography. At the time the campaign was no trace wrong place.� �� What happened next and the exact sequence of events varied slightly between the witnesses. There was� aspirate/vomit which resulted in suctioning of the airway which I am told was not unexpected, as they� were aware that Joe had previously vomited. The aspirate then quickly became larger volumes of vomit.� Both doctors accepted that with hindsight the amount of vomit was too much to come from the lungs.� �� �� During this time Joe�s oxygen levels were dropping and he was heading to cardiac arrest so he called for� back-up from [REDACTED], Consultant in Anaesthesia and Intensive Care Medicine.�� �� Joe went into cardiac arrest, at around 9.41am, chest compressions were started, advanced life support� was given.� �� When�[REDACTED] arrived, he noted no trace on the capnograph and asked if the tube was in the right�place, he said, because of the uncertainty, he looked with the laryngoscope and saw that it was in the�osopahagus, he took it out and put in a new tube. Return of spontaneous circulation was achieved after Joe had been correctly intubated at around 9.48 �� 9.49am�� �� Joe was taken to the intensive care unit but unfortunately did not recover due to a significant brain� injury.�� �� [REDACTED], Specialist in Intensive Care Medicine and Anesthetist provided his expert opinion, of note�he said:��� The initial cause of Joe�s neurological decline was the opiate overdose, with initial early recovery due to the actions of the ambulance staff.� �� He continued to have impaired respiratory function but his respiratory rate was normal with low� oxygen saturations. �� Once at the emergency department the decision was made to intubate. That the tube was found to be in the oesophagus, this is a recognized complication. �� It was after accidental oesophageal intubation that Joe went into cardiac arrest.� �� That it was during the cardiac arrest that the hypoxia caused the brain injury. �� That the standard at the time was to see a recognisable waveform trace on the capnograph. �� That if the tube is in the oesophagus you can still get some trace. �� He agreed that they needed to pass suction to deal with the aspirate which was expected, but that� the volume of vomit was not questioned, he said that it is a much smaller volume of vomit that� would be in the airways,��� That the time when the clinicians should have focused most attention on the end tidal trace is after� intubation and then if not progressing as expected to re-assess the end tidal trace.��� It is unlikely that there was a recognizable capnograph trace in this case. So recognition of the� accidental oesophageal intubation should have occurred relatively early, but in this case did not.� That the volume of vomit should also have triggered a suspicion of accidental oesophageal� intubation. �� That they should have re-intubated, which would have meant that the period of hypoxia would have been transient and would not have resulted in Joe�s death.

I have sent a copy of my report to the chief coroner and to the following interested persons: Family of the deceased North Bristol NHS Trust [REDACTED] South Western Ambulances Service Trust I have also sent a copy to [REDACTED]. I am also under a duty to send the chief coroner a copy of your response. The chief coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make� representations to me, the coroner, at the time of your response, about the release or the publication of� your response by the chief coroner.

Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: Royal College of Anaesthetists | Faculty of Intensive Care Medicine | Royal College of Emergency Medicine | NHS England

06/12/2024

2024-0674

Michael Thompson

Birmingham and Solihull

Royal Orthopaedic Hospital NHS Foundation Trust

On 22 August 2024 I commenced an investigation into the death of Michael John THOMPSON. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Died� from a recognised complication of necessary surgery for chondrosarcoma

Mr Thompson was found to have an extensive chondrosarcoma of the pelvis. He was admitted to� the Royal Orthopaedic hospital on 05/04/24 and had a right sided hindquarter amputation and soft� tissue reconstruction on 08/04/24. This was complex surgery involving two consultant orthopaedic� oncology surgeons and plastic surgeons. During the surgery a defect was made in the peritoneum� during resection of the tumour which was repaired with sutures and bleeding was controlled from� the internal iliac vein. There was damage to the contralateral common iliac vein likely caused by� dissection during the surgery. This vein injury was difficult to control and required surgeons to� attend from University Hospital Birmingham who repaired the defect with a synthetic vascular graft. The surgery was completed and as he was unstable Mr Thompson was transferred to the Queen� Elizabeth Hospital ITU for 4 days for resuscitation and closer monitoring. He returned to the Royal� orthopaedic hospital on 12/04/24 and appeared to be making good recovery. He developed�hiccups overnight on 15/16th April which were treated medically with a plan to arrange a CT scan if this did not resolve. In the early hours of 18/04/24 he sadly collapsed having had a large vomit and� should not be resuscitated. Post-mortem examination found a defect in the peritoneum through� which small bowel had become herniated leading to vomiting and aspiration.� Following a post mortem the medical cause of death was determined to be: 1a ASPIRATION 1b�� INTERNAL HERNIA WITH SMALL BOWEL EXTENDING THROUGH A DEFECT IN THE PERITONEUM INTO THE SURGICAL BED� 1c HINDQUARTER AMPUTATION FOR CHONDROSARCOMA 1d �II

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

Royal Orthopaedic Hospital NHS Foundation Trust

24/07/2023

2023-0276

Alan Nippard

Avon

Royal United Hospital

INVESTIGATION and INQUEST � On 7 July 2022?I commenced an investigation into the death of?Alan Christopher?NIPPARD. The investigation concluded at the end of the inquest. The conclusion of the inquest was a narrative including a finding of neglect. Mr Nippard�s death was caused by a pressure sore. The pressure sore was preventable with the provision of basic nursing care, this was not provided. There was a gross failure to provide basic nursing care. Once he had the pressure sore his death could have been prevented with the provision of basic nursing care, such as, skin care, regular re-positioning and personal care, this was not achieved at all. He was not managed in line with recognised nursing practice and as a consequence his death was contributed to by neglect. � The medical cause of death was recorded as: 1a???Sepsis 1b???Necrotising fasciitis/Fournier s gangrene 1c???Pressure sore sacrum ? II????Septic arthritis, Type 2 diabetes mellitus, chronic kidney disease, left ventricular systolic dysfunction

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21st September 2023. I, the coroner, may extend the period. � Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.

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

24/02/2023

2023-0072

Sharon Harman

Cornwall and the Isles of Scilly

Rt Hon Chris Philip MP Minister of State for Crime, Policing and Fire

On 24 February, I concluded an inquest into the death of Sharon Elaine Harman, 49, who was stabbed to death by her husband at their home address in Polperro, Cornwall on 6 August 2021. Mr Harman then cut his own throat. Tragically, both these events took place in front of the couple�s teenage daughters. Elaine�s medical cause of death was recorded as: 1a) Stab wounds to the neck and chest � I recorded a Conclusion of Unlawful Killing.

On 31 July and 4 August 2021, Elaine was assaulted by her husband. He was arrested by police on suspicion of assaulting her and occasioning actual bodily harm. In interview on 5 August, he denied the charge. He was released from custody later that day on police bail subject to two conditions (i) not to contact Elaine or their two children and (ii) not to attend the property. � On 6 August, it had been arranged for Mr Harman�s son to collect personal items from Elaine at the home address. Mr Harman rang his son to delay the appointment. In breach of the bail conditions, he then attended the home address, forced entry and stabbed Elaine to death.

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

Other related deaths

Minister of State for Crime, Policing and Fire

04/04/2015

2023-0508

Julie McCabe

North Yorkshire and York

Rt Hon Dr Vince Cable M.P [REDACTED] Director General CPTA Chief Coroner � HH Judge Peter Thornton QC

On 30/11/2012 I commenced an investigation into the death of Julie McCabe (aged 39). The investigation concluded at the end of the 3 day, inquest on 19/02/2015 � The conclusion of the inquest was: Accidental death due to a rare but known potential adverse reaction to hair dye which caused irreversible brain damage due to anaphylactic shock on 30th October, 2011. � Cause of death was: � 1a) Acute Cardiorespiratory Arrest 1b) Longstanding Severe Anoxic Brain Damage 1c) Anaphylactic Shock on 30th October 2011

Julie McCabe died as a result of an adverse reaction to a chemical component contained in hair dye. That component; Para-Phenylenediamine (PPD) is a long recognised potent and powerful allergen. Julie and her treating G.P.�s were aware of her longstanding allergy to hair dye going back to at least 2005. Julie was known to have had a black (probably) henna tattoo in 2007. The frequency of her visits to the G.P. increased after 2007. Black Henna, which contains PPD, is known to sensitise people who use hair dye which also contains PPD. That is all permanent and to a lesser extent, some non-permanent hair dye � Julie had used hair colourants for probably 10 years before she died. During that time she had visited her G.P.�s surgery 16 maybe 20 times, and the local hospital twice following adverse reactions. Evidence was given that Julie would have a reaction every time she used hair colourant. ft would appear she did not seek professional help every time.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] � Director General, Cosmetic Toiletry and Perfume 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 This report is being sent to: CPTA

18/04/2023

2023-0120

John Stiff

East London

Rt Hon Steve Barclay MP, Secretary of State for Health & Social Care � ���������������������������������� [REDACTED] CEO Barking, Havering and Redbridge University Hospitals NHS Trust

On 1 December 2022 I commenced an investigation into the death of John Edward Stiff. The investigation concluded at the end of the inquest on the 5 April 2023. The conclusion of the inquest was that Mr Stiff died as a result of an accident (following a fall).

On the 10 November 2022, Mr. Stiff was admitted to Queen�s Hospital having suffered a believed unwitnessed fall. In Queen�s Hospital, he was diagnosed as suffering from an undisplaced fracture of the pelvis. A decision was taken to treat Mr. Stiff conservatively. Even though there was no surgical intervention, he was admitted under the care of the orthopaedic team. The orthopaedic team are not specialists in controlling medical problems associated with fractures. During the course of the admission, Mr. Stiff�s appetite was much reduced. He was not offered any nutritional supplements. On the 15 November 2022 he had reduced oxygen saturations and the medical team became involved in his care. He was diagnosed as suffering from a chest infection. He was treated with supplemental oxygen; intravenous fluids and intravenous antibiotics. Sadly, Mr. Stiff did not recover and he passed away at Queen�s Hospital on the 16 November 2022. It is likely that the fall and fractured pelvis on the 10 November 2022 caused a decline in health and mobility which would have contributed to the development of the fatal pneumonia.

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

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

24/04/2023

2023-0132

Christopher Evans

Avon

Rt Hon Steve Barclay MP, Secretary of State for Health and Social Care [REDACTED] brother of the Deceased Commission Supported Independence Limited Chief Coroner

On 9th December 2020 I commenced an investigation into the death� of Mr. Christopher Evans age 56 years. The investigation concluded at the end of the inquest on 1st March 2023. The conclusion was that the medical cause of death was l(a) Acute myocardial ischaemia; 1(b) Coronary Artery Atheroma and immersion in hot water and the conclusion as to the death was that �The Deceased died of an acute cardiac event following immersion in very hot water�

The Deceased had a long history of alcohol misuse, although he had a very low level of alcohol in his blood at the time of his death, and poorly controlled diabetes mellitus. As a result he was vulnerable and his physical health was deteriorating. Following a Care Act assessment on 7th September 2020 social services determined that the Deceased required placement with 24-hour care appropriate to meet his care and support needs. A referral was made to the Extra Care Housing team in order that a suitable placement be found. In the meantime the Deceased was placed in supported accommodation provided by Supported Independence Limited. The services provided Supported Independence Limited were registered with the Care Quality Commission (CQC). However, the Deceased�s accommodation was a small flat within a single building comprising a number of similar fiats. The building was licensed with the local authority as a house in multiple occupation (HMO) and therefore was not within the remit of the CQC. On moving to his supported accommodation on 6th February 2019 a support plan and risk assessment were prepared. One of the risks identified was that he was at risk when bathing independently due to his mobility issues, his heavy drinking and his diabetes. The risk was to be managed by the Deceased telling the staff when he was going to have a bath and the staff would then monitor him regularly so that they could attend to any problems he may have. On the morning of 28th September 2020 the Deceased was found by a member of staff unresponsive in his bath. He had not informed staff of his intention to take a bath. The bath was full of water and the Deceased was almost completely submerged. A member of staff described the water as �boiling� meaning it was very hot and not literally. A paramedic who attended was unable to put his gloved hand into the water because it was so hot. The Deceased was pronounced dead at the scene. The post-mortem examination confirmed the Deceased had suffered with injuries in keeping with scalding. The degree of burns/ scalding was not sufficient to cause death on their own but the pain and trauma likely precipitated acute myocardial ischaemia. Death by drowning was considered unlikely.

I have sent a copy of my report to[REDACTED] , brother of the deceased, Supported Independence Limited and the Care Quality Commission. I shall send a copy of your response to [REDACTED], brother of the deceased, Supported Independence Limited and the Care Quality Commission. 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.

Other related deaths This report is being sent to: Department of Health and Social Care | Care Quality Commission | Supported Independence Limited

18/04/2023

2023-0124

Patrick Soames

South London

Rt Hon Steve Barclay MP: Secretary of State for Health and Social Care � [REDACTED] Chief Executive, NHS England

On 6th July 2021 an investigation was commenced into the death of Patrick Soames, who was 24 years old when he died on 21st June 2021. I assumed conduct of that investigation on about 18th February 2022 and I concluded that investigation at the end of Patrick�s inquest on 21st February 2023. The conclusion of the inquest was one of suicide with a medical cause of death: Ia suspension.

Patrick lived at home with his parents and was employed. However, in the final month of his life, Patrick experienced a severe emotional deterioration. He engaged in repeated episodes of serious self-harm including cutting his arms, medication overdose and uncharacteristic excessive alcohol misuse. At one point, he briefly went missing when he travelled to Yorkshire � where he also self-harmed. � On 9 occasions during that final month, Patrick attended various hospital accident and emergency departments (in different NHS Trust areas), following incidents of self-harm. Some incidents also involved police contact. Patrick, however, declined to engage with psychiatric liaison services on these occasions and abruptly terminated a brief engagement with psychiatric assessment services following referral. Patrick had mental capacity to refuse treatment.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1)�����[REDACTED]�(Patrick�s parents) (2)��� Croydon Health Service NHS Trust (3)��� Surrey and Sussex Healthcare NHS Trust (4)��� South London and Maudsley NHS Foundation Trust (5)��� Surrey and Borders Partnership NHS Foundation Trust (6)�� London Borough of Sutton � I have also sent it to the MPS, Keston Medical Practice and Rotherham 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.

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

21/04/2023

2024-0099

Sarah Waller and Laura Pottinger

Bedfordshire and Luton

Rt Hon Therese COFFEY MP, Secretary of State for the Environment. Food and Rural Affairs Chief Executive of Environment Agency, Chair of Environment Agency

INVESTIGATION � On 20 April 2023 I commenced an investigation into the death of two women aged 56 and 52. The investigation has not yet concluded and the inquest has not been heard.

Both Deceased were found in the River Great Ouse at Kempston Mill, BEDFORD, on Sunday 16 April 2023 at around 10.50 hours. It appears that, at 10.00am that morning, they had rented out two canoes from KEMPSTON outdoor centre and had been due to return them at 11:00hrs. At the time of discovery, one of the Deceased was still caught in the circulating flow at the base of the weir along with two canoes and 2 life jackets. Although both Deceased were recovered from the water, they were prounced dead at the scene. The outdoor centre have indicated that both women had been renting canoes for them regularly for some years and had experience of the river.

I have sent a copy of my report to the Chief Coroner and to the � Inland Waterways ASSOCIATION � 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: Department for Environment, food and Rural Affairs | Environment Agency

07/03/2024

2024-0130

Nicola Rayner

Suffolk

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

On 16th June 2023 I commenced an investigation into the death of Nicola RAYNER � The investigation concluded at the end of the inquest on 23rd February 2024. The conclusion of the inquest was that the death was the result of: Suicide, resulting directly from a lack of Mental Health bed provision in Suffolk and nationally. � The medical cause of death was confirmed as: � 1a Traumatic asphyxia 1b Hanging

Nicola Raynor was verified as deceased at 19:43 on 10th June 2023, at the Addenbrookes Hospital, Cambridge, Cambridgeshire. � On the 6th June 2023 Nicola had been found hanging [REDACTED]. The emergency services attended, and Nicola was taken to Addenbrookes Hospital where she subsequently passed away as the result of a hypoxic brain injury. � Nicola had a history of poor mental health, and at the time of her death was under the care of the Mental Health Services. � Prior to Nicola being found hanging on the 6th June 2023, she had earlier that day attended a consultation with a psychiatrist, who had wanted to admit Nicola to a Mental Health ward immediately, however no beds were available. � Nicola had a few days earlier (on 29th May 2023), also been seen by a Mental Health Nurse at the local Accident and Emergency department, who had also wanted to immediately admit Nicola into hospital, but due to Bank Holiday pressures, again no bed had been available. At the time of her death Nicola had been placed on a waiting list to be admitted to hospital, but due to non-availability locally, or nationally, admission was not possible. � Had a Mental Health bed been available on the 6th June 2023, Nicola�s death would not have occurred.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- � Nicola�s next of kin. � The Chief Executive Norfolk and Suffolk NHS Foundation Trust. � I am under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Senior 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

30/05/2024

2024-0295

Katie Madden

Suffolk

Rt Hon Victoria Atkins MP Secretary of State Department of Health and Social Care 39 Victoria Street London SW1H 0EU � Right Hon Laura Farris MP Under-Secretary of State Victims and Safeguarding House of Commons London SW1A 0AA � The Chief Executive Norfolk and Suffolk NHS Foundation Trust, Trust Headquarters Hellesdon Hospital Drayton High Road Norwich NR6 5BE. � Suffolk County Council Head of Adult and Child Services Endeavour House 8 Russel Road Ipswich Suffolk � CEO of the NHS Norfolk and Waveney Integrated Care Board County Hall Martineau Lane Norwich NR1 2DH � The Chief Constable Suffolk Constabulary Police Headquarters Portal Ave Martlesham Heath Ipswich IP5 QS

On 7th June 2023 I commenced an investigation into the death of Katie MADDEN � The investigation concluded at the end of the inquest on 21st May 2024. The conclusion of the inquest was that the death was the result of: Suicide, whilst the balance of her mind was disturbed. The medical cause of death was confirmed as: � 1a Hanging

Katie Madden was declared deceased on 4th June 2023 at the [REDACTED] in Suffolk. � Kate had been found by a friend, hanging [REDACTED] � Kate�s friend had attended after not being able to contact her for a couple of days. � Kate was diagnosed with anxiety, depression, and emotionally unstable personality disorder which made her act impulsively when faced with emotionally painful situations and stress. � Kate had previously received a Claire�s Law Domestic Violence Disclosure, and was known to be in a toxic relationship. Kate had historically and recently been the victim of domestic violence. � Kate was known to both Mental Health Services, and Social Services, and her children were in care. � Despite restrictions in place, Kate had argued with the subject of the Domestic Violence Disclosure just prior to her death. During the argument Kate was told to go and kill herself. � Kate�s toxic relationship, in conjunction with Kate�s known mental health conditions, affected her state of mind and therefore contributed to her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; � Kate�s next of kin. Suffolk Safeguarding Partnership � I am under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Senior 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 | Home Office | Norfolk and Suffolk NHS Foundation Trust | Suffolk County Council | Norfolk and Waveney Integrated Care Board | Suffolk Constabulary Police Headquarters

29/05/2024

2024-0291

Hayley Cowan

Manchester North

Rt Hon Victoria Atkins, Department of Health And Social Care, 39 Victoria Street, London, SW1H 0EURt Hon James Cleverley Secretary of State for Ministry of Justice, House of Commans, London, SW1A 0AA

On the 22nd�June 2022, I commenced an investigation into the death of Hayley Jayne Cowan. Hayley died on the 4th June 2022. The investigation concluded on the 23rd May 2024. The medical cause of death was confirmed as 1a) Adverse event arising out of mixed drug use A jury concluded Hayley died as a result of misadventure.

CIRCUMSTANCES OF DEATH Hayley had been detained under Section 3 of the Mental Health Act 1983 since July 2021. She had a long history of involvement with mental health services and had previously been detained. She had a diagnosis of Paranoid Schizophrenia and ADHD. Hayley was a risk to herself and others. As well as her serious mental health illness, Hayley had a long history of illicit drug use. In July 2021 having set fire to her flat she was detained at the Edenfield unit within Prestwich hospital run by Greater Manchester Mental Health and Social Care Trust (�GMMH�). Hayley responded well to the re-introduction of her anti-psychotic medication and as part of her therapeutic work she was granted Section 17 MHA�83 leave. There were times when her leave was escorted and following progress it was on occasions unescorted. Her leave also progressed from being on the hospital grounds to the local Tesco store opposite and at times into the local village. There had been at least two occasions when Hayley had absconded and run off from the staff with her. She had taken drugs and then returned to the hospital. At all times she was considered to be at risk of absconding which was driven by her urge to use drugs. On the 3rd June 2022 Hayley was granted accompanied leave with a support worker to the local tesco store. Both Hayley and the support worker needed to use the bathroom and during this time Hayley absconded. She was found deceased the following day, having used drugs at a friends house where she had gone to. There was no guidance to staff as to what to do should they need to use the bathroom. There was guidance given as to what to do should a patient need to use the bathroom, therefore being out of sight. � � By June 2022 the court heard that Borrowdale ward had introduced a practice of �accompanied leave� by a band 2 support worker rather than the normal �escorted leave� with a band 3 worker who would have received enhanced training. This was due to a shortage of band 3 workers and a desire to facilitate patient leave.

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

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

08/01/2024

2024-0012

Sarah Mitchell

Suffolk

Rt Hon Victoria Atkins, Secretary of State for Department of Health and Social Care [REDACTED], Chief Executive NHS England [REDACTED], Chief Executive James Paget University Hospitals NHS Trust [REDACTED], Rosedale Surgery Lowestoft

On 07 October 2022 I commenced an investigation into the death of Sarah Julie MITCHELL aged 41. The investigation concluded at the end of the inquest on 27 November 2023. The conclusion of the inquest was that: � Drug related � The medical cause of death was confirmed as: � 1a Toxicity of Multiple Drugs, including Morphine, Promethazine, Gabapentin, Fluoxetine 2 Fatty Liver

Sarah Julie MITCHELL suffered from chronic back pain for over 15 years and struggled to manage this as well as the addictive effects of the pain medication she was prescribed to alleviate her pain.� During the 12 years prior to her death she had made several attempts to reduce her pain medication in conjunction with her GP. The debilitating affects of her condition had also negatively impacted on her mental health and she suffered from periodic bouts of low mood and depression for which she was prescribed medication to help alleviate the symptoms. � In the two years leading up to her death, Ms. MITCHELL self medicated, using dosages of her medication in excess of the prescription. She was known to hoard her prescription medication. This resulted in several overdose events where Ms. MITCHELL required ambulance attendance and hospitalisation. Following these overdose events, her GP reduced Ms. MITCHELL�s prescription requiring her to attend daily to receive her medication. This would be increased to weekly following a period of compliance and due to the hardship Ms. MITCHELL experienced having to collect medication on a daily basis. � On the 3rd August 2022, in the early morning (00.13 hours), Ms. MITCHELL was admitted to the James Paget University Hospital A&E Department having been involved in a Road Traffic Collision. Police had brought Ms. MITCHELL to hospital and there was a concern that she had taken an overdose of Gabapentin, one of her prescribed medications. Ms MITCHELL was discharged that morning with 14 days of medication. At the time Ms. MITCHELL was being prescribed her medication on a weekly basis due to concerns relating to her risk of overdose. � In the early evening of the 3rd August 2022 (18.28 hours) Ms. MITCHELL was re-admitted to the James Paget University Hospital following a suspected overdose. She was seen by Mental Health Liaison Staff and assessed as not having suicidal ideation or intent, but having a high risk of accidental death due to overdose from self-prescribing. Ms. MITCHELL was discharged on the 4th August 2022 with a further 14 days of medication provided. The cumulative effect of the provision of 14 days medication on each of her two discharges meant she received 28 days worth of prescribed medication in less than a 48 hour period. Her weekly medication prescriptions from her GP continued meaning that Ms. MITCHELL had further opportunities to hoard her prescription medication. � Ms. MITCHELL took a further overdose on the 11th August 2022 and was admitted again to the James Paget University Hospital in the late evening (23.48 hours) and she underwent a further Mental Health assessment the next day (12th August 2022) by Mental Health Liaison staff. Ms. MITCHELL expressed remorse as to her actions and she was again assessed as not having suicidal ideation or intent.� She was assessed as being at high risk of accidental death from overdose. She was on weekly prescriptions for her medication at this point. A referral was made for further Mental Health Services support/treatment and at the time of her death she was pending an appointment scheduled for the following week. � Ms. MITCHELL was found deceased at her residence on 22nd September 2022. Police enquiries revealed no suspicious circumstances or third party involvement. Post mortem examination found that Ms. MITCHELL had died from Multiple drug toxicity of prescribed medication. Pregabalin, a medication she was not prescribed at the time was also detected, although not at a fatal concentration.

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

Alcohol, drug and medication related deaths This report is being sent to: Department of Health and Social Care | NHS England | James Paget University Hospitals NHS Trust | Rosedale Surgery Lowestoft

08/02/2023

2023-0085

Maxine Davison, Lee Martyn, Sophie Martyn, Stephen Washington and Kate Shepherd

Plymouth, Torbay and South Devon

Rt Hon. Suella Braverman MP, The Home Secretary � Rt Hon Chris Philp MP, Minister of State for Crime, Policing and Fire � NPCC lead for policing, CC Tedds � All Chief Constables in England and Wales � The College of Policing � This document is but one of a number of prevention of future deaths reports that I am issuing following the inquests into the five deaths of those shot by Jake Davison in Keyham on 12 August 2021. I shall copy every addressee all other prevention of future death reports arising from these inquests for their information.

On 19 August 2021 I commenced an investigation into the deaths of Maxine Davison (age 51), Lee Martyn (age 43), Sophie Martyn (age 3), Stephen Washington (age 59) and Kate Shepherd (age 66). The investigation concluded at the end of the inquest held before a jury on 20 February 2023. The conclusion of the jury in respect of these five conjoined inquests was as follows: � Maxine Betty Davison On the 12th August 2021 between 18:05-18:08, Maxine Betty Davison died as a result of shotgun wounds to the head and torso. This occurred at her address, [REDACTED] following an argument with the perpetrator. � Lee Raymond John Martyn On the 12th August 2021 between 18:08-18:10, Lee Raymond John Martyn died as a result of shotgun wounds to the head and torso. This occurred whilst walking with his daughter Sophie Iris Martyn in the street, Biddick Drive, Keyham, Plymouth. � Sophie Iris Martyn On the 12th August 2021 between 18:08-18:10, Sophie Iris Martyn died as a result of a shotgun wound to her head. This occurred whilst walking with her father Lee Raymond John Martyn in the street, Biddick Drive, Keyham, Plymouth. � Stephen John Godfrey Washington On the 12th August 2021 between 18:10-18:12, Stephen John Godfrey Washington died as a result of a shotgun wound to his chest. This occurred whilst walking on Snakey path (Linear Park), a footpath behind Biddick Drive, Keyham, Plymouth whilst walking his dogs. � Kathryn Jane Shepherd (known as Kate). On the 12th August 2021, Kathryn Jane Shepherd received a shotgun wound to her abdomen at 18:13 outside Blush Salon, Henderson Place, Plymouth and subsequently died later that day in Derriford Hospital, Plymouth. � In respect of each deceased the jury also found as follows� Under Section 3 of the Record of Inquest� �The perpetrator came to be and remain in lawful possession of a shotgun at the material time due to the following circumstances: � The initial shotgun licence application In 2017, given the absence of medical information, the known history of assaults and the intelligence held by Devon & Cornwall Police suggesting involvement in other violent episodes, it was a serious failure to protect the public and the peace to grant a licence to the perpetrator. � There was a serious failure within the Firearms and Explosives Licensing Unit (FELU) to heed and apply the 2016 Home Office guidance, that high risk decisions on grant of a licence should be made by the Firearms Licensing Manager (FLM). � Despite the 2016 Home Office guidance in force at that time, inadequate steps were taken to obtain specific medical evidence regarding the extent to which the perpetrator�s declared autism and Asperger�s might impact upon his suitability to hold a shotgun licence. � This was further compounded by the confusion caused by the move from the use of a post to pre-grant letter, without the update to the Home Office guidance which previously stated would be provided. � It was not a safe system to assume that in the absence of a substantive response to the standard pre-grant letter from the GP, there were no relevant medical conditions that could affect the perpetrator�s suitability to hold a shotgun licence. � The mechanism agreed by the FLM and Local Medical Committee to obtain specific factual information about a self-declared medical condition was not communicated to or followed by the Firearms Enquiry Officer (FEO) or the Firearms Licencing Supervisor (FLS). � The referee�s tasks and responsibilities were not made clear and insufficient inquiries were made of the referee given the known history of assaults at school. � Reflecting the culture within the FELU at the time, an insufficient degree of professional curiosity was demonstrated by the FEO and FLS. � The review of the licence The decision to return the shotgun and licence to the perpetrator in July 2021 was fundamentally flawed and as a result failed to protect the public and the peace. � The officer investigating the skate park assaults in September 2020 should have noted that the perpetrator was a firearms certificate holder and taken immediate steps to alert the FELU to the incident. � It was unreasonable to categorise the level of the assault upon the boy in the skate park as battery. There were clear aggravating factors to suggest this should have been charged at a higher level and there was inadequate investigation of whether the assault on the boy in the skate park had led to his unconsciousness. � The use of the Pathfinder scheme in this instance was wholly inadequate in reducing the perpetrator�s future offending. � On reviewing the perpetrator�s suitability to retain the shotgun certificate, the FEO ought to have shown a greater degree of professional curiosity in obtaining and evaluating further information. The case was not passed to the FLM for review which was against Home Office guidance. � General There was a serious failure at a national level by the government, Home Office and National College of Policing to implement the recommendation from Lord Cullen�s Report in 1996 arising out of the fatal shootings in Dunblane, to provide training for FEOs and the subsequent recommendation in Her Majesty�s Inspectorate of the Constabulary�s Targeting the Risk Report in 2015 for an accredited training regime for FEOs. The most recent statutory guidance from the Home Office (2021) has failed to include any mention of FEO specific training. � The training and informal mentoring was insufficient to enable the FEOs to safely discharge their duties. Informal mentoring had inherent limitations, meaning incorrect processes were perpetuated and not formally recorded as an agreed training method to deliver learning outcomes. � There was a catastrophic failure in the management of the FELU, with a lack of managerial supervision, inadequate and ineffective leadership. This was compounded by a lack of senior management and executive leadership who failed to notice or address the issues. � There was a lack of scrutiny and professional curiosity at all levels. The ineffective auditing and governance of the FELU in place led to an inadequate system of dip sampling, qualitative assessment of staff�s decision-making, and learning from the results of the same. � There was a seriously unsafe culture within the FELU of defaulting to granting licences and to returning licences after review. There was a dangerous lack of understanding on the part of the Devon and Cornwall Police FELU staff regarding the use and application of the FELU risk matrix. � Incompatible IT systems both within Devon and Cornwall Police and outside agencies contributed to a failure to communicate effectively. � Budgetary limitations and staff shortages within Devon and Cornwall Police increased the probability of risk being incorrectly assessed which led to unsafe licences being issued. These limitations were not confined to Devon and Cornwall Police but also existed at a national level, for example the National College of Policing not assigning resources to run an accredited national FEO training course.� � The jury�s conclusion in respect of each death under Section 4 of the Record of Inquest was as follows:� �The deceased was unlawfully killed. � The death was caused by the fact that the perpetrator had a lawfully held shotgun. The following contributed to this position. � There were serious failures by Devon and Cornwall Police FELU in granting and, later, failing to revoke the perpetrator�s shotgun certificate. � In licencing the perpetrator to have a shotgun there was a serious failure by Devon and Cornwall Police to protect the deceased. � There was a failure of Devon and Cornwall Police to have in place safe and robust systems. Foremost, the training of FELU staff, governance of the FELU, quality assurance of FELU staff�s decision-making and ensuring decisions were made at the correct level. � There was a failure by Devon and Cornwall Police FELU staff to obtain sufficient medical information in respect of the perpetrator�s application for a shotgun certificate and also on review. � There was a failure by Devon and Cornwall Police FELU staff to properly seek out and consider all the relevant evidence and information available before deciding whether to grant the perpetrator a shotgun certificate. � Following the perpetrator having assaulted two children in 2020, there was a failure by Devon and Cornwall Police to protect the public and the peace. Firstly, within the Local Investigation team regarding the downgraded charge and secondly, within the FELU to sufficiently investigate whether it was safe to return to the perpetrator his shotgun and certificate after initially seizing them. � Incorrect application of the risk matrix meant there was a serious failure by Devon and Cornwall Police to implement an adequate system to ensure that the decision whether or not to (i) grant or (ii) return a shotgun certificate following review, was made or approved by a manager of sufficient seniority. � A lack of national accredited Firearms licensing training has and continues to fail to equip police staff to protect the public safety. � There was a catastrophic failure in the management of the FELU, with a lack of managerial supervision, inadequate and ineffective leadership. This was compounded by a lack of senior management and executive leadership who failed to notice or address the issues.

On 12 August 2021 Jake Davison, who was a licenced shotgun holder, took up his lawfully held pump action shotgun and loaded it with 12-gauge OOB �buckshot� cartridge. He shot and killed his mother Maxine Davison at their home, and then entered the street where he shot six people who were strangers to him, four of whom suffered fatal injuries.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons listed on the appended document, and to the Local Safeguarding Board/Domestic Homicide Review authors. I have also sent it to those also named on the appended document 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 | Child Death (from 2015)

Home Office | National Police Chiefs� Council | Chief Constables | College of Policing

08/04/2024

2024-0190

Carole Mather

Manchester North

Rt Honourable Victoria Atkins Secretary of State for Health and Social Care

On 13 January 2023 an investigation into the death of Carole Mather was commenced. The investigation concluded at the end of the inquest on 5 April 2024. I recorded a conclusion of Misadventure.

CIRCUMSTANCES OF DEATH The Deceased was 66 years old when her body was found in an alleyway next to her home address on 2 January 2023. A post-mortem examination established that she had died of hypothermia. The Deceased had a background of poor mental health and alcohol dependency. In December 2022, she experienced a downturn in mood and relapsed in her use of alcohol following an extended period of abstinence. She presented at Fairfield General Hospital on 1 January 2023 in an intoxicated state and complaining of shortness of breath. She discharged herself from hospital later that afternoon against medical advice which included the fact that she was placing herself at risk of death by declining hospital admission. The doctor who assessed her as having capacity to make the decision to discharge herself was not aware of her history of involvement with mental health services and did not consult with a senior colleague or obtain advice from on- call psychiatry as was required by the hospital protocol. The Deceased returned home directly from the hospital and was observed by neighbours to be in an intoxicated state on her arrival. Her body was found in an alleyway the following morning.

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

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

17/04/2024

2024-0204

William Erskine

Manchester South

Rt. Hon. Michael Gove MP, Secretary of State for Levelling Up, Housing and Communities

On 13th September 2023, Alison Mutch OBE, Senior Coroner for Manchester South, opened an inquest into the death of William Erskine who died on 26th August 2023 on the Concourse of Stretford House, Chapel Lane, Stretford. The investigation concluded with an inquest which I heard on 22nd March 2024. � A post-mortem examination conducted by�[REDACTED], Consultant Pathologist on the Home Office Register, concluded that Mr Erskine died as a consequence of multiple injuries. At the end of the inquest, I recorded a conclusion of Misadventure.

Mr Erskine died on 26th August 2023 on the concourse of Stretford House, Stretford, as a result of multiple injuries sustained when he fell or jumped from the open window of his 16th floor flat whilst his judgement was impaired through cocaine and alcohol use and following a recent violent altercation with his partner. A police investigation has concluded there was no third party involvement in his death.

I have sent a copy of my report to the Chief Coroner, Mr Erskine�s daughter and his partner, and to Devonshires Solicitors LLP on behalf of London and Quadrant Housing Trust. I have also sent a copy to Trafford 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.

Alcohol, drug and medication related deaths This report is being sent to: Ministry of Housing, Communities & Local Government

29/05/2024

2024-0287

John Hartey

Manchester South

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

On 3rd April 2024, Alison Mutch OBE, Senior Coroner, opened an inquest into the death of John Richard Hartey who was found dead at his home on 20th October 2023, aged 57 years. The investigation concluded with an inquest which I heard on 3rd May 2024. A post mortem examination determined the medical cause of Mr Hartey�s death as being:- a) Congestive cardiac failure; Hypertensive heart disease; Type 1 Diabetes Mellitus II) Acute bronchitis and transplant immunosuppression The conclusion of the inquest was a Narrative Conclusion of natural causes contributed to by recognised complications arising from transplant immunosuppression.

Mr Hartey was found dead at his home on 20th October 2023 as a consequence of congestive cardiac failure against a background of hypertensive heart disease and Type 1 Diabetes Mellitus. His death was contributed to by acute bronchitis and transplant immunosuppression.

I have sent a copy of my report to the Chief Coroner, and to Mr Hartey�s sister. � I have also sent a copy to Urmston Group Practice and 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.

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

13/02/2023

2023-0145

Minaal Salam

Stoke on Trent and North Staffordshire

STOKE-ON-TRENT CITY COUNCIL

On 19/04/2022 I commenced an investigation into the death of Minaal Salam, aged 5. The investigation concluded at the end of the inquest on 17th January 2023. The conclusion of the inquest was Minaal Salam passed away on the 1 April 2022 outside her primary school Newstead Primary Academy, Blurton, Stoke-on-Trent, on Waterside Drive, after she was struck by a Volkswagen Touran. This caused poly trauma that led to a traumatic cardiac arrest. � The medical cause of death was: 1a) Traumatic cardiac arrest. 1b) Polytrauma. 1c) Road Traffic Collision (Car on Pedestrian).

Minaal Salam was being collected, by her father, from her school. This is Newstead Primary Academy Blurton Stoke-on-Trent. The incident occurred outside the pedestrian school gate on Waterside Drive. When leaving the school with her father, they were standing on the side of the road, waiting to cross. She was hit by a motor vehicle, which caused survivable injuries. She passed away at the sight of the incident.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1.������ The family of Minaal Salam; and � 2.������ Staffordshire Police � 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 other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

Child Death (from 2015) | Road Traffic Collision This report is being sent to: Stoke on Trent City Council

26/01/2024

2024-0041

Paul Frear

Black Country

Sandwell HighwaysNational Highways Agency

On 4/10/23 I commenced an investigation into the death of PAUL ANDREW FREAR aged 45 years who died on 22/9/23. The investigation concluded at the end of the inquest on 23/1/24. The conclusion of the inquest was Road Traffic Collision. The medical cause for the death of Mr Frear was 1a) Multiple Injuries 1b) Road Traffic Collision

On 22/9/23 Mr Frear passed away at the Queen Elizabeth Hospital, Birmingham from injuries sustained in a road traffic collision on 21/9/23. The collision occurred on the A457 Tollhouse Way, Smethwick at the junction with the B4135 Rolfe Street. CCTV revealed that Mr Frear was a pedestrian waiting at a crossing area, when he entered the carriageway whilst the pedestrian lights were showing red and collided with a vehicle travelling in lane 2.

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

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

29/12/2023

2023-0550

Karmchand Gulzar

Black Country

Sandwell and Birmingham NHS Trust

On 26 September 2022 an investigation was commenced into the death of Karmchand GULZAR. The investigation concluded at the end of the inquest on 13 December 2023. The findings and conclusion of the inquest were � Mr Karmchand Gulzar died at Sandwell hospital on 24 September 2022 during the course of an emergency operation to treat dilated large bowel. There had been a delay in obtaining a CT scan which showed the extent of the condition, meaning that the prospects of surviving surgery had reduced significantly by the time of the operation. Other warning signs of the significance of the surgical abdomen obstruction were not noted including a lactate level of 5 showing that Mr Gulzar was deteriorating. An immediate surgical review was not undertaken. These matters contributed more than minimally to Mr Gulzar�s death. � Natural Causes contributed to by neglect. 1a�Multiorgan Failure 1b Sigmoid Tumor causing Large Bowel Obstruction 1c II�� Schizophrenia

On 23rd September 2022, Karmchand was taken from his secure care home where he was a resident under a Mental Health Act Section to Sandwell Hospital with features of abdominal distension and pain. A member of staff was with him. On arrival he was triaged at 11:01 and assessed by a physician associate at 13:34. This was reviewed by the Emergency Medicine Consultant and a diagnosis of acute intestinal obstruction was made based on the clinical assessment and x- ray of the abdomen which showed distended bowel loops. He was deemed stable and was referred to the nurse co-ordinator on the Surgical Assessment Unit (SAU) at 14:30. Evidence was provided at the inquest that the NELA (National emergency laparotomy audit) risk of death score was 2.3% at this time of referral. � Crucially no CT scan was undertaken which would have provided better resolution and information on the presenting condition. Evidence was given at the inquest that this would form basic medical treatment for an acute intestinal obstruction and consideration of an abdominal emergency laparotomy. Later under examination from the trust representative, the witness recanted slightly on this stating that more junior doctors may not be minded to seek a CT scan, and commented surprisingly that requesting a scan by a consultant in the Emergency department could not be guaranteed. � I received evidence in the form of the serious incident report that there were nursing shortages on that day and that the department was under considerable pressure. No surgical referral had been made. Concerns were raised that observations were not completed on time and I heard evidence from family members that their concerns about Karmchand and the pain he was suffering were not taken on board by staff. The SI report noted that there were difficulties in assessing his condition due to his mental health difficulties meaning that he could not express pain to staff as easily. His family and staff who knew him raised concerns, but adequate notice does not appear to have been taken.. � At 20:30 Karmchand Deteriorated with decreasing level of consciousness and oxygen saturations and was escalated to the ED registrar and transferred to the resuscitation area where he was intubated and taken for CT scan at 22:00. The CT scan demonstrated dilated large bowel and a decision was taken for him to have urgent surgery � The delay in seeking a CT scan, which did not occur until that evening meant that surgery to treat the bowel distention only occurred much later into the evening and into the early morning of 24 September 2022. By this time, the NELA risk assessment had increased from 2.3% to 52% in other words, death was more likely to occur at that point of surgery than earlier in the day. � Mr Gulzar died during surgery in the early hours of 24 September 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1 �� [REDACTED] � Brother on behalf of the Family 2 � Sandwell and Birmingham NHS Trust. I have also sent it to NHS England who may find it useful or of interest. � I am also under a duty to send 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: Sandwell and West Birmingham NHS Trust

18/01/2024

2024-0027

Dorota Kuklinska

Birmingham and Solihull Category

Sandwell and West Birmingham Hospitals NHS Trust University Hospitals Birmingham NHS Foundation Trust

On 10 September 2023 I commenced an investigation into the death of Dorota Marta KUKLINSKA. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Died from a catastrophic brain bleed caused by a cerebral artery aneurysm due to a misreported CT scan and not referring to specialist neurosurgeons.

Mrs Kuklinska attend the City Hospital on 27/06/23 having woken at 05.00 am with a severe headache 10/10 in severity and radiating down the neck and eyes. The headache was associated with vomiting, fever, chills and light sensitivity. There was concern she had suffered a brain bleed so a CT scan was arranged which was misreported as normal as it was later found to show some subtle signs of cerebral swelling but no brain bleed. Had the CT scan been correctly reported it is likely a referral would have been made through NORSE to specialist neurosurgeons and the condition would have been identified and successfully treated. Clinicians advised that a lumber puncture was necessary to confirm or rule out a brain bleed. This was explained to Mrs Kuklinska who was advised of the risks and benefits of a lumber puncture and given an information leaflet but she declined a lumber puncture and self-discharged against medical advice. She was advised to see her GP about the high blood pressure which was identified at the hospital. Given the strong clinical signs of a brain bleed and refusal of lumber puncture a referral should have been made through NORSE to the specialist neurosurgeons which would on balance have identified the condition and successful treatment would have been provided. She attended her GP on 28/06/23 and was prescribed blood pressure medication. On 07/07/23 she advised the GP her headache had resolved as her blood pressure became normal. She collapsed at home on 20/07/23 and was readmitted to hospital where a CT scan confirmed an unsurvivable brain bleed caused by a right middle cerebral aneurysm. She died at the hospital on 21/07/23. � Following a post mortem/Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a Spontaneous Intracerebral Bleed 1b Right Middle Cerebral Aneurysm 1c II

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 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: Sandwell and West Birmingham Hospitals NHS Trust | University Hospitals Birmingham NHS Foundation Trust

31/01/2023

2023-0423

Andrew Bowles

Birmingham and Solihull

Sandwell and West Birmingham NHS Trust and Birmingham and Solihull Mental Health NHS Foundation Trust.

On 1 June 2023 I commenced an investigation into the death of Andrew BOWLES. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Drowned in a canal, having recently attended hospital suffering with a deterioration in mental health. It is unknown how he entered the water nor his intent at the time.

On 15th May 2023 the deceased, who had an extensive mental health background including self-harm, was taken to Birmingham City Hospital, concerns having been raised after he had been seen running in and out of traffic. He was deemed medically fit and was referred for psychiatric assessment. Following assessment referrals were made to the home treatment team and the homeless pathway team, there being no undue concerns noted by psychiatric liaison. Discharge was documented at 23.30, with an expectation that the deceased would remain in A&E until the following morning. CCTV footage showed the deceased leaving the hospital grounds at 23.28. The deceased was found face down in the canal under the road bridge of Dudley Road at 6.34 on the 16th May 2023, it being unclear how and when he entered the water. � Following a post mortem the medical cause of death was determined to be: � 1a Drowning

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The next of kin. � I have also sent it to the Medical Examiner, Birmingham and Solihull Integrated Care board, Public Health England, Department of Health, University Hospitals Birmingham 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.

Other related deaths This report is being sent to: Sandwell and West Birmingham NHS Trust | Birmingham and Solihull Mental Health NHS Foundation Trust

18/09/2024

2024-0506

Ali Nazemi

West Yorkshire (East)

Schindler Ltd, North Office, Wilson House, Crab Lane, Fearnhead, Warrington WA2 0XP

On 25/01/2024 I commenced an investigation into the death of Ali Mohammed Nazemi, aged 53. The investigation concluded at the end of the Inquest on 17/09/2024. The conclusion of the Inquest was that this was a death due to natural causes, the certified cause of death being 1a) Sepsis leading to multi organ failure; b) Aspiration pneumonia c) Acute stroke 2) Ex-intravenous drug use.

Mohammad Nazemi died from natural causes on 18th January 2024 in Pinderfields Hospital where he had been admitted from home the previous day having sustained an acute stroke and aspirated in the early morning. Paramedics were called some hours after the onset of symptoms. Mr Nazemi�s transfer to hospital was delayed when he and the attending paramedics became trapped in the lift at his home address, the oxygen that he was receiving from the paramedics running out before they were rescued, and being restored when he was placed in the ambulance. On the balance of probabilities, he was so unwell by the time of the paramedics� first attendance that the delay in his arrival at hospital did not cause or contribute to the already inevitable outcome.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:- Yorkshire Ambulance Service; Wakefield District Housing. I have also sent it to the West Yorkshire Fire and Rescue 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) | Product related deaths

Schindler Ltd

31/01/2025

2025-0055

Kim Robinson

Suffolk

Secretary of State Department of Health and Social Care

On 13th May 2024 I commenced an investigation into the death of Kim Jeanette ROBINSON The investigation concluded at the end of the inquest on 28th January 2025. The conclusion of the inquest was that the death was the result of:- Suicide The medical cause of death was confirmed as: 1a�[REDACTED] toxicity

Kim Robinson�s death was recognised at 05:16 on 12th May 2024, at her home address in Suffolk. Kim had suffered for many years with chronic and debilitating leg and back pain, for which she took prescribed medication. Kim also suffered with her mental health and had previously taken overdoses of her prescribed medication. Toxicological analysis identified that Kim had the drug [REDACTED] in her system (an anxiety, heart and blood pressure medication) significantly above the toxic level. Kim was not prescribed [REDACTED] at the time of her death by her usual GP, but had obtained a supply from an on-line pharmacy. In order to obtain�[REDACTED] on-line Kim ensured she supplied the required details, rather than her correct details. The process required to do this was described as a �tick- box� exercise in court. When the online prescription was made (6th May 2024), the prescribing clinician had no access to Kim�s online GP records. Evidence was heard that had access to Kim�s GP records been available to the prescribing clinician, the prescription of�[REDACTED] would not have been made. Evidence heard in court identified that Kim�s normal prescriptions were secured by a loved one, who controlled the amounts of prescription medication Kim could access at any one time. When delivered, the package containing the [REDACTED] was addressed to Kim, providing her direct access to a fatal quantity of prescription medication. Had the online prescription not be made, Kim�s death would not have occurred.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- 1.� The other Interested Persons in this matter I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. 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 Senior 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�| Suicide (from 2015)

Department of Health and Social Care

13/12/2024

2024-0691

Timothy De Boos

Suffolk

Secretary of State Department of Health and Social Care

On 6 February 2024 I commenced an investigation into the death of � Timothy Robert DE BOOS � The investigation concluded at the end of the inquest on 5 December 2024. The conclusion of the inquest was that the death was the result of:- � The effects of a self-ignited fire at his home address, whilst suffering a relapse of his known psychotic illness. � The medical cause of death was confirmed as: � 1a Smoke inhalation and severe burns 1b Domestic fire 2 Paranoid schizophrenia, severe right coronary artery atherosclerosis

Timothy De Boos was declared deceased at his home address in Ipswich, Suffolk on the 6? February 2024. � Earlier that day a fire had to be seen coming from the ground floor flat of the address. Tim was seen by a witness to close the window of the flat whilst it was on fire, then disappear from view. Tim made no attempt to leave, and when found was sat or slumped against the door of the room. Timothy was known to the mental health services, and had a prolonged history of being mentally unwell (being diagnosed with paranoid schizophrenia in 2004), with evidence of a previous stated suicidal thought. A subsequent post-mortem examination identified that Tim had died from smoke inhalation and burns. Although clearly able to do so Tim made no effort to leave the burning building, and on a balance of probabilities basis, deliberately remained inside with a view to ending his life Tim had suffered a mental health crisis on the 2 February 2024 and Tim himself, Tim�s family, and Tim�s Mental Health Care Coordinator, all believed he should be admitted to a Mental Health Unit at that time as a voluntary patient. This could not be immediately actioned as a referral to another team was required, and members of that team who subsequently saw Tim the following day, deemed he was no longer in a mental health crisis. If Tim�s admission to hospital had been actioned on the 2?� February 2024, he could not have been admitted in any event, as there was already a list of five other individuals waiting to be admitted to the same unit. Had Tim been admitted to a Mental Health Unit on the 2?� February 2024, his tragic death would not have occurred.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- � Timothy�s next of kin. Norfolk and Suffolk Foundation Trust � I am under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. 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 Senior 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

Department of Health and Social Care

22/07/2024

2024-0391

Gemima Christodoulou-Peace

Suffolk

Secretary of State Department of Health and Social Care

On 1st August 2023 I commenced an investigation into the death of Gemima CHRISTODOULOU-PEACE. The investigation concluded at the end of the inquest on 17th July 2024. The conclusion of the inquest was that the death was the result of:- Gemima died as the result of a suspension hanging, but there is insufficient evidence to show that at all material times she intended her death, due to impulsivity associated with her diagnosed mental illness, and the intoxicating effect of [REDACTED]. The medical cause of death was confirmed as: 1a Suspension Hanging

Gemima Christodoulou-Peace was declared deceased on Monday 31st July 2023 at, [REDACTED] in Suffolk. Gemima had been found inside the premises, suspended by her neck from a ligature. A subsequent post-mortem examination identified marks on Gemima�s neck consistent with death by suspension by a ligature. Police investigations of digital media evidence identified on a balance of probabilities, that Gemima died on, or about the 26th July 2023. Gemima was known to suffer with her mental health (Emotionally Unstable Personality Disorder, anxiety, and depression), had previously taken overdoses of medication, and had previously been admitted to hospital mental health units. At the time of her death Gemima was found to have a high level of [REDACTED] in her system, which can induce feelings of detachment, confusion, altered perception of space and time, and panic attacks. In addition, in May 2023 Gemima received a repeat prescription of a drug called Montelukast, which in rare cases is known to increase suicidal behaviour. It is however not known when Gemima last took this drug, and none was found in Gemima�s system at the time of her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- Gemima�s next of kin. The other listed IP�s in this case. Haringey Social Services � I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Senior 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: Department of Health and Social Care

09/10/2024

2024-0537

Nigel Hammond

Suffolk

Secretary of State Department of Health and Social Care � The Chief Executive Norfolk and Suffolk NHS Foundation Trust, � Suffolk County Council, Head of Social Work Mental Health Services

On 18th March 2024 I commenced an investigation into the death of � Nigel Hutton HAMMOND � The investigation concluded at the end of the inquest on 8th October 2024. The conclusion of the inquest was that the death was the result of: � � Suicide, whilst the balance of his mind was disturbed. � The medical cause of death was confirmed as: � 1a Left Middle Cerebral Artery infarction, Traumatic Brain Injury 2�� Depression, Lymphoma

Nigel Hammond�s death was verified at 10:20 on 14th March 2024, at the Addenbrooke�s Hospital, Cambridge. � On the 11th March 2024 Nigel fell [REDACTED] at his home address. � An ambulance was called, and Nigel was initially taken to the Ipswich Hospital but was transferred to the trauma centre at Addenbrooke�s hospital due to the extent of his injuries. � Nigel succumbed to the injuries received in the fall, three days later. � Nigel had suffered with his mental health for a protracted period, and it is more likely than not that his fall from the window was a deliberate attempt to end his life.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- � Nigel�s next of kin. Nigel�s GP � I am under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. 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 Senior 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

Department of Health and Social Care | Norfolk and Suffolk NHS Foundation Trust | Suffolk County Council

26/11/2024

2024-0651

Amy Butcher

Suffolk

Secretary of State for Department of Health & Social Care The Chief Executive of Norfolk and Suffolk NHS Foundation Trust

On 19th May 2023 I commenced an investigation into the death of Amy Jade BUTCHER The investigation concluded at the end of the inquest on 1st November 2024. The conclusion of the inquest was that the death was the result of:- Suicide as the result of a deterioration in her mental health, exacerbated by an ineffective PRN medication prescription which failed to resolve her heightened anxiety crisis when needed. The medical cause of death was confirmed as: 1a Fatal Pressure on Neck

Amy Butcher was declared deceased at 07:26 hours on the 14th May 2023 at [REDACTED] in Suffolk. Amy had been found inside the premises, [REDACTED]. Amy was being treated by Mental Health services and had four days earlier (10th May 2024) been admitted to A&E in a heightened anxiety crisis and wanting to die. At this time Amy was given Lorazepam (a �pro re nata� [PRN] �take as needed� medication). This medication was very effective for her, and once her anxiety crisis had passed, she was allowed home. Following her discharge Amy had consultations with her mental health crisis team and her GP, and made repeated requests for a prescription of Lorazepam, to take as a PRN medicine, if she suffered a further heightened anxiety crisis. Taking a PRN medication was one of the steps identified in Amy�s agreed crisis plan. Amy�s request for Lorazepam was declined, and alternative PRN medications where subsequently prescribed. On the evening of the 13th May 2024 Amy was particularly distressed, and it took her partner hours to calm her down, until Amy finally fell asleep. At some point Amy had taken her prescribed PRN medication (as evidenced in subsequent toxicology analysis), but in the early hours of the 14th May 2023, Amy awoke and suspended herself with a ligature around her neck. Amy�s prescribed PRN medication had therefore not alleviated her heightened anxiety crisis. Had Amy had access to Lorazepam as a PRN medication on the evening of the 13th May 2023 (knowing the positive outcome this had for her on the 10th May 2023), it is more likely than not, that her death would not have occurred. Notes written by Amy, and disclosed to the Mental Health on the 8th May 2023, addressed to her loved ones, indicate that she premediated thoughts about taking her life, and therefore intended her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Amy�s next of kin I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. 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 Senior 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 | Mental Health related deaths | Suicide (from 2015)

Norfolk and Suffolk NHS Foundation Trust | Department of Health and Social Care

27/11/2023

2023-0488

Gerald Cruse

Avon

Secretary of State for Health Bristol Ambulance Emergency Medical Services [REDACTED], Friend of the deceased Royal United Hospitals Bath NHS Foundation Trust South Western Ambulance Service NHS Foundation Trust Chief Coroner

On 12th December 2022 an investigation was commenced into the death of Gerald Roy Cruse. The investigation concluded at the end of the inquest on 27 November 2023. The conclusion of the inquest was: Accident � The cause of death was recorded as: � 1a) Pneumonia 1b) Rib fractures, haemopneumothorax 2) Osteoporosis, frailty, ischaemic heart disease, transient ischaemic attack

On 23 November 2022, Gerald Cruse was taken to the Royal United Hospitals Bath by ambulance following a fall at home. He was assessed as being suitable for the Ambulance Cohort Area, which was run by Bristol Ambulance Emergency Medical Services. Mr Cruse was placed in a bed once one became available. He needed to use the toilet so a member of ambulance staff lowered the bed rails and sat Mr Cruse on the edge of the bed before then going to get a wheelchair to transport him to the toilets. Mr Cruse then stood up and fell. He sustained a significant chest injury, including multiple rib fractures, a haemopneumothorax and surgical emphysema. He was cared for on a surgical ward in accordance with the admissions pathway, with input from the older persons medical team. Despite active treatment, his condition deteriorated and he developed pneumonia. Mr Cruse died on 7 December 2022at the Royal United Hospitals Bath.

I have sent a copy of my report to [REDACTED], friend if the Deceased, to the Royal United Hospitals NHS Trust and to the Chief Coroner. I have also sent it to South Western Ambulance Service NHS Foundation Trust who may find it useful or of interest, as I understand that they work very closely with Bristol Ambulance Emergency Medical Services. � 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 | Bristol Ambulance Emergency Medical Services | Royal United Hospitals Bath NHS Foundation Trust | South Western Ambulance Service NHS Foundation Trust

15/11/2023

2023-0450

Calogero Di Blasi

Avon

Secretary of State for Health University Hospitals Bristol & Weston NHS Foundation Trust [REDACTED] daughter of the Deceased The Royal College of PhysiciansChief Coroner

On 13th December 2022 an investigation was commenced into the death of Calogero Di Blasi. The investigation concluded at the end of the inquest on 15th November 2023. The conclusion of the inquest was: � The deceased died as a result of a recognised complication of an investigative medical procedure in circumstances where underlying cirrhosis and resultant varices were unknown, and not recognised as a possibility, by the Endoscopist � The cause of death was recorded as: � 1a) Haemorrhagic shock 1b) Perforated gastric varix (post surgical procedure) 1c) Portal hypertension due to chronic alcoholic liver disease

On 10 August 2022, Calogero Di Blasi was referred by his GP to the Upper Gastro- intestinal team at the Bristol Royal Infirmary for possible stomach cancer. He underwent an endoscopy on 18 August 2022 where biopsies were taken. The results showed abnormal cells. On 15 September, Mr Di Blasi was referred by a GP to the Lower Gastro-intestinal team for possible bowel cancer and had a CT scan on 4 November 2022. The CT scan revealed cirrhosis with portal hypertension and gastric varices, which were new incidental findings. The Lower GI team had been made aware of the investigations ongoing by the Upper GI team, but the upper GI team were unaware of the Lower GI team�s involvement. Both referrals were made on the 2 week cancer referral pathway. The CT Scan was reported on 14 November, and double reported on 16 November 2022. However, the referring clinician did not review the report until the day after Mr Di Blasi�s death, on 2 December 2022. The incidental findings were not considered to be �significant� by the Radiologists and were not therefore warrant an alert being sent to the referring clinician, leaving the report to be reviewed when they were able to. My investigation revealed that the timeframe for seeing patients on the cancer referral pathway is the date of the first appointment and there are no other target dates in respect of investigations of subsequent treatment. � Mr Di Blasi underwent a further endoscopy on 30 November 2022. The Endoscopist was unaware of these incidental findings. A biopsy was taken from an area which looked abnormal but was actually a gastric varix. As a result of this, Mr Di Blasi suffered a massive bleed and despite maximal supportive measures, he died on 1 December 2022 at the Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW.

I have sent a copy of my report to [REDACTED] the daughter of the Deceased, and to the Chief Coroner. I have also sent a copy to The Royal College of Physicians who I understand are involved in the training of Endoscopists. � 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 Bristol and Weston NHS Foundation Trust | Royal College of Physicians

09/02/2022

2023-0220

Michelle Jennings

Manchester South

Secretary of State for Health & Social Care � � Secretary of State at Ministry of Justice

On 6th October 2020 I commenced an investigation into the death of Michelle Louise Jennings. The investigation concluded on the 24th November 2021 and the conclusion was one of suicide. The medical cause of death was 1a hanging

Michelle Louise Jennings had a history of contact with mental health services and had a history of indicating suicidal ideation to a number of agencies. She was assessed as being suitable for step 4 therapy. However at the time of the assessment of her need there was a 2 year waiting list to access therapy. On the balance of probabilities this delay possibly contributed to her death. On 11th April 2019, 17th July 2019, 28th July 2019, 17th January 2020 and 8th May 2020 she was dealt with by British Transport Police (BTP) and indicated suicidal thoughts. Following the incident on 8th May 2020 BTP prosecuted her for obstructing the railways when she had indicated she had suicidal ideation at the time she was on the railway. She was subsequently arrested on a warrant and held in custody before being sentenced. On the balance of probabilities this decision to prosecute possibly contributed to the deterioration in her mental health and her subsequent death. On 1st August 2020 following calls to the mental health crisis line she was referred for a mental health assessment by the Primary Care Mental Health Team (PCMHT) part of Cheshire & Wirral partnership NHS Trust (CWP). On 3rd September 2020 she was assessed by telephone by the PCMHT and then the case was referred to the PCMHT MDT. On 6th September she rang Cheshire Police from Delamere Forrest with suicidal thoughts. She was taken to Hospital and discharged the following day. On 9th September 2020 her case was considered by the PCMHT MDT. They determined her needs were too complex for the PCMHT and she was to be referred to the Community Mental Health Team (CMHT) part of CWP. The referral was not made until 16th September 2020. At the point of referral she was discharged from the PCMHT caseload. On 17th September 2020 she presented at Stepping Hill Hospital with suicidal thoughts. She was assessed by mental health services and discharged. On 23rd September 2020 she was discussed at the CMHT MDT where the referral was rejected and she was to be referred back to the PCMHT. She was discharged from the CMHT caseload at that point. She was no longer on the caseload of either the PCMHT or the CMHT. Despite the complexity of her needs and her deteriorating mental health there was no discussion between the PCMHT and the CMHT in relation as to how to manage or mitigate the risk at this point although it was documented that she felt rejected by mental health services. On the balance of probabilities the poor communication between the PCMHT and the CMHT, the failure to assess risk effectively to ensure she remained on the caseload of either the PCMHT or the CMHT probably contributed to the further decline in her mental health and her death. On 3rd October 2020 she made her way�[REDACTED] and hanged herself [REDACTED] She was found on 5th October 2020.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the Family, Pennine Care, Cheshire & Wirral Partnership NHS, and Cheshire West & Chester 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) This report is being sent to: Department of Health and Social Care | Ministry of Justice

14/03/2024

2024-0142

Joseph Miller

Manchester South

Secretary of State for Health and Social Care

On 6th June 2023 I commenced an investigation into the death of Joseph Michael Miller. The investigation concluded on the 2nd February 2023 and the conclusion was one of narrative: Died from the complications of a seizure contributed to by the use of cocaine. The medical cause of death was 1a) Hypoxic Brain Injury 1b) Cardiac Arrest on the background of a seizure and cocaine use

On the 31st May 2023, Joseph Michael Miller was seen by a neighbour to be fitting in the garden of his home address. A call was made to the ambulance service that was initially categorised as category 1 but downgraded to category 3 when it was reported that he was no longer fitting. A further call was made when he had another seizure and became unconscious. Ambulance crews attended. The initial Rapid Response Team were there within eight minutes. He did not return to consciousness despite extensive efforts to resuscitate him. He was transferred to Tameside General Hospital where tests on the 3rd June confirmed severe hypoxic brain injury and he was declared dead on 5th June.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely [READCTED] 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 This report is being sent to: Department of Health and Social Care

20/12/2024

2024-0699

Oliver Winson

Norfolk

NHS England By Email

On 20 June 2024 I commenced an investigation into the death of Oliver James WINSON aged 33. The investigation concluded at the end of the inquest on 19 December 2024. The medical cause of death was: 1a)������ Cocaine Toxicity The conclusion of the inquest was: Drug related

Oliver Winson was a 33 year old man who had a history of drug misuse and he was under the care off substance misuse services since December 2013.� He had previously been diagnosed with a mixed anxiety and depressive disorder for which he was prescribed medication. In 2017 he was referred to the adult ADHD (attention deficit hyperactivity disorder) service as his GP was concerned that his attention span was limited, and he had become quite hyperactive.� In a response to a request for further information, his GP confirmed that Mr Winson had been concerned for many years about his low attention span and found it difficult to concentrate and there were concerns that this might point to hyperactivity and drug related behaviour.� He had a history of impulsive behaviour, and this led to a risk of him becoming aggressive and a risk of going back to significant drug abusing behaviour. The GP felt that he was at quite a high risk of significant harm to himself in the long run if he was not diagnosed and managed appropriately.� As Mr Winson was under the care of the drug and alcohol service it was felt that someone in that team could see him so the referral was not accepted at that time. However, the service misuse team referred Mr Winson back to the mental health Trust on 19th June 2020 for an adult ADHD undiagnosed assessment.� They confirmed that he had been abstinent from drugs for four to five years and was on daily methadone.� The adult ADHD service said they would accept the referral on to the undiagnosed wait list but indicated he should remain abstinent from drugs to benefit from the service.� At that time, it was indicated that the waiting list was likely to be in the region of two years. The substance misuse service regularly sought updates on the waiting list and were advised that this was very lengthy due to unprecedented referrals and that the COVID pandemic had also impacted on this. By May 2023 when seeking an update, the service raised the concern that it had taken five years and a lot of hard work for Mr Winson to get to the point that he was at and that they were concerned that his historic drug use was chaotic, and he was at risk of death by overdose. Sadly, Mr Winston did relapse into drug use and on 10th June 2024 police were called to his home address where he was found deceased and toxicology evidence confirmed drug use prior to death and that death was as a result of cocaine toxicity.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Mother of Oliver Winson � Norfolk and Suffolk NHS Foundation Trust I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who 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.

Alcohol, drug and medication related deaths�| Mental Health related deaths

NHS England

12/7/2024

2024-0377

Judith Obholzer

Inner West London

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

On 12 July 2023 I commenced an investigation into the death of Judith Maike OBHOLZER. The investigation concluded at the end of the inquest on 11 July 2024. The conclusion of the inquest was: Judith Maike Obholzer died on 12 July 2023 at [REDACTED] from injuries caused from jumping in front of a moving train (suicide) following a significant period of worsening depressive illness for which she was receiving treatment. Delays by the Wandsworth SPA team in assessment and to being added to the waiting list for a full assessment by a Consultant, and the private psychiatrist not being able to directly access crisis support may have contributed to the death.

Mrs Obholzer took her own life by jumping in front of a moving train at [REDACTED] Train Station on 12 July 2023. From at least March 2023 Mrs Obholzer was suffering from depression and anxiety. She was receiving treatment through her GP in the form of antidepressants and had attended weekly Cognitive Behavioural Treatment (CBT) since 12 March 2023 with a private practitioner. Mrs Obholzer was referred to Wandsworth SPA team by her GP on 15 May 2023 and assessed by a triage nurse on 18 May. I found that there was a delay within the Wandsworth team following the initial triage assessment which led to a delay in Mrs Obholzer being put on the waiting list for assessment by a consultant psychiatrist, but that given the waiting times at that stage it was unclear whether or not she would have been assessed by the time of her death (as she had triaged as being a routine patient). She was not put on the waiting list for assessment by a consultant psychiatrist until 10 July. Throughout, Mrs Obholzer was experiencing thoughts of suicide and planning. Due to the deterioration in her condition and the wait for NHS care, Mrs Obholzer attended a consultation with a private consultant psychiatrist on 11 July 2023. The private consultant psychiatrist diagnosed her as suffering from severe post natal depression and presenting with significant suicidal risk. He recommended informal admission to a private hospital, but Mrs Obholzer was against this due to financial concerns. The private consultant psychiatrist planned to write to Mrs Obholzer�s GP to request an urgent assessment by her local Home Treatment/Crisis resolution team, but that letter was not sent on that day for a variety of reasons. The private consultant psychiatrist gave evidence that he was not able to refer Mrs Obholzer to those teams directly. � Following a post mortem examination the medical cause of death was determined to be: 1a Multiple Traumatic Injuries

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED] (husband) South West London and St George�s Mental Health Trust � I have also sent it to Royal College of Psychiatrists and 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.

Suicide (from 2015)�� � This report is being sent to: NHS England | Department of Health | South West London and St George�s Mental Health Trust

20/12/2023

2023-0539

James Campion

Liverpool and Wirral

NHS England NHS Improvement Department of Health and Social Care

On 02 August 2022 I commenced an investigation into the death of James CAMPION aged 57. The investigation concluded at the end of the inquest on 19 December 2023. The conclusion of the inquest was that: � Narrative Conclusion : The consumption of an excessive amount of prescription medication whilst under the influence of alcohol, contributed to by the delay in medical treatment.

James Campion was 57 year old gentleman who had a number of co-morbidities, including a history of depression and previous drug overdoses. Mr Campion was also known to drink alcohol to excess, described by family as a functioning alcoholic. On 1 July 2022 Mr Campion contacted the crisis teams indicated he was going to overdose and then proceeded to overdose on prescription medication. He was conveyed to the Royal Liverpool University Hospital where he was treated for the overdose and seen by the mental health team. A mental health assessment was not carried out and he was discharged with the advice to contact the crisis team if needed. On the evening of 20 July 2022 Mr Campion spoke to a friend who confirms Mr Campion appeared intoxicated but appeared to be his normal self. In the early hours of 21 July 2022, Mr Campion made contact with the Psychiatric Crisis Team threatening to take an overdose of [REDACTED] and his heart medication, he also stated that he had been drinking vodka. In the light of their concerns the Crisis Team contacted the North West Ambulance Service (NWAS) by 999 at 2.10am. The initial call was allocated a category III classification (attendance within one hour and 90% of calls within two hours). The Service was stated to be very busy at that time. It was four and a half hours from the original call before the case was reviewed by a clinician but there does not appear to have been a welfare check phone call at that time. It was not until six hours after the initial call that an ambulance was allocated and when the crew arrived at his home address at 8:26am they found Mr Campion deceased in the living room. The post mortem and toxicology investigation found the cause of death to be mirtazapine and alcohol toxicity. Mirtazapine is an antidepressant medication and has a number of common side- effects including feeling sleepy and in overdose it can lead to reduced consciousness and coma. The TOXBASE guidance notes that peak plasma concentrations occur approximately two hours after ingestion. It also states that the effects on the central nervous system may be enhanced or prolonged following co-ingestion of other central nervous system depressants including alcohol. Though it is unknown as to exactly what time Mr Campion took the overdose of mirtazapine, in the opinion of the expert the delay of over 6 hours from the initial call to the ambulance service to an ambulance crew being allocated and arriving on scene is very significant. It is more likely than not if Mr Campion had been in hospital at a point at least two hours after ingestion he would have survived this event. There were a number of missed opportunities in the care and treatment of Mr Campion. The family contact details noted by the mental health team were incorrect. There was very little evidence of family involvement throughout the mental health interactions, this being a critical and crucial element of the mental heath treatment plan. On 1 July 2022 a full mental health assessment should have been carried out, which is likely to have resulted in immediate support for Mr Campion and measures been put in place for further referrals to the appropriate mental health services. On 21 July 2022 the ambulance call handler did not give the time estimate of the ambulance to the crisis team member; that said the numbers for the family were incorrect and so would not have led to anyone being contacted. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the� demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Mr Campion clearly consumed an excessive amount of prescription medication whilst under the influence of alcohol and as such his state of mind is likely to have been impaired. Taking account of his past actions, particularly that of 1st July 2022, it is more likely than not he carried out the act not with the intention of taking his own life.

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

Emergency services related deaths (2019 onwards) | Alcohol, drugs medication related deaths This report is being sent to: Department of Health and Social Care | NHS Improvement | NHS England

02/08/2023

2023-0281

Dumile Thompson

West Yorkshire (Eastern)

NHS England NHS National Patient Safety Alerting Committee

On 12 November 2020 an investigation was commenced into the death of Dumile Daniel Thompson, aged 49 years, who died on 31 October 2020. The investigation concluded at the end of the inquest on 5 July 2023. The medical cause of death was 1a) Hypoxic Brain Injury with myoclonic status epilepticus 1b) Ramipril Induced Angiodema II End stage renal failure requiring dialysis, hypertensive heart disease. The conclusion was a narrative conclusion, reflecting the circumstances of the death as set out below.

Mr Thompson was a man of African-American origin. He suffered a reaction to recently prescribed Ramipril medication and developed angioedema on 23 October 2020. He attended hospital at around 09.15hr. ACE Inhibitor induced angioedema was confirmed following assessments by the emergency department he was referred to an ENT consultant who commenced treatment with a plan to admit to ITU and set a low threshold for intubation upon deterioration. Following reassessment� by an ITU consultant it was determined admission to that unit was not required and admission to a high observation unit was appropriate. � ACE Inhibitor angioedema is a rare event and the limited knowledge of its trajectory, including the potential for rapid deterioration in circumstances where Mr Thompson appeared to be improving, offered false reassurance at a number of points in care namely, there was no request for specialist input from immunology, the potential for an alternative medication regime was therefore not considered, there was no clear plan for ongoing monitoring requirements, and he was not admitted to ITU. � At approximately 20.20hr he was seen by an A&E doctor because of a report of increased swelling, which was the first report of a deterioration since admission. This should have prompted a request for reassessment by a specialist in airway compromise who would likely have attended promptly and noted the decline in Mr Thompson�s condition. Shortly after 20.35hr Mr Thompson suffered a respiratory collapse which caused a catastrophic brain injury and passed away several days later when life support was withdrawn.

I have sent a copy of my report to: ������� The Chief Coroner ������� Mr Thompson�s wife ������� Leeds Teaching Hospitals NHS Trust ������� Medicines and Healthcare Products Regulatory Agency ������� Royal College of Emergency Medicine 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: NHS England and NHS National Patient Safety Alerting Committee

30/04/2024

2024-0229

Jason Pulman

East Sussex

NHS England National Referral Support Service, NHS Arden and Greater East Midlands Commissioning Support Unit (Arden & GEM).

On 27 April 2022 I commenced an investigation into the death of Jason PULMAN aged 15. The investigation concluded at the end of the inquest on 12 April 2024. The conclusion of the inquest was that: � Narrative: Jason Pulman died as a result of suicide. Jason died by hanging, potentially through his mental health and gender identity issues. Within this context, it is possible his relationship with his boyfriend exacerbated his low mood. It is also possible Jason may have been prevented from committing suicide if British Transport Police had been notified that Jason was a missing person who was possibly on a train.

Jason Pulman was found on 19 April 2022, by a member of the public, [REDACTED]. �He was pronounced dead on the scene.

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

Suicide (from 2015) | Child Death (from 2015) This report is being sent to: NHS England | National Referral Support Service

12/11/2024

2024-0618

John Doyle

Coventry and Warwickshire

NHS England The Chief Executive Officer of the Coventry and Warwickshire Partnership Trust The Chief Executive of George Eliot Hospital NHS Trust UK Kidney Association British Transplant Society Renal Association

INVESTIGATION AND INQUEST: On 9 January 2024, an investigation was commenced into the death of John Frederick Doyle, who died on the 30 December 2023 aged 60. � The investigation concluded at the end of the inquest on 8 November 2024. � The conclusion was: � 1a Multiple Organ Failure � 1b Cytomegalovirus Infection � 1c Chronic kidney disease (unknown aetiology, kidney transplant in 2022) � II Hypertension � Natural causes against a background of missed opportunities to diagnose and treat cytomegalovirus infection, together with the impact of the resident (formerly junior) doctors� strike on the provision of consistent patient care.

: � In March 2022, John underwent a kidney transplant at Manchester Royal Infirmary and subsequently received follow-up care and regular reviews at the Royal Derby Hospital (RDH). He was first admitted to George Eliot Hospital (GEH) on 2 December 2023, presenting with rectal bleeding and a persistent cough. � Evidence was presented that GEH, like many hospitals, does not have an in-house renal team. As a result, GEH relied on telephone consultations with specialist hospitals for advice on investigations and treatment for renal-related issues. � During John�s treatment, the team at GEH sought guidance from both RDH and University Hospital Coventry and Warwickshire (UHCW), the latter being the nearest specialist centre. Following John�s admission, tests were ordered to rule out cytomegalovirus (CMV) colitis. However, without receiving these test results, John was discharged on 6 December, despite evidence suggesting he was still very unwell. He was re-admitted via emergency ambulance on 8 December. Unsuccessful attempts were made to test for the presence of CMV during his stay at GEH. � John�s condition continued to deteriorate, and he was transferred to UHCW on 21 December. A diagnosis was not made until 28 December, when tests showed he had 27 million copies of CMV per milliliter of blood, an extremely high count. Treatment with ganciclovir and anti-CMV immunoglobulin was commenced. By this stage, it is likely that John had developed CMV encephalitis. He was intubated and ventilated, but his condition declined, leading to multiple organ failure. John died on 30 December 2023. � Evidence was received that whilst CMV rarely causes more than cold or flu-like symptoms in the general population, it is one of the most common infectious complications of solid organ transplantation and is reported to increase graft loss and patient mortality. It was acknowledged that an earlier diagnosis and treatment of CMV could have potentially changed the outcome for John and would have increased the likelihood of successful treatment. � Consultants from both hospitals testified that, due to the junior doctors� strike, they had to assume additional responsibilities and manage a higher patient load, which affected their ability to maintain a consistent overview of patients� conditions and treatments. In John�s case, the impact was the failure to notice that the test results had not been received at both GEH and UHCW. The patient safety incident investigation by GEH identified human error and systemic issues in handling CMV testing and the care of renal patients: Sample Collection Errors: Multiple errors were identified in sample collection for CMV testing: The laboratory operated by UHCW failed to freeze one sample and one sample was incorrectly rejected as unusable Clinicians used the wrong tubes, failing to use the necessary, purple-topped tube that prevents the blood collected from clotting. Human error led to prompts for correct tube selection being ignored and the use of paper labelling did not prompt the use of the correct tube. Expedited testing needs were not clearly communicated, leading to delays. Staff were unaware of the testing schedule in place at UHCW for CMV testing Documentation and Communication: Medical notes lacked thorough documentation on the selection and dispatch of samples, contributing to inefficiencies and miscommunication among staff. Delayed Transfer to Specialist Care: John should have been transferred earlier to UHCW, which has the necessary renal services, including dialysis and specialised renal diets. GEH/UHCW lacked the protocols for timely patient transfer. The report also recommended that patients who are at risk of transplant failure should be managed proactively. Evidence given at the inquest showed there is currently no clear protocol at GEH regarding which hospital to contact for advice or when a patient should be considered for transfer to a specialist unit. Additionally, it was unclear whether the transfer should be initiated by the specialist centre or by GEH. Evidence was received that some training had been delivered on the correct procedure regarding sampling and that draft protocols were being drawn up but were not yet finalised or published. None of the consultants from GEH who gave evidence had expertise in renal medicine or experience with transplant patients. Additionally, although it was planned to develop guidance, only the renal consultant at UHCW was familiar with the Renal Association and the British Transplantation Society�s guidelines, specifically the �Clinical Practice Guideline Post-Operative Care in the Kidney Transplant Recipient�. This guidance states: �This document is intended for those engaged in the care of kidney transplant recipients (KTR) who are non-experts. With increasing efforts to deliver healthcare locally, many renal transplant recipients are followed up in centres remote from the main surgical transplant unit. At the same time, transplantation medicine has evolved into an increasingly complex and specialised field of nephrology. The following guidelines reflect this alteration in clinical practice and are intended for those healthcare professionals who look after renal transplant patients. They are also intended to be useful to both medical and surgical trainees, general practitioners, nurse specialists and other associated healthcare professionals involved in the care of renal transplant patients.� � It was noted that the guideline aims to inform and support non-experts caring for transplant patients, not to replace assistance from specialist centres. It does not appear that there is any specialist guidelines or examples of best practice regarding collaborative ways of working between specialist and non-specialist centres.

COPIES AND PUBLICATION: I have sent a copy of my report to the following interested persons: John�s family NHS England The Chief Executive Officer of the Coventry and Warwickshire Partnership Trust The Chief Executive of George Eliot Hospital NHS Trust UK Kidney Association British Transplant Society Renal Association 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.

Hospital Death (Clinical Procedures and medical management) related deaths

NHS England | Coventry and Warwickshire Partnership Trust | George Eliot Hospital NHS Trust | UK Kidney Association | British Transplant Society | Renal Association

17/10/2023

2023-0395

Tyler Ryan

Newcastle upon Tyne and North Tyneside

NHS England The Rt Honourable Steve Barclay MP, Secretary of State for Health and Social Care The Royal College of Pathologists The General Medical Council

On 26th April 2022 the Senior Coroner opened an inquest into the death of Tyler Jay Ryan. � On 17th October 2023 I resumed and concluded the inquest.

Tyler Jay Ryan (born 02.09.2009) died at the Royal Victoria Infirmary, Newcastle upon Tyne on 12.02.2021 aged 11 years old. � Tyler had been found in his bedroom at his home address in a collapsed state by his mother on the morning of 12th February 2021. Police, Paramedics and the Great North Air Ambulance Service attended at the home address and attempted to resuscitate him. He remained asystole. He was conveyed to the RVI, Newcastle by Air Ambulance. Sadly, his death was pronounced after prolonged attempts to resuscitate him. � Post� Mortem� examination� was� carried out by [REDACTED], Consultant Perinatal and Paediatric Pathologist at the RVI on 17th February 2021. His report was filed on 20th� December 2021, over 10 months later.� He �concluded that the death was due to 1a) Acute Anaphylactic Shock. The family did not accept this conclusion on the basis that Tyler had no known medical history of allergies and no agent was identified to have triggered this reaction. The family contended that there must have been an undiagnosed and potentially hereditary underlying condition. Tyler had four surviving siblings and the family were concerned that they too may be at risk of sudden fatal collapse. HM� Senior� Coroner� for Newcastle instructed [REDACTED], Consultant Paediatric Histopathologist to report as an independent expert. Her report is dated 15th August 2022. In her opinion, Tyler died of Sudden Unexpected Death in Childhood. She recommended that an analysis of Tyler�s tissue samples should be conducted to explore whether Tyler had an underlying genetic condition which may have caused an arrhythmia. � Genetic testing, via molecular autopsy, subsequently confirmed that Tyler had two variants in the gene RYR2. The scientific evidence strongly suggests that these variants are pathogenic and therefore expected to cause human disease. The RYR2 gene is known to be associated with a rare genetic condition, type 1 catecholaminergic polymorphic ventricular tachycardia �CPVT�. This condition can lead to the development of a potentially dangerous heart rhythm disturbance called Ventricular Tachycardia �VT�, usually when exercising or under conditions of stress or emotional arousal. VT can degenerate to Ventricular Fibrillation �VF�. VF is lethal if it is not corrected by defibrillation. � CPVT is a cause of sudden death in children and young adults with a mortality rate of up to 50% by the age of 30 years old if left undiagnosed and untreated. It is possible that Tyler�s siblings may have inherited this condition. Having heard the evidence, I concluded that Tyler died of Sudden Unexpected Death in Childhood.

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

Child Death (from 2015) This report is being sent to: NHS England | Department of Health and Social Care | The Royal College of Pathologists | The General Medical Council

22/06/2023

2023-0209

Stephen Richardson

Liverpool and Wirral

NHS England & NHS Improvement (PFDs) Secretary of State for the Department of Health and Social Care, Mr S Barclay

On 04 October 2019 I commenced an investigation into the death of Stephen Norman RICHARDSON aged 47. The investigation concluded at the end of the inquest on 22 June 2023. The conclusion of the inquest was that: � Stephen Norman Richardson died from the effects of a self-inflicted ligature [REDACTED], however his intention in doing so remains unclear as the evidence presented Stephen had a fear of dying by suicide.

i.�The Jury found, ii. Self-inflicted ligature on 24th September 2019 at Sid Watkins Unit. Stephen Norman Richardson is a male who was 47 years of age at his time of death. Stephen had suffered with treatment resistant paranoid schizophrenia, from the age of 18. iii.�Following a number of medications being unsuccessful in managing Stephen�s condition and also a long period of inpatient treatment, Stephen was prescribed clozapine in 2006. Clozapine allowed Stephen to live independently and be able to mostly manage his mental well-being. iv. Stephen was regularly monitored by blood testing and in 2018, he had a number of results which concluded that clozapine could no longer be used to treat Stephen�s condition. v.�The Jury have reached the conclusion that it was reasonable to stop the clozapine at this time. However, the Jury are of the view that there were missed opportunities to treat the neutropenia with a view to restart clozapine and also no exploration of whether other medication that Stephen was prescribed could have been the cause of his neutropenia, rather than clozapine. vi.�Almost immediately following clozapine being stopped Stephen�s mental health deteriorated. On the 20th May 2018 there was a marked deterioration in Stephen�s mental health. A schedule of daily visits was put in place in recognition of this. vii. On 24th May 2018 there was a further deterioration in Stephen�s mental health. The view at this time was that Stephen met the criteria to be sectioned under the Mental Health Act. However, he was not sectioned at this time and the Jury heard that this was due to no bed being available on an acute mental health unit. viii.�Stephen was advised that the plan for him was to be admitted to hospital 2 days later. A plan was put in place for the community crisis team to visit Stephen at his home at least twice a day. ix.�On the 26th May 2019 Stephen was still not admitted or sectioned under the Mental Health Act. x.�Visits from the Mental Health Team had not been completed as previously discussed. On May 29th Stephen was visited and the conclusion from this visit was that Stephen should be prioritised for admission. xiii. Later on that day Stephen attempted to hang himself. xiv. The Jury are of the conclusion that the failure to secure a bed on an acute Mental Health Unit for Stephen was a gross failure that contributed to the attempted hanging. Furthermore, this failure also contributed to Stephen sustaining a hypoxic brain injury, and the damage he sustained to his throat, which resulted in Stephen needing to be peg fed. xv. Whilst as an inpatient at the Royal Liverpool Hospital, Stephen�s behaviour became cause for concern, this resulted in the plan for Stephen being that he would be admitted to Clock View rather than the Brain Injury Unit, A bed was found on 28th June 2019. Stephen became an inpatient at Clock View 2nd July 2019. xvi. Stephen was viewed as having a settled period at Clock View. xvii. On 11th July 2019 Stephen was transferred to the Brain Injury Unit, this was described as an emergency transfer due to the need for his bed to be used by another patient. xviii. The Jury are in agreement with Stephen�s family in that this transfer was not in Stephen�s best interest, as there had been no plan of care established for Stephen at the time of transfer. Whilst being an inpatient at the Brain Injury Unit, there were incidents of Stephen assaulting staff. Due to these incidents Stephen was returned to Clock View on 24th July 2019. xix. On 14th August 2019�[REDACTED] was found outside Stephen�s room, when asked about the�[REDACTED], Stephen said that it fell out of his pants. xx. Following this incident a written record was made and the information was verbally shared at the start of the handover. However there was no alteration to Stephen�s risk assessment. xxi. In addition to this there was no safeguarding plan implemented to reflect the incident and any possible related risks. xxii. The jury have noted that, prior to the cord being found Stephen had requested to call his mother. Following Stephen being unable to contact his mother the cord was found. xxiii. The jury have concluded that non-completion of the risk assessment document was in itself a significant failure. On discussion of a transfer back to the Brain Injury Unit family shared concerns as to the ligature risks, and the loss of protective factors such as familiarity with his surroundings and staff. xxiv. At the unit family were also in disagreement with a transfer to the Brain Injury Unit at this stage due to their views that the physical environment at the unit being a risk to Stephen. xxv. Following an assessment of Stephen a phased transfer plan was proposed. xxvi. The Jury have concluded that this was a significant failure in that this plan was not communicated to relevant persons. xxvii. In addition to this the Jury conclude that in the one instance that the plan was shared it was misunderstood by bed management. This is viewed by the jury as a missed opportunity for Stephen. xxviii. Despite the proposed phased return to the Brain Injury Unit and the concerns raised by the family Stephen was transferred with immediate effect on the 16th September 2019. Between 7th September 2019 and the 25th September 2019, no risk assessment was completed either by Clock View or the Brain Injury Unit. xxix. The Jury concluded that this was a serious missed opportunity as there was an absence of documentation to inform care planning and safeguarding steps for Stephen. xxx. Documentation that was completed for Stephen prior to 24th September 2019 recorded occasions of Stephen having suicidal thoughts. xxxi. It is also documented that Stephen had a recognition of his thoughts at this time and requested support in an effect to keep himself safe. xxxii. On the day of the ligature incident (24th September) observations from ward staff state that he was settled, watched TV, spent time in his room, showered, went shopping and wash and dried his clothes. Stephen�s sister also visited him that evening. xxxiii. Following the staff handover on the ward, Stephen�s observations show that there was a change in Stephen�s presentation. He is noted as refusing his medication, refusing access to his room and throwing an item around his room. Stephen is also recorded in observations as being anxious. The Jury heard in evidence that there was no qualified mental health nurse on shift working that evening. xxxiv. Stephen�s behaviour continued and a decision was made to allow him to have time to calm down. At 23:20 Stephen spoke to staff to request that he could make a telephone call to his mother. Stephen was bare chested and he was asked to put a top on but refused to do this. xxxv. At 23:40 Stephen repeated his request to call his mother again. He was told that he could use the phone in the office, but refused and said that he had changed his mind, saying it did not matter. xxxvi.�A short time later staff noticed that Stephen�s room was in darkness. A light on a mobile phone was shone into the room, This was in an attempt to see where Stephen was in the room. The door of Stephen�s room was found to be barricaded and the jury heard in evidence that it took 4 � 6 minutes to clear the barricade and enter the room. xxxvii.�Evidence was also given that no noise was heard at any time of Stephen barricading his bedroom door. On entering the bedroom, Stephen was found ligatured behind the bathroom door. xxviii. It has been discussed in court that the procedure to be followed at the Brain Injury Unit in such circumstances is to call 2222 and 999 to alert emergency services. Although staff called 999 at 23:53 no call was made to 2222. The Jury have concluded that there were missed opportunities due to there being no knowledge of the correct procedures to follow. xxxix.�However it is acknowledged that this failure would not have altered the outcome for Stephen. The Jury also conclude that lack of communication between persons on duty was a failure to respond appropriately to Stephen�s behaviours. xl.�For example, there was no information shared as to the�[REDACTED] being found 4 weeks earlier. The sharing of the incident could have allowed for additional risk planning. xli.�As a jury we would like to offer Stephen�s family our sincere condolences. xlii. Stephen was transferred to ICU at University Hospital Aintree on the 24th September 2019 and sadly passed on 28th September 2019. As a result of his extensive brain damage the decision was made by his family to withdraw his life support. Stephen was pronounced dead.�

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

Mental Health related deaths This report is being sent to: NHS England & NHS Improvement | Department of Health and Social Care

30/11/2023

2023-0489

Katherine Flynn

Liverpool and Wirral

NHS England & NHS Improvement (PFDs) Society of British Neurological Surgeons

On 23 October 2023 I commenced an investigation into the death of Katherine Sarah FLYNN aged 34. The investigation concluded at the end of the inquest on 29 November 2023. The conclusion of the inquest was that: Misadventure contributed to by Neglect

Katherine Sarah Flynn was a 34 year old lady who on 30 November 2020 was found to have a small syrinx (fluid collection in the spinal cord). On 30 June 2021 Katherine was referred to the syringomyelia clinic (specialist clinic for patients with a syrinx). Although Katherine had back pain there was not felt to be a spinal surgical cause for this, and she was discharged from the complex spine clinic but was then referred to the pain team. Katherine had a history of progressive sensory and motor symptoms on the right side and because this could not be explained by her syrinx, an urgent MRI brain scan was requested. This scan was performed on 31 August 2021 and reported as normal. On 13 December 2021 Katherine was seen by a Consultant in Pain Medicine who noted the brain MRI of August looked abnormal and requested a review of the scan. On review there was a mass lesion that had been missed. Katherine underwent a further MRI of the brain where she was found to have tumour (left superior cerebellar / left quadrigeminal cistern region) which had increased in size by approximately 10mm since 31 August 2021. On 18 January 2022 a biopsy was undertaken to establish the type of tumour and a further scan took place on 2 February 2022 when the tumour was felt to have increased in size further. The tumour was found to be an atypical teratoid/rhabdoid tumour (AT/RT). This being a highly malignant central nervous system neoplasm which generally affects infants and is reported to rarely occur in adults. The prognosis of this type of tumour was poor. The management plan was to remove as much of the tumour as possible and then treat it with chemotherapy and radiation. Katherine was consented for the procedure where the risk to life was deemed low. Katherine was admitted to the Walton Centre on 21 February 2022 and underwent the surgery on 22 February 2022. The surgery was uneventful, and a large portion of the tumour was removed but there was still part of the tumour that remained as it could not be removed. Post -operatively, Katherine was slow to wake, and a CT brain scan showed there was some blood at the site of surgery, and it was reviewed by the operating surgeons and no further surgery was felt to be necessary. The plan was to leave the external ventricular drain (EVD) in and continue high dose steroids to help reduce post operative swelling. Katherine was transferred to the intensive care unit to be kept sedated and ventilated overnight. As the sedation was reduced, Katherine became aware of the endotracheal tube (ETT) and bit down on it causing significant trauma to her tongue at the same time. The sedation was increased to enable Katherine to tolerate the tube again. Later that day the tongue was noted to be very swollen and was assessed as being a risk to the airway which prevented the removal of the ETT. The sedation was reduced over the ensuing 48 hours and neurological assessment showed improvement, eye opening to stimuli, obeying commands on the left side however there was still a severe weakness on the right side. Over the following days on intensive care, the respiratory support was reduced slowly, and Katherine was breathing spontaneously but some sedation was still required to help Katherine tolerate the ETT. Due to her tongue swelling it was not deemed appropriate to remove the ETT. On 3 March 2022, Katherine developed fever/sepsis, was started on antibiotics, and subsequently showed an E. coli infection. On 4 March 2022 at 00:00 hours the EVD stopped draining for 2 hours and so the on-call neurosurgeon was contacted who asked if it was oscillating, it was, so he wasn�t concerned and, in the hours thereafter, the EVD started to drain again. Later that evening there was some leakage from the site of the drain resulting in a wet dressing but, contrary to policy, the medical team were not informed or consulted. On 4 /5 March 2022 midnight it was recorded only 1ml of fluid had drained. At 01.00 hours on 5 March 2022, it was recorded only 1ml of fluid had drained again. At 02.00 hours and 03.00 hours 0ml of fluid had drained. At no stage was the medical team informed or consulted. Between 04.25 hours and 04.35 hours that morning the surgical registrar received a call from the nursing staff stating Katherine�s pupils were enlarged and unreactive and the EVD had not drained anything for 3 hours. An urgent CT was requested (04.50 hours) and the scan confirmed hydrocephalus and the fact the EVD had dislodged and moved out of the ventricle, Katherine was taken to theatre at 06:08 hours. Katherine�s pupils remained dilated and unresponsive to light postoperatively and she died on 6 March 2022. There were a number of missed opportunities with the care and treatment afforded to Katherine. There was a missed opportunity to correctly report the findings on the scan of 31 August 2021. This resulted in significant delay in identifying that Katherine had a tumour and this consequently delayed treatment by several months during which time her symptoms were deteriorating. No clear factors were identified that could have contributed to the incorrect reporting of the scan. This was a basic failure resulting in a missed opportunity to investigate the tumour and possible treatments at the earliest opportunity. However, the care and treatment are more likely than not to have been the same had the tumour been reported correctly in August 2021. Once the tumour was identified the decisions made were reasonable and appropriate and the plan to operate to remove the tumour were also reasonable and appropriate to provide Katherine with the best chance of survival for as long as possible. Katherine was dependent upon the EVD postoperatively, but the hope was this could be removed, however it became apparent she would remain heavily reliant upon the drain and so there had been plans to place a permanent drain (VP shunt) on 7 March 2022: again, this being appropriate and reasonable. On 4 March 2022 there was evidence of leakage from the drain due to a wet dressing. There was a failure to inform and consult with the medical team, contrary to policy. This was a basic failure resulting in a missed opportunity to investigate the leakage, though unclear as to what stage the drain dislodged, this may have been an opportunity for a scan to be carried out to confirm whether the drain was still in situ. In the early hours of 5 March 2022 there was a failure to escalate the lack of drainage to the medical team, this was a basic failure and a missed opportunity to provide Katherine with lifesaving medical attention. Those caring for Katherine were falsely re-assured by the fact her observations were in range and the fact that there was still oscillation at 2am (though not recorded prior to that). This was a lengthy time with little or no fluid output, and this taken together with the wet dressing was sufficient to justify medical team invention. Despite there being 4 hours of little or no output the medical team were not called until her pupils were fixed. This is a lack of basic care which was more likely than not compounded by the lack of Guidance when nursing this presentation. Had advice and intervention of the medical team been sought earlier it is more likely than not Katherine would have survived at this time. The fact that the drain could become dislodged, and leak is a known inadvertent consequence of a necessary procedure, however, the failure to escalate the drainage observations to the medical team and appreciate the full clinical picture, given that at 03.00 hours there had been 3 hours of little draining and a wet dressing, is a basic gross failure, namely neglect.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS England | NHS Improvement | Society of British Neurological Surgeons

04/11/2024

2024-0593

Neil Yates

Liverpool and the Wirral

NHS England & NHS Improvement� (PFDs) The Chief Coroner

On 31 January 2024 I commenced an investigation into the death of Neil Michael YATES aged 53. The investigation concluded at the end of the inquest on 01 November 2024. The conclusion of the inquest was that Neil died of a Drug Related Death. The cause of death being: 1a Mixed Drug Toxicity, Bronchopneumonia II. Chronic Obstructive Pulmonary Disease, Cirrhosis

Neil Michael Yates was a 53 year old gentleman who had a number of co-morbidities, including long QT syndrome. Neil also had a history of being a habitual heroin user.� Whilst in the community Neil was prescribed MST (morphine sulphate tablets) instead of liquid morphine due to the risk of liquid morphine on his long QT syndrome. This was prescribed by a voluntary sector organisation specialising in substance misuse and criminal justice intervention projects in England and Wales. On being remanded into custody the GP records were reviewed by the prison GP, this medication change did not appear on his records and so liquid morphine was prescribed to him.� This change did not cause or contribute to his death, however, during the inquest evidence was heard that when organisations, other than GPs, prescribe medications to individuals it takes a number of weeks before the information is sent to the GP surgery for it to be placed on the GP summary for that individual; thus posing a risk that further medication is prescribed to the patient without knowledge of what has already been prescibed.

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

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

NHS England & NHS Improvement

09/08/2023

2023-0289

Rohan Godhania

Milton Keynes

NHS England and NHS Improvement The Food Standards Agency

On 02 November 2022 I commenced an investigation into the death of Rohan GODHANIA aged 16. The investigation concluded at the end of the inquest on 21 July 2023. The narrative conclusion of the inquest was: � The deceased was admitted to West Middlesex Hospital on 16th August 2020. His hyperammonaemia and OTC deficiency was not diagnosed. The failure to carry out a test for ammonia that would have revealed the hyperammonaemia resulted in a lost opportunity to render further medical treatment that may, on the balance of probabilities, have prevented his death. He died on 18th August 2020.

The deceased consumed a high protein drink on 15th August 2020 and became unwell. He was admitted to West Middlesex Hospital. Advice was taken from the neurologists at Charing Cross Hospital who advised that he should be tested for ammonia. The test was not carried carried out. His condition deteriorated and he died from Ornithine Transcarbamylase Deficiency (OTC) on the 18th August 2020.

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

Other related deaths | Child Death (from 2015) This report is being sent to: NHS England and NHS Improvement | The Food Standards Agency

15/05/2023

2023-0151

Raymond Lee

Manchester South

NHS England and NICE (National Institute for Health and Care Excellence)

On 16th September 2021 I commenced an investigation into the death of Raymond Lee. The investigation concluded on the 19th January 2023 and the conclusion was one of Narrative: Died from complications of treatment for oesophageal cancer and a subsequent oesophageal stricture. The medical cause of death was 1a) Gastrointestinal Haemorrhage; 1b) Aorta- oesophageal fistula on the background of oesophageal stent; 1c) Oesophageal cancer treated by radiotherapy

Raymond Douglas Lee had oesophageal cancer. Due to his underlying health, he was treated with radiotherapy- other treatments were not felt to be suitable. He developed an oesophageal stricture as a consequence of the radiotherapy treatment. Dilatation procedure did not lead to an improvement. A biodegradable stent was inserted to try to improve the position. He was in significant pain as a consequence of the stent. Pain is a recognised complication of stenting in these circumstances. He was admitted to Stepping Hill Hospital on 13th September 2021 following episodes of bleeding. A gastroscopy on 14th September 2021 confirmed that the bleeding was from the oesophagus � from an aorta/oesophageal fistula. On the balance of probabilities, the stent had contributed to the development of the fistula. Raymond Douglas Lee continued to deteriorate and died at Stepping Hill Hospital on 14th September 2021.

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) [REDACTED] 3) The Christie NHS Foundation Trust; and 4) Stockport NHS Foundation Trust, who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

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

15/05/2023

2023-0152

Rebekah Mills

Manchester South

NHS England and NICE (National Institute for Health and Care Excellence)

On 3rd August 2022 I commenced an investigation into the death of Rebekah Juliet Mills. The investigation concluded on the 6th February 2023 and the conclusion was one of Narrative: Died from post-operative complications of surgery following an accidental fall resulting in injury. The medical cause of death was 1a) Pulmonary Embolus; 1b) Post Meniscus Repair

Rebekah Juliet Mills had an accidental fall when skiing and she hurt her knee. She went to Stepping Hill Hospital and was seen in the Emergency Department. An examination identified no obvious injury. The notes did not capture her being on oral contraceptive or the degree of her lack of mobility. The virtual fracture clinic review on 13th June 2022 referred her to the physiotherapy team for an appointment. � Backlogs meant this did not take place as envisaged. On 22nd June she sought further help. She was seen on 11th July and a scan on 13th July identified a significant knee injury that had caused her knee to lock. She was seen on 21st July, and it was identified as repairable with surgery, but the surgery was urgently required. She was asked to stop taking oral contraceptive (a risk factor for surgery) which she did. On 28th July 2022 she was operated on. She was discharged home. On 1st August 2022 she collapsed and was taken to Stepping Hill Hospital where she died from a pulmonary embolism.

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

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

29/08/2024

2024-0473

Kasey Beech

London Inner (South)

NHS England at [REDACTED] FAO: NHS England Standardising Acuity Measures in Emergency Departments/Urgent Treatment Centres [REDACTED], Chief Executive, National Institute for Health and Care Excellence at [REDACTED} [REDACTED], President of The Royal College of Emergency Medicine at [REDACTED] FAO Quality Team

On 19 October 2021 an investigation commenced into the death of Kasey Beech, a 19-year-old woman who died following a cardiac arrest caused in turn by a likely infective exacerbation of her longstanding asthma. Her inquest was concluded on 8 November 2023. The conclusion of the inquest was that she died by natural causes.��Following the inquest further submissions and evidence were sought in relation to the risk of future deaths.

On 5 October 2021 Ms Beech self-presented to the urgent treatment centre at Medway Maritime Hospital (MMH), in light of difficulty breathing. She had also been experiencing chest pain. At MMH the traditional Accident & Emergency service has been replaced by an Urgent Treatment Centre (UTC) for walk-in patients. The UTC operates the nationally stipulated STREAMing model (�Simple Triage Rapid Emergency Assessment Method�), a system whereby patients are assessed on arrival and sent to the appropriate area for further review and care. Ms Beech was assessed and directed to the Medway on Call Care (MedOCC), where she was informed of a three hour wait. She decided to go to a friend�s home nearby where she could access a nebuliser more promptly. Shortly after arrival there her breathing worsened suddenly, she was unable to inhale deeply from the nebuliser and she arrested. She was subsequently taken by ambulance to MMH, and then transferred to St Thomas� Hospital London. Despite treatment she did not recover and she passed away at St Thomas� on 13 October 2021.

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

Hospital Death (Clinical Procedures and medical management) related deaths

NHS England | National Institute for Health and Care Excellence | The Royal College of Emergency Medicine

31/01/2023

2023-0033

David Nash

West Yorkshire (Eastern)

NHS England � Primary Care Complaints Team

On 13 November 2020 an investigation commenced into the death of David John Nash born on 26 August 1994. The investigation concluded at the end of the inquest on 20 January 2023. The conclusion of the inquest was: � David died on 4 November 2020 at Leeds General Infirmary as a result of a brain-stem infarction, arising from a cerebella abscess caused by mastoiditis. On 2 November 2020 there was a missed opportunity to direct David to seek face-to-face care during his GP appointment that morning. Had he been directed to seek face-to-face or urgent care by the GP Practice it is more likely than not that he would have undergone neurosurgery approximately 10 hours earlier than he actually did; which at that time it is more likely than not would have been successful. The medical cause of death was: 1a: Brain-stem infarction 1b: Cerebellar abscess 1c: Mastoiditis

1. David first spoke to his GP on the phone about some swollen lumps on his neck on 14 October 2020. He was advised that he should have blood tests and these were booked for 2 November 2020. � 2. On 23 October 2020 he further sought advice from the GP because he had pain in his ear and was complaining of an ear infection. At this telephone appointment there was an assessment for mastoiditis and otitis externa was diagnosed. Antibiotic ear drops were prescribed. � 3. He was then spoken to on the phone again on 28 October 2020 because he felt that he had blood in his urine. He was advised to deliver a urine sample to the Practice which he did and when tested contained blood and white cells resulting in further antibiotics being prescribed. The view of the GP expert was that this was unlikely to be a UTI however there would be no basis on which a GP would link these symptoms to mastoiditis and therefore the treatment was not unreasonable on this occasion. 4. From the evidence [REDACTED], ENT consultant it is more likely than not that at some point in the days after this appointment, David began to develop the abscess that would ultimately prove fatal. 5.�On 2 November 2020 David had a telephone consultation with an ANP at his practice. He had continued fever, pain behind his eye and sinus pain. He had had a negative covid-19 swab in the week prior to this appointment but nevertheless his blood tests were cancelled and he was advised not to visit the surgery but to take a further Covid-19 swab and await the results. This clearly unsettled David who was concerned to get his blood tests completed and the ANP gave reassurance that as soon as he had a negative covid-19 swab she would book him in for his blood tests and see him urgently in practice. 6.�As the 2 November 2020 progressed David became increasingly unwell. This resulted in David�s partner contacting NHS 111. She explained his symptoms and was advised that a clinician would call back within 6 hours. Unfortunately David then vomited and so his partner called NHS 111 again and was given the same advice. When a clinician did call David�s partner was advised not to wake him if he was sleeping and to keep up to date with the codeine pain relief. About an hour later David began to be disorientated and his partner made a final call to NHS 111 resulting in an ambulance being called. 7. David was placed on the dental pathway for NHS 111 which meant that he missed the opportunity to be asked questions which may have identified mastoiditis. However this pathway at the time was not unreasonable for him on the basis of his symptoms. 8. David was taken to St James� Hospital initially. He was triaged quickly and a working diagnosis of either meningitis or encephalitis was made. Both of these conditions would be treated at St James�. He required a CT scan which was undertaken just over 2 hours after it was booked. This was within the context of an ED suffering significant pressures. 9.�As soon as the CT scan was undertaken it was apparent how unwell David was and urgent steps were taken to transfer him to the LGI for neurosurgery. 10. Unfortunately whilst David was in the resuscitation part of ED he deteriorated very significantly and suffered a fall resulting in head lacerations. This fall did not contribute to his death but nevertheless represented an acute deterioration in� his condition with his GCS going from 10 to 3 and requiring immediate ventilation. 11. David survived to the LGI and underwent surgery to insert an external ventricular drain. This appeared to be a successful procedure at first and David responded however he continued to deteriorate over the course of the 3 and 4th�of November 2020 and clinicians determined that his condition was unsurvivable. 12.�David died at the LGI on 4 November 2020.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr and Mrs Nash and Burley Park GP Practice. 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. In this case I have sent a copy of this report to NHS West Yorkshire ICB as the organisation which will take on responsibility for primary care complaints in 2023. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of 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

NHS England

02/02/2024

2024-0056

Samuel Jordan

Exeter and Devon

NHS England, PO Box 16738, Redditch, B97 9PT

On 1st April 2020 an inquest was opened into the death of Samuel Thomas Jordan aged 25 years. The investigation concluded at the end of the inquest on 30th January 2024. The conclusion of the inquest jury was that Samuel Thomas Jordan died as a result of suspension by a ligature, his death being by suicide whilst suffering from mental illness.

Samuel Thomas Jordan was sentenced to 8 weeks� imprisonment at HMP Exeter. This was his first time in prison. He suffered from mental illness which whilst in prison manifested itself in bizarre behaviour and an act of self-harm. Following fights with a cell mate on 26th March 2020 he was placed in a single occupancy cell where he was found hanging about 4 � hours later

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the Samuel Thomas Jordan�s family, Oxleas NHS Foundation Trust, Practice Plus Group, Cornwall Partnership NHS Trust, Devon Partnership NHS Trust and 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.

Suicide (from 2015) This report is being sent to: NHS England

24/10/2023

2023-0402

Jonathan McCarthy

Northampton

NHS England, PO Box 16738, Redditch, B97 9PT Chief Executive Officer Practice Plus Group (PPG) Hawker House 5-6 Napier Road Reading Berkshire RG1 8BW Lord Chancellor and Secretary of State for the Ministry of Justice, 102 Petty France, London SW1H 9AJ, Serco Group plc, Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY (responsible for HMP Thameside)

On 08/11/2018 I commenced an investigation into the death of Mr Jonathan Michael McCarthy (�Mr McCarthy�). The investigation concluded at the end of an inquest on 12/10/2023. I recorded the conclusion as natural causes. � The medical cause of death was:� 1a � Bronchopneumonia and multi organ failure 1b � Acute cardiac arrhythmia (with initial resuscitation) 1c � Myocardial fibrosis (related to drug and alcohol abuse)

Mr McCarthy died on 12th August 2018 at University Hospital Coventry� and Warwickshire as a result of a cardiac arrhythmia whilst at HMP Onley. The arrhythmia occurred as result of scarring of the heart.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � a)����� [REDACTED] (Spouse of Mr McCarthy). b)����� HM Prisons and Probation Service (HMPPS) c)������Northamptonshire Healthcare NHS Foundation Trust d)����� Prisons and Probate Ombudsman �� Similarly, you are 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.

State Custody related deaths This report is being sent to: NHS England | Practice Plus Group | Ministry of Justice | Serco House

26/01/2024

2024-0043

James Atkinson

Newcastle and North Tyneside

NHS England, Wellington House, 133-135 Waterloo Road, London, SE1 8UG Ministerial Correspondence and Public Enquiries Unit, Department of Health and Social Care, 39 Victoria Street, London, SW1H 0EU

On 16 July 2020 I commenced an investigation into the death of James ATKINSON. The investigation concluded on 15 January 2024 at the end of the inquest. The conclusion of the inquest was � Anaphylaxis following peanut ingestion James Stuart Atkinson died on 10th July 2020 after eating a Chicken Tikka Masala pizza 3 purchased from Dadyal Takeaway Restaurant in Newcastle upon Tyne via Deliveroo application. The pizza contained peanuts to which he was allergic. � The Dadyal menu did not contain specific information in respect of peanuts or other allergens. � James did not contact the takeaway to advise them of his allergy. � He ate the pizza, following which he suffered an anaphylactic reaction. No Epi-pen was located and delayed his access to adrenaline until Paramedics attended.

James was 23 years old with a history of Asthma. In 2010 he was confirmed to have an allergy to nuts and in particular peanuts. � He was prescribed an Epi-pen and antihistamines to manage his allergy. His Epi-pen was renewed only on his request, James last requested his Epi-pen in 2015. He attended 3 asthma reviews prior to his death. His allergy was not addressed during the reviews. There was no regular allergy review procedure provided locally or nationally. � On 10 July 2020 he ordered food for himself and flatmates from Dadyal Takeaway Restaurant. Their menu contained limited information as to the ingredients used in the dishes produced and no allergen information or allergen matrix. James ordered a Chicken Tikka Masala pizza. The presence of peanuts in both the dishes produced and in use in the kitchen was not referred to in the menu. James knew about his nut/peanut allergy. He did not contact Dadyal to advise of his allergy and was unaware that the Chicken Tikka Masala pizza ordered contained mixed nut powder comprising of up to 99 per cent peanuts. He suffered an allergic reaction shortly after consuming the pizza. He called an ambulance which arrived within four minutes of his call. His Epi-pen could not be located; missing an opportunity for an adrenaline injection prior to Paramedic arrival. Despite Paramedic and hospital care and treatment James died due to anaphylaxis resulting from peanut ingestion.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: family of James Stuart Atkinson, Food Standards Agency, NHS England (North East). I have also sent it to Deliveroo 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: NHS England | Department of Health and Social Care | Newcastle City Council